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2. Trauma MCQs

Practice Set 258 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 5141

Topic: 2. Trauma
A 22-year-old farmer sustains an open tibial shaft fracture after his leg is caught in a tractor power take-off. The wound is 12 cm long with extensive muscle crushing, but pulses are intact (Gustilo-Anderson IIIA). The wound is heavily contaminated with soil and manure. In addition to a first-generation cephalosporin and an aminoglycoside, what prophylactic antibiotic should be strongly considered in this specific environment?
. High-dose Penicillin
. Vancomycin
. Clindamycin
. Doxycycline
. Metronidazole

Correct Answer & Explanation

. High-dose Penicillin

Explanation

In agricultural injuries or wounds heavily contaminated with soil, there is a significantly increased risk of anaerobic infections, specifically Clostridium perfringens, which can cause devastating gas gangrene. High-dose Penicillin (or Ampicillin) is classically added to the standard antibiotic regimen (Cephalosporin + Aminoglycoside) to provide coverage against these anaerobes.

Question 5142

Topic: 2. Trauma

A 22-year-old track athlete is diagnosed with a stress fracture of the navicular. This is considered a 'high-risk' stress fracture primarily due to a relative avascular zone located in which anatomic region of the navicular?

. The medial tuberosity
. The dorsal cortex of the distal articular surface
. The central third of the body
. The plantar surface near the spring ligament attachment
. The lateral pole articulating with the cuboid

Correct Answer & Explanation

. The central third of the body

Explanation

The navicular is prone to stress fractures, particularly in jumping and sprinting athletes. It is considered a high-risk stress fracture (high risk of delayed union or nonunion) due to a watershed area of poor blood supply in the central third of the navicular body. Blood vessels enter the navicular medially and laterally, leaving the central portion relatively avascular.

Question 5143

Topic: 2. Trauma

A 45-year-old female sustains a Bosworth fracture-dislocation of the ankle. Standard closed reduction attempts in the emergency department are unsuccessful. This irreducibility is due to the proximal fibular fragment becoming entrapped behind which anatomic structure?

. The medial malleolus
. The anterior tubercle of the tibia (Chaput tubercle)
. The posterior tubercle of the tibia
. The talar neck
. The calcaneofibular ligament

Correct Answer & Explanation

. The posterior tubercle of the tibia

Explanation

A Bosworth fracture-dislocation is a rare injury characterized by an irreducible fracture-dislocation of the ankle where the proximal fragment of the fractured fibula displaces posteriorly and becomes mechanically locked behind the posterior tubercle of the distal tibia. Closed reduction is typically impossible, necessitating emergent open reduction.

Question 5144

Topic: 2. Trauma

A 20-year-old collegiate basketball player presents with lateral foot pain. Radiographs reveal a non-displaced fracture of the proximal fifth metatarsal diaphysis, distal to the fourth and fifth metatarsal articulation (Zone 3). What is the recommended primary treatment to ensure optimal return to play?

. A short leg cast with non-weight bearing for 6 weeks
. A hard-soled shoe with full weight-bearing as tolerated
. Intramedullary screw fixation
. Excision of the proximal fragment and peroneus brevis advancement
. Open reduction with a lateral locking plate

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

The patient has a Zone 3 fracture of the fifth metatarsal, which is a stress fracture of the proximal diaphysis. These fractures have a high rate of nonunion due to poor blood supply. In an elite athlete, early surgical intervention with intramedullary screw fixation is highly recommended to decrease the risk of nonunion and expedite return to sport. Zone 1 fractures (pseudo-Jones/tuberosity) are treated symptomatically; Zone 2 (Jones) fractures occur at the metaphyseal-diaphyseal junction and can be treated non-operatively in non-athletes, but athletes often undergo IM screw fixation as well.

Question 5145

Topic: 2. Trauma

A 35-year-old male sustains a high-energy Type C tibial pilon fracture. He is initially placed in a spanning external fixator. Which of the following is the most reliable clinical indicator that the soft tissue envelope has recovered sufficiently to proceed with definitive open reduction and internal fixation?

