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2. Trauma MCQs

Practice Set 581 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 11601

Topic: 2. Trauma

Following open reduction and internal fixation of a 3-part proximal humerus fracture with a locking plate, a patient complains of persistent pain and stiffness. What is the most common hardware-related complication leading to reoperation in this scenario?

. Plate breakage
. Intra-articular screw penetration
. Humeral shaft fracture below the plate
. Axillary nerve entrapment under the plate
. Subacromial impingement of the plate

Correct Answer & Explanation

. Intra-articular screw penetration

Explanation

Intra-articular screw penetration is the most common hardware-related complication after locked plating of proximal humerus fractures, often due to avascular necrosis or fracture settling. Meticulous fluoroscopic evaluation and avoiding excessively long screws can help prevent this.

Question 11602

Topic: 2. Trauma

A 40-year-old male sustains a closed fracture of the distal third of the humeral shaft. On presentation, he has a normal neurovascular exam. Following a closed reduction and application of a coaptation splint, he is noted to have a new complete radial nerve palsy. What is the most appropriate next step in management?

. Immediate surgical exploration and nerve release
. Observation and clinical follow-up for 3 to 4 months
. Electromyography (EMG) within 24 hours
. Emergent MRI of the arm
. Removal of the splint and placement in a hanging arm cast

Correct Answer & Explanation

. Immediate surgical exploration and nerve release

Explanation

A secondary (post-reduction) radial nerve palsy in the setting of a closed humeral shaft fracture, particularly a Holstein-Lewis type, is an absolute indication for immediate surgical exploration. The nerve may be iatrogenically entrapped in the fracture site during the reduction maneuver.

Question 11603

Topic: 2. Trauma

A 30-year-old male sustains a highly comminuted radial head fracture, a tear of the interosseous membrane, and distal radioulnar joint (DRUJ) disruption. To prevent longitudinal instability of the forearm, which of the following interventions is critical in addition to stabilizing the DRUJ?

. Radial head excision without replacement
. Radial head arthroplasty
. Resection of the distal ulna (Darrach procedure)
. Proximal row carpectomy
. Fasciotomy of the deep volar compartment

Correct Answer & Explanation

. Radial head arthroplasty

Explanation

This triad of injuries describes an Essex-Lopresti fracture-dislocation. Restoring radiocapitellar contact with a radial head arthroplasty is essential to prevent proximal migration of the radius, which would lead to chronic DRUJ pain and ulnocarpal impingement.

Question 11604

Topic: 2. Trauma

In the management of a closed midshaft clavicle fracture in an active adult, which of the following is a widely accepted relative indication for acute open reduction and internal fixation?

. Displacement of 5 mm
. Shortening greater than 2 cm
. Comminution with an intact butterfly fragment
. Any fracture in a patient over 65 years old
. Middle third fracture with a single non-displaced butterfly fragment

Correct Answer & Explanation

. Shortening greater than 2 cm

Explanation

Shortening of greater than 2 cm in a midshaft clavicle fracture is a widely accepted relative indication for acute surgical fixation in active adults. Severe shortening alters shoulder mechanics, weakens abduction, and increases the risk of nonunion.

Question 11605

Topic: 2. Trauma

A 22-year-old collegiate sprinter presents with lateral foot pain. Radiographs reveal a transverse fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction, extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management for this athlete?

. Hard-soled shoe for 4-6 weeks and immediate return to play as tolerated
. Short leg non-weight-bearing cast for 6-8 weeks
. Intramedullary screw fixation
. Open reduction and internal fixation with a lateral plate
. Excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This describes a Zone 2 fracture of the fifth metatarsal (Jones fracture). Because this area represents a vascular watershed zone, these fractures have a high rate of delayed union or nonunion. In a high-level athlete, early intramedullary screw fixation is recommended to reduce the risk of nonunion and accelerate return to play.

Question 11606

Topic: 2. Trauma

A 22-year-old professional basketball player suffers an acute, nondisplaced fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (Zone 2). To minimize the risk of nonunion and expedite return to play, what is the standard of care?

. Non-weight-bearing cast for 6 to 8 weeks
. Intramedullary screw fixation
. Excision of the proximal fragment and advancement of the peroneus brevis
. Tension band wiring
. Dorsal plating with bone grafting

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This is a Jones fracture (Zone 2 of the 5th metatarsal base). Due to the precarious watershed blood supply to this region, these fractures have a high rate of delayed union or nonunion. In high-level athletes, early operative intervention with an intramedullary solid or cannulated screw is the gold standard to expedite healing and decrease the risk of nonunion or refracture compared to conservative treatment.

