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 1721
Topic: 2. Trauma
A 29-year-old female undergoes operative fixation for a displaced, comminuted navicular body fracture. Which of the following is considered a potential late complication specifically associated with this type of navicular fracture?
Correct Answer & Explanation
. D. Post-traumatic osteoarthritis of the talonavicular joint.
Explanation
Correct Answer: DThe case lists 'Late complications include non-union and loss of medial longitudinal arch support, painful talonavicular joint, post-traumatic osteoarthritis, as well as avascular necrosis and collapse.' Post-traumatic osteoarthritis is a common and significant late complication of intra-articular fractures, especially if articular congruity is not perfectly restored. Compartment syndrome (A), nerve injury (B), and anesthetic complications (E) are classified as immediate or early complications. Deep vein thrombosis (C) is a general surgical complication but not specifically highlighted as alatecomplication ofthis fracturein the same way OA is.
Question 1722
Topic: 2. Trauma
During the discussion of management options for a navicular body fracture, the candidate mentions an alternative for cases with severe comminution. In cases of severe comminution of the articular surface of the navicular, what alternative surgical intervention might be considered, as mentioned by the candidate?
Correct Answer & Explanation
. B. Primary fusion of the talonavicular joint.
Explanation
Correct Answer: BThe candidate states: 'However, sometimes that is not possible due to severe comminution of the articular surface, in which case I may consider primary fusion of the talonavicular joint.' This highlights that if the articular surface cannot be adequately reconstructed due to severe comminution, a primary fusion may be a more predictable option to achieve a pain-free and stable foot, albeit at the cost of motion. External fixation (A) is typically a temporary measure or for highly contaminated open fractures. Excision (C) is generally not performed for the navicular. Non-operative management (D) is usually insufficient for severe comminution. Bone grafting (E) is often an adjunct to fixation, not a standalone definitive treatment for an unstable fracture.
Question 1723
Topic: 2. Trauma
A 9-year-old boy falls and sustains a pathologic fracture through a centrally located, completely lytic lesion in the proximal humerus diaphysis. A radiopaque fragment is seen dependent within the cyst. What is the most appropriate initial management?
Correct Answer & Explanation
. Immobilization in a sling or cast to allow fracture healing
Explanation
The "fallen leaf" sign is pathognomonic for a unicameral bone cyst (UBC). Initial management of a pathologic fracture through a UBC in the upper extremity is non-operative, as the fracture may stimulate spontaneous cyst healing.
Question 1724
Topic: 2. Trauma
A 12-year-old boy presents with a minimally displaced pathologic fracture of the distal tibia through an eccentric, cortically based, multiloculated lucent lesion with a sclerotic margin. What is the most appropriate management?
Correct Answer & Explanation
. Cast immobilization until fracture healing
Explanation
The radiographic description is classic for a non-ossifying fibroma (NOF). Pathologic fractures through NOFs typically heal well with cast immobilization, and the underlying lesion often ossifies and resolves as the skeleton matures.
Question 1725
Topic: 2. Trauma
An 82-year-old female with a history of severe knee osteoarthritis sustains a comminuted intra-articular distal femur fracture following a ground-level fall.
She lives independently but struggles with rehabilitation protocols. What is the most reliable surgical option that allows immediate full weight-bearing?
Correct Answer & Explanation
. Distal femoral replacement (megaprosthesis)
Explanation
In an elderly patient with poor bone quality, comminution, and pre-existing severe osteoarthritis, distal femoral replacement provides immediate stability and allows early full weight-bearing. ORIF or nailing typically require restricted weight-bearing, which is poorly tolerated in this demographic.
Question 1726
Topic: 2. Trauma
A 35-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture. He undergoes urgent debridement and external fixation. According to current literature, what is the optimal timeframe for definitive soft tissue coverage to minimize deep infection rates?
Correct Answer & Explanation
. Within 72 hours
Explanation
Early soft tissue coverage, ideally within 72 hours (and generally within 5-7 days), significantly decreases the risk of deep infection and promotes better outcomes in severe open tibia fractures.
Question 1727
Topic: Pelvic & Acetabular Trauma
A 28-year-old male is brought to the trauma bay with a heart rate of 120 bpm and blood pressure of 85/50 mmHg. Pelvic radiographs show an anteroposterior compression (APC-III) injury. To be maximally effective, a pelvic binder should be centered over which anatomic landmark?
