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2. Trauma MCQs

Practice Set 597 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 11921

Topic: 2. Trauma

An 84-year-old female presents with acute shoulder pain following a fall. Her X-ray shows a fracture of the surgical neck and a fracture of the greater tuberosity, with both fragments significantly displaced. The lesser tuberosity and articular head are intact. What is the Neer classification for this injury?

. 1-part fracture
. 2-part fracture
. 3-part fracture
. 4-part fracture
. Impacted fracture

Correct Answer & Explanation

. 3-part fracture

Explanation

In the Neer classification, the four anatomical parts are the humeral head, greater tuberosity, lesser tuberosity, and the shaft. If a surgical neck fracture (separating head from shaft) and a displaced greater tuberosity fracture are present, this involves three displaced segments (head-shaft unit, and the greater tuberosity), making it a 3-part fracture. The lesser tuberosity and articular head are intact, so it's not 4-part or an articular displacement.

Question 11922

Topic: 2. Trauma

What is the primary utility of an 'axillary lateral view' in the shoulder series of an 84-year-old patient with suspected trauma?

. To assess the acromioclavicular joint space
. To detect subtle clavicle fractures
. To confirm glenohumeral joint congruity and dislocation direction
. To visualize the subacromial space for impingement
. To evaluate for avascular necrosis of the humeral head

Correct Answer & Explanation

. To confirm glenohumeral joint congruity and dislocation direction

Explanation

The axillary lateral view is crucial for evaluating glenohumeral joint congruity and definitively identifying the direction of dislocation (anterior, posterior, or inferior) as it provides a true lateral projection of the articulation. It is also important for detecting glenoid rim fractures. Other views are better suited for AC joint, clavicle fractures, or subacromial space visualization.

Question 11923

Topic: 2. Trauma

An examiner presents a case of a patient with a proximal humerus fracture. When describing your classification system for this injury, what is the most commonly used and clinically relevant system?

. Gustilo-Anderson classification.
. AO/OTA classification.
. Salter-Harris classification.
. Neer classification.
. Rockwood classification.

Correct Answer & Explanation

. Neer classification.

Explanation

The Neer classification system is the most widely accepted and clinically relevant classification for proximal humerus fractures. It classifies fractures based on the number of 'parts' (anatomical neck, surgical neck, greater tuberosity, lesser tuberosity) that are displaced by 1 cm or angulated by 45 degrees. The AO/OTA classification is also used but is more complex and less intuitive for general communication. Gustilo-Anderson is for open fractures, Salter-Harris for physeal fractures, and Rockwood for AC joint injuries.

Question 11924

Topic: 2. Trauma

An examiner asks about the 'danger zone' in proximal humerus fracture plating. What is the primary anatomical concern when placing screws in the proximal humerus?

. Penetration of the biceps tendon.
. Injury to the axillary nerve.
. Intra-articular screw penetration.
. Damage to the brachial artery.
. Distal locking screw stripping.

Correct Answer & Explanation

. Intra-articular screw penetration.

Explanation

Intra-articular screw penetration is the most critical and common 'danger' associated with proximal humerus plating. Screws that extend into the glenohumeral joint can cause articular damage, pain, loss of motion, and early osteoarthritis, often necessitating revision surgery. While axillary nerve injury is a risk with deltoid dissection, intra-articular screw penetration is a direct complication of screw placement specific to the 'danger zone' near the articular surface. The other options are less specific or less common for proximal humerus plating.

Question 11925

Topic: Upper Extremity Trauma

For a patient presenting with suspected acromioclavicular (AC) joint injury, which plain radiograph view is essential, in addition to standard AP views, to accurately assess the degree of horizontal instability?

. Axillary lateral view.
. Scapular Y view.
. Zanca view (AP with 10-15 degrees cephalic tilt).
. Stress views with weights.
. Axial view of the clavicle.

Correct Answer & Explanation

. Stress views with weights.

Explanation

Stress views with weights (typically 10-15 lbs held in each hand) are crucial for assessing the integrity of the coracoclavicular ligaments and the degree of vertical instability in AC joint injuries. While the Zanca view optimizes AC joint visualization, it doesn't dynamically assess stability. The question asks about horizontal stability, which is typically assessed clinically or with specific axial views, but stress views are paramount for vertical instability, which often dictates management.

Question 11926

Topic: 2. Trauma

When discussing the indications for non-operative management of a mid-shaft clavicle fracture, what is the most critical factor to consider in an adult patient?

