Surgery - Traumatology

Question 1

SUR - 2.1
An open fracture can be treated in the same way as a closed fracture if
A) it is a type 1 open fracture
B) has only minimal lateral dislocation
C) it is a type 2 open fracture
D) in any type of open fracture, after proper treatment of the wound

Answer 1

ANSWER
A) it is a type 1 open fracture

EXPLANATION
Only type 1 open fractures can be treated in the same manner as closed fractures because type 1 open fractures are a result of low energy trauma, the fractured bone ruptures the skin and soft tissue from inside out, therefor the incidence of bacterial infection is low. This is why this type of fracture is considered and treated in a similar way as closed fractures.

Question 2

SUR - 2.2
The following is true concerning compartment syndrome:
A) early absence of peripheral pulse
B) early absence of capillary refill
C) no pain
D) it does not occur if the injury is open

Answer 2

ANSWER
B) early absence of capillary refill

EXPLANATION
Immense pain and the early absence of capillary refill are characteristic of compartment syndrome. It can occur even in open injuries. Pulselessness is a late symptom.

Question 3

SUR - 2.3
What type of x-ray is needed to differentiate between the types of acromioclavicular joint dislocations?
A) clavicle x-ray
B) lateral scapula shoulder Y view
C) comparative weight bearing stress x-ray
D) shoulder x-ray

Answer 3

ANSWER
C) comparative weight bearing stress x-ray

EXPLANATION
Only the comparative weight bearing stress x-ray is the appropriate examination: the patient holds weights in both arms. No changes will be seen on the uninjured-intact side, whereas on the injured side, the AC joint dislocation will be obvious

Question 4

SUR - 2.4
Which is the most common nerve injury resulting from shoulder dislocations?
A) Axillary nerve
B) Brachial plexus
C) Radial nerve
D) Ulnar nerve

Answer 4

ANSWER
A) Axillary nerve

EXPLANATION
The most commonly injured nerve is the axillary (circumflex) nerve, since it travels around the surgical neck of the humerus and is stretched during the dislocation. The brachial plexus is less frequently injured, when the dislocated humeral head directly presses it.

Question 5

SUR - 2.5
Which classification system is best for prognosis of proximal humerus fractures?
A) The Neer classification based on the number of fractured fragments
B) Garden classification
C) Böhler classification
D) Pauwels classification

Answer 5

ANSWER
A) The Neer classification based on the number of fractured fragments

EXPLANATION
The Neer classification pertains to the treatment of proximal humerus fractures.

Question 6

SUR - 2.6
Which is the most frequently missed shoulder dislocation?
A) Luxatio erecta – inferior dislocation
B) Posterior dislocation
C) Axillary dislocation
D) Anterior dislocation

Answer 6

ANSWER
B) Posterior dislocation

EXPLANATION
The posterior shoulder dislocation is missed most often; we must think of this if the contour of the humerus head and glenoid contour overlap each other.

Question 7

SUR - 2.7
In a Monteggia fracture, where is the location of the radius head dislocation?
A) In the proximal radioulnar joint
B) In the distal radioulnar joint
C) There is no dislocation, it follows the fracture line
D) The elbow joint is dislocated

Answer 7

ANSWER
A) In the proximal radioulnar joint

EXPLANATION
In a Monteggia fracture, the dislocation of the radius head is located in the proximal radioulnar joint by definition.

Question 8

SUR - 2.9
Locking of the knee joint and recurrent knee joint swelling with longer symptom-free periods are characteristics of which injury?
A) Meniscal tear
B) Cruciate ligament tear
C) Arthritis
D) Baker-cyst

Answer 8

ANSWER
A) Meniscal tear

EXPLANATION
Characteristics of a meniscal tear include locking of the knee joint, recurrent knee joint swelling and longer symptom-free periods. Hemarthros is typical in the acute phase of a cruciate ligament injury, while instability is the main symptom in the chronic phase. Baker cyst inhibits full knee flexion, while pain to weight bearing is the leading symptom of knee arthritis.

Question 9

SUR - 2.10
Surgical fixation is necessary in a dislocated (distracted) patella fracture where there is incongruence of the articular surface.
A) It always requires surgical treatment
B) It does not always require surgical treatment, only when there is discontinuity of the extensor apparatus
C) Just as good results can be achieved with conservative treatment
D) Surgical treatment is only necessary if there is an osteochondral fracture

Answer 9

ANSWER
A) It always requires surgical treatment

EXPLANATION
In patella fractures, surgical fixation is indicated when there is dislocation (distraction) as well as when there is articular surface incongruence. Dislocation (distraction) leads to insufficient function, due to the discontinuity of the extensor apparatus, while incongruence of the articular surface of the patella leads to early posttraumatic arthritis.

