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2. Trauma MCQs

Practice Set 101 of 640

This practice set contains high-yield board review questions covering key concepts in 2. Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2001

Topic: 2. Trauma

The initial radiographic series for this 42-year-old male with a high-energy pilon fracture reveals a highly comminuted, complete articular fracture of the distal tibia. Specific findings include significant metaphyseal comminution with varus collapse, a fibula fracture at the level of the syndesmosis, proximal talar migration, a central die-punch fragment, a fractured medial malleolus with vertical extension, and gross displacement of the anterolateral (Chaput) fragment. Which of the following AO/OTA classifications BEST describes this injury?

. 43-A3
. 43-B1
. 43-C1
. 43-C3
. 44-C2

Correct Answer & Explanation

. 43-C3

Explanation

Correct Answer: DThe case explicitly states, 'Utilizing the more comprehensive AO/OTA classification, the fracture is designated as a 43-C3.' The '43' denotes the distal tibia segment. The 'C' indicates a complete articular fracture, meaning the articular surface is completely separated from the diaphysis. The '3' specifies that both the articular surface and the metaphyseal region are multifragmentary. This aligns perfectly with the description of a 'highly comminuted, complete articular fracture of the distal tibia' with 'significant metaphyseal comminution' and 'proximal talar migration,' indicating a severe, multifragmentary injury involving both the articular surface and the metaphysis.Option A (43-A3)represents an extra-articular fracture of the distal tibia, which is incorrect as the case describes a complete articular fracture.Option B (43-B1)represents a partial articular fracture, which is incorrect as the case describes a complete articular fracture.Option C (43-C1)represents a complete articular fracture with simple metaphyseal involvement, which is incorrect as the case describes multifragmentary metaphyseal comminution.Option E (44-C2)refers to a fracture of the ankle (malleolar region) and is not the primary classification for a pilon fracture of the distal tibia (43).

Question 2002

Topic: 2. Trauma
The patient's pilon fracture is classified as a Rüedi-Allgöwer Type III. This classification, along with the AO/OTA 43-C3 designation, underscores the extreme complexity of the injury. Which of the following statements accurately describes the key characteristic of a Rüedi-Allgöwer Type III pilon fracture?
. A simple, non-displaced articular fracture with minimal metaphyseal comminution.
. A partial articular fracture with significant displacement of a single articular fragment.
. A highly comminuted articular surface with significant metaphyseal impaction and displacement of major weight-bearing columns.
. An extra-articular fracture of the distal tibia with an intact articular surface.
. A fracture involving only the medial malleolus with no central articular involvement.

Correct Answer & Explanation

. A highly comminuted articular surface with significant metaphyseal impaction and displacement of major weight-bearing columns.

Explanation

Under the Rüedi-Allgöwer system, this injury is classified as a Type III fracture. This indicates a highly comminuted articular surface with significant metaphyseal impaction and displacement of the major weight-bearing columns. This definition perfectly matches the description of the patient's severe pilon fracture, characterized by extensive articular and metaphyseal damage.

Question 2003

Topic: 2. Trauma

The definitive reconstruction of this high-energy pilon fracture follows a specific, sequential algorithm. After the fibula is addressed, attention is turned to the articular surface. Which of the following sequences represents the MOST appropriate order for reducing the articular fragments of the distal tibia, as described in the case?

. Elevate the central die-punch fragment, then reduce the medial malleolar fragment, then the anterolateral fragment.
. Reduce the medial malleolar fragment, then the posterolateral fragment, then elevate the central die-punch fragment.
. Reduce the anterolateral (Chaput) fragment to the reconstructed fibula, then the posterolateral (Volkmann) fragment, then elevate the central die-punch fragments.
. Reduce the posterolateral (Volkmann) fragment first, then the anterolateral fragment, then the medial malleolar fragment.
. Reduce the central die-punch fragment first, then the medial malleolar fragment, then the posterolateral fragment.

Correct Answer & Explanation

. Reduce the anterolateral (Chaput) fragment to the reconstructed fibula, then the posterolateral (Volkmann) fragment, then elevate the central die-punch fragments.

