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 1641
Topic: 2. Trauma
A 35-year-old male sustains a spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). On initial presentation, his radial nerve function is intact. Following closed reduction and splint application, he is found to have a complete wrist drop and inability to extend his MCP joints. What is the most appropriate management?
Correct Answer & Explanation
. Immediate surgical exploration of the nerve and fracture fixation
Explanation
While radial nerve palsies present at the time of injury can often be observed, a secondary radial nerve palsy that develops AFTER closed reduction strongly suggests the nerve has become entrapped in the fracture site. This is an absolute indication for surgical exploration.
Question 1642
Topic: 2. Trauma
A 39-year-old catcher presents with an acutely locked right knee after standing up quickly. Her knee has a limited range of motion, moving from 30 to 45 degrees of knee flexion. Beyond this arc, the endpoint is firm and painful. Anterior-posterior and lateral x-rays reveal an aligned knee without fracture or dislocation. What is the most appropriate next step in her care?
Correct Answer & Explanation
. Obtain an MRI of the right knee
Explanation
Correct Answer: BAn acutely locked knee with a firm endpoint and normal radiographs strongly suggests a mechanical block to motion, most commonly a meniscal tear (e.g., bucket-handle tear) or a loose body. An MRI is the gold standard imaging modality for evaluating the integrity of the menisci, articular cartilage, and identifying loose bodies, providing crucial information for diagnosis and surgical planning. Corticosteroid injections or oral anti-inflammatories will not address a mechanical block. While a long-leg splint might provide comfort, it does not advance the diagnosis or treatment. Attempting a closed reduction without a clear diagnosis from MRI could be inappropriate or ineffective if the block is due to a large meniscal tear or loose body.
Question 1643
Topic: 2. Trauma
A 7-year-old girl, weighing 35 kg, presents with a right femoral shaft fracture after playing tackle football. Initial radiographs are shown in and . She is hemodynamically stable with an intact neurovascular examination. Based on her age, weight, and fracture characteristics, what is the most appropriate definitive treatment?
Correct Answer & Explanation
. Flexible intramedullary nails
Explanation
Correct Answer: DThe patient is a 7-year-old girl weighing 35 kg with a diaphyseal femur fracture. According to the provided guidelines for femur fracture treatment by age, flexible intramedullary nails are the optimal choice for children aged 6-8 years. While a spica cast is an option for this age group, flexible nailing is generally preferred for its benefits to the patient and family, allowing for earlier mobilization and easier care. Lateral trochanteric intramedullary nails are typically reserved for children 9 years of age or older, those weighing over 49 kg, or those with length-unstable fractures, none of which apply to this patient. External fixation is usually reserved for severely comminuted or open fractures, or in the setting of damage control orthopaedics, which is not indicated here. Traction followed by delayed spica casting is a less preferred option compared to flexible nailing for this age and weight.
Question 1644
Topic: 2. Trauma
Following the decision to proceed with flexible intramedullary nailing for the 7-year-old patient, you measure the preoperative x-ray at the femoral isthmus, which is 7.5 mm. To achieve optimal stability, what size nails should be used to obtain approximately 80% canal fill?
Correct Answer & Explanation
. Two 3-mm nails, resulting in 80% canal fill
Explanation
Correct Answer: BThe goal for flexible intramedullary nail fixation of a femur fracture is to achieve approximately 80% canal fill. The patient's femoral isthmus measures 7.5 mm. To calculate the appropriate nail size, we need to find two nails whose combined diameter is 80% of 7.5 mm. 80% of 7.5 mm is 0.80 * 7.5 mm = 6.0 mm. Therefore, using two 3-mm nails (3 mm + 3 mm = 6 mm) will achieve exactly 80% canal fill. Option A (two 2.5-mm nails = 5 mm) would result in 67% canal fill (5/7.5), which is less than ideal and could lead to fixation failure. Option C (one 3.0-mm and one 3.5-mm nail = 6.5 mm) would result in 87% canal fill (6.5/7.5), which is greater than 80% and increases the risk of complications, as does using nails of different sizes which can contribute to loss of reduction and malalignment. Option D (two 3.5-mm nails = 7 mm) would result in 93% canal fill (7/7.5), which is too high. Option E (one 2.5-mm and one 3.0-mm nail = 5.5 mm) would result in 73% canal fill (5.5/7.5), which is also suboptimal.
Question 1645
Topic: 2. Trauma
When discussing the potential complications of flexible intramedullary nailing for a pediatric femoral shaft fracture with the patient's parents, which of the following is the most common complication you should inform them about?