Question 10

SUR - 2.11
What is the goal in the treatment of distal radius fractures?
1) To retain the original length of the bone
2) To restore the Böhler joint angles
3) To restore congruency of the joint
4) To inhibit redislocation

A) all of the answers are correct
B) only the 1st and 2nd answers are correct
C) only the 1st, 3rd and 4th answers are correct
D) only the 1st and 4th answers are correct

Answer 10

ANSWER
A) all of the answers are correct

EXPLANATION
All of the mentioned conditions are necessary to achieve good wrist joint function.

Question 11

SUR - 2.12
Which of the following have a high risk in a traumatic hip joint dislocation?
1) Femoral head necrosis
2) Extensive cartilage damage/early arthritis
3) Sciatic (ischiadic) nerve injury
4) Infection

A) only the 1st and 2nd answers are correct
B) only the 1st, 2nd and 3rd answers are correct
C) all of the answers are correct
D) only the 4th answer is correct

Answer 11

ANSWER
B) only the 1st, 2nd and 3rd answers are correct

EXPLANATION
The risk of joint infection in a traumatic hip dislocation is minimal.

Question 12

SUR - 2.13
In a medial femoral neck fracture, the affected lower limb is shortened, in external rotation, and the patient cannot actively elevate his leg.
1) This is true for all types of femoral neck fractures
2) This is not true for laterobasal femoral neck fractures
3) This is not true for valgus type impacted femoral neck fractures
4) This is not true for non-dislocated Garden type II femoral neck fractures

A) only the 1st answer is correct
B) only the 2nd answer is correct
C) only the 3rd answer is correct
D) only the 3rd and 4th answers are correct

Answer 12

ANSWER
D) only the 3rd and 4th answers are correct

EXPLANATION
In Garden type III and IV medial femoral neck fractures, the affected lower limb is shortened, in external rotation, and the patient cannot actively elevate his leg. In impacted, non-dislocated femoral neck fractures (Garden type II) and in valgus impacted fractures (Garden type I), the patient can frequently even elevate the leg.

Question 13

SUR - 2.14
Which of the following are correct regarding a degloving injury?
1) The skin and its underlying tissues are torn off the fascia
2) It can be an open or closed injury
3) It can be associated with significant blood loss
4) Skin necrosis is common

A) only the 1st answer is correct
B) only the 1st and 2nd answers are correct
C) only the 1st, 2nd and 3rd answers are correct
D) only the 1st, 2nd, 3rd and 4th answers are correct

Answer 13

ANSWER
D) only the 1st, 2nd, 3rd and 4th answers are correct

EXPLANATION
In a degloving injury, the skin and its underlying tissues are torn off the fascia. Significant amount of bleeding can develop into the recessed area. The blood supply to the skin above the injury is severed, therefore skin necrosis is common. The injury can be open or closed.

Question 14

SUR - 2.14
Which of the following are correct regarding a degloving injury?
1) The skin and its underlying tissues are torn off the fascia
2) It can be an open or closed injury
3) It can be associated with significant blood loss
4) Skin necrosis is common

A) only the 1st answer is correct
B) only the 1st and 2nd answers are correct
C) only the 1st, 2nd and 3rd answers are correct
D) only the 1st, 2nd, 3rd and 4th answers are correct

Answer 14

ANSWER
D) only the 1st, 2nd, 3rd and 4th answers are correct

EXPLANATION
In a degloving injury, the skin and its underlying tissues are torn off the fascia. Significant amount of bleeding can develop into the recessed area. The blood supply to the skin above the injury is severed, therefore skin necrosis is common. The injury can be open or closed.

Question 15

SUR - 2.15
What can be the cause of delayed bone healing and nonunion?
1) Disturbed blood supply of the fractured bone
2) Soft tissue damage
3) Soft tissue interposition
4) Too much distance between the fractured bony ends

A) only the 1st answer is correct
B) only the 1st and 2nd answers are correct
C) only the 1st, 2nd and 3rd answers are correct
D) all of the answers are correct

Answer 15

ANSWER
D) all of the answers are correct

EXPLANATION
The primary cause of delayed bone healing and nonunion is disturbed blood supply to the fractured bony ends. This can be due to damage to the soft tissue, soft tissue interposition between the fractured ends and too much traction causing too much distance between fractured ends of the bone.

Question 16

SUR - 2.17
Which of the following are associated injuries of shoulder dislocations, which lead to recurrent shoulder dislocation?
1) Bankart-lesion
2) Hill–Sachs-lesion
3) Rotator cuff injury
4) Axillary nerve paresis

A) only the 1st answer is correct
B) only the 2nd answer is correct
C) only the 1st, 2nd, 3rd and 4th answers are correct
D) only the 1st and 2nd answers are correct

Answer 16

ANSWER
D) only the 1st and 2nd answers are correct

EXPLANATION
Recurrent shoulder dislocations can occur due to all associated injuries, which lead to the instability of the joint. In Bankart lesions, the capsule and part of the labrum are torn off the glenoid. In a Hill-Sachs lesion, the depressed fracture of the humerus head leads to incongruence of the joint, which may cause luxation when the rotational position of the depressed humeral head allows it to dislocate from the glenoid cavity.

