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2. Trauma MCQs

Practice Set 257 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 5121

Topic: 2. Trauma

A 40-year-old male presents with a posteromedial shear fracture of the tibial plateau (Schatzker IV). Which surgical approach is most appropriate for direct visualization and buttress plating of this specific fragment?

. Anterolateral approach
. Direct lateral approach
. Posteromedial approach
. Anteromedial approach
. Direct posterior approach

Correct Answer & Explanation

. Posteromedial approach

Explanation

Posteromedial tibial plateau fractures require a posteromedial approach between the pes anserinus and the medial head of the gastrocnemius. This allows for biomechanically superior anti-glide or buttress plating of the posteromedial fragment.

Question 5122

Topic: Pelvic & Acetabular Trauma

A 32-year-old female presents with an anteroposterior compression (APC) type II pelvic ring injury following a crush accident. Which specific ligamentous structures are completely disrupted in an APC-II injury compared to an APC-I injury?

. Anterior sacroiliac, sacrotuberous, and sacrospinous ligaments
. Posterior sacroiliac and iliolumbar ligaments
. Iliolumbar and sacrotuberous ligaments only
. Anterior and posterior sacroiliac ligaments
. Sacrospinous ligament only

Correct Answer & Explanation

. Anterior sacroiliac, sacrotuberous, and sacrospinous ligaments

Explanation

According to the Young-Burgess classification, an APC-II injury involves symphyseal diastasis with disruption of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. This results in rotational instability while maintaining vertical stability since the posterior SI ligaments remain intact.

Question 5123

Topic: 2. Trauma

A 28-year-old male sustains a transverse subtrochanteric femur fracture. Which muscle group is primarily responsible for the characteristic flexion and external rotation deformity of the proximal fragment?

. Gluteus medius and piriformis
. Iliopsoas and short external rotators
. Adductor magnus and gracilis
. Rectus femoris and sartorius
. Gluteus maximus and tensor fasciae latae

Correct Answer & Explanation

. Iliopsoas and short external rotators

Explanation

The proximal fragment in a subtrochanteric fracture is characteristically flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the short external rotators.

Question 5124

Topic: 2. Trauma
A 35-year-old farmer sustains a severe open tibia fracture (Gustilo-Anderson Type IIIA) contaminated with soil and farm debris. According to current guidelines, which of the following antibiotic regimens is most appropriate for initial management?
. First-generation cephalosporin only
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin and high-dose penicillin
. Third-generation cephalosporin and a fluoroquinolone
. Vancomycin and metronidazole

Correct Answer & Explanation

. First-generation cephalosporin and high-dose penicillin

Explanation

For open fractures heavily contaminated with farm soil or displaying gross crush injury, high-dose penicillin should be added to the standard regimen (a first-generation cephalosporin and/or aminoglycoside) to cover for Clostridium species.

Question 5125

Topic: Upper Extremity Trauma

A 50-year-old weightlifter presents with an inability to actively extend his elbow against gravity following a sudden pop. MRI shows a complete avulsion of the triceps tendon from the olecranon. During surgical repair, an anatomic reattachment is planned. Where is the true anatomic footprint of the triceps tendon located on the olecranon?

. Directly at the proximal tip of the olecranon process
. Approximately 1-2 cm distal to the tip on the posterior surface
. 3 cm distal to the tip on the lateral border
. Intra-articularly along the sublime tubercle
. Medial to the ulnar nerve groove

Correct Answer & Explanation

. Approximately 1-2 cm distal to the tip on the posterior surface

Explanation

The triceps footprint is located approximately 1 to 2 cm distal to the very tip of the olecranon on the posterior surface. Reattaching it too proximally (at the very tip) can cause mechanical impingement in the olecranon fossa during extension, leading to a loss of full terminal extension.

Question 5126

Topic: Upper Extremity Trauma
A 26-year-old cyclist falls directly onto his right shoulder. Radiographs reveal superior displacement of the distal clavicle. The axillary view clearly demonstrates the distal clavicle displaced posteriorly into the trapezius muscle fascia. What is the Rockwood classification of this acromioclavicular injury?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

Rockwood classification: Type I (sprain), Type II (AC torn, CC sprained), Type III (AC and CC torn, clavicle superiorly displaced up to 100%), Type IV (clavicle displaced posteriorly into or through the trapezius muscle), Type V (clavicle displaced superiorly >100-300%), Type VI (clavicle displaced inferiorly under the coracoid or acromion). The posterior displacement into the trapezius defines a Type IV injury.