Correct Answer & Explanation
. Pain or irritation at the knee (insertion sites)
Explanation
Correct Answer: CThe most common complication associated with flexible intramedullary nailing for pediatric femur fractures is pain or irritation at the insertion sites, typically around the knee where the nails exit the bone. This is often due to the ends of the nails irritating the surrounding soft tissues. Studies have shown relatively low rates of infection, significant bleeding, and loss of reduction (especially with length-stable fractures) when proper surgical technique is employed. Delayed union or nonunion is also a rare complication in pediatric femur fractures treated with flexible nails. To minimize the risk of insertion site irritation, it is suggested that the nails be left no more than 25 mm out of the bone.
Question 1646
Topic: 2. Trauma
During the preoperative discussion with the family regarding the 7-year-old's femur fracture, they inquire about potential long-term complications, specifically limb length discrepancy. What information should you provide regarding the risk and typical amount of ipsilateral overgrowth that may occur following a femoral shaft fracture in this age group?
Correct Answer & Explanation
. Ipsilateral overgrowth does occur, usually around 9 mm in children aged 2 to 10 years.
Explanation
Correct Answer: CChildren between the ages of 2 and 10 years are at the highest risk for ipsilateral overgrowth following a femoral shaft fracture. While the reported range of overgrowth can be broad (approximately 4 to 25 mm), the average amount of overgrowth observed in this age group is typically around 9 mm. Therefore, stating that there is no risk of overgrowth at this age (Option A) or that it only occurs in children under 2 or over 10 (Option E) is incorrect. Options B and D either underestimate or overestimate the average amount of overgrowth commonly seen in this specific age range.
Question 1647
Topic: 2. Trauma
A 14-year-old boy presents with right knee pain after a basketball injury. CT imaging, as shown in , reveals a tibial tubercle fracture. Which of the following conditions is considered a significant risk factor for this type of fracture?
Correct Answer & Explanation
. Osgood–Schlatter disease
Explanation
Correct Answer: BTibial tubercle fractures occur more commonly in adolescents who have a history of Osgood–Schlatter disease. Osgood–Schlatter disease is an overuse injury characterized by repetitive strain across the tibial tubercle apophysis, which can weaken the apophysis and predispose it to avulsion fractures. While a direct causal relationship is not always definitively proven, the association is well-recognized. Patellofemoral syndrome involves anterior knee pain related to overuse but is not a direct risk factor for tibial tubercle avulsion. Sinding-Larsen–Johansson syndrome is similar to Osgood–Schlatter but affects the inferior pole of the patella, not the tibial tubercle. Patellar tendonitis is inflammation of the patellar tendon and is not specifically linked to an increased risk of tibial tubercle fractures. Chondromalacia patellae refers to softening of the articular cartilage of the patella and is unrelated to tibial tubercle fractures.
Question 1648
Topic: 2. Trauma
A 14-year-old boy sustains a tibial tubercle fracture. You are concerned about the potential for compartment syndrome. Which compartment is most commonly at risk, and what specific vessel is primarily implicated in this injury?
Correct Answer: BTibial tubercle fractures, particularly displaced ones, carry a significant risk of developing an isolated anterior compartment syndrome. This is primarily due to injury to the recurrent anterior tibial artery, which is located in close proximity to the tibial tubercle and can be damaged during the fracture event or subsequent swelling. The anterior tibial artery itself is a larger vessel but the recurrent branch is more directly involved in the local vascularity around the tibial tubercle. The medial inferior geniculate artery supplies the knee joint but is not the primary vessel implicated in compartment syndrome with this specific fracture. The lateral compartment and fibular artery are not typically involved in compartment syndrome secondary to a tibial tubercle fracture.
Question 1649
Topic: 2. Trauma
A 14-year-old boy has a displaced Type III tibial tubercle fracture, as seen on CT. Given the displacement and the patient's age, what is the most appropriate definitive treatment strategy?
Correct Answer & Explanation
. Open reduction and internal fixation with cannulated screws, including an arthrotomy
Explanation
For a displaced Type III tibial tubercle fracture in an adolescent, an open reduction is necessary to achieve anatomical alignment. Closed reduction with casting or pinning is insufficient for displaced fractures of this type. While pinning can be used, screw fixation is generally preferred over pins or sutures in larger adolescents due to the significant pulling forces exerted by the quadriceps and to provide more stable fixation, allowing for earlier range of motion. Furthermore, Type III fractures are associated with a risk of intra-articular pathology (e.g., meniscal injury, soft tissue incarceration), making an arthrotomy (or arthroscopy) essential to ensure anatomical joint surface reduction and address any associated injuries.
