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2. Trauma MCQs

Practice Set 241 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 4801

Topic: 2. Trauma

Which of the following is the most absolute indication for operative fixation of a closed patella fracture?

. 2 mm of articular step-off
. Transverse fracture pattern
. Inability to perform a straight leg raise
. Presence of a significant hemarthrosis
. Age greater than 60 years

Correct Answer & Explanation

. Inability to perform a straight leg raise

Explanation

The inability to perform a straight leg raise indicates a disruption of the extensor mechanism, which is an absolute indication for operative repair in patella fractures regardless of the degree of displacement.

Question 4802

Topic: 2. Trauma

A 22-year-old man sustains a closed bilateral femoral shaft fracture. He undergoes reamed intramedullary nailing 12 hours after injury. On post-operative day 2, he develops petechiae, confusion, and hypoxia. What is the primary pathophysiologic mechanism of this syndrome?

. Thrombus embolization from the deep calf veins
. Systemic inflammatory response to intramedullary reaming
. Release of marrow fat droplets into the venous circulation
. Bacterial seeding of the pulmonary vasculature
. Transfusion-related acute lung injury

Correct Answer & Explanation

. Release of marrow fat droplets into the venous circulation

Explanation

Fat Embolism Syndrome (FES) presents with the classic triad of hypoxia, neurologic abnormalities, and a petechial rash. It is caused by the release of marrow fat droplets into the venous circulation during trauma or intramedullary instrumentation.

Question 4803

Topic: 2. Trauma

In the management of posterior wall acetabular fractures, which of the following radiographic findings is an absolute indication for open reduction and internal fixation?

. Fracture involving 10% of the posterior wall
. Intra-articular incarcerated bone fragment
. Gull-sign on the obturator oblique view
. Spur sign on the iliac oblique view
. Medial displacement of the quadrilateral plate

Correct Answer & Explanation

. Intra-articular incarcerated bone fragment

Explanation

An intra-articular incarcerated fragment following reduction of a hip dislocation with a posterior wall fracture is an absolute indication for surgical intervention to prevent rapid joint destruction.

Question 4804

Topic: 2. Trauma
A 35-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). Which of the following fixation constructs provides the most biomechanically stable fixation against vertical shear forces and varus collapse?
. Three cannulated screws in an inverted triangle configuration
. Three cannulated screws in a standard triangle configuration
. A sliding hip screw with a supplemental derotation screw
. A short cephalomedullary nail
. A dynamic condylar screw

Correct Answer & Explanation

. A sliding hip screw with a supplemental derotation screw

Explanation

For unstable, vertically oriented femoral neck fractures (Pauwels type III), a sliding hip screw with a derotation screw offers superior biomechanical stability against vertical shear and varus collapse compared to multiple cancellous screws.

Question 4805

Topic: Lower Extremity Trauma

A 45-year-old male sustains a high-energy Schatzker IV tibial plateau fracture featuring a displaced posteromedial shear fragment. Which surgical approach is most appropriate for direct visualization and buttress plating of this specific fragment?

. Anterolateral approach with submeniscal arthrotomy
. Direct medial approach
. Posteromedial approach between the pes anserinus and the medial head of the gastrocnemius
. Posterolateral approach with fibular osteotomy
. Anterior midline approach with tibial tubercle osteotomy

Correct Answer & Explanation

. Posteromedial approach between the pes anserinus and the medial head of the gastrocnemius

Explanation

The posteromedial approach interval is between the pes anserinus tendons anteriorly and the medial head of the gastrocnemius posteriorly. It allows direct access to posteromedial shear fragments for optimal anti-glide or buttress plating.

Question 4806

Topic: 2. Trauma

A 25-year-old male polytrauma patient sustains a comminuted femoral shaft fracture, bilateral flail chest, and severe pulmonary contusions. His serum lactate is 4.5 mmol/L and pH is 7.21 despite initial fluid resuscitation. What is the most appropriate initial management of the femur fracture?

