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2. Trauma MCQs

Practice Set 217 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 4321

Topic: 2. Trauma

According to the Fracture-Related Infection (FRI) Consensus Group, which of the following clinical or laboratory findings is considered a 'confirmatory' (absolute) criterion for diagnosing a fracture-related infection?

. Elevated serum C-reactive protein (CRP) > 100 mg/L
. Local signs of redness, swelling, and increased temperature
. Presence of a sinus tract communicating with the bone or implant
. A single positive deep tissue culture taken during surgical debridement
. Purulent drainage from the superficial skin incision only

Correct Answer & Explanation

. Elevated serum C-reactive protein (CRP) > 100 mg/L

Explanation

The FRI Consensus definition identifies confirmatory criteria as: 1) a fistula/sinus tract communicating with bone/implant, 2) purulent drainage or pus around the bone/implant, 3) phenotypically identical pathogens isolated from 2 or more separate deep tissue/implant cultures, or 4) presence of microorganisms in deep tissue on histopathological examination. Elevated CRP, local clinical signs, and a single positive culture are 'suggestive' but not confirmatory.

Question 4322

Topic: 2. Trauma
A 35-year-old farm worker sustains a Gustilo-Anderson Grade IIIA open tibia fracture that is heavily contaminated with soil and manure. In addition to prompt surgical debridement, which of the following antibiotic regimens classically represents the most appropriate initial prophylaxis for this specific injury pattern?
. Cefazolin monotherapy
. Ceftriaxone monotherapy
. Cefazolin and gentamicin
. Cefazolin and clindamycin
. Cefazolin, gentamicin, and penicillin

Correct Answer & Explanation

. Cefazolin, gentamicin, and penicillin

Explanation

For Grade III open fractures, standard historical protocol includes a first-generation cephalosporin (e.g., Cefazolin) and an aminoglycoside (e.g., Gentamicin). In cases of severe soil or farm contamination, there is a high risk of Clostridium perfringens infection (gas gangrene). Therefore, high-dose penicillin is classically added to the regimen to cover these anaerobic organisms.

Question 4323

Topic: 2. Trauma
According to the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT trial), how does the choice between reamed and unreamed intramedullary nailing affect outcomes in OPEN tibial shaft fractures?
. Reamed nailing significantly increases the risk of deep infection and should be avoided.
. Unreamed nailing leads to a significantly higher rate of nonunion requiring reoperation.
. Reamed nailing provides a statistically significant advantage in time to union over unreamed nailing.
. There is no significant difference in the rates of infection or nonunion between reamed and unreamed nailing.
. Unreamed nailing significantly decreases the risk of compartment syndrome.

Correct Answer & Explanation

. There is no significant difference in the rates of infection or nonunion between reamed and unreamed nailing.

Explanation

The landmark SPRINT trial evaluated reamed versus unreamed intramedullary nailing in tibial shaft fractures. For the subgroup of patients with open fractures, the study found no statistically significant difference in primary outcomes (including deep infection and nonunion) between the two techniques.

Question 4324

Topic: 2. Trauma

A 22-year-old male sustains a low-velocity civilian handgun injury to the thigh resulting in a nondisplaced midshaft femur fracture. Physical examination reveals no absent pulses, normal ABI, and soft compartments. Which of the following is the most appropriate management regarding the retained bullet lodged in the vastus lateralis?

. Urgent surgical exploration to remove the bullet and extensively wash out the tract
. Intravenous antibiotics for 14 days and non-operative fracture management
. Local wound care, short-course IV antibiotics (24-48 hours), standard fracture fixation, and leaving the bullet in situ
. Immediate application of an external fixator with planned serial soft tissue debridements
. CT-guided percutaneous extraction of the bullet to prevent future lead toxicity

Correct Answer & Explanation

. Urgent surgical exploration to remove the bullet and extensively wash out the tract

Explanation

Low-velocity gunshot wounds (typical civilian handguns) that cause fractures are generally treated similarly to closed fractures or Grade I open fractures. Standard of care is local wound care, 24-48 hours of IV antibiotics, and appropriate fracture fixation. The bullet does not require removal unless it is intra-articular, impinging on a nerve/vessel, in the spinal canal causing a deficit, or causing mechanical block.

Question 4325

Topic: 2. Trauma

In the management of a severely injured polytrauma patient, the concept of 'Damage Control Orthopedics' (DCO) aims to mitigate the risk of Multiple Organ Dysfunction Syndrome (MODS). According to the 'two-hit' hypothesis, which of the following interventions classically constitutes an iatrogenic 'second hit' if performed during the peak inflammatory window (days 2 to 5 post-injury)?

