Orthopedic Board Prep: Trauma & Fracture MCQ Practice

Question 1

A 45-year-old male sustains a high-energy trauma resulting in a closed Gustilo-Anderson Type I fracture of the tibia and fibula. He is stabilized, and 6 hours post-injury, he complains of excruciating pain in the calf disproportionate to the injury. On examination, his calf is tense, and passive dorsiflexion of the ankle elicits severe pain. Distal pulses are present, and capillary refill is brisk. Which of the following is the most appropriate next step in management?

Explanation

The clinical presentation of excruciating pain disproportionate to the injury, a tense calf, and pain on passive stretching of the muscles are classic signs of acute compartment syndrome, despite the presence of distal pulses and brisk capillary refill. The most appropriate next step is to measure compartment pressures. If pressures are elevated (typically within 30 mmHg of diastolic blood pressure, or absolute pressure >30-45 mmHg), emergent fasciotomy is indicated. Delaying diagnosis and treatment can lead to irreversible muscle and nerve damage. While vascular injury is a concern in high-energy trauma, the clinical picture is more suggestive of compartment syndrome. Pain relief alone without addressing the underlying pathology is inappropriate. Open reduction and internal fixation of the fracture would typically follow fasciotomy if required, but the immediate life-saving/limb-saving step is addressing compartment syndrome. Elevation of the limb and ice packs are contraindicated as they can further compromise perfusion.

Question 2

A 32-year-old construction worker falls from a height, sustaining a closed midshaft femur fracture. He is hemodynamically stable. Plain radiographs confirm the diagnosis. What is the definitive treatment for this injury in a healthy adult?

Explanation

Intramedullary nailing is the gold standard definitive treatment for closed midshaft femur fractures in healthy adults. It provides excellent stability, allows for early weight-bearing, and has high union rates with low complication rates. Traction and cast application are historical treatments largely abandoned due to prolonged bed rest, stiffness, and less predictable results. External fixation is primarily used for open fractures, polytrauma patients requiring damage control, or temporarily stabilizing high-energy injuries, not as a definitive treatment for closed fractures. Plate and screw fixation is an option for certain fracture patterns (e.g., supracondylar, very proximal) or specific patient populations, but IM nailing is preferred for midshaft. Skeletal traction followed by cast is a dated approach.

Question 3

A 72-year-old female presents after a ground-level fall, complaining of hip pain. Radiographs reveal a Garden Type III femoral neck fracture. She is otherwise fit and well with no significant comorbidities. Which of the following is the most appropriate management strategy?

Explanation

A Garden Type III femoral neck fracture is a displaced fracture. In an active, otherwise healthy 72-year-old, total hip arthroplasty (THA) is often favored over hemiarthroplasty, especially in patients with pre-existing arthritis or good functional demands. While hemiarthroplasty is an option for displaced femoral neck fractures in the elderly, THA generally provides better long-term functional outcomes and reduces the need for revision surgery compared to hemiarthroplasty in active patients. ORIF with cannulated screws has a high risk of avascular necrosis and non-union in displaced fractures in this age group. Non-operative management is reserved for non-displaced or impacted fractures in very frail patients. DHS is not suitable for femoral neck fractures.

Question 4

A 28-year-old male sustains an isolated ankle injury during a football game. Clinical examination reveals tenderness over the distal fibula and medial malleolus, with instability on stress testing. Radiographs show a bimalleolar ankle fracture. Which of the following statements regarding its management is most accurate?

Explanation

Bimalleolar ankle fractures are unstable injuries involving both the lateral (fibula) and medial (tibia) malleoli. They disrupt the ankle mortise, leading to instability. Open reduction and internal fixation (ORIF) is the standard of care to restore anatomical alignment, stability, and congruence of the ankle joint. This minimizes the risk of post-traumatic arthritis and improves functional outcomes. Non-operative treatment is generally reserved for stable, isolated malleolar fractures or patients who are unfit for surgery. External fixation is rarely used as a definitive treatment for isolated bimalleolar fractures but may be used as a temporary measure in severe open injuries. Ankle fusion is a salvage procedure for severe arthritis, not a primary treatment for acute fractures. A significant deltoid ligament injury (often implied in a bimalleolar fracture, or evidenced by widening of the medial clear space) effectively creates a 'trimalleolar equivalent' injury and contributes to instability, and its reduction is crucial, though direct repair is not always needed if bony fixation achieves stability.

Question 5

A 10-year-old boy falls off a bicycle, sustaining a completely displaced supracondylar humerus fracture (Gartland Type III). He has a palpable radial pulse, but is unable to extend his fingers and has numbness in the distribution of the median nerve. Which of the following is the most urgent next step?

Explanation

A completely displaced supracondylar humerus fracture (Gartland Type III) requires urgent reduction and fixation due to the high risk of neurovascular compromise and development of Volkmann's ischaemic contracture. The presence of median nerve palsy, even with a palpable radial pulse, indicates significant injury and potential for further compromise. Urgent closed reduction and percutaneous pinning (CRPP) is the treatment of choice. Restoration of anatomical alignment often resolves or improves nerve deficits and protects the vascular supply. Delay can lead to irreversible damage. Nerve conduction studies or MRI are not needed urgently and would delay critical intervention. Corticosteroids are not indicated. Observation is dangerous and inappropriate.

Question 6

A 68-year-old male presents with acute onset of severe low back pain and bilateral leg weakness following a fall from standing. He has a known history of prostate cancer with bone metastases. On examination, he has bilateral lower extremity weakness (3/5) and urinary retention. Which of the following investigations is most crucial for immediate management?

Explanation

This patient presents with signs and symptoms highly suggestive of acute cauda equina syndrome secondary to spinal cord compression, likely from metastatic disease, given his history of prostate cancer. Urinary retention and bilateral leg weakness are red flag symptoms. An urgent MRI of the entire spine (or at least the thoracolumbar region) is crucial to define the level and extent of compression, as this dictates surgical planning for decompression. Plain radiographs and CT scans are less sensitive for spinal cord compression and soft tissue involvement. A bone scan would show metabolic activity but not directly assess compression. EMG is not an acute diagnostic tool for cord compression.

Question 7

A 25-year-old collegiate football player sustains a knee injury after a direct blow to the lateral aspect of his knee, with his foot planted. He reports immediate pain and instability. On examination, there is a positive Lachman test, pivot shift, and a grade III medial collateral ligament (MCL) laxity. Which of the following is the most appropriate initial management approach?

Explanation

This patient presents with a combined ACL rupture (positive Lachman, pivot shift) and a Grade III MCL tear. While ACL reconstruction is often indicated in active individuals, MCL tears, especially Grade III, generally heal well with non-operative management. The standard approach for combined ACL and MCL injuries is to initially treat the MCL non-operatively, allowing it to heal, typically with bracing and protected weight-bearing. Once the MCL has healed (usually 6-8 weeks), the ACL can then be addressed surgically if the patient remains symptomatic or desires to return to high-level activities. Immediate reconstruction of all ligaments can lead to increased stiffness and poorer outcomes for the MCL. Diagnostic arthroscopy is not an initial management step. Long leg casting is typically avoided due to stiffness. MRI is important for confirmation but does not replace the initial management strategy.

Question 8

A 55-year-old male falls onto an outstretched hand, sustaining a comminuted distal radius fracture with significant dorsal angulation and articular involvement (AO Type C3). He is a moderately active individual. What is the most appropriate surgical management for this fracture?

Explanation

A comminuted, significantly displaced distal radius fracture with articular involvement (AO Type C3) in an active individual typically requires anatomical reduction and stable internal fixation. Volar locking plate fixation has become the gold standard for these fractures, offering stable fixation, allowing early range of motion, and providing excellent control of volar/dorsal tilt and radial length. Closed reduction and splinting alone are unlikely to maintain an adequate reduction for this type of unstable fracture. External fixation may be used temporarily or in conjunction with pinning, but alone, it may not achieve or maintain adequate reduction of articular fragments. Percutaneous pinning is suitable for less displaced or less comminuted fractures. Dorsal plating is an option but is associated with higher rates of extensor tendon irritation and rupture compared to volar plating.

Question 9

A 7-year-old boy presents with pain and swelling in his left thigh following a playground fall. Radiographs show a midshaft femur fracture. He is hemodynamically stable. Which of the following is the most appropriate definitive management option for this patient?

