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 11361
Topic: 2. Trauma
A 28-year-old male presents with severe elbow stiffness 6 months after internal fixation of a distal humerus fracture. Radiographs show mature heterotopic ossification (HO) blocking flexion. What is the optimal surgical timing and prophylaxis strategy for HO excision?
Correct Answer & Explanation
. Immediate excision with post-op low-molecular-weight heparin
Explanation
Surgical excision of HO is classically indicated once the bone is radiographically mature and alkaline phosphatase levels normalize. Postoperative prophylaxis with indomethacin or a single dose of radiation is highly effective at preventing recurrence.
Question 11362
Topic: 2. Trauma
A 28-year-old cyclist sustains a midshaft clavicle fracture. Which of the following radiographic findings is considered a relative indication for open reduction and internal fixation to prevent symptomatic nonunion and poor functional outcome?
Correct Answer & Explanation
. Inferior displacement of the medial fragment
Explanation
Shortening greater than 2 cm, 100% displacement, and severe comminution (Z-deformity) in midshaft clavicle fractures are associated with a higher risk of nonunion and poor functional outcomes when managed nonoperatively.
Question 11363
Topic: 2. Trauma
A 62-year-old woman sustains a 3-part proximal humerus fracture. Which of the following radiographic criteria is the most reliable predictor of subsequent avascular necrosis (AVN) of the humeral head?
Correct Answer & Explanation
. Greater tuberosity displacement >1 cm
Explanation
Disruption of the medial hinge (>2 mm), short calcar length (<8 mm), and anatomic neck fracture lines are the strongest predictors of humeral head ischemia and subsequent AVN following proximal humerus fractures.
Question 11364
Topic: 2. Trauma
A 70-year-old woman with severe rheumatoid arthritis presents with an acute, highly comminuted, osteopenic distal humerus fracture. A total elbow arthroplasty (TEA) is planned. Which of the following is an absolute contraindication for using an unlinked (resurfacing) TEA implant?
Correct Answer & Explanation
. Age greater than 65 years
Explanation
Unlinked (resurfacing) total elbow arthroplasty relies heavily on the soft tissue envelope for joint stability. Therefore, incompetent collateral ligaments or significant bone loss precluding ligament repair are absolute contraindications.
Question 11365
Topic: Upper Extremity Trauma
A 24-year-old man sustains a Grade V acromioclavicular (AC) joint separation. During anatomic coracoclavicular (CC) ligament reconstruction, where should the conoid and trapezoid bone tunnels be sequentially placed on the clavicle relative to the distal end?
Correct Answer & Explanation
. Conoid at 1.5 cm, Trapezoid at 3.0 cm
Explanation
The anatomic insertion of the conoid ligament is approximately 4.5 cm medial to the distal clavicle, and the trapezoid ligament is approximately 3.0 cm medial. Accurate tunnel placement is critical for restoring normal AC joint biomechanics.
Question 11366
Topic: Upper Extremity Trauma
A 28-year-old cyclist sustains a Grade V acromioclavicular (AC) joint separation. During surgical reconstruction, anatomical restoration of the coracoclavicular ligaments is planned. Which of the following accurately describes the native anatomy of these ligaments?
Correct Answer & Explanation
. The conoid is medial and posterior to the trapezoid
Explanation
The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid is situated medial and posterior to the trapezoid and is the primary restraint to superior translation of the clavicle.
Question 11367
Topic: 2. Trauma
A 28-year-old sustains a transverse, non-comminuted olecranon fracture and undergoes tension band wiring. Six months later, the fracture has healed but the patient complains of posterior elbow pain directly over the hardware. What is the most likely cause of this complication?
Correct Answer & Explanation
. Intra-articular prominent K-wires backing out into the triceps
Explanation
Symptomatic hardware is the most common complication following tension band wiring of olecranon fractures, occurring in up to 80% of patients. It is typically caused by the K-wires backing out proximally and irritating the local subcutaneous tissues and bursa.
Question 11368
Topic: Pelvic & Acetabular Trauma
A 35-year-old male is evaluated in the trauma bay following a motorcycle collision. Pelvic radiographs demonstrate a 3.5 cm widening of the pubic symphysis. CT scan confirms widening of the anterior sacroiliac joints bilaterally, but the posterior sacroiliac ligaments remain intact. According to the Young and Burgess classification, what is the specific injury pattern?