. Application of a damage control external fixator for a femur fracture
. Early definitive intramedullary nailing of a bilateral femur fracture
. Resuscitation with balanced crystalloids and blood products
. Administration of broad-spectrum prophylactic antibiotics
. Decompressive laparotomy for intra-abdominal hypertension

Correct Answer & Explanation

. Application of a damage control external fixator for a femur fracture

Explanation

The initial trauma serves as the 'first hit', activating the systemic inflammatory response syndrome (SIRS). A major definitive surgery, such as reamed intramedullary nailing of a femur, acts as an iatrogenic 'second hit' that can amplify the inflammatory cascade, leading to ARDS and MODS. DCO (using external fixation) minimizes this second hit.

Question 4326

Topic: 2. Trauma
A 55-year-old diabetic male presents with rapidly progressive leg swelling, erythema, and disproportionate pain after a minor abrasion. Lab work shows CRP 200 mg/L, WBC 18x10^9/L, hemoglobin 11 g/dL, sodium 130 mmol/L, creatinine 1.8 mg/dL, and glucose 200 mg/dL. Based on the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, what is the most appropriate next step?
. Intravenous antibiotics and serial observation
. Urgent MRI of the lower extremity
. Immediate surgical exploration and debridement
. Hyperbaric oxygen therapy
. Fasciotomy for compartment syndrome

Correct Answer & Explanation

. Immediate surgical exploration and debridement

Explanation

The LRINEC score stratifies risk for necrotizing fasciitis based on CRP, WBC, Hb, Na, Creatinine, and Glucose. A score >= 6 indicates a high risk, warranting immediate surgical exploration, which is both diagnostic and life-saving.

Question 4327

Topic: 2. Trauma
A 30-year-old male sustains a Gustilo-Anderson IIIB open tibia fracture. Following initial definitive skeletal stabilization and thorough debridement, what is the optimal timeframe for definitive soft tissue coverage to minimize the risk of deep infection?
. Within 24 hours
. Within 5 to 7 days
. Between 10 to 14 days
. After 3 weeks when granulation tissue is robust
. After 6 weeks to allow fracture early callus

Correct Answer & Explanation

. Within 5 to 7 days

Explanation

Extensive literature demonstrates that definitive soft tissue coverage of severe open tibia fractures within 5 to 7 days significantly decreases the rates of deep infection and flap failure. Delaying coverage beyond this window increases complication rates.

Question 4328

Topic: 2. Trauma

A 40-year-old farmer sustains a severe, contaminated open forearm fracture from a tractor accident. He is unsure of his tetanus immunization history but believes he had some childhood shots. What is the appropriate tetanus prophylaxis strategy in the emergency department?

. Tetanus toxoid only
. Tetanus immune globulin only
. Tetanus toxoid and tetanus immune globulin
. No prophylaxis needed if debridement is adequate
. Oral antibiotics alone are sufficient

Correct Answer & Explanation

. Tetanus toxoid only

Explanation

For a tetanus-prone wound in a patient with an unknown or incomplete (<3 doses) immunization history, both the tetanus toxoid-containing vaccine and tetanus immune globulin (TIG) are indicated.

Question 4329

Topic: 2. Trauma

A 40-year-old fisherman sustains an open radius fracture from a boat propeller in the Gulf of Mexico. Within 24 hours, he develops rapidly progressive hemorrhagic bullae and septic shock. Which of the following is the most likely causative organism?

. Mycobacterium marinum
. Vibrio vulnificus
. Aeromonas hydrophila
. Erysipelothrix rhusiopathiae
. Pseudomonas aeruginosa

Correct Answer & Explanation

. Mycobacterium marinum

Explanation

Vibrio vulnificus is a highly virulent, gram-negative, comma-shaped bacterium found in warm, coastal marine environments. It classically causes rapidly progressive necrotizing wound infections and sepsis, particularly in patients with underlying liver disease.

Question 4330

Topic: 2. Trauma

A 34-year-old male sustains a severely contaminated open tibia fracture from a farming accident. He states he has never received any childhood vaccines and does not know his tetanus status. What is the most appropriate tetanus prophylaxis strategy in the emergency department?

. No prophylaxis required
. Tetanus toxoid-containing vaccine (Tdap) only
. Tetanus immune globulin (TIG) only
. Tetanus toxoid-containing vaccine (Tdap) and Tetanus immune globulin (TIG)
. Intravenous penicillin and Tetanus immune globulin (TIG)

Correct Answer & Explanation

. No prophylaxis required

Explanation

For a patient with an unknown or incomplete primary tetanus immunization history (<3 doses) who presents with a dirty or contaminated wound, BOTH the tetanus toxoid vaccine (Td or Tdap) and Tetanus Immune Globulin (TIG) are strictly indicated.

