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 1421
Topic: 2. Trauma
A 22-year-old male is involved in a motorcycle collision and sustains a highly comminuted midshaft humerus fracture and ipsilateral displaced fractures of the radius and ulna shafts. He has a normal neurovascular exam. What is the most appropriate management for the humerus fracture?
Correct Answer & Explanation
. Open reduction and internal fixation (ORIF)
Explanation
This patient has a 'floating elbow' (ipsilateral humerus and forearm fractures), which is an absolute indication for surgical stabilization (ORIF) of both the humerus and forearm. This allows for early mobilization and prevents severe joint stiffness.
Question 1422
Topic: 2. Trauma
A 60-year-old male with a history of alcohol abuse presents to the emergency department after a seizure. He has a locked-in internally rotated right arm and severe shoulder pain. Radiographs reveal a posterior shoulder dislocation. Which proximal humerus fracture is most commonly associated with this specific type of dislocation?
Correct Answer & Explanation
. Lesser tuberosity fracture
Explanation
Posterior shoulder dislocations are classically associated with lesser tuberosity fractures (or reverse Hill-Sachs lesions) due to the avulsion pull of the subscapularis or direct impaction. Anterior dislocations are associated with greater tuberosity fractures.
Question 1423
Topic: 2. Trauma
A 19-year-old male sustains an open distal third humeral shaft fracture after a rollover motor vehicle accident. The arm is pale, pulseless, and cool to the touch. Immediate closed reduction fails to restore the pulse. In the operating room, what is the correct sequence of management?
Correct Answer & Explanation
. Temporary intraluminal shunt, followed by rigid internal fixation, followed by definitive vascular repair
Explanation
In the setting of a humerus fracture with an ischemic limb, the standard sequence is to place a temporary intravascular shunt to restore perfusion, perform rigid skeletal fixation, and then perform definitive vascular repair.
Question 1424
Topic: Upper Extremity Trauma
A patient is evaluated for an AC joint injury after a fall. Examination shows severe inferior displacement of the distal clavicle, resting underneath the coracoid process, posterior to the conjoint tendon. What is the Rockwood classification for this injury?
Correct Answer & Explanation
. Type VI
Explanation
A Rockwood Type VI AC joint injury involves inferior displacement of the distal clavicle into a subcoracoid or subacromial position. This is a severe, high-energy injury that invariably requires surgical reduction.
Question 1425
Topic: 2. Trauma
A 50-year-old female presents with a nonunion of a midshaft humerus fracture 8 months after initial non-operative management in a functional brace. She is healthy and a non-smoker. Radiographs show a hypertrophic nonunion with adequate bone stock. What is the most appropriate surgical management?
Correct Answer & Explanation
. Compression plating without bone grafting
Explanation
Hypertrophic nonunions possess adequate biology but lack rigid mechanical stability. Therefore, they are best treated by providing stable mechanical fixation, typically with compression plating, without the strict need for bone grafting.
Question 1426
Topic: 2. Trauma
Which of the following clinical scenarios represents an absolute indication for early surgical exploration of the radial nerve in the setting of a newly sustained humeral shaft fracture?
Correct Answer & Explanation
. Open humeral shaft fracture with an associated primary radial nerve palsy.
Explanation
Absolute indications for early radial nerve exploration in humeral shaft fractures include an open fracture with a nerve palsy, penetrating trauma, and a concomitant vascular injury requiring surgical repair. Primary palsies in closed fractures are typically observed initially.
Question 1427
Topic: 2. Trauma
A 34-year-old male sustains a closed spiral fracture of the distal third of the humeral shaft. On initial presentation in the emergency department, his neurovascular exam is completely intact. A closed reduction is performed, and a coaptation splint is applied. Immediately post-reduction, the patient is unable to actively extend his wrist or fingers, and he has decreased sensation over the dorsal first web space. What is the most appropriate next step in management?
Correct Answer & Explanation
. Immediate surgical exploration and internal fixation
Explanation
A secondary (post-reduction) radial nerve palsy in the setting of a humeral shaft fracture is an absolute indication for surgical exploration. This presentation suggests the nerve may be entrapped within the fracture site following the reduction attempt.
