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2. Trauma MCQs

Practice Set 220 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 4381

Topic: 2. Trauma
An 11-year-old boy stepped on a nail and sustained a puncture to the right forefoot 6 days ago. He was wearing tennis shoes at the time of injury. Treatment in the emergency department consisted of local debridement and tetanus prophylaxis; a radiograph was negative for foreign body, chondral defect, or fracture. He was discharged with a 3-day prescription of amoxicillin and clavulanate. The patient now has increasing pain and tenderness at the puncture site. What is the best course of action?
. Change the antibiotic to ciprofloxacin
. Initiate gentamicin
. Resume the prescription for amoxicillin and clavulanate
. Observation and follow-up in 48 hours
. Surgical debridement

Correct Answer & Explanation

. Surgical debridement

Explanation

The initial treatment consisting of oral antibiotics was appropriate, but with progressive symptoms, surgical debridement is necessary. Ciprofloxacin is contraindicated in children, and at this stage, oral antibiotics are inadequate. Intravenous antibiotics may be necessary, but surgical debridement is paramount. Failure to respond to the initial management precludes further observation.

Question 4382

Topic: 2. Trauma

-Ten or more years after severe polytrauma, premenopausal women, compared to men

. need less psychological support.
. are less likely to feel well rehabilitated.
. have a shorter duration of rehabilitation.
. show no difference in quality-of-life scores.
. show higher rates of posttraumatic stress disorder and take more sick leave time.

Correct Answer & Explanation

. need less psychological support.

Explanation

Question 4383

Topic: 2. Trauma
Osteoporotic vertebral compression fractures are associated with
. neurologic deterioration in 33% of patients.
. osteomalacia in 50% of patients.
. a further fracture risk rate of 20%.
. chronic pain in 75% of patients.
. a 2-year mortality rate that is less than that associated with hip fractures.

Correct Answer & Explanation

. a further fracture risk rate of 20%.

Explanation

Osteoporotic vertebral compression fractures are associated with neurologic complications in less than 1% of patients. After the initial fracture, however, patients have a 20% risk of further fractures. The mortality rate of patients with vertebral fractures exceeds that of patients with hip fractures when they are followed beyond 6 months.

Question 4384

Topic: 2. Trauma

During surgical fixation of a fibula fracture, a concomitant syndesmotic injury is suspected. Which of the following intraoperative findings best predicts syndesmotic instability requiring fixation?

. Fibula fracture 5 cm above the joint line.
. Widening of the medial clear space on external rotation stress test.
. Concomitant medial malleolus fracture.
. Tibiofibular clear space > 5mm on a mortise view without stress.
. Avulsion of the deltoid ligament on MRI.

Correct Answer & Explanation

. Fibula fracture 5 cm above the joint line.

Explanation

The intraoperative external rotation stress test or lateral hook test is the gold standard for diagnosing occult syndesmotic instability. Widening of the medial clear space or tibiofibular clear space under stress indicates dynamic instability of the syndesmosis and deltoid complex, necessitating stabilization.

Question 4385

Topic: 2. Trauma

A 40-year-old smoker undergoes ORIF of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following is the most significant modifiable patient-specific risk factor for postoperative wound complications in this setting?

. Current smoking
. Body Mass Index (BMI) < 25
. Age > 35
. Use of a thigh tourniquet
. Male gender

Correct Answer & Explanation

. Current smoking

Explanation

Current smoking is one of the most critical modifiable patient-specific risk factors for wound edge necrosis and deep infection following an extensile lateral approach for calcaneus fractures. Smoking cessation should be highly encouraged, and some surgeons consider active heavy smoking a relative contraindication to the extensile lateral approach.

Question 4386

Topic: 2. Trauma

A 30-year-old sustains a spiral distal third tibial shaft fracture during a skiing accident. What associated injury must be specifically ruled out via advanced imaging or dedicated radiographs prior to operative intervention?

. Anterior process calcaneus fracture
. Posterior malleolus fracture
. Lisfranc injury
. Sustentaculum tali fracture
. Proximal fibula fracture

Correct Answer & Explanation

. Anterior process calcaneus fracture

Explanation

Spiral distal third tibial shaft fractures have a highly associated risk (frequently cited between 25% and 90%) of a concomitant, often occult, posterior malleolus fracture. Preoperative CT scanning or dedicated internal rotation views are recommended to identify this intra-articular extension to alter surgical planning.

