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2. Trauma MCQs

Practice Set 111 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 2201

Topic: 2. Trauma
A resident is presenting a case of a Gustilo-Anderson Grade IIIb open tibial fracture. During the discussion, an attending surgeon challenges the resident on the precise definition of a Grade IIIb injury, specifically regarding the necessity of a flap for classification. Based on the historical context and clarification provided in the case, which statement accurately reflects the definition of a Gustilo-Anderson Grade IIIb open fracture?
. It is defined by a wound greater than 10 cm with extensive contamination.
. It is an open fracture with extensive soft tissue damage but adequate soft tissue coverage, requiring a local flap.
. It is an open fracture with extensive soft tissue loss and periosteal stripping, where the need for a flap is part of its definition.
. It is an open fracture with extensive soft tissue loss and periosteal stripping, but the need for a flap is NOT part of its classification definition.
. It is an open fracture with an associated arterial injury requiring repair, regardless of soft tissue loss.

Correct Answer & Explanation

. It is an open fracture with extensive soft tissue loss and periosteal stripping, but the need for a flap is NOT part of its classification definition.

Explanation

The case specifically addresses the confusion surrounding the IIIb subtype. It states: 'Type IIIb is described in the previous table and the need for a flap is not part of the classification system.' The definition provided in the table for IIIb is 'An open fracture with extensive soft tissue loss and periosteal stripping.' While Gustilo himself noted that IIIb fractures often need full-thickness soft-tissue coverage, Brumback and Jones clarified that this criterion was not part of the definition of the IIIb subtype published in 1984. While Grade III fractures are often high-energy and contaminated, the specific wound size and contamination level are not the sole defining factors for IIIb. Grade IIIa describes extensive soft tissue damage but adequate soft tissue coverage, not IIIb. Grade IIIc describes an open fracture with an associated arterial injury requiring repair.

Question 2202

Topic: 2. Trauma

A 40-year-old male presents with a Gustilo-Anderson Grade II open tibial fracture after a fall. He has no known allergies. Following initial wound care and splinting in the emergency department, what is the most appropriate antibiotic regimen and duration, according to the BOAST guidelines mentioned in the case?

. Oral cephalexin for 5 days.
. Intravenous cefuroxime 1.5 g IV, continued for 72 hours or until wound closure, whichever occurs soonest.
. Intravenous vancomycin and gentamicin for 7 days.
. Intravenous penicillin G for 24 hours.
. No antibiotics are necessary if the wound is thoroughly debrided within 24 hours.

Correct Answer & Explanation

. Intravenous cefuroxime 1.5 g IV, continued for 72 hours or until wound closure, whichever occurs soonest.

Explanation

Correct Answer: BThe case states, 'I would give antibiotics as per local microbiology protocols (the BOAST guidelines suggest cefuroxime 1.5 g IV)... Antibiotics would be given at the time of surgery and continued for 72 hours or until wound closure, whichever occurs soonest.' This directly matches option B.Option A:Oral antibiotics are generally insufficient for open fractures, which require intravenous administration for adequate tissue penetration and systemic effect.Option C:While vancomycin and gentamicin might be used for specific types of contamination (e.g., farmyard, marine) or in cases of penicillin allergy, cefuroxime is the general recommendation for Grade I/II open fractures as per BOAST guidelines mentioned in the text. The duration of 7 days is also longer than the recommended 72 hours or until wound closure.Option D:Penicillin G is not the broad-spectrum antibiotic of choice for open fractures; cefuroxime (a second-generation cephalosporin) provides broader coverage against common pathogens in open fractures.Option E:Antibiotic prophylaxis is crucial for all open fractures, regardless of the timing of debridement, to reduce the risk of infection.

Question 2203

Topic: 2. Trauma

A 35-year-old male undergoes surgical debridement and internal fixation for a high-energy open tibial fracture. Twenty-four hours post-operatively, he develops severe, unremitting pain in the affected leg, disproportionate to the injury, and has increasing paresthesias in the foot. Clinical examination reveals a tense and firm anterior compartment. Despite the open nature of the fracture, the orthopedic team suspects acute compartment syndrome. What is the definitive treatment for this condition?

. Elevation of the limb and close observation.
. Administration of intravenous mannitol to reduce swelling.
. Emergency two-incision, four-compartment fasciotomy of the lower leg.
. Application of a cast to immobilize the limb and reduce pain.
. Repeat surgical debridement of the fracture site.