. Reamed antegrade intramedullary nailing
. Unreamed retrograde intramedullary nailing
. Open reduction and internal fixation with a lateral locking plate
. Application of a spanning external fixator
. Skeletal traction via a proximal tibial pin for definitive management

Correct Answer & Explanation

. Application of a spanning external fixator

Explanation

This patient is physiologically unstable (high lactate, acidosis) and falls into the "borderline" or "in extremis" category. Damage control orthopedics (DCO) with rapid application of a spanning external fixator is indicated to minimize the second hit of systemic inflammation.

Question 4807

Topic: 2. Trauma
A 30-year-old male is involved in a motor vehicle collision and sustains a posterior hip dislocation associated with a femoral head fracture and a posterior wall acetabular fracture. According to the Pipkin classification, what type of injury is this?
. Pipkin Type I
. Pipkin Type II
. Pipkin Type III
. Pipkin Type IV
. Pipkin Type V

Correct Answer & Explanation

. Pipkin Type IV

Explanation

A Pipkin Type IV fracture is defined as a femoral head fracture associated with an acetabular fracture. Type I and II relate to the fovea, while Type III involves an associated femoral neck fracture.

Question 4808

Topic: 2. Trauma

When treating a stable intertrochanteric femur fracture with a sliding hip screw, which of the following radiographic parameters is most strongly predictive of lag screw cut-out?

. A neck-shaft angle greater than 135 degrees
. A tip-apex distance greater than 25 mm
. Placement of the screw in the inferior third of the head on the AP radiograph
. Use of a 4-hole side plate instead of a 2-hole side plate
. Presence of a basicervical fracture pattern

Correct Answer & Explanation

. A tip-apex distance greater than 25 mm

Explanation

The Tip-Apex Distance (TAD) described by Baumgaertner is the most reliable predictor of lag screw cut-out. A TAD greater than 25 mm significantly increases the risk of fixation failure.

Question 4809

Topic: 2. Trauma
A 64-year-old man with a history of diabetes mellitus underwent open reduction and internal fixation of a displaced ankle fracture 8 weeks ago. Examination now reveals recent onset erythema, warmth, and swelling of the midfoot. Radiographs are shown in Figures 23a through 23d. What is the most likely reason for the swelling of the foot?
. Infection
. Charcot arthropathy
. Delayed compartment syndrome
. Deep venous thrombosis
. Gout

Correct Answer & Explanation

. Charcot arthropathy

Explanation

A Charcot flare in adjacent joints is not uncommon in patients with neuropathy who undergo surgery or other trauma. Venous thrombosis would present with swelling of the entire leg, while infection would present earlier in the postoperative period. The radiographs are pathognomonic of Charcot arthropathy, not an unrecognized fracture or gout. A compartment syndrome this late after injury is extremely rare, and there would be no bony distraction associated with compartment syndrome.

Question 4810

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal. He wishes to return to play as soon as safely possible. What is the most appropriate management?

. Non-weight-bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Open reduction and internal fixation with a tension band construct
. Percutaneous intramedullary screw fixation
. Excision of the proximal fragment and advancement of the peroneus brevis

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

Elite athletes with acute Jones (Zone 2) fractures are best treated with intramedullary screw fixation to minimize nonunion risk and expedite return to play. Non-operative management carries a high rate of delayed union or nonunion in this population.

Question 4811

Topic: 2. Trauma

A 20-year-old elite basketball player presents with lateral foot pain after an inversion injury. Radiographs reveal a fracture pattern identical to the one shown.

The fracture is transverse at the metaphyseal-diaphyseal junction extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management to ensure rapid return to play?

. Short leg walking cast for 6 weeks
. Hard-soled shoe with immediate weight bearing as tolerated
. Closed reduction and percutaneous pinning
. Intramedullary screw fixation
. Excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This is a Zone 2 (Jones) fracture, which has a high risk of delayed union or nonunion due to a watershed blood supply. In elite athletes, early intramedullary screw fixation is the standard of care to minimize nonunion risk and expedite return to play.