Question 4387

Topic: 2. Trauma

A 19-year-old college basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2). The high risk of nonunion in this region is primarily due to a vascular watershed area involving the blood supply from which of the following?

. Dorsalis pedis artery
. Medial plantar artery
. Nutrient artery and metaphyseal vessels
. Peroneal artery
. Lateral plantar artery

Correct Answer & Explanation

. Dorsalis pedis artery

Explanation

The metaphyseal-diaphyseal junction (Zone 2, Jones fracture) receives an intramedullary blood supply from a nutrient artery and extramedullary supply from metaphyseal vessels. A vascular watershed area exists at this specific junction, predisposing these fractures to delayed union or nonunion.

Question 4388

Topic: 2. Trauma

A 45-year-old male falls from a height and sustains a highly comminuted, displaced tibial pilon fracture with severe soft tissue swelling and fracture blisters. A spanning external fixator is planned. Which of the following represents the most appropriate principle for fibular fixation in this specific setting?

. The fibula should be fixed acutely in all cases to restore length and rotation.
. Fibular fixation should be delayed if the fracture is at the level of the joint and the approach would further compromise the soft tissue envelope.
. The fibula should never be fixed in pilon fractures.
. Fibular fixation acutely reduces the risk of deep infection of the tibia.
. Fibular fixation should only be performed via an intramedullary nail in this setting.

Correct Answer & Explanation

. The fibula should be fixed acutely in all cases to restore length and rotation.

Explanation

While historically the fibula was fixed acutely to 'restore the lateral column', modern evidence indicates that acute fibular fixation through compromised soft tissue (especially at the level of the joint where incisions may compromise later tibial approaches) increases the risk of wound complications. It can safely be delayed or even omitted depending on the fracture pattern and soft tissue status.

Question 4389

Topic: 2. Trauma

A patient presents with an ankle fracture characterized by an anterior inferior tibiofibular ligament rupture, a spiral fracture of the fibula starting anteroinferiorly and exiting posterosuperiorly, a posterior malleolus fracture, and a transverse fracture of the medial malleolus. Based on the Lauge-Hansen classification, what is the mechanism of injury?

. Supination-External Rotation
. Pronation-External Rotation
. Supination-Adduction
. Pronation-Abduction
. Pronation-Adduction

Correct Answer & Explanation

. Supination-External Rotation

Explanation

This sequence perfectly describes a Supination-External Rotation (SER) stage IV pattern. Stage 1: AITFL sprain/rupture. Stage 2: Spiral fibula fracture (anteroinferior to posterosuperior). Stage 3: PITFL rupture or posterior malleolus fracture. Stage 4: Transverse medial malleolus fracture or deltoid ligament rupture.

Question 4390

Topic: 2. Trauma

A 20-year-old collegiate track athlete complains of vague dorsal midfoot pain that worsens with sprinting. Radiographs are negative, but an MRI demonstrates a stress fracture of the central third of the tarsal navicular. The fracture is non-displaced and involves only the dorsal cortex. What is the most appropriate initial management?

. Continued weight-bearing in a stiff-soled shoe
. Open reduction and internal fixation
. Strict non-weight-bearing cast for 6-8 weeks
. Weight-bearing as tolerated in a pneumatic walking boot
. Extracorporeal shockwave therapy

Correct Answer & Explanation

. Continued weight-bearing in a stiff-soled shoe

Explanation

Tarsal navicular stress fractures occur in a high-risk watershed vascular zone in the central third of the bone. The standard initial treatment for a non-displaced navicular stress fracture is strict non-weight-bearing in a short leg cast for 6 to 8 weeks. Continued weight-bearing is associated with high rates of nonunion and fracture propagation.

Question 4391

Topic: 2. Trauma

The Sanders classification for intra-articular calcaneus fractures is utilized to guide surgical treatment and predict outcomes. This classification is primarily based on the number and location of articular fracture lines seen on which of the following imaging modalities?

