Chapter 12 – Trauma I Structured SBA

Abstract

Trauma I Structured SBA Questions

Chapter 12 Trauma I Structured SBA

Tim Brock and Rishi Dhir

Trauma I Structured SBA Questions

1. A 75-year-old female presents with a shoulder injury following a fall. Radiographs show a fractured proximal humerus (Figure 12.1).

Figure 12.1 (a) Anteroposterior (AP) and (b) lateral scapula view radiographs proximal humerus

Which of the following is NOT a good predictor of humeral head ischaemia?

Basic fracture pattern

Calcar fragment <8mm

Glenohumeral dislocation

Integrity of the medial hinge

Length of the metaphyseal head extension

2. A 35-year-old male sustains a closed proximal tibial fracture and elects to undergo intramedullary nailing. His radiographs are shown in Figure 12.2.

Figure 12.2 (a) Anteroposterior (AP) and (b) lateral radiographs of the right tibia

Which of the following surgical technique is used to prevent a valgus and procurvatum deformity?

Place a coronal Poller (blocking) screw in the anterior half of the distal aspect of the proximal fragment

Place a sagittal Poller (blocking) screw on the medial convex side of the distal aspect of the proximal fragment

Suprapatellar nailing

Use of a nail with a more distally based bend

Using a more medial entry point

3. While playing rugby, a 30-year-old male sustained the injury seen in Figure 12.3, taken on presentation to the ED.

Figure 12.3 Lateral radiograph finger

Which of the following is true?

If reduced and stable, it does not require extension splinting

It can lead to a Swan neck deformity

It has a positive Elson’s test

It is associated with a volar plate injury

It is the most common type of PIPJ dislocation

4. A 40-year-old roofer fell 10 feet off a ladder onto his left foot. Radiograph and CT scan are shown in Figure 12.4.

Figure 12.4 (a) Lateral radiograph calcaneum and (b) sagittal CT view calcaneum

Regarding this injury, which of the following is TRUE?

A reduced angle of Gissane indicates collapse of the posterior facet

An enlarged Bohler’s angle indicates collapse of the posterior facet

Sanders classification is based on the number of articular fragments on the sagittal CT image

The sustentaculum tali (anteromedial) fragment is referred to as the ‘constant fragment’

Double density sign seen on lateral radiographs indicates a superiorly displaced calcaneus fracture/dislocation

5. Regarding radiology for Lisfranc injuries, which of the following is FALSE?

The ‘fleck sign’ is pathognomic and indicates avulsion of the Lisfranc ligament

The ‘step off sign’ is caused by dorsal displacement of the 2nd metatarsal relative to the cuboid

The gap between the 2nd metatarsal and medial cuneiform is <2mm

The medial border of the cuboid should normally line up with the medial border of the 4th metatarsal on the oblique view

The medial edge of the 2nd metatarsal should normally line up with the medial edge of the middle cuneiform on the AP radiograph

6. Which of the following is INCORRECT concerning Lisfranc joint anatomy?

The 2nd tarsometatarsal joint produces the so-called ‘keystone’ in the ‘Roman Arch’

The dorsal ligaments are stronger than the plantar ligaments

There is no intermetatarsal ligament between the 1st and 2nd metatarsals

The Lisfranc ligament runs from the first cuneiform to the medial base of the 2nd metatarsal

The Lisfranc joint is formed by the five metatarsals that articulate with the three cuneiform and cuboid bones

7. Which mode of plating should be ideally used for the distal radius fracture pattern seen in Figure 12.5?

Figure 12.5 Lateral radiograph distal radius

Buttress

Neutralisation

Bridging

Locking

Compression

8. Which of the following techniques mainly produces healing by a high strain fracture environment?

Overdrilling the near cortex to 3.5mm and the far cortex to 2.5mm in a Weber B ankle fracture

Using a partially threaded cancellous screw in a transverse medial malleolar fracture

Drilling an eccentric hole in an LCP plate

Using an articulated compression device

Using hybrid fixation for a periarticular fracture with metaphyseal comminution

9. Regarding the injury shown in Figure 12.6, indications for urgent surgical treatment do NOT include which of the following?