Question 1428
Topic: 2. Trauma
A 28-year-old female sustains a midshaft humeral fracture and is being treated non-operatively with a functional brace (Sarmiento). To achieve an acceptable functional and cosmetic outcome without requiring surgical intervention, the maximum acceptable limits of radiographic deformity must not be exceeded. Which of the following represents the maximum acceptable deformity for non-operative management of a humeral shaft fracture?
The accepted deformity limits for successful non-operative management of a humeral shaft fracture using functional bracing are up to 30 degrees of varus/valgus angulation, 20 degrees of anterior/posterior bowing, and 3 cm of shortening.
Question 1429
Topic: Upper Extremity Trauma
An orthopedic surgeon is performing an anatomic coracoclavicular (CC) ligament reconstruction for a chronic Type V acromioclavicular joint separation. To accurately reproduce the native anatomy and optimize biomechanical stability, where should the surgeon place the clavicular drill tunnel for the conoid ligament?
Correct Answer & Explanation
. 4.5 cm medial to the distal clavicle articular surface and posteriorly
Explanation
The conoid ligament inserts approximately 4.5 cm medial to the distal articular end of the clavicle and slightly posterior to the midline. The trapezoid ligament inserts approximately 3.0 cm medial to the distal clavicle and anteriorly.
Question 1430
Topic: 2. Trauma
A 25-year-old male sustains a polytrauma including a diaphyseal humerus fracture that requires surgical stabilization. Comparing intramedullary nailing to compression plating for humeral shaft fractures, intramedullary nailing is most consistently associated with which of the following postoperative outcomes?
Correct Answer & Explanation
. A higher rate of shoulder pain and impingement
Explanation
Compared to compression plating, intramedullary nailing of humeral shaft fractures is associated with a significantly higher incidence of postoperative shoulder pain and impingement, as well as an increased overall reoperation rate. Plating carries a higher risk of iatrogenic radial nerve palsy.
Question 1431
Topic: Upper Extremity Trauma
A 30-year-old cyclist falls directly onto the point of his shoulder. Clinical examination reveals an irreducible, posteriorly displaced clavicle that is firmly palpable within the trapezius muscle belly. Radiographs, including an axillary lateral view, confirm the distal clavicle is displaced posteriorly relative to the acromion. Which Rockwood classification type does this injury represent?
Correct Answer & Explanation
. Type IV
Explanation
A Rockwood Type IV injury is characterized by posterior displacement of the distal clavicle into or through the deltotrapezial fascia. This is an absolute indication for operative reduction and fixation, as closed reduction is generally unsuccessful.
Question 1432
Topic: 2. Trauma
A 65-year-old female presents with severe arm pain and mobility at the fracture site 8 months after sustaining a midshaft humerus fracture initially treated with a functional brace. Radiographs demonstrate a persistent fracture line with sclerotic, rounded bone ends and an absence of bridging callus. Laboratory inflammatory markers are normal. What is the gold standard surgical intervention for this specific complication?
Correct Answer & Explanation
. Open reduction and internal fixation with a compression plate and autogenous bone graft
Explanation
The clinical scenario describes an atrophic nonunion of the humeral shaft. The gold standard treatment involves open reduction, rigid internal fixation (typically with a compression plate), and the addition of autologous bone graft to provide the necessary biological osteogenic stimulus.
Question 1433
Topic: 2. Trauma
A 30-year-old female sustains a knee dislocation during a skiing accident. She is brought to the emergency department where the knee is successfully reduced. Initial neurovascular assessment reveals palpable distal pulses and an ABI of 1.0. Neurological exam is intact. Plain radiographs confirm reduction and show no acute fractures. The patient is stable and comfortable in a splint. What is the MOST appropriate next imaging study to guide definitive surgical planning?
Correct Answer & Explanation
. Magnetic Resonance Imaging (MRI) of the knee.
