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2. Trauma MCQs

Practice Set 224 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 4461

Topic: 2. Trauma

A 42-year-old male sustains a severe ankle injury. Radiographs show a fracture-dislocation with the fibula resting posterior to the tibia. Closed reduction in the emergency department is unsuccessful. In this classic Bosworth fracture-dislocation, which anatomical structure typically entraps the proximal fibular fragment?

. Anterior inferior tibiofibular ligament
. Posterior malleolus
. Posterolateral ridge of the distal tibia
. Flexor hallucis longus tendon
. Peroneal tendon complex

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

A Bosworth fracture-dislocation is characterized by the proximal fibular fragment becoming physically locked behind the posterolateral ridge of the distal tibia. The intact interosseous membrane acts as a tether. This mechanical block makes closed reduction virtually impossible and represents a surgical emergency to prevent skin necrosis and neurovascular compromise.

Question 4462

Topic: 2. Trauma

Following a severe crush injury to the foot from heavy machinery, a patient develops excruciating pain out of proportion to the injury, pain with passive toe stretch, and tense swelling. You suspect compartment syndrome. How many anatomically distinct fascial compartments are recognized in the foot for the purposes of surgical fasciotomy?

. 3
. 5
. 7
. 9
. 11

Correct Answer & Explanation

. 3

Explanation

There are 9 recognized fascial compartments in the foot: medial, lateral, superficial central, deep central, calcaneal, and four interosseous compartments. Adequate surgical decompression requires specific approaches (often dual dorsal incisions and occasionally a medial approach) to release all 9 compartments to prevent devastating ischemic contractures.

Question 4463

Topic: 2. Trauma

A 55-year-old female sustains an isolated medial malleolus fracture. In deciding between tension band wiring and lag screw fixation, which of the following scenarios represents the clearest advantage for utilizing a tension band construct?

. Large, non-comminuted vertical shear fractures
. A desire for less prominent hardware to minimize soft tissue irritation
. Small, avulsion-type or osteoporotic fragments
. Minimizing the risk of superficial postoperative infection
. Eliminating the need for intraoperative fluoroscopy

Correct Answer & Explanation

. Large, non-comminuted vertical shear fractures

Explanation

Tension band wiring is particularly advantageous for small, transverse avulsion-type fractures or in poor quality osteoporotic bone. In these scenarios, lag screws may not achieve adequate purchase or may split the small fragment. The tension band converts eccentric tensile forces into compressive forces at the articular surface. Disadvantages include prominent hardware.

Question 4464

Topic: 2. Trauma

A 35-year-old construction worker sustains a Gustilo-Anderson Type II open ankle fracture. Based on current literature and major trauma guidelines, what is the single most critical factor in reducing the risk of subsequent deep infection?

. Time from injury to surgical debridement being strictly under 6 hours
. Administration of appropriate intravenous antibiotics as soon as possible, ideally within 1 hour of injury
. Use of high-pressure pulsatile lavage during debridement
. Primary anatomical closure of the traumatic wound during the index procedure
. Prophylactic application of a negative pressure wound therapy (NPWT) device

Correct Answer & Explanation

. Time from injury to surgical debridement being strictly under 6 hours

Explanation

Extensive literature review has shown that the early administration of intravenous antibiotics (ideally within 1 hour of injury) is the most critical intervention in reducing infection rates in open fractures. The rigid '6-hour rule' for surgical debridement has been largely debunked by recent evidence, although urgent thorough debridement (within 24 hours) remains the standard of care. High-pressure lavage is generally avoided as it may drive debris deeper into tissues.

Question 4465

Topic: 2. Trauma

A 21-year-old elite collegiate basketball player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal during practice. He wishes to return to competitive play as quickly and safely as possible. What is the evidence-based recommended treatment?

. Non-weight-bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a stiff-soled boot
. Early operative intervention with intramedullary screw fixation
. Open reduction and internal fixation utilizing a dorsal mini-fragment plate
. Excision of the proximal bone fragment and advancement of the peroneus brevis tendon

Correct Answer & Explanation

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

Explanation

A fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal is defined as a Jones fracture. Because this area is a vascular watershed zone, conservative treatment carries a higher risk of delayed union or nonunion. In high-level athletes, early intramedullary screw fixation is highly recommended as it significantly reduces the time to union and facilitates a faster, more reliable return to play.

