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2. Trauma MCQs

Practice Set 595 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 11881

Topic: 2. Trauma

Which of the following staging systems for elbow osteoarthritis primarily focuses on quantifying osteophyte size and joint space narrowing?

. Gustilo-Anderson classification for open fractures
. Broberg and Morrey classification
. Outerbridge classification for chondral lesions
. Mason classification for radial head fractures
. Mayo Elbow Performance Score (MEPS)

Correct Answer & Explanation

. Broberg and Morrey classification

Explanation

The Broberg and Morrey classification system is a widely recognized radiographic staging system specifically designed for elbow osteoarthritis. It classifies OA based on the extent of joint space narrowing, osteophyte formation, and the presence of loose bodies. The Gustilo-Anderson classification is for open fractures. The Outerbridge classification is an arthroscopic grading system for chondral lesions. The Mason classification is for radial head fractures. The Mayo Elbow Performance Score (MEPS) is a clinical outcome score that assesses pain, function, range of motion, and stability, not a radiographic staging system for OA severity.

Question 11882

Topic: 2. Trauma

Which specific surgical approach for open debridement of the elbow for osteoarthritis provides the best access to both anterior and posterior osteophytes while minimizing disruption of the triceps mechanism?

. Medial approach with ulnar nerve transposition
. Lateral approach with Kocher interval
. Posterolateral approach (Campbell or Boyd)
. Anconeus approach (modified posterior)
. Straight posterior midline approach with olecranon osteotomy

Correct Answer & Explanation

. Anconeus approach (modified posterior)

Explanation

The anconeus approach (or modified posterior approach through the anconeus muscle) is a versatile approach that allows good access to both posterior and lateral aspects of the elbow, as well as decent access to the anterior compartment (with careful dissection and capsular release) while preserving the triceps insertion. This approach minimizes the risk of triceps disruption and provides excellent visualization for removing both posterior olecranon osteophytes and coronoid osteophytes. A medial approach primarily addresses the medial compartment and ulnar nerve. A lateral approach primarily addresses the lateral compartment. A straight posterior midline approach with olecranon osteotomy provides excellent access but is more invasive and requires fixation of the osteotomy, leading to increased morbidity and potential complications. Posterolateral approaches (like Campbell or Boyd) are more for fracture fixation than for comprehensive OA debridement.

Question 11883

Topic: 2. Trauma

Which of the following is a known risk factor for the development of primary elbow osteoarthritis, distinct from post-traumatic causes?

. Previous supracondylar humerus fracture
. Panner's disease in childhood
. Chronic valgus stress (e.g., throwing sports)
. Systemic inflammatory arthropathy (e.g., rheumatoid arthritis)
. Radial head fracture

Correct Answer & Explanation

. Chronic valgus stress (e.g., throwing sports)

Explanation

Chronic valgus stress, particularly seen in overhead throwing athletes, is a significant risk factor for primary elbow osteoarthritis. The repetitive high-load valgus stress leads to cartilage degeneration, osteophyte formation (especially medially), and progressive stiffness. While Panner's disease, supracondylar fractures, radial head fractures, and systemic inflammatory arthropathy can all lead to elbow degeneration, they are generally considered secondary (post-traumatic or inflammatory) causes rather than primary degenerative OA from repetitive microtrauma and overuse.

Question 11884

Topic: Upper Extremity Trauma

Following arthroscopic debridement for elbow osteoarthritis, a patient is noted to have persistent pain at terminal flexion. Which anatomical structure is most likely the source of this persistent pain?

. Olecranon osteophytes
. Posterior capsule scarring
. Radiocapitellar osteophytes
. Coronoid osteophytes and anterior capsular contracture
. Medial collateral ligament impingement

Correct Answer & Explanation

. Coronoid osteophytes and anterior capsular contracture

Explanation

Pain at terminal flexion is typically caused by anterior impingement. This is most commonly due to osteophytes on the coronoid process (anterior olecranon) impinging against the coronoid fossa of the humerus, or an anterior capsular contracture limiting full flexion. Olecranon osteophytes and posterior capsule scarring primarily limit extension (posterior impingement). Radiocapitellar osteophytes primarily affect pronation/supination and sometimes flexion/extension. Medial collateral ligament impingement is rare in isolated OA and more associated with valgus instability.