. Fracture comminution.
. Associated neurovascular injury.
. Shortening less than 2 cm and minimal displacement.
. Patient age over 60 years.
. Presence of a significant skin tent.

Correct Answer & Explanation

. Shortening less than 2 cm and minimal displacement.

Explanation

For adult mid-shaft clavicle fractures, non-operative management (sling immobilization) is typically indicated for fractures with minimal displacement, less than 2 cm of shortening, and no significant comminution that would lead to malunion. Shortening less than 2 cm and minimal displacement are key criteria for successful non-operative management. Neurovascular injury or significant skin tenting are indications for surgical intervention, and comminution or age are modifying factors but not the sole determinant for non-op management.

Question 11927

Topic: 2. Trauma

An examiner asks about the most common complication following distal clavicle excision (Mumford procedure) for AC joint arthritis.

. Infection.
. Neurovascular injury.
. Persistent pain.
. Heterotopic ossification.
. Acromial fracture.

Correct Answer & Explanation

. Persistent pain.

Explanation

While all listed are potential complications, persistent pain is unfortunately the most common complication following distal clavicle excision. This can be due to residual impingement, nerve irritation, or referred pain from surrounding structures. Infection and neurovascular injury are rare. Heterotopic ossification can occur but is less common than persistent pain. Acromial fracture is not typical for this procedure.

Question 11928

Topic: Upper Extremity Trauma
When discussing surgical options for chronic, symptomatic acromioclavicular joint separation (Rockwood Type III and higher), what is a key principle you must convey to the examiner regarding reconstructive techniques?
. Immediate return to heavy lifting is expected.
. The primary goal is pain relief, not necessarily full anatomical reduction.
. Coracoclavicular ligament reconstruction is crucial for lasting stability.
. Acromioclavicular ligament repair alone is sufficient.
. Deltoid and trapezius repair are the main determinants of success.

Correct Answer & Explanation

. Coracoclavicular ligament reconstruction is crucial for lasting stability.

Explanation

For chronic, symptomatic AC joint separations (Rockwood Type III and higher), especially Types IV, V, and VI, surgical reconstruction focuses on restoring the superior-inferior and anterior-posterior stability of the AC joint. Reconstruction of the coracoclavicular (CC) ligaments (conoid and trapezoid) is considered crucial for durable stability. Simply repairing the AC ligaments is often insufficient due to their inherent weakness. While deltotrapezial fascia repair is part of the procedure, CC ligament reconstruction is the primary principle for stability.

Question 11929

Topic: 2. Trauma

When discussing the indications for surgical fixation of a humeral shaft fracture, what is a primary indication for operative intervention, even in a stable, closed fracture?

. Comminuted fracture pattern.
. Obesity with soft tissue interposition.
. Patient preference for surgical intervention.
. Radial nerve palsy occurring after closed reduction attempts.
. Associated elbow or forearm fractures (floating elbow).

Correct Answer & Explanation

. Associated elbow or forearm fractures (floating elbow).

Explanation

An associated ipsilateral forearm or elbow fracture (a 'floating elbow') is a strong indication for surgical fixation of a humeral shaft fracture. This is because non-operative management of both fractures simultaneously can be challenging and impede rehabilitation. While radial nerve palsy might lead to surgery if it doesn't recover, and comminution can be managed non-operatively, the floating elbow scenario significantly benefits from stabilization. Patient preference alone is not a primary medical indication for a stable closed fracture.

Question 11930

Topic: 2. Trauma

You are discussing a patient with a proximal humerus fracture who develops a post-operative infection. When formulating your answer, what is the most critical initial management step?

. Immediate removal of all hardware.
. Long-term oral antibiotics alone.
. Surgical debridement, tissue culture, and intravenous antibiotics.
. Referral for hyperbaric oxygen therapy.
. Re-implantation of a new prosthesis immediately.

Correct Answer & Explanation

. Surgical debridement, tissue culture, and intravenous antibiotics.

Explanation

The most critical initial management step for a suspected post-operative infection in any orthopedic surgery, including proximal humerus fractures, is prompt surgical debridement, obtaining tissue cultures to guide antibiotic therapy, and initiation of empiric broad-spectrum intravenous antibiotics. Delaying surgical debridement allows the infection to become more established and makes eradication more difficult. Hardware removal is often necessary but typically after debridement and with a plan for definitive treatment. Oral antibiotics alone are insufficient for deep infections.