Question 17

SUR - 2.19
Which of the following pose the greatest risk in pediatric supracondylar humerus fractures?
1) Misdiagnosis of brachial artery injury
2) Volkmann‘s ischemic contracture
3) Nonunion
4) Median nerve injury

A) all of the answers are correct
B) only the 1st and 2nd answers are correct
C) only the 1st, 2nd and 3rd answers are correct
D) only the 4th answer is correct

Answer 17

ANSWER
B) only the 1st and 2nd answers are correct

EXPLANATION
The greatest risk of pediatric supracondylar humerus fractures are missed diagnosis of brachial artery injuries, which leads to Volkmann’s ischemic contracture

Question 18

SUR - 2.20
What do we need to take into consideration in tibia pilon (plafond) fractures?
1) The mosaic type fracture of the cartilage of the tibiotalar joint
2) Severe soft tissue damage
3) Delayed bone union
4) Posttraumatic arthritis

A) only the 1st, 2nd, 3rd and 4th answers are correct
B) only the 2nd and 3rd answers are correct
C) only the 3rd answer is correct
D) only the 3rd and 4th answers are correct

Answer 18

ANSWER
A) only the 1st, 2nd, 3rd and 4th answers are correct

EXPLANATION
Severe damage to the articular surfaces of the talotibial joint are always present in tibia pilon (plafond) fractures, and this always leads to the development of posttraumatic arthritis in the ankle joint. Severe soft tissue damage is also always present. Due to these factors as well as due to the comminuted fracture and bone loss, we can count on delayed bone union.

Question 19

SUR - 2.21
After reduction of an elbow dislocation, if the joint is stable, we should not immobilize the joint for over 1 week because the risk of extension deficit increases linearly with the time period of immobilization.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 19

ANSWER
C) Both statements are true and there is a logical correlation between the two

EXPLANATION
The elbow joint is rather sensitive to all kinds of trauma and immobilization. If the joint is stable after reduction, the shortest time period of immobilization is practical. The hindrance of early mobilization is due to pain. After reduction of the elbow joint, we apply a cast splint, but after a few days, the arm should be removed from the splint for physiotherapy and then placed back into the splint. The time of immobilization should still not exceed one week.

Question 20

SUR - 2.22
Isolated radius head subluxation (nursemaid’s elbow) in children is caused by the sudden pulling of the arm, therefor the child is unable to pronate the forearm.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 20

ANSWER
C) Both statements are true and there is a logical correlation between the two

EXPLANATION
Radial head subluxation in children is caused by the sudden pulling of the child’s arm, after which the elbow’s movements are impaired. Not only is flexion and extension reduced, but also pronation of the forearm. This is also called pronation dolorosa infantum, or pulled elbow or nursemaid’s elbow for these reasons.

Question 21

SUR - 2.23
The most frequent complication of femoral neck fractures - femoral head necrosis – only occurs in Garden type 3 and 4 fractures because the arterial blood vessels are injured only in these types of fractures.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 21

ANSWER
D) Both statements are false

EXPLANATION
Arterial blood vessel injury leading to femoral head necrosis can occur in all types of femoral neck fractures. Undoubtedly, it is more frequent in Garden type 3 and 4 fractures.

Question 22

SUR - 2.24
The prognosis of femoral neck fractures is the same in the elderly and young patients because the mechanism of injury is the same in both groups.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 22

ANSWER
D) Both statements are false

EXPLANATION
The prognosis of femoral neck fractures in the elderly and young patients is not the same; in young patients, the mechanism of injury is high energy trauma, having a much worse prognosis.

Question 23

SUR - 2.25
The ideal time of treatment of femoral neck fractures is within 6-12 hours of the injury because the incidence of all complications are statistically the lowest within this timeframe.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 23

ANSWER
C) Both statements are true and there is a logical correlation between the two

EXPLANATION
The ideal timeframe for treatment of femoral neck fractures is within the shortest time since the injury. Sometimes the general condition of the patient, certain medications such as anticoagulants, and due to logistical reasons, it may be very difficult to operate the patient within 24 hours. According to statistics, femoral head necrosis, secondary dislocation, general complications (pneumonia, skin ulceration, urine infection) as well as survival rate all have better results if the surgery is done within 6-12 hours, but at least within 24 hours of the injury.

Question 24

SUR - 2.26
The best implant choice for fixation of intertrochanteric fractures is the trochanteric nail because it give the most stability, allowing early mobilization of the elderly patient.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 24

ANSWER
C) Both statements are true and there is a logical correlation between the two

EXPLANATION
A very good stability can be achieved with the use of trochanteric nails inserted from the greater trochanter into the intramedullary canal having a fix collodiaphyseal angulated screw or blade fixation into the femoral head. This allows for the early mobilization of the patients postoperatively.