Question 5127

Topic: Upper Extremity Trauma

A 50-year-old weightlifter with recalcitrant, isolated acromioclavicular (AC) joint osteoarthritis is undergoing an arthroscopic distal clavicle excision. To prevent postoperative iatrogenic anteroposterior instability of the clavicle, the surgeon must be careful to preserve which of the following structures during the resection?

. The superior and posterior AC capsular ligaments
. The conoid ligament
. The trapezoid ligament
. The coracoacromial ligament
. The coracoclavicular fascia

Correct Answer & Explanation

. The superior and posterior AC capsular ligaments

Explanation

During a distal clavicle excision (Mumford procedure), it is crucial to resect an adequate amount of bone to prevent impingement (usually 5-8 mm) but not so much that the stabilizing ligaments are compromised. The superior and posterior AC ligaments are the primary restraints to anteroposterior translation of the distal clavicle. Excessive resection (>10-15 mm) risks disrupting these capsular ligaments, leading to AP instability. The coracoclavicular (conoid and trapezoid) ligaments prevent superior translation and are located further medially.

Question 5128

Topic: 2. Trauma

When performing a shoulder hemiarthroplasty for a complex 4-part proximal humerus fracture, what factor is the strongest predictor of a successful functional outcome?

. Retroversion of the humeral stem at exactly 40 degrees
. Restoration of humeral length
. Anatomic healing of the greater and lesser tuberosities
. The use of a press-fit rather than a cemented stem
. Excision of the coracoacromial ligament

Correct Answer & Explanation

. Anatomic healing of the greater and lesser tuberosities

Explanation

Functional outcomes following hemiarthroplasty for proximal humerus fractures depend almost exclusively on the anatomic reduction and stable healing of the tuberosities to the shaft and the prosthesis. Failure of tuberosity healing leads to profound weakness and loss of active elevation.

Question 5129

Topic: 2. Trauma

A 78-year-old female presents after a ground-level fall. CT scan reveals a displaced Anderson and D'Alonzo Type II odontoid fracture with 6 mm of posterior translation. She is neurologically intact. Which of the following factors is most strongly associated with a high rate of nonunion for this fracture type if managed conservatively with a rigid collar?

. Age older than 50 years
. Anterior displacement rather than posterior
. Fracture gap of less than 1 mm
. A concurrent C2 pars fracture
. Associated non-displaced C1 arch fracture

Correct Answer & Explanation

. Age older than 50 years

Explanation

Type II odontoid fractures have a notoriously high rate of nonunion due to poor local vascularity at the base of the dens. Major risk factors for nonunion include patient age older than 50 years, initial displacement > 5 mm, posterior displacement (more so than anterior), and a fracture gap > 1 mm. Given her age and displacement, conservative management has a very high failure rate.

Question 5130

Topic: 2. Trauma

An 82-year-old female presents with neck pain following a ground-level fall. Imaging reveals a Type II odontoid fracture with 6 mm of posterior displacement. She is neurologically intact but has significant medical comorbidities. Which of the following factors is the strongest predictor of nonunion if this patient is managed conservatively with a hard collar?

. Direction of fracture angulation
. Initial fracture displacement greater than 5 mm
. The patient's gender
. Concurrent C1 arch fracture
. Presence of osteoporosis

Correct Answer & Explanation

. Initial fracture displacement greater than 5 mm

Explanation

In Type II odontoid fractures, an initial displacement of greater than 5 mm and age greater than 50 years are the most significant risk factors for nonunion. Consequently, surgical stabilization is often favored in these patients despite advanced age, provided they can tolerate surgery.

Question 5131

Topic: 2. Trauma

A 72-year-old male presents with a Type II odontoid fracture following a ground-level fall. He is being considered for nonoperative management in a hard cervical collar. Which of the following fracture characteristics is most strongly associated with an increased risk of nonunion in this scenario?

. Anterior displacement of 3 mm
. Initial fracture displacement greater than 5 mm
. Impacted fracture pattern
. Concomitant C1 ring fracture
. Fracture angulation of 5 degrees

Correct Answer & Explanation

. Initial fracture displacement greater than 5 mm

Explanation

Risk factors for nonunion of Type II odontoid fractures include initial displacement > 5 mm, angulation > 10 degrees, age > 65 years, and delayed treatment. Displacement > 5 mm significantly decreases the vascularity and cortical contact needed for healing.