Explanation

Correct Answer: CThe case explicitly states the reduction sequence: 'The reduction proceeds from the periphery to the center. The anterolateral (Chaput) fragment is mobilized and reduced to the reconstructed fibula. The posterolateral (Volkmann) fragment is then reduced... Once the peripheral rim is re-established, the central die-punch fragments are elevated.' This 'periphery to center' approach is a fundamental principle in pilon fracture reconstruction, using the intact fibula as a template for the lateral column and then building the articular surface outwards from there, finally addressing the central impaction.Options A, B, D, and E are incorrectbecause they do not follow the described 'periphery to center' reduction strategy, nor do they align with the specific sequence outlined in the case, which prioritizes reducing the peripheral fragments (Chaput, Volkmann) to the fibula before addressing the central impaction.

Question 2004

Topic: 2. Trauma
A 42-year-old male presents with a high-energy pilon fracture, classified as Rüedi-Allgöwer Type III and AO/OTA 43-C3. The initial management involves a spanning external fixator. The patient's soft tissues are severely compromised, with extensive edema and hemorrhagic fracture blisters. The definitive reconstruction is planned for 14 days post-injury, once the 'wrinkle sign' is positive. What is the primary biomechanical and biological imperative for maintaining a minimum skin bridge of 7 centimeters between the planned anterolateral and posteromedial incisions?
. To ensure adequate space for implant placement and screw trajectory.
. To prevent nerve entrapment between the two incisions.
. To preserve the delicate angiosomal blood supply and prevent catastrophic skin necrosis.
. To allow for easier wound closure by distributing tension evenly.
. To minimize the risk of heterotopic ossification.

Correct Answer & Explanation

. To preserve the delicate angiosomal blood supply and prevent catastrophic skin necrosis.

Explanation

It is an absolute biomechanical and biological imperative that a minimum skin bridge of 7 centimeters is maintained between the two incisions to preserve the delicate angiosomal blood supply and prevent catastrophic skin necrosis. This highlights the critical importance of respecting the soft tissue vascularity, especially in high-energy injuries with compromised envelopes. Inadequate skin bridges can lead to ischemia and necrosis of the intervening skin, resulting in devastating wound complications.

Question 2005

Topic: 2. Trauma

The patient's initial radiographs show a highly comminuted, complete articular fracture of the distal tibia with significant metaphyseal comminution and varus collapse. The fibula is fractured at the level of the syndesmosis, and the talus is proximally migrated. The CT scan further delineates a large, central die-punch fragment impacted 15 millimeters proximally. Based on these findings, which of the following comparative pathologies is LEAST likely to present with a similar degree of central articular impaction and metaphyseal comminution?

. A high-energy talar body fracture.
. A trimalleolar ankle fracture.
. A distal tibial shaft fracture with intra-articular extension.
. A severe calcaneal fracture with joint depression.
. A high-energy pilon fracture (as described in the case).

Correct Answer & Explanation

. A trimalleolar ankle fracture.

Explanation

Correct Answer: BThe case's differential diagnosis table clearly distinguishes between pilon fractures and trimalleolar ankle fractures. For trimalleolar ankle fractures, it states, 'Articular involvement is peripheral, lacking central impaction.' In contrast, pilon fractures are characterized by 'Complete articular involvement, metaphyseal comminution, central die-punch fragments, proximal talar migration.' Therefore, a trimalleolar ankle fracture is the least likely to present with the central articular impaction and metaphyseal comminution seen in this pilon fracture.Option A (high-energy talar body fracture)can involve significant comminution and impaction within the talus itself, which is a different bone but can be a high-energy injury with complex articular involvement.Option C (distal tibial shaft fracture with intra-articular extension)can have an articular split, but the primary fracture is diaphyseal/metaphyseal, and while it extends into the joint, it typically lacks the profound central impaction and comminution characteristic of a pilon.Option D (severe calcaneal fracture with joint depression)is a high-energy hindfoot injury that frequently involves significant impaction and depression of the subtalar joint articular surface, making it similar in concept of articular impaction, though in a different bone.Option E (a high-energy pilon fracture)is the exact pathology described in the case and is characterized by central articular impaction and metaphyseal comminution.

Question 2006

Topic: 2. Trauma

In the management of a subtrochanteric femur fracture, the proximal fragment typically assumes a characteristic deformed position due to the pull of attaching musculature. Which of the following best describes the typical position of the proximal fragment and the primary muscle responsible for its flexion?

