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2. Trauma MCQs

Practice Set 124 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 2461

Topic: 2. Trauma

A 71-year-old male with osteoporosis sustains a distal tibia pilon fracture.

The decision to proceed with early total care versus a staged approach (spanning external fixation followed by delayed ORIF) is primarily dictated by which of the following?

. The degree of intra-articular comminution.
. The patient's baseline bone mineral density.
. The absolute neutrophil count on presentation.
. The condition of the surrounding soft tissue envelope.
. The presence of a concurrent fibula fracture.

Correct Answer & Explanation

. The condition of the surrounding soft tissue envelope.

Explanation

In high-energy distal tibia (pilon) fractures, the status of the soft tissue envelope (swelling, fracture blisters, open wounds) is the most critical determinant. Staged protocols (span and scan) are utilized to allow soft tissues to heal before formal ORIF, drastically reducing wound complications.

Question 2462

Topic: 2. Trauma

A 55-year-old male presents with a nonunion of a tibial shaft fracture 8 months after initial intramedullary nailing. Radiographs show an atrophic nonunion. Infection has been ruled out. What is the most appropriate next step in management?

. Dynamization of the current nail by removing distal locking screws.
. Application of an external bone stimulator and continued observation.
. Removal of the nail and application of a circular external fixator.
. Plate osteosynthesis retaining the current intramedullary nail.
. Exchange intramedullary nailing with a larger diameter nail and bone grafting.

Correct Answer & Explanation

. Exchange intramedullary nailing with a larger diameter nail and bone grafting.

Explanation

Atrophic nonunions lack both mechanical stability and biological healing potential. The standard of care for an aseptic atrophic tibial nonunion previously treated with a nail is exchange nailing (providing stability) combined with bone grafting (providing biology).

Question 2463

Topic: 2. Trauma

In the management of highly comminuted osteoporotic tibia fractures, the principle of 'relative stability' is often employed. Which of the following fixation constructs best exemplifies relative stability?

. A bridge plate spanning the comminuted segment.
. Lag screws with a neutralization plate.
. A dynamic compression plate (DCP) causing absolute rigid fixation.
. Dual plating with anatomic reduction of all intermediate fragments.
. A tension band wiring construct.

Correct Answer & Explanation

. A bridge plate spanning the comminuted segment.

Explanation

Relative stability allows for controlled micro-motion at the fracture site, which promotes callus formation (secondary bone healing). A bridge plate spanning a comminuted segment provides this environment, whereas lag screws and compression plates aim for absolute stability.

Question 2464

Topic: 2. Trauma

During locked plate fixation of an osteoporotic distal tibia fracture, the surgeon ensures that a minimum of 3 to 4 bicortical locking screws are placed in the distal fragment. What is the primary reason for avoiding unicortical locking screws in this specific scenario?

. Unicortical screws increase the risk of thermal necrosis during drilling.
. Unicortical screws prevent the use of minimally invasive percutaneous techniques.
. Unicortical screws are more likely to penetrate the ankle joint.
. Unicortical screws in osteoporotic bone lack sufficient pull-out strength and torsional stability.
. Unicortical screws induce excessive stress shielding.

Correct Answer & Explanation

. Unicortical screws in osteoporotic bone lack sufficient pull-out strength and torsional stability.

Explanation

While locking plates provide a fixed-angle construct, relying on unicortical fixation in poor-quality osteoporotic bone significantly reduces torsional stability and pull-out resistance. Bicortical fixation is strongly recommended in osteoporotic diaphyseal and metaphyseal segments to prevent construct failure.

Question 2465

Topic: Lower Extremity Trauma

A 48-year-old highly active female presents with isolated lateral compartment knee osteoarthritis and a fixed 15-degree valgus deformity. She has failed all non-operative measures. What is the most appropriate joint-preserving surgical intervention?