Question 11607

Topic: 2. Trauma

A 28-year-old construction worker sustains a crush injury to the foot. He develops severe, unremitting pain out of proportion to the clinical findings, and pain on passive stretching of the toes. Compartment syndrome of the foot is suspected. According to the standard anatomical description (e.g., Manoli and Weber), how many distinct fascial compartments exist in the foot?

. 3
. 5
. 7
. 9
. 11

Correct Answer & Explanation

. 9

Explanation

The foot contains 9 distinct fascial compartments: medial, lateral, superficial central, calcaneal (deep central), adductor, and four separate interosseous compartments. A thorough fasciotomy for foot compartment syndrome requires releasing all 9 compartments, typically through a dual dorsal approach or a combined medial and dorsal approach.

Question 11608

Topic: 2. Trauma

A 20-year-old competitive track athlete complains of an insidious onset of ill-defined dorsal midfoot pain, worse with sprinting.

A CT scan is obtained and confirms a navicular stress fracture. Which anatomic region of the navicular is at the highest risk for stress fractures due to its underlying watershed blood supply?

. The central third of the navicular body
. The medial tuberosity
. The lateral third near the cuboid articulation
. The plantar surface only
. The dorsal cortex at the talonavicular joint

Correct Answer & Explanation

. The central third of the navicular body

Explanation

Navicular stress fractures most commonly occur in the central third of the bone. This region represents an avascular 'watershed' zone between the medial blood supply (branches of the posterior tibial and dorsalis pedis arteries) and the lateral supply. The combination of hypovascularity and high repetitive shear stresses makes the central third highly susceptible to delayed union and nonunion if not treated aggressively.

Question 11609

Topic: 2. Trauma

A 28-year-old snowboarder sustained a talar neck fracture. He was treated with open reduction and internal fixation. A radiograph taken 8 weeks postoperatively is shown.

This radiographic finding, known as the Hawkins sign, represents which underlying pathophysiological process?

. Imminent collapse of the talar dome secondary to avascular necrosis
. Resorption of subchondral bone secondary to hyperemia indicating intact vascularity
. Infection of the subchondral bone resulting in osteolysis
. Nonunion of the talar neck fracture with hardware failure
. Hypertrophic callus formation at the articular margin

Correct Answer & Explanation

. Resorption of subchondral bone secondary to hyperemia indicating intact vascularity

Explanation

The Hawkins sign is characterized by a subchondral radiolucent band in the dome of the talus, visible on AP or mortise radiographs typically 6 to 8 weeks after a talar neck fracture. This radiolucency represents subchondral osteopenia (bone resorption) due to hyperemia of the talus. The presence of the Hawkins sign is a highly reliable indicator that the talar body retains its vascular supply and that avascular necrosis (AVN) will not occur. An absence of the sign does not guarantee AVN, but its presence is an excellent prognostic indicator.

Question 11610

Topic: 2. Trauma

A 19-year-old collegiate basketball player sustains a fracture to the base of the fifth metatarsal. Radiographs demonstrate a transverse fracture located strictly distal to the 4th/5th intermetatarsal articulation, extending into the diaphysis. Intramedullary screw fixation is elected. Which of the following technical errors during screw insertion is most likely to result in medial gapping and subsequent nonunion of this specific fracture pattern?

. Using a partially threaded solid screw instead of a cannulated screw
. Choosing a screw diameter that fully engages the endosteal cortex
. Utilizing a screw that is too long and perfectly straight, causing the screw to "straighten" the lateral bow of the metatarsal
. Countersinking the screw head deeply into the tuberosity
. Tapping the intramedullary canal prior to screw insertion

Correct Answer & Explanation

. Utilizing a screw that is too long and perfectly straight, causing the screw to "straighten" the lateral bow of the metatarsal

Explanation

The fracture described is a Zone 3 diaphyseal stress fracture of the fifth metatarsal. The fifth metatarsal shaft normally has a natural lateral bow. When utilizing intramedullary screw fixation, if a screw is selected that is too long and straight, it will not conform to the metatarsal's bow. As the screw is advanced, it effectively straightens the bone, which causes distraction and "gapping" at the medial cortex of the fracture site. Medial gapping in an area with a tenuous watershed blood supply drastically increases the risk of delayed union or nonunion.

Question 11611

Topic: 2. Trauma

A 21-year-old track athlete presents with an 8-week history of vague, cramping midfoot pain exacerbated by sprinting. Clinical exam shows localized tenderness over the dorsum of the midfoot. Plain radiographs are negative. A CT scan confirms a dorsal cortical fracture line in the navicular, extending into the central third of the bone, with surrounding sclerosis. What anatomical vascular feature is primarily responsible for the high risk of nonunion in this specific fracture?