Explanation
Correct Answer: CThe case outlines the imaging sequence for knee dislocations. After initial reduction and confirmation of vascular integrity (normal pulses, ABI 1.0), the next critical step is to precisely delineate the extent of soft tissue injuries. The text states: 'MRI: Performed after stabilization, often within the first 7-10 days (or acutely if limb is stable and patient is going to OR for vascular repair) to precisely delineate the extent of ligamentous, meniscal, and chondral injuries. This guides definitive surgical planning.' Given the patient is stable with no vascular compromise, MRI is essential to plan the multi-ligament reconstruction.Option A (Repeat plain radiographs) is unnecessary unless there's clinical suspicion of re-dislocation or new fracture.Option B (Immediate CT angiogram) is not indicated here because the ABI is normal (1.0) and pulses are palpable, indicating no suspicion of arterial injury. CTA is reserved for abnormal ABI or 'hard signs' of vascular injury.Option D (Ultrasound of the popliteal fossa) might be used to assess for hematoma or pseudoaneurysm if there was suspicion of vascular injury, but CTA is the gold standard for arterial assessment, and MRI is superior for soft tissue structures.Option E (Bone scan) is not indicated for acute knee dislocation; it's used for conditions like stress fractures or osteomyelitis, which are not the primary concern here.
Question 1434
Topic: 2. Trauma
A 38-year-old male presents to the emergency department after a high-speed motor vehicle accident. He complains of severe right hip pain and is unable to bear weight. Radiographs reveal a Garden IV femoral neck fracture. The patient is otherwise hemodynamically stable after initial ATLS resuscitation. Which of the following statements regarding the management of this patient's fracture is most accurate?
Correct Answer & Explanation
. Urgent anatomic reduction and stable internal fixation with multiple cannulated screws within 6-12 hours is critical to optimize femoral head viability.
Explanation
Correct Answer: A. Intracapsular hip fractures in young, neurologically intact patients are high-energy injuries requiring urgent management. For a Garden IV (completely displaced) fracture in a young patient, the primary goal is native hip preservation by achieving anatomic reduction and stable fixation. Time to surgery is a critical factor, with intervention ideally within 6-12 hours to decompress the intracapsular hematoma and restore blood flow, minimizing the risk of avascular necrosis and nonunion. Multiple cannulated screws in an inverted triangle configuration are considered the gold standard for stable internal fixation in this population.
Question 1435
Topic: 2. Trauma
A 28-year-old male sustains a femoral neck fracture after a fall from height. Pre-operative imaging reveals a Pauwels Type III fracture. During surgical planning, the orthopedic surgeon must consider the biomechanical implications of this fracture pattern. Which of the following statements best describes the Pauwels Type III classification and its management implications?
Correct Answer & Explanation
. Pauwels Type III fractures exhibit a fracture angle greater than 50 degrees to the horizontal, indicating predominantly shear forces and high instability, requiring robust fixation.
Explanation
Correct Answer: A. The Pauwels classification focuses on the angle of the fracture line relative to the horizontal plane, reflecting the shear forces acting on the fracture site. Pauwels Type III fractures are defined by an angle greater than 50 degrees. This high angle indicates that the fracture is subjected to predominantly shear forces, making it highly unstable and prone to nonunion without robust fixation. The goal of surgical fixation is to counteract these shear forces.
Question 1436
Topic: 2. Trauma
A 42-year-old male presents with a displaced femoral neck fracture. During pre-operative planning, the surgeon reviews the critical blood supply to the femoral head. Which of the following arteries is considered the dominant source of blood supply to the femoral head and is most vulnerable in an intracapsular fracture?