. Medial opening wedge high tibial osteotomy
. Lateral closing wedge high tibial osteotomy
. Medial closing wedge distal femoral osteotomy
. Tibial tubercle anteriorization osteotomy
. Proximal fibular osteotomy

Correct Answer & Explanation

. Medial closing wedge distal femoral osteotomy

Explanation

For a young, active patient with isolated lateral compartment knee osteoarthritis and a significant valgus deformity, the deformity typically originates in the distal femur. A distal femoral osteotomy (such as a medial closing wedge) is the procedure of choice, as correcting large valgus deformities via the tibia creates an unacceptable, non-physiologic joint line obliquity.

Question 2466

Topic: 2. Trauma

A 28-year-old male presents to the emergency department after a motorcycle accident. Radiographs and a CT scan reveal a displaced acetabular fracture with a fracture line extending from the iliac crest through the ASIS, anterior wall, and quadrilateral surface, into the pubic ramus. There is also an intra-articular loose body. Which of the following fracture patterns is most consistent with these findings, and for which the Smith-Petersen approach would be the primary choice?

. A. Posterior wall fracture
. B. Both column fracture
. C. Anterior column fracture
. D. Transverse fracture with posterior wall involvement
. E. Isolated posterior column fracture

Correct Answer & Explanation

. C. Anterior column fracture

Explanation

Correct Answer: CThe description of a fracture line extending from the iliac crest through the ASIS, anterior wall, and quadrilateral surface, into the pubic ramus, is the classic definition of an anterior column acetabular fracture. The Smith-Petersen approach provides excellent direct access to the anterior aspect of the hip joint, the iliac wing, and the anterior column of the acetabulum, making it the primary choice for the open reduction and internal fixation of such fractures, especially when displaced and associated with intra-articular loose bodies.Why other options are incorrect:A. Posterior wall fracture:Posterior wall fractures are best approached posteriorly (e.g., Kocher-Langenbeck approach) as the Smith-Petersen approach offers limited posterior visualization.B. Both column fracture:While the Smith-Petersen approach can be part of a combined approach for both column fractures, it is not the sole primary approach for the entire fracture pattern, which involves both anterior and posterior columns.D. Transverse fracture with posterior wall involvement:Transverse fractures can be approached anteriorly or posteriorly depending on the primary displacement. However, significant posterior wall involvement would typically necessitate a posterior approach or a combined approach.E. Isolated posterior column fracture:Similar to posterior wall fractures, isolated posterior column fractures are primarily managed via a posterior approach.

Question 2467

Topic: 2. Trauma

A 72-year-old patient with a history of severe peripheral vascular disease, uncontrolled diabetes (HbA1c 10.5%), and active cellulitis overlying the hip region presents with a displaced anterior column acetabular fracture. The orthopedic trauma surgeon is evaluating the patient for surgical intervention via the Smith-Petersen approach. Which of the following factors represents an absolute contraindication to proceeding with surgery at this time?

. A. Displaced anterior column acetabular fracture
. B. Patient age of 72 years
. C. History of severe peripheral vascular disease
. D. Uncontrolled diabetes (HbA1c 10.5%)
. E. Active cellulitis in the surgical field

Correct Answer & Explanation

. E. Active cellulitis in the surgical field

Explanation

Correct Answer: EActive infection in the surgical field, such as cellulitis, is an absolute contraindication to elective or semi-elective orthopedic surgery. Proceeding with surgery in the presence of active infection significantly increases the risk of surgical site infection, which can lead to devastating complications, especially with implant placement. The cellulitis must be treated and resolved before surgical intervention can be considered.Why other options are incorrect:A. Displaced anterior column acetabular fracture:This is an indication for the Smith-Petersen approach, not a contraindication.B. Patient age of 72 years:While advanced age can increase surgical risk, it is not an absolute contraindication. Many elderly patients undergo successful hip surgery.C. History of severe peripheral vascular disease:This is a significant comorbidity that increases surgical risk and may require pre-operative vascular assessment and optimization, but it is not an absolute contraindication on its own.D. Uncontrolled diabetes (HbA1c 10.5%):Uncontrolled diabetes is a major risk factor for surgical complications, including infection and poor wound healing. It requires aggressive pre-operative optimization to lower the HbA1c and improve glycemic control. However, it is typically a relative contraindication, prompting medical optimization rather than an absolute bar to surgery, especially in trauma where delay can be detrimental. The active cellulitis, however, is an immediate and absolute contraindication.

Question 2468

Topic: Pelvic & Acetabular Trauma

A 12-year-old patient is scheduled for a Salter osteotomy for developmental dysplasia of the hip (DDH) via the Smith-Petersen approach. During the deep muscular dissection, the surgeon needs to reflect the rectus femoris muscle to expose the anterior hip capsule. From which two distinct anatomical locations do the direct and indirect heads of the rectus femoris originate?

. A. Direct head from the anterior inferior iliac spine (AIIS); Indirect head from the iliac crest.
. B. Direct head from the anterior superior iliac spine (ASIS); Indirect head from the anterior inferior iliac spine (AIIS).
. C. Direct head from the pubic symphysis; Indirect head from the ischial tuberosity.
. D. Direct head from the greater trochanter; Indirect head from the lesser trochanter.
. E. Direct head from the iliac crest; Indirect head from the ASIS.

Correct Answer & Explanation

. B. Direct head from the anterior superior iliac spine (ASIS); Indirect head from the anterior inferior iliac spine (AIIS).

Explanation

Correct Answer: BThe rectus femoris muscle, a key structure encountered and reflected during the deep dissection of the Smith-Petersen approach, originates via two distinct heads: the direct head originates from the Anterior Superior Iliac Spine (ASIS), and the indirect (reflected) head originates from a groove superior to the acetabulum, specifically the Anterior Inferior Iliac Spine (AIIS). Both heads converge to form a single tendon.Why other options are incorrect:A. Direct head from the anterior inferior iliac spine (AIIS); Indirect head from the iliac crest:This is incorrect. The direct head is from the ASIS, and the indirect head is from the AIIS. The iliac crest is the origin for muscles like the TFL and gluteus medius, but not the rectus femoris heads.C. Direct head from the pubic symphysis; Indirect head from the ischial tuberosity:These are origins for other hip and thigh muscles (e.g., adductors, hamstrings), not the rectus femoris.D. Direct head from the greater trochanter; Indirect head from the lesser trochanter:The greater and lesser trochanters are insertion points for various hip muscles (e.g., gluteus medius/minimus, iliopsoas), not origins for the rectus femoris.E. Direct head from the iliac crest; Indirect head from the ASIS:This is incorrect. The direct head is from the ASIS, and the indirect head is from the AIIS. The iliac crest is not an origin for the rectus femoris.

Question 2469

Topic: 2. Trauma

A 52-year-old woman with a painful MOM hip resurfacing is being investigated for her symptoms. The examiner asks about the British Hip Society's recommendations for investigation. Beyond a careful history and physical examination, which of the following is the most appropriate initial diagnostic step according to the British Hip Society guidelines mentioned in the case?

. Immediate revision surgery due to the high suspicion of pseudotumour.
. A bone scan to rule out stress fracture or infection.
. Measurement of blood cobalt and chromium ion levels.
. An electromyogram (EMG) to assess for nerve impingement.
. A diagnostic hip injection with local anesthetic to confirm intra-articular pathology.

Correct Answer & Explanation

. Measurement of blood cobalt and chromium ion levels.

Explanation

Correct Answer: CThe case states, when prompted about British Hip Society recommendations: 'Blood cobalt and chromium ions should be measured, as these are indicators of surface wear. If levels are raised the patient will require close observation. If levels are rising and the hip is painful it may be sensible to consider revising the implant.'Option A is incorrect because investigation precedes surgery. While revision may be necessary, it's not the immediate diagnostic step.Option B is a general diagnostic tool but not specifically highlighted as the initial British Hip Society recommendation for a painful MOM resurfacing in the context of metal ion concerns.Option D is incorrect. While nerve impingement could be an extrinsic cause of pain, the primary concern with a painful MOM resurfacing is intrinsic pathology related to the implant, for which metal ion levels are a key indicator.Option E is a diagnostic tool but not the specific initial recommendation from the British Hip Society for evaluating MOM resurfacing complications related to wear and metal ions.

Question 2470

Topic: 2. Trauma

During a total hip arthroplasty (THA) for a patient with severe Paget's disease of the proximal femur, the surgeon encounters extremely hard and sclerotic bone, making reaming and broaching difficult. Which of the following technical considerations is MOST appropriate in this scenario?

. A. Proceed with standard reaming and broaching techniques, as bone density will not significantly impede instrumentation.
. B. Utilize burrs to create an initial entry point into the bone before attempting reaming and broaching.
. C. Abandon the procedure and consider non-surgical management due to the bone's unsuitability for implant placement.
. D. Switch to an uncemented femoral component, as it requires less precise bone preparation.
. E. Increase the reamer size significantly to overcome the bone's resistance.

Correct Answer & Explanation

. B. Utilize burrs to create an initial entry point into the bone before attempting reaming and broaching.

Explanation

Correct Answer: BThe case explicitly addresses technical issues of performing THA in Paget's disease, stating: 'Bone can be very hard and sclerotic making it difficult to ream and broach. Burrs may be needed to enter the bone prior to reaming and/or broaching.' Therefore, using burrs to facilitate initial entry is the most appropriate technical consideration.Option A is incorrect because the case highlights that hard, sclerotic bonedoesmake reaming and broaching difficult, contradicting the idea of proceeding with standard techniques without modification. Option C is an extreme measure and generally not necessary, as the case discusses various strategies to overcome surgical challenges. Option D is incorrect; while uncemented components are used, they still require precise bone preparation for ingrowth, and the difficulty in reaming/broaching applies to both cemented and uncemented preparations. Option E, significantly increasing reamer size without proper preparation, could lead to iatrogenic fracture or malalignment in sclerotic bone.

Question 2471

Topic: 2. Trauma
A 45-year-old male presents following a high-speed motor vehicle collision. He is hemodynamically unstable, with a heart rate of 120 bpm and blood pressure of 80/50 mmHg. Physical examination reveals a widely abducted lower extremity, perineal ecchymosis, and scrotal swelling. A Foley catheter insertion is attempted but meets resistance. A CT scan confirms an open-book pelvic fracture (APC-III) with significant symphyseal diastasis and sacral fractures. Which of the following is the most appropriate immediate next step in management after initial ATLS protocol?
. Application of an external fixator to the pelvis
. Referral for formal angiography and embolization
. Placement of a C-clamp for posterior pelvic compression
. Application of a circumferential pelvic binder
. Laparotomy for intra-abdominal hemorrhage control

Correct Answer & Explanation

. Application of a circumferential pelvic binder

Explanation

The most immediate and life-saving intervention for a hemodynamically unstable patient with an open-book pelvic fracture (APC-III) after initial ATLS assessment is the application of a circumferential pelvic binder. This maneuver reduces pelvic volume, compresses vascular structures, and helps tamponade hemorrhage, thereby improving hemodynamic stability. While other interventions like angiography/embolization, C-clamp, or external fixation may be required, they are typically performed after initial stabilization with a binder. Laparotomy would be considered for identified intra-abdominal hemorrhage, but the initial focus is on the pelvic instability as the primary source of bleeding in this scenario. The urethral injury (resistance to Foley) needs to be addressed with a suprapubic catheter, but it is secondary to hemodynamic instability in this critical phase.

Question 2472

Topic: 2. Trauma

A patient with Paget's disease sustains a subtrochanteric femur fracture. Radiographs show a transverse 'chalk-stick' fracture pattern. What specific anatomic complication is most likely to interfere with antegrade intramedullary nailing?

. Obliteration of the medullary canal by dense cortical bone
. Inability to pass the nail due to excessive anterolateral bowing
. Rapid massive heterotopic ossification during the procedure
. Immediate catastrophic failure of the greater trochanter
. Severe acetabular protrusio preventing proper positioning

Correct Answer & Explanation

. Inability to pass the nail due to excessive anterolateral bowing

Explanation

The femur in Paget's disease frequently develops severe anterolateral bowing. This altered geometry can prevent the passage of standard rigid intramedullary nails, often necessitating corrective osteotomies or alternative fixation.

Question 2473

Topic: 2. Trauma

A 70-year-old patient with highly active Paget's disease sustains a severe polytrauma and becomes completely bedbound. Five days later, the patient develops confusion, severe constipation, and polyuria. What is the most likely underlying complication?

. Deep vein thrombosis extending to the mesenteric vessels
. Hypercalcemia of immobilization
. Fat embolism syndrome
. Pagetic steal syndrome
. Acute traumatic acute tubular necrosis

Correct Answer & Explanation

. Hypercalcemia of immobilization

Explanation

Sudden, complete immobilization in patients with active Paget's disease halts osteoblastic bone formation while osteoclastic resorption continues unchecked. This imbalance rapidly leads to severe, potentially life-threatening hypercalcemia.

Question 2474

Topic: 2. Trauma

A 68-year-old man with long-standing Paget's disease sustains a low-energy fall. Radiographs show a fracture of the proximal third of the femur. Which of the following fracture patterns is most characteristic of long bones affected by Paget's disease?

. Spiral fracture starting on the compression side
. Transverse fracture initiating on the tension (convex) side
. Highly comminuted fracture with a large butterfly fragment
. Avulsion fracture of the lesser trochanter
. Vertical shear fracture of the femoral head

Correct Answer & Explanation

. Transverse fracture initiating on the tension (convex) side

Explanation

Pathologic fractures in Paget's disease most commonly occur in the femur and tibia due to altered biomechanics and bone quality. They characteristically present as transverse or short oblique fractures that initiate on the convex (tension) side of the bowed bone, resembling a "chalk stick" fracture.

Question 2475

Topic: 2. Trauma

A 74-year-old male with untreated, advanced Paget's disease sustains a minor trip and fall, resulting in a tibial shaft fracture. Based on the altered biomechanics and structure of pagetic bone, what is the most likely fracture pattern and its typical clinical course?

. Spiral fracture with accelerated healing
. Comminuted fracture with normal healing rates
. Oblique fracture with a high risk of compartment syndrome
. Transverse 'chalk stick' fracture with a high rate of delayed union or nonunion
. Avulsion fracture with excessive callus formation

Correct Answer & Explanation

. Transverse 'chalk stick' fracture with a high rate of delayed union or nonunion

Explanation

Fractures in pagetic bone classically occur as transverse 'chalk stick' fractures due to the brittle, disorganized nature of the woven bone. They are notoriously prone to delayed union, nonunion, and hardware failure.

Question 2476

Topic: 2. Trauma

A 35-year-old male sustains a spiral fracture of the mid-shaft femur. He undergoes intramedullary nailing. Which of the following biomechanical principles BEST explains why a long intramedullary nail is effective in stabilizing this diaphyseal fracture?

. It provides absolute stability at the fracture site.
. It acts as a load-sharing device, reducing stress shielding of the bone.
. It creates an environment conducive to primary bone healing.
. It primarily provides torsional and bending stability.
. It relies on biological fixation, promoting periosteal callus formation.

Correct Answer & Explanation

. It primarily provides torsional and bending stability.