. Retrograde blood flow via the deltoid ligament
. Lack of intramedullary endosteal blood supply
. A relatively avascular watershed zone in the central third of the bone between dorsal and plantar vascular networks
. Obliteration of the artery of the tarsal canal by the acute swelling
. Compression of the medial plantar artery by the posterior tibial tendon

Correct Answer & Explanation

. A relatively avascular watershed zone in the central third of the bone between dorsal and plantar vascular networks

Explanation

Navicular stress fractures typically occur in young running or jumping athletes and have a notoriously high rate of delayed union or nonunion. This is anatomically dictated by its blood supply. The navicular receives blood primarily from branches of the dorsalis pedis (dorsal) and medial plantar arteries (plantar). These vessels supply the medial and lateral poles, leaving the central third of the navicular as a relatively avascular "watershed" zone. Stress fractures overwhelmingly occur in this central third, making them prone to nonunion and often requiring surgical intervention (screws +/- graft) if there is a complete fracture, a cortical break, or sclerosis.

Question 11612

Topic: 2. Trauma

A 55-year-old man undergoes endoscopic plantar fasciotomy for recalcitrant plantar fasciitis. Postoperatively, his original heel pain resolves, but three months later he develops new-onset, severe, aching pain along the lateral border of his midfoot, particularly over the calcaneocuboid joint, and a noticeable flattening of his medial longitudinal arch. What technical error during the surgery most likely precipitated this new pathology?

. Inadvertent transection of the medial calcaneal nerve
. Release of greater than 50% of the plantar fascia width
. Failure to resect the calcaneal heel spur
. Simultaneous release of the abductor hallucis fascia
. Damage to the flexor digitorum brevis origin

Correct Answer & Explanation

. Release of greater than 50% of the plantar fascia width

Explanation

Plantar fasciotomy involves releasing the medial and central bands of the plantar fascia. Current recommendations stress releasing only the medial 30% to 50% of the fascia. Complete or excessive release (>50%) drastically reduces the tension-band effect of the plantar fascia, leading to a loss of the medial longitudinal arch, increased strain on the spring ligament, and lateral column overload. This biomechanical shift causes severe lateral midfoot pain, often localized to the calcaneocuboid joint, which is a classic and difficult-to-treat complication of over-aggressive plantar fascia release.

Question 11613

Topic: 2. Trauma

A 32-year-old male sustains a closed talar neck fracture following a motor vehicle collision and undergoes open reduction and internal fixation. At his 8-week postoperative visit, a radiograph demonstrates a subchondral lucent band in the talar dome.

What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Imminent collapse of the talar dome
. Intact vascularity to the talar body
. Nonunion of the talar neck
. Septic arthritis of the tibiotalar joint

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The subchondral lucency shown is known as Hawkins' sign. It is a radiographic indicator of intact vascularity to the talar body. It represents subchondral osteopenia secondary to hyperemia associated with fracture healing. If the bone were avascular, it would not undergo this resorption and would remain radiodense relative to the surrounding osteopenic bone.

Question 11614

Topic: 2. Trauma

A 35-year-old male presents with a displaced talar neck fracture following a motor vehicle collision. Radiographs demonstrate subluxation of the subtalar joint with an intact ankle joint (Hawkins Type II). At the 8-week postoperative follow-up, an AP radiograph of the ankle reveals a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

. Impending avascular necrosis (AVN) of the talar body
. Intact vascularity to the talar body
. Nonunion of the talar neck
. Early onset post-traumatic osteoarthritis
. Subclinical osteomyelitis

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band seen at 6 to 8 weeks post-injury, representing subchondral osteopenia secondary to hyperemia. Its presence is a reliable indicator that the vascular supply to the talar body is intact, ruling out AVN.

Question 11615

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains an inversion injury to his foot and is diagnosed with an acute fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (Zone 2). To expedite his return to sports and minimize the risk of nonunion, what is the recommended treatment?

. Non-weight bearing in a short leg cast for 6 weeks
. Weight bearing as tolerated in a stiff-soled shoe
. Intramedullary screw fixation
. Open reduction and internal fixation with a mini-fragment plate
. Primary excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone 2 fractures (Jones fractures) occur in a vascular watershed area with a high risk of nonunion. In high-level athletes, early intramedullary screw fixation is recommended to reduce nonunion rates and expedite return to play.

Question 11616

Topic: 2. Trauma

A 23-year-old track athlete presents with insidious onset, vague midfoot pain that worsens with sprinting.

MRI reveals a stress fracture in the central third of the tarsal navicular. Why is conservative management with non-weight-bearing cast immobilization strictly required, and what dictates the high risk of nonunion in this specific area?