Correct Answer & Explanation
. Greater trochanters
Explanation
Pelvic binders provide the most effective reduction of pelvic volume and bleeding control when placed directly over the greater trochanters. Placement higher over the iliac crests is less effective and can paradoxically open the pelvic ring further.
Question 1728
Topic: 2. Trauma
Six hours after intramedullary nailing of a closed diaphyseal tibia fracture, a patient complains of severe leg pain out of proportion to the injury. Passive stretch of the toes exacerbates the pain. Which of the following compartment pressure measurements is the accepted threshold for performing a fasciotomy?
The most reliable diagnostic threshold for acute compartment syndrome is a delta pressure (diastolic blood pressure minus intracompartmental pressure) of less than 30 mmHg. Relying on absolute pressure alone can lead to overtreatment or undertreatment.
Question 1729
Topic: 2. Trauma
A 25-year-old male sustains a vertically oriented (Pauwels Type III) femoral neck fracture. Which biomechanical force contributes most to the high rate of nonunion and displacement in this specific fracture pattern?
Correct Answer & Explanation
. High shear forces
Explanation
Pauwels Type III fractures are characterized by a highly vertical fracture line. This orientation converts normal physiologic loads into high shear forces at the fracture site, leading to a high incidence of displacement and nonunion.
Question 1730
Topic: 2. Trauma
A 40-year-old male presents with a closed, highly comminuted tibial pilon fracture with severe soft tissue swelling. A spanning external fixator is applied. What is the most appropriate clinical indicator that the soft tissues are ready for definitive open reduction and internal fixation?
Correct Answer & Explanation
. Appearance of skin wrinkles
Explanation
The "wrinkle sign" indicates that the acute swelling and soft tissue edema have resolved enough to safely allow surgical incisions for definitive fixation. This minimizes the risk of wound dehiscence and deep infection.
Question 1731
Topic: 2. Trauma
A 9-year-old boy presents with mild shoulder pain after a minor fall. Radiographs show a centrally located, lucent metaphyseal lesion in the proximal humerus with a "fallen leaf" sign. What is the most appropriate initial management?
Correct Answer & Explanation
. Immobilization in a sling to allow fracture healing
Explanation
The "fallen leaf" sign is pathognomonic for a pathologic fracture through a unicameral (simple) bone cyst. The initial management is immobilization to allow the fracture to heal, which occasionally leads to spontaneous resolution of the cyst.
Question 1732
Topic: 2. Trauma
A 45-year-old skier sustains a Schatzker Type II tibial plateau fracture. During open reduction and internal fixation, the surgeon must be prepared to address an associated soft-tissue injury. Which of the following is the most commonly associated intra-articular injury with this fracture pattern?
Correct Answer & Explanation
. Lateral meniscus tear
Explanation
Schatzker Type II fractures involve a split and depression of the lateral tibial plateau. The most common associated soft-tissue injury is a tear or peripheral detachment of the lateral meniscus, which often gets incarcerated in the fracture site.
Question 1733
Topic: 2. Trauma
A 45-year-old female presents with a displaced fracture of the femoral shaft. She has a history of a soft tissue sarcoma of the thigh treated with wide resection and adjuvant external beam radiation 7 years ago. Which of the following best describes the healing potential of this fracture?
Correct Answer & Explanation
. High risk of nonunion due to profound depletion of osteoprogenitor cells and hypovascularity
Explanation
Irradiated bone undergoes endarteritis and a profound depletion of cellular elements, including osteocytes and osteoprogenitor cells. This results in brittle, hypovascular bone with a substantially diminished healing capacity, leading to a high rate of nonunion following fracture.
Question 1734
Topic: 2. Trauma
A 32-year-old male sustains a displaced diaphyseal fracture of the radius and ulna after a high-energy motor vehicle accident. During preoperative planning, the orthopedic surgeon reviews the patient's contralateral uninjured forearm radiographs to determine the optimal plate contouring for the radius. According to the seminal biomechanical studies on radial anatomy, what are the average magnitude and location of the maximum radial bow that the surgeon aims to restore?