Question 11885

Topic: 2. Trauma

Which factor has the strongest association with increased risk of heterotopic ossification (HO) after elbow surgery for osteoarthritis?

. Female gender
. Age over 70 years
. History of previous elbow trauma or fracture
. Arthroscopic approach for debridement
. Prophylactic ulnar nerve transposition

Correct Answer & Explanation

. History of previous elbow trauma or fracture

Explanation

A history of previous elbow trauma, fracture, or multiple prior surgeries on the elbow is the strongest predictor of developing heterotopic ossification (HO) after subsequent elbow surgery for osteoarthritis. The severity of initial injury and the extent of soft tissue disruption play a significant role. While other factors might have minor associations, trauma stands out. Arthroscopic approaches are generally associated with a lower incidence of HO compared to extensive open procedures, but HO can still occur. Gender, age, and ulnar nerve transposition are not as strongly correlated with HO risk.

Question 11886

Topic: 2. Trauma

Which type of elbow osteoarthritis is most commonly associated with valgus instability?

. Primary degenerative osteoarthritis in a sedentary individual
. Post-traumatic osteoarthritis from a healed distal humerus fracture
. Osteoarthritis secondary to chronic valgus overload (e.g., in throwing athletes)
. Osteoarthritis with severe flexion contracture
. Osteoarthritis predominantly affecting the radiocapitellar joint

Correct Answer & Explanation

. Osteoarthritis secondary to chronic valgus overload (e.g., in throwing athletes)

Explanation

Osteoarthritis secondary to chronic valgus overload, as commonly seen in throwing athletes, is most frequently associated with valgus instability. The repetitive valgus stress and microtrauma can lead to attenuation or tearing of the medial collateral ligament (MCL), contributing to progressive instability. This often occurs concurrently with valgus extension overload syndrome and may be associated with posteromedial olecranon osteophytes and capitellar chondrosis. Primary degenerative OA or post-traumatic OA from a healed fracture are less directly linked to primary valgus instability unless the fracture itself caused ligamentous injury or malunion. Flexion contractures or isolated radiocapitellar OA are not directly linked to valgus instability.

Question 11887

Topic: 2. Trauma

A 75-year-old patient with severe elbow osteoarthritis is undergoing a total elbow arthroplasty. To minimize the risk of intraoperative humeral fracture, which technical principle is most important during preparation of the humeral canal?

. Aggressive reaming of the humeral canal to achieve a press-fit.
. Using the largest possible humeral implant regardless of canal size.
. Careful, sequential reaming and rasping to achieve a cortical-sparing fit.
. Employing a fully constrained implant to provide greater stability.
. Avoiding cementation to allow for natural bone ingrowth.

Correct Answer & Explanation

. Careful, sequential reaming and rasping to achieve a cortical-sparing fit.

Explanation

Intraoperative humeral fracture is a known complication during total elbow arthroplasty, especially in older patients with osteopenic bone. Careful, sequential reaming and rasping of the humeral canal to achieve a cortical-sparing fit is paramount. This technique ensures adequate preparation for the implant without over-resecting or over-reaming, which would weaken the humeral shaft and increase fracture risk. Aggressive reaming or using an oversized implant increases fracture risk. Fully constrained implants don't directly prevent intraoperative fracture. Avoiding cementation is generally not done in TEA for OA, where cement is often used for fixation.

Question 11888

Topic: 2. Trauma

A 32-year-old collegiate baseball pitcher complains of acute, sharp pain in his right elbow after throwing a fastball. He immediately felt a 'pop' and now has difficulty extending his elbow and a feeling of instability. On examination, there is marked tenderness over the medial epicondyle and a positive valgus stress test at 30 degrees of flexion, with increased gapping compared to the contralateral side. Plain radiographs are negative for fracture. What is the most likely diagnosis?

