Multiple Choice Questions

Trauma

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Please use the comments section at the bottom of the page if you have any query or feedback about any of the questions.

 

78.Which muscle is affected if during the approach to this fracture ? it’s innervating nerve and accompanying blood vessel are compromised?

A) Teres Major
B) Infraspinatus
C) Subscapularis
D) Teres Minor
E) Deltoid

Correct Answer : D

Teres Minor this a posterior rim fracture of glenoid the most appropriate approach is the posterior approach which goes through internervous plane between the suprascapular nerve and axillary nerve which travels with the posterior circumflex humeral artery which supply Teres Minor
Teres Major is supplied by lower subscapular nerve

Author : David Hughes

 

77. In humeral shaft fractures, all of the following are absolute indications for ORIF except:

A) Open fracture
B) Vascular injury
C)Radial nerve palsy
D) Ipsilateral forearm fracture
E) Compartment Syndrome

Correct Answer : C

Radial nerve palsy - as a neurologic injury - is not an indication for ORIF, and patient can be treated with functional brace.
While Brachial plexus injury is an absolute indication for ORIF.

 

Author : Muhammad Rafat Meda

 

76. A 45 years old man has sustained a minimally displaced spiral fracture at the junction of the middle and distal third of the humerus shaft.
He has extensive bruising and swelling of the upper arm, but no open wound is present. He has loss of sensation over the lateral aspect of the forearm and also difficulty in flexion of the elbow.

Which is the most likely structure involved?

A) Radial nerve
B) Axillary nerve
C) Musculocutaneous nerve
D) Suprascapular nerve
E) Median nerve

Correct Answer : C

Musculocutaneous nerve supplies  the flexors of the elbow namely, Biceps and Brachialis and other muscle is coracobrachialis. The sensory innervation is lateral aspect of forearm. 

 

Author : Dr Sushil Vijay

 

75. A 27-year-old banker injures his foot and sustains a displaced divergent Lisfranc fracture-dislocation.

The optimal management would consist of:

A) Below knee plaster cast
B) Closed or open reduction and screw stabilization
C) Closed or open reduction and K-wire stabilization
D) A bridging external fixator
E) Closed or open reduction and combined screw and K-wire stabilization

Correct Answer : E

The tarsometatarsal joint is best thought of in three columns: a medial column (first tarsometatarsal joint), a middle column (second and third tarsometatarsal joints) and a lateral column (fourth and fifth tarsometatarsal joints).

Any dislocation or subluxation needs reduction. A cast or external fixator does not hold the reduction adequately.
Although there are many ways to stabilize the fracture-dislocation after reduction, it is generally accepted that the medial and middle columns should be treated with permanent fixation (for example screws) and the lateral column should have temporary fixation (for example K-wires removed after 6–12 weeks). This is due to the relatively greater mobility of the lateral column.
 

Author : Zihad Taher

 

74. Nail bed injury in the adult might be associated with which of the following:

A) Seymour fracture
B) Tuft fracture
C) Fracture of middle phalanx
D)Proximal phalanx fracture
E) Avulsion of central slip

Correct Answer: B

Nailbed Injury is associated with tuft fracture in adults and Seymour fracture in children.

Author: S Kamat

 

73. The mother of a 4-month-old boy brings him to be evaluated for a swollen leg . 

The most likely diagnosis is:

A) Rickets
B) Osteogenesis imperfecta (OI)
C) Scurvy
D) Nonaccidental injury
E) Caffey’s disease

Correct Answer : D

This radiograph shows two fractures in different stages of healing. Note the old femur fracture at the top of the field. 

No evidence of decreased cortical thickness, diaphyseal thinning, or bowing suggests OI. 

The physis of the distal femur and proximal tibia show no signs of rickets. 

The presence of fractures rather than periosteal reaction make Caffey’s disease unlikely. 

The fractures in scurvy are more commonly located in the physis. 

The diagnosis of nonaccidental injury should be made only after performing a thorough patient history and physical

Author: Rajesh Bahadur Lakhey

 

72. A 14-year-old ice hockey player had a jersey pulled over his head in a brawl during a game. He finished the game without incident and denies any other traumatic event. 