Correct Answer & Explanation
. Anteroposterior Compression (APC) Type II
Explanation
This is an Anteroposterior Compression (APC) Type II injury. APC II is characterized by disruption of the symphysis pubis (typically > 2.5 cm) and tearing of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. Crucially, the posterior sacroiliac ligaments remain intact, providing vertical stability but leaving the pelvis rotationally unstable. APC III would involve disruption of the posterior sacroiliac ligaments as well, causing both rotational and vertical instability.
Question 11369
Topic: 2. Trauma
An 82-year-old female sustains a reverse obliquity intertrochanteric femur fracture (AO/OTA 31-A3). Which of the following internal fixation constructs is most biomechanically appropriate and yields the lowest rate of clinical failure for this specific fracture pattern?
Correct Answer & Explanation
. A sliding hip screw (dynamic hip screw) with a 135-degree angle
Explanation
Reverse obliquity intertrochanteric fractures (AO 31-A3) have a primary fracture line extending from proximal-medial to distal-lateral. Because of this geometry, the lateral femoral cortex does not provide a buttress for the proximal fragment. Use of a sliding hip screw allows the femoral shaft to displace medially, leading to high failure rates. A cephalomedullary nail acts as an intramedullary buttress, preventing medial shaft displacement, and is the biomechanically superior standard of care for reverse obliquity fractures.
Question 11370
Topic: 2. Trauma
A 28-year-old male sustains a vertically oriented (Pauwels Type III) basicervical femoral neck fracture following a motor vehicle collision. Which of the following fixation strategies provides the greatest biomechanical resistance against vertical shear forces for this fracture pattern?
Correct Answer & Explanation
. A sliding hip screw (DHS) supplemented with an anti-rotation cancellous screw
Explanation
Pauwels Type III basicervical and transcervical fractures are highly vertically oriented (>50 degrees), subjecting them to intense vertical shear forces rather than compressive forces. Multiple parallel cancellous screws provide inadequate stability against these shear forces and have a high rate of varus collapse. A sliding hip screw (DHS) provides superior biomechanical stability against vertical shear. A supplemental anti-rotation screw is typically added to control rotational forces.
Question 11371
Topic: 2. Trauma
A 40-year-old male sustains a severe pelvic injury in a motor vehicle collision. CT imaging reveals an acetabular fracture with a transverse fracture line across the acetabulum separating the ilium from the ischiopubic segment, combined with a vertical fracture line exiting inferiorly through the obturator ring, dividing the anterior and posterior inferior elements. Based on the Letournel classification, what is the specific diagnosis?
Correct Answer & Explanation
. Associated both column fracture
Explanation
A T-type acetabular fracture in the Letournel and Judet classification is an associated fracture pattern. It consists of a transverse fracture component (which divides the innominate bone into upper and lower halves) combined with a vertical 'stem' fracture line that extends inferiorly, dividing the ischiopubic segment and exiting through the obturator ring. This differs from a both-column fracture, in which no portion of the articular surface remains attached to the intact axial skeleton (the 'spur sign').
Question 11372
Topic: 2. Trauma
A 70-year-old female on chronic bisphosphonate therapy presents with prodromal thigh pain. Radiographs demonstrate lateral cortical thickening, a transverse 'beak', and severe lateral bowing of the subtrochanteric femur. Prophylactic intramedullary nailing is planned for this impending atypical femoral fracture. To prevent iatrogenic fracture during nail insertion into this bowed femur, which of the following technical modifications is most strongly recommended?
Correct Answer & Explanation
. Using an intramedullary nail with a larger radius of curvature (e.g., >3.0 meters)
Explanation
Atypical femoral fractures (AFFs) associated with bisphosphonates often occur in femurs with excessive anterolateral bowing. Modern intramedullary nails are relatively straight (radius of curvature ~1.5 to 3.0 meters). Inserting a straight nail into a bowed femur risks nail incarceration, cortical penetration, or iatrogenic fracture. To accommodate this mismatch, it is recommended to over-ream the canal by at least 2.0-2.5 mm larger than the intended nail diameter. Using a nail with a larger radius of curvature means it is straighter, which worsens the mismatch.
Question 11373
Topic: Pelvic & Acetabular Trauma
In the evaluation of adults with early-onset hip osteoarthritis secondary to childhood Legg-Calvรฉ-Perthes disease, the Stulberg classification is utilized to describe the residual head shape and its congruency with the acetabulum, which dictates the long-term prognosis. Which of the following best describes the radiographic appearance of a Stulberg Class III hip?