. Flexed, adducted, and internally rotated; Iliopsoas
. Extended, abducted, and externally rotated; Gluteus maximus
. Flexed, abducted, and externally rotated; Iliopsoas
. Flexed, abducted, and internally rotated; Gluteus medius
. Extended, adducted, and externally rotated; Adductor magnus

Correct Answer & Explanation

. Flexed, abducted, and externally rotated; Iliopsoas

Explanation

The proximal fragment in a subtrochanteric fracture is characteristically flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the short external rotators. Understanding these deforming forces is critical for achieving anatomic reduction prior to intramedullary nailing.

Question 2007

Topic: 2. Trauma

A 45-year-old male sustains a high-energy pilon fracture with severe soft tissue compromise, including fracture blisters over the medial and lateral ankle. A spanning external fixator is placed on the day of injury. What is the most reliable clinical indicator that the soft tissue envelope is safe for definitive open reduction and internal fixation?

. A decrease in the patient's visual analog pain scale score to less than 3
. Resolution of fracture blisters and a positive 'wrinkle test' of the skin
. Normalization of the patient's serum C-reactive protein (CRP) levels
. Fourteen days having elapsed since the initial injury
. The appearance of bridging callus on follow-up radiographs

Correct Answer & Explanation

. Resolution of fracture blisters and a positive 'wrinkle test' of the skin

Explanation

The timing of definitive fixation in pilon fractures is dictated by the status of the soft tissue envelope, not a strict timeline. The return of skin lines (positive 'wrinkle test') and epithelialization of fracture blisters indicate that swelling has resolved sufficiently to allow for safe surgical incisions with reduced risk of wound breakdown.

Question 2008

Topic: 2. Trauma

A 68-year-old female with a 10-year history of alendronate therapy presents with a displaced atypical subtrochanteric femur fracture. Her contralateral femur exhibits significant anterolateral bowing and a thickened lateral cortex. During intramedullary nailing of the fractured femur, what technical complication is most directly associated with her altered femoral geometry?

. Iatrogenic fracture of the greater trochanter during reaming
. Anterior cortical perforation by the distal tip of the nail
. Posterior cortical perforation by the proximal portion of the nail
. Delayed union due to excessive endosteal reaming
. Failure of distal interlocking screw insertion due to nail torsion

Correct Answer & Explanation

. Anterior cortical perforation by the distal tip of the nail

Explanation

Patients with atypical femur fractures often have increased anterolateral femoral bowing. Using a standard, relatively straight intramedullary nail in a highly bowed femur can lead to an anterior cortical mismatch, resulting in anterior cortical perforation or iatrogenic fracture at the distal nail tip.

Question 2009

Topic: 2. Trauma

During intramedullary nailing of a subtrochanteric fracture utilizing a trochanteric entry point, the surgeon inadvertently establishes the starting hole too far medial on the greater trochanter, encroaching on the piriformis fossa. What is the most likely resulting coronal plane malalignment?

. Valgus malalignment
. Varus malalignment
. Anterior procurvatum
. Posterior recurvatum
. Rotational malalignment

Correct Answer & Explanation

. Varus malalignment

Explanation

If a trochanteric-entry nail is started too far medially (towards the piriformis fossa), the nail will strike the medial cortex of the proximal fragment as it is inserted. This forces the proximal fragment into varus malalignment relative to the distal segment.

Question 2010

Topic: 2. Trauma

A 66-year-old female presents with a non-displaced transverse fracture of the patella 6 months following an uncomplicated total knee arthroplasty. The patellar component is well-fixed, and the patient has a fully intact extensor mechanism with the ability to perform a straight leg raise. What is the most appropriate management?

. Open reduction and internal fixation with tension band wiring
. Partial patellectomy with advancement of the quadriceps tendon
. Revision of the patellar component with lateral retinacular release
. Nonoperative management with a knee immobilizer or hinged brace
. Total patellectomy

Correct Answer & Explanation

. Nonoperative management with a knee immobilizer or hinged brace

Explanation

Periprosthetic patellar fractures with an intact extensor mechanism (demonstrated by the ability to perform a straight leg raise) and a well-fixed component are best treated nonoperatively. Surgical intervention in this setting has a high rate of complications, including infection, nonunion, and hardware failure.