Explanation

For a midshaft femur fracture in a 7-year-old, flexible intramedullary nailing (e.g., Ender nails or titanium elastic nails, TENs) is a common and appropriate definitive treatment. It provides stable fixation, allows for early mobilization and weight-bearing, and minimizes the risk of growth plate injury as the nails are inserted retrograde from the distal femur or antegrade from the greater trochanteric apophysis (avoiding the physis). Spica casting is an option for younger children (typically under 5-6 years old) or for less complex fractures but can be cumbersome and associated with complications like skin breakdown. Rigid intramedullary nailing is generally reserved for older adolescents or adults due to the risk of avascular necrosis of the femoral head or damage to the greater trochanteric physis. Submuscular plating is an alternative, but IM nailing is often preferred due to less soft tissue stripping. External fixation is usually reserved for open fractures, polytrauma, or significant soft tissue injury as a temporary or definitive option but is not typically the first choice for isolated closed fractures in this age group.

Question 10

A 38-year-old male sustains a severe open pilon fracture (distal tibia articular surface) with significant soft tissue damage, classified as Gustilo-Anderson Type IIIB. Which of the following principles guides the initial surgical management?

Explanation

For severe open pilon fractures, especially Gustilo-Anderson Type IIIB, the initial management focuses on damage control principles. This involves thorough surgical debridement of all contaminated and non-viable tissue to prevent infection, followed by stabilization of the fracture with an external fixator (often spanning the ankle joint). This allows the soft tissues to recover and reduces swelling. Definitive reconstruction (e.g., plate and screw fixation) is typically performed in a staged manner once the soft tissue envelope has improved and the risk of infection is minimized, usually 7-14 days later. Immediate definitive ORIF carries a high risk of infection and wound complications in the presence of severe soft tissue injury. Primary ankle arthrodesis is a salvage procedure, not an initial approach. Primary amputation is only considered for unsalvageable limbs. Placement of an external fixator without debridement is inadequate and increases infection risk.

Question 11

A 22-year-old male sustains a high-energy posterior hip dislocation. After successful closed reduction, what is the most critical immediate post-reduction investigation to assess for associated injuries?

Explanation

After successful closed reduction of a posterior hip dislocation, the most critical immediate post-reduction investigation is a CT scan of the hip and pelvis. This is essential to rule out occult intra-articular fragments (e.g., osteochondral fragments from the femoral head or acetabulum), assess for acetabular fractures (especially posterior wall fractures), and confirm the concentric reduction. Undetected fragments or unstable acetabular fractures can lead to early post-traumatic arthritis, avascular necrosis, or recurrent dislocation. Repeat plain radiographs are necessary to confirm reduction but are insufficient to detect intra-articular fragments or subtle fractures. MRI is useful for soft tissue injuries (labrum, cartilage) and avascular necrosis but is not typically the first-line post-reduction imaging due to accessibility and time. Angiogram is reserved for suspected vascular injury (rarely seen acutely) and EMG is for nerve injury assessment, neither is the immediate priority after reduction itself.

Question 12

A 60-year-old female experiences acute onset of severe shoulder pain after a fall. Radiographs show a three-part proximal humerus fracture (surgical neck and greater tuberosity). She has good bone quality. Which surgical option offers the best chance for functional recovery in this active patient?

Explanation

For a three-part proximal humerus fracture in an active 60-year-old with good bone quality, open reduction and internal fixation (ORIF) with a locking plate is often considered the gold standard. Locking plates provide stable fixation, allowing for early mobilization and preserving the patient's own humeral head, which typically yields better functional outcomes than prosthetic replacement if healing occurs. Non-operative management is generally reserved for minimally displaced or two-part fractures. Tension band wiring is typically used for two-part surgical neck fractures or tuberosity fractures, not complex three-part injuries. Hemiarthroplasty is considered for patients with poor bone quality, highly comminuted fractures where ORIF is not feasible, or older, less active patients. RSA is usually reserved for older patients with irreparable rotator cuff tears, failed hemiarthroplasties, or complex fracture-dislocations, as it alters shoulder biomechanics significantly.

Question 13

A 4-year-old child presents with a 'pulled elbow' after being swung by his arm. He refuses to use his arm, which is held in flexion and pronation. Which of the following maneuvers is most likely to reduce the subluxation?

Explanation

A 'pulled elbow' or nursemaid's elbow is a radial head subluxation, typically caused by longitudinal traction on the pronated and extended arm. The classic reduction maneuver involves supination and then flexion of the forearm. This maneuver attempts to reduce the annular ligament back into its normal position around the radial head. Pronation and extension, supination and extension, or traction and direct pressure are not the primary successful maneuvers and may even worsen the subluxation. Flexion and internal rotation are not indicated.

Question 14

A 50-year-old male falls from a ladder, sustaining a calcaneal fracture. Radiographs show a severely comminuted intra-articular fracture with significant subtalar joint involvement (tongue-type). He has no other injuries. Which factor is most important in determining the functional outcome of this fracture?

Explanation

For intra-articular calcaneal fractures, the quality of the reduction of the subtalar joint articular surface is the most critical factor influencing long-term functional outcome and the development of post-traumatic subtalar arthritis. Anatomical reduction and stable fixation, when indicated, are paramount. While age and soft tissue status (open wound) are important, and the duration of non-weight-bearing and type of fixation play roles, none supersede the importance of restoring the joint congruity. A poor reduction significantly increases the risk of chronic pain, stiffness, and arthritis, irrespective of other factors.

Question 15

A 30-year-old female presents to the emergency department with a history of recurrent anterior shoulder dislocations. She is considering surgical stabilization. Which physical examination finding would most strongly suggest the presence of a Bankart lesion and indicate the need for surgery?

Explanation

A positive apprehension test (eliciting apprehension or pain when the arm is abducted and externally rotated) is the classic clinical sign for anterior glenohumeral instability and strongly suggests a Bankart lesion or other anterior labral pathology. The apprehension test assesses the anterior stability of the shoulder. A sulcus sign indicates inferior instability/multidirectional instability. O'Brien's test is for SLAP lesions (superior labral tears). Pain on resisted abduction could be impingement or rotator cuff pathology. Weakness of external rotation suggests rotator cuff pathology. While other findings may be present, the apprehension test is the most direct indicator of anterior instability leading to recurrent dislocations.

Question 16

A 48-year-old male sustains a fall directly onto his knee, resulting in a patellar fracture. Radiographs show a transverse patellar fracture with 5mm of displacement and 3mm of articular step-off. He is able to actively extend his knee against gravity. Which of the following is the most appropriate management?

Explanation

A transverse patellar fracture with 5mm displacement and 3mm articular step-off, even with intact active knee extension (which suggests an intact extensor mechanism, but the displacement is significant), typically requires surgical intervention to restore articular congruity and reconstruct the extensor mechanism. Open reduction and internal fixation (ORIF) with tension band wiring is the gold standard for displaced transverse patellar fractures. This technique converts tensile forces into compressive forces across the fracture site, promoting healing and restoring the extensor mechanism. Non-operative management is reserved for non-displaced fractures with an intact extensor mechanism. Partial or total patellectomy are salvage procedures for highly comminuted fractures or non-unions, usually avoided if reconstruction is possible. External fixation is not standard for patellar fractures.

Question 17

A 65-year-old woman with osteoporosis presents with acute onset of severe back pain after bending over. Plain radiographs reveal a vertebral compression fracture at L1. Neurological examination is unremarkable. Which of the following is the most appropriate initial management?

Explanation

For an osteoporotic vertebral compression fracture without neurological deficit, the initial management is typically non-operative. This includes pain management with analgesia, bracing (e.g., thoracolumbosacral orthosis - TLSO) for comfort and stability, and aggressive management of osteoporosis to prevent future fractures. Vertebroplasty or kyphoplasty can be considered if pain remains intractable despite conservative measures, but are not always first-line. Surgical stabilization is reserved for unstable fractures or those with neurological compromise. Bed rest for prolonged periods is generally discouraged due to deconditioning. An MRI is important if there's suspicion of neurological involvement or malignancy, but if the neurological exam is unremarkable, it might not be immediately emergent after initial radiographs confirm the fracture.

Question 18

A 40-year-old male sustains a right femoral shaft fracture in a motor vehicle accident. He is taken to the operating theatre for intramedullary nailing. During reaming, he suddenly becomes hypotensive, hypoxic, and develops petechial rash. Which of the following is the most likely diagnosis?

Explanation

The classic triad of symptoms (hypotension, hypoxia, and petechial rash) occurring during or shortly after intramedullary nailing of a long bone fracture, particularly the femur, is highly characteristic of fat embolism syndrome (FES). The release of fat globules from the bone marrow into the circulation during reaming is thought to be a key mechanism. Anaphylactic reactions would typically involve bronchospasm, urticaria, and angioed, and less likely petechiae. Pulmonary embolism would present with hypoxia and hypotension but petechiae are not a typical feature. Cardiac tamponade is unlikely in this context without specific chest trauma. Sepsis would have a slower onset and fever.

Question 19

A 20-year-old male falls during a basketball game, sustaining an acute Achilles tendon rupture. Examination reveals a palpable gap in the tendon and a positive Thompson test. Which of the following is the most appropriate management in a young, active individual?

