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2. Trauma MCQs

Practice Set 21 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 401

Topic: 2. Trauma

A 35-year-old man sustains a severe traumatic brain injury and a transverse acetabular fracture in a fall. He undergoes open reduction and internal fixation of the acetabulum. To prevent heterotopic ossification, which is highly prevalent in this clinical scenario, what is the most appropriate prophylactic regimen?

. Low-molecular-weight heparin for 6 weeks
. Indomethacin for 3 to 6 weeks or localized single-fraction radiation
. Oral bisphosphonates for 6 months
. High-dose intravenous vitamin C
. A tapering dose of oral corticosteroids over 2 weeks

Correct Answer & Explanation

. Indomethacin for 3 to 6 weeks or localized single-fraction radiation

Explanation

Patients with combined head trauma and acetabular fractures are at very high risk for heterotopic ossification. Prophylaxis typically consists of NSAIDs (e.g., indomethacin) for several weeks or a single perioperative dose of localized radiation therapy.

Question 402

Topic: 2. Trauma

A 24-year-old man with a displaced closed femoral shaft fracture develops a petechial rash across his axillae, confusion, and hypoxemia 48 hours post-admission. What is the most appropriate initial management for this condition?

. Therapeutic intravenous heparin
. High-dose intravenous corticosteroids
. Supportive care with oxygen and mechanical ventilation if needed
. Immediate intramedullary nailing of the femur
. Administration of tissue plasminogen activator (tPA)

Correct Answer & Explanation

. Supportive care with oxygen and mechanical ventilation if needed

Explanation

Fat embolism syndrome typically presents with a triad of hypoxemia, neurological abnormalities, and a petechial rash 24 to 72 hours after long bone fractures. The mainstay of treatment is supportive care, primarily focusing on maintaining adequate oxygenation and ventilation. Corticosteroids and heparin have not been proven to change the overall outcome.

Question 403

Topic: 2. Trauma

A 62-year-old housewife presents with a 2-month history of lethargy associated with shortness of breath. She has never smoked and takes no medication. Her chest X-ray shows multiple round lesions, increasing in size and numbers at the base, and bulky hilar lymph nodes. Urine testing reveals 2+ haematuria, but no protein. What is the most likely diagnosis?

. Lung abscesses
. Pulmonary metastases
. Rib fractures
. Silicosis
. Tuberculosis

Correct Answer & Explanation

. Pulmonary metastases

Explanation

Correct Answer: B- Pulmonary metastases Explanation Pulmonary metastases This lady is likely to have a primary renal cell carcinoma with pulmonary metastases. Multiple metastases range enormously in size and number, from ‘cannon balls’ to miliary shadowing, and can be accompanied by hilar lymphadenopathy or pleural effusion. The most common underlying tumours are breast, colon, renal and lung primaries, but other tumours (that are amenable to chemotherapy) can metastasise to the lung, such as testicular cancer and choriocarcinoma. Diagnosis can be achieved by cytology or histology on various samples from the pleura or lung, and can occasionally be made from cytology of expectorated or induced sputum. Lung abscesses Lung abscesses is incorrect. Lung abscesses are rounded lesions, but air/fluid levels would be visible. There are also no infective symptoms described here, making lung abscesses unlikely. Rib fractures Rib fractures is incorrect. No part in the description of this case is suggestive of rib fractures. Silicosis Silicosis is incorrect. Silicosis is characterised by pulmonary nodules, but these are usually small and predominantly affect the upper lobes. Silicosis is not associated with haematuria. Hilar nodes classically show ‘eggshell’ calcification. Tuberculosis Tuberculosis is incorrect. Tuberculosis can present with lung lesions, lymphadenopathy and lethargy; however, the description of the lesions as round with increasing size and numbers at the base is more in keeping with lung metastases. There is no mention of fever, night sweats or productive cough. If renal TB was suspected it is likely there would be proteinuria as well as haematuria.