The boy presents the following day with a stiff neck tilted to the right side and an inability to bring his head to a neutral position. On physical examination, the boy’s head is tilted to the right 20°, rotated to the left 20°, and slightly flexed. Attempts at passive rotation to a neutral position produce pain. The exam is otherwise unremarkable. 

Computerized tomography scans show atlantoaxial rotatory displacement with no anterior displacement of C1 on C2. Treatment should include:

A) Urgent C1 to C2 fusion
B) Use of a soft collar, exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Head halter traction and NSAIDs
D) Philadelphia collar, Minerva casting, and NSAIDs
E) Occiput to C2 fusion

Correct Answer : B

A soft collar, exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs) should be tried for 1 week if the diagnosis of atlantoaxial rotatory displacement is made within a week of its onset. The patient’s progress must be followed closely. 

If NSAIDs and a collar do not work after 1 week, the patient should be hospitalized and head halter traction should be administered along with muscle relaxants. 

If head halter traction successfully reduces the deformity, the patient should be placed in a Philadelphia collar with Minerva casting for 6 weeks. If the patient has no neurologic findings and no anterior displacement, the condition is likely to resolve with conservative measures alone. 

If surgery becomes necessary, the occiput should not be included in surgical treatment of atlantoaxial rotatory displacement. 

Author: Rajesh Bahadur Lakhey

 

71. Which of the following zones of the physis is involved in Salter Harris Type I and II fractures?

A) Proliferative zone
B) Perichondrial ring
C) Reserve zone
D) Node of Ranvier
E) Zone of provisional calcification

Correct Answer : E

Salter Harris Type I and II fractures occur through the zone of provisional calcification or through the hypertrophic zone. 

The reserve and proliferative zone remain intact and growth can proceed normal after healing of the fracture.

Author: Rajesh Bahadur Lakhey

 

70. Initially, the most appropriate method to evaluate a patient with suspected peripheral nerve injury involves:

A) An imaging study, preferably magnetic resonance imaging (MRI), of the injured region
B) Electromyography and nerve conduction velocity studies
C) A doppler ultrasound to study blood flow to the injured area
D) An MRI of the entire spine to evaluate possible spinal cord injury
E) A detailed neurologic evaluation noting distal motor function

Correct Answer: E

After a traumatic injury to peripheral nerves, early clinical examination is imperative. The key is to test for motor
function in the most distal aspect of the nerve and be able to localize the site of injury. 

Imaging studies are far sensitive than clinical examinations. 

Electromyography and nerve conduction velocity studies are usually performed during the follow-up examination to assess for residual, or recovery of, function.

Author: Rajesh Bahadur Lakhey

 

 

69. Appropriate treatment of a nondisplaced Jefferson fracture is:

A) Hard cervical orthosis
B) Halo vest
C) Soft collar
D) Posterior surgical stabilization
E) Nerve treatment necessary

Correct Answer: A

Fractures involving the C1 or atlas are generally caused by axial compression with either a flexion or extension
force. Generally, fractures involving the C1 consist of multiple fragments. 

The classical Jefferson fracture is a 4-part fracture of the atlas and can be unstable. However, in this situation, a nondisplaced fracture represents a relatively stable injury. 

An open-mouth odontoid anteroposterior radiograph is frequently useful to evaluate unstable patterns. An unstable fracture typically has displacement of the lateral masses greater than 8 mm. If displacement of this amount occurs, generally, the transverse ligament has been disrupted and should be treated by halo vest immobilization. 

In the nondisplaced situation, a hard Philadelphia collar is the most appropriate form of treatment.

Author: Rajesh Bahadur Lakhey

 

68.  All of the statements regarding the atypical femur fracture due to bisphosphonate therapy are true EXCEPT :

A) Fracture is located along femoral diaphysis from distal to the lesser trochanter to proximal to supracondylar ridge
B) Fracture is sustained with minimal or no trauma
C) Complete fracture extends through both cortices
D) The fracture line originates at the lateral cortex and is usually transeverse
E) The incomplete fracture can involve either the medial or lateral cortex

Best Answer : E

In 2013, the American Society for Bone and Mineral Research task force developed a revised case definition of atypical femoral fractures. Its definition is that of a fracture located along the femoral diaphysis from just distal to the lesser trochanter to just proximal to the supracondylar flare, with at least four of five major features present. These features are: sustained with minimal or no trauma, the fracture line originates at the lateral cortex and is substantially transverse in its orientation (although it may become oblique as it progresses medially across the femur).

Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex, non-comminuted or minimally-comminuted fractures and localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site.

Author - Fouad Chaudhry

 

67. A 45-year-old man has neck pain following a motor vehicle accident. His neurologic examination is normal. His plain
radiographs are shown . 

The most likely diagnosis is:

A) Cervical strain (whiplash-type injury)
B) Compression fracture of C5
C) Unilateral facet dislocation
D) Bilateral facet dislocation
E) Spinous process fracture

Correct Answer: C

The lateral radiograph shows translation and kyphosis at the level of injury. The facets of C4 do not
superimpose on each to create a "double sail" sign. This patient has a unilateral facet dislocation. With
unilateral facet dislocations, there is usually 3 mm to 4 mm of forward translation and 5° to 7° of angulation.

Author: Rajesh Bahadur Lakhey

 

66. Which of the following fracture types is the most stable fracture:

A) Teardrop fracture
B) Burst fracture
C) Unilateral facet dislocation
D) Hangman’s fracture
E) Clay-shoveler’s fracture

Correct Answer: E

The avulsion of part or all of the spinous process that occurs after a violent flexion motion is a one-column injury. The
injury is a stable fracture treated by external orthosis, which rarely results in neurologic impairment. 

The other answer choices may be considered stable in some instances, but none of them are stable all of the time.

Author: Rajesh Bahadur Lakhey

 

65. Compression fractures of the spine secondary to metastatic disease usually first affect which component of the nervous system first:

A) Balance
B) Bowel and bladder function
C) Light touch sensation
D) Pain perception
E) Motor function

Correct Answer: E

When metastatic tumor grows, the posterior longitudinal ligament may be destroyed first and followed by involvement of the spinal cord. Spinal cord compromise can result from direct compression of an enlarging metastatic mass or intradural spreading of the metastatic tumor cells. Retropulsion of osseous fragments or metastatic mass into the spinal canal also may be caused by pathological fracture of vertebral collapse. 

The motor function of the anterior part of the spinal cord (anterior corticospinal tract) is usually affected first, followed by sensory loss (dorsal columns) because the spinal cord is located directly posterior to the vertebral body.

Author: Rajesh Bahadur Lakhey

 

64. Which of the following is the time window from the time of injury during which treatment of nonpenetrating spinal cord injury with methylprednisolone is indicated:

A) 2 hours
B) 4 hours
C) 8 hours
D) 12 hours
E) 24 hours

Correct Answer: C

Administration of methylprednisolone within 8 hours of injury provides benefit to patients with spinal cord injury.
Treatment of patients arriving after 8 hours of treatment has been shown to worsen morbidity. Therefore, patients
arriving at trauma centers within this time receive methylprednisolone treatment as part of the standard of care. The exception is the group of patients with penetrating spinal cord injuries where the risk of treatment outweighs the

Author: Rajesh Bahadur Lakhey

 

63. A 38-year-old construction worker falls from a scaffolding and sustains a pure flexion-compression injury to T12. In this type of injury, which portion of the vertebral body fails first:

A) End plate
B) Subcortical cancellous bone
C) Posterior elements
D) Middle column
E) Lamina

Correct Answer: A

Failure occurs first at the end plate. The intact intervertebral disk has limited compressibility. Therefore, when
the compressive forces exceed the disk compressibility, the load is transmitted to the contiguous bone. 

The end plate will rupture first followed by the subcortical cancellous vertebral bone.

Author: Rajesh Bahadur Lakhey

 

62. Appropriate treatment of a nondisplaced Jefferson fracture is:

A) Hard cervical orthosis
B) Halo vest
C) Soft collar
D) Posterior surgical stabilization
E) Nerve treatment necessary

Correct Answer: A

Fractures involving the C1 or atlas are generally caused by axial compression with either a flexion or extension
force. Generally, fractures involving the C1 consist of multiple fragments. The classical Jefferson fracture is a 4-
part fracture of the atlas and can be unstable. However, in this situation, a nondisplaced fracture represents a
relatively stable injury. An open-mouth odontoid anteroposterior radiograph is frequently useful to evaluate
unstable patterns. 

