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2. Trauma MCQs

Practice Set 129 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 2561

Topic: 2. Trauma

A 40-year-old female sustains a distal femur fracture. CT imaging reveals a coronal plane fracture of the lateral femoral condyle. Which of the following best describes this fracture pattern?

. Barton fracture
. Segond fracture
. Hoffa fracture
. Rolando fracture
. Tillaux fracture

Correct Answer & Explanation

. Hoffa fracture

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle, most commonly involving the lateral condyle. It is easily missed on plain AP radiographs and typically requires surgical fixation with anterior-to-posterior directed screws.

Question 2562

Topic: 2. Trauma

A 25-year-old male sustains a closed comminuted tibial shaft fracture. Within 12 hours, he develops severe leg pain out of proportion to the injury. Which of the following pressure measurements is the most accurate threshold for diagnosing acute compartment syndrome and indicating fasciotomy?

. Absolute compartment pressure > 20 mmHg
. Absolute compartment pressure > 25 mmHg
. Diastolic blood pressure minus compartment pressure < 30 mmHg
. Mean arterial pressure minus compartment pressure < 40 mmHg
. Systolic blood pressure minus compartment pressure < 50 mmHg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure < 30 mmHg

Explanation

A Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is the most reliable threshold for diagnosing acute compartment syndrome. Absolute pressure alone is less accurate as it does not account for systemic perfusion pressure.

Question 2563

Topic: 2. Trauma
A 34-year-old male sustains an open tibia fracture with a 12 cm laceration, extensive periosteal stripping, and exposed bone without adequate soft tissue coverage. The distal pulses are intact. What is the Gustilo-Anderson classification and the optimal timing for soft tissue coverage?
. Type IIIA, within 24 hours
. Type IIIB, within 5 to 7 days
. Type IIIC, immediate flap
. Type IIIB, within 4 weeks
. Type II, secondary intention

Correct Answer & Explanation

. Type IIIB, within 5 to 7 days

Explanation

This is a Gustilo-Anderson Type IIIB fracture due to extensive soft tissue loss requiring a flap for coverage, with intact vascularity. Current evidence suggests that soft tissue coverage performed within 5 to 7 days reduces infection and flap failure rates.

Question 2564

Topic: 2. Trauma
A 25-year-old male sustains a Hawkins Type III talar neck fracture requiring open reduction and internal fixation. Six weeks postoperatively, an AP radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?
. Impending nonunion of the fracture
. Deep space osteomyelitis
. Avascular necrosis (AVN)
. Intact vascularity to the talar body
. Early subtalar osteoarthritis

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The presence of a subchondral radiolucent band in the talar dome at 6-8 weeks is known as Hawkins sign. It represents subchondral atrophy and indicates intact vascularity to the talar body, as disuse osteopenia cannot occur without blood supply.

Question 2565

Topic: 2. Trauma

A 32-year-old male is admitted with a highly comminuted midshaft tibia fracture. He develops escalating leg pain out of proportion to the injury. Compartment pressure monitoring reveals an anterior compartment pressure of 45 mmHg and a diastolic blood pressure of 65 mmHg. What is the most appropriate management?

. Observe and reassess compartment pressures in 4 hours
. Elevate the leg above the level of the heart
. Perform an immediate four-compartment fasciotomy
. Administer intravenous mannitol and hypertonic saline
. Remove the splint and flex the knee to 90 degrees

Correct Answer & Explanation

. Perform an immediate four-compartment fasciotomy

Explanation

The delta pressure (Diastolic BP minus Compartment Pressure) is 65 - 45 = 20 mmHg. A delta pressure less than 30 mmHg is highly diagnostic for acute compartment syndrome and mandates emergent four-compartment fasciotomy.

Question 2566

Topic: 2. Trauma

A 40-year-old male sustains a high-energy Schatzker VI tibial plateau fracture. On examination, the leg is grossly swollen with fracture blisters developing over the proximal tibia. Compartments are soft. What is the most appropriate initial management?

. Immediate open reduction and internal fixation with dual plating
. Application of a knee-spanning external fixator
. Intramedullary nailing of the tibia
. Placement in a long leg cast
. Fasciotomies of the lower leg

Correct Answer & Explanation

. Application of a knee-spanning external fixator

Explanation

In high-energy tibial plateau fractures with severe soft tissue compromise, a spanning external fixator is the standard initial treatment. Definitive fixation is delayed until the soft tissue envelope recovers, typically 10 to 21 days.