Figure 12.6 Lateral radiograph supracondylar fracture elbow

Absent radial pulse

Threatened skin viability

Capillary refill time of 5 sec

Displacement greater than 100%

Pale hand

10. A 53-year-old male fell down 12 flights of steps onto his right elbow. His radiographs are shown in Figure 12.7.

Figure 12.7 (a) Anteroposterior (AP) radiograph and (b) lateral radiographs fractured distal right humerus

Regarding his injury, which of the following is NOT a technical objective to achieve maximal fixation and stability?

Every screw in the distal fragments should pass through a plate

The screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure

Plates should be strong enough and stiff enough to resist breaking or bending

Each screw should be as long as possible

Lag screw to be used outside the plate to fix fracture fragments

11. A 24-year-old male sustains a type II odontoid fracture following a diving injury.

Regarding anterior pin placement for a Halo device, which of the following is true?

If the pins are placed more laterally, then there is a risk of injury to the orbicularis muscle

Should be placed 2cm above the lateral one-third of the eyebrow

Should be placed below the equator of the skull

Should be placed medial to the supraorbital nerve

The supraorbital nerve exits the skull at the level of the frontal sinus

12. A 26-year-old male patient fell directly on his right shoulder with the arm in an outstretched and overhead position. Pain and swelling were immediate and were associated with a ‘step deformity’. The patient had limited right shoulder range of motion (ROM), strength and function.

Regarding this injury, which of the following statements is correct?

Type II injuries involve rupture of the AC ligament and a CC ligament sprain

Type III injuries involve posterior displacement of the lateral clavicle through the trapezius

Type IV injuries involve rupture of both AC and CC ligaments with increased CC distance of 25–100%.

Type VI injuries involve increased CC distance from 100–300% of contralateral side

Type V injuries involve inferior dislocation of the lateral clavicle

13. A 20-year-old right-handed man sustained a displaced comminuted radial head fracture following a traffic accident.

Regarding fixation of radial head fractures, which of the following is correct?

Kocher’s approach is in the interval between triceps and brachioradialis

PIN palsy causes weakness of wrist extension and abduction

Supination should be performed to protect the posterior interossesus nerve

The capsule should not be dissected too far posteriorly, as the PIN runs over the back of the posterolateral portion of the elbow capsule

The safe zone of fixation is between the radial styloid and Lister’s tubercle

14. A 30-year old patient falls off his motorbike and sustains the injury shown in Figure 12.8. He has a blood pressure of 90/60 and pulse of 110 on arrival in ED.

Figure 12.8 Anteroposterior (AP) radiograph pelvis

Which of the following would initial management NOT include?

Administer tranexamic acid

Apply an external fixator

Apply a pelvic binder

Give FFP and cryoprecipitate

Initiate a massive transfusion protocol

15. A 45-year-old woman has sustained a talar neck fracture following a motor vehicle accident. She has been added to the trauma list for ORIF. The CT1 on call at the time of admission has read up that the possibility of AVN developing in this fracture is high.

The blood supply to the talar neck does NOT include which of the following?

Anterior tibial artery

Artery to tarsal canal

Deltoid branches

Lateral plantar artery

Peroneal artery

16. A toddler was brought to the ED with irritability.

In an investigation of non-accidental injury, which of the following has a high specificity for NAI?

Complex skull fractures

Digital fractures

Femoral fracture in an ambulatory child

Metaphyseal fracture (junction of metaphysis and physis)

Vertebral body fractures

17. A 30-year-old, right-hand-dominant man sustained an isolated injury to the right wrist after a fall from a height of approximately 15 feet. The patient reported that he fell on his outstretched hand with the wrist in extension. The right wrist was painful, swollen and tender to palpation. The hand was neurovascularly intact with no sensory deficit in the distribution of the median nerve. His radiographs are shown in Figure 12.9.

Figure 12.9 (a) Anteroposterior (AP) and (b) lateral radiographs right wrist

In the pathoanatomy of the injury, which of the following lists the events in the correct order?

Failure of lunocapitate ligament – failure of scapholunate ligament – failure of lunotriquetral ligament – lunate dislocates into carpal tunnel

Failure of lunotriquetral ligament – failure of lunocapitate ligament – failure of scapholunate ligament – lunate dislocates into carpal tunnel

Failure of lunotriquetral ligament – failure of scapholunate ligament – failure of lunocapitate ligament – lunate dislocates into carpal tunnel

Failure of scapholunate ligament – failure of lunocapitate ligament – failure of lunotriquetral ligament – lunate dislocates into carpal tunnel

Failure of scapholunate ligament – failure of lunotriquetral ligament- failure of lunocapitate ligament – lunate dislocates into carpal tunnel

18. An 18-year-old tennis player attended the orthopaedic clinic complaining of radial-sided wrist pain after a fall on an outstretched hand. Radiographs have shown a displaced waist of scaphoid fracture.