Question 4466

Topic: 2. Trauma

A 25-year-old marathon runner presents with a 4-week history of vague, progressively worsening dorsal midfoot pain. Initial radiographs are negative, but an MRI demonstrates a stress fracture strictly localized to the central third of the navicular body. The characteristically high risk of delayed union or nonunion in this specific region is anatomically due to:

. Extreme, unremitting compressive forces from the talar head during the stance phase
. Continuous avulsion forces applied by the broad insertion of the tibialis posterior tendon
. A relative watershed avascular zone in the central third of the navicular bone
. Inhibition of osteogenesis by articular fluid infiltrating from the talonavicular joint
. Excessive multiplanar mobility of the cuneonavicular joint complex

Correct Answer & Explanation

. Extreme, unremitting compressive forces from the talar head during the stance phase

Explanation

The navicular bone has a tenuous, centripetal blood supply originating from branches of the dorsalis pedis and medial plantar arteries. This microvascular anatomy leaves a relative avascular 'watershed' zone in the central third of the navicular body. Stress fractures in this precise location are notoriously prone to delayed union or frank nonunion and often require strict non-weight-bearing in a cast or surgical intervention (screw fixation).

Question 4467

Topic: 2. Trauma

Following reduction and screw fixation of a syndesmotic injury in a pronation-external rotation (PER) ankle fracture, the surgeon is concerned about malreduction. Which of the following modalities is the most sensitive and specific for detecting syndesmotic malreduction postoperatively?

. Standard anteroposterior (AP) radiograph
. Standard mortise radiograph
. Gravity stress radiograph
. Computed tomography (CT) scan
. Magnetic resonance imaging (MRI)

Correct Answer & Explanation

. Standard anteroposterior (AP) radiograph

Explanation

Postoperative CT is the gold standard for assessing syndesmotic reduction. Plain radiographs have been shown to be highly insensitive for detecting subtle sagittal plane translation and rotational deformities.

Question 4468

Topic: 2. Trauma
Recent biomechanical and clinical studies regarding the fixation of the posterior malleolus in trimalleolar ankle fractures have shifted the paradigm away from solely using fragment size (>25%) as the primary indication for fixation. What is the primary biomechanical advantage of directly fixing the posterior malleolus?
. It decreases the nonunion rate of the medial malleolus.
. It anatomically restores the posterior incisura, providing superior syndesmotic stability compared to syndesmotic screws alone.
. It negates the need for fixation of the lateral malleolus.
. It prevents impingement of the flexor hallucis longus.
. It significantly reduces the rate of anterior talar translation.

Correct Answer & Explanation

. It anatomically restores the posterior incisura, providing superior syndesmotic stability compared to syndesmotic screws alone.

Explanation

Direct fixation of the posterior malleolus anatomically restores the posterior incisura and the attached posterior inferior tibiofibular ligament (PITFL). This provides greater biomechanical syndesmotic stability than utilizing trans-syndesmotic screws alone.

Question 4469

Topic: 2. Trauma

A 72-year-old female with severe, poorly controlled diabetes mellitus, profound peripheral neuropathy, and a BMI of 38 presents with a closed, highly comminuted unstable ankle fracture. The soft tissues are significantly compromised. Which of the following surgical options offers the most rigid construct and lowest risk of soft tissue failure in this specific high-risk patient?

. Standard open reduction and internal fixation (ORIF) with one-third tubular plate
. Percutaneous pinning of the medial and lateral malleoli
. Primary tibiotalocalcaneal (TTC) retrograde nailing
. Conservative management in a short leg cast
. Spanning external fixation as definitive treatment

Correct Answer & Explanation

. Standard open reduction and internal fixation (ORIF) with one-third tubular plate

Explanation

In severe neuropathic (Charcot-risk) diabetic patients with unstable fractures and poor soft tissue envelopes, primary TTC nailing provides a load-sharing construct that bypasses compromised soft tissues, significantly reducing complication rates.

Question 4470

Topic: 2. Trauma

A 32-year-old male sustains a severe ankle injury. Closed reduction in the emergency department is unsuccessful. Radiographs demonstrate a fracture-dislocation where the proximal fibular fragment is displaced posterior to the posterior tubercle of the distal tibia. Which of the following is the most appropriate management?

. Repeat closed reduction under conscious sedation in the ED
. Application of a spanning external fixator without further reduction attempts
. Immediate open reduction and internal fixation to release the entrapped fibula
. Skeletal traction via a calcaneal pin
. Closed reduction using a skeletal traction table

Correct Answer & Explanation

. Repeat closed reduction under conscious sedation in the ED

Explanation

This describes a Bosworth fracture-dislocation. The proximal fibular fragment becomes locked behind the posterior tubercle of the tibia, rendering closed reduction impossible and necessitating urgent surgical release and open reduction.