Explanation

For an acute Achilles tendon rupture in a young, active individual, surgical repair is generally favored. Surgical repair provides a lower re-rupture rate and potentially better functional outcomes compared to non-operative treatment, especially in high-demand patients. Non-operative management with cast immobilization is an option, particularly for older, less active patients, but carries a higher re-rupture rate. While PRP injections are being studied, they are not a primary definitive treatment. Ultrasound-guided percutaneous repair is a minimally invasive surgical option but still falls under surgical repair. Immediate weight-bearing is contraindicated for an acute rupture.

Question 20

A 75-year-old male with multiple comorbidities presents with a painful, swollen ankle after a fall. Radiographs show a trimalleolar ankle fracture (medial, lateral, and posterior malleolus involved). He is deemed high-risk for surgery due to cardiac and respiratory issues. Which of the following is the most appropriate management strategy?

Explanation

For a trimalleolar ankle fracture in a high-risk patient unfit for definitive ORIF, the priority is to achieve and maintain a reasonable reduction to prevent skin breakdown and future severe arthritis, while minimizing surgical risks. The most appropriate approach is to attempt a closed reduction. If successful, the ankle is then immobilized in a short leg cast or removable boot with strict non-weight-bearing. The goal is often to obtain a 'best possible' reduction rather than an anatomical one, accepting a slightly less perfect outcome to avoid high surgical risks. External fixation can be used as a temporary measure or sometimes as a definitive measure for extremely high-risk patients, but a well-reduced casted ankle is often preferred if stable. Immediate ORIF is contraindicated due to medical comorbidities. Non-operative management with early mobilization is inappropriate for an unstable trimalleolar fracture. Primary ankle arthrodesis is a salvage procedure.

Question 21

A 15-year-old competitive gymnast complains of chronic wrist pain, particularly with weight-bearing and hyperextension, following an injury sustained 6 months ago. Plain radiographs are normal. What is the most likely diagnosis and appropriate next investigation?

Explanation

Chronic wrist pain in a gymnast, especially with weight-bearing and hyperextension, with normal plain radiographs, is highly suggestive of a Triangular Fibrocartilage Complex (TFCC) tear. The TFCC is a critical stabilizer of the distal radioulnar joint and load distributor. MRI of the wrist, ideally with arthrogram, is the investigation of choice to visualize TFCC tears, which can be difficult to see on standard MRI due to their complex anatomy and small size. Distal radius growth plate injury is less likely given the 6-month duration and normal X-rays. Scaphoid non-union is a possibility, but typically leads to tenderness in the anatomical snuffbox and is often visible on delayed X-rays or standard MRI; however, TFCC is a better fit for gymnast symptoms. Ganglion cysts are usually palpable. Carpal tunnel syndrome causes nerve symptoms, not primarily mechanical pain with weight-bearing.

Question 22

A 58-year-old morbidly obese male sustains a crush injury to his foot. He develops severe pain, swelling, and paresthesias in the forefoot. Dorsalis pedis and posterior tibial pulses are present. Pain is exacerbated by passive stretch of the toes. What is the most appropriate next step?

Explanation

The patient's symptoms (severe pain, swelling, paresthesias, pain on passive toe stretch) following a crush injury, despite palpable pulses, are classic for acute foot compartment syndrome. The presence of pulses does not rule out compartment syndrome. Elevation and ice are contraindicated as they can worsen perfusion. IV fluids and analgesia are supportive but do not address the underlying compartment syndrome. A CT scan may show bony injury but not compartment pressures. Arterial Doppler studies are not the primary investigation for compartment syndrome. Urgent measurement of compartment pressures is indicated, and if elevated, emergent fasciotomy of the foot compartments is required to prevent ischemic damage and tissue necrosis.

Question 23

A 28-year-old male sustains an open tibia fracture (Gustilo-Anderson Type IIIA). He is brought to the emergency department. Which of the following is the highest priority in the initial management of this injury?

Explanation

For an open fracture, prompt administration of broad-spectrum intravenous antibiotics (e.g., a cephalosporin and an aminoglycoside, plus penicillin for Type III or grossly contaminated wounds) and tetanus prophylaxis are the highest initial priorities. This significantly reduces the risk of infection. While debridement is critical, it typically occurs in the operating theatre after antibiotics have been initiated and resuscitation is underway. Applying a sterile dressing and splinting are important for temporary care. Imaging is necessary but does not take precedence over infection control. Immediate definitive ORIF is not typically performed for open fractures; damage control (debridement and external fixation) is usually the first surgical step, followed by definitive fixation in a staged approach.

Question 24

A 6-year-old girl falls onto her elbow and presents with a minimally displaced lateral condyle fracture of the humerus. Which of the following is a significant concern specific to this fracture in children?

Explanation

Lateral condyle fractures in children, even if minimally displaced, have a high incidence of non-union or malunion if not anatomically reduced and stably fixed. This is due to the cartilaginous nature of the condyle, which makes accurate assessment and fixation challenging, and the pull of the common extensor muscles. Non-union can lead to progressive valgus deformity, secondary ulnar nerve palsy, and stiffness. While Volkmann's ischaemic contracture and compartment syndrome are concerns for supracondylar fractures, they are less common for lateral condyle fractures. Ulnar nerve injury is a concern with medial epicondyle or supracondylar fractures. Cubitus varus is typically associated with malunited supracondylar fractures.

Question 25

A 35-year-old male sustains a fall from a height, landing on his feet. He complains of bilateral heel and back pain. Radiographs confirm bilateral calcaneal fractures. What additional injury must be specifically evaluated given the mechanism of injury?

Explanation

A fall from a height, landing on the feet, imparts axial load through the lower extremities. This mechanism frequently results in associated injuries, classically affecting the calcaneus, tibia, femur, and spine (especially thoracolumbar compression fractures) as the force is transmitted upwards. Therefore, a careful assessment and imaging (e.g., clinical examination and potentially radiographs or CT of the spine) for spinal compression fractures is mandatory in a patient with calcaneal fractures from a fall from height. While other injuries are possible, spinal fractures are a well-recognized and critical association.

Question 26

A 42-year-old female presents with a chronic non-union of her humeral shaft fracture after 9 months of conservative management. The fracture site is not infected, and there is hypertrophic callus evident on X-ray, but a persistent fracture line. What is the most appropriate next step in management?

Explanation

A chronic non-union with hypertrophic callus but a persistent fracture line (hypertrophic non-union) indicates biological activity but insufficient stability for union. In this scenario, surgical intervention to achieve greater stability is required. Revision open reduction and internal fixation with plate and screws, often augmented with autogenous bone grafting, is a common and effective treatment. Bone grafting provides osteogenic cells, osteoinductive factors, and an osteoconductive scaffold. Bone stimulation can be helpful for atrophic non-unions or as an adjunct, but for hypertrophic non-union requiring increased stability, it's usually insufficient as a standalone treatment. Continuing conservative management is unlikely to succeed. Conversion to an IM nail is an option, but plating with bone graft is also a strong choice, especially in the context of an existing non-union. Debridement and external fixation are less common for a sterile hypertrophic non-union.

Question 27

A 70-year-old male with a prosthetic aortic valve on warfarin therapy sustains a displaced intertrochanteric hip fracture. His INR is 3.5. Which of the following is the most appropriate perioperative anticoagulant management?

Explanation

For a patient with a displaced intertrochanteric hip fracture on warfarin, timely surgery is crucial to reduce morbidity and mortality. Reversing warfarin with Prothrombin Complex Concentrate (PCC) provides rapid correction of INR within hours, and Vitamin K provides sustained effect. The goal is typically to achieve an INR <1.5 to safely proceed with surgery, ideally within 24-48 hours. Stopping warfarin alone will take days to normalize INR, increasing DVT risk and delaying surgery. Bridging with unfractionated heparin is too slow and not indicated for emergent INR reversal. Continuing warfarin with an INR of 3.5 carries a significant bleeding risk. Immediate surgery without reversal is highly dangerous. Balancing the risk of bleeding with the need for prompt surgery is critical, and PCC combined with Vitamin K offers the quickest and safest pathway.

Question 28

A 25-year-old male presents with a painful, swollen knee following a twisting injury while playing soccer. There is a large effusion, and he has limited range of motion. Aspiration of the knee joint yields frank blood. Which of the following injuries is most likely?

Explanation

Hemarthrosis (frank blood in the joint) after acute knee trauma, especially a twisting injury, is highly indicative of a significant intra-articular injury with rich blood supply. The most common cause is an Anterior Cruciate Ligament (ACL) tear, which involves disruption of the highly vascular ACL. Other causes include osteochondral fractures, peripheral meniscal tears (less common to cause frank hemarthrosis on their own), and patellar dislocations. Isolated meniscus tears or MCL sprains, prepatellar bursitis, and patellar tendinitis typically do not cause frank hemarthrosis. An MCL sprain is extra-articular.