Regarding the volar approach to the scaphoid, which of the the following statement is FALSE?

It is indicated in distal pole fractures

It is indicated in humpback flexion deformities

It is indicated in proximal pole fractures

It is indicated in waist fractures

It utilises the interval between FCR and the radial artery

19. Which of the following is NOT a content of the anterior compartment of the leg?

Extensor digitorum longus

Extensor hallucis longus

Peroneus longus

Peroneus tertius

Tibialis anterior

20. A 6-year-old boy falls off a trampoline onto his left elbow and sustains the injury noted on radiographs shown in Figure 12.10.

Figure 12.10 (a) Anteroposterior (AP) and (b) lateral radiograph child’s elbow

Regarding the elbow fracture, which of the following statements is CORRECT?

May be associated with wasting of the first dorsal interosseus

Minimally displaced fractures (<2mm gap) should be treated with open reduction internal fixation

The external oblique view is the most accurate view to show fracture displacement

The fracture fragment most often lies anterolateral

When fixed with K-wires, 2mm K-wires should be used

21. A 46-year-old motorcyclist sustains the isolated closed injury (Figure 12.11) after falling off his motorbike at high speed.

Figure 12.11 Anteroposterior (AP) and lateral radiographs tibia

Regarding the initial management of this injury, which of the following is CORRECT?

Intramedullary nailing has better disability ratings at 6 months

Intramedullary nailing is more cost-effective compared to locking plates

Recovery rates for IM nailing and locking plates are equivalent

There is a statistically higher infection rate when using locking plates compared to intramedullary nailing

There is no difference in further surgery between IM nailing and locking plates

22. Principles of elastic (TENS) nails include all of the following except which?

They can be used for comminuted forearm fractures

Nail diameter should be no more than 40% of the isthmus of the medullary canal.

They should be pre-bent to three times the diameter of the isthmus

The apex of the bow of the elastic nail should be at the level of the fracture

The entry point for the nail should be 2.5–3cm proximal to the physis

23. Which of the following increases the pull-out strength of a screw in bone?

Decrease the cortex thickness

Decrease the outer diameter

Decrease the thread density (increased distance between threads)

Increase the inner diameter

Increase the outer diameter

24. Undisplaced distal radius fractures are most associated with the rupture of which structure?

Extensor digitorum communis

Extensor indicis proprius

Extensor pollicis longus

Flexor pollicis brevis

Flexor pollicis longus

25. A 30-year-old patient sustains an epileptic fit and attends the ED complaining of severe right shoulder pain. An anteroposterior (AP) shoulder radiograph is shown in Figure 12.12. It is irreducible in the ED.

Figure 12.12. Anteroposterior (AP) radiograph right shoulder

Which of the following is NOT a recommended treatment option?

Femoral head allograft reconstruction

Reverse shoulder arthroplasty

Rotational osteotomy

Subscapularis transfer +/– lesser tuberosity

Emergency closed reduction under GA

26. A 35-year-old man is found 6 hours after sustaining a comminuted fracture of his right tibia secondary to a high-velocity gunshot wound. He has a systolic BP of 90 but responds well to fluids. He has a weak dorsalis pedis pulse but good capillary refill.

What is his MESS value?

27. Paediatric fractures occur through which layer of the physis?

Maturation zone

Primary spongiosa

Proliferative zone

Reserve zone

Zone of provisional calcification

28. A 25-year-old male was resuscitated after coming off a motorbike at 50mph. He sustained an open humerus fracture, femur and tibia fracture and spinal fracture. His ISS score was 20. After he was resuscitated initially, the trauma team wanted to plan for fixation of his injuries.

In the Early Appropriate Care (EAC) protocol which of the following is INCORRECT regarding fracture fixation?