. Lateral plain radiograph
. Harris axial plain radiograph
. Sagittal CT reconstruction
. Coronal CT reconstruction
. Axial CT reconstruction

Correct Answer & Explanation

. Lateral plain radiograph

Explanation

The Sanders classification is based on coronal CT images that show the widest portion of the posterior facet of the calcaneus (sustentaculum tali). It dictates the number of articular fragments (types I-IV) and the location of the primary fracture lines.

Question 4392

Topic: 2. Trauma

A 28-year-old male is involved in a severe crush injury to his foot and rapidly develops tense swelling, excruciating pain with passive toe extension, and paresthesias. Compartment syndrome of the foot is diagnosed. How many distinct osseofascial compartments are generally recognized in the foot for the purpose of fasciotomy?

. 4
. 5
. 7
. 9
. 11

Correct Answer & Explanation

. 4

Explanation

There are 9 recognized osseofascial compartments in the foot: the medial, lateral, superficial, calcaneal, 4 distinct interosseous compartments, and the adductor compartment. Complete surgical release requires dual dorsal incisions and often a medial incision to decompress all 9 compartments.

Question 4393

Topic: 2. Trauma

A 40-year-old male sustains a severe rotational ankle injury. Radiographs reveal a fracture-dislocation of the ankle where the proximal fibular shaft fragment is locked behind the posterior tubercle of the distal tibia. What is the eponymous name of this specific injury pattern?

. Tillaux fracture
. Maisonneuve fracture
. Wagstaffe-Le Fort fracture
. Bosworth fracture-dislocation
. Dupuytren fracture

Correct Answer & Explanation

. Tillaux fracture

Explanation

A Bosworth fracture-dislocation is a rare, severe pattern characterized by posterior dislocation of the proximal fibular fragment behind the posterior tubercle of the tibia. This results in a locked fibula that typically cannot be reduced closed and requires urgent open reduction to relieve skin tension and restore joint congruity.

Question 4394

Topic: 2. Trauma

A 42-year-old construction worker falls from a ladder and sustains an intra-articular calcaneus fracture.

On the lateral radiograph, Bohler's angle is measured. What is the normal range for Bohler's angle, and what typically happens to it in a depressed intra-articular calcaneus fracture?

. Normal 20-40 degrees; it increases in a fracture.
. Normal 20-40 degrees; it decreases in a fracture.
. Normal 100-130 degrees; it increases in a fracture.
. Normal 100-130 degrees; it decreases in a fracture.
. Normal 0-10 degrees; it decreases in a fracture.

Correct Answer & Explanation

. Normal 20-40 degrees; it increases in a fracture.

Explanation

Bohler's angle is formed by the intersection of a line drawn from the highest point of the anterior process to the highest point of the posterior facet, and a line from the highest point of the posterior facet to the superior edge of the tuberosity. It is normally between 20 and 40 degrees. In a depressed intra-articular calcaneus fracture, the posterior facet is driven plantarly, which typically leads to a decrease or flattening of Bohler's angle.

Question 4395

Topic: 2. Trauma

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, a full-thickness flap is elevated. Which of the following structures is most at risk if the inferior limb of the incision is carried too far plantarly or deeply into the abductor digiti minimi fascia?

. Sural nerve
. Superficial peroneal nerve
. Lateral plantar nerve
. Medial plantar nerve
. Lateral calcaneal artery

Correct Answer & Explanation

. Sural nerve

Explanation

The lateral plantar nerve, a branch of the tibial nerve, courses plantarly and is highly at risk if the inferior limb of the extensile lateral approach is carried too deep or too far plantarly. The sural nerve is at risk at the proximal aspect of the vertical limb. The lateral calcaneal artery is intentionally included in the full-thickness flap to preserve the vascularity to the corner of the skin flap.

Question 4396

Topic: 2. Trauma

A 45-year-old construction worker falls from a height and sustains a severely displaced, comminuted OTA/AO type 43-C3 tibial pilon fracture with massive soft tissue swelling and fracture blisters. The most appropriate initial management strategy is:

. Immediate open reduction and internal fixation with dual plating
. Application of a spanning external fixator and delayed ORIF
. Intramedullary nailing of the tibia
. Primary arthrodesis of the tibiotalar joint
. Closed reduction and long leg cast

Correct Answer & Explanation

. Immediate open reduction and internal fixation with dual plating

Explanation

High-energy pilon fractures with severe soft tissue compromise (e.g., massive swelling, fracture blisters) are best managed with a staged protocol: initial spanning external fixation across the ankle joint to restore length and alignment while allowing the soft tissues to recover. This is followed by delayed ORIF (typically 10-21 days later) once the 'wrinkle sign' is present, significantly reducing the risk of wound dehiscence and deep infection.