Question 25

SUR - 2.27
The prognosis of intertrochanteric femoral fractures is worse than that of subtrochanteric fractures because intertrochanteric fractures are more likely to have nonunion.
A) The first statement is true
B) The first statement is false
C) Both statements are true and there is a logical correlation between the two
D) Both statements are false

Answer 25

ANSWER
D) Both statements are false

EXPLANATION
Intertrochanteric fractures have a good prognosis and healing rate. If the implant allows compression of the fractured bone ends, the fracture always heals. As opposed to this, subtrochanteric fractures occur in a zone where the femur has the worst blood supply and they heal very slowly, which often can lead to breakage of the implants and thus redislocation of the fracture.

Question 26

SUR - 2.28
Peroneal nerve injuries and lateral collateral ligament injuries are associated injuries of fibula head fractures therefor they cannot be treated conservatively.
A) Both statements are true, but there is no logical correlation between the two
B) Both statements are true and there is a logical correlation between the two
C) Only the first statement is true
D) Only the second statement is true

Answer 26

ANSWER
C) Only the first statement is true

EXPLANATION
It is true that the peroneal nerve and the lateral collateral ligaments are associated injuries of fibula head fractures, but the fracture is usually still treated conservatively.

Question 27

SUR - 2.29
Isolated tibia fractures regularly displace in varus and in recurvation therefor they usually require surgical fixation.
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) Only the first statement is true
D) Only the second statement is true

Answer 27

ANSWER
A) Both statements are true and there is a logical correlation between the two

EXPLANATION
Surgical fixation is always indicated of isolated closed fractures of the tibia because without fixation, varus and retrocurvature deformity always develop.

Question 28

SUR - 2.30
Surgical fixation of crural (tibia) fractures is advantageous because they heal slower with conservative treatment and mobilization of the patient takes place much later.
A) Both statements are true
B) Both statements are false
C) Only the first statement is true
D) Only the second statement is true

Answer 28

ANSWER
A) Both statements are true

EXPLANATION
Traditional conservative treatment of crural (tibia) fractures involve traction followed by cast fixation for a period of 12 weeks. With this type of fixation, the patient will suffer from complications due to the long term application of casts and immobilization: joint contractures, muscle hypotrophy, etc. As opposed to this, the current primary treatment of intramedullary nailing does not require postoperative cast fixation and allows for very early joint mobilization. Partial weight bearing is allowed a few days following the surgery and full weight bearing is usually allowed from the 6th postoperative week.

Question 29

SUR - 2.31
The goal of surgical fixation of lateral malleolar fractures is to correct the shortening of the fibula because a shortened fibula cause subluxation of the talus
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) Only the first statement is true
D) Only the second statement is true

Answer 29

ANSWER
A) Both statements are true and there is a logical correlation between the two

EXPLANATION
During reduction of the ankle fracture, we achieve congruency of the tibiotalar joint by correcting the length of the fibula

Question 30

SUR - 2.32
In metatarsal fractures, the arch of the foot is impaired, therefor the restoration of the 1st and 5th metatarsals are necessary to achieve painless weight bearing gait.
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) Only the first statement is true
D) Only the second statement is true

Answer 30

ANSWER
A) Both statements are true and there is a logical correlation between the two

EXPLANATION
During weight bearing of the foot, there are three pressure points: the tuber calcanei and the heads of the 1st and 5th metatarsals. The remaining metatarsals in between have only an inferior role in normal circumstances.

Question 31

SUR - 2.34
In lateral compression trauma of the pelvis, displacement of the anterior pelvic ring occurs, therefor associated urinary bladder injury is frequent.
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) Only the first statement is true
D) Only the second statement is true

Answer 31

ANSWER
A) Both statements are true and there is a logical correlation between the two

EXPLANATION
In lateral compression fractures of the pelvis, the fractured pubic rami of the anterior pelvic ring may pierce the urinary bladder.

Question 32

SUR - 2.35
There are two principles of treatment in severely injured (polytraumatized) patients: primary definitive care or damage control treatment; the treatment of choice is independent of the patient’s condition.
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) Only the first statement is true
D) Only the second statement is true

Answer 32

ANSWER
C) Only the first statement is true

EXPLANATION
The principle upon whether we treat a polytraumatized patient with primary definitive care or damage control surgery chiefly depends on the condition of the patient. This all depends on the severity of the injuries, the general condition of the patient, and the age of the patient. The higher the ISS (indicating the severity), the older the patient, and the worse general condition of the patient, the more necessary it is to treat according to damage control surgery protocols.

Question 33

SUR - 2.36
In acetabulum fractures and in fracture luxations of the hip joint, cartilage damage and hip joint arthritis in correlation with joint incongruence as well as femoral head avascular necrosis can occur.
A) True
B) False

Answer 33

ANSWER
A) True

EXPLANATION
During a hip dislocation, the capsule of the joint along with the blood vessels in the capsule, as well as the teres ligament can all tear, leading to avascular femoral head necrosis. Hip dislocation and acetabulum fractures result in cartilage damage or articular surface incongruence. This will thus lead to hip arthritis.