Question 11931

Topic: Pelvic & Acetabular Trauma

What is the primary biomechanical advantage of an interbody fusion cage (e.g., TLIF or ALIF cage) in treating spondylolisthesis?

. It prevents hardware failure of pedicle screws.
. It provides immediate pain relief by distracting the vertebral bodies.
. It restores anterior column support and disc height, promoting indirect decompression and better sagittal balance.
. It replaces the need for posterior instrumentation.
. It allows for dynamic stabilization.

Correct Answer & Explanation

. It restores anterior column support and disc height, promoting indirect decompression and better sagittal balance.

Explanation

Interbody cages are critical for restoring anterior column support, which in turn helps restore disc height, opens the neuroforamina (indirect decompression), and contributes to the restoration of optimal sagittal balance (lordosis). This robust anterior column support shares load, promoting solid arthrodesis. It complements, rather than replaces, posterior instrumentation for stability, and it doesn't directly prevent hardware failure or provide immediate pain relief (fusion is a slower process).

Question 11932

Topic: Upper Extremity Trauma

Current anatomical studies evaluating the vascular supply to the proximal humerus demonstrate that the principal blood supply to the humeral head is derived primarily from which of the following vessels?

. Anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Subscapular artery
. Profunda brachii artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the anterior humeral circumflex artery (via its anterolateral ascending branch, the arcuate artery) was thought to be the main blood supply. However, more recent quantitative anatomical studies (e.g., Brooks et al., and Hettrich et al.) have demonstrated that the posterior humeral circumflex artery actually provides the majority (up to 64%) of the blood supply to the humeral head.

Question 11933

Topic: 2. Trauma

The Dubberley classification is used to describe coronal shear fractures of the distal humerus. What does the 'B' modifier in this classification system indicate?

. Intra-articular comminution of the radial head
. Presence of posterior condylar comminution
. Associated injury to the ulnar collateral ligament
. Extension of the fracture line through the olecranon fossa
. Open fracture pattern

Correct Answer & Explanation

. Presence of posterior condylar comminution

Explanation

In the Dubberley classification for coronal shear fractures (capitellum/trochlea), Type 1 is a capitellar fracture, Type 2 includes the capitellum and lateral trochlea in one piece, and Type 3 features the capitellum and lateral trochlea as separate fragments. The modifiers 'A' and 'B' denote the absence or presence of posterior condylar comminution, respectively. The 'B' modifier often dictates the need for a posterior approach with an olecranon osteotomy.

Question 11934

Topic: Upper Extremity Trauma

During a coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular joint separation, the surgeon must replicate the native anatomy of the conoid and trapezoid ligaments. Which of the following best describes the anatomical orientation of the conoid ligament insertion on the clavicle relative to the trapezoid ligament?

. Posterior and medial
. Posterior and lateral
. Anterior and medial
. Anterior and lateral
. Directly inferior

Correct Answer & Explanation

. Posterior and medial

Explanation

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is positioned medial and posterior to the trapezoid ligament. It inserts on the conoid tubercle of the posterior-inferior clavicle, while the trapezoid inserts anterolaterally on the trapezoid line.

Question 11935

Topic: Upper Extremity Trauma

A 45-year-old bodybuilder feels a 'pop' in his posterior distal arm while performing heavy bench presses. MRI confirms a complete triceps tendon rupture. During surgical repair, an anatomical understanding of the triceps footprint is essential. The normal triceps insertion is best described as:

. A narrow transverse strip located strictly at the proximal tip of the olecranon
. A broad, dome-shaped area covering the posterior-proximal olecranon, extending distally
. A split insertion onto the coronoid process and proximal ulna
. An attachment onto the lateral epicondyle merging with the anconeus fascia
. A focal insertion solely within the olecranon fossa of the humerus

Correct Answer & Explanation

. A broad, dome-shaped area covering the posterior-proximal olecranon, extending distally

Explanation

The triceps tendon does not insert merely on the tip of the olecranon. Its anatomic footprint is broad, dome-shaped, and covers a wide area on the posterior-proximal olecranon. Restoring this broad footprint during repair (often using transosseous-equivalent double-row or strong single-row techniques) is important to recreate normal biomechanical pull and strength.

Question 11936

Topic: 2. Trauma

A 19-year-old football player sustains a high-energy blow to the medial clavicle. He presents in the trauma bay with shortness of breath, venous engorgement of the ipsilateral arm, and dysphagia. What is the most critical initial step in the management of this patient?