Question 4397

Topic: 2. Trauma

A 22-year-old collegiate basketball player experiences acute lateral foot pain during a game. Radiographs demonstrate a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction, extending into the 4th-5th intermetatarsal articulation. Which of the following is the most appropriate management for this athlete to minimize the risk of nonunion and expedite return to play?

. Non-weight bearing in a short leg cast for 6-8 weeks
. Protected weight-bearing in a stiff-soled shoe for 4 weeks
. Intramedullary screw fixation
. Open reduction and dorsal plating
. Primary bone grafting and Kirschner wire fixation

Correct Answer & Explanation

. Non-weight bearing in a short leg cast for 6-8 weeks

Explanation

This is a classic Jones fracture (Zone 2), located at the metaphyseal-diaphyseal junction and extending into the 4th-5th intermetatarsal facet. This area constitutes a vascular watershed zone, predisposing to delayed union and nonunion. In a high-level competitive athlete, intramedullary screw fixation is the treatment of choice to decrease time to union and allow a faster, more reliable return to sport compared to non-operative management.

Question 4398

Topic: 2. Trauma

A 19-year-old track athlete presents with insidious onset, ill-defined midfoot pain that worsens with running. CT scan reveals an incomplete stress fracture of the tarsal navicular in the sagittal plane. The high risk of nonunion in this bone is primarily attributed to its vascular anatomy, which is characterized by:

. A dense intraosseous anastomotic network from the medial plantar artery
. An avascular central third due to retrograde blood supply from the lateral margins
. An avascular central third secondary to vessels entering only the dorsal, plantar, and medial tuberosity aspects
. Blood supply entirely dependent on the artery of the tarsal canal
. Direct arterial branches from the dorsalis pedis entering the central articular surface

Correct Answer & Explanation

. A dense intraosseous anastomotic network from the medial plantar artery

Explanation

The tarsal navicular has a well-documented relative avascular zone in its central third. Vessels from the dorsalis pedis and medial plantar arteries enter the bone peripherally along the dorsal and plantar non-articular surfaces and the medial tuberosity. These vessels converge toward the center but leave the central third poorly perfused, creating a watershed area. This predisposes sagittal plane stress fractures in this zone to delayed union and nonunion.

Question 4399

Topic: 2. Trauma
A 40-year-old man falls from a ladder and sustains a displaced intra-articular calcaneus fracture. The coronal CT scan shows two distinct fracture lines traversing the posterior facet, creating three separate articular fragments. According to the Sanders classification, what is the grade of this fracture?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

The Sanders classification is based on coronal CT images of the posterior facet of the calcaneus at the widest point of the undersurface of the posterior talus. Type I: all non-displaced fractures. Type II: one fracture line in the posterior facet (two articular fragments). Type III: two fracture lines in the posterior facet (three articular fragments). Type IV: three or more fracture lines in the posterior facet (highly comminuted).

Question 4400

Topic: 2. Trauma

A 35-year-old male sustains a high-energy ankle fracture-dislocation. Radiographs show a fracture of the distal fibula, but on the lateral view, the proximal fibular shaft fragment is locked behind the posterior tubercle of the distal tibia. Closed reduction attempts in the emergency department are completely unsuccessful. What is this specific irreducible injury pattern called?

. Maisonneuve fracture
. Dupuytren fracture
. Bosworth fracture
. Tillaux fracture
. Wagstaffe fracture

Correct Answer & Explanation

. Maisonneuve fracture

Explanation

A Bosworth fracture-dislocation is a rare, irreducible fracture-dislocation of the ankle where the proximal segment of the fibula becomes severely entrapped behind the prominent posterior tubercle of the tibia. Closed reduction is typically impossible because the intact interosseous membrane and the bony anatomy act as an unforgiving tether, necessitating emergent open reduction.

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