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2. Trauma MCQs

Practice Set 260 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 5181

Topic: 2. Trauma

A 21-year-old elite collegiate basketball player complains of lateral foot pain after a cutting maneuver. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management for this specific patient profile?

. Hard-soled shoe weight-bearing as tolerated for 4 weeks
. Non-weight-bearing in a short leg cast for 6 to 8 weeks
. Intramedullary screw fixation
. Excision of the proximal fragment and peroneus brevis advancement
. Open reduction with a tension band construct

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This is a Jones fracture (Zone 2 of the base of the 5th metatarsal). Because it occurs in a vascular watershed area, it carries a high risk of nonunion. In elite or highly competitive athletes, early operative intervention with an intramedullary screw is the standard of care to maximize union rates and minimize time away from play.

Question 5182

Topic: 2. Trauma

A 35-year-old equestrian falls from a horse, sustaining an axial load with forceful abduction of the forefoot. Radiographs demonstrate a comminuted fracture of the cuboid with lateral column shortening. Which of the following is considered an absolute indication for operative fixation of a cuboid fracture?

. Any intra-articular extension into the calcaneocuboid joint
. Lateral column shortening greater than 3 mm
. Concomitant avulsion of the bifurcate ligament
. Presence of a 'nutcracker' mechanism of injury
. Mild asymptomatic nonunion identified incidentally

Correct Answer & Explanation

. Lateral column shortening greater than 3 mm

Explanation

Nutcracker fractures of the cuboid involve crushing the cuboid between the calcaneus and the 4th/5th metatarsals. Absolute indications for surgery to prevent disabling planovalgus deformity and late midfoot arthritis include lateral column shortening > 3 mm (some sources cite > 2 mm) or articular displacement > 1-2 mm.

Question 5183

Topic: 2. Trauma

A 28-year-old male suffers a severe crush injury to his right foot. Intracompartmental pressures are measured, and a diagnosis of foot compartment syndrome is made. A double dorsal incision approach is planned for fasciotomy. Which compartments are accessed through the medial dorsal incision?

. Medial, central, and lateral compartments
. First and second interosseous, and medial compartments
. Second and third interosseous, and central compartments
. Calcaneal, lateral, and fourth interosseous compartments
. Only the central compartment

Correct Answer & Explanation

. First and second interosseous, and medial compartments

Explanation

The foot contains 9 compartments. In a double dorsal incision fasciotomy, the medial incision (placed medial to the 2nd metatarsal) provides access to the medial compartment and the 1st and 2nd interosseous compartments. The lateral incision (lateral to the 4th metatarsal) accesses the lateral, central, and 3rd/4th interosseous compartments. The calcaneal compartment is typically accessed medially.

Question 5184

Topic: 2. Trauma

A 21-year-old elite track athlete develops insidious onset dorsal midfoot pain. A CT scan confirms a dorsal cortical radiolucency in the central third of the navicular. Which underlying anatomic factor predominantly predisposes this specific region to poor healing and nonunion?

. Disruption of the medial plantar artery
. A relative avascular watershed area in the central third of the bone
. Excessive traction from the insertion of the tibialis posterior tendon
. Shear forces applied by the anterior tibial tendon
. Impingement from an accessory navicular bone

Correct Answer & Explanation

. A relative avascular watershed area in the central third of the bone

Explanation

Navicular stress fractures typically occur in the central third of the bone. This region represents an avascular watershed area between the branches of the dorsalis pedis and medial plantar arteries, predisposing it to delayed union or nonunion.

Question 5185

Topic: 2. Trauma

Navicular stress fractures carry a high risk of delayed union and nonunion. This risk is primarily attributed to an avascular watershed zone located in which region of the navicular bone?

. Medial third
. Central (middle) third
. Lateral third
. Dorsal cortical margin
. Plantar cortical margin

Correct Answer & Explanation

. Central (middle) third

Explanation

The central third of the navicular is an avascular watershed zone because it receives limited collateral blood supply from the dorsalis pedis and medial plantar arteries, which predominantly supply the periphery.

Question 5186

Topic: 2. Trauma

A patient is evaluated 8 weeks after closed reduction and percutaneous pinning of a non-displaced talar neck fracture. 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?

. Impending avascular necrosis of the talar body
. Subchondral collapse and early arthritis
. Intact vascular supply with normal bone resorption
. Osteomyelitis of the talar dome
. Nonunion of the talar neck

Correct Answer & Explanation

. Intact vascular supply with normal bone resorption

Explanation

The Hawkins sign is a subchondral radiolucent band representing disuse osteopenia. It confirms that the talar body has an intact vascular supply capable of generating a hyperemic resorptive response, thus virtually ruling out avascular necrosis.