Question 29

A 50-year-old male sustains a severe crush injury to his right forearm, resulting in an open, comminuted radius and ulna fracture. The patient is hemodynamically stable. After initial debridement and external fixation, what is the most appropriate next step in the management of the soft tissue defect?

Explanation

For severe open fractures with significant soft tissue defects (often Gustilo-Anderson Type IIIB or higher), immediate primary closure or skin grafting is often contraindicated due to contamination and swelling, which would lead to high rates of infection or graft failure. The 'vacuum-assisted closure (VAC) device, followed by delayed definitive soft tissue coverage (e.g., local or free flap)' is a common and effective strategy. The VAC device helps manage exudate, reduces edema, promotes granulation tissue formation, and prepares the wound bed for subsequent definitive soft tissue coverage, which typically occurs within 5-7 days of injury, or after multiple debridements depending on wound status. Repeated debridements are often necessary, but the soft tissue defect needs a plan. Amputation is a last resort for unsalvageable limbs.

Question 30

A 3-year-old child presents with a spiral fracture of the tibia (toddler's fracture) after a minor fall. He is otherwise healthy. What is the most appropriate treatment?

Explanation

A 'toddler's fracture' is a common, often minimally or non-displaced spiral or oblique fracture of the distal tibia in young children (typically 9 months to 3 years old), usually caused by low-energy trauma. The treatment is conservative, typically with a short leg walking cast for 3-4 weeks. These fractures heal reliably well with excellent outcomes. Rigid or long-term casting is unnecessary. Intramedullary nailing, external fixation, or surgical exploration and plating are overly aggressive and inappropriate for this benign fracture.

Question 31

A 60-year-old female presents with acute pain and deformity in her wrist after a fall onto an outstretched hand. Radiographs show a Galeazzi fracture-dislocation (fracture of the distal radius with dislocation of the distal radioulnar joint). What is the preferred treatment for this injury in an adult?

Explanation

A Galeazzi fracture-dislocation in an adult is an inherently unstable injury and typically requires open reduction and internal fixation (ORIF) of the radial shaft fracture to restore its length and rotation. Once the radius is anatomically reduced and fixed, the distal radioulnar joint (DRUJ) usually reduces spontaneously. The DRUJ must then be assessed for stability, and if unstable, it may require temporary K-wire fixation across the DRUJ and/or repair of the TFCC. Closed reduction and casting are rarely successful in adults due to the instability of the DRUJ. External fixation is generally reserved for severe open injuries or as a temporary measure. Percutaneous pinning is inadequate for this fracture pattern. DRUJ fusion is a salvage procedure, not a primary treatment.

Question 32

A 30-year-old motorcyclist sustains a pelvic fracture after a high-speed collision. He is hemodynamically unstable, with a systolic blood pressure of 80 mmHg. Initial assessment reveals a widely displaced open book pelvic fracture (APC Type III). What is the immediate life-saving intervention?

Explanation

In a hemodynamically unstable patient with a widely displaced open book pelvic fracture (APC Type III), applying a pelvic binder or sheet is the immediate life-saving intervention. This maneuver closes the 'open book,' reduces the pelvic volume, and tamponades bleeding from disrupted venous plexuses and cancellous bone, thus stabilizing the pelvis and reducing ongoing hemorrhage. This should be done concurrently with volume resuscitation (crystalloids and blood products). While external fixation, angiography with embolization, and eventual internal fixation are critical parts of definitive management, they are not the first immediate step. Volume resuscitation is ongoing, but mechanical stabilization of the pelvis is crucial to stemming the source of hemorrhage.

Question 33

A 55-year-old male with a history of chronic alcoholism presents with a displaced femoral neck fracture. He is deemed unfit for total hip arthroplasty due to significant medical comorbidities. Which of the following is the most appropriate surgical option?

Explanation

For a displaced femoral neck fracture in an elderly patient with significant medical comorbidities who is deemed unfit for a more extensive procedure like THA, hemiarthroplasty is often the preferred choice. It offers immediate stability, allows for early mobilization, and has a lower operative time and complexity compared to THA. ORIF with cannulated screws in displaced femoral neck fractures in older patients carries a high risk of avascular necrosis and non-union, which would necessitate revision surgery in a frail patient. Non-operative management leads to prolonged bed rest and its associated complications. THA is typically for more active or healthier patients. DHS is not used for femoral neck fractures.

Question 34

A 12-year-old boy sustains a physeal injury to his distal tibia (Salter-Harris Type II) after a sports injury. The fracture is minimally displaced. What is the most important factor to counsel the parents about regarding potential long-term complications?

Explanation

Salter-Harris fractures involve the physis (growth plate) and, therefore, carry a risk of growth disturbance. For a Salter-Harris Type II fracture, the fracture line extends through the physis and into the metaphysis, but spares the epiphysis. While generally having a good prognosis, any physeal injury has the potential for premature physeal closure, leading to growth arrest and subsequent angular deformity (e.g., limb length discrepancy or malalignment). The risk increases with the severity of the Salter-Harris type (Type V being the highest risk) and the extent of growth plate damage. Infection, avascular necrosis, and post-traumatic arthritis are less common or primary concerns for this specific injury type. Recurrent sprains are not a direct complication of a physeal fracture.

Question 35

A 30-year-old male sustains a Lisfranc injury (tarsometatarsal joint complex) after a motor vehicle accident. Radiographs show diastasis between the first and second metatarsal bases, and displacement. Which of the following is the most appropriate management for this injury?

Explanation

Lisfranc injuries, especially with displacement and instability, are serious foot injuries that can lead to significant long-term disability if not treated adequately. Open reduction and internal fixation (ORIF) with screws is the gold standard for displaced and unstable Lisfranc injuries. The goal is anatomical reduction and stable fixation of the tarsometatarsal joints to restore the arch and prevent post-traumatic arthritis. Non-operative management is reserved for truly non-displaced, stable injuries, which must be confirmed with stress radiographs. Primary arthrodesis may be considered for highly comminuted or chronically symptomatic joints, but not typically as the primary approach for acute, reconstructible injuries. External fixation is usually temporary for severe open injuries. Fixing only the first ray is insufficient for a global Lisfranc injury.

Question 36

A 60-year-old female sustains a fall directly onto her elbow. Radiographs show a comminuted olecranon fracture with significant displacement and involvement of the articular surface. What is the most appropriate management?

Explanation

A displaced, comminuted olecranon fracture with articular involvement significantly disrupts the extensor mechanism of the elbow and the joint surface. Open reduction and internal fixation (ORIF) is the standard treatment to restore articular congruity and the extensor mechanism. Tension band wiring is effective for simple transverse fractures, while plate and screw fixation is often preferred for comminuted or oblique fractures to achieve stable fixation and allow early range of motion. Non-operative management is only for non-displaced fractures with an intact extensor mechanism. Excision of the olecranon is considered for very small, highly comminuted fragments or in older, low-demand patients, but typically not for significant articular involvement. Radial head replacement is for radial head fractures. Skeletal traction is not used for olecranon fractures.

Question 37

A 45-year-old male sustains a fall from a roof and is found to have a C5 burst fracture with incomplete spinal cord injury (ASIA C). He has significant pain and weakness. Which of the following is the most appropriate immediate management strategy?

Explanation

For an unstable cervical spine fracture (like a burst fracture) with an incomplete spinal cord injury (ASIA C), immediate surgical decompression and stabilization are generally indicated. Early surgical intervention aims to relieve pressure on the spinal cord, restore spinal alignment, and stabilize the spine, potentially improving neurological recovery. While initial immobilization (hard collar) and pain control are important, they are not definitive. High-dose methylprednisolone is no longer routinely recommended for acute spinal cord injury due to lack of clear benefit and potential for harm. Traction may be used for specific fracture patterns or dislocations, but not as the sole immediate definitive management for a burst fracture with neurological deficit. MRI is crucial for assessing cord compression, but if the fracture type is clear and neurological deficit present, delaying surgery for observation is inappropriate.

Question 38

A 30-year-old female presents with a chronic, symptomatic non-union of the scaphoid after 12 months. Radiographs show sclerosis and cystic changes at the fracture site, with no signs of avascular necrosis of the proximal pole. What is the most appropriate surgical management?

Explanation

For a chronic scaphoid non-union without avascular necrosis of the proximal pole, a non-vascularized bone graft (often from the distal radius or iliac crest) combined with internal fixation (typically a headless compression screw) is the standard surgical management. The bone graft provides osteoconductive and osteoinductive properties, promoting union, while the screw provides stable compression. Vascularized bone grafts are reserved for cases with avascular necrosis of the proximal pole or failed non-vascularized grafts. Continued cast immobilization is unlikely to succeed after 12 months. Percutaneous screw fixation is for acute, non-displaced fractures. Proximal row carpectomy is a salvage procedure for severe wrist arthritis or failed multiple procedures.