Question 4331

Topic: 2. Trauma

A 28-year-old female presents with acute purulent drainage, erythema, and fever 16 days after undergoing ORIF of a closed tibial shaft fracture. Radiographs show unchanged, stable hardware alignment. According to the principles of Debridement, Antibiotics, and Implant Retention (DAIR), which of the following features makes this patient an appropriate candidate for hardware retention?

. The infection is caused by MRSA
. The duration of symptoms and time from surgery is less than 3 weeks
. The presence of a well-formed biofilm on the hardware
. The fracture exhibits signs of hypertrophic nonunion
. The hardware has loosened but maintains partial stability

Correct Answer & Explanation

. The infection is caused by MRSA

Explanation

DAIR is generally indicated for acute fracture-related infections presenting within 3 to 4 weeks of surgery, provided the hardware remains mechanically stable and the soft tissue envelope can be closed. Loose hardware or chronic infections require implant removal.

Question 4332

Topic: 2. Trauma
A 45-year-old male sustains a Gustilo-Anderson IIIB open fracture of the distal third of the tibia with extensive soft tissue loss exposing the bone and hardware. Following serial debridements and negative cultures, which of the following is the most appropriate option for soft tissue coverage of this specific defect?
. Medial gastrocnemius rotational flap
. Soleus rotational flap
. Reverse sural artery flap
. Free tissue transfer (e.g., Anterolateral thigh flap)
. Split-thickness skin graft directly over exposed bone

Correct Answer & Explanation

. Free tissue transfer (e.g., Anterolateral thigh flap)

Explanation

Soft tissue defects of the distal third of the tibia lack adequate local muscle bulk for rotational flaps. They typically require free tissue transfer (e.g., ALT, latissimus dorsi) for definitive coverage. Gastrocnemius covers the proximal third, and soleus covers the middle third.

Question 4333

Topic: 2. Trauma

Which of the following interventions has been shown in the orthopedic literature to have the most significant impact on reducing the risk of deep infection in the management of high-energy open tibia fractures?

. High-pressure pulsatile lavage during debridement
. Administration of intravenous antibiotics within 1 hour of injury
. Definitive soft tissue coverage within 24 hours of injury
. Use of negative pressure wound therapy (NPWT) immediately post-injury
. Application of local antibiotic beads within 6 hours

Correct Answer & Explanation

. High-pressure pulsatile lavage during debridement

Explanation

Early administration of systemic intravenous antibiotics (ideally within 1 hour of injury) is the most critical factor in reducing the infection rate in open fractures. Delays in antibiotic administration significantly increase the risk of osteomyelitis.

Question 4334

Topic: 2. Trauma

According to the Fracture-Related Infection (FRI) Consensus Group, diagnosing an FRI involves 'confirmatory' and 'suggestive/suspicious' criteria. Which of the following is considered a 'suggestive' criterion rather than a 'confirmatory' absolute criterion?

. Presence of a draining sinus tract communicating with the bone/implant
. Purulent drainage directly from the surgical wound
. Two deep tissue cultures growing phenotypically identical organisms
. Elevated serum C-reactive protein (CRP) in the post-operative period
. Histopathological finding of >5 polymorphonuclear neutrophils per high-power field

Correct Answer & Explanation

. Presence of a draining sinus tract communicating with the bone/implant

Explanation

Elevated serum inflammatory markers (CRP, WBC), fever, and erythema are 'suggestive' criteria for FRI. Confirmatory criteria include a sinus tract, gross purulence, identical pathogens in 2+ separate deep cultures, or positive histopathology (>5 PMNs/HPF).

Question 4335

Topic: 2. Trauma

During revision surgery for a suspected fracture-related infection (FRI), intraoperative tissue samples are sent for histopathological analysis. According to the international consensus definition, which of the following findings is an absolute (confirmatory) criterion for FRI?

. >5 neutrophils per high-power field (HPF) in a single tissue sample
. >5 neutrophils per high-power field (HPF) in at least five separate fields
. Presence of a draining sinus tract that does not communicate with the bone
. A single positive deep tissue culture for Staphylococcus epidermidis
. Elevated serum C-reactive protein >100 mg/L

Correct Answer & Explanation

. >5 neutrophils per high-power field (HPF) in a single tissue sample

Explanation

The consensus criteria for FRI define >5 polymorphonuclear neutrophils (PMNs) per high-power field in at least five separate fields as a confirmatory (absolute) sign of infection. A single positive culture or elevated inflammatory markers are considered suggestive, not confirmatory.