Question 2011

Topic: 2. Trauma

In the biomechanical comparison of intramedullary nailing versus lateral locked plating for subtrochanteric femur fractures, intramedullary nailing demonstrates superior load-sharing characteristics. This is primarily because the intramedullary nail:

. Increases the bending moment arm applied to the lateral cortex
. Acts as a tension band on the lateral side of the femur
. Possesses a shorter moment arm, reducing bending stresses on the implant
. Completely prevents torsional micro-motion at the fracture site
. Stimulates aggressive endosteal bone formation without cortical healing

Correct Answer & Explanation

. Possesses a shorter moment arm, reducing bending stresses on the implant

Explanation

An intramedullary nail is positioned closer to the mechanical axis of the lower extremity compared to a laterally applied plate. This significantly decreases the moment arm, thereby reducing the bending stresses exerted on the implant and lowering the risk of hardware fatigue and failure.

Question 2012

Topic: 2. Trauma

A patient with a Vancouver A periprosthetic fracture involving the greater trochanter presents with 3 centimeters of proximal displacement. The femoral stem is solidly fixed. The patient complains of significant lateral hip pain and an active abductor lurch is noted. What is the most appropriate management for this specific clinical presentation?

. Immediate revision of the femoral stem
. Nonoperative management with protected weight-bearing for 6 weeks
. Open reduction and internal fixation of the greater trochanter using a claw or tension band technique
. Resection of the displaced trochanteric fragment to prevent heterotopic ossification
. Injection of bone morphogenetic protein (BMP) into the fracture gap

Correct Answer & Explanation

. Open reduction and internal fixation of the greater trochanter using a claw or tension band technique

Explanation

While many Vancouver A fractures (involving the trochanters) are treated nonoperatively, indications for surgical fixation of the greater trochanter include displacement greater than 2 to 2.5 cm, symptomatic nonunion, or severe abductor weakness (abductor lurch). Fixation is typically achieved with a trochanteric claw, cables, or specialized plating.

Question 2013

Topic: 2. Trauma

When approaching the medial aspect of the distal tibia for pilon fracture fixation, what neurovascular structures are at highest risk and must be meticulously protected during the approach?

. Posterior tibial artery and tibial nerve
. Great saphenous vein and saphenous nerve
. Small saphenous vein and sural nerve
. Anterior tibial artery and deep peroneal nerve
. Peroneal artery and superficial peroneal nerve

Correct Answer & Explanation

. Great saphenous vein and saphenous nerve

Explanation

The anteromedial approach to the distal tibia places the great saphenous vein and the saphenous nerve at direct risk, as they cross the medial malleolus and anterior aspect of the ankle. The deep posterior structures (posterior tibial artery/tibial nerve) are protected behind the medial malleolus.

Question 2014

Topic: 2. Trauma

A 55-year-old male undergoes closed reduction and intramedullary nailing of a subtrochanteric fracture. Despite gross alignment, intraoperative fluoroscopy reveals a persistent gap at the medial cortex. Why is achieving medial cortical continuity (contact) critical in the fixation of subtrochanteric fractures?

. It prevents iatrogenic injury to the medial circumflex femoral artery
. It neutralizes the pull of the gluteus maximus
. It restores the compressive load-bearing column, thereby protecting the implant from excessive bending moments
. It is necessary to create a closed medullary canal for cement pressurization
. It guarantees the restoration of native femoral anteversion

Correct Answer & Explanation

. It restores the compressive load-bearing column, thereby protecting the implant from excessive bending moments

Explanation

The medial cortex of the subtrochanteric region is subjected to massive compressive forces. Restoring medial cortical contact is crucial as it re-establishes the structural column, sharing the load with the intramedullary nail. A medial gap subjects the implant to unopposed bending moments and high risk of fatigue failure.

Question 2015

Topic: 2. Trauma

A 65-year-old patient presents with a severe AO/OTA 43-C3 pilon fracture accompanied by extensive articular cartilage loss and osteopenia. The patient is relatively low-demand but requires a stable, plantigrade foot for ambulation. The surgeon deems the articular surface unreconstructable. What is the most appropriate definitive surgical intervention?