Question 2567

Topic: 2. Trauma
A 24-year-old male presents with multiple injuries from an MVA, including a closed right femoral shaft fracture and severe bilateral pulmonary contusions. His initial lactate is 5.0 mmol/L, and he requires vasopressors to maintain a MAP > 60 mmHg. What is the most appropriate management for his femur fracture?
. Immediate reamed intramedullary nailing
. Immediate unreamed intramedullary nailing
. Damage control external fixation
. Skeletal traction until pulmonary contusions resolve
. Open reduction and internal fixation with a compression plate

Correct Answer & Explanation

. Damage control external fixation

Explanation

In a hemodynamically unstable polytrauma patient, damage control orthopedics (DCO) with temporary external fixation is indicated. Early total care (intramedullary nailing) in this setting significantly increases the risk of acute respiratory distress syndrome and fat embolism syndrome.

Question 2568

Topic: 2. Trauma

A 29-year-old male presents with a closed tibial shaft fracture. He complains of severe pain out of proportion to the injury. His blood pressure is 110/70 mmHg. Intracompartmental pressure testing yields a reading of 45 mmHg in the anterior compartment. What is the most appropriate management?

. Observation with repeated pressure checks in 4 hours
. Immediate four-compartment fasciotomy
. Bivalve the cast and elevate the leg
. Administer intravenous mannitol and steroids
. Application of a spanning external fixator

Correct Answer & Explanation

. Immediate four-compartment fasciotomy

Explanation

Acute compartment syndrome is a clinical diagnosis supported by an absolute compartment pressure greater than 30 mmHg or a Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg. Here, the Delta P is 25 mmHg (70 - 45), indicating the need for immediate fasciotomy.

Question 2569

Topic: 2. Trauma

In the management of a stress fracture of the femoral neck, which of the following is an absolute indication for surgical fixation?

. Posterior-medial tension-side fracture.
. Anterior-superior compression-side fracture.
. Military recruit with a stress fracture.
. Athlete desiring early return to play.
. Minimally displaced fracture.

Correct Answer & Explanation

. Posterior-medial tension-side fracture.

Explanation

Correct Answer: ATension-side stress fractures of the femoral neck (typically posterior-medial) are inherently unstable and have a high risk of progression to complete fracture and displacement, and a higher risk of avascular necrosis. Therefore, they are considered an absolute indication for surgical fixation (e.g., with cannulated screws). Compression-side fractures (anterior-superior) are generally more stable and can often be managed non-operatively with activity modification and protected weight-bearing, unless displacement occurs. While military recruits and athletes may benefit from surgical fixation to expedite return to activity, it's not an absolute indication for all stress fractures unless instability or displacement is present. Minimally displaced fractures would fall under the category of compression or tension-side and the management depends on that distinction.

Question 2570

Topic: 2. Trauma

A 30-year-old patient with a transverse fracture of the tibial shaft presents with severe pain, swelling, and tense compartments in the lower leg. Compartment pressures are elevated. What is the most appropriate immediate intervention?

. Apply a bivalved cast and elevate the limb.
. Administer high-dose NSAIDs and observe.
. Perform emergency fasciotomy.
. Arrange for CT angiography.
. Begin hyperbaric oxygen therapy.

Correct Answer & Explanation

. Perform emergency fasciotomy.

Explanation

Correct Answer: CElevated compartment pressures in the setting of severe pain, swelling, and tense compartments indicate acute compartment syndrome, which is a surgical emergency. The definitive treatment is an emergency fasciotomy to decompress the involved compartments and prevent irreversible muscle and nerve ischemia. Delay can lead to permanent disability (Volkmann's contracture), nerve damage, and even limb loss. All other options are inappropriate or cause critical delays.

Question 2571

Topic: 2. Trauma

A 49-year-old female is diagnosed with a Lisfranc tarsometatarsal fracture dislocation after falling down stairs. The CT scan confirms significant subluxation of the tarsometatarsal joints with a comminuted fracture at the base of the second metatarsal. Based on the case discussion, what is the MOST appropriate definitive management strategy for this patient?

. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.
. Open reduction and internal fixation (ORIF) with screws and possible plating.
. Primary arthrodesis of the tarsometatarsal joints.
. Closed reduction and percutaneous pinning.
. Below-knee backslab for pain control and delayed definitive treatment.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with screws and possible plating.

Explanation

Correct Answer: BExplanation:The case outlines the treatment strategy based on the severity of the injury. For subluxation or dislocation, "accurate reduction and stable fixation is essential." The candidate specifically states, "In this case, I would consider open reduction and internal fixation with screws and possible plating, as required."Option A (Non-weightbearing cast for 6 weeks):This is indicated only for "undisplaced stable injury or sprain." The patient's CT scan shows "significant subluxation" and a "comminuted fracture," which clearly indicates an unstable, displaced injury requiring surgical intervention.Option B (Open reduction and internal fixation (ORIF) with screws and possible plating):This is the primary treatment for displaced Lisfranc injuries, as described in the case. The goal is accurate anatomical reduction and stable fixation to restore joint congruity and prevent post-traumatic osteoarthritis.Option C (Primary arthrodesis of the tarsometatarsal joints):Primary arthrodesis is reserved for "severely comminuted fracture" where anatomical reduction and stable fixation are not achievable, or in cases of chronic instability or severe arthritis. While the patient has a comminuted fracture, the primary approach for acute subluxation/dislocation is typically ORIF unless the comminution is so severe that reconstruction is impossible.Option D (Closed reduction and percutaneous pinning):While sometimes used for less severe or purely ligamentous injuries, the presence of a comminuted fracture and significant subluxation often necessitates open reduction to achieve anatomical alignment and more robust fixation than percutaneous pinning can provide.Option E (Below-knee backslab for pain control and delayed definitive treatment):A backslab is appropriate for initial stabilization and pain control, as mentioned in the case, but it is not the definitive treatment for a displaced Lisfranc injury. Definitive treatment should not be unduly delayed.

Question 2572

Topic: 2. Trauma

A 49-year-old female with a Lisfranc injury is undergoing initial management. The orthopedic resident is performing a physical examination of the injured foot. Which of the following clinical findings, if present, would raise the MOST immediate concern for a developing compartment syndrome?

. Painful passive abduction/pronation of the foot.
. Ecchymosis and swelling around the midfoot.
. Diminished dorsalis pedis pulse with severe pain out of proportion to injury.
. Tenderness over the tarsometatarsal joints.
. Inability to bear weight on the affected limb.

Correct Answer & Explanation

. Diminished dorsalis pedis pulse with severe pain out of proportion to injury.

Explanation

Correct Answer: CExplanation:The case specifically highlights the importance of assessing neurovascular status and excluding compartment syndrome. The candidate states, "Neurovascular status, dorsalis pedis pulse" and "Compartment syndrome must be excluded." The classic signs of compartment syndrome include the '6 Ps': Pain (out of proportion), Pallor, Paresthesia, Pulselessness, Paralysis, and Poikilothermia. Among the options, a diminished pulse combined with severe pain out of proportion is a critical red flag.Option A (Painful passive abduction/pronation):This is a classic clinical sign of a Lisfranc injury itself, indicating instability and pain at the tarsometatarsal joints, but not specifically indicative of compartment syndrome.Option B (Ecchymosis and swelling around the midfoot):These are common findings in any significant foot trauma, including a Lisfranc injury, and while they can contribute to compartment syndrome, they are not direct signs of it.Option C (Diminished dorsalis pedis pulse with severe pain out of proportion to injury):"Pain out of proportion" is the hallmark symptom of compartment syndrome. A diminished dorsalis pedis pulse indicates compromised arterial flow, which is a late and ominous sign of severe compartment syndrome, suggesting significant tissue ischemia. This combination warrants immediate concern and intervention.Option D (Tenderness over the tarsometatarsal joints):This is a direct sign of a Lisfranc injury, indicating localized trauma and fracture/dislocation, but not specific to compartment syndrome.Option E (Inability to bear weight):This is a general symptom of severe lower limb injury and is expected with a Lisfranc injury, but it does not specifically point to compartment syndrome.

Question 2573

Topic: 2. Trauma

A 49-year-old female presents with a Lisfranc injury. During the initial assessment, the orthopedic team is vigilant for the development of compartment syndrome. If compartment syndrome is clinically diagnosed in the foot, what is the MOST appropriate immediate management step?

. Administer high-dose corticosteroids to reduce swelling.
. Apply ice packs and elevate the limb to decrease compartment pressures.
. Perform emergency surgical decompression (fasciotomy) of the foot compartments.
. Monitor compartment pressures hourly and reassess clinical signs.
. Order an urgent MRI to confirm the diagnosis and identify affected compartments.

Correct Answer & Explanation

. Perform emergency surgical decompression (fasciotomy) of the foot compartments.

Explanation

Correct Answer: CExplanation:The case clearly states, "Once compartment syndrome has been diagnosed clinically, emergency decompression is required." This highlights the urgency and definitive nature of surgical intervention for this limb-threatening condition.Option A (Administer high-dose corticosteroids):Corticosteroids are not indicated for the treatment of acute compartment syndrome and may even be detrimental.Option B (Apply ice packs and elevate the limb):While elevation is generally good for swelling, in compartment syndrome, excessive elevation can further compromise blood flow. Ice packs are not a treatment for compartment syndrome. These measures are insufficient to reduce dangerously elevated compartment pressures.Option C (Perform emergency surgical decompression (fasciotomy) of the foot compartments):This is the definitive and emergency treatment for acute compartment syndrome. The case describes the specific technique of decompressing the nine compartments of the foot through three incisions.Option D (Monitor compartment pressures hourly and reassess clinical signs):While compartment pressures can be monitored, once the clinical diagnosis of compartment syndrome is made, surgical decompression should not be delayed by prolonged monitoring. Clinical diagnosis is paramount.Option E (Order an urgent MRI):MRI is not the primary diagnostic tool for acute compartment syndrome and would cause an unacceptable delay in treatment. Clinical diagnosis and immediate surgical intervention are critical to prevent irreversible tissue damage.

Question 2574

Topic: 2. Trauma

A 49-year-old female presents with a Lisfranc injury. The initial management includes analgesia, elevation, and splinting with a below-knee backslab. The candidate emphasizes the importance of regular clinical examinations and monitoring. What is the primary reason for this vigilant monitoring in the acute phase?

. To assess for signs of infection in the bruised and swollen foot.
. To ensure proper alignment of the fracture within the backslab.
. To detect early signs of developing compartment syndrome.
. To evaluate the patient's pain tolerance and adjust analgesia.
. To prepare the patient for immediate weight-bearing once swelling subsides.

Correct Answer & Explanation

. To detect early signs of developing compartment syndrome.

Explanation

Correct Answer: CExplanation:The case explicitly states, "On admission to hospital I would arrange for regular clinical examinations and monitoring in order not to miss an early developing compartment syndrome." This highlights the critical importance of vigilance for this potentially devastating complication.Option A (To assess for signs of infection):While infection is a concern with any injury, especially open ones, it is not the primary acute concern driving immediate, regular monitoring in the context of a closed Lisfranc injury.Option B (To ensure proper alignment of the fracture within the backslab):While important, alignment is typically assessed radiographically. Clinical monitoring is more focused on physiological changes.Option C (To detect early signs of developing compartment syndrome):This is the most critical reason for vigilant monitoring in the acute phase of a significant foot injury. Compartment syndrome can lead to irreversible tissue damage if not promptly diagnosed and treated.Option D (To evaluate the patient's pain tolerance and adjust analgesia):Pain management is important, but it is a secondary goal compared to detecting a limb-threatening condition like compartment syndrome.Option E (To prepare the patient for immediate weight-bearing):Patients with Lisfranc injuries, especially those requiring surgery, are typically non-weightbearing for an extended period, not immediately after swelling subsides.

Question 2575

Topic: Lower Extremity Trauma

A 49-year-old female with a Lisfranc injury is being managed. The case mentions that for an undisplaced stable injury or sprain, non-operative management is an option. What does this non-operative management typically entail?

. Immediate weight-bearing in a walking boot for 4 weeks.
. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.
. Physical therapy focusing on early range of motion and strengthening.
. Pain management with NSAIDs and activity modification only.
. Custom orthotics and gradual return to activity over 2 months.

Correct Answer & Explanation

. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.

Explanation

Correct Answer: BExplanation:The case clearly outlines the non-operative management for undisplaced stable injuries: "There is a role for non-operative management of an undisplaced stable injury or sprain which includes a non-weightbearing cast for 6 weeks and regular clinical and radiological review."Option A (Immediate weight-bearing in a walking boot):This is inappropriate for any Lisfranc injury, even stable ones, as it risks displacement and further damage.Option B (Non-weightbearing cast for 6 weeks with regular clinical and radiological review):This directly matches the description in the case for stable, undisplaced injuries. The non-weightbearing period allows for ligamentous healing.Option C (Physical therapy focusing on early range of motion and strengthening):Early range of motion and strengthening would be contraindicated during the initial non-weightbearing phase for a Lisfranc injury, as it could disrupt healing.Option D (Pain management with NSAIDs and activity modification only):This is insufficient for a Lisfranc injury, even a stable sprain, which requires immobilization and protection from weight-bearing.Option E (Custom orthotics and gradual return to activity):Orthotics may be used later in rehabilitation, but they are not the primary initial non-operative management for a Lisfranc injury.

Question 2576

Topic: 2. Trauma
A 28-year-old male is involved in a high-speed motor vehicle collision and sustains a displaced Pauwels type III femoral neck fracture and an ipsilateral comminuted midshaft femur fracture. He is hemodynamically stable. What is the most appropriate sequence and strategy for operative fixation?
. Antegrade cephalomedullary nailing to address both fractures simultaneously
. Retrograde intramedullary nailing of the shaft followed by closed reduction and percutaneous pinning of the neck
. Closed or open reduction and internal fixation of the femoral neck first, followed by intramedullary nailing of the femoral shaft
. Application of a spanning external fixator followed by delayed definitive fixation of both injuries
. Open reduction and internal fixation of the shaft with plates first, followed by hemiarthroplasty of the hip

Correct Answer & Explanation

. Closed or open reduction and internal fixation of the femoral neck first, followed by intramedullary nailing of the femoral shaft

Explanation

In ipsilateral femoral neck and shaft fractures, priority must be given to anatomic reduction and secure fixation of the femoral neck to minimize the risk of avascular necrosis and nonunion. Once the neck is stabilized, the shaft fracture can be addressed.

Question 2577

Topic: 2. Trauma

A 45-year-old male sustains a severe closed Schatzker VI tibial plateau fracture. On presentation, the leg is significantly swollen with hemorrhagic fracture blisters over the proximal lateral tibia. What is the most appropriate initial management?

. Immediate open reduction and internal fixation through the fracture blisters
. Application of a knee-spanning external fixator, delaying definitive fixation until soft tissue swelling resolves and skin wrinkles appear
. Incision and drainage of the fracture blisters followed by a bridging plate
. Immediate intramedullary nailing to avoid soft tissue compromise
. Application of a long leg cast until fracture blisters resolve

Correct Answer & Explanation

. Application of a knee-spanning external fixator, delaying definitive fixation until soft tissue swelling resolves and skin wrinkles appear

Explanation

In high-energy periarticular fractures with significant soft tissue compromise (e.g., severe swelling, fracture blisters), a staged approach using a spanning external fixator is the standard of care. Definitive internal fixation is safely performed once soft tissue swelling subsides, indicated by the 'wrinkle sign'.

Question 2578

Topic: 2. Trauma
A 35-year-old male is brought to the trauma bay in hemorrhagic shock after a motorcycle accident. Pelvic radiographs show a severely displaced anteroposterior compression type III (APC-III) pelvic ring injury. The trauma team decides to apply a non-invasive commercial pelvic binder. To be maximally effective in reducing pelvic volume, where must the binder be centered?
. Over the iliac crests
. Over the greater trochanters
. Over the pubic symphysis
. Over the umbilicus
. Over the proximal third of the femoral shafts

Correct Answer & Explanation

. Over the greater trochanters

Explanation

To effectively reduce the pelvic volume and stabilize the fracture, a pelvic binder or sheet must be centered directly over the greater trochanters. Placing it too high (over the iliac crests) can paradoxically widen the pelvic outlet or fail to close the pelvic ring.

Question 2579

Topic: 2. Trauma

A 30-year-old male sustains a closed tibia shaft fracture. Overnight, he develops excruciating leg pain requiring escalating doses of narcotics. Passive stretch of his toes reproduces severe pain. Which of the following formulas correctly defines the 'delta P' used to diagnose acute compartment syndrome, and what threshold warrants emergent fasciotomy?

. Systolic Blood Pressure minus Compartment Pressure; < 40 mmHg
. Diastolic Blood Pressure minus Compartment Pressure; < 30 mmHg
. Mean Arterial Pressure minus Compartment Pressure; < 30 mmHg
. Systolic Blood Pressure plus Compartment Pressure; > 100 mmHg
. Diastolic Blood Pressure minus Compartment Pressure; > 30 mmHg

Correct Answer & Explanation

. Diastolic Blood Pressure minus Compartment Pressure; < 30 mmHg

Explanation

Acute compartment syndrome is diagnosed when the Delta P (Diastolic Blood Pressure minus Compartment Pressure) is less than 30 mmHg. This objective measurement is especially useful in obtunded or poly-trauma patients.

Question 2580

Topic: 2. Trauma
A 40-year-old farmer sustains a Gustilo-Anderson Type IIIA open tibia fracture from a tractor power take-off injury. The wound is grossly contaminated with soil and manure. In addition to a first-generation cephalosporin and an aminoglycoside, what additional prophylactic antibiotic must be initiated in the emergency department?
. Vancomycin
. Ciprofloxacin
. Penicillin
. Clindamycin
. Metronidazole

Correct Answer & Explanation

. Penicillin

Explanation

Farm injuries, or wounds heavily contaminated with soil, carry a high risk of anaerobic infection, specifically Clostridium perfringens. High-dose Penicillin is added to the standard open fracture antibiotic regimen to provide specific coverage against these organisms.

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