Correct Answer & Explanation

. Emergency two-incision, four-compartment fasciotomy of the lower leg.

Explanation

Correct Answer: CThe case directly addresses the treatment of compartment syndrome: 'I would perform an emergency two-incision, four-compartment fasciotomy of the lower leg.' This is the definitive surgical treatment for acute compartment syndrome.Option A:Elevation and observation are contraindicated in suspected compartment syndrome as they delay definitive treatment and can worsen outcomes. Elevation can decrease arterial inflow, further compromising perfusion.Option B:Mannitol is a diuretic that can reduce generalized edema but is not effective in reversing the high compartmental pressures seen in acute compartment syndrome, which requires surgical decompression.Option D:Applying a cast would further restrict the limb and exacerbate the compartment syndrome by increasing external pressure, making it highly detrimental.Option E:While repeat debridement might be necessary for the open fracture wound itself, it does not address the underlying pathology of compartment syndrome, which is increased pressure within the fascial compartments. A fasciotomy is required to relieve this pressure.

Question 2204

Topic: 2. Trauma

A 25-year-old cyclist sustains a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

. 100% displacement with 1.5 cm of shortening
. Z-type comminution with a butterfly fragment
. Impending skin necrosis with severe tenting
. Associated nondisplaced scapular body fracture
. Patient occupation as an overhead laborer

Correct Answer & Explanation

. Impending skin necrosis with severe tenting

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, associated neurovascular injury, and skin tenting causing impending necrosis. Displacement and shortening are relative indications evaluated on a case-by-case basis.

Question 2205

Topic: 2. Trauma

A 45-year-old man sustains a completely displaced Type II distal clavicle fracture (Neer classification). What is the primary deforming force responsible for the displacement of the proximal fragment?

. Deltoid muscle
. Pectoralis major
. Trapezius
. Sternocleidomastoid
. Latissimus dorsi

Correct Answer & Explanation

. Trapezius

Explanation

In Type II distal clavicle fractures, the coracoclavicular ligaments are detached from the proximal fragment. The trapezius muscle then pulls the unsupported proximal clavicular fragment superiorly and posteriorly.

Question 2206

Topic: 2. Trauma
A 35-year-old male sustains a high-energy trauma resulting in a 'floating shoulder.' What defines the true anatomic basis of this injury pattern?
. Disruption of the Superior Suspensory Shoulder Complex (SSSC) in two places
. Concomitant humerus and clavicle fractures
. Acromioclavicular and coracoclavicular ligament ruptures
. Tearing of the coracoacromial ligament with a clavicle fracture
. Glenohumeral dislocation combined with a clavicle fracture

Correct Answer & Explanation

. Disruption of the Superior Suspensory Shoulder Complex (SSSC) in two places

Explanation

A true floating shoulder is defined by a double disruption of the Superior Suspensory Shoulder Complex (SSSC). This is classically a displaced clavicle fracture combined with a displaced surgical neck fracture of the scapula.

Question 2207

Topic: 2. Trauma

In a severe 4-part proximal humerus fracture, what is the primary arterial supply to the humeral head that is typically disrupted, leading to a high risk of avascular necrosis?

. Anterior circumflex humeral artery
. Posterior circumflex humeral artery
. Suprascapular artery
. Thoracoacromial artery
. Profunda brachii artery

Correct Answer & Explanation

. Posterior circumflex humeral artery

Explanation

Recent microvascular studies (e.g., Hettrich et al.) demonstrated that the posterior circumflex humeral artery provides the primary blood supply to the humeral head. This updated the older teaching that emphasized the anterior circumflex artery.

Question 2208

Topic: Upper Extremity Trauma
A 28-year-old male falls onto his adducted shoulder, sustaining an acromioclavicular (AC) joint injury. Radiographs show superior displacement of the clavicle by 150% of the acromion width, with severe disruption of the deltotrapezial fascia. Which Rockwood classification type is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type V

Explanation

Rockwood Type V AC injuries are characterized by 100% to 300% superior displacement of the clavicle relative to the acromion. This severe displacement indicates extensive disruption of the CC ligaments and the deltotrapezial fascia.

Question 2209

Topic: 2. Trauma

To better visualize the sternoclavicular joint and assess anterior versus posterior displacement in a trauma patient, a 'serendipity view' is ordered. What is the proper X-ray beam angulation for this specialized view?

