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2. Trauma MCQs

Practice Set 603 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 12041

Topic: Upper Extremity Trauma
A 28-year-old male presents after falling directly onto his left shoulder during a rugby match. On examination, there is obvious superior displacement of the distal clavicle relative to the acromion, and a significant 'step-off' deformity. The patient experiences severe pain with any arm movement, and the piano key sign is positive. Radiographs show complete disruption of the AC ligaments and coracoclavicular ligaments, with significant superior displacement of the clavicle but no posterior displacement or involvement of the deltoid/trapezius fascia. According to the Rockwood classification, what type of AC joint injury is most likely present?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type III

Explanation

The clinical presentation describes a complete disruption of both the acromioclavicular (AC) and coracoclavicular (CC) ligaments, with significant superior displacement of the clavicle, consistent with a Rockwood Type III injury. Type II involves AC ligament disruption and sprain/partial CC ligament injury, with only partial superior displacement. Type IV involves posterior displacement of the clavicle into the trapezius. Type V involves severe superior displacement (>25-100% of acromial height) with extensive deltoid and trapezius fascial stripping. Type VI involves inferior displacement of the clavicle.

Question 12042

Topic: Upper Extremity Trauma

Which anatomical structure is primarily responsible for preventing superior migration of the distal clavicle?

. Acromioclavicular capsule
. Coracoclavicular ligaments (conoid and trapezoid)
. Deltoid muscle
. Trapezius muscle
. Pectoralis minor muscle

Correct Answer & Explanation

. Coracoclavicular ligaments (conoid and trapezoid)

Explanation

The coracoclavicular (CC) ligaments, composed of the conoid and trapezoid ligaments, are the primary vertical stabilizers of the AC joint. While the AC capsule and surrounding musculature (deltoid, trapezius) contribute to overall stability, the CC ligaments are critical in preventing significant superior displacement of the clavicle relative to the acromion.

Question 12043

Topic: Upper Extremity Trauma
What is the primary differentiating feature between a Rockwood Type II and a Type III AC joint injury?
. Complete vs. partial tear of the deltoid and trapezius fascia.
. Partial vs. complete tear of the acromioclavicular ligaments.
. Presence vs. absence of a 'step-off' deformity.
. Partial vs. complete tear of the coracoclavicular ligaments.
. Anterior vs. posterior displacement of the clavicle.

Correct Answer & Explanation

. Partial vs. complete tear of the coracoclavicular ligaments.

Explanation

The key differentiation between Rockwood Type II and Type III lies in the integrity of the coracoclavicular ligaments. In Type II, the AC ligaments are torn, and the CC ligaments are sprained or partially torn, leading to subluxation but not complete dislocation of the clavicle from the acromion (CC distance is normal or minimally increased <25%). In Type III, both AC and CC ligaments are completely torn, resulting in frank dislocation and a significant increase in the CC distance (>25% compared to contralateral) and a distinct 'step-off' deformity. AC ligaments are torn in both to varying degrees, but CC ligament integrity is the critical differentiator for superior migration.

Question 12044

Topic: Upper Extremity Trauma
A patient with a suspected AC joint injury has no visible deformity, minimal pain with direct palpation over the AC joint, and pain primarily with cross-body adduction. Radiographs are normal. What Rockwood type is this most consistent with?
. Type 0
. Type I
. Type II
. Type III
. Type IV

Correct Answer & Explanation

. Type I

Explanation

This presentation describes a Rockwood Type I injury. It involves a sprain of the AC ligaments without significant tearing, minimal to no displacement, and normal radiographs (AC and CC distances are normal). Pain is localized to the AC joint, often exacerbated by specific movements like cross-body adduction. Type 0 is not a standard Rockwood classification category. Type II would show subluxation and some CC ligament injury, with mild radiographic changes.

Question 12045

Topic: Upper Extremity Trauma

Which of the following ligaments provides the primary horizontal stability to the AC joint?