Question 4471

Topic: 2. Trauma

A 28-year-old female presents with an ankle fracture following an inversion injury. Radiographs reveal a transverse fracture of the distal fibula below the level of the syndesmosis and a vertical fracture of the medial malleolus. What is the most biomechanically sound fixation strategy for the medial malleolus in this injury pattern?

. Two parallel partially threaded cancellous lag screws
. A tension band wiring construct
. A medial anti-glide plate
. A single fully threaded trans-syndesmotic screw
. A lateral neutralization plate

Correct Answer & Explanation

. Two parallel partially threaded cancellous lag screws

Explanation

This is a Supination-Adduction (SAD) injury. The vertical medial malleolus fracture involves shear forces and is best stabilized biomechanically with an anti-glide plate applied to the medial or anteromedial surface of the tibia to resist vertical displacement.

Question 4472

Topic: 2. Trauma

A surgeon chooses to use a posterolateral anti-glide plate for a Danis-Weber type B lateral malleolus fracture. While biomechanically superior to lateral plating, this technique is most commonly associated with which of the following complications?

. Sural nerve entrapment
. Peroneal tendon irritation
. Nonunion of the fibula
. Tibialis posterior tendon rupture
. Intra-articular screw penetration

Correct Answer & Explanation

. Sural nerve entrapment

Explanation

Posterolateral anti-glide plating provides superior biomechanical stability by resisting the posterior glide of the distal fragment. However, hardware prominence can cause irritation or tenosynovitis of the peroneal tendons.

Question 4473

Topic: 2. Trauma

During pre-operative planning for an ankle fracture, a CT scan reveals a large avulsion fracture of the posterolateral aspect of the distal tibia. This specific fragment, which serves as the attachment site for the posterior inferior tibiofibular ligament (PITFL), is eponymously referred to as:

. Chaput tubercle
. Wagstaffe-Le Fort fragment
. Tillaux fragment
. Volkmann fragment
. Cedell fracture

Correct Answer & Explanation

. Chaput tubercle

Explanation

The Volkmann fragment is the posterolateral aspect of the distal tibia where the PITFL attaches. A fracture here defines a classical posterior malleolar avulsion injury.

Question 4474

Topic: 2. Trauma

A 30-year-old male sustains a twisting injury to his foot. Radiographs demonstrate a transverse fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction, extending into the intermetatarsal articulation (between the 4th and 5th metatarsals). What anatomical feature puts this specific area at high risk for nonunion?

. It is supplied exclusively by multiple metaphyseal arteries.
. It is heavily invested by thick periosteal vessels.
. It relies on a single intramedullary nutrient artery, creating a watershed area.
. It is supplied primarily by branches of the dorsalis pedis artery.
. It is supplied primarily by lateral plantar artery branches entering the tuberosity directly.

Correct Answer & Explanation

. It relies on a single intramedullary nutrient artery, creating a watershed area.

Explanation

This describes a true Jones fracture (Zone II). The base of the 5th metatarsal has a distinct watershed blood supply at the metaphyseal-diaphyseal junction, which relies predominantly on a single retrograde intramedullary nutrient artery. This tenuous blood supply is responsible for the high rates of delayed union and nonunion seen in Jones fractures.

Question 4475

Topic: 2. Trauma

A 22-year-old track athlete presents with an insidious onset of vague dorsal midfoot pain that worsens with sprinting. Examination reveals localized tenderness over the 'N-spot'. Radiographs are negative. MRI confirms a non-displaced stress fracture in the central third of the tarsal navicular. What is the recommended initial treatment?

. Continue running with custom orthotics
. Weight-bearing in a walking boot for 4 weeks
. Strict non-weight-bearing cast immobilization for 6-8 weeks
. Immediate open reduction and internal fixation
. Extracorporeal shock wave therapy

Correct Answer & Explanation

. Strict non-weight-bearing cast immobilization for 6-8 weeks

Explanation

Tarsal navicular stress fractures occur most frequently in the relatively avascular central third of the bone, placing them at high risk for nonunion. The gold standard initial treatment for a non-displaced navicular stress fracture is strict non-weight-bearing cast immobilization for a minimum of 6 to 8 weeks.

Question 4476

Topic: 2. Trauma

A 40-year-old construction worker falls from a ladder and sustains a high-energy, comminuted distal tibia intra-articular fracture (AO/OTA 43-C3) with severe soft tissue swelling, fracture blisters, and shortening. What is the standard of care for the initial management of this injury?