Question 39

A 16-year-old male sustains a fracture through the base of the first metatarsal, extending into the articular surface, with lateral displacement of the metatarsal. Which of the following describes this injury?

Explanation

A fracture through the base of the first metatarsal, extending into the articular surface, with lateral displacement of the metatarsal, is characteristic of a Bennett's fracture. This is an intra-articular fracture-dislocation of the base of the first metacarpal (typically, the question mistakenly says metatarsal, but Bennett's classically refers to the hand). Assuming the question intended 'first metacarpal,' this is a Bennett's fracture. Jones fracture is a transverse fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal. Stress fractures are typically hairline fractures. Dancer's fracture (or spiral fracture of the fifth metatarsal) is usually a result of inversion and plantarflexion. Avulsion fracture of the base of the 5th metatarsal is due to pull from the peroneus brevis tendon.

Question 40

A 40-year-old male sustains an anterior glenohumeral dislocation. After successful closed reduction, what is the most important radiographic view to obtain to assess for associated injuries?

Explanation

After closed reduction of an anterior glenohumeral dislocation, the axillary view is the most important radiographic view. It is crucial for confirming concentric reduction and for detecting associated injuries such as a Hill-Sachs lesion (compression fracture of the posterior humeral head), bony Bankart lesion (fracture of the anteroinferior glenoid rim), or greater tuberosity fracture. While AP and Y-scapular views are important for initial diagnosis and pre-reduction assessment, they may not adequately visualize these specific associated injuries post-reduction. The Stryker notch view is specifically for Hill-Sachs lesions, and the outlet view is for impingement, but the axillary view provides a comprehensive post-reduction assessment.

Question 41

A 2-year-old child presents with a femoral shaft fracture. What is the most appropriate initial management for this injury in a healthy child of this age?

Explanation

For a femoral shaft fracture in a healthy child aged 6 months to 5 years (some sources say up to 6 years), an immediate spica cast is the preferred initial management. Children in this age group have excellent remodeling potential, and a spica cast effectively immobilizes the fracture, allows for early discharge, and has high union rates. Skeletal traction followed by a spica cast is a valid older method but is more cumbersome and requires hospitalization. Flexible intramedullary nailing is typically for children aged 6-12 years. External fixation is reserved for open fractures, polytrauma, or significant soft tissue injury. Submuscular plating is also for older children or specific fracture patterns.

Question 42

A 55-year-old male presents with a neglected mallet finger deformity (flexion deformity of the DIP joint) that occurred 6 months ago. He complains of pain and difficulty with fine motor tasks. Which of the following is the most appropriate management?

Explanation

A neglected mallet finger (extensor tendon rupture at the DIP joint) of 6 months duration, causing pain and functional deficit, is unlikely to resolve with continued splinting. Surgical reconstruction of the extensor tendon is the most appropriate management in such cases, often involving tendon repair or grafting, potentially with K-wire stabilization. This aims to restore active extension at the DIP joint. DIP joint fusion is a salvage procedure for severe arthritis or failed reconstructions, sacrificing motion. PIP joint manipulation is not relevant to a DIP joint injury. Steroid injections are not indicated for tendon ruptures.

Question 43

A 40-year-old male sustains a direct blow to the lateral aspect of his knee. He has severe pain and inability to bear weight. Radiographs show a depressed lateral tibial plateau fracture (Schatzker Type II). Which of the following is the most critical aspect of surgical management?

Explanation

For a depressed lateral tibial plateau fracture (Schatzker Type II), the critical aspect of surgical management is the elevation of the depressed articular segment and support of the elevated segment with a bone graft (autograft or allograft), followed by stable plate and screw fixation. This aims to restore articular congruity and mechanical alignment of the joint, which is paramount to preventing post-traumatic arthritis. While external fixation might be used temporarily for severe open injuries, it's not the definitive articular management. Arthroscopic debridement alone is insufficient. Primary knee arthroplasty is a salvage procedure for severe arthritis, not acute fractures. Repair of the lateral collateral ligament might be needed if injured, but the primary pathology is the articular depression.

Question 44

A 28-year-old male sustains an open Monteggia fracture-dislocation (ulnar shaft fracture with radial head dislocation). Which of the following is the most important principle of surgical management?

Explanation

A Monteggia fracture-dislocation (ulnar shaft fracture with associated radial head dislocation) is an unstable injury. The key principle of surgical management in adults is to anatomically reduce and stably fix the ulnar shaft fracture (typically with a plate and screws). Once the ulnar length and alignment are restored, the radial head dislocation usually reduces spontaneously. The radial head reduction must then be confirmed both clinically and radiographically. If the radial head remains dislocated after ulnar fixation, soft tissue interposition or annular ligament injury may require further exploration. Closed reduction and casting are rarely successful in adults. Radial head excision is generally avoided in younger patients. External fixation is reserved for severe open injuries. Primary elbow arthrodesis is a salvage procedure.

Question 45

A 6-year-old boy presents with pain and swelling in his forearm after a fall. Radiographs show a greenstick fracture of both the radius and ulna, with apex dorsal angulation. What is the most appropriate management?

Explanation

Greenstick fractures are incomplete fractures common in children. While they have excellent remodeling potential, significant angulation (especially apex dorsal) needs to be corrected to prevent malunion and functional impairment, particularly in the forearm where rotation is critical. Closed reduction under anesthesia, followed by a long arm cast, is the standard treatment for displaced greenstick forearm fractures. The intact cortex on the concave side of the fracture must often be completed (broken) during reduction to prevent recurrent angulation. Rigid cast immobilization without reduction is inappropriate for significant angulation. ORIF or elastic nailing are reserved for highly unstable or irreducibility fractures. Dynamic splinting is not sufficient for an acute fracture.

Question 46

A 25-year-old male sustains a femoral shaft fracture. During reaming for intramedullary nailing, he experiences a sudden drop in end-tidal CO2, hypoxia, and hypotension. The surgical team suspects fat embolism. What is the most appropriate immediate therapeutic intervention?

Explanation

When fat embolism is suspected during intramedullary nailing, the most appropriate immediate therapeutic intervention is to stop reaming and ventilate the patient with 100% oxygen. This stops the ongoing embolization and maximizes oxygen delivery to combat the hypoxia. While vasopressors might be needed to support blood pressure and optimizing ventilation is part of supportive care, stopping the causative factor and addressing hypoxia directly are paramount. High-dose corticosteroids have not shown consistent benefit. Heparin is not indicated for fat embolism syndrome as it's not a thrombotic event.

Question 47

A 48-year-old female presents with a chronic posterior malleolus non-union of her ankle fracture, leading to persistent pain and instability. What is the most likely long-term complication if this is left untreated?

Explanation

The posterior malleolus is a weight-bearing portion of the ankle joint and contributes significantly to ankle stability and congruity, especially when it involves more than 25-30% of the articular surface. A chronic non-union of the posterior malleolus, particularly if displaced or involving a significant portion of the articular surface, will lead to altered biomechanics, joint incongruity, and progressive degeneration of the ankle joint, ultimately resulting in post-traumatic arthritis. While chronic instability is a symptom, arthritis is the major long-term pathological consequence. Avascular necrosis of the talus is more common with talar neck fractures. Peroneal tendonitis and tarsal tunnel syndrome are less direct consequences of a posterior malleolus non-union.

Question 48

A 35-year-old male sustains a high-energy trauma with a closed Schatzker Type VI tibial plateau fracture. The patient is hemodynamically stable. Which of the following is the most appropriate initial surgical approach?

Explanation

A Schatzker Type VI tibial plateau fracture involves a dissociation of the metaphysis from the diaphysis and often extends into the articular surface, representing a highly unstable, complex injury. For a hemodynamically stable patient, immediate definitive open reduction and internal fixation (ORIF) is often the preferred treatment. This involves restoring the articular surface, buttressing the metaphysis, and fixing the diaphyseal dissociation. While temporary external fixation can be used for damage control in polytrauma or for swelling, definitive ORIF is typically pursued as early as soft tissue conditions allow. Non-operative management is unsuitable for such unstable fractures. Primary knee arthrodesis is a salvage procedure. Arthroscopic reduction is typically for less complex, well-contained fractures (e.g., Schatzker Type I or II non-depressed fractures).

Question 49

A 78-year-old female with severe dementia and multiple comorbidities sustains a stable, non-displaced pubic rami fracture after a ground-level fall. She is otherwise neurologically intact. What is the most appropriate management?