. Conoid ligament
. Trapezoid ligament
. Acromioclavicular ligaments (superior and inferior)
. Coracoacromial ligament
. Capsular ligaments of the glenohumeral joint

Correct Answer & Explanation

. Acromioclavicular ligaments (superior and inferior)

Explanation

The acromioclavicular (AC) ligaments, particularly the superior and inferior AC ligaments, are the primary stabilizers against horizontal translation (anterior-posterior shear) of the AC joint. The coracoclavicular ligaments (conoid and trapezoid) provide vertical stability. The coracoacromial ligament forms part of the coracoacromial arch and is not a direct stabilizer of the AC joint itself.

Question 12046

Topic: Upper Extremity Trauma

The coracoclavicular distance is measured on an AP radiograph. What structures does this measurement assess the integrity of?

. Acromioclavicular ligaments
. Coracoacromial ligament
. Coracoclavicular ligaments
. Glenohumeral ligaments
. Sternoclavicular joint capsule

Correct Answer & Explanation

. Coracoclavicular ligaments

Explanation

The coracoclavicular (CC) distance, measured from the superior aspect of the coracoid process to the inferior cortex of the clavicle, directly reflects the integrity of the coracoclavicular ligaments (conoid and trapezoid). An increase in this distance compared to the contralateral side indicates tearing of these ligaments and superior displacement of the clavicle. While AC ligaments are also involved in injury, the CC distance specifically evaluates the CC ligaments.

Question 12047

Topic: 2. Trauma
According to the provided content, Rockwood Type III AC joint injuries account for approximately what percentage of all ACJ injuries?
. 5%
. 10%
. 25%
. 40%
. 60%

Correct Answer & Explanation

. 40%

Explanation

The provided content explicitly states: 'Controversies of surgical versus non-surgical management surround type III fractures, which make up 40% of all ACJ injuries.' This is a direct recall from the provided text.

Question 12048

Topic: 2. Trauma
When differentiating between a Rockwood Type III and Type IV AC joint injury, what specific radiographic finding is crucial?
. The degree of superior clavicle displacement.
. The presence of an associated distal clavicle fracture.
. The presence of posterior displacement of the clavicle into the trapezius muscle.
. The involvement of the coracoid process.
. The widening of the AC joint space on an AP view.

Correct Answer & Explanation

. The presence of posterior displacement of the clavicle into the trapezius muscle.

Explanation

The critical distinguishing feature between Rockwood Type III and Type IV AC joint injuries is the posterior displacement of the distal clavicle. In Type IV, the clavicle is displaced posteriorly and often 'buttonholes' through the trapezius muscle fascia. This specific displacement pattern requires an axial view or specialized lateral views to confirm, which differentiates it from the purely superior displacement of a Type III injury.

Question 12049

Topic: Upper Extremity Trauma
Which of the following describes the anatomical structures involved in a Rockwood Type II AC joint injury?
. AC ligaments sprained, CC ligaments intact.
. AC ligaments torn, CC ligaments sprained or partially torn, mild superior subluxation.
. AC ligaments and CC ligaments completely torn, significant superior dislocation.
. AC ligaments and CC ligaments completely torn, posterior displacement of clavicle.
. AC ligaments and CC ligaments completely torn, inferior displacement of clavicle.

Correct Answer & Explanation

. AC ligaments torn, CC ligaments sprained or partially torn, mild superior subluxation.

Explanation

A Rockwood Type II injury involves a torn acromioclavicular (AC) capsule and ligaments, with a sprain or partial tear of the coracoclavicular (CC) ligaments. This results in subluxation of the AC joint, meaning there is some superior displacement, but not a complete dislocation, and the CC distance is only minimally increased (less than 25% compared to the contralateral side). Type I has only sprained AC ligaments and intact CC ligaments. Type III has complete tears of both AC and CC ligaments.

Question 12050

Topic: Upper Extremity Trauma

The Rockwood classification system primarily describes AC joint injuries based on the degree of displacement and the integrity of which two ligamentous structures?

. Glenohumeral ligaments and joint capsule
. Coracoacromial ligament and deltoid fascia
. Acromioclavicular (AC) ligaments and coracoclavicular (CC) ligaments
. Transverse humeral ligament and rotator cuff tendons
. Superior glenohumeral ligament and inferior glenohumeral ligament

Correct Answer & Explanation

. Acromioclavicular (AC) ligaments and coracoclavicular (CC) ligaments

Explanation

The Rockwood classification system for AC joint injuries is fundamentally based on the progressive disruption of the acromioclavicular (AC) ligaments and the coracoclavicular (CC) ligaments (conoid and trapezoid), and the resulting displacement of the clavicle. The integrity of these two ligament groups dictates the stability and classification type.