. Reduction of the ESR to less than 20 mm/hr
. The presence of epithelializing skin wrinkles over the fracture site
. Formation of a fracture callus on plain radiographs
. Negative blood cultures at 48 hours
. Resolution of fracture blisters to reveal a red, moist base

Correct Answer & Explanation

. The presence of epithelializing skin wrinkles over the fracture site

Explanation

Timing of definitive surgery for pilon fractures is dictated by the status of the soft tissue envelope to avoid catastrophic wound complications. The most reliable clinical sign that the swelling has subsided adequately is the return of normal skin creases, often assessed by the 'wrinkle test' (epithelializing skin wrinkles). This typically takes 10 to 21 days.

Question 5146

Topic: 2. Trauma

An 8-week postoperative AP radiograph of an ankle after open reduction and internal fixation of a Hawkins Type II talar neck fracture reveals a subchondral radiolucent band in the dome of the talus. This radiographic finding (Hawkins sign) is indicative of which of the following processes?

. Imminent collapse of the talar dome due to avascular necrosis
. Intact vascular supply and active subchondral bone resorption
. Septic arthritis of the ankle joint
. Nonunion of the talar neck fracture
. Post-traumatic osteoarthritis of the subtalar joint

Correct Answer & Explanation

. Intact vascular supply and active subchondral bone resorption

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the dome of the talus on an AP or mortise ankle radiograph, typically visible 6 to 8 weeks after a talar neck fracture. It represents subchondral osteopenia/resorption due to disuse. Because bone resorption requires an active blood supply, the presence of a Hawkins sign is a highly reliable indicator that the talar body retains sufficient vascularity and that avascular necrosis is unlikely to occur.

Question 5147

Topic: 2. Trauma

A 32-year-old male sustains a Hawkins Type II talar neck fracture. At his 8-week follow-up, an AP radiograph of the ankle reveals a subchondral radiolucent band in the dome of the talus (Hawkins sign). What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Revascularization of the talar body
. Intact vascularity of the talar body
. Impending subchondral collapse
. Nonunion of the talar neck

Correct Answer & Explanation

. Intact vascularity of the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band seen in the talar dome on an AP or mortise radiograph 6 to 8 weeks after a talar neck fracture. It represents subchondral atrophy from disuse in the presence of an intact blood supply, thereby indicating intact vascularity and serving as a reliable negative predictor of avascular necrosis.

Question 5148

Topic: Lower Extremity Trauma

When evaluating a patient for a suspected syndesmotic injury on standard ankle radiographs, which of the following parameters is the most accurate radiographic indicator of syndesmosis widening on an AP view?

. Tibiofibular overlap less than 10 mm
. Tibiofibular clear space greater than 5 mm
. Medial clear space greater than 4 mm
. Talar tilt greater than 5 degrees
. Talocrural angle less than 75 degrees

Correct Answer & Explanation

. Tibiofibular clear space greater than 5 mm

Explanation

The tibiofibular clear space is measured 1 cm proximal to the joint line. A distance of >5 mm on the AP or mortise view is considered abnormal and is the most reliable radiographic indicator of syndesmotic injury. Tibiofibular overlap is highly dependent on rotation and is therefore less reliable.

Question 5149

Topic: 2. Trauma

In the context of a pilon fracture, the anterior inferior tibiofibular ligament (AITFL) remains attached to which of the following specific fracture fragments?

. Volkmann fragment
. Chaput fragment
. Wagstaffe fragment
. Earle's fragment
. Die-punch fragment

Correct Answer & Explanation

. Chaput fragment

Explanation

The Chaput (or Tillaux-Chaput) fragment is the anterolateral tibial fragment to which the anterior inferior tibiofibular ligament (AITFL) attaches. The Wagstaffe (or Le Fort-Wagstaffe) fragment is the anteromedial fibular avulsion of the AITFL. The Volkmann fragment is the posterolateral tibial fragment where the PITFL attaches.

Question 5150

Topic: 2. Trauma

A 40-year-old male sustains an irreducible ankle fracture-dislocation. Radiographs show a fibula fracture with the proximal fibular fragment entrapped behind the posterior tubercle of the distal tibia. What is this specific injury pattern named?