Question 34

SUR - 2.37
It is good to know the mechanism of injury in severely injured (polytraumatized) patients because we can then suspect characteristic injury-combinations, which can help us in properly diagnosing an unconscious patient.
A) True
B) False

Answer 34

ANSWER
A) True

EXPLANATION
In an unconscious patient, only the physical exam and radiology help us in reaching a diagnosis. Missed injuries are frequent. For this reason, we should examine a patient multiple times. A high index of suspicion arises if we know the characteristic combination of injuries based on the mechanism

Question 35

SUR - 2.39
Only non-dislocated, anatomically reduced, stable and retainable ankle fractures can be treated conservatively.
A) True
B) False

Answer 35

ANSWER
A) True

EXPLANATION
Ankle fractures usually require surgical fixation, since the length of the fibula must be precisely restored. Only those fractures can be treated conservatively, which are in anatomic position and non-dislocated, providing that they are stable.

Question 36

SUR - 2.40
There is no risk of aseptic necrosis in talus fractures.
A) True
B) False

Answer 36

ANSWER
B) False

EXPLANATION
In talus neck fractures, the blood vessels to the talar dome are injured, therefor there is a high risk of avascular necrosis

Question 37

SUR - 2.41
The aftercare of operated talus fractures involves immediate full weight bearing.
A) True
B) False

Answer 37

ANSWER
B) False

EXPLANATION
Operative treatment of talus fractures is usually screw fixation. This is never a weight bearing fixation, it is only stable to movement. In fact, in comminuted fractures, sometimes only adaptation stability can be achieved. Due to the compromised blood supply, the fracture site of the talus requires absolute immobilization, since this is the zone where revascularization takes place. Therefore, in the treatment of talus fractures, weight bearing is restricted until 3 months following the injury.

Question 38

SUR - 2.42
In which type of hand infection is antibiotic treatment necessary?
A) Pulp space infection (felon)
B) Pyogenic (suppurative) arthritis
C) Pyogenic (suppurative) tenosynovitis
D) Deep hand phlegmon
E) In any type of hand infection, if there is associated lymphangitis

Answer 38

ANSWER
E) In any type of hand infection, if there is associated lymphangitis

EXPLANATION
Lymphangitis is a sign of generalized infection, which requires antibiotic treatment next to surgical treatment. Localized hand infections require surgical treatment; antibiotics treatment alone is not enough to treat the inflammation.

Question 39

SUR - 2.43
Which of the following is NOT true regarding perilunate dislocations?
A) Perilunate dislocations result from high energy trauma.
B) On the AP view, the displaced lunate has a triangular profile, rather than its normal quadrilateral image.
C) The head of the capitate does not sit within the distal articular cup of the lunate.
D) Osteoporosis plays a major role in the cause of the injury
E) It can be associated with a scaphoid fracture.

Answer 39

ANSWER
D) Osteoporosis plays a major role in the cause of the injury

EXPLANATION
Perilunate dislocations most often occur in younger (usually male) patients. Osteoporosis does not play a role in the occurrence of the injury. Injury to an osteoporotic wrist results in a distal radius fracture.

Question 40

SUR - 2.44
What do we have to be most aware of when treating metacarpal fractures?
A) Prevention of shortening.
B) Any palmar displacement requires reduction.
C) It is important to perfectly reduce the small wedge fragment.
D) To decrease lateral displacement.
E) To completely eliminate any rotational malalignment

Answer 40

ANSWER
E) To completely eliminate any rotational malalignment

EXPLANATION
It is most important to eliminate any rotational malalignment when treating metacarpal fractures, because if the metacarpus has healed in rotational malalignment, the neighboring fingers’ functions are also decreased during flexion of the fingers.

Question 41

SUR - 2.45
Patients should perform Kleinert postoperative controlled mobilization exercises following primary tendon suture repair surgery in the “no man’s land’ area, because this will reduce the risk of the sutured deep and superficial tendon adhesions to the tendon sheath.
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) The first statement is true, the second statement is false
D) The first statement is false, the second statement is true
E) Both statements are false

Answer 41

ANSWER
A) Both statements are true and there is a logical correlation between the two

EXPLANATION
Postoperative controlled mobilization exercises following primary tendon suture repair surgery in the “no man’s land’ area prevents tendon adhesions, and should be done in a way to avoid tendon rerupture, yet allowing the intrinsic blood supply propagate healing of the tendon.