Correct Answer & Explanation
. C. 15.3 mm at 60% of radial length from the bicipital tuberosity
Explanation
Correct Answer: CThe teaching case explicitly states, 'Classic biomechanical studies by Schemitsch and Richards defined the normal parameters of the radial bow. The maximum radial bow averages 15.3 millimeters (range, 10 to 22 mm), and the location of this maximum bow is situated at approximately 60% of the total radial length, measured from the bicipital tuberosity to the radiocarpal joint.' This precise anatomical restoration is critical for optimal forearm rotation.Options A, B, D, and E present incorrect values for either the magnitude or the location of the maximum radial bow, which would lead to suboptimal functional outcomes if used as a surgical target. Failure to restore these specific parameters directly correlates with a proportional loss of forearm rotation, as highlighted in the case.
Question 1735
Topic: 2. Trauma
A 28-year-old construction worker presents with a malunited diaphyseal radius fracture, sustained 6 months prior, resulting in a significant loss of pronation and supination. Clinical examination reveals a fixed deformity. Based on the biomechanical principles discussed in the case, which of the following angular deformities is most likely to cause a severe and clinically significant loss of forearm rotation?
Correct Answer & Explanation
. D. An angular deformity of 25 degrees in any plane, particularly involving a loss of the radial bow
Explanation
Correct Answer: DThe teaching case, referencing Matthews et al., states: 'Matthews et al. demonstrated that angular deformities of less than 10 degrees in any plane do not significantly restrict forearm rotation. However, deformities exceeding 20 degrees, particularly those involving a loss of the radial bow, result in a severe and clinically significant loss of pronation and supination.' An angular deformity of 25 degrees clearly exceeds this 20-degree threshold, making it the most likely cause of severe rotational loss.Options A, B, C, and E describe angular deformities that are either below or at the threshold of 10 degrees, which the literature suggests do not significantly restrict forearm rotation. While a 15-degree deformity (Option C) is greater than 10 degrees, the case specifically highlights deformitiesexceeding 20 degreesas leading tosevereand clinically significant loss. Therefore, 25 degrees is the most accurate answer for a severe loss of function.
Question 1736
Topic: 2. Trauma
A 38-year-old male undergoes ORIF for a displaced mid-diaphyseal radial fracture. The surgeon uses a standard straight 3.5 mm LC-DCP. Postoperatively, the patient experiences significant restriction in forearm pronation and supination. Intraoperative fluoroscopy confirmed length and axial alignment. What is the most likely cause of the restricted rotation in this scenario?
Correct Answer & Explanation
. C. Applying a straight plate to the curved radial diaphysis, which flattened the radial bow and narrowed the interosseous space.
Explanation
Correct Answer: CThe teaching case explicitly warns: 'Applying a straight plate to the curved radial diaphysis will inevitably flatten the radial bow, narrowing the interosseous space and restricting rotation.' This is a classic cause of malunion and loss of forearm rotation after radial shaft fixation, especially when standard straight plates are used without meticulous contouring.Option A is incorrect because over-contouring would lead to excessive bowing, not flattening, and while it can also cause impingement, the scenario describes using astraightplate. Option B is incorrect; while inadequate stability can lead to nonunion, it's less directly linked to immediate mechanical restriction of rotation compared to a flattened bow. Option D is a risk factor for hardware failure or nonunion, but not the primary cause of mechanical rotational restriction due to incorrect radial bow. Option E describes a potential rehabilitation complication, but the question implies a mechanical issue related to the surgical technique and plate application, not a rehabilitation error.
Question 1737
Topic: 2. Trauma
A 22-year-old male sustains an open, comminuted diaphyseal fracture of both the radius and ulna after a fall from a height. He undergoes emergent irrigation and debridement followed by ORIF of both bones through separate volar (Henry) and dorsal ulnar incisions. Despite meticulous surgical technique, the patient develops progressive loss of forearm rotation over several months. Which of the following complications is most likely, and what is a key risk factor for its development that the surgeon attempted to mitigate?
Correct Answer & Explanation
. C. Radioulnar synostosis; mitigated by using dual incisions.
Explanation
Correct Answer: CThe teaching case lists 'Radioulnar Synostosis' as a complication with an incidence of 2-8%. Key risk factors include 'High-energy trauma, closed head injury, single-incision approach for both bones, severe soft tissue stripping, delayed surgery.' The case also states, 'Furthermore, the routine use of dual incisions (separate volar Henry and dorsal ulnar approaches) is universally recommended over single-incision approaches to minimize the devastating complication of radioulnar synostosis.' The patient's high-energy trauma is a risk factor, and the surgeon's use of dual incisions was a direct attempt to mitigate synostosis.Options A, B, D, and E are all potential complications, and the listed mitigation strategies are correct. However, the question specifically asks for the complication that leads to 'progressive loss of forearm rotation over several months' and a risk factor that the surgeon 'attempted to mitigate' by using dual incisions. Radioulnar synostosis directly causes loss of rotation and is specifically mitigated by dual incisions, making it the best answer in this context.