Question 4336

Topic: 2. Trauma

A 28-year-old surfer sustains an open tibia fracture after striking a coral reef. The wound is heavily contaminated with saltwater and marine debris. Which of the following organisms should be specifically covered in the initial empiric antibiotic regimen?

. Pasteurella multocida
. Eikenella corrodens
. Vibrio vulnificus
. Mycobacterium avium
. Sporothrix schenckii

Correct Answer & Explanation

. Pasteurella multocida

Explanation

Saltwater and marine injuries carry a high risk for infection with Vibrio vulnificus. Empiric antibiotic coverage should include a third-generation cephalosporin or a fluoroquinolone to adequately cover this organism, alongside standard open fracture prophylaxis.

Question 4337

Topic: 2. Trauma

A 55-year-old farmer sustains a severely crushed, contaminated open femur fracture. He has not received a tetanus booster in 15 years, and his childhood immunization status is unknown. What is the most appropriate tetanus prophylaxis regimen?

. Tetanus toxoid only
. Tetanus immune globulin (TIG) only
. Both tetanus toxoid and tetanus immune globulin (TIG)
. Intravenous penicillin and close observation
. No prophylaxis is necessary if adequate debridement is performed

Correct Answer & Explanation

. Tetanus toxoid only

Explanation

For a patient with unknown or incomplete initial tetanus immunization (<3 doses) who sustains a tetanus-prone (dirty/contaminated) wound, both the tetanus toxoid-containing vaccine and tetanus immune globulin (TIG) are indicated. Clean wounds in such patients require only the toxoid.

Question 4338

Topic: 2. Trauma
A 32-year-old male sustains a Gustilo-Anderson Grade IIIB open tibia fracture. According to Godinaโ€™s classic study on early microsurgical reconstruction, free tissue transfer performed within what timeframe is associated with the lowest rates of flap failure and deep infection?
. Within 24 hours
. Within 72 hours
. Between 3 and 7 days
. Between 1 and 2 weeks
. After 4 weeks

Correct Answer & Explanation

. Within 72 hours

Explanation

Marko Godina's landmark 1986 study demonstrated that early free flap coverage of complex extremity trauma within 72 hours of injury significantly minimized infection rates, flap failure, and time to bone union.

Question 4339

Topic: 2. Trauma

A 69-year-old female sustains the injuries seen in Figures A and

. This injury is best classified as which of the following?
. Schatzker type I tibial plateau fracture
. Schatzker type III tibial plateau fracture
. Schatzker type IV tibial plateau fracture
. Schatzker type V tibial plateau fracture
. Schatzker type VI tibial plateau fracture

Correct Answer & Explanation

. This injury is best classified as which of the following?

Explanation

The radiographs and CT scan images show a depressed lateral tibial plateau fracture, which is correctly classified as a Schatzker III tibial plateau fracture. This fracture typically occurs as the result of the femoral condyle directly impacting the articular surface in older patients with osteopenia.The referenced article by Bennett et al reviews the associated soft tissue injury with tibial plateau fractures. They found a 56% frequency of associated soft tissue injuries overall, with MCL injured in 20%, the LCL in 3% , the menisci in 20%, the peroneal nerve in 3%, and the anterior cruciate ligaments in 10%.Schatzker type IV and type II fracture patterns were associated with the highest frequency of soft tissue injuries.

Question 4340

Topic: Upper Extremity Trauma
Figure 17 shows the radiograph of a 25-year-old professional football player who has superior shoulder pain that prevents him from sports participation. History reveals that he sustained a shoulder injury that was treated with closed reduction and temporary pinning 3 years ago. The best course of action should be
. no further participation in contact sports.
. open reduction of the acromioclavicular joint and coracoclavicular screw stabilization.
. open repair of the coracoclavicular ligaments.
. Weaver-Dunn reconstruction and coracoclavicular reconstruction.
. excision of the distal clavicle.

Correct Answer & Explanation

. Weaver-Dunn reconstruction and coracoclavicular reconstruction.

Explanation

The radiograph shows a complete acromioclavicular separation. Because the patient is a professional athlete who is unable to participate, surgery is indicated. Chronic separations, especially those with previous trauma from joint pinning, should be treated with resection of the distal clavicle and stabilization to the coracoid. Some type of biologic reconstruction of the coracoclavicular ligaments is generally recommended. Open repair of the ligaments is generally not possible in such a delayed fashion. Screw fixation alone will not provide a lasting solution as the screws usually need to be removed, leaving no fixation in place. Reconstruction using the coracoacromial ligament is generally recommended with coracoclavicular fixation to protect the repair while it heals.

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