An unstable fracture typically has displacement of the lateral masses greater than 8 mm. If displacement of this amount occurs, generally, the transverse ligament has been disrupted and should be treated by halo vest immobilization. In this nondisplaced situation, a hard Philadelphia collar is the most appropriate form of treatment.

Author: Rajesh Bahadur Lakhey

 

61. A 55-year-old man with ankylosing spondylitis has a minor fall and is suffering with neck pain. Anteroposterior and lateral radiographs are negative with no evidence of fracture. He has no neurologic loss and has normal strength with the exception of severe restricted motion. 

Twelve hours following injury, he is found to have bilateral bicep and tricep weakness. 

The appropriate management and the work up of this individual is:

A) Computerized tomography (CT) anteroposterior lateral radiographs of the cervical spine
B) CT scan of the cervical spine
C) Magnetic resonance imaging (MRI) of the cervical spine
D) Bone scan of the MRI
E) Electromyogram to better delineate all the nerve neuropathy

Correct Answer: C

The patient is within 12 hours of having normal cervical spine films. Approximately one third of patients with
ankylosing spondylitis incur occult injuries to the cervical spine that are not identified by plain films prior to
kyphotic progression. A bone scan would delineate a fracture after 72 hours. However, the presence of
progressive weakness should raise suspicion of a potential epidural hematoma. For this reason, magnetic
resonance imaging would better delineate epidural hematoma.

Author: Rajesh Bahadur Lakhey

 

60. Comparing manual traction and finger trap traction in reducing distal radius fracture

A)  Manual traction may better correct dorsal tilt
B)  Finger traction may better restore ulnar height
C)  There is lower incidence of CRPS with finger trap traction
D)  There is higher incidence of carpal tunnel syndrome with finger trap traction
E)  Manual pain cause less pain during reduction than finger trap reduction

Correct Answer: C

Two primary methods for closed reduction exist and have been evaluated in the literature: manual traction and finger trap traction. Both methods assist the provider to manipulate and reduce the fracture appropriately by restoring the radial length. 

Sosborg-Wurtz et al6 conducted a recent systematic review of the two methods and noted that reduction by manual traction may better correct volar tilt while finger trap traction may better restore radial length, although these results were not found to be clinically significant. 

Furthermore,finger trap traction may result in a lower incidence of complex regional pain syndrome (CRPS) and carpal tunnel syndrome and cause less pain during reduction.

Source / Further reading:

J Am Acad Orthop Surg 2021;29:e1105-e1116 DOI: 10.5435/JAAOS-D-20-01335

Author: Fouad Chaudhry

 

59. What percentage of women with osteoporotic fractures develop kyphosis:

A) 10%
B) 15%
C) 25%
D) 30%
E) 60%

Correct Answer: B

Approximately 15% of women with osteoporotic fractures develop kyphosis. 

This is often due to the presence of multiple vertebral compression fractures with segmental kyphosis at each level.

Author: Rajesh Bahadur Lakhey

 

58. An 18-year-old man presents to the emergency department after sustaining a high-velocity gunshot wound to the umbilical region of the abdomen. 

An exit wound is found at the L3-L5 region of the lower back. Neurological examination shows grade 0/5 strength in his tibialis anterior muscles, gastrocnemius/soleus muscles, and extensor hallucis longus muscles bilaterally. His quadriceps and hamstrings strength is grade 2/5 bilaterally. 

A bullet fragment was seen at L4 within the spinal canal on computed tomography (CT) imaging. The patient sustained significant gastrointestinal trauma as a result of the bullet traversing his body. 

Management should consist of:

A) Administration of a broad-spectrum antibiotic for 14 days
B) Removal of the bullet fragment at L4
C) Continued serial neurologic examinations
D) Intravenous administration of dexamethasone for 24 hours
E) A, B, and C

Correct Answer: E

Because the bullet entered the patient’s umbilical region of the abdomen, significant gastrointestinal damage is
suspected. When this occurs, administration of a broad-spectrum antibiotic for 7 to 14 days is indicated to prevent
infection and sepsis from gastrointestinal flora. 

The bullet fragment at L4 should be removed because studies have shown that removal of a bullet from a patient with complete or incomplete neural deficits at T12 to L4 is associated with statistically significant increases in motor recovery as compared to nonoperative management. 