Question 4812

Topic: 2. Trauma
A 19-year-old man was struck by a car and is seen in the emergency department with a grade IIIC open distal tibia and fibula fracture. Examination reveals that the toes are cool and dusky with a sluggish capillary refill. Angiography reveals a lesion in the posterior tibial artery amenable to repair. There is no sensation on the plantar aspect of the foot, and he is unable to flex his toes. A clinical photograph and radiograph are shown in Figures 2a and 2b. What is the next most appropriate step in management?
. Irrigation and debridement with immediate intramedullary fixation, vascular repair, and primary closure
. Irrigation and debridement with external fixation, vascular repair, and delayed closure
. Irrigation and debridement with external fixation, vascular repair, exploration of the tibial nerve, and delayed closure
. Guillotine amputation at the fracture site with delayed closure
. Immediate below-knee amputation

Correct Answer & Explanation

. Irrigation and debridement with external fixation, vascular repair, and delayed closure

Explanation

In the past, loss of plantar sensation in this grade IIIC tibial fracture would have been an indication for below-knee amputation regardless of the potential for vascular repair. However, the 2002 LEAP study divided 55 patients with loss of plantar sensation into two groups, the insensate amputation group and the insensate limb salvage group, with 55% of patients in the insensate salvage group regaining normal sensation 2 years after injury. Furthermore, those in the salvage group who remained insensate after 2 years had equivalent outcomes to those in the amputation group. Because of these findings, limb salvage with vascular repair and external stabilization with delayed closure is deemed appropriate treatment. Immediate intramedullary fixation is not indicated. Because ischemia, contusion, and stretch can adversely affect the tibial nerve, the additional insult of exploration of the nerve is also not advisable given the soft-tissue compromise.

Question 4813

Topic: 2. Trauma
A 26-year-old woman is seen in the emergency department with an intra-articular distal tibia fracture and a fibular fracture (pilon). The patient, her husband, and three small children have recently immigrated to the United States from Mexico. The husband and wife have both been in a migrant labor camp but have no immediate relatives in the States. What factor is most important when considering her recommended care and treatment?
. It may be difficult to obtain informed consent, even with an interpreter.
. The husband may be unwilling to allow his wife to have the appropriate surgery.
. Associated comorbidities in the patient increase the risk of surgical intervention.
. There is the potential of not being able to obtain a satisfactory CT scan because of claustrophobia.
. Postsurgical care may be jeopardized by the patientโ€™s role as caretaker for her children, thus compromising her ability to comply with weight-bearing restrictions.

Correct Answer & Explanation

. Postsurgical care may be jeopardized by the patientโ€™s role as caretaker for her children, thus compromising her ability to comply with weight-bearing restrictions.

Explanation

With documented use of a competent interpreter, informed consent should not be an issue. In Hispanic families, the husband often makes the ultimate decision regarding proceeding with surgery; however, he would not be expected to withhold recommended treatment. Hispanics may have a higher risk of comorbidities, but you do not expect this to be a significant concern with this patient. Claustrophobia and some fear of the unfamiliar may make additional imaging studies more difficult to arrange, but not impossible. The real concern is that with no extended family and three small children, the postoperative demand on the patient could significantly jeopardize her ability to comply with weight-bearing restrictions and overall ambulatory demands. Discharge planning and appropriate help may be paramount for a good outcome.

Question 4814

Topic: 2. Trauma

A 28-year-old male sustains a closed, distal-third spiral fracture of the humerus. On initial exam, he has full wrist and finger extension. Following a closed reduction and splint application, he is unable to extend his wrist or fingers. What is the most appropriate next step in management?

. Immediate surgical exploration and nerve release
. Observation and follow-up in 1 to 2 weeks
. MRI of the humerus to evaluate the nerve
. Electromyography (EMG) testing
. Administration of systemic corticosteroids

Correct Answer & Explanation

. Immediate surgical exploration and nerve release

Explanation

A secondary radial nerve palsy that develops immediately after a closed reduction of a humeral shaft fracture is an absolute indication for surgical exploration. This is due to the high risk of the nerve being entrapped within the fracture fragments during the reduction maneuver.

Question 4815

Topic: 2. Trauma
A 35-year-old female sustains a severe pelvic crush injury resulting in spinopelvic dissociation (U-type sacral fracture). On examination, she has profound weakness of the gastrocnemius-soleus complex and loss of perianal sensation. Which of the following nerve root levels is most likely directly compromised by the fracture pattern?
. L3-L4
. L4-L5
. L5-S1
. S1-S3
. S4-S5

Correct Answer & Explanation

. L5-S1

Explanation

Spinopelvic dissociation often involves Denis Zone III sacral fractures, which frequently injure the S1-S3 nerve roots. Compromise of these roots leads to plantarflexion weakness (S1, S2), loss of bowel/bladder control, and perianal numbness (S2-S4).