Correct Answer & Explanation
. An aspherical (ovoid or mushroom-shaped) femoral head that is congruent with the acetabulum
Explanation
The Stulberg classification predicts osteoarthritis risk. Class I is normal. Class II is a spherical head with a short, wide neck (coxa magna/breva). Class III is an aspherical (often ovoid or mushroom-shaped) femoral head that remains congruent with the shape of the acetabulum (they adapt to each other). Class IV is an aspherical head that is incongruent with the acetabulum (flat head, round cup). Class V is a completely flat, severely incongruent joint. Class III hips typically develop mild-to-moderate arthritis in late adulthood, whereas Class IV/V hips develop severe arthritis much earlier.
Question 11374
Topic: 2. Trauma
A 32-year-old male sustains a displaced basicervical femoral neck fracture. Which of the following fixation constructs is associated with the highest biomechanical stability for this specific fracture pattern?
Correct Answer & Explanation
. Three parallel cancellous screws
Explanation
Basicervical femoral neck fractures behave similarly to intertrochanteric fractures and are highly unstable. Biomechanical studies have shown that a sliding hip screw (DHS) provides superior stability compared to multiple cancellous screws for basicervical patterns. Adding a derotational screw improves rotational stability and mitigates rotation during lag screw insertion.
Question 11375
Topic: Pelvic & Acetabular Trauma
A 40-year-old patient is involved in an MVC and sustains an anteroposterior compression type III (APC-III) pelvic ring injury. In the trauma bay, the patient is hypotensive and tachycardic. A pelvic binder is applied. What is the correct anatomical landmark for the placement of the pelvic binder to effectively reduce pelvic volume?
Correct Answer & Explanation
. Over the greater trochanters
Explanation
Pelvic binders must be centered over the greater trochanters (at the level of the symphysis pubis) to effectively compress the pelvic ring, internally rotate the hemi-pelves, and reduce the intrapelvic volume. Placement over the iliac crests is a common error and can worsen the rotational deformity.
Question 11376
Topic: 2. Trauma
A 28-year-old male sustains a closed tibia fracture and undergoes intramedullary nailing. Six hours postoperatively, he requires increasing doses of opioids and complains of severe leg pain exacerbated by passive stretch of his toes. Compartment pressure monitoring reveals an anterior compartment pressure of 45 mmHg and a diastolic blood pressure of 60 mmHg. What is the delta pressure, and what is the indicated management?
Correct Answer & Explanation
. Delta pressure is 15 mmHg; immediate four-compartment fasciotomy
Explanation
Delta pressure is calculated as Diastolic Blood Pressure minus Compartment Pressure. Here, 60 - 45 = 15 mmHg. A delta pressure of < 30 mmHg represents inadequate tissue perfusion and is the clinical threshold for diagnosing acute compartment syndrome, necessitating emergent four-compartment fasciotomy.
Question 11377
Topic: Pelvic & Acetabular Trauma
A 45-year-old motorcyclist sustains a closed pelvic ring injury. Clinically, there is a large, fluctuant swelling over the greater trochanter with ecchymosis. Aspiration yields serosanguinous fluid. What is the most appropriate initial management of this specific soft tissue lesion?
Correct Answer & Explanation
. Immediate wide surgical excision
Explanation
The patient has a Morel-Lavallee lesion, a closed degloving injury where skin and subcutaneous fat are separated from the underlying fascia. Initial management of acute lesions often involves percutaneous drainage and firm compression to obliterate the dead space and prevent pseudocyst formation.
Question 11378
Topic: 2. Trauma
In a patient with a tibia fracture and suspected compartment syndrome, which of the following clinical findings is classically considered the earliest and most sensitive indicator of increased intracompartmental pressure?
Correct Answer & Explanation
. Loss of peripheral pulses
Explanation
Pain out of proportion to the apparent injury, specifically exacerbated by passive stretch of the muscles in the involved compartment, is the earliest and most sensitive clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are late, often irreversible signs.
Question 11379
Topic: 2. Trauma
A 30-year-old man sustains a closed tibia fracture and develops severe pain out of proportion to the injury. Which of the following physical examination findings is considered the earliest and most sensitive clinical sign of acute compartment syndrome?
Correct Answer & Explanation
. Loss of palpable pulses
Explanation
Pain with passive stretch of the muscles in the affected compartment is typically the earliest clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are very late and ominous signs indicating irreversible ischemic damage.
Question 11380
Topic: 2. Trauma
Secondary fracture healing with callus formation is typically seen with which of the following fixation methods?
Correct Answer & Explanation
. Compression plating
Explanation
Intramedullary nailing provides 'relative' stability rather than absolute rigid stability. This allows for micromotion at the fracture site, which promotes secondary (endochondral) bone healing characterized by callus formation. Compression plating and lag screws achieve absolute stability, resulting in primary (intramembranous) bone healing.
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