Question 42

SUR - 2.46
In humerus shaft fractures, which nerve can be injured and how do you examine it?
A) Radial nerve: examine wrist flexion
B) Median nerve: examine wrist extension and 2nd-5th fingers’ extension
C) Radial nerve: examine wrist extension and 2nd-5th fingers’ extension
D) Ulnar nerve: examine wrist extension, 2nd-5th fingers’ extension, as well as extension and abduction of the thumb
E) Radial nerve: examine wrist extension, 2nd-5th fingers’ extension, as well as extension and abduction of the thumb

Answer 42

ANSWER
E) Radial nerve: examine wrist extension, 2nd-5th fingers’ extension, as well as extension and abduction of the thumb

EXPLANATION
In humerus shaft fractures, the radial nerve - running its course in the radial sulcus - is the most likely to be injured. Therefore, we examine the muscles innervated by the radial nerve: wrist extensors, 2nd-5th fingers’ extensors (MCP extension!) as well as thumb extensors and abductor pollicis longus’ function.

Question 43

SUR - 2.47
Which of the following is NOT TRUE regarding the clinical symptoms and surgical treatment of Bennett fractures?
A) The thumb is dislocated from the trapezium in a radials and proximal direction.
B) A small fragment is fractured from the base of the 1st metacarpal.
C) The dislocation is caused by the pulling of the abductor pollicis tendon.
D) The dislocation can only be reduced by open surgical.
E) After reduction, temporary arthrodesis gives the best results usually.

Answer 43

ANSWER
D) The dislocation can only be reduced by open surgical.

EXPLANATION
Bennett fractures can be easily reduced in a closed manner, but maintaining the reduction is not possible. Therefore, temporary arthrodesis is necessary with K-wire fixation or alternatively, open reduction with lag screw fixation is used to treat these fractures.

Question 44

SUR - 2.48
Which of the following characteristics are NOT a clinical symptom of proximal median nerve injuries?
A) “Hand of Benediction” deformity
B) Loss of sensation of the 1-7 digital nerves
C) Loss of opposition of the thumb
D) Loss of extension of the thumb
E) The skin of the hand is dry where innervated by the median nerve, due to loss of sudomotor function

Answer 44

ANSWER
D) Loss of extension of the thumb

EXPLANATION
In proximal median nerve injuries, extension of the thumb is not impaired, since it is innervated by the radial nerve.

Question 45

SUR - 2.49
Brachial plexus injuries can be surgically treated with nerve transfer or neurotization. This is followed by physiotherapy, which leads to rapid healing.
A) Both statements are true and there is a logical correlation between the two
B) Both statements are true, but there is no logical correlation between the two
C) The first statement is true, the second statement is false
D) The first statement is false, the second statement is true
E) Both statements are false

Answer 45

ANSWER
C) The first statement is true, the second statement is false

EXPLANATION
It is true that brachial plexus injuries can be surgically treated, but functional improvement is very slow (often requiring years of physiotherapy).

Question 46

SUR - 2.50
Regeneration after microsurgical nerve repair…
A) Immediately takes place
B) Takes place within 3 months
C) Takes place within 3 weeks
D) Regeneration is approximately 1 mm/day in a distal direction
E) Regeneration is approximately 1 cm/day in a distal direction

Answer 46

ANSWER
D) Regeneration is approximately 1 mm/day in a distal direction

EXPLANATION
Following microsurgical nerve repair, the nerve regeneration speed is approximately 1 mm/day in the distal direction, therefor the regaining of the function depends on the proximity of the nerve injury. While a median nerve injury at the level of the wrist requires about half a year neuroregeneration time, an ulnar nerve injury at the level of the elbow will require one and a half years to regenerate.

Question 47

SUR - 2.51
Which of the following statements is NOT TRUE concerning pyogenic (suppurative) tenosynovitis?
A) The entire length of the tendon sheath is swollen and tender.
B) The involved finger is in a flexed posture.
C) The tendon sheath must be opened in at least 2 places, irrigated and drained.
D) Delayed treatment of pyogenic tenosynovitis leads to damage and/or necrosis of the flexor tendon.
E) V-shaped phlegmon is not a tenosynovitis.

Answer 47

ANSWER
E) V-shaped phlegmon is not a tenosynovitis.

EXPLANATION
The type of pyogenic tenosynovitis extending between the thumb and the little finger is called a V-shaped phlegmon, because the tendon sheaths reach the level of the wrist, but on the 2nd-4th fingers, they extend only to the distal palmar crease.