Question 1650
Topic: 2. Trauma
A 13-year-old male presents with a left ankle injury sustained in a soccer match. Based on the available imaging, you diagnose this patient with a triplane fracture. Which of the following correctly describes the Salter–Harris classification appearance of a classic triplane fracture on different radiographic views?
Correct Answer & Explanation
. Salter–Harris II on sagittal view; Salter–Harris III on anteroposterior (AP) view
Explanation
Classically, a triplane fracture of the distal tibia presents with a characteristic radiographic appearance: it appears as a Salter–Harris II fracture on lateral radiographs (sagittal view) and as a Salter–Harris III fracture (which corresponds to the Tillaux fragment) on coronal imaging (anteroposterior or AP view). This unique combination reflects the fracture's involvement of the physis, epiphysis, and metaphysis in different planes.
Question 1651
Topic: 2. Trauma
Following a closed reduction attempt for the triplane ankle fracture, post-reduction CT images are obtained. The images reveal a residual articular gap of >4 mm. Based on this finding, what is the most appropriate next step in management?
Correct Answer & Explanation
. Surgical reduction and internal fixation using a construct involving placement of lag screws in both the epiphyseal and metaphyseal fracture fragments
Explanation
Correct Answer: D. A residual articular diastasis of greater than 2 mm after reduction of a triplane fracture is generally considered an indication for surgical intervention to minimize the risk of abnormal joint contact forces and subsequent degenerative changes. This patient has a residual articular gap of >4 mm, clearly indicating the need for surgery. While surgical approaches vary, a common and effective method involves reducing the articular surface and fixing it with all-epiphyseal lag screws placed perpendicular to the fracture line in an extraphyseal and extra-articular manner. Given that the patient has a large metaphyseal fragment, additional fixation with lag screws placed across this metaphyseal spike (in addition to epiphyseal screws) would optimize fracture fixation and stability. Therefore, a construct involving lag screws in both the epiphyseal and metaphyseal fragments is the most comprehensive and appropriate surgical approach. Continued immobilization (Option A) is not indicated due to the significant residual displacement. Physeal-spanning compression plates (Option E) are generally not indicated for these fractures due to the risk of physeal arrest.
Question 1652
Topic: 2. Trauma
Prior to surgical intervention for the acute flexor tendon laceration, standard posteroanterior (PA), true lateral, and oblique radiographs of the left hand and middle finger were obtained. In this specific clinical scenario, the primary indication for these plain film radiographs is to:
Correct Answer & Explanation
. Rule out associated phalangeal fractures, bony avulsions, or radiopaque foreign bodies.
Explanation
Correct Answer: CThe case explicitly states the primary indications for plain film radiography in the setting of a sharp penetrating injury: 1) Exclusion of Foreign Bodies (e.g., metallic shards, glass), and 2) Assessment of Osseous Integrity (e.g., phalangeal fractures, cortical nicking, bony avulsions). While the patient reported a knife injury, it's crucial to rule out other potential foreign bodies or associated bony trauma that might complicate the repair or recovery. The radiographs in this patient demonstrated normal osseous architecture and no foreign bodies.Option A is incorrect; radiographs are not effective for assessing tendon retraction or gap formation, which are soft tissue structures. Option B is incorrect; radiographs cannot evaluate the integrity of annular pulleys. Option D is incorrect; the anatomical zone of injury is determined clinically by the laceration's location relative to anatomical landmarks and tendon function deficits. Option E is incorrect; while soft tissue swelling can be noted on radiographs, it's not the primary indication, and other imaging modalities or clinical examination are better for quantifying soft tissue changes.
Question 1653
Topic: 2. Trauma
A radiograph of an acutely injured knee demonstrates an avulsion fracture of the lateral tibial plateau.
This "Segond fracture" is pathognomonic for a tear of the ACL. Which specific ligamentous structure is directly responsible for this bony avulsion?
Correct Answer & Explanation
. Anterolateral ligament
Explanation
The Segond fracture is an avulsion of the anterolateral ligament (ALL) from its tibial insertion, located just posterior to Gerdy's tubercle. It is highly specific for an underlying ACL rupture.
Question 1654
Topic: 2. Trauma
A 10-year-old boy presents after his right index finger was crushed in a door. Examination reveals a flexion deformity at the DIP joint, an avulsed proximal nail plate resting superficial to the eponychial fold, and localized bleeding. Radiographs show a Salter-Harris I fracture of the distal phalanx. What is the most appropriate management?
Correct Answer & Explanation
. Irrigation and debridement, nailbed repair, and fracture stabilization
Explanation
This is a Seymour fracture, characterized by a displaced physeal fracture of the distal phalanx with an associated nailbed laceration (open fracture). Proper management requires irrigation and debridement, nailbed repair, fracture stabilization, and antibiotics to prevent osteomyelitis.