Explanation

For a stable, non-displaced pubic rami fracture, especially in an elderly patient with comorbidities, the management is almost always non-operative. The primary goal is pain control to allow for early mobilization as tolerated. Prolonged bed rest is associated with significant complications in the elderly (e.g., pneumonia, DVT, pressure ulcers, deconditioning). Surgical stabilization or external fixation are reserved for unstable pelvic fractures. MRI is not necessary for a confirmed stable fracture without suspicion of neurological injury or occult instability.

Question 50

A 25-year-old male presents with a painful, swollen wrist after punching a wall. Radiographs show a fracture of the neck of the fifth metacarpal, with 40 degrees of volar angulation. Which of the following is the most appropriate management?

Explanation

A fracture of the neck of the fifth metacarpal (Boxer's fracture) with 40 degrees of volar angulation typically requires reduction to prevent rotational deformity and functional impairment. Closed reduction, often by applying axial pressure and flexion to the digit, followed by immobilization in an ulnar gutter splint with the metacarpophalangeal (MCP) joint flexed to 90 degrees (which uses the collateral ligaments to stabilize the fracture), is the standard of care. Acceptable angulation is generally up to 30-40 degrees for the 5th metacarpal. A short arm cast without proper MCP joint positioning is inadequate. ORIF or K-wire fixation is reserved for irreducible fractures, severe angulation (>40-50 degrees), or rotational deformity. Excision of the metacarpal head is a salvage procedure.

Question 51

A 5-year-old child sustains a displaced femoral shaft fracture. Which of the following is the most appropriate definitive management option given the child's age?

Explanation

For a displaced femoral shaft fracture in a 5-year-old, a spica cast is a highly effective and widely used definitive treatment. Children in this age group have excellent remodeling potential, and a spica cast provides stable immobilization allowing for good functional outcomes. Flexible intramedullary nailing is typically reserved for children aged 6 to 12 years. Rigid intramedullary nailing is for older adolescents/adults due to growth plate risk. External fixation is usually for open fractures or polytrauma. Open reduction and plate fixation are less common for this age group unless other methods are contraindicated or fail.

Question 52

A 32-year-old male sustains a proximal humerus fracture after a motorcycle accident. Radiographs show a displaced two-part surgical neck fracture. What is the most appropriate management in this young, active patient?

Explanation

For a displaced two-part surgical neck fracture of the humerus in a young, active patient, open reduction and internal fixation (ORIF) with a locking plate is the preferred treatment. This approach aims to achieve anatomical reduction and stable fixation, preserving the native humeral head and allowing for early rehabilitation to restore function. Non-operative management is typically for minimally displaced or impacted fractures. Hemiarthroplasty or reverse shoulder arthroplasty are prosthetic replacements usually reserved for older patients, poor bone quality, or complex fractures where ORIF is not feasible or likely to fail. Intramedullary nailing can be used for certain surgical neck fractures, but locking plates offer good stability, especially for two-part surgical neck fractures.

Question 53

A 60-year-old male with a history of diabetes and peripheral neuropathy sustains a foot injury. He presents with a plantar ulcer and radiographic evidence of a midfoot collapse and bone fragmentation consistent with Charcot neuroarthropathy. Which of the following is the most appropriate management principle?

Explanation

Charcot neuroarthropathy in the acute 'Eichenholtz Stage I' (fragmentation/destruction) or 'rocker-bottom' foot with ulceration requires aggressive non-operative management initially. This primarily involves strict non-weight-bearing in a total contact cast (TCC) to protect the foot, reduce inflammation, and allow for healing, often for several months. Surgical reconstruction is considered only after the acute inflammatory phase has subsided ('Stage III coalescence') and the foot is stable, and only for specific indications such as severe deformity preventing bracing or recurrent ulceration. Amputation is a last resort. Debridement and antibiotics are essential for the ulcer but do not address the Charcot process itself. Strict bed rest is not practical or necessary; controlled weight-bearing in a TCC is the key.

Question 54

A 10-year-old child sustains a Salter-Harris Type IV fracture of the distal tibia. The fracture is displaced. Which of the following is the most significant concern regarding potential complications?

Explanation

A Salter-Harris Type IV fracture involves a fracture line extending through the epiphysis, physis, and metaphysis. This type of fracture directly violates the growth plate and involves the germinal cells, carrying a significantly high risk of growth arrest and angular deformity if not anatomically reduced and stably fixed. The risk of growth arrest is higher than Type I, II, or III fractures. While vascular or nerve injury and compartment syndrome are general trauma concerns, they are not specific to Type IV Salter-Harris in the way growth arrest is. Non-union is less of a concern than growth arrest in this particular fracture type.

Question 55

A 28-year-old male sustains a traumatic knee dislocation. After successful reduction, he has a palpable popliteal pulse, but decreased sensation in the foot and weakness of ankle dorsiflexion. Which nerve injury is most likely involved?

Explanation

Knee dislocations are high-energy injuries associated with a high risk of neurovascular damage. The common peroneal nerve is the most frequently injured nerve in knee dislocations, especially posterolateral dislocations. Injury to the common peroneal nerve typically manifests as weakness of ankle dorsiflexion (foot drop) and eversion, and sensory loss over the dorsum of the foot and lateral leg. While the popliteal pulse is palpable, nerve injury can occur independently of major vascular injury. Femoral and obturator nerves are less commonly injured. Sciatic nerve injury is less specific to knee dislocation compared to common peroneal. Tibial nerve injury would cause weakness of ankle plantarflexion and toe flexion, and sensory loss on the plantar foot.

Question 56

A 70-year-old male falls and sustains a femoral neck fracture. He has a history of Parkinson's disease, severe osteoporosis, and is minimally ambulatory with a walker. Radiographs show a displaced Garden Type IV femoral neck fracture. What is the most appropriate surgical management?

Explanation

For an elderly patient with significant comorbidities (Parkinson's, severe osteoporosis, minimally ambulatory) and a displaced femoral neck fracture, hemiarthroplasty is generally the most appropriate surgical option. It offers immediate stability, allowing for early mobilization and weight-bearing, which is crucial to prevent complications of prolonged bed rest in this frail population. It is a less extensive procedure than THA and associated with lower dislocation rates in patients with cognitive impairment. ORIF has a high failure rate (non-union, avascular necrosis) in displaced fractures in elderly patients with osteoporosis. THA is typically reserved for more active patients or those with pre-existing arthritis. Non-operative management is associated with high mortality and morbidity. DHS is not used for femoral neck fractures.

Question 57

A 40-year-old male sustains a comminuted fracture of the distal humerus (AO Type C3) with significant articular involvement. Which of the following is the most important principle for surgical management to optimize functional outcome?

Explanation

A comminuted distal humerus fracture with significant articular involvement (AO Type C3) is a challenging injury. The most important principle for optimizing functional outcome is anatomical reduction of the articular surface and stable internal fixation. This typically involves dual plating (medial and lateral) to restore the column integrity and reconstruct the articular surface, allowing for early range of motion. Early immobilization leads to severe stiffness. External fixation may be used temporarily but not as a definitive treatment for articular reconstruction. Excision of fragments sacrifices bone and can lead to instability. Radial head replacement is for radial head fractures, not the distal humerus itself.

Question 58

A 14-year-old male sustains a displaced epiphyseal fracture of the medial epicondyle of the humerus. Radiographs show the fragment is incarcerated in the elbow joint. Which of the following is the most appropriate management?

Explanation

A displaced medial epicondyle fracture, especially if incarcerated within the elbow joint, requires open reduction and internal fixation (ORIF). The fragment needs to be anatomically reduced and fixed (typically with a screw or K-wires) to restore elbow stability and prevent ongoing mechanical blockage or ulnar nerve irritation. Attempting closed reduction is unlikely to succeed if the fragment is truly incarcerated. Excision is generally avoided in a growing child to preserve the physis. Observation or traction are inappropriate for an incarcerated fragment.

Question 59

A 65-year-old female presents with acute pain and swelling in her distal forearm after a fall. Radiographs show a distal radius fracture (Colles' type) with significant dorsal displacement and shortening. She has good bone quality. What is the most appropriate management strategy for this active patient?

Explanation

For a displaced distal radius fracture with significant dorsal displacement and shortening in an active 65-year-old with good bone quality, volar locking plate fixation is generally considered the preferred management. It allows for anatomical reduction and stable internal fixation, permitting early range of motion and leading to better functional outcomes compared to casting, external fixation, or percutaneous pinning for significantly displaced fractures. Closed reduction and casting may not maintain reduction for unstable fractures. External fixation or percutaneous pinning are options, but locking plates often provide superior stability and earlier return to function for this type of injury in active patients.

Question 60

A 50-year-old male sustains an isolated unstable ankle fracture-dislocation. After successful closed reduction, the ankle mortise is still widened, especially medially. Which of the following is the most likely additional injury?