Question 48

SUR - 2.52
What can be the cause of pain on the radial side of the wrist?
1) De Quervain stenosing tendovaginitis
2) Irritation or rupture of the extensor pollicis longus muscle after a radius fracture
3) A previously asymptomatic scaphoid non-union
4) Degeneration or injury to the triangular fibrocartilage complex (TFCC)
5) Trapezium injury or posttraumatic arthritis

A) only the 1st, 3rd and 5th answers are correct
B) only the 1st, 2nd, 3rd and 5th answers are correct
C) only the 1st, 3rd, 4th and 5th answers are correct
D) only the 1st, 2nd, 4th and 5th answers are correct
E) only the 2nd, 3rd and 5th answers are correct

Answer 48

ANSWER
B) only the 1st, 2nd, 3rd and 5th answers are correct

EXPLANATION
Pain on the radial side of the wrist is caused by De Quervain stenosing tendovaginitis, with crepitation and tenderness above the styloid process of the radius. The pain can be associated with a distal radius fracture, where the extensor pollicis longus tendon running its course in the tight canal next to Lister’s tubercle, can be irritated by the fracture or if operated, by the implant’s screw (in fact, it may even rupture the tendon). A previous scaphoid fracture may result in scaphoid non-union, which may become painful spontaneously or due to another injury, and in this case the snuff box is tender. Trapezium injury or posttraumatic arthritis of the 1st CMC joint causes pain and tenderness also in the distal part of the wrist above the joint. However, injury or degeneration to the triangular fibrocartilage discus (triangular fibrocartilage complex, TFCC) causes pain on the ulnar side of the wrist.

Question 49

SUR - 2.53
What should be done with the amputated body part and stump for replantation?
1) The amputated part should be wrapped in sterile gauze and be placed in ice during transport.
2) The amputated part should be placed inside a closed, sterile plastic bag, which is then placed inside another bag containing ice water.
3) Ligature or temporary clamping of the bleeding vessels of the stump with a Hemostat.
4) Slowing the bleeding of the stump by applying a compression bandage.
5) Writing down a short status of the level of injury, type of injury, and arranging fast transport.

A) only the 1st, 3rd and 5th answers are correct
B) only the 1st, 2nd and 5th answers are correct
C) only the 2nd, 3rd and 4th answers are correct
D) only the 2nd, 4th and 5th answers are correct
E) only the 1st, 4th and 5th answers are correct

Answer 49

ANSWER
D) only the 2nd, 4th and 5th answers are correct

EXPLANATION
If the amputated body part is placed in ice, it will freeze and will not be replantable. For this reason, it should be placed inside a bag of ice water, cooling it to +4°C. Ligature or clamping of the blood vessels on the stump is forbidden, because this part of the blood vessel will need to be resected, making replantation technically more difficult. Therefore, only compression bandaging is used. It is important that the hospital receives precise information about the amputated limb, the level of amputation and the type of injury. Transportation time to the hospital performing the replantation is also very important (within 6 hours!).

Question 50

SUR - 2.54
A ball has injured the middle finger of a young athlete. The PIP joint is swollen, deformed and painful. What injury do you think of?
1) fracture of the head of the middle phalanx
2) palmar plate injury
3) Boutonniere deformity
4) PIP joint dislocation
5) intraarticular proximal phalanx head fracture

A) only the 1st, 2nd and 3rd answers are correct
B) only the 1st, 3rd and 4th answers are correct
C) only the 2nd, 3rd, 4th and 5th answers are correct
D) only the 1st, 2nd, 3rd and 4th answers are correct
E) all of the answers are correct

Answer 50

ANSWER
C) only the 2nd, 3rd, 4th and 5th answers are correct

EXPLANATION
In PIP joint injuries, we should think of dislocations, palmar plate injuries, extensor tendon injuries (Boutonniere deformity) of intraarticular fractures of the head of the proximal phalanx. Fracture of the head of the middle phalanx affect the DIP joint.

Question 51

SUR - 2.55
Which of the following are characteristic of scaphoid fractures?
1) tenderness of the snuff box
2) there are no characteristic clinical symptoms
3) hematoma and deformity on the radial side of the wrist
4) painful wrist extension
5) due to the mild symptoms, patients often do not go to a doctor

A) only the 1st, 2nd and 3rd answers are correct
B) only the 1st, 2nd and 5th answers are correct
C) only the 1st, 3rd, 4th and 5th answers are correct
D) only the 1st, 2nd, 4th and 5th answers are correct
E) only the 2nd, 3rd, 4th and 5th answers are correct

Answer 51

ANSWER
D) only the 1st, 2nd, 4th and 5th answers are correct

EXPLANATION
It is typical that there are no characteristic symptoms (no hematoma or deformity, etc.) of scaphoid fractures.

Question 52

SUR - 2.56
Which are symptoms of carpal tunnel syndrome?
1) hypotrophic hypothenar
2) hypoesthesia from the thumb to the middle of the ring finger of the hand
3) weakened opposition of the thumb, sometimes even atrophy
4) the pain and paresthesia is more intense at night
5) hypoesthesia spreads to the entire arm (brachialgia paresthetica nocturna)

A) only the 1st, 2nd and 4th answers are correct
B) only the 1st, 3rd, 4th and 5th answers are correct
C) only the 1st, 2nd, 4th and 5th answers are correct
D) only the 1st, 4th and 5th answers are correct
E) only the 2nd, 3rd, 4th and 5th answers are correct

Answer 52

ANSWER
E) only the 2nd, 3rd, 4th and 5th answers are correct

EXPLANATION
The median nerve is compressed in carpal tunnel syndrome; the hypothenar is not affected, since it is innervated by the ulnar nerve.