Base Excess should be >5.5mmol/L

Definitive fixation should be performed within 36 hr of injury

Lactate should be <4mmol/L

Patients should respond to resuscitation with pressor support

pH should be >7.25

29. A 74-year-old man falls downstairs while intoxicated and attends ED complaining of neck pain. Plain lateral radiograph cervical spine is shown in Figure 12.13. He is awake and alert.

Figure 12.13 Lateral radiograph cervical spine

Which of the following is the most appropriate INITIAL management following resuscitation?

Closed reduction in Gardner–Wells tongs with serial traction

Immediate anterior discectomy and fusion

Halo application

MRI and urgent neurosurgical consult

Immediate posterior discectomy and fusion

30. An 80-year-old male presented to the ED with neck pain following a mechanical fall at home. Coronal CT image cervical spin is shown in Figure 12.14.

Figure 12.14 Coronal CT scan cervical spine

Which of the following statements is FALSE in elderly patients with this injury pattern?

Anterior screw fixation is indicated with transverse or posterior oblique fracture lines

Posterior fusion has higher union rates than anterior fixation in type II fractures

Surgical stabilisation of type II fractures improves survival compared to non-surgical treatment in elderly patients (65–85)

The complication rate of non-surgical and surgical treatment of type II fractures in the elderly is higher

Type II fractures sit in a watershed area and have a greater risk of non-union

31. A 35-year-old male came off a motorbike. Following resuscitation, he complained of weakness in both legs and lower back pain. Clinical examination revealed bruising and swelling over his lumbar spine with M3 power in both legs and bilateral paraesthesia. Sagittal CT imaging is shown in Figure 12.15.

Figure 12.15 Sagittal CT iimage lumbar spine

What is the most appropriate management following initial resuscitation?

Mobilise with a spinal brace with flexion and extension views at 6 weeks

Mobilise with physiotherapy with no brace with flexion and extension views at 6 weeks

Prolonged bed rest with full spinal precautions

Surgical decompression

Surgical stabilisation

32. A 33-year-old male falls down a flight of stairs while intoxicated, sustaining an injury to his right upper arm. Anteroposterior (AP) radiograph is shown in Figure 12.16(a) and clinical photograph is shown in Figure 12.16(b). The injury is isolated. On clinical examination, he is unable to dorsiflex his wrist and extend his fingers at the MCPJs.

Figure 12.16 (a) Anteroposterior (AP) radiograph right humerus and (b) clinical photograph upper limb

The most appropriate next step in management would be which of the following?

Coaptation splint followed by functional brace

Humeral nailing

Open reduction, internal fixation and exploration of the median nerve

Open reduction, internal fixation and exploration of the radial nerve

Urgent nerve conduction studies and MRI upper limb

33. A 41-year-old woman undergoes a radial head fixation for a Mason II radial head fracture. The Kaplan approach is used.

Postoperatively, what complication is most likely?

Inability to abduct the fingers

Inability to extend the wrist in radial deviation

Inability to extend the wrist in ulnar deviation

Inability to flex the wrist in radial deviation

Inability to flex the wrist in ulnar deviation

34. A 77-year-old woman resident of a nursing home with limited functional ability falls onto concrete sustaining the above closed injury. She has radiographs performed, which confirm the injury (Figure 12.17).

Figure 12.17. Lateral radiograph elbow

What is the most appropriate management option?

Total elbow replacement

Tension-band wiring of the olecranon

Conservative treatment

Open reduction, internal fixation with locking plate

Excision and triceps advancement

35. A 31-year-old man falls off his motorbike. sustaining the isolated injury shown in Figure 12.18. He is neurovascularly intact and is initially resuscitated in the ED.

Figure 12.18 AP and lateral radiographs elbow

What is the most appropriate definitive management?

Closed reduction, examination under anaesthetic and early range of motion

Radial head arthroplasty and coronoid open reduction internal fixation

Radial head arthroplasty, coronoid open reduction internal fixation and lateral collateral ligament repair

Radial head fixation and coronoid open reduction internal fixation

Radial head fixation, coronoid open reduction internal fixation and medial collateral ligament repair

36. A 63-year-old golfer falls awkwardly onto his left shoulder. He is neurovascularly intact. Anteroposterior (AP) radiograph demonstrates a three-part fracture of the proximal humerus involving the surgical neck and the greater tuberosity (Figure12.19). There is posterior and superior displacement of the greater tuberosity by 1cm