Correct Answer & Explanation
. Medial femoral circumflex artery (MFCA)
Explanation
Correct Answer: CThe case explicitly states that the Medial Femoral Circumflex Artery (MFCA) is the dominant source of blood supply to the femoral head. It typically arises from the profunda femoris artery and gives off ascending branches that form the retinacular vessels (posterior superior, posterior inferior, anterior superior, anterior inferior) which ascend along the femoral neck within the synovium. The posterior superior retinacular vessels, derived from the MFCA, are considered the most critical, supplying the majority of the superior and posterior femoral head. An intracapsular fracture, especially with displacement, directly threatens these retinacular vessels, leading to ischemia and a high risk of avascular necrosis.Option A is incorrect:The LFCA contributes primarily to the extracapsular arterial ring but typically has less direct supply to the femoral head itself compared to the MFCA.Option B is incorrect:The profunda femoris artery is the origin of the MFCA, but not the direct dominant supply to the femoral head itself.Option D is incorrect:The artery of the ligamentum teres (foveal artery), a branch of the obturator artery, supplies a small, variable portion of the inferomedial femoral head. Its contribution is generally minor in adults.Option E is incorrect:The superior gluteal artery primarily supplies the gluteal muscles and contributes to the blood supply of the greater trochanter, but not directly to the femoral head.
Question 1437
Topic: 2. Trauma
A 55-year-old active patient sustains a Garden II femoral neck fracture. After initial closed reduction attempts, fluoroscopy shows a near-anatomic reduction with less than 2mm displacement. The surgeon proceeds with internal fixation. Which of the following fixation constructs is considered the gold standard for this patient, and what is its typical configuration?
Correct Answer & Explanation
. Three parallel cannulated screws in an inverted triangle configuration, engaging the subchondral bone.
Explanation
Correct Answer: CThe case, particularly the 'Detailed Surgical Approach / Technique' and 'Summary of Key Literature / Guidelines' sections, explicitly states that 'multiple cannulated screws' are the most common and effective method for internal fixation of intracapsular hip fractures in young patients. Specifically, 'three parallel cannulated cancellous screws are used' in an 'inverted triangle configuration' to provide optimal biomechanical stability against shear and rotational forces. The screws should be placed parallel to the axis of the femoral neck and end in the subchondral bone of the femoral head, as depicted in the provided image.Option A is incorrect:A single lag screw is insufficient for rotational stability. While a DHS (Dynamic Hip Screw) is a type of lag screw, the case states it is 'less commonly used for true intracapsular fractures in young patients due to the larger metalwork, potential for hardware prominence, and less ideal biomechanics for pure femoral neck fractures.' The image clearly shows three screws, not a single large one.Option B is incorrect:Two screws provide less stability than three, especially against rotational forces. The inverted triangle configuration with three screws is preferred.Option D is incorrect:Angulated blade plates were historically used but have largely been supplanted by cannulated screws due to less invasive application and similar or superior biomechanical performance.Option E is incorrect:A dynamic condylar screw (DCS) is typically used for distal femoral fractures, not femoral neck fractures.
Question 1438
Topic: 2. Trauma
A 32-year-old male undergoes internal fixation for a displaced femoral neck fracture. Post-operatively, he develops persistent hip pain, a limp, and radiographs at 8 months show no signs of healing and progressive implant failure. The femoral head appears viable. Which of the following complications is most likely, and what is the appropriate next step in management?
Correct Answer & Explanation
. Nonunion; consider revision internal fixation with bone grafting or total hip arthroplasty.
Explanation
Correct Answer: CThe patient's symptoms of persistent pain, limp, inability to bear weight, and radiographic evidence of progressive implant failure and lack of healing at 8 months post-op are classic signs of nonunion. The case defines nonunion as 'persistent pain, limb shortening, inability to bear weight, progressive implant failure, and lack of radiographic healing >6 months post-op.' Since the femoral head is described as viable, the management options for nonunion include 'revision internal fixation with improved fixation (e.g., more stable construct, valgus osteotomy to convert shear to compression) and bone grafting (autograft or allograft)' or, if deemed unlikely to succeed, 'Total Hip Arthroplasty (THA).'Option A is incorrect:While AVN is a common complication, the question states the femoral head appears viable. AVN would typically show signs like sclerosis, cystic changes, or subchondral collapse. Core decompression and vascularized fibula grafting are treatments for early, pre-collapse AVN.Option B is incorrect:Malunion implies the fracture healed in an incorrect position, leading to deformity. Here, the fracture has not healed (nonunion), and there is implant failure. A corrective osteotomy is for symptomatic malunion, not nonunion.Option D is incorrect:While infection is a possibility, the symptoms described (persistent pain, limp, implant failure, lack of healing) are more indicative of nonunion. There are no signs of infection mentioned (fever, erythema, drainage, elevated inflammatory markers).Option E is incorrect:Hardware prominence would typically cause localized pain over the hardware, not necessarily a limp, inability to bear weight, or progressive implant failure. Hardware removal is considered only after fracture union is complete, or if it's causing direct impingement/pain, not as a primary treatment for nonunion.