Intravenous administration of dexamethasone is not indicated for gunshot wounds to the spine because the benefits of steroids do not outweigh the risks.

Author: Rajesh Bahadur Lakhey

 

57. Which of the following statements regarding lesions of the spinal cord caused by bullet wounds is true:

A) Twenty-five percent of patients with complete lesions recover one motor level after 1 year
B) Thirty-three percent of patients with incomplete lesions usually have a partial or complete recovery after 1 year
C) Complete lesions occur in more than 50% of all gunshot wounds to the spine
D) 75% of patients in whom the bullet has passed through the spinal canal will experience a complete lesion
E) All of the above

Correct Answer: E

All of the statements are true. Knowledge of these facts is important in decision-making and management of patients
who are victims of gunshot wounds to the spine

Author: Rajesh Bahadur Lakhey

 

56. An 11-year-old boy sustains a fall while jumping on a trampoline. 

He has moderate back pain, an L-5 radiculopathy, and weakness of the right extensor hallucis longus. 

Radiographs and a computerized tomography scan of the lumbar spine demonstrate a slipped vertebral apophysis. 

Posterior ring apophyseal fracture | Radiology Reference Article | Radiopaedia.org

The recommended treatment is:

A) Laminectomy and excision of annulus and vertebral bony margin
B) Bed rest
C) Thoracolumbosacral orthosis
D) Physical therapy
E) Spinal traction

Correct Answer: A

This patient has a slipped vertebral apophysis as a result of trauma. This is analogous to a Salter-Harris type II fracture. 

A portion of the apophysis and annulus slip posteriorly and may impinge on the exiting nerve root. 

These usually do not resolve spontaneously or improve with conservative therapy, and excision is indicated. The disk fragments and retropulsed bone must be removed from the canal with a laminectomy for exposure.

Author: Rajesh Bahadur Lakhey

 

55. A type 3 traumatic spondylolisthesis of the axis, as classified by Levine and Edwards, is best treated with which of the following:

A) Soft collar immobilization
B) Hard Philadelphia cervical orthosis
C) Halo vest immobilization
D) Open reduction and operative posterior stabilization
E) Gardner-Wells tongs application and awake reduction, then posterior stabilization

Correct Answer: D

The Levine classification of traumatic spondylolisthesis or Hangman fractures involving C2 .In the type 3 injury has a combined bilateral facet dislocation at C2-C3 as well as the traumatic spondylolisthesis of the axis. 

Closed reduction could not be performed secondary to the traumatic spondylolisthesis at the C2 isthmus.

Author: Rajesh Bahadur Lakhey

 

54. What are the main findings of medial tibial stress syndrome on a bone scan?

A) Delayed uptake of tracer and nonfocal uptake over the posteromedial tibial border
B) Lack of uptake of tracer in all phases
C) Focal uptake of tracer in early phase only
D) Focal uptake of tracer in delayed phases
E) Nonspecific uptake of tracer in all phases

Correct Answer: A

Medial tibial stress syndrome (MTSS), commonly known as “shin splints,” is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes.

Medial tibial stress syndrome has a characteristic finding on bone scan of uptake only in the delayed phase. Uptake is
nonfocal and is along the posteromedial border of the tibia. 

These findings contrast with a stress fracture, which has focal uptake in the early phase.

Nuclear medicine bone scan demonstrating diffuse longitudinal periositis (a) of stress reactions (arrows) bilaterally in the tibiae, in contrast to (b) which shows a more focal uptake ssociated with stress fracture

Author: Firas Arnaout

 

53. Which best describes a type IIA distal clavicle fracture?

A) The fracture is lateral to the coracoclavicular ligaments
B) The fracture involves intra-articular injury of the acromioclavicular joint
C) The fracture line is between the conoid and trapezoid ligaments
D) The fracture is medial to the coracoclavicular ligaments
E) The fracture involves comminuted distal clavicle fracture

Correct Answer: D

A type IIA distal clavicle fracture occurs medial to the coracoclavicular ligaments. 

Type I is an extra-articular fracture lateral to the coracoclavicular ligaments. 

Type III is an intra-articular injury of the acromioclavicular joint.