. 40 degrees cephalad tilt
. 40 degrees caudal tilt
. 15 degrees cephalad tilt
. 15 degrees caudal tilt
. 90 degrees strictly orthogonal

Correct Answer & Explanation

. 40 degrees cephalad tilt

Explanation

The serendipity view is taken with the patient supine and the X-ray beam aimed 40 degrees cephalad. On this view, a posteriorly dislocated clavicle will appear inferior to the sternum, while an anterior dislocation appears superior.

Question 2210

Topic: 2. Trauma

A 42-year-old polytrauma patient is diagnosed with a displaced scapular body and neck fracture. Which of the following measurements is considered a strong relative indication for open reduction and internal fixation (ORIF) to restore shoulder biomechanics?

. Glenoid articular step-off of 2 mm
. Medial/lateral displacement of the scapular body of 10 mm
. Glenopolar angle (GPA) of 20 degrees
. Associated nondisplaced rib fractures
. Ipsilateral clavicle fracture with 5 mm displacement

Correct Answer & Explanation

. Glenopolar angle (GPA) of 20 degrees

Explanation

A Glenopolar angle (GPA) of less than 22 degrees indicates severe rotational malalignment of the glenoid. This disrupts normal shoulder kinematics and is a widely accepted relative indication for operative fixation.

Question 2211

Topic: 2. Trauma

Which of the following specific combinations of injuries constitutes the classic 'terrible triad of the shoulder'?

. Anterior shoulder dislocation, rotator cuff tear, and neurologic injury
. Posterior shoulder dislocation, surgical neck humerus fracture, and axillary artery tear
. AC separation, clavicle fracture, and coracoid fracture
. Anterior shoulder dislocation, Bankart lesion, and Hill-Sachs lesion
. Glenohumeral dislocation, clavicle fracture, and scapular spine fracture

Correct Answer & Explanation

. Anterior shoulder dislocation, rotator cuff tear, and neurologic injury

Explanation

The 'terrible triad of the shoulder' consists of an anterior shoulder dislocation, a rotator cuff tear, and a neurologic injury (most commonly affecting the axillary nerve). It typically occurs in older patients.

Question 2212

Topic: 2. Trauma

A 30-year-old male presents with a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis) and an isolated, dense radial nerve palsy present immediately after the injury. What is the most appropriate initial management?

. Immediate open reduction internal fixation and nerve exploration
. Application of a coaptation splint or Sarmiento brace and observation
. External fixation and delayed nerve grafting
. Immediate nerve conduction studies (EMG/NCS)
. Humeral nailing with percutaneous nerve release

Correct Answer & Explanation

. Application of a coaptation splint or Sarmiento brace and observation

Explanation

An immediate radial nerve palsy in a closed humeral shaft fracture (including Holstein-Lewis patterns) is treated expectantly with functional bracing. Spontaneous nerve recovery occurs in 70-90% of cases over 3 to 4 months.

Question 2213

Topic: 2. Trauma

Which of the following is considered the most significant radiographic risk factor for the development of a nonunion in a midshaft clavicle fracture treated non-operatively?

. Angulation greater than 15 degrees
. Z-type comminution with less than 1 cm shortening
. 100% displacement (complete lack of cortical apposition)
. Fracture location at the medial third
. Presence of a butterfly fragment with residual cortical contact

Correct Answer & Explanation

. 100% displacement (complete lack of cortical apposition)

Explanation

Complete displacement (100% lack of cortical apposition) and shortening greater than 2 cm are the most significant and well-documented radiographic risk factors for nonunion in midshaft clavicle fractures.

Question 2214

Topic: Upper Extremity Trauma

When performing an open distal clavicle excision (Mumford procedure), the surgeon must be careful not to resect too much bone to prevent iatrogenic acromioclavicular instability. What is the maximum amount of distal clavicle that should safely be resected?

. 2-4 mm
. 8-10 mm
. 15-20 mm
. 25-30 mm
. 35-40 mm

Correct Answer & Explanation

. 8-10 mm

Explanation

Distal clavicle resection should ideally be limited to 8-10 mm. Resecting more than 1 cm compromises the insertion of the coracoclavicular (CC) ligaments, which can lead to iatrogenic horizontal and superior instability.

