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2. Trauma MCQs

Practice Set 122 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 2421

Topic: 2. Trauma

A surgeon is repairing a depressed tibial plateau fracture in an osteoporotic 80-year-old patient. After elevating the articular surface, a significant metaphyseal void is present. Which of the following void fillers provides the greatest immediate structural support and highest screw pullout augmentation in this setting?

. Demineralized bone matrix (DBM)
. Cancellous allograft chips
. Platelet-rich plasma (PRP)
. Calcium phosphate cement
. Autologous iliac crest bone graft

Correct Answer & Explanation

. Calcium phosphate cement

Explanation

Calcium phosphate cement possesses high compressive strength and hardens isothermally. It provides immediate structural support to elevated articular fragments and significantly increases screw pullout strength in osteoporotic metaphyseal bone compared to standard bone grafting.

Question 2422

Topic: 2. Trauma

A 28-year-old male undergoes open reduction and internal fixation for a highly comminuted tibia fracture. Postoperatively, he develops severe pain out of proportion to the injury, exacerbated by passive stretch of the hallux. If a four-compartment fasciotomy is performed, which leg compartment is statistically most likely to be inadequately decompressed or missed?

. Anterior compartment
. Lateral compartment
. Superficial posterior compartment
. Deep posterior compartment
. Peroneal compartment

Correct Answer & Explanation

. Deep posterior compartment

Explanation

The deep posterior compartment is the most commonly missed or inadequately released compartment during a lower extremity fasciotomy. Failure to fully decompress this compartment can lead to flexor hallucis longus and tibialis posterior necrosis.

Question 2423

Topic: 2. Trauma
A 45-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture requiring a rotational flap. To minimize the risk of deep infection and optimize outcomes, the definitive soft tissue coverage should ideally be performed within what timeframe?
. Within 24 hours of injury
. Within 3 to 7 days of injury
. Between 10 and 14 days of injury
. After 21 days once granulation tissue is robust
. Only after definitive fracture union is achieved

Correct Answer & Explanation

. Within 3 to 7 days of injury

Explanation

Extensive literature, including the principles established by Godina, demonstrates that early soft tissue coverage (within 3 to 7 days) of Type IIIB open tibia fractures significantly decreases infection rates and flap failure compared to delayed coverage.

Question 2424

Topic: 2. Trauma

When utilizing bridge plating for a comminuted diaphyseal tibia fracture in an osteoporotic patient, the surgeon aims to optimize the construct's working length. Which of the following screw configurations achieves this and decreases the risk of plate fracture?

. Filling every screw hole in the plate (screw density 1.0)
. Placing screws as close to the fracture site as possible
. Increasing the distance between the innermost screws closest to the fracture
. Using exclusively non-locking screws in the metaphysis
. Decreasing the plate span ratio to less than 2.0

Correct Answer & Explanation

. Increasing the distance between the innermost screws closest to the fracture

Explanation

Increasing the working length (the distance between the two innermost screws flanking the fracture) decreases the stiffness of the construct and distributes strain over a longer segment of the plate, which promotes secondary healing and reduces the risk of plate fatigue failure.

Question 2425

Topic: 2. Trauma

Review the radiograph of an elderly female who sustained a distal tibia fracture.

To decrease the risk of construct over-stiffness and promote secondary bone healing while using a locked plate, which strategy is most biomechanically sound?

. Use entirely non-locking cortical screws to compress the comminution
. Decrease the plate working length by placing screws immediately adjacent to the fracture
. Utilize far cortical locking (FCL) screws to allow symmetric biphasic micromotion
. Increase the screw density to 1.0 to maximize rigidity
. Lag the comminuted fragments directly through the locked plate

Correct Answer & Explanation

. Utilize far cortical locking (FCL) screws to allow symmetric biphasic micromotion

Explanation

Standard locked plates can be overly rigid, leading to asymmetric callus formation or nonunion. Utilizing far cortical locking (FCL) screws reduces axial stiffness and permits parallel interfragmentary motion, which stimulates robust callus formation.

Question 2426

Topic: 2. Trauma

A 74-year-old female with an osteoporotic proximal tibia fracture (T-score -3.1) is indicated for operative fixation.