. Maisonneuve fracture
. Tillaux fracture
. Bosworth fracture-dislocation
. Cotton fracture
. Dupuytren fracture

Correct Answer & Explanation

. Bosworth fracture-dislocation

Explanation

A Bosworth fracture-dislocation is a rare injury where the proximal fibular shaft fragment displaces posteriorly and becomes mechanically entrapped behind the posterior tubercle of the tibia. This typically requires open reduction because closed reduction is blocked by the intact interosseous membrane and the bony anatomy of the posterolateral tibia.

Question 5151

Topic: 2. Trauma

A 22-year-old elite basketball player sustains a fracture of the fifth metatarsal. Radiographs show a transverse fracture extending into the intermetatarsal articulation between the 4th and 5th metatarsals. What is the most appropriate initial management for this specific injury to ensure the fastest return to play and lowest nonunion rate?

. Non-weight bearing in a short leg cast for 6-8 weeks
. Immediate intramedullary screw fixation
. Weight-bearing as tolerated in a hard-soled shoe
. Open reduction and tension band wiring
. Plate and screw fixation

Correct Answer & Explanation

. Immediate intramedullary screw fixation

Explanation

This describes a true Jones fracture (Zone 2), which involves the metaphyseal-diaphyseal junction and extends into the 4th-5th intermetatarsal facet. Due to the watershed blood supply in this region, there is a high risk of nonunion. In elite or competitive athletes, early intramedullary screw fixation is recommended to decrease the time to return to play and reduce the nonunion risk compared to conservative management.

Question 5152

Topic: 2. Trauma
According to the Lauge-Hansen classification, a Supination-External Rotation (SER) stage II ankle injury is characterized by which of the following?
. Rupture of the anterior inferior tibiofibular ligament (AITFL)
. Spiral fracture of the distal fibula
. Rupture of the posterior inferior tibiofibular ligament (PITFL) or posterior malleolus fracture
. Transverse fracture of the medial malleolus
. Vertical fracture of the medial malleolus

Correct Answer & Explanation

. Transverse fracture of the medial malleolus

Explanation

In the Lauge-Hansen Supination-External Rotation (SER) classification: Stage I is injury to the AITFL; Stage II is a spiral or short oblique fracture of the distal fibula (posteroinferior to anterosuperior); Stage III is injury to the PITFL or a posterior malleolus fracture; Stage IV is a transverse fracture of the medial malleolus or deltoid ligament rupture.

Question 5153

Topic: 2. Trauma

When performing fasciotomies for acute compartment syndrome of the foot using a combined dorsal and medial approach, the surgeon must access the calcaneal compartment. Which of the following muscles is uniquely located within the calcaneal compartment?

. Abductor hallucis
. Flexor digitorum brevis
. Quadratus plantae
. Adductor hallucis
. Flexor hallucis brevis

Correct Answer & Explanation

. Quadratus plantae

Explanation

The foot has 9 distinct fascial compartments. The calcaneal compartment contains the quadratus plantae muscle and the lateral plantar neurovascular bundle. The medial compartment contains the abductor hallucis and flexor hallucis brevis. The superficial compartment contains the flexor digitorum brevis. The adductor compartment contains the adductor hallucis.

Question 5154

Topic: 2. Trauma

A 42-year-old female presents with a high-energy pilon fracture. On examination, the anteromedial ankle exhibits several blood-filled fracture blisters. What histological difference distinguishes blood-filled fracture blisters from clear fluid-filled fracture blisters?

. Blood-filled blisters represent epidermal cleavage only
. Blood-filled blisters indicate a deeper injury completely separating the epidermis from the dermis
. Blood-filled blisters are sterile, whereas clear blisters are typically infected
. Blood-filled blisters contain intact adnexal structures within the blister roof
. Clear blisters require immediate unroofing, whereas blood-filled blisters should be left intact

Correct Answer & Explanation

. Blood-filled blisters indicate a deeper injury completely separating the epidermis from the dermis

Explanation

Clear fluid blisters represent cleavage within the epidermis, leaving the basal layer intact. Blood-filled blisters represent a deeper injury, characterized by complete separation of the epidermis from the dermis, which disrupts the dermal vascular plexus. Re-epithelialization takes much longer for blood-filled blisters, and surgical incisions through these areas carry a significantly higher risk of wound breakdown.