. Immediate bedside closed reduction without imaging to relieve the airway
. Obtain an urgent CT scan of the chest and involve cardiothoracic surgery
. Proceed directly to open reduction and internal fixation with a hook plate
. Obtain an MRI of the brachial plexus to rule out nerve avulsion
. Perform a duplex ultrasound of the subclavian vein

Correct Answer & Explanation

. Obtain an urgent CT scan of the chest and involve cardiothoracic surgery

Explanation

This patient has a posterior sternoclavicular (SC) joint dislocation with signs of mediastinal compression (dyspnea, venous engorgement, dysphagia). This is a surgical emergency. The standard of care mandates obtaining a CT scan to define the exact relationship of the clavicle to the great vessels and trachea, and cardiothoracic surgery must be on standby during reduction due to the high risk of catastrophic vascular injury during manipulation.

Question 11937

Topic: 2. Trauma

A 34-year-old male sustains a closed, highly comminuted olecranon fracture that extends distally past the level of the coronoid process. What is the preferred method of internal fixation to minimize the risk of hardware failure and maximize stability?

. Tension band wiring using Kirschner wires
. Intramedullary screw fixation
. Excision of the proximal fragment and triceps advancement
. Pre-contoured posterior locking plate
. Hinged external fixator application

Correct Answer & Explanation

. Pre-contoured posterior locking plate

Explanation

Tension band wiring relies on the anterior cortex acting as a buttress to convert tension forces into compression at the articular surface. In comminuted olecranon fractures, or those extending distal to the coronoid process, the anterior buttress is deficient. Tension band wiring in this setting will lead to collapse, shortening, and failure. A posterior pre-contoured locking plate is the treatment of choice to span the comminution and provide rigid stability.

Question 11938

Topic: 2. Trauma

A 12-year-old gymnast sustains a medial epicondyle fracture of the humerus. Which of the following is considered an absolute indication for open reduction and internal fixation in this patient?

. Displacement greater than 2 millimeters
. Ulnar nerve paresthesias
. Incarceration of the fracture fragment within the joint
. Valgus instability in 30 degrees of flexion
. Dominant arm involvement

Correct Answer & Explanation

. Incarceration of the fracture fragment within the joint

Explanation

Absolute indications for operative intervention in pediatric medial epicondyle fractures include incarceration of the fragment within the joint space and an open fracture. Relative indications include significant displacement (traditionally >5mm, though controversial), ulnar neuropathy, and valgus instability, particularly in high-level throwing athletes or gymnasts who require absolute stability.

Question 11939

Topic: 2. Trauma

Scapulothoracic dissociation is a high-energy injury characterized by complete disruption of the scapulothoracic articulation. Which of the following associated injuries dictates the functional prognosis of the upper extremity in these patients?

. Massive rotator cuff tear
. Axillary artery pseudoaneurysm
. Sternoclavicular joint dislocation
. Brachial plexus injury
. Long thoracic nerve avulsion

Correct Answer & Explanation

. Brachial plexus injury

Explanation

Scapulothoracic dissociation involves severe lateral displacement of the scapula, often accompanied by clavicle fractures or AC/SC joint disruptions. The most devastating and prognosis-dictating complication is a traction injury to the brachial plexus, which occurs in the vast majority of cases. Complete brachial plexus avulsions are common and often lead to a flail limb, sometimes necessitating early amputation despite vascular repairs.

Question 11940

Topic: Upper Extremity Trauma

A 22-year-old collegiate baseball pitcher complains of posterior elbow pain that is worse during the deceleration phase of throwing. Examination reveals a 15-degree flexion contracture and point tenderness over the posteromedial olecranon. If a conservative program fails, what is the best initial surgical intervention?

. Medial ulnar collateral ligament reconstruction
. Open reduction and internal fixation of the olecranon
. Arthroscopic excision of the posteromedial olecranon osteophyte
. Ulnar nerve anterior transposition
. Arthroscopic capsular release of the anterior capsule

Correct Answer & Explanation

. Arthroscopic excision of the posteromedial olecranon osteophyte

Explanation

This patient has valgus extension overload (Pitcher's elbow), which results from repetitive valgus stress and extreme extension during the deceleration phase of throwing. This leads to posteromedial impingement and the formation of a posteromedial olecranon osteophyte. The appropriate surgical treatment is excision of the osteophyte. Care must be taken not to resect too much olecranon (typically limiting resection to <3 mm), as over-resection dramatically increases the strain on the anterior bundle of the MUCL, potentially causing iatrogenic valgus instability.

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