To maximize fixation longevity in her osteoporotic bone, a locked plating construct is chosen. This construct differs from conventional plating by providing stability through which primary mechanism?

. Friction between the undersurface of the plate and the periosteum
. Dynamic compression across the fracture site
. Fixed-angle stability irrespective of bone-plate contact
. Individual screw toggle resistance in the near cortex
. Primary cortical healing via absolute stability

Correct Answer & Explanation

. Fixed-angle stability irrespective of bone-plate contact

Explanation

Conventional plates rely on friction generated by compressing the plate against the bone. Locked plates rely on fixed-angle stability because the screw heads thread into the plate, which preserves periosteal blood supply and prevents failure via individual screw toggle in osteoporotic bone.

Question 2427

Topic: 2. Trauma

A 50-year-old male sustains a high-energy tibial pilon fracture with severe soft tissue swelling and fracture blisters. A two-stage protocol is selected. What is the most reliable clinical indicator that the soft tissue envelope is ready for definitive open reduction and internal fixation?

. Resolution of fracture blisters within 48 hours
. Erythrocyte sedimentation rate (ESR) returning to normal
. Appearance of the 'wrinkle sign' on the overlying skin
. Patient reporting a pain score of less than 3/10
. Clear drainage from the external fixator pin sites

Correct Answer & Explanation

. Appearance of the 'wrinkle sign' on the overlying skin

Explanation

The 'wrinkle sign' indicates that the acute soft tissue edema has subsided enough to safely permit surgical incisions. Proceeding with definitive ORIF before this sign appears significantly increases the risk of wound dehiscence and deep infection.

Question 2428

Topic: 2. Trauma

A 35-year-old male underwent statically locked intramedullary nailing for a closed midshaft tibia fracture. At 4 months postoperatively, radiographs show a persistent fracture gap with minimal callus, but the limb length and alignment are stable. What is the best indication for nail dynamization in this scenario?

. To treat an infected nonunion
. To correct a malalignment of greater than 10 degrees
. To manage a highly comminuted, length-unstable fracture
. To promote healing in an axially stable delayed union
. To relieve anterior knee pain from the proximal nail tip

Correct Answer & Explanation

. To promote healing in an axially stable delayed union

Explanation

Dynamization involves removing the interlocking screws furthest from the fracture to allow axial compression during weight-bearing. It is indicated for delayed unions in axially stable fractures (e.g., transverse or short oblique) typically between 3 to 6 months postoperatively.

Question 2429

Topic: 2. Trauma

A 68-year-old female on long-term bisphosphonate therapy presents with thigh and leg pain. She is diagnosed with atypical long bone fractures. While atypical femoral fractures typically occur on the lateral (tensile) cortex, where do atypical bisphosphonate-related tibial fractures characteristically originate?

. The medial tibial plateau
. The posterior cortex of the distal tibia
. The anterior cortex of the tibial diaphysis
. The medial malleolus
. The interosseous crest of the lateral tibia

Correct Answer & Explanation

. The anterior cortex of the tibial diaphysis

Explanation

Atypical fractures associated with prolonged bisphosphonate use occur on the tensile side of the bone. In the tibia, the normal anterior bow places the anterior cortex under tension, making it the characteristic location for focal cortical thickening and atypical fracture initiation.

Question 2430

Topic: 2. Trauma

To prevent a valgus deformity during intramedullary nailing of a proximal third tibia fracture using a standard infrapatellar approach, what is the ideal starting point for the entry reamer?

. Directly medial to the medial tibial eminence
. Posterior to the tibial tuberosity
. Slightly lateral to the center of the lateral tibial eminence
. Directly over the medial meniscus
. Inferior to the pes anserinus insertion

Correct Answer & Explanation

. Slightly lateral to the center of the lateral tibial eminence

Explanation

A medial entry point directs the nail towards the lateral cortex of the distal segment, causing a valgus deformity at the proximal fracture site. Choosing a starting point slightly lateral to the center of the lateral tibial eminence helps prevent this apex-medial angulation.