. Olecranon stress fracture
. Medial epicondyle avulsion fracture
. Ulnar collateral ligament (UCL) rupture
. Posteromedial olecranon impingement
. Flexor-pronator mass strain

Correct Answer & Explanation

. Ulnar collateral ligament (UCL) rupture

Explanation

The patient's presentation with acute pain, a 'pop,' instability, and a positive valgus stress test in a baseball pitcher is highly characteristic of an acute ulnar collateral ligament (UCL) rupture. This injury is common in overhead athletes due to repetitive valgus stress. While a medial epicondyle avulsion fracture could present similarly, the absence of a fracture on radiographs makes UCL rupture more likely. Olecranon stress fractures cause more chronic pain, and posteromedial olecranon impingement presents with posterior elbow pain. A flexor-pronator mass strain would typically involve less instability and less distinct 'pop' sensation.

Question 11889

Topic: 2. Trauma

A 68-year-old female sustains a comminuted distal humerus fracture involving both columns. She has no neurological deficits. Given the comminution and her age, surgical fixation is planned. What is the preferred surgical approach for optimal exposure of both columns in a comminuted distal humerus fracture?

. Lateral paratricipital approach
. Medial paratricipital approach
. Olecranon osteotomy
. Posterior triceps-splitting approach
. Anterolateral approach

Correct Answer & Explanation

. Olecranon osteotomy

Explanation

For comminuted intra-articular distal humerus fractures involving both columns, an olecranon osteotomy is often preferred. This approach provides excellent, extensile exposure of the entire distal humerus articular surface, allowing for anatomical reduction and stable fixation. While paratricipital approaches can be used, they offer more limited visualization of both columns, especially the articular surface. A triceps-splitting approach can damage the triceps muscle and its innervation. The anterolateral approach is primarily for supracondylar fractures and does not provide adequate posterior exposure for bicondylar fractures.

Question 11890

Topic: 2. Trauma

What is the most common complication of a Monteggia fracture-dislocation (ulnar shaft fracture with radial head dislocation)?

. Nonunion of the ulna fracture
. Malunion of the ulna fracture
. Posterior interosseous nerve (PIN) injury
. Persistent radial head dislocation
. Elbow stiffness

Correct Answer & Explanation

. Persistent radial head dislocation

Explanation

While all listed are potential complications, malunion of the ulnar fracture (especially in children) leading to persistent radial head dislocation is a significant and common problem if not anatomically reduced and stably fixed. PIN injury is a well-known acute complication (especially with Bado Type I), but persistent radial head dislocation due to inadequate ulnar reduction is arguably the most common and functionally devastating long-term complication if primary fixation is suboptimal. Elbow stiffness is also common but often secondary to the initial trauma and prolonged immobilization or malunion.

Question 11891

Topic: Upper Extremity Trauma

A 55-year-old male with a history of recurrent gout presents with acute, severe pain and swelling over the posterior aspect of his right elbow. Examination reveals a tense, erythematous, exquisitely tender swelling overlying the olecranon. He is afebrile. Aspirate of the bursa reveals cloudy fluid with uric acid crystals. What is the most appropriate initial treatment?

. Surgical bursectomy
. Oral antibiotics
. Corticosteroid injection into the bursa
. NSAIDs, rest, and cold compresses
. Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Corticosteroid injection into the bursa

Explanation

This patient presents with acute olecranon bursitis secondary to gout. While surgical bursectomy is an option for chronic/recurrent cases or septic bursitis unresponsive to other measures, an acute, non-septic gouty flare in the bursa can be effectively treated with aspiration and a corticosteroid injection. This reduces inflammation and provides significant pain relief. Oral antibiotics are indicated for septic bursitis (which this is not, given uric acid crystals and afebrile status). NSAIDs, rest, and cold compresses are conservative measures that may help but are often insufficient for severe gouty flares. Intravenous antibiotics and surgical debridement are for severe septic bursitis.