Question 5155

Topic: 2. Trauma

A 32-year-old man sustained a Hawkins type II talar neck fracture and underwent open reduction and internal fixation. At 8 weeks postoperatively, an AP radiograph of the ankle reveals subchondral radiolucency in the talar dome. What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Impending nonunion
. Presence of vascularity to the talar body
. Deep surgical site infection
. Early post-traumatic osteoarthritis

Correct Answer & Explanation

. Presence of vascularity to the talar body

Explanation

The Hawkins sign is subchondral radiolucency of the talar dome visible on an AP radiograph typically 6 to 8 weeks after injury. It indicates subchondral atrophy from disuse and relies on intact vascularity to the talar body, thereby essentially ruling out avascular necrosis.

Question 5156

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains an acute Jones fracture (Zone 2 of the fifth metatarsal base). He desires the fastest possible return to play. Which of the following treatments provides the most reliable and rapid return to sports?

. Short leg cast non-weight bearing for 6 weeks
. Walking boot for 6 weeks
. Intramedullary screw fixation
. Tension band wiring
. Plating of the fifth metatarsal

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction and involve the 4-5 intermetatarsal articulation. In elite athletes, early intramedullary screw fixation is recommended to reduce the risk of nonunion and allow for an accelerated return to play compared to nonoperative management.

Question 5157

Topic: 2. Trauma

A 19-year-old track athlete complains of vague dorsal midfoot pain that worsens with sprinting. Radiographs are normal. MRI shows a linear signal abnormality in the central third of the navicular. CT scan confirms an incomplete, non-displaced fracture in the sagittal plane. What is the recommended initial management?

. Weight-bearing in a CAM boot for 4 weeks
. Non-weight bearing cast for 6 weeks
. Open reduction and internal fixation with screws
. Dorsal spanning plate
. Excision of the accessory navicular

Correct Answer & Explanation

. Non-weight bearing cast for 6 weeks

Explanation

Non-displaced navicular stress fractures are initially treated with a strict non-weight bearing cast for 6-8 weeks. Weight-bearing or walking boots have an unacceptably high rate of failure and nonunion. Surgical fixation is indicated for displaced fractures, nonunions, or recurrent fractures.

Question 5158

Topic: 2. Trauma

The Sanders classification for intra-articular calcaneus fractures is based on the number of fracture lines through the posterior facet as seen on which specific imaging view?

. Lateral radiograph
. Axial radiograph
. Sagittal CT reconstruction
. Coronal CT reconstruction
. Axial CT reconstruction

Correct Answer & Explanation

. Coronal CT reconstruction

Explanation

The Sanders classification of intra-articular calcaneus fractures relies on coronal CT images. The classification is based on the number and location of fracture lines entering the posterior facet at the widest point of the undersurface of the posterior facet of the talus.

Question 5159

Topic: 2. Trauma

During the surgical planning for a complex tibial pilon fracture, the surgeon notes a distinct anterolateral distal tibia fracture fragment. Which ligament provides the primary soft tissue attachment to this fragment (Chaput fragment)?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Deltoid ligament
. Interosseous ligament
. Anterior talofibular ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The anterolateral fragment of the distal tibia in pilon and Tillaux fractures is known as the Chaput fragment. It serves as the tibial attachment for the anterior inferior tibiofibular ligament (AITFL).

Question 5160

Topic: 2. Trauma

A 22-year-old dancer complains of chronic pain under the first metatarsal head. Radiographs reveal a bipartite medial sesamoid. Which radiographic feature best differentiates a true sesamoid fracture from a normal bipartite sesamoid?

. Smooth, corticated edges of the fragments
. Transverse orientation of the radiolucent line
. Irregular, sharp, uncorticated fracture margins
. Presence of the medial sesamoid only
. Bilateral occurrence in 25% of patients

Correct Answer & Explanation

. Irregular, sharp, uncorticated fracture margins

Explanation

Bipartite sesamoids (most commonly the medial sesamoid) are often bilateral and have smooth, corticated margins. True fractures will present with sharp, irregular, and uncorticated edges on radiographs.

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