Question 4816

Topic: 2. Trauma

A 32-year-old woman sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). Neurological examination prior to manipulation is fully intact. Immediately following closed reduction and splinting, she exhibits complete loss of wrist and finger extension and numbness in the first dorsal web space. What is the most appropriate next step in management?

. Observation and repeat EMG at 6 weeks
. Immediate surgical exploration
. Loosening of the splint and clinical follow-up in 1 week
. MRI of the upper extremity
. Intra-articular corticosteroid injection

Correct Answer & Explanation

. Immediate surgical exploration

Explanation

A radial nerve palsy that appears immediately after a closed reduction of a humeral shaft fracture requires immediate surgical exploration. The nerve is at high risk of being entrapped within the fracture site.

Question 4817

Topic: 2. Trauma

A 75-year-old man presents with neck pain after a minor fall and is diagnosed with a Type II odontoid fracture. Non-operative management with a cervical orthosis is being considered. Which of the following represents the strongest independent risk factor for nonunion in this scenario?

. Initial fracture displacement greater than 5 mm
. Anterior angulation of the fracture
. Age younger than 50 years
. Presence of a concurrent C1 arch fracture
. Male sex

Correct Answer & Explanation

. Initial fracture displacement greater than 5 mm

Explanation

The two most significant risk factors for nonunion in Type II odontoid fractures treated non-operatively are initial fracture displacement > 5 mm and patient age > 50 years.

Question 4818

Topic: 2. Trauma
A 30-year-old man sustains a completely displaced, vertically oriented femoral neck fracture (Pauwels Type III) following a high-energy fall. Surgical fixation is planned to preserve the native hip joint. Biomechanically, which of the following constructs provides the highest resistance to shear forces for this specific fracture pattern?
. Three parallel 7.3 mm partially threaded cancellous screws
. A sliding hip screw (SHS) with a supplemental derotation screw
. Two crossed cancellous screws
. A standard cephalomedullary nail
. An intramedullary hip screw without supplemental fixation

Correct Answer & Explanation

. A sliding hip screw (SHS) with a supplemental derotation screw

Explanation

Pauwels Type III fractures have high vertical shear angles. A sliding hip screw coupled with a derotation screw has been shown biomechanically to provide superior stability against vertical shear forces compared to multiple parallel cancellous screws.

Question 4819

Topic: 2. Trauma

A 25-year-old man sustains a severely comminuted, closed tibial shaft fracture. Two hours later, he complains of severe leg pain out of proportion to the injury. An intracompartmental pressure monitor is placed. What absolute tissue pressure threshold is classically cited as an indication for immediate four-compartment fasciotomy?

. Absolute pressure > 10 mm Hg
. Absolute pressure > 20 mm Hg
. Absolute pressure > 30 mm Hg
. Delta pressure > 40 mm Hg
. Delta pressure > 10 mm Hg

Correct Answer & Explanation

. Absolute pressure > 30 mm Hg

Explanation

An absolute compartment pressure greater than 30 mm Hg is classically considered the threshold for performing a fasciotomy to prevent ischemic muscle necrosis. Alternatively, a delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mm Hg is also widely used.

Question 4820

Topic: 2. Trauma

Which of the following is considered the most significant risk factor for nonunion of an Anderson-D'Alonzo Type II odontoid fracture treated with halo vest immobilization?

. Age greater than 40 years
. Anterior displacement of 3 mm
. Initial fracture displacement greater than 5 mm
. Concomitant C1 ring fracture
. Treatment delay of 3 days

Correct Answer & Explanation

. Initial fracture displacement greater than 5 mm

Explanation

The most significant risk factors for nonunion of a Type II odontoid fracture include initial displacement greater than 5 mm, angulation greater than 10 degrees, and advanced age (typically >50 years). Displacement >5 mm can lead to nonunion rates as high as 80% with nonoperative management.

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