Question 11892

Topic: 2. Trauma

Which of the following describes the 'terrible triad' injury of the elbow?

. Radial head fracture, coronoid fracture, and ulnar collateral ligament rupture
. Radial head fracture, olecranon fracture, and medial epicondyle fracture
. Coronoid fracture, olecranon fracture, and radial collateral ligament rupture
. Distal humerus fracture, radial head fracture, and elbow dislocation
. Elbow dislocation, radial head fracture, and coronoid fracture

Correct Answer & Explanation

. Elbow dislocation, radial head fracture, and coronoid fracture

Explanation

The 'terrible triad' of the elbow refers to a combination of three distinct injuries: an elbow dislocation, a radial head fracture, and a coronoid process fracture. This combination often leads to significant instability and is challenging to manage, with a high risk of stiffness and recurrent instability. Understanding this specific constellation is crucial for diagnosis and treatment planning.

Question 11893

Topic: 2. Trauma

A 16-year-old competitive gymnast presents with chronic posteromedial elbow pain, particularly during hyperextension and weight-bearing activities. Radiographs show an ossicle in the posteromedial olecranon fossa. What is the most likely diagnosis?

. Olecranon stress fracture
. Medial epicondyle apophysitis
. Posteromedial olecranon impingement
. Ulnar neuropathy at the cubital tunnel
. Flexor-pronator strain

Correct Answer & Explanation

. Posteromedial olecranon impingement

Explanation

The patient's symptoms (chronic posteromedial elbow pain with hyperextension/weight-bearing) and radiographic findings (ossicle in the posteromedial olecranon fossa) are characteristic of posteromedial olecranon impingement. This condition is common in athletes involved in activities requiring repetitive elbow extension and valgus stress (e.g., gymnasts, throwers), leading to bone spur formation and impingement. Olecranon stress fractures cause more diffuse posterior pain. Medial epicondyle apophysitis is common in younger throwers but presents with medial epicondyle pain. Ulnar neuropathy presents with neurological symptoms. Flexor-pronator strain causes medial pain, but not typically with impingement symptoms.

Question 11894

Topic: 2. Trauma

In the setting of a Type II open distal humerus fracture, what is the initial management priority after wound debridement and stabilization?

. Early range of motion to prevent stiffness
. Definitive internal fixation with plates and screws
. Delayed primary wound closure at 72 hours
. Administration of broad-spectrum intravenous antibiotics
. Vascular exploration for potential arterial injury

Correct Answer & Explanation

. Administration of broad-spectrum intravenous antibiotics

Explanation

For any open fracture, the initial priority after wound debridement and stabilization (usually with temporary external fixation) is the administration of broad-spectrum intravenous antibiotics to prevent infection. This should be done as soon as possible. Vascular exploration would only be an initial priority if there were signs of active ischemia. Definitive fixation is performed after the soft tissue envelope has improved and infection risk is minimized. Early range of motion is for stable, closed fractures. Delayed primary closure is appropriate for open fractures, but antibiotics precede it.

Question 11895

Topic: 2. Trauma

Which compartment of the forearm is primarily affected in Volkmann's ischemic contracture after an elbow injury?

. Superficial posterior compartment
. Deep posterior compartment
. Superficial anterior (flexor) compartment
. Deep anterior (flexor) compartment
. Lateral compartment

Correct Answer & Explanation

. Deep anterior (flexor) compartment

Explanation

Volkmann's ischemic contracture typically affects the deep anterior (flexor) compartment of the forearm. This compartment contains the critical flexor muscles (like FDP, FPL) and the median and ulnar nerves, which are highly susceptible to ischemia due to their position and limited space. Compartment syndrome in this region leads to muscle necrosis and subsequent contracture if not treated promptly with fasciotomy.

Question 11896

Topic: 2. Trauma

What is the most common nerve injured in a proximal ulnar shaft fracture with associated radial head dislocation (Monteggia fracture-dislocation)?