Explanation

Widening of the ankle mortise, particularly medially after reduction of an ankle fracture-dislocation (assuming the malleoli are addressed or the fracture doesn't explain the widening), strongly suggests a syndesmotic injury (disruption of the tibiofibular ligaments). This instability needs to be addressed surgically, typically with syndesmotic screws or a suture-button device, to stabilize the distal tibiofibular joint. Other injuries listed are possible but do not directly explain the mortise widening after reduction. Posterior tibial tendon rupture, fibular head fracture, talus osteochondral lesion, and calcaneal fracture do not typically result in persistent ankle mortise widening.

Question 61

A 2-month-old infant presents with a transverse femoral shaft fracture after a suspicious mechanism of injury. What is the most critical next step in management beyond fracture care?

Explanation

In an infant (typically under 1 year, but often up to 2 years), a transverse femoral shaft fracture, especially with a suspicious mechanism, raises high concern for non-accidental injury (child abuse). The most critical next step, beyond stabilizing the fracture, is a referral to a child protection team (social services). A skeletal survey for other occult fractures and an MRI of the brain (for subdural hematomas) are also important investigations to complete the workup for abuse, but the referral ensures the safety of the child. A Pavlik harness is for developmental dysplasia of the hip. Traction and spica cast are for fracture management but not the immediate priority for investigation of abuse.

Question 62

A 45-year-old male sustains a traumatic amputation of the thumb at the metacarpophalangeal (MCP) joint level. He is otherwise stable, and the amputated part is viable. What is the most appropriate management plan?

Explanation

Thumb amputation, even at the MCP joint level, is a critical injury due to the thumb's immense functional importance (accounting for approximately 50% of hand function). Therefore, replantation of a viable thumb is generally the preferred management whenever technically feasible, regardless of the level of amputation. Primary closure, delayed revision, or skin grafting are considered only if replantation is not possible or contraindicated. Toe-to-hand transfer is a reconstructive option for failed replantation or unavailable parts, not a primary procedure for an acutely viable amputated thumb.

Question 63

A 60-year-old female presents with a painful shoulder after a fall. Radiographs show a posterior dislocation of the glenohumeral joint with a large reverse Hill-Sachs lesion (impaction fracture of the anteromedial humeral head). What is the most appropriate management for this specific injury pattern?

Explanation

A posterior shoulder dislocation with a large reverse Hill-Sachs lesion (often referred to as a 'locked posterior dislocation') indicates significant bone loss from the humeral head, which can prevent successful closed reduction or lead to recurrent dislocation if left unaddressed. Open reduction and internal fixation (ORIF) of the reverse Hill-Sachs lesion (e.g., using an allograft, autograft, or filling with a bone paste) combined with capsular repair or subscapularis tenodesis is often required to restore articular congruity and stability. Immobilization in external rotation (rather than internal) may be used after reduction for anterior dislocations, but for posterior dislocations, immobilization in internal rotation is typically used. However, for a locked dislocation with a large bony defect, simple immobilization won't suffice. Hemiarthroplasty is for severely comminuted fractures or significant humeral head destruction. Diagnostic arthroscopy may be part of the workup but not the definitive treatment for a large bony lesion.

Question 64

A 28-year-old male falls from a ladder and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body?

Explanation

Hawkins Type III fractures involve dislocation of the talar body from both the subtalar and tibiotalar joints. This disrupts all three major blood supplies to the talar body, leading to an AVN rate approaching 100%.

Question 65

A 24-year-old male sustains a closed, spiral fracture of the distal third of his humerus (Holstein-Lewis fracture). On examination, he has a complete radial nerve palsy that was present immediately after the injury. What is the most appropriate initial management of the radial nerve?

Explanation

Closed humeral shaft fractures with immediate radial nerve palsy are generally managed non-operatively with bracing, as up to 90% resolve spontaneously. Surgical exploration is indicated for open fractures, penetrating trauma, or secondary palsy after closed manipulation.

Question 66

A hemodynamically unstable 35-year-old male arrives in the trauma bay after a motorcycle collision. Radiographs show an Anteroposterior Compression (APC) Type III pelvic ring injury. A pelvic binder has been applied but he remains hypotensive despite aggressive fluid resuscitation. FAST scan is negative. What is the most appropriate next step?

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and negative FAST, retroperitoneal hemorrhage is the most likely cause. Preperitoneal pelvic packing and angioembolization are the primary life-saving interventions to control this bleeding.

Question 67

A 22-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid waist nonunion with a humpback deformity and dorsal intercalated segment instability (DISI). No arthritic changes are present. Which of the following is the most appropriate surgical treatment?

Explanation

A scaphoid nonunion with a humpback deformity (volar flexion of the scaphoid) and DISI requires correction of the deformity to restore carpal kinematics. A volar wedge graft with internal fixation achieves structural deformity correction and restores length.

Question 68

A 40-year-old farmer sustains an open tibial shaft fracture heavily contaminated with soil (Gustilo-Anderson IIIB). He has a documented history of severe anaphylaxis to penicillin. According to current guidelines, what is the most appropriate initial intravenous antibiotic regimen?

Explanation

Farm injuries require coverage for Gram-positive, Gram-negative, and anaerobic organisms (specifically Clostridium). In a patient with an anaphylactic penicillin allergy, Clindamycin provides anaerobic and Gram-positive coverage, while high-dose Gentamicin covers Gram-negative organisms.

Question 69

A 38-year-old female sustains a Schatzker VI tibial plateau fracture. Post-operatively, she develops increasing pain and paresthesias in the first web space of her foot. Measurement of compartment pressures reveals a deep posterior compartment pressure of 35 mmHg and a diastolic blood pressure of 60 mmHg. What is the most accurate interpretation?

Explanation

Delta pressure is calculated as diastolic blood pressure minus compartment pressure (60 - 35 = 25 mmHg). A delta pressure of less than 30 mmHg in the setting of clinical signs of compartment syndrome is an absolute indication for emergency fasciotomy.

Question 70

A 45-year-old male sustains a high-energy distal femur fracture. CT imaging reveals a coronal plane fracture of the lateral femoral condyle. What is the standard classification for this specific fracture pattern, and what is the preferred fixation strategy?

Explanation

A coronal shear fracture of the femoral condyle is known as a Hoffa fracture. Fixation is best achieved using posterior-to-anterior lag screws inserted perpendicular to the fracture line to maximize compression and minimize hardware prominence in the joint.

Question 71

A 28-year-old male is brought in after a motor vehicle accident with a closed bilateral femoral shaft fracture, severe pulmonary contusions, and a GCS of 8. His initial lactate is 5.5 mmol/L. What is the most appropriate management of his femur fractures?

Explanation

In a polytraumatized patient who is borderline or unstable (pulmonary contusions, high lactate, closed head injury), Damage Control Orthopedics (DCO) with external fixation is indicated. This minimizes the second hit of the systemic inflammatory response associated with prolonged surgery and intramedullary reaming.

Question 72

A 7-year-old boy falls on an outstretched hand and presents with a swollen, painful forearm. Radiographs demonstrate a fracture of the proximal third of the ulna with an associated anterior dislocation of the radial head. What is the eponym for this injury pattern?

Explanation

A Monteggia fracture-dislocation consists of a proximal third ulnar shaft fracture with a radial head dislocation. Bado Type I is characterized by an anterior dislocation of the radial head, which is the most common pattern in the pediatric population.

Question 73

A 24-year-old athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm widening between the base of the 1st and 2nd metatarsals. What is the primary stabilizing structure disrupted in this injury?

Explanation

The Lisfranc ligament is a critical interosseous ligament connecting the medial cuneiform to the base of the second metatarsal. Disruption of this ligament destabilizes the tarsometatarsal joint complex, often leading to lateral displacement of the lesser metatarsals.

Question 74

A 42-year-old male sustains a transverse fracture of the acetabulum with a large posterior wall component. Which surgical approach provides the best direct access to address both the posterior wall and the posterior column?

Explanation

The Kocher-Langenbeck is the workhorse posterior approach to the acetabulum. It provides excellent direct visualization for reduction and fixation of posterior wall, posterior column, and specific associated transverse fractures.

Question 75

A 68-year-old female presents with a 4-part proximal humerus fracture. According to Hertel's radiographic criteria, which of the following combinations is the most reliable predictor of subsequent avascular necrosis of the humeral head?

Explanation

Hertel identified specific predictors of ischemia in proximal humerus fractures. The combination of an anatomical neck fracture pattern, a short calcar segment attached to the articular surface (< 8 mm), and a disrupted medial hinge (> 2 mm) has a positive predictive value of 97% for ischemia.

Question 76

A 55-year-old female presents with a distal radius fracture characterized by a volar marginal articular fragment with palmar displacement of the carpus. This injury is best classified as a:

Explanation

A Volar Barton fracture is an intra-articular shear fracture of the volar lip of the distal radius, typically accompanied by subluxation of the radiocarpal joint. It represents a highly unstable pattern requiring open reduction and buttress plating.