Question 5187

Topic: 2. Trauma

A patient develops a compartment syndrome of the foot following a severe crush injury. There are a total of 9 compartments in the foot. Which of the following muscles is uniquely located within the calcaneal compartment?

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

Correct Answer & Explanation

. Quadratus plantae

Explanation

The calcaneal compartment is a distinct deep compartment in the hindfoot that primarily contains the quadratus plantae muscle, as well as the lateral plantar nerve and vessels.

Question 5188

Topic: 2. Trauma

When performing an olecranon osteotomy for exposure of an intra-articular distal humerus fracture, what is the optimal technique to maximize construct stability and minimize nonunion?

. Transverse osteotomy at the level of the coronoid process
. Apex-proximal chevron osteotomy through the articular cartilage
. Apex-distal chevron osteotomy targeting the bare area of the sigmoid notch
. Sagittal osteotomy splitting the triceps insertion
. Oblique osteotomy from dorsal-proximal to volar-distal

Correct Answer & Explanation

. Apex-distal chevron osteotomy targeting the bare area of the sigmoid notch

Explanation

An apex-distal chevron osteotomy is the preferred technique. It provides intrinsic rotational stability due to the chevron shape and a large surface area for healing. The osteotomy should be directed to exit the articular surface at the 'bare area' (the non-articular portion of the greater sigmoid notch) to minimize damage to the articular cartilage of the proximal ulna.

Question 5189

Topic: 2. Trauma
A 35-year-old woman falls on her outstretched arm and sustains an isolated fracture of the capitellum. CT scan demonstrates a fracture in the coronal plane consisting primarily of a thin shell of articular cartilage with very minimal subchondral bone attached. According to the Bryan and Morrey classification, what type of fracture is this and what is the typical treatment if displaced?
. Type I (Hahn-Steinthal); treated with large headless compression screws
. Type II (Kocher-Lorenz); treated with excision or small bioabsorbable pins
. Type III (Broberg-Morrey); treated with lateral collateral ligament repair
. Type IV (McKee); treated with immediate total elbow arthroplasty
. Type II (Kocher-Lorenz); treated with large cannulated lag screws

Correct Answer & Explanation

. Type II (Kocher-Lorenz); treated with excision or small bioabsorbable pins

Explanation

Bryan and Morrey Type II capitellar fractures (Kocher-Lorenz) are 'uncapital' shear fractures involving a thin sliver of articular cartilage with little subchondral bone. Because of the lack of bone stock, they are extremely difficult to fix with standard screws. Treatment typically involves either excision of the fragment or fixation with very small bioabsorbable pins or resorbable darts. Type I (Hahn-Steinthal) fractures have a large segment of subchondral bone and are amenable to headless screw fixation.

Question 5190

Topic: 2. Trauma
A 34-year-old agricultural worker is caught in a tractor power take-off, sustaining a Gustilo-Anderson Type IIIB open fracture of the humeral shaft with gross soil contamination. In addition to prompt surgical debridement, what is the most appropriate initial intravenous antibiotic regimen according to current trauma guidelines?
. Cefazolin alone
. Cefazolin and gentamicin
. Ceftriaxone and vancomycin
. Cefazolin, gentamicin, and penicillin G
. Clindamycin and ciprofloxacin

Correct Answer & Explanation

. Cefazolin, gentamicin, and penicillin G

Explanation

For severe open fractures (Gustilo III), standard prophylaxis involves a first-generation cephalosporin (Cefazolin) for Gram-positive coverage and an aminoglycoside (Gentamicin) for Gram-negative coverage. When an injury occurs in an agricultural setting or involves gross soil contamination, there is a high risk of Clostridium infection. Therefore, high-dose Penicillin G must be added to the regimen for anaerobic coverage to prevent gas gangrene.

Question 5191

Topic: 2. Trauma

A 24-year-old male presents to the emergency department following an arm wrestling match. Radiographs reveal a spiral fracture of the distal third of the humeral shaft. On examination, he is unable to actively extend his wrist or fingers, though he can forcefully extend his elbow. Sensation is decreased over the dorsal web space. Which of the following is the most appropriate initial management of this fracture and associated nerve injury?

. Immediate surgical exploration of the radial nerve and rigid internal fixation
. Application of a coaptation splint and observation of the neurological deficit
. Immediate external fixation and delayed primary nerve repair
. Intramedullary nailing with percutaneous nerve decompression
. High-resolution ultrasound to document nerve discontinuity prior to intervention

Correct Answer & Explanation

. Application of a coaptation splint and observation of the neurological deficit

Explanation

This is a Holstein-Lewis fracture (spiral fracture of the distal third of the humerus) with a primary radial nerve palsy. Despite the specific fracture pattern, the treatment of a primary radial nerve palsy associated with a closed humeral shaft fracture remains non-operative initially. Over 70-90% