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2. Trauma MCQs

Practice Set 125 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 2481

Topic: 2. Trauma
A 45-year-old male is brought to the ED after a motorcycle collision. He has an anteroposterior compression (APC) type III pelvic ring injury and blood at the urethral meatus. According to ATLS and oral board management protocols, what is the most appropriate next step in evaluating the urogenital tract?
. Perform a blind Foley catheter insertion.
. Perform a suprapubic cystostomy.
. Perform a retrograde urethrogram.
. Perform a CT cystogram.
. Perform an MRI of the pelvis.

Correct Answer & Explanation

. Perform a retrograde urethrogram.

Explanation

Blood at the urethral meatus is a cardinal sign of urethral injury, which is common in anterior pelvic ring disruptions. A retrograde urethrogram must be performed to evaluate urethral integrity before any attempt at passing a urethral catheter.

Question 2482

Topic: Pelvic & Acetabular Trauma
A 28-year-old male is brought to the trauma bay after a motorcycle accident. He is hemodynamically unstable with a blood pressure of 80/40 mmHg. FAST exam is negative. Pelvic radiograph shows an anteroposterior compression type III (APC III) injury. A pelvic binder is applied, but the patient remains persistently hypotensive despite aggressive fluid resuscitation. What is the most appropriate next step in management?
. Application of a pelvic external fixator
. Immediate exploratory laparotomy
. Bilateral internal iliac artery embolization
. Pelvic angiography or preperitoneal pelvic packing
. Emergent symphyseal plating

Correct Answer & Explanation

. Pelvic angiography or preperitoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam, the bleeding is presumed to be retroperitoneal. After applying a pelvic binder, persistent instability requires either angiography with embolization or preperitoneal pelvic packing based on institutional protocols.

Question 2483

Topic: 2. Trauma

A 30-year-old polytrauma patient presents with bilateral femur fractures and a severe closed head injury. His initial arterial lactate is 5.2 mmol/L, base deficit is -8, and pH is 7.21. In the context of Damage Control Orthopedics (DCO), what is the MOST appropriate initial management for his femur fractures?

. Immediate bilateral reamed intramedullary nailing
. Immediate bilateral unreamed intramedullary nailing
. External fixation of both femurs
. Skeletal traction and strict bed rest for 7 days
. Open reduction and internal fixation with plates

Correct Answer & Explanation

. External fixation of both femurs

Explanation

This patient is physiologically unstable (elevated lactate, severe base deficit, acidosis) and has a severe head injury. Early Total Care (intramedullary nailing) could exacerbate the systemic inflammatory response and secondary brain injury, making rapid external fixation (Damage Control Orthopedics) the safest initial step.

Question 2484

Topic: 2. Trauma

You are discussing a complication case during your ABOS Part II oral exam. A patient developed a deep surgical site infection following an open reduction internal fixation of a pilon fracture. Which of the following responses is the MOST professional and safe way to frame your initial management approach?

. Attribute the infection to the patient's uncontrolled diabetes and poor compliance.
. Admit the complication, detail personal responsibility in immediate evaluation, obtain cultures, and perform urgent debridement.
. State that a colleague was covering the weekend call and should have caught the infection sooner.
. Explain that oral antibiotics are always the first step to avoid unnecessary return to the operating room.
. Focus solely on how the literature supports a high infection rate for pilon fractures to justify the outcome.

Correct Answer & Explanation

. Admit the complication, detail personal responsibility in immediate evaluation, obtain cultures, and perform urgent debridement.

Explanation

Oral board examiners look for candidate accountability, patient safety, and structured problem-solving. Admitting the complication, taking personal responsibility, and detailing an aggressive, safe management plan (cultures and surgical debridement) demonstrates mature, board-level competency.

Question 2485

Topic: 2. Trauma
A 35-year-old motorcyclist sustains a Gustilo-Anderson Type IIIB open tibia fracture. Initial management in the trauma bay includes antibiotics, tetanus prophylaxis, and a temporary splint. What is the single most important factor in decreasing the risk of deep infection in this patient?
. Early administration of systemic intravenous antibiotics
. Time to definitive soft tissue coverage (flap)
. Immediate intramedullary nailing within 6 hours
. Use of high-pressure pulsatile lavage
. Application of a negative pressure wound therapy device

Correct Answer & Explanation

. Early administration of systemic intravenous antibiotics

Explanation

Extensive literature confirms that the most critical variable in reducing infection rates in open fractures is the early administration of systemic antibiotics, ideally within 1 to 3 hours of injury.

Question 2486

Topic: 2. Trauma

A 24-year-old competitive skier falls while holding his ski pole and sustains an acute injury to his right thumb. On examination, there is localized tenderness over the ulnar aspect of the thumb metacarpophalangeal (MCP) joint. Valgus stress testing reveals 40 degrees of laxity when the MCP joint is flexed to 30 degrees, but only 5 degrees of laxity when the MCP joint is in full extension. Which of the following is the most accurate interpretation of these physical examination findings?

. Isolated tear of the accessory ulnar collateral ligament (UCL)
. Isolated tear of the proper ulnar collateral ligament (UCL)
. Combined tear of the proper and accessory ulnar collateral ligaments
. Tear of the adductor aponeurosis
. Avulsion fracture of the volar plate

Correct Answer & Explanation

. Isolated tear of the proper ulnar collateral ligament (UCL)

Explanation

The proper UCL is the primary restraint to valgus stress with the MCP joint in 30 degrees of flexion, while the accessory UCL is the primary restraint in full extension. Laxity in flexion with stability in extension indicates an isolated tear of the proper UCL.

Question 2487

Topic: 2. Trauma

A 22-year-old athlete sustains a bony avulsion of the thumb UCL. Radiographs demonstrate a displaced bone fragment at the volar-ulnar base of the proximal phalanx that measures approximately 30% of the articular surface. What is the preferred surgical approach for this specific injury?

. Excision of the fragment and advancement of the UCL with a suture anchor
. Closed reduction and percutaneous pinning of the MCP joint
. Open reduction and internal fixation with a tension band or mini-screws
. Primary reconstruction using a palmaris longus tendon graft
. Adductor aponeurosis interposition arthroplasty

Correct Answer & Explanation

. Open reduction and internal fixation with a tension band or mini-screws

Explanation

When a UCL injury involves a bony avulsion containing >15-20% of the articular surface, open reduction and internal fixation (ORIF) with pins, mini-screws, or tension banding is preferred to restore joint congruity, rather than fragment excision.

Question 2488

Topic: 2. Trauma

A 12-year-old boy presents with a crush injury to his right long finger tip. Examination reveals a laceration through the nail bed, the nail plate is avulsed proximally, and the DIP joint is flexed. Radiographs show a widened distal phalanx physis. What is the most critical step in management?

. Strict extension splinting for 6 weeks
. Administration of antibiotics, nail bed repair, and reduction of the Seymour fracture
. Closed reduction and percutaneous pinning of the DIP joint
. Observation and reassurance
. Amputation of the distal phalanx

Correct Answer & Explanation

. Administration of antibiotics, nail bed repair, and reduction of the Seymour fracture

Explanation

This is a Seymour fracture (juxta-epiphyseal fracture of the distal phalanx) which is considered an open fracture due to the associated nail bed injury. It requires urgent antibiotics, irrigation, debridement, removal of interposed tissue, and reduction.

Question 2489

Topic: 2. Trauma

A 10-year-old boy presents to the emergency department after 'jamming' his right middle finger while catching a football. He exhibits a flexed posture at the distal interphalangeal (DIP) joint and cannot actively extend it. Examination reveals swelling and bleeding from beneath the proximal nail fold. Radiographs show a widened distal phalanx physis. What is the most appropriate management?

. Continuous splinting in full extension for 6-8 weeks
. Closed reduction and casting for 4 weeks
. Nail plate removal, irrigation and debridement, and pinning of the fracture
. Immediate DIP joint arthrodesis
. Buddy taping to the adjacent digit for 3 weeks

Correct Answer & Explanation

. Nail plate removal, irrigation and debridement, and pinning of the fracture

Explanation

This is a Seymour fracture (juxta-epiphyseal fracture of the distal phalanx), which often presents as a 'mallet equivalent' with a laceration of the nail bed, making it an open fracture. Proper management requires nail plate removal, formal I&D, nail bed repair, and often percutaneous pinning.

Question 2490

Topic: 2. Trauma
A 34-year-old construction worker sustains an open right tibial shaft fracture (Gustilo-Anderson Type IIIA) after being crushed by a steel beam. He is hemodynamically stable. What is the most critical initial management step after addressing life-threatening injuries?
. Immediate definitive intramedullary nailing
. Application of a cast and delayed definitive fixation
. Urgent irrigation and debridement within 6 hours, followed by stabilization
. Administration of systemic antibiotics and observation
. Primary closure of the wound

Correct Answer & Explanation

. Urgent irrigation and debridement within 6 hours, followed by stabilization

Explanation

For an open fracture, especially Gustilo-Anderson Type IIIA, urgent irrigation and debridement (I&D) within 6-8 hours is paramount to minimize the risk of infection. This is a surgical emergency. Following thorough debridement, stabilization of the fracture (often with external fixation initially for severe open fractures, or intramedullary nailing in less contaminated Type I/II/IIIA fractures, depending on surgeon preference and wound status) is performed. Definitive intramedullary nailing is typically performed after initial debridement and often after several days if the wound requires observation or further debridement. Primary wound closure is generally contraindicated in contaminated open fractures until the wound is clean and infection risk is minimized. Systemic antibiotics are crucial but are adjunctive to surgical debridement.

Question 2491

Topic: 2. Trauma

Which factor is most strongly associated with an increased risk of chronic regional pain syndrome (CRPS) Type 1 following an orthopedic injury or surgery?

. Patient age over 60 years.
. Presence of pre-existing peripheral neuropathy.
. Delayed mobilization after injury.
. Pre-existing psychological distress or anxiety.
. Fracture location in the axial skeleton.

Correct Answer & Explanation

. Pre-existing psychological distress or anxiety.

Explanation

Correct Answer: DPre-existing psychological distress, anxiety, depression, and somatization disorders are strongly associated with an increased risk of developing CRPS Type 1. While CRPS can occur at any age, younger to middle-aged adults are more commonly affected than those over 60. Peripheral neuropathy is a risk factor for CRPS Type 2 (causalgia), not typically Type 1. Delayed mobilization can contribute to stiffness but is not as strong a predictor for CRPS as psychological factors. CRPS primarily affects the extremities, not the axial skeleton.

Question 2492

Topic: Pelvic & Acetabular Trauma

A 35-year-old male is brought to the ED after a high-speed motorcycle collision. He is hypotensive with a systolic BP of 70 mmHg. Pelvic radiograph shows a completely disrupted pubic symphysis with severe widening and disruption of the posterior sacroiliac ligaments bilaterally. After initiating massive transfusion, what is the most appropriate next step in orthopedic management?

. Immediate open reduction and internal fixation of the symphysis pubis
. Application of a pelvic binder centered over the greater trochanters
. Pelvic angiography and embolization
. Retrograde urethrogram
. Application of a pelvic binder centered over the iliac crests

Correct Answer & Explanation

. Application of a pelvic binder centered over the greater trochanters

Explanation

In a hemodynamically unstable patient with an anteroposterior compression (APC) pelvic ring injury, the initial step is applying a pelvic binder over the greater trochanters. This reduces pelvic volume and helps tamponade venous bleeding before considering angiography or surgery.

Question 2493

Topic: 2. Trauma

A 45-year-old male sustains a high-energy pilon fracture (OTA/AO 43-C3) with severe soft tissue swelling and fracture blisters over the medial ankle. What is the most appropriate initial management?

. Immediate open reduction and internal fixation (ORIF) with dual plating
. Application of a spanning external fixator and delayed definitive fixation
. Closed reduction and long leg cast application
. Primary ankle arthrodesis
. Immediate intramedullary nailing

Correct Answer & Explanation

. Application of a spanning external fixator and delayed definitive fixation

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with staged treatment. Initial spanning external fixation allows soft tissues to heal prior to definitive ORIF, significantly reducing the risk of wound complications and infection.

Question 2494

Topic: 2. Trauma

A 28-year-old male sustains a closed midshaft tibia fracture. Four hours post-admission, he develops severe pain out of proportion to the injury, pain with passive stretch of the hallux, and paresthesias in the first web space. Compartment pressures measure 45 mmHg in the anterior compartment with a diastolic BP of 65 mmHg. What is the indicated treatment?

. Observation and elevation above the level of the heart
. Immediate fasciotomy of all four compartments of the leg
. Immediate fasciotomy of the anterior and lateral compartments only
. Administration of IV mannitol and re-evaluate in 2 hours
. Application of a short leg cast

Correct Answer & Explanation

. Immediate fasciotomy of all four compartments of the leg

Explanation

The patient has clinical signs of acute compartment syndrome and a delta-P (diastolic BP minus compartment pressure) of 20 mmHg, confirming the diagnosis. Immediate four-compartment fasciotomy of the leg is the standard of care to prevent irreversible muscle and nerve necrosis.

Question 2495

Topic: 2. Trauma
A 30-year-old male sustains a displaced Pauwels type III (vertical) femoral neck fracture. Which fixation construct provides the greatest biomechanical stability to resist the high shear forces inherent to this fracture pattern?
. Three parallel cancellous screws placed in an inverted triangle
. A sliding hip screw with a derotational screw
. Two crossed cancellous screws
. A dynamic condylar screw
. Intramedullary nailing with single head screw

Correct Answer & Explanation

. A sliding hip screw with a derotational screw

Explanation

Pauwels type III fractures have a highly vertical orientation, resulting in significant shear forces. Biomechanical studies demonstrate that a sliding hip screw provides superior stability against shear stress compared to multiple parallel cancellous screws.

Question 2496

Topic: 2. Trauma

A 40-year-old female sustains a Schatzker Type VI tibial plateau fracture. Postoperatively, she develops foot drop and numbness in the first web space. During the surgical approach, which structure was most likely injured, and where is its most vulnerable anatomical location in this context?

. Tibial nerve at the popliteal fossa
. Deep peroneal nerve crossing the anterior ankle
. Common peroneal nerve at the fibular neck
. Saphenous nerve at the medial joint line
. Sural nerve at the posterolateral calf

Correct Answer & Explanation

. Common peroneal nerve at the fibular neck

Explanation

Foot drop and numbness in the first web space indicate a peroneal nerve injury. The common peroneal nerve wraps around the fibular neck, making it highly vulnerable during lateral or posterolateral approaches to complex tibial plateau fractures.

Question 2497

Topic: 2. Trauma
A 25-year-old male sustains a high-energy Pauwels type III femoral neck fracture. To maximize biomechanical stability and minimize the risk of varus collapse, which fixation construct provides the highest resistance to the vertical shear forces inherent to this fracture pattern?
. Three parallel partially threaded cancellous screws
. A sliding hip screw (DHS) with an anti-rotation screw
. A short cephalomedullary nail
. A long cephalomedullary nail
. Non-vascularized fibular graft with cancellous screws

Correct Answer & Explanation

. A sliding hip screw (DHS) with an anti-rotation screw

Explanation

Pauwels type III fractures have a highly vertical orientation, resulting in significant shear forces that promote varus collapse. A sliding hip screw (fixed-angle device) provides superior biomechanical stability against vertical shear compared to multiple parallel cancellous screws.

Question 2498

Topic: 2. Trauma

A 32-year-old male sustains a closed comminuted tibial shaft fracture. Two hours post-injury, he complains of severe pain exacerbated by passive stretch of the hallux. His blood pressure is 90/60 mmHg. Intracompartmental pressure testing reveals an anterior compartment pressure of 35 mmHg. What is the most definitive indication for a four-compartment fasciotomy in this patient?

. Absolute compartment pressure > 30 mmHg
. Delta pressure (Diastolic BP - Compartment Pressure) < 30 mmHg
. Loss of palpable dorsalis pedis pulse
. Presence of paresthesias in the deep peroneal nerve distribution
. Delta pressure (Mean Arterial Pressure - Compartment Pressure) < 40 mmHg

Correct Answer & Explanation

. Delta pressure (Diastolic BP - Compartment Pressure) < 30 mmHg

Explanation

A delta pressure (diastolic blood pressure minus intracompartmental pressure) of less than 30 mmHg is the most reliable threshold for diagnosing acute compartment syndrome. Relying on absolute pressure can lead to overtreatment, especially in hypotensive patients.

Question 2499

Topic: 2. Trauma

A 45-year-old female sustains an intra-articular distal humerus fracture involving the capitellum and the entire trochlea, lacking posterior comminution (Dubberley Type 3A). Which surgical approach provides the most optimal visualization for direct reduction of this specific articular shear fracture?

. Extended lateral approach
. Triceps-reflecting anconeus pedicle (TRAP) approach
. Olecranon osteotomy approach
. Anterior Henry approach
. Posterior triceps-splitting approach

Correct Answer & Explanation

. Extended lateral approach

Explanation

Capitellar and trochlear shear fractures (Dubberley classification) are best visualized and fixed via an extended lateral approach. Olecranon osteotomy provides excellent posterior exposure but suboptimal visualization of anterior shear fragments.

Question 2500

Topic: Pelvic & Acetabular Trauma
A 35-year-old male is involved in a high-speed motor vehicle collision. Pelvic radiographs show a widened symphysis pubis of 3.5 cm. CT scan reveals disruption of the anterior sacroiliac ligaments but intact posterior sacroiliac ligaments. What is the correct Young-Burgess classification of this injury?
. Anteroposterior Compression (APC) I
. Anteroposterior Compression (APC) II
. Anteroposterior Compression (APC) III
. Lateral Compression (LC) I
. Lateral Compression (LC) II

Correct Answer & Explanation

. Anteroposterior Compression (APC) II

Explanation

An APC II injury is characterized by a symphyseal diastasis greater than 2.5 cm and disruption of the anterior sacroiliac ligaments. The posterior sacroiliac ligaments remain intact, providing vertical stability but rotational instability.

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