Question 77

A 33-year-old roofer falls 15 feet, landing directly on his heels. Radiographs show a displaced intra-articular calcaneal fracture with a severely flattened Bohler's angle. What are the normal anatomic landmarks used to measure Bohler's angle?

Explanation

Bohler's angle is determined on a lateral radiograph by drawing a line from the highest point of the anterior process to the highest point of the posterior facet, and another line from the posterior facet to the superior edge of the calcaneal tuberosity. The normal angle is 20 to 40 degrees.

Question 78

A 70-year-old female on long-term alendronate therapy presents with acute thigh pain after stepping off a curb. Radiographs show a transverse subtrochanteric fracture with lateral cortical thickening and a medial spike. Which of the following is an essential step in her management?

Explanation

Bisphosphonate-associated atypical femur fractures require immediate cessation of the medication and evaluation of the contralateral femur, as bilateral involvement occurs in up to 30% of patients. Fixation of the symptomatic fractured side is typically achieved with an intramedullary nail.

Question 79

A 26-year-old male sustains an external rotation injury to his ankle. Radiographs show a widened medial clear space and a proximal fibular shaft fracture (Maisonneuve). What is the most appropriate intraoperative test to assess the integrity of the distal tibiofibular syndesmosis after fibular fixation?

Explanation

The Cotton test, or lateral hook test, is performed intraoperatively by grasping the fibula with a bone hook and applying a lateral force under fluoroscopy. Widening of the syndesmosis under stress confirms instability requiring syndesmotic fixation.

Question 80

A 40-year-old male polytrauma patient presents with a blood pressure of 70/40 mmHg. Pelvic radiographs reveal an Anteroposterior Compression Type III (APC-III) pelvic ring injury. A pelvic binder is applied, and 2 units of PRBCs are administered, but his blood pressure remains 75/45 mmHg. A FAST exam is negative. What is the most appropriate next step in management?

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, the bleeding is likely from the retroperitoneal venous plexus or arterial sources. After mechanical stabilization with a binder, pelvic angiography with embolization is the intervention of choice for persistent arterial hemorrhage.

Question 81

A 6-year-old boy falls onto an outstretched hand and sustains a Gartland Type III supracondylar humerus fracture. On examination, his hand is pink but pulseless, with brisk capillary refill. What is the most appropriate initial management?

Explanation

A pink, pulseless hand in the setting of a displaced supracondylar fracture is typically due to brachial artery kinking or vasospasm. The first step is urgent closed reduction and percutaneous pinning, which relieves the traction on the vessel and frequently restores the palpable pulse.

Question 82

A 30-year-old male sustains a Hawkins Type III talar neck fracture following a high-energy motor vehicle collision. Which of the following vessels provides the primary blood supply to the talar body, placing it at high risk for avascular necrosis (AVN) in this injury?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. A Hawkins Type III fracture involves the talar neck with dislocation of both the subtalar and tibiotalar joints, completely disrupting this critical blood supply.

Question 83

A 25-year-old male polytrauma patient presents with bilateral closed femoral shaft fractures and severe pulmonary contusions. His initial lactate is 5.0 mmol/L, and his core temperature is 34.5°C. According to Damage Control Orthopedics (DCO) principles, what is the best management for his femur fractures?

Explanation

This patient is physiologically unstable with "borderline" or "in extremis" criteria, including coagulopathy, hypothermia, and severe chest trauma. Damage Control Orthopedics (DCO) dictates the use of temporary external fixation to minimize the inflammatory "second hit" associated with early intramedullary nailing.

Question 84

A 45-year-old female sustains a high-energy intra-articular distal femur fracture. A CT scan reveals a coronal plane shear fracture of the lateral femoral condyle. What is the eponym for this specific fracture pattern?

Explanation

A Hoffa fracture is a coronal plane shear fracture of the distal femoral condyle, most commonly affecting the lateral condyle. It is often hidden on standard AP radiographs and requires independent anterior-to-posterior or posterior-to-anterior lag screw fixation.

Question 85

A 22-year-old male presents with wrist pain after a fall. Radiographs reveal a displaced fracture through the proximal pole of the scaphoid. Why does this specific fracture pattern carry a significantly high risk of nonunion and avascular necrosis?

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the distal pole and perfuses the bone in a retrograde fashion. Fractures at the proximal pole isolate the fragment from this retrograde flow, drastically increasing AVN risk.

Question 86

A 35-year-old male sustains a closed, highly comminuted tibial pilon fracture (OTA 43C) with marked soft tissue swelling and fracture blisters circumferentially. What is the optimal initial operative management?

Explanation

Severe pilon fractures with significant soft tissue compromise are best managed with a "span, scan, and plan" protocol. Temporary spanning external fixation allows the precarious soft tissue envelope to heal prior to definitive open reduction and internal fixation.

Question 87

A 40-year-old farmer sustains an open tibial shaft fracture in a barnyard with massive soft tissue stripping and bone loss (Gustilo-Anderson IIIB). According to advanced trauma guidelines, which intravenous antibiotic regimen is most appropriate upon initial presentation?

Explanation

For Gustilo IIIB fractures, gram-positive and gram-negative coverage (like a first-generation cephalosporin and an aminoglycoside) is standard. In environments heavily contaminated with soil or feces (barnyard), Penicillin is added to specifically cover Clostridium species and prevent gas gangrene.

Question 88

A 28-year-old male sustains a posterior hip dislocation and an associated posterior wall acetabular fracture. Following closed reduction, a new ipsilateral foot drop is noted. Which nerve division is most likely injured?

Explanation

The sciatic nerve is at high risk during posterior hip dislocations and posterior wall fractures. The common peroneal division is lateral and securely tethered at the fibular head, making it significantly more susceptible to stretch injuries than the tibial division.

Question 89

An active 75-year-old female presents with a closed 4-part proximal humerus fracture. The humeral head is split, the tuberosities are severely displaced, and radiographs reveal underlying severe glenohumeral osteoarthritis. What is the best definitive surgical management?

Explanation

In elderly patients with poor bone quality, 4-part fractures, and pre-existing osteoarthritis, a Reverse Total Shoulder Arthroplasty (RTSA) provides the most reliable functional recovery. It relies on the deltoid for elevation, mitigating the poor outcomes associated with tuberosity nonunion seen in hemiarthroplasty.

Question 90

A 33-year-old roofer falls from a height, sustaining a closed Sanders Type III calcaneus fracture. If operative intervention via an extensile lateral approach is chosen, what is the most critical clinical indicator of appropriate surgical timing to minimize wound necrosis?

Explanation

The extensile lateral approach to the calcaneus has a notoriously high risk of wound dehiscence and infection. Surgery must be delayed (often 10-14 days) until acute soft tissue swelling subsides, reliably indicated by the appearance of skin wrinkles on the lateral hindfoot.

Question 91

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. Rupture of which specific structure is the primary cause of this diastasis?

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Its disruption results in instability of the tarsometatarsal joint complex, requiring surgical stabilization.

Question 92

A 45-year-old male is involved in a motor vehicle collision, resulting in severe cervical hyperextension. CT of the cervical spine reveals bilateral fractures through the pars interarticularis of C2 with 2 mm of C2-C3 anterior translation. What is the diagnosis?

Explanation

A Hangman's fracture (traumatic spondylolisthesis of the axis) involves bilateral fractures of the C2 pars interarticularis, typically caused by hyperextension and axial loading. Mildly displaced injuries (Levine-Edwards Type I) are generally treated with a rigid cervical collar.

Question 93

A 20-year-old elite collegiate basketball player develops lateral foot pain. Radiographs show a non-displaced transverse fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (Zone 2). To ensure the quickest and most reliable return to sport, what is the recommended treatment?

Explanation

Zone 2 fractures (Jones fractures) occur in a vascular watershed area and have a high rate of nonunion. In competitive athletes, early intramedullary screw fixation is the standard of care to accelerate healing and prevent delayed union or refracture.

Question 94

A 50-year-old male sustains a lateral tibial plateau fracture. CT demonstrates a purely central articular depression with a completely intact lateral cortical rim (Schatzker Type III). What is the preferred surgical approach for elevating the joint surface?

Explanation

In a Schatzker Type III pure depression fracture, the lateral cortex is intact. The joint surface is best elevated by creating a small cortical window in the metaphysis, using a bone tamp to push the depressed fragment superiorly, followed by bone grafting and raft screw fixation.

Orthopedic Trauma MCQs & Clinical Insights: Advanced Exam Preparation

Orthopedic Trauma & Fracture MCQ Practice: Board Exam Preparation

Key Takeaway

Orthopedic Trauma & Fracture MCQ Practice: Board Exam Preparation

Chapter Index