Explanation

Correct Answer: DAn intramedullary nail is highly effective in stabilizing diaphyseal fractures primarily by resisting torsional and bending forces along the length of the diaphysis. This is crucial for long bone fractures, which are frequently subjected to these types of loads during daily activities. While an intramedullary nail also acts as a load-sharing device, allowing for controlled micromotion conducive to secondary (callus) bone healing, its direct mechanical effectiveness in preventing rotation and angulation is paramount for stabilization.

Question 2477

Topic: Lower Extremity Trauma

A 28-year-old athlete sustains a meniscal tear in his knee. Understanding the normal function of the menisci, which of the following is considered their primary biomechanical role in the knee joint?

. Limit hyperextension of the knee.
. Increase the congruity between the femoral condyles and tibial plateau.
. Provide intrinsic stability against varus and valgus stress.
. Lubricate the articular surfaces.
. House proprioceptive nerve endings for joint position sense.

Correct Answer & Explanation

. Increase the congruity between the femoral condyles and tibial plateau.

Explanation

Correct Answer: BThe menisci are C-shaped fibrocartilaginous structures that sit on the tibial plateau. Their primary biomechanical roles include increasing the contact area between the femoral condyles and tibial plateau, which significantly reduces contact stress on the articular cartilage. They also contribute to joint stability, shock absorption, and some lubrication, but increasing congruity and reducing stress are their most critical functions. Ligaments limit hyperextension and provide varus/valgus stability.

Question 2478

Topic: Pelvic & Acetabular Trauma

A 35-year-old male sustains an anteroposterior compression type II (APC-II) pelvic ring injury. Which of the following ligaments is torn in this specific injury pattern, distinguishing it from an APC-I injury?

. Sacrospinous, sacrotuberous, and anterior sacroiliac ligaments
. Symphyseal ligaments only
. Posterior sacroiliac ligaments
. Iliolumbar ligaments
. Anterior and posterior sacroiliac ligaments

Correct Answer & Explanation

. Sacrospinous, sacrotuberous, and anterior sacroiliac ligaments

Explanation

In an APC-II injury, the pubic diastasis is greater than 2.5 cm, and the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments are disrupted. The posterior sacroiliac ligaments remain intact, providing vertical stability.

Question 2479

Topic: 2. Trauma

A 40-year-old male sustains a high-energy Schatzker VI tibial plateau fracture. Which of the following is the most appropriate initial management to minimize soft tissue complications while providing skeletal stability?

. Immediate dual plating through a single midline incision
. Immediate dual plating through anterolateral and posteromedial incisions
. Knee-spanning external fixation with delayed definitive fixation
. Long leg cast application in 20 degrees of flexion
. Intramedullary nailing of the proximal tibia

Correct Answer & Explanation

. Knee-spanning external fixation with delayed definitive fixation

Explanation

High-energy tibial plateau fractures (Schatzker VI) are associated with severe soft tissue compromise. The standard of care is temporary spanning external fixation to allow soft tissues to recover before definitive open reduction and internal fixation.

Question 2480

Topic: 2. Trauma

A 22-year-old male sustains a proximal pole scaphoid fracture. Which of the following best explains the high risk of avascular necrosis (AVN) and nonunion associated with this specific fracture pattern?

. The blood supply enters the scaphoid volarly and flows proximal to distal.
. The blood supply enters the scaphoid dorsally and flows distal to proximal.
. The proximal pole lacks articular cartilage, impeding synovial fluid nutrition.
. The proximal pole relies solely on the radioscaphocapitate ligament for vascularity.
. The fracture inherently disrupts the volar carpal arterial arch.

Correct Answer & Explanation

. The blood supply enters the scaphoid dorsally and flows distal to proximal.

Explanation

The scaphoid has a retrograde blood supply. The major vascular contribution enters the dorsal ridge at the waist and distal pole, flowing proximally. Therefore, proximal pole fractures interrupt this supply, leading to a high rate of AVN.

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