Question 12051

Topic: Upper Extremity Trauma
A patient presents with pain over the AC joint. On examination, there is no obvious deformity or step-off. Palpation over the AC joint elicits tenderness. Cross-body adduction test is positive. Radiographs, including stress views, show no abnormal widening of the AC joint or increased coracoclavicular distance. This clinical picture is most consistent with which Rockwood classification type?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type I

Explanation

This presentation is consistent with a Rockwood Type I AC joint injury. It involves a sprain of the AC ligaments with no significant tearing, thus no radiographic changes (normal AC and CC distances, even on stress views), and no visible deformity. Tenderness over the AC joint and a positive cross-body adduction test are typical. Type II would show some subluxation and minimal radiographic changes, and Type III would show frank dislocation and clear radiographic abnormalities.

Question 12052

Topic: Upper Extremity Trauma
A patient presents with a palpable gap between the distal clavicle and the acromion, and significant pain on palpation. Radiographs show a widened AC joint space but the coracoclavicular distance is within normal limits. This suggests disruption of the AC ligaments, but intact CC ligaments. What Rockwood type is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

This describes a Rockwood Type II injury. There is a complete tear of the acromioclavicular ligaments, causing widening of the AC joint space and superior subluxation. However, the coracoclavicular ligaments are intact or only partially sprained, meaning the coracoclavicular distance remains normal or only minimally increased (<25% of contralateral), preventing frank dislocation. Type I would have normal radiographs. Type III would have increased CC distance.

Question 12053

Topic: 2. Trauma
Which factor, if present in a Type III AC joint injury, would lead some surgeons to favor early operative intervention over conservative management?
. Age over 65 years.
. Sedentary lifestyle.
. Associated glenoid fracture.
. Dominant arm involvement in a high-level overhead athlete.
. Minimal cosmetic deformity.

Correct Answer & Explanation

. Dominant arm involvement in a high-level overhead athlete.

Explanation

In a Rockwood Type III AC joint injury, involvement of the dominant arm in a high-level overhead athlete is a significant factor that often sways surgeons towards early operative intervention. These individuals have high functional demands and may benefit from anatomical reduction and stabilization to optimize their return to sport. The other factors generally favor conservative management (age, sedentary lifestyle, minimal deformity) or would influence glenoid fracture management (associated glenoid fracture).

Question 12054

Topic: Upper Extremity Trauma

Which ligament, if torn, allows for the 'piano key' sign and significant superior displacement of the clavicle?

. Coracoacromial ligament
. Transverse humeral ligament
. Coracoclavicular ligaments
. Superior glenohumeral ligament
. Acromioclavicular ligaments

Correct Answer & Explanation

. Coracoclavicular ligaments

Explanation

The 'piano key' sign and significant superior displacement are hallmark signs of complete disruption of the coracoclavicular ligaments (conoid and trapezoid). These ligaments are the primary restraints to superior migration of the clavicle. While AC ligaments are also torn in these injuries, it is the CC ligament disruption that permits the dramatic vertical instability.

Question 12055

Topic: Upper Extremity Trauma

Which of the following describes the Rockwood Type 0 AC joint injury?

. Sprain of the AC ligaments, no displacement, normal radiographs.
. Normal AC and CC distances, but symptomatic.
. Partial tear of AC ligaments, mild subluxation, normal CC distance.
. Complete dislocation of AC joint, but intact CC ligaments.
. This is not a recognized Rockwood classification type.

Correct Answer & Explanation

. Normal AC and CC distances, but symptomatic.

Explanation

While the Rockwood classification officially starts from Type I, some clinicians and researchers use a 'Type 0' to describe a symptomatic AC joint where there are clinical signs of injury (e.g., pain on palpation, cross-body adduction) but no radiographic evidence of AC joint or CC ligament displacement or widening. It essentially describes a clinically significant but radiographically occult sprain. However, within theofficialRockwood classification system from the provided text, it's not listed. But given the options, 'Normal AC and CC distances, but symptomatic' aligns best with how 'Type 0' is informally used, and is distinct from Type I where 'sprain' is specified. The question asks 'which of the following describes', implying a recognized descriptor even if not officially numbered.