Question 5132

Topic: 2. Trauma
A 45-year-old roofer falls 15 feet and sustains a closed Sanders Type III calcaneus fracture. According to the Canadian Orthopaedic Trauma Society (COTS) multicenter randomized trial comparing operative versus nonoperative management of displaced intra-articular calcaneus fractures, which patient subgroup demonstrated significantly better outcomes with operative treatment?
. Women, and patients not receiving worker's compensation
. Men older than 50 years with heavy manual labor occupations
. Patients receiving worker's compensation, regardless of gender
. Smokers with bilateral fracture patterns
. Patients with an initial Böhler's angle less than 0 degrees

Correct Answer & Explanation

. Women, and patients not receiving worker's compensation

Explanation

The landmark COTS trial (Buckley et al.) demonstrated that while overall functional outcomes were not significantly different between the operative and nonoperative groups as a whole, specific subgroups had significantly better outcomes with ORIF. These subgroups included women, younger patients, patients with a higher initial Böhler's angle, and patients who were not receiving worker's compensation.

Question 5133

Topic: 2. Trauma

A 45-year-old male sustains a high-energy closed OTA/AO 43-C3 pilon fracture. A staged protocol (spanning external fixation followed by definitive ORIF) is selected. What is the most critical clinical indicator guiding the safe timing of definitive open reduction and internal fixation?

. Appearance of the "wrinkle sign" on the anterior ankle skin
. Resolution of all fracture blisters, including clear and hemorrhagic
. A strict 14-day timeline post-injury, regardless of swelling
. Normalization of systemic inflammatory markers (CRP and ESR)
. Formation of visible soft callus on plain radiographs

Correct Answer & Explanation

. Appearance of the "wrinkle sign" on the anterior ankle skin

Explanation

Soft tissue condition strictly dictates the timing of definitive fixation in pilon fractures to minimize catastrophic wound complications. The appearance of skin wrinkles (the "wrinkle sign") indicates that soft-tissue edema has subsided sufficiently to allow surgical incisions to be closed without excessive tension.

Question 5134

Topic: 2. Trauma

A 20-year-old track athlete complains of vague dorsal midfoot pain over the last 3 months. A CT scan confirms a non-displaced stress fracture through the central third of the tarsal navicular. What is the recommended initial management?

. Strict non-weight-bearing in a short leg cast for 6 to 8 weeks
. Protected weight-bearing in a controlled ankle motion (CAM) boot for 4 weeks
. Immediate operative intervention with a percutaneous lag screw
. Extracorporeal shockwave therapy and immediate return to running
. Platelet-rich plasma (PRP) injection and aggressive physical therapy

Correct Answer & Explanation

. Strict non-weight-bearing in a short leg cast for 6 to 8 weeks

Explanation

Non-displaced navicular stress fractures are typically treated with strict non-weight-bearing in a short leg cast for 6-8 weeks. The central third of the navicular is relatively avascular (a vascular watershed area), making these fractures highly prone to nonunion or delayed union if weight-bearing is allowed early.

Question 5135

Topic: 2. Trauma
A 30-year-old male sustains a Gustilo-Anderson Grade IIIA open tibial shaft fracture. Based on the results of the Fluid Lavage of Open Wounds (FLOW) trial, which of the following irrigation strategies is recommended during the initial surgical debridement?
. High-pressure pulsatile lavage with normal saline
. Low-pressure gravity flow with normal saline
. High-pressure pulsatile lavage with castile soap
. Low-pressure gravity flow with bacitracin solution
. High-pressure pulsatile lavage with chlorhexidine solution

Correct Answer & Explanation

. Low-pressure gravity flow with normal saline

Explanation

The FLOW trial demonstrated that low-pressure irrigation is an acceptable, cost-effective alternative to high-pressure lavage, and that there was no benefit to using castile soap compared to normal saline. Low-pressure normal saline resulted in a lower reoperation rate for infection or wound healing problems compared to high-pressure lavage.