Question 2215

Topic: 2. Trauma

Which of the following clinical findings is considered an absolute indication for operative fixation of an acute midshaft clavicle fracture?

. Greater than 2 cm of fracture shortening
. 100% fracture displacement with lack of cortical contact
. Skin tenting that demonstrates localized blanching
. Severe Z-type fracture comminution
. Presence of a concomitant non-displaced scapular body fracture

Correct Answer & Explanation

. Skin tenting that demonstrates localized blanching

Explanation

Skin tenting with blanching indicates impending skin necrosis, which can convert a closed fracture to an open one. This is an absolute indication for urgent operative intervention, whereas shortening and displacement are relative indications.

Question 2216

Topic: Upper Extremity Trauma

What is the primary stabilizing function of the costoclavicular (rhomboid) ligament in the shoulder girdle?

. Restricts anterior translation of the medial clavicle
. Restricts superior translation of the medial clavicle
. Restricts posterior translation of the medial clavicle
. Restricts inferior translation of the lateral clavicle
. Provides dynamic stability to the acromioclavicular joint

Correct Answer & Explanation

. Restricts superior translation of the medial clavicle

Explanation

The costoclavicular ligament is a strong extra-articular ligament that attaches the first rib to the inferior clavicle. It acts as the primary restraint against superior displacement of the medial clavicle, counteracting the upward pull of the sternocleidomastoid muscle.

Question 2217

Topic: Upper Extremity Trauma
A 30-year-old cyclist falls onto the point of his shoulder and is diagnosed with a Rockwood Type III acromioclavicular (AC) joint separation. Which of the following accurately describes the status of the supporting ligaments in this injury pattern?
. AC ligaments sprained; CC ligaments intact
. AC ligaments torn; CC ligaments sprained
. AC ligaments torn; CC ligaments torn
. AC ligaments intact; CC ligaments torn
. AC ligaments torn; CC ligaments torn; deltotrapezial fascia torn

Correct Answer & Explanation

. AC ligaments torn; CC ligaments torn

Explanation

In a Rockwood Type III AC separation, both the acromioclavicular (AC) and coracoclavicular (CC) ligaments are completely disrupted, resulting in 25% to 100% superior displacement of the distal clavicle. The deltotrapezial fascia remains intact.

Question 2218

Topic: 2. Trauma

During open reduction and internal fixation of a comminuted midshaft clavicle fracture, the surgeon drills from anterior to posterior to place a lag screw. Which neurovascular structure is most at risk from over-penetration by the drill bit?

. Subclavian vein
. Subclavian artery
. Brachial plexus roots
. Suprascapular nerve
. Internal jugular vein

Correct Answer & Explanation

. Subclavian vein

Explanation

The subclavian vein lies directly posterior and slightly inferior to the medial and middle thirds of the clavicle. It is the structure most vulnerable to injury from misplaced instruments or drills passing posteriorly through the mid-clavicle.

Question 2219

Topic: 2. Trauma

Which of the following patients with a midshaft clavicle fracture possesses the highest risk of nonunion if managed nonoperatively?

. A 15-year-old male with 2 cm of fracture shortening
. A 25-year-old male with an undisplaced transverse fracture
. A 65-year-old female with a comminuted and 100% displaced fracture
. A 40-year-old male with 1 cm of fracture shortening
. A 10-year-old female with a severely angulated greenstick fracture

Correct Answer & Explanation

. A 65-year-old female with a comminuted and 100% displaced fracture

Explanation

Established risk factors for nonunion in midshaft clavicle fractures include advanced age, female gender, 100% displacement, and severe comminution.

Question 2220

Topic: 2. Trauma

A 34-year-old male sustains a Neer Type IIB distal clavicle fracture. Why is operative fixation strongly considered for this specific fracture pattern?

. High risk of subsequent pneumothorax
. High risk of nonunion due to displacement by the coracoclavicular ligaments
. High risk of rapidly progressive glenohumeral arthritis
. Frequent involvement of the acromioclavicular articular surface
. High association with immediate brachial plexus palsy

Correct Answer & Explanation

. High risk of nonunion due to displacement by the coracoclavicular ligaments

Explanation

Neer Type II distal clavicle fractures occur medial to the intact coracoclavicular ligaments, which remain attached to the distal fragment. The proximal fragment is displaced superiorly by the trapezius, resulting in a nonunion rate of up to 30% with nonoperative care.

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