Question 1655
Topic: 2. Trauma
A 45-year-old mechanic with suspected Hypothenar Hammer Syndrome undergoes catheter-based digital subtraction angiography. Which of the following classic angiographic findings most specifically supports this diagnosis?
Correct Answer & Explanation
. A "corkscrew" appearance of the ulnar artery with occlusion and collateralization
Explanation
The classic angiographic finding in HHS is occlusion or aneurysm of the ulnar artery adjacent to the hook of the hamate, often accompanied by a tortuous "corkscrew" appearance of collateral vessels. This indicates chronic localized trauma and compensatory flow.
Question 1656
Topic: 2. Trauma
Which of the following pathophysiologic mechanisms best differentiates Hypothenar Hammer Syndrome from primary Raynaud's disease?
Correct Answer & Explanation
. HHS involves direct intimal injury and microemboli, whereas primary Raynaud's is idiopathic and vasospastic.
Explanation
HHS is caused by repetitive mechanical trauma leading to intimal disruption, thrombosis, false aneurysm, and distal microembolization. In contrast, primary Raynaud's disease is an idiopathic, bilateral, non-structural vasospastic disorder.
Question 1657
Topic: 2. Trauma
In a patient requiring surgical reconstruction for an ulcerating, embolic Hypothenar Hammer Syndrome, which of the following is considered the gold standard surgical procedure?
Correct Answer & Explanation
. Resection of the thrombosed segment and reconstruction with a reversed interposition vein graft
Explanation
For HHS with severe ischemia or failure of conservative management, excision of the damaged arterial segment (thrombus/aneurysm) is required to stop distal microembolization. Reconstruction with a reversed interposition vein graft restores flow and is considered the gold standard for active laborers.
Question 1658
Topic: 2. Trauma
What is the primary histopathologic finding in the ulnar artery of a patient with hypothenar hammer syndrome?
Correct Answer & Explanation
. Intimal hyperplasia, medial fibrosis, and disruption of the internal elastic lamina
Explanation
Hypothenar hammer syndrome is caused by repetitive blunt trauma leading to structural damage of the vessel wall. Histology reveals intimal hyperplasia, fragmentation of the internal elastic lamina, and medial fibrosis, without signs of primary inflammatory vasculitis.
Question 1659
Topic: 2. Trauma
A 42-year-old mechanic presents with unilateral cold intolerance and pain in the small and ring fingers. Angiography reveals an aneurysm of the ulnar artery. The primary site of vascular injury in this condition is most commonly adjacent to which of the following osseous structures?
Correct Answer & Explanation
. Hook of the hamate
Explanation
Hypothenar hammer syndrome involves trauma to the ulnar artery as it passes superficial to the hook of the hamate. Repeated blunt trauma leads to vasospasm, thrombosis, or aneurysm formation in this vulnerable zone.
Question 1660
Topic: 2. Trauma
A 7-year-old girl is transferred to the ER after suffering a right thigh injury playing tackle football. She has notable deformity and significant pain. Initial radiographs are shown below.
Which of the following is the most appropriate initial surgical treatment for this patient, considering her age and weight (35 kg)?
Correct Answer & Explanation
. Flexible intramedullary nails
Explanation
Correct Answer: Flexible intramedullary nailsThe patient is a 7-year-old girl weighing 35 kg with a diaphyseal femur fracture. According to current pediatric orthopedic guidelines, flexible intramedullary nails (FINs) are the optimal choice for femur fractures in children aged 6-8 years, and also for children 8 years to adolescent who are under 50 kg, especially for length-stable fractures. FINs offer the advantages of early mobilization and improved patient and family convenience compared to spica casting.Reduction and immediate spica cast:While spica casting is an option for this age group, flexible nailing is generally preferred due to better patient and family outcomes, allowing for earlier weight-bearing and easier care.Lateral trochanteric intramedullary nail fixation:This method is typically reserved for older children (at least 9 years of age or older) who weigh over 49 kg, or those with length-unstable fractures. The patient's age and weight do not meet these criteria, and there are risks of greater trochanteric apophyseal arrest and osteonecrosis of the femoral head with this approach.Traction followed by delayed spica casting:Traction is often used as a temporary measure or for very young children, but for a 7-year-old, definitive fixation with flexible nails is generally preferred over prolonged traction and casting.External fixation:External fixation is a viable option for pediatric femur fractures but is usually reserved for specific situations such as severely comminuted or open fractures, or in the context of damage control orthopaedics, none of which are indicated in this case.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.