. Primary below-knee amputation
. Open reduction and internal fixation utilizing bioabsorbable pins
. Spanning external fixation left in place for 6 months as definitive treatment
. Primary tibiotalar arthrodesis
. Total ankle arthroplasty

Correct Answer & Explanation

. Primary tibiotalar arthrodesis

Explanation

In cases of severe, unreconstructable articular comminution in a low-demand or elderly patient, or when extensive cartilage is lost from the injury, primary tibiotalar arthrodesis is an appropriate salvage procedure. It avoids the high morbidity of multiple failed attempts at joint reconstruction and provides a stable, pain-free, plantigrade limb.

Question 2016

Topic: 2. Trauma

A 45-year-old male sustains a subtrochanteric femur fracture. During closed reduction for intramedullary nailing, the proximal segment is consistently positioned in flexion, abduction, and external rotation. Which muscle group is primarily responsible for the external rotation deformity of the proximal fragment?

. Iliopsoas
. Gluteus medius and minimus
. Piriformis and short external rotators
. Adductor longus and brevis
. Gluteus maximus

Correct Answer & Explanation

. Iliopsoas

Explanation

The proximal fragment in a subtrochanteric fracture is flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the piriformis and short external rotators. Understanding these deforming forces is critical for achieving anatomical reduction prior to implant insertion.

Question 2017

Topic: 2. Trauma

A 35-year-old male presents with a high-energy closed tibial pilon fracture with severe soft tissue swelling and clear fracture blisters. A spanning external fixator is placed on the day of injury. What clinical finding best dictates when it is safe to proceed with definitive open reduction and internal fixation?

. Complete desquamation of the fracture blisters
. Re-epithelialization of the external fixator pin sites
. Appearance of the 'wrinkle sign' on the anterior ankle skin
. Normalization of serum ESR and CRP levels
. Radiographic evidence of early bridging callus

Correct Answer & Explanation

. Appearance of the 'wrinkle sign' on the anterior ankle skin

Explanation

Definitive surgical fixation of high-energy pilon fractures must be delayed until the soft tissue envelope recovers to minimize wound complications. The appearance of skin wrinkles (the 'wrinkle sign') indicates that edema has subsided enough to safely perform surgical incisions.

Question 2018

Topic: 2. Trauma

During antegrade intramedullary nailing of a subtrochanteric fracture, an overly lateral entry point on the greater trochanter will most likely result in which of the following malreductions?

. Varus
. Valgus
. Flexion
. Extension
. Internal rotation

Correct Answer & Explanation

. Varus

Explanation

An entry point that is too lateral on the greater trochanter forces the intramedullary nail medially as it enters the diaphysis. This pushes the proximal fragment into varus, which is a common and poorly tolerated malreduction in subtrochanteric fractures.

Question 2019

Topic: 2. Trauma

A preoperative CT scan of a complex pilon fracture identifies a displaced anterolateral articular fragment of the distal tibia. Which ligamentous structure remains attached to this specific fragment, occasionally allowing for indirect reduction?

. Posterior inferior tibiofibular ligament
. Anterior inferior tibiofibular ligament
. Deltoid ligament
. Calcaneofibular ligament
. Spring ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The anterolateral fragment of the distal tibia is the Chaput fragment, which serves as the tibial attachment point for the anterior inferior tibiofibular ligament (AITFL). Pulling on the intact fibula or AITFL can sometimes aid in the indirect reduction of this fragment.

Question 2020

Topic: 2. Trauma

A 68-year-old male with a well-functioning posterior-stabilized total knee arthroplasty sustains a displaced distal femur fracture above the anterior flange of the femoral component. Radiographs confirm the femoral component remains well-fixed. What is the most appropriate definitive management?

. Hinged knee brace and restricted weight-bearing
. Revision to a distal femoral replacement
. Open reduction and internal fixation with a locked plate or retrograde nail
. Non-operative management in a long leg cast
. Revision of the femoral component using a stemmed implant

Correct Answer & Explanation

. Open reduction and internal fixation with a locked plate or retrograde nail

Explanation

This is a Rorabeck Type II periprosthetic distal femur fracture (displaced fracture with a well-fixed implant). Surgical stabilization using either lateral locked plating or retrograde intramedullary nailing is the standard of care to allow early mobilization.

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