. Median nerve
. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN) is the most commonly injured nerve in Monteggia fracture-dislocations, especially Bado Type I (anterior radial head dislocation). The PIN is a purely motor branch of the radial nerve, and it can be stretched or entrapped around the radial head or the supinator muscle during the dislocation. While radial nerve proper injury is also possible, PIN is more specific to this injury pattern.

Question 11897

Topic: 2. Trauma

Which type of nonunion is typically treated with intramedullary nailing in the ulna?

. Atrophic nonunion with bone loss
. Hypertrophic nonunion of the distal ulna
. Olecranon nonunion
. Midshaft ulnar hypertrophic nonunion
. Coronoid nonunion

Correct Answer & Explanation

. Midshaft ulnar hypertrophic nonunion

Explanation

Intramedullary nailing is a viable option for midshaft ulnar hypertrophic nonunion, especially in cases where previous plate fixation has failed or when the bone defect is minimal. It provides good stability and biological stimulation. For atrophic nonunions with bone loss, bone grafting is usually required. Olecranon and coronoid nonunions typically require plate/screw fixation or tension band wiring. Distal ulna hypertrophic nonunion may also be amenable to plating or non-operative management if asymptomatic.

Question 11898

Topic: 2. Trauma

What is the most common complication following surgical fixation of an intra-articular distal humerus fracture?

. Nonunion
. Infection
. Ulnar nerve palsy
. Loss of reduction
. Post-traumatic arthritis and stiffness

Correct Answer & Explanation

. Post-traumatic arthritis and stiffness

Explanation

The most common and challenging complication following surgical fixation of an intra-articular distal humerus fracture is post-traumatic arthritis and elbow stiffness. While nonunion, infection, ulnar nerve palsy, and loss of reduction can occur, stiffness and eventual degenerative changes are almost universal to some degree, often requiring extensive rehabilitation or further intervention. The complexity of the joint and the extensive soft tissue dissection contribute to this.

Question 11899

Topic: 2. Trauma

A 12-year-old throws a baseball with a valgus force. He experiences medial elbow pain during acceleration phase of throwing. Physical examination reveals tenderness over the medial epicondyle. Radiographs show widening of the physis around the medial epicondyle. What is the most likely diagnosis?

. Ulnar collateral ligament tear
. Medial epicondyle avulsion fracture
. Little Leaguer's elbow (medial epicondyle apophysitis)
. Olecranon stress fracture
. Flexor-pronator mass strain

Correct Answer & Explanation

. Little Leaguer's elbow (medial epicondyle apophysitis)

Explanation

The patient's age (12-year-old growing athlete), throwing mechanism with valgus stress, medial elbow pain, tenderness over the medial epicondyle, and radiographic finding of widening of the physis are all classic signs of Little Leaguer's elbow, which is synonymous with medial epicondyle apophysitis. This is an overuse injury due to repetitive traction on the medial epicondyle apophysis. A medial epicondyle avulsion fracture is a more acute, complete separation and would usually show more displacement. UCL tear is less likely with open physes. Olecranon stress fracture is posterior pain. Flexor-pronator strain is a muscle injury.

Question 11900

Topic: 2. Trauma

A 75-year-old female presents with severe pain and inability to move her elbow after a fall. Radiographs show a comminuted fracture of the olecranon. She has osteoporosis. What surgical fixation method is generally preferred for comminuted olecranon fractures in osteoporotic bone?

. Tension band wiring
. Intramedullary nailing
. Excision of the fragments and triceps advancement
. Plate and screw fixation
. External fixation

Correct Answer & Explanation

. Plate and screw fixation

Explanation

For comminuted olecranon fractures, especially in osteoporotic bone, plate and screw fixation is generally preferred over tension band wiring. Tension band wiring is more suitable for simple, transverse, or oblique fractures but can fail in comminuted or osteoporotic bone due to inadequate bone purchase. Excision of fragments and triceps advancement is usually reserved for very small, non-reconstructible fragments in low-demand patients. Intramedullary nailing is not typically used for comminuted olecranon fractures. External fixation is reserved for open fractures, severe soft tissue compromise, or temporary stabilization.

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