Question 5136

Topic: 2. Trauma

A 25-year-old male presents with a closed, highly displaced tibial shaft fracture. Continuous compartment pressure monitoring reveals an absolute pressure of 35 mmHg in the anterior compartment. His current blood pressure is 115/80 mmHg. The patient is awake, alert, and reports moderate pain that is adequately controlled with oral analgesics. What is the most appropriate next step in management?

. Immediate four-compartment fasciotomy in the operating room
. Continuous clinical observation and pressure monitoring
. Administering intravenous mannitol and elevating the leg above the heart
. Bivalving the splint and discharging the patient with close follow-up
. Application of a circular external fixator immediately

Correct Answer & Explanation

. Continuous clinical observation and pressure monitoring

Explanation

Acute compartment syndrome diagnosis via monitoring is based on the delta pressure (Diastolic BP - Compartment Pressure). A delta pressure of < 30 mmHg is the accepted threshold for fasciotomy. Here, the delta pressure is 80 - 35 = 45 mmHg. Because delta pressure is > 30 mmHg and clinical signs do not indicate definitive ACS (pain is well-controlled), continued observation and monitoring are indicated.

Question 5137

Topic: 2. Trauma
A 28-year-old female sustains a vertically oriented (Pauwels Type III) femoral neck fracture following a high-energy trauma. ORIF with a sliding hip screw and a derotational screw is planned. Biomechanically, what is the primary mode of construct failure for this specific fracture pattern?
. Varus collapse with superior screw cut-out
. Inferior screw cut-out into the calcar
. Fracture propagation through the greater trochanter
. Anterior translation of the femoral head
. Valgus impaction with subsequent avascular necrosis

Correct Answer & Explanation

. Varus collapse with superior screw cut-out

Explanation

Pauwels Type III femoral neck fractures have a vertical fracture line (angle > 50 degrees). Biomechanically, they experience massive shear forces rather than compressive forces. The primary mode of failure is varus collapse and subsequent superior cut-out of the internal fixation construct.

Question 5138

Topic: Pelvic & Acetabular Trauma

A 45-year-old pedestrian struck by a car presents with a hemodynamically stable APC-II (Anteroposterior Compression Type II) pelvic ring injury. Radiographs show a 3 cm pubic symphysis diastasis and widening of the anterior sacroiliac joints. According to the Young-Burgess classification, which of the following ligaments remains intact, preventing vertical instability?

. Anterior sacroiliac ligament
. Sacrotuberous ligament
. Sacrospinous ligament
. Posterior sacroiliac ligament
. Symphyseal ligament

Correct Answer & Explanation

. Posterior sacroiliac ligament

Explanation

In an APC-II injury, the pubic symphysis, anterior sacroiliac ligaments, sacrotuberous, and sacrospinous ligaments are disrupted. The posterior sacroiliac ligaments remain intact. This allows the hemipelvis to externally rotate (rotational instability or "open book") but prevents cranial migration (maintains vertical stability).

Question 5139

Topic: Lower Extremity Trauma

A 24-year-old skier presents with acute lateral ankle pain and a snapping sensation posterior to the fibula after an inversion and forced dorsiflexion injury. Radiographs reveal a "fleck sign" adjacent to the lateral malleolus. Injury to which anatomic structure is most strongly indicated by this radiographic finding?

. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Calcaneofibular ligament
. Anterior talofibular ligament
. Peroneus brevis tendon

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The "fleck sign" represents a bony avulsion from the posterolateral ridge of the fibula, which is the attachment site of the superior peroneal retinaculum (SPR). Injury to the SPR is the hallmark of peroneal tendon subluxation or dislocation.

Question 5140

Topic: 2. Trauma

A horseback rider falls and catches their foot in the stirrup, causing forced plantarflexion and abduction of the forefoot. They sustain a comminuted "nutcracker" fracture of the cuboid. What is the primary biomechanical goal of operative treatment (e.g., ORIF and bone grafting) for this specific injury?

. Restoration of lateral column length
. Primary arthrodesis of the calcaneocuboid joint
. Resection of the distal tip of the fibula
. Release and tenodesis of the peroneus longus tendon
. Rigid internal fixation of the medial column

Correct Answer & Explanation

. Restoration of lateral column length

Explanation

A "nutcracker" fracture of the cuboid is a compression/crush injury resulting in severe shortening of the lateral column of the foot. The primary goal of operative management is to restore lateral column length and maintain alignment of the midfoot, often requiring a bridging plate and structural bone graft.

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