. The central third is relatively avascular, receiving blood supply only from distal capsular vessels.
. The central third is under constant tension from the tibialis anterior tendon.
. The central third has an inherently poor trabecular bone structure.
. The fracture disrupts the insertion of the spring ligament.
. The central third receives its blood supply from the lateral tarsal artery, which is frequently anomalies.

Correct Answer & Explanation

. The central third is relatively avascular, receiving blood supply only from distal capsular vessels.

Explanation

The central third of the tarsal navicular is a vascular watershed zone, receiving limited blood supply compared to the medial and lateral poles. This anatomic avascularity makes stress fractures here highly prone to delayed union or nonunion.

Question 11617

Topic: 2. Trauma

A patient is evaluated for a suspected acute compartment syndrome of the foot following a severe crush injury. To properly debride and decompress the foot, the surgeon must be aware of the compartmental anatomy. How many discrete fascial compartments are classically described in the foot, and which compartment contains the quadratus plantae muscle?

. 4 compartments; the deep compartment
. 5 compartments; the medial compartment
. 7 compartments; the superficial compartment
. 9 compartments; the calcaneal compartment
. 10 compartments; the central compartment

Correct Answer & Explanation

. 9 compartments; the calcaneal compartment

Explanation

There are classically 9 compartments in the foot: medial, lateral, superficial, calcaneal, adductor, and four interosseous compartments. The calcaneal compartment houses the quadratus plantae muscle and the lateral plantar nerve.

Question 11618

Topic: Upper Extremity Trauma

Surgical reconstruction of a chronic Type V acromioclavicular (AC) joint separation requires addressing the coracoclavicular (CC) ligaments to restore biomechanical stability. Which of the following statements regarding the native CC ligaments is correct?

. The conoid ligament attaches laterally and provides primary restraint to anterior translation.
. The trapezoid ligament attaches medially and provides primary restraint to superior translation.
. The conoid ligament is posteromedial and is the primary restraint to superior displacement of the clavicle.
. The trapezoid ligament is posteromedial and primarily resists posterior displacement.
. Both ligaments blend seamlessly with the coracoacromial ligament at their superior insertion.

Correct Answer & Explanation

. The conoid ligament is posteromedial and is the primary restraint to superior displacement of the clavicle.

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is located posteromedial to the trapezoid and acts as the primary restraint to superior translation of the clavicle. The trapezoid is located anterolateral and is the primary restraint to axial compression of the shoulder.

Question 11619

Topic: 2. Trauma

A 19-year-old collegiate football player sustains a midshaft clavicle fracture with 2.5 cm of shortening and no comminution. He desires to return to play as safely and predictably as possible. According to current literature, what is the primary advantage of open reduction internal fixation (ORIF) over non-operative management in this specific patient?

. Decreased risk of nonunion and lower rate of symptomatic malunion
. Lower rate of neurovascular injury during healing
. Zero risk of needing a subsequent surgery
. Prevention of secondary acromioclavicular (AC) joint arthritis
. Immediate return to contact sports at 2 weeks post-op

Correct Answer & Explanation

. Decreased risk of nonunion and lower rate of symptomatic malunion

Explanation

For significantly displaced or shortened (>2 cm) midshaft clavicle fractures in young, active patients, ORIF has been shown to significantly reduce the rates of nonunion and symptomatic malunion compared to non-operative management, leading to more predictable functional outcomes. Return to contact sports still requires clinical and radiographic evidence of healing (usually 8-12 weeks).

Question 11620

Topic: Upper Extremity Trauma

The coracoclavicular (CC) ligaments provide the primary vertical stability to the acromioclavicular (AC) joint. Which of the following best describes the anatomical location and primary biomechanical role of the conoid ligament?

. It attaches lateral to the trapezoid ligament and resists anterior translation of the clavicle.
. It attaches medial to the trapezoid ligament and provides primary resistance to superior translation of the clavicle.
. It attaches lateral to the trapezoid ligament and provides primary resistance to superior translation of the clavicle.
. It attaches medial to the trapezoid ligament and resists posterior translation of the clavicle.
. It attaches directly to the acromion and resists inferior translation of the clavicle.

Correct Answer & Explanation

. It attaches lateral to the trapezoid ligament and provides primary resistance to superior translation of the clavicle.

Explanation

The coracoclavicular (CC) complex consists of the conoid and trapezoid ligaments. Anatomically, the conoid ligament is positioned posteromedial to the trapezoid ligament. Biomechanically, the conoid ligament is the primary restraint to superior translation of the clavicle relative to the acromion. The trapezoid ligament, located anterolaterally, acts primarily to resist axial compression (posterior translation of the clavicle toward the acromion).

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