. Immediate single-stage open reduction and internal fixation with dual plating
. Immediate intramedullary nailing of the tibia
. Spanning external fixation and delayed definitive fixation once the soft tissue envelope improves
. Closed reduction and long leg casting for 6 weeks
. Primary ankle arthrodesis

Correct Answer & Explanation

. Spanning external fixation and delayed definitive fixation once the soft tissue envelope improves

Explanation

High-energy pilon fractures are notorious for severe soft tissue compromise. Immediate open reduction and internal fixation carries an unacceptably high risk of wound breakdown and deep infection. The standard 'damage control' approach is the application of a spanning external fixator to restore length and alignment until the soft tissues recover (typically 10-21 days), followed by definitive internal fixation.

Question 4477

Topic: 2. Trauma



A 22-year-old collegiate basketball player sustains a fracture of the proximal fifth metatarsal. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction without distal extension beyond the fourth-fifth intermetatarsal articulation. What is the primary anatomic reason this specific fracture is at high risk for nonunion?

. It involves the insertion of the peroneus brevis tendon.
. It involves the insertion of the lateral band of the plantar fascia.
. It occurs in a vascular watershed area.
. It is an intra-articular fracture involving the cuboid.
. It is subject to continuous distraction forces from the extensor digitorum longus.

Correct Answer & Explanation

. It involves the insertion of the peroneus brevis tendon.

Explanation

A Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal. This area is a vascular watershed zone, supplied retrogradely by the nutrient artery and antegrade by metaphyseal vessels. Because of the tenuous blood supply, these fractures are at high risk for delayed union or nonunion. High-level athletes often undergo early intramedullary screw fixation to expedite healing and return to play.

Question 4478

Topic: 2. Trauma



A 45-year-old male sustains a high-energy, closed tibial pilon fracture. The soft tissues are significantly swollen with fracture blisters present. What is the currently recommended protocol for managing this injury to minimize soft tissue complications?

. Immediate open reduction and internal fixation (ORIF) of the tibia and fibula
. Application of a spanning external fixator, followed by definitive ORIF once soft tissue swelling resolves (typically 10-21 days)
. Immediate intramedullary nailing of the tibia
. Open reduction of the fibula and closed reduction of the tibia in a cast
. Primary ankle arthrodesis

Correct Answer & Explanation

. Immediate open reduction and internal fixation (ORIF) of the tibia and fibula

Explanation

High-energy pilon fractures are associated with profound soft tissue injury. Early ORIF historically led to devastating wound complications and infection (up to 30-50%). The standard of care is a staged approach: immediate spanning external fixation (with or without fibular fixation) to restore length and alignment, allowing the soft tissue envelope to recover (wrinkle sign present, blisters healed) over 10-21 days, followed by definitive tibial ORIF.

Question 4479

Topic: 2. Trauma

A 20-year-old track athlete presents with insidious onset, vague midfoot pain that worsens with sprinting. A CT scan confirms a nondisplaced stress fracture in the central third of the tarsal navicular. What is the most appropriate initial management?

. Continued weight bearing in a rigid sole shoe
. Non-weight bearing in a short leg cast for 6-8 weeks
. Immediate percutaneous screw fixation
. Open bone grafting
. Extracorporeal shock wave therapy

Correct Answer & Explanation

. Continued weight bearing in a rigid sole shoe

Explanation

The central third of the tarsal navicular is a relative avascular zone, predisposing it to stress fractures and nonunion. For acute, nondisplaced navicular stress fractures, strict non-weight bearing in a short leg cast for 6-8 weeks is the gold standard initial treatment, yielding high healing rates. Weight-bearing casts or boots have a higher failure rate.

Question 4480

Topic: 2. Trauma

A 45-year-old male sustains a displaced intra-articular calcaneus fracture.

The surgeon decides to proceed with an extensile lateral approach. To minimize the risk of apical tip necrosis of the lateral soft tissue flap, the surgeon must preserve the primary blood supply to this angiosome. Which artery is responsible for this blood supply?

. Medial calcaneal artery
. Lateral calcaneal artery
. Sural artery
. Dorsalis pedis artery
. Posterior tibial artery

Correct Answer & Explanation

. Medial calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, supplies the lateral skin flap used in an extensile lateral approach. Protecting this vessel by ensuring a subperiosteal dissection and a full-thickness 'no-touch' flap retraction is critical to preventing wound necrosis.

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