Question 1738
Topic: 2. Trauma
A 60-year-old female presents with a chronic malunion of her radial shaft fracture, sustained 18 months prior, leading to severe restriction of pronation and supination. Imaging reveals a significant loss of the radial bow. The orthopedic surgeon plans a corrective osteotomy. What is the most recommended advanced imaging and planning tool to ensure precise restoration of the radial bow in this complex salvage setting?
Correct Answer & Explanation
. C. Computed tomography (CT) with three-dimensional reconstructions and advanced planning software utilizing contralateral templating.
Explanation
Correct Answer: CThe teaching case emphasizes the importance of advanced imaging for complex deformities: 'In complex comminuted fractures or established malunions, computed tomography (CT) with three-dimensional reconstructions is highly recommended. Advanced planning software can mirror the contralateral intact radius, allowing for precise calculation of the required osteotomy angles or the degree of plate contouring necessary to restore the native anatomy.' This approach is crucial for accurate restoration of the radial bow in malunions.Option A (standard radiographs) is mandatory for initial assessment but insufficient for precise 3D planning of a corrective osteotomy for a malunion. Option B (stress radiographs) is used for instability assessment, not for planning bone correction. Option D (MRI) is excellent for soft tissue but less precise for bony morphology and 3D planning of osteotomies. Option E (EMG/NCS) is for nerve function assessment, not for anatomical bone reconstruction planning.
Question 1739
Topic: 2. Trauma
A 42-year-old male sustains an isolated, non-displaced ulnar shaft fracture (nightstick fracture) after a direct blow. He has no associated injuries, and his PRUJ and DRUJ are stable. Based on the provided case, what is the most appropriate initial management strategy for this patient?
Correct Answer & Explanation
. C. Non-operative management with immobilization and close monitoring.
Explanation
Correct Answer: CThe teaching case outlines operative decision-making: 'Non-operative management is reserved for a highly select, narrow subset of injuries or for patients with prohibitive surgical risks.' The table further specifies 'Non Operative Indications' including 'Truly non-displaced, isolated ulnar shaft fractures (Nightstick)' and 'Intact radial bow parameters.' Given the patient has a non-displaced, isolated ulnar shaft fracture with stable PRUJ and DRUJ, non-operative management is the most appropriate initial strategy.Option A (immediate ORIF) is the gold standard for most displaced adult forearm fractures but not for truly non-displaced isolated ulnar shaft fractures. Option B (external fixation) is typically reserved for severe open fractures or medically unstable patients. Option D (urgent CT) is not indicated for a non-displaced isolated fracture where standard radiographs are sufficient. Option E (diagnostic arthroscopy) is overly aggressive and not indicated for this specific injury pattern.
Question 1740
Topic: 2. Trauma
A 25-year-old male sustains a complex, comminuted diaphyseal fracture of the radius. During surgical planning, the surgeon notes significant fragmentation. According to the principles of fixation for such complex fractures, what is the primary objective and the recommended plating technique?
Correct Answer & Explanation
. B. Primary objective: Restoration of length, alignment, and rotation; Recommended technique: Bridge plating.
Explanation
Correct Answer: BThe teaching case differentiates fixation principles based on fracture complexity: 'Fixation principles dictate the achievement of absolute stability for simple fracture patterns (AO/OTA Type A and B) utilizing lag screws and neutralization plates, or compression plating techniques. For complex, comminuted fractures (AO/OTA Type C), bridge plating techniques are employed to preserve the soft tissue envelope and vascularity of the fracture fragments, focusing on the restoration of length, alignment, and rotation rather than anatomical reduction of every butterfly fragment.'Option A is incorrect because anatomical reduction of every fragment is not the primary goal for comminuted fractures; bridge plating focuses on overall length, alignment, and rotation. Option C describes techniques for simple fractures, not complex comminuted ones. Option D is incorrect; external fixation is typically temporary, and early weight-bearing is not the primary objective for complex fractures. Option E is incorrect; while intramedullary nailing can be used for some long bone fractures, plating is the standard for diaphyseal forearm fractures, and minimizing exposure is a goal of bridge plating, but not the primary objective over restoration of function.
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