Question 2431

Topic: 2. Trauma

A surgeon is evaluating the screw density for a bridge plate applied to a severely comminuted diaphyseal tibia fracture in an osteoporotic patient. Screw density is defined as the number of inserted screws divided by the number of plate holes. To optimize the mechanical environment for secondary bone healing, what is the recommended screw density?

. Greater than 0.8
. Between 0.6 and 0.8
. Less than 0.5
. Exactly 1.0 (filling every hole)
. Zero (using cables instead of screws)

Correct Answer & Explanation

. Less than 0.5

Explanation

For bridge plating, a screw density of less than 0.5 (filling fewer than half the plate holes) is recommended. This avoids creating an overly rigid construct, evenly distributes stress along the plate, and minimizes the risk of implant fatigue failure.

Question 2432

Topic: 2. Trauma

To prevent coronal and sagittal malalignment during intramedullary nailing of a proximal third tibia fracture, blocking (Poller) screws are frequently utilized. To prevent the typical apex anterior and valgus deformity, where should the blocking screws be placed relative to the intramedullary nail?

. Anterior and medial
. Anterior and lateral
. Posterior and medial
. Posterior and lateral
. Directly central in the metaphysis

Correct Answer & Explanation

. Posterior and lateral

Explanation

The typical deformity for proximal third tibia fractures is apex anterior (procurvatum) and valgus. Blocking screws should be placed on the concave side of the deformity (posterior and lateral) to narrow the medullary canal and direct the nail into the correct trajectory.

Question 2433

Topic: 2. Trauma

A 65-year-old osteoporotic patient sustains a closed, isolated transverse tibia shaft fracture. If non-operative management in a long leg cast is chosen, what are the maximum acceptable radiographic alignment parameters?

. < 10 degrees varus/valgus, < 15 degrees AP angulation, < 2 cm shortening
. < 5 degrees varus/valgus, < 10 degrees AP angulation, < 1 cm shortening
. < 15 degrees varus/valgus, < 5 degrees AP angulation, < 1 cm shortening
. < 5 degrees varus/valgus, < 5 degrees AP angulation, < 2 cm shortening
. Anatomic alignment is strictly required for non-operative management

Correct Answer & Explanation

. < 5 degrees varus/valgus, < 10 degrees AP angulation, < 1 cm shortening

Explanation

Acceptable alignment for a tibia shaft fracture treated non-operatively includes < 5 degrees of varus/valgus angulation, < 10 degrees of anterior/posterior angulation, > 50% cortical apposition, and < 1 cm of shortening.

Question 2434

Topic: 2. Trauma

A 72-year-old female on long-term bisphosphonate therapy presents with thigh and leg pain. Radiographs reveal an impending atypical tibia fracture. Which of the following radiographic features is most characteristic of this specific injury?

. Hypertrophy of the medial cortex with a spiral fracture pattern
. Cortical thinning of the anterior cortex with a highly comminuted pattern
. Hypertrophy of the lateral (tensile) cortex with a transverse or short oblique fracture line
. Periosteal reaction isolated to the posterior cortex
. Multi-level segmental fractures with severe osteopenia

Correct Answer & Explanation

. Hypertrophy of the lateral (tensile) cortex with a transverse or short oblique fracture line

Explanation

Atypical fractures related to prolonged bisphosphonate use characteristically occur on the tensile side of the bone (lateral cortex of the femur, anterior/lateral tibia). They exhibit focal cortical thickening (beaking) and present as transverse or short oblique fractures.

Question 2435

Topic: 2. Trauma

In the surgical management of distal tibia extra-articular fractures (OTA 43-A), how does intramedullary nailing compare to minimally invasive plate osteosynthesis (MIPO) regarding complications?

. Nailing has a higher risk of wound complications, while plating has a higher risk of malunion.
. Nailing has a higher risk of malunion, while plating has a higher risk of wound complications.
. Nailing significantly increases the rate of nonunion compared to plating.
. Plating has a higher rate of anterior knee pain and hardware removal.
. There is no difference in the complication profiles between the two techniques.

Correct Answer & Explanation

. Nailing has a higher risk of malunion, while plating has a higher risk of wound complications.