Question 53

SUR - 2.57
Which are symptoms of cubital tunnel syndrome (sulcus ulnaris syndrome)?
1) hypoesthesia on the ulnar half of the ring finger and on the pinky
2) positive Froment’s sign: the patient cannot grip a piece of paper between their thumb and index finger.
3) the ring finger and pinky are in a flexed pose, the patient cannot fully extend the PIP and DIP joints
4) the patient cannot close the pinky to the extended ring finger due to the impaired motor function of the intrinsic muscles
5) the patient cannot flex the thumb

A) only the 1st, 2nd, 3rd and 4th answers are correct
B) only the 1st, 3rd, 4th and 5th answers are correct
C) only the 2nd, 3rd, 4th and 5th answers are correct
D) only the 1st, 4th and 5th answers are correct
E) only the 2nd, 3rd and 5th answers are correct

Answer 53

ANSWER
A) only the 1st, 2nd, 3rd and 4th answers are correct

EXPLANATION
In cubital tunnel syndrome, the area of sensory innervation and muscles of motor innervation by the ulnar nerve are affected; the median nerve is responsible for flexion of the thumb.

Question 54

SUR - 2.58
Which of the following are characteristic of trigger finger?
1) The triggering or “popping” is caused by a thickened nodule in the tendon passing through the pulley
2) If the thickening of the tendon continues, the finger locks and gets stuck in a bent position and can only be extended passively.
3) Trigger finger cannot be treated surgically, the patient must use a finger splint.
4) Swelling and tenderness can be observed at the entrance to the tendon sheath.
5) Surgical release of the pulley in local anesthesia relieves the symptoms.

A) only the 1st, 2nd and 3rd answers are correct
B) only the 1st, 3rd, 4th and 5th answers are correct
C) only the 1st, 2nd and 4th answers are correct
D) only the 1st, 2nd, 4th and 5th answers are correct
E) only the 2nd, 3rd, 4th and 5th answers are correct

Answer 54

ANSWER
D) only the 1st, 2nd, 4th and 5th answers are correct

EXPLANATION
Trigger finger can be treated with the most simple surgical methods (same day surgery), and its symptoms are characteristic.

Question 55

SUR - 2.59
Which of the following are correct regarding Dupuytren’s contracture?
1) Among many other risk factors, Dupuytren’s contracture is likely to be hereditary.
2) Most often occurs in middle-aged males.
3) The disease progresses and worsens over time and causes the flexion contractures of the fingers.
4) Dupuytren’s contracture can be treated with splinting, cast fixation and dynamic redressing bandaging
5) The surgical treatment involves complete removal of the thickened, degenerated tissue as well as the intact aponeurosis.

A) only the 1st, 2nd, 3rd and 4th answers are correct
B) only the 1st, 2nd, 3rd and 5th answers are correct
C) only the 1st, 2nd, 4th and 5th answers are correct
D) only the 2nd, 3rd, 4th and 5th answers are correct
E) all of the answers are correct

Answer 55

ANSWER
B) only the 1st, 2nd, 3rd and 5th answers are correct

EXPLANATION
Dupuytren’s contracture cannot be treated with conservative methods (splinting, cast fixation and redressing bandaging techniques); it requires surgery (recently, collagenase injection methods have been introduced)

Question 56

SUR - 2.60
Which of the following are correct regarding functional (intrinsic plus position) immobilization of the hand?
1) The wrist is in 30° extension
2) The pollex is in abduction-opposition position
3) All MCP joints are in 70–80° flexion
4) The PIP and DIP joints are in extension
5) The MCP joints are in extension, while the PIP and DIP joints are in 20° flexion

A) only the 1st, 2nd and 4th answers are correct
B) only the 1st, 3rd and 4th answers are correct
C) only the 1st, 2nd, 3rd and 4th answers are correct
D) only the 2nd, 3rd and 5th answers are correct
E) only the 3rd, 4th and 5th answers are correct

Answer 56

ANSWER
C) only the 1st, 2nd, 3rd and 4th answers are correct

EXPLANATION
The advantage of immobilization in the functional (intrinsic plus) position is that after removal of the splint, early recovery of the functional range of motion of the hand can occur.

Question 57

SUR - 2.61
Which of the following are indications for replantation?
1) More than one finger amputation
2) Thumb amputation
3) Amputation of the entire hand
4) Amputation in children
5) Extensive destruction of the amputated finger

A) only the 1st, 2nd, 3rd and 4th answers are correct
B) all of the answers are correct
C) only the 3rd, 4th and 5th answers are correct
D) only the 4th and 5th answers are correct
E) answer is correct only the 2nd

Answer 57

ANSWER
A) only the 1st, 2nd, 3rd and 4th answers are correct

EXPLANATION
Destruction of the amputated finger makes replantation impossible.