Question 12056

Topic: 2. Trauma

In the context of AC joint examination, what is the significance of evaluating the entire clavicle, not just the distal end?

. To assess for sternoclavicular joint instability.
. To rule out a concomitant midshaft clavicle fracture or an associated coracoid fracture.
. To check for referred pain from the cervical spine.
. To identify potential brachial plexus injury.
. To assess for the presence of a congenital pseudarthrosis.

Correct Answer & Explanation

. To rule out a concomitant midshaft clavicle fracture or an associated coracoid fracture.

Explanation

When evaluating an AC joint injury, it's crucial to examine the entire clavicle to rule out a concomitant clavicle shaft fracture, especially in high-energy trauma. Furthermore, forces that disrupt the AC joint can also cause associated fractures of the coracoid process, which also need assessment. While other issues like SC joint instability or brachial plexus injury are important to consider, a clavicle or coracoid fracture are directly related to the local trauma and can mimic or coexist with AC joint pathology.

Question 12057

Topic: Upper Extremity Trauma

Which of the following ligaments of the AC joint is typically stronger and more crucial for horizontal stability?

. Superior acromioclavicular ligament
. Inferior acromioclavicular ligament
. Conoid ligament
. Trapezoid ligament
. Coracoacromial ligament

Correct Answer & Explanation

. Superior acromioclavicular ligament

Explanation

The superior acromioclavicular ligament is typically thicker and stronger than the inferior AC ligament and is considered the primary stabilizer of the AC joint against horizontal shear forces (anterior-posterior translation). The coracoclavicular ligaments (conoid and trapezoid) are the primary vertical stabilizers.

Question 12058

Topic: 2. Trauma

A 65-year-old female sustains a 4-part proximal humerus fracture.

According to Hertel's criteria, which of the following is the strongest radiographic predictor for the development of avascular necrosis (AVN) of the humeral head?

. Metaphyseal head extension (calcar length) less than 8 mm
. Greater tuberosity displacement greater than 5 mm
. Angulation of the humeral head greater than 45 degrees
. Intact medial hinge
. Fracture of the lesser tuberosity

Correct Answer & Explanation

. Metaphyseal head extension (calcar length) less than 8 mm

Explanation

Hertel identified primary predictors of ischemia in proximal humerus fractures. The strongest predictors include a metaphyseal head extension (calcar length) less than 8 mm, disruption of the medial hinge, and a basicervical fracture pattern.

Question 12059

Topic: 2. Trauma

According to Hertel's criteria, which combination of radiographic findings is the most reliable predictor of humeral head ischemia following a proximal humerus fracture?

. Anatomic neck fracture with a short calcar length (>8 mm)
. Displacement of the greater tuberosity >5mm and an intact medial hinge
. Short calcar length (<8 mm) attached to the articular segment and a disrupted medial hinge
. Varus angulation >20 degrees and an intact calcar

Correct Answer & Explanation

. Short calcar length (<8 mm) attached to the articular segment and a disrupted medial hinge

Explanation

Hertel identified that a short metaphyseal extension (less than 8 mm of calcar attached to the articular segment), a disrupted medial hinge, and an anatomic neck fracture pattern are the strongest individual predictors of humeral head ischemia and subsequent avascular necrosis.

Question 12060

Topic: 2. Trauma

A 28-year-old sustains a closed, spiral fracture of the distal third of the humerus (Holstein-Lewis fracture) and exhibits an immediate, complete radial nerve palsy in the emergency department. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve
. Closed reduction and functional bracing with clinical observation
. Immediate EMG and nerve conduction studies
. Open reduction internal fixation to explore the nerve immediately

Correct Answer & Explanation

. Closed reduction and functional bracing with clinical observation

Explanation

An immediate radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis patterns) is overwhelmingly a neuropraxia. The standard initial management is closed treatment with a functional brace and observation for 3 to 4 months before considering exploration.

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