Explanation

Intramedullary nailing of distal tibia fractures is associated with higher rates of malalignment (particularly valgus) compared to plating. However, plating carries a significantly higher risk of soft tissue and wound complications.

Question 2436

Topic: 2. Trauma

When using locked plate constructs for the fixation of osteoporotic tibia fractures, what is the primary mode of failure compared to conventional non-locked plating?

. Sequential pulling out of individual screws
. Screw head shearing at the plate-hole interface
. En bloc pullout of the entire plate-screw construct
. Loss of frictional force between the plate and the bone
. Fracture through the screw holes

Correct Answer & Explanation

. En bloc pullout of the entire plate-screw construct

Explanation

Locked plates act as a single, fixed-angle construct. In poor-quality osteoporotic bone, failure typically occurs as an 'en bloc' pullout of the entire construct rather than the sequential screw loosening seen with conventional non-locked plates.

Question 2437

Topic: 2. Trauma

What is the primary biomechanical advantage of the suprapatellar approach over the traditional infrapatellar approach for intramedullary nailing of proximal tibia fractures?

. It completely eliminates the risk of anterior knee pain.
. It avoids all intra-articular structures, decreasing septic arthritis risk.
. It maintains the knee in semi-extension, relaxing the extensor mechanism and minimizing apex anterior deforming forces.
. It allows for a more distal starting point to avoid the infrapatellar fat pad.
. It requires less sophisticated fluoroscopic imaging.

Correct Answer & Explanation

. It maintains the knee in semi-extension, relaxing the extensor mechanism and minimizing apex anterior deforming forces.

Explanation

The suprapatellar approach allows the knee to remain in semi-extension (10-15 degrees of flexion) during nailing. This relaxes the quadriceps mechanism, significantly reducing the apex anterior (procurvatum) deforming force typical in proximal tibia fractures.

Question 2438

Topic: 2. Trauma
A 34-year-old male sustains a severe closed tibia plateau fracture. In monitoring for acute compartment syndrome, which of the following objective measurements is the most accepted threshold for indicating an emergent fasciotomy?
. Absolute compartment pressure > 20 mmHg
. Absolute compartment pressure > 25 mmHg
. Mean arterial pressure (MAP) minus compartment pressure < 40 mmHg
. Diastolic blood pressure minus compartment pressure ≤ 30 mmHg
. Systolic blood pressure minus compartment pressure ≤ 30 mmHg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure ≤ 30 mmHg

Explanation

A delta pressure (Diastolic Blood Pressure minus Compartment Pressure) of ≤ 30 mmHg is the most reliable objective indicator for acute compartment syndrome and mandates emergent fasciotomy.

Question 2439

Topic: 2. Trauma

Which initial intervention has been shown to most significantly decrease the rate of infection in patients presenting with open tibia shaft fractures?

. High-pressure pulsatile lavage in the emergency department
. Administration of early systemic antibiotics within 1 hour of injury
. Immediate primary wound closure
. Application of a negative pressure wound therapy device
. Administration of systemic corticosteroids

Correct Answer & Explanation

. Administration of early systemic antibiotics within 1 hour of injury

Explanation

The most critical factor in reducing infection rates in open fractures is the early administration of systemic antibiotics, ideally within 1 hour of the injury. Timing of antibiotics is more predictive of infection than the timing of surgical debridement.

Question 2440

Topic: 2. Trauma

At 4 months post-operatively, a patient with a transverse midshaft tibia fracture treated with a statically locked intramedullary nail demonstrates a delayed union with a 2 mm fracture gap. What is the most appropriate next step in management?

. Exchange nailing with a larger diameter reamed nail
. Plate augmentation leaving the nail in situ
. Dynamization by removing the static interlocking screws furthest from the fracture
. Application of a circular external fixator
. Pulsed electromagnetic field therapy only

Correct Answer & Explanation

. Dynamization by removing the static interlocking screws furthest from the fracture

Explanation

Dynamization (removal of locking screws to allow axial compression) is highly effective for axially stable delayed unions (transverse or short oblique fractures) when performed between 3 and 6 months post-operatively.

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