Question 1439
Topic: 2. Trauma
A 48-year-old male with a displaced femoral neck fracture is brought to the operating room. The surgeon attempts closed reduction using the Leadbetter maneuver. Which of the following describes the correct sequence of the Leadbetter maneuver and its primary goal?
Correct Answer & Explanation
. Gentle hip flexion to 30-45 degrees, maximal internal rotation, and then gentle abduction to correct external rotation and varus.
Explanation
Correct Answer: BThe case describes the classic Leadbetter maneuver under 'Reduction Maneuvers': 'While applying longitudinal traction, gently internally rotate the leg, abduct slightly, and then flex the hip.' The detailed surgical approach section refines this: 'gentle hip flexion to 30-45 degrees, maximal internal rotation (often to 45 degrees), and then gentle abduction. This maneuver aims to disimpact the fracture, correct external rotation, and restore the neck-shaft angle.' The primary goal is to achieve an anatomic reduction, correcting the common varus and external rotation deformities seen in displaced femoral neck fractures.Option A is incorrect:This describes maneuvers that would likely worsen a displaced femoral neck fracture, which is typically externally rotated and in varus.Option C is incorrect:While longitudinal traction is applied, adduction and external rotation would not typically reduce a displaced femoral neck fracture effectively.Option D is incorrect:Hip flexion to 90 degrees is generally avoided in the early post-operative period due to stress on the fracture, and axial compression is not the primary mechanism of the Leadbetter maneuver.Option E is incorrect:The sequence is incorrect, and the specific angles and goals are not accurately represented.
Question 1440
Topic: 2. Trauma
A 22-year-old collegiate athlete undergoes internal fixation for a Garden I impacted valgus femoral neck fracture. Post-operatively, the rehabilitation protocol is initiated. Which of the following is the most appropriate initial weight-bearing instruction for this patient?
Correct Answer & Explanation
. Toe-touch weight-bearing (TTWB) or partial weight-bearing (PWB) for 6-8 weeks, followed by radiographic assessment.
Explanation
Correct Answer: CThe 'Post-Operative Rehabilitation Protocols' section clearly outlines the initial weight-bearing instructions: 'Toe-Touch Weight-Bearing (TTWB) or Partial Weight-Bearing (PWB) (10-20% body weight): This is the standard for 6-8 weeks.' The rationale is to 'provide micromotion believed to enhance osteogenesis while minimizing excessive shear or compressive forces that could displace the fracture or cause hardware failure.' Even for a stable Garden I fracture in a young, active patient, optimizing union and avoiding AVN is paramount, hence protected weight-bearing is crucial.Option A is incorrect:Full weight-bearing immediately is generally too aggressive and carries a significant risk of fracture collapse, loss of reduction, or nonunion, even in a Garden I fracture, especially in a young patient where long-term outcomes are critical.Option B is incorrect:Non-weight-bearing for 12 weeks is overly conservative for a Garden I fracture and would unnecessarily delay rehabilitation and increase the risk of stiffness and muscle atrophy. TTWB/PWB is preferred to allow for some loading.Option D is incorrect:Weight-bearing as tolerated after only 2 weeks is too early for most femoral neck fractures, even Garden I, given the high risk of complications in young patients.Option E is incorrect:While CPM can be used for some joint conditions, it's not the primary weight-bearing instruction for a femoral neck fracture, and complete non-weight-bearing for 4 weeks is not the standard initial approach for a Garden I fracture.
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