Question 404

Topic: 2. Trauma
A 32-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). What biomechanical advantage does a sliding hip screw (SHS) with a derotation screw provide over multiple cancellous screws for this specific fracture pattern?
. Better rotational control
. Decreased risk of avascular necrosis
. Superior resistance to vertical shear forces
. Less disruption of the lateral femoral wall
. Earlier weight-bearing capability

Correct Answer & Explanation

. Superior resistance to vertical shear forces

Explanation

Pauwels type III fractures experience high vertical shear forces. An SHS with a derotation screw offers superior biomechanical resistance to these shear forces compared to multiple cancellous screws, significantly reducing the risk of varus collapse.

Question 405

Topic: 2. Trauma

A 45-year-old construction worker falls from a ladder, sustaining a severely comminuted, depressed lateral tibial plateau fracture with associated widening of the metaphysis (Schatzker Type II). Which of the following surgical strategies is essential to restore joint congruity and prevent late varus/valgus collapse?

. Percutaneous screw fixation alone
. Spanning external fixation without internal reduction
. Submeniscal arthrotomy, elevation of the joint surface, bone grafting, and lateral buttress plating
. Intramedullary nailing
. Primary total knee arthroplasty

Correct Answer & Explanation

. Submeniscal arthrotomy, elevation of the joint surface, bone grafting, and lateral buttress plating

Explanation

Schatzker II fractures require anatomical reduction of the articular surface to prevent post-traumatic arthritis. This mandates elevating the depressed articular fragments, filling the resulting metaphyseal void with bone graft, and supporting the construct with a lateral plate.

Question 406

Topic: 2. Trauma

A 24-year-old male sustains a closed comminuted diaphyseal femur fracture. 36 hours post-admission, he develops tachycardia, a petechial rash over his axilla, and confusion. What is the most likely diagnosis?

. Deep vein thrombosis
. Fat embolism syndrome
. Pulmonary embolism
. Acute respiratory distress syndrome
. Systemic inflammatory response syndrome

Correct Answer & Explanation

. Fat embolism syndrome

Explanation

Fat embolism syndrome typically presents 24-72 hours after long bone fractures with the classic triad of hypoxemia, neurological abnormalities, and a petechial rash. The rash is considered pathognomonic but only occurs in a subset of patients.

Question 407

Topic: 2. Trauma

A 28-year-old male undergoes four-compartment fasciotomies of the leg for acute compartment syndrome following a severe tibial plateau fracture. Which compartment is most frequently inadequately decompressed, leading to residual necrosis?

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

Correct Answer & Explanation

. Deep posterior compartment

Explanation

The deep posterior compartment is the most commonly missed or inadequately released compartment in the lower leg. Inadequate release can lead to muscle necrosis, contractures, and severe claw toe deformities.

Question 408

Topic: 2. Trauma

A 26-year-old man presents with chronic wrist pain and is diagnosed with a scaphoid nonunion. MRI demonstrates avascular necrosis (AVN) of the proximal pole. Which surgical intervention is most appropriate to optimize healing?

. Percutaneous screw fixation alone
. Vascularized bone grafting and internal fixation
. Non-vascularized iliac crest bone graft and internal fixation
. Proximal row carpectomy
. Four-corner fusion

Correct Answer & Explanation

. Vascularized bone grafting and internal fixation

Explanation

In the setting of a scaphoid nonunion complicated by avascular necrosis of the proximal pole, a vascularized bone graft is recommended to revascularize the bone and promote union. Non-vascularized grafts have a significantly higher failure rate in the presence of AVN.

Question 409

Topic: 2. Trauma
A 30-year-old male is brought to the trauma bay after a motorcycle accident. He has an anteroposterior compression (APC) type III pelvic ring injury. His blood pressure is 70/40 mmHg, and he is tachycardic. After initial fluid resuscitation and application of a pelvic binder, he remains hemodynamically unstable. FAST exam is negative. What is the most appropriate next step in management?
. CT scan of the abdomen and pelvis
. Immediate open reduction and internal fixation of the pelvis
. Preperitoneal pelvic packing or angioembolization
. Exploratory laparotomy
. Placement of a REBOA and observation

Correct Answer & Explanation

. Preperitoneal pelvic packing or angioembolization

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and negative FAST, the source of bleeding is likely retroperitoneal from the pelvic fracture. Preperitoneal pelvic packing or angioembolization are the treatments of choice to control the hemorrhage.

Question 410

Topic: 2. Trauma
A 32-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). What is the biomechanical rationale for using a sliding hip screw with a derotation screw rather than three parallel cancellous screws?
. Increased resistance to varus collapse and superior shear stability
. Decreased risk of osteonecrosis
. Preservation of the lateral epiphyseal artery
. Allowance for earlier weight bearing
. Prevention of fracture nonunion by stimulating angiogenesis

Correct Answer & Explanation

. Increased resistance to varus collapse and superior shear stability

Explanation

Pauwels type III fractures experience high shear forces and are mechanically unstable. A fixed-angle device like a sliding hip screw offers superior biomechanical stability against varus collapse compared to parallel cancellous screws.

Question 411

Topic: Pelvic & Acetabular Trauma
In the acute management of an unstable anteroposterior compression (APC III) pelvic ring injury, where should a pelvic binder be anatomically centered to optimally reduce the pelvic volume?
. Over the iliac crests
. Over the greater trochanters
. Over the anterior superior iliac spines
. Just proximal to the umbilicus
. At the level of the ischial tuberosities

Correct Answer & Explanation

. Over the greater trochanters

Explanation

A pelvic binder must be centered over the greater trochanters to effectively compress the pelvic ring and reduce pelvic volume. Placement over the iliac crests can cause paradoxical opening of the pelvic floor and exacerbate bleeding.

Question 412

Topic: 2. Trauma

A 28-year-old male sustains a closed tibial shaft fracture. Within 8 hours, he complains of severe pain out of proportion to the injury. Which of the following clinical findings is the earliest and most sensitive indicator of acute compartment syndrome?

. Loss of peripheral pulses
. Pallor of the distal extremity
. Pain with passive stretch of the involved muscles
. Paresthesias in the web space of the toes
. Motor paralysis

Correct Answer & Explanation

. Pain with passive stretch of the involved muscles

Explanation

Pain with passive stretch is generally the earliest and most sensitive clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are late signs indicating irreversible ischemia.

Question 413

Topic: 2. Trauma

A 24-year-old male falls on an outstretched hand and sustains a fracture of the proximal pole of the scaphoid. Why is this specific fracture pattern at highest risk for avascular necrosis?

. The proximal pole has a dominant dorsal blood supply that is frequently disrupted
. Blood supply enters distally and flows retrograde to the proximal pole
. The proximal pole is devoid of any ligamentous attachments
. Increased intracapsular pressure obliterates the arterial supply
. The fracture line usually involves the radioscaphocapitate ligament

Correct Answer & Explanation

. Blood supply enters distally and flows retrograde to the proximal pole

Explanation

The scaphoid receives its primary blood supply from branches of the radial artery that enter distally and flow retrograde. Fractures at the proximal pole disrupt this supply, leading to a high rate of avascular necrosis and nonunion.

Question 414

Topic: 2. Trauma

A 45-year-old male falls from a roof and sustains an L1 burst fracture. He has weakness in ankle dorsiflexion and decreased perianal sensation. Which of the following radiographic findings dictates the need for anterior column support during surgical stabilization?

. Facet joint dislocation
. Loss of vertebral body height greater than 50 percent
. Spinous process fracture
. Intact posterior longitudinal ligament
. Widening of the interpedicular distance

Correct Answer & Explanation

. Loss of vertebral body height greater than 50 percent

Explanation

Significant anterior column comminution, such as greater than 50% loss of vertebral height or severe kyphosis, indicates gross instability. This necessitates anterior column reconstruction to prevent delayed kyphosis and hardware failure.

Question 415

Topic: 2. Trauma

A 35-year-old male is evaluated for a hypertrophic nonunion of a tibial shaft fracture 9 months after intramedullary nailing. Radiographs show abundant callus formation that fails to bridge the fracture site. What is the most appropriate surgical treatment?

. Bone grafting without hardware exchange
. Removal of the nail and application of a circular external fixator
. Dynamization of the current intramedullary nail
. Exchange nailing with a larger diameter reamed nail
. Pulsed electromagnetic field therapy

Correct Answer & Explanation

. Exchange nailing with a larger diameter reamed nail

Explanation

Hypertrophic nonunions have adequate biology but lack sufficient mechanical stability. Exchange nailing with a larger diameter reamed nail provides increased stability and directly addresses the mechanical failure.

Question 416

Topic: Pelvic & Acetabular Trauma
A 45-year-old male presents with hemorrhagic shock following an anteroposterior compression type III (APC-III) pelvic ring injury. Despite application of a pelvic binder, he remains hypotensive. What is the most common anatomic source of major pelvic hemorrhage in this setting?
. Superior gluteal artery
. Internal pudendal artery
. Presacral venous plexus
. Corona mortis
. Obturator artery

Correct Answer & Explanation

. Presacral venous plexus

Explanation

The presacral venous plexus and bleeding from fractured cancellous bone surfaces account for 80-90% of bleeding in pelvic ring injuries. Arterial bleeding accounts for only 10-20% of cases, despite being the target of angioembolization.

Question 417

Topic: Pelvic & Acetabular Trauma

According to the Young-Burgess classification, an anteroposterior compression type II (APC-II) pelvic ring injury is characterized by rupture of which of the following ligaments?

. Anterior sacroiliac, sacrotuberous, and sacrospinous ligaments only
. Anterior and posterior sacroiliac ligaments
. Iliolumbar ligaments only
. Posterior sacroiliac and sacrotuberous ligaments only
. Sacrotuberous, sacrospinous, and posterior sacroiliac ligaments

Correct Answer & Explanation

. Anterior sacroiliac, sacrotuberous, and sacrospinous ligaments only

Explanation

An APC-II injury involves symphyseal diastasis with tearing of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. The posterior sacroiliac ligaments remain intact, providing vertical stability.

Question 418

Topic: 2. Trauma

A 30-year-old male suffers a highly comminuted tibial plateau fracture. He develops escalating pain out of proportion to the injury. Compartment pressure measurements show an anterior compartment pressure of 38 mmHg and a diastolic blood pressure of 60 mmHg. What is the most appropriate next step?

. Elevation of the limb above the level of the heart
. Application of ice and reassessment in 2 hours
. Four-compartment fasciotomy
. Immediate application of a long leg cast
. Administration of intravenous mannitol

Correct Answer & Explanation

. Four-compartment fasciotomy

Explanation

The patient has a delta pressure of 22 mmHg (Diastolic BP 60 - Compartment Pressure 38). A delta pressure less than 30 mmHg in the setting of clinical signs dictates immediate surgical fasciotomy.

Question 419

Topic: 2. Trauma

In the setting of a high-energy closed tibial shaft fracture, which of the following is the most reliable early clinical indicator of acute compartment syndrome?

. Loss of distal pulses
. Capillary refill greater than 4 seconds
. Pallor of the extremity
. Pain out of proportion and with passive stretch
. Motor paralysis

Correct Answer & Explanation

. Pain out of proportion and with passive stretch

Explanation

Pain out of proportion to the injury and exacerbated by passive stretch of the muscles in the involved compartment is the most sensitive and earliest clinical sign of compartment syndrome. Pulselessness, pallor, and paralysis are late and unreliable signs.

Question 420

Topic: Pelvic & Acetabular Trauma

A 22-year-old male is brought to the trauma bay after an MVC with an open-book pelvic fracture and systolic blood pressure of 80 mmHg. A pelvic binder is applied. To be most effective in reducing pelvic volume, the binder should be centered over which of the following anatomic landmarks?

. Iliac crests
. Anterior superior iliac spines
. Greater trochanters
. Pubic symphysis
. Sacroiliac joints

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders should be placed directly over the greater trochanters to maximize closure of the pelvic ring and reduce pelvic volume. Placement over the iliac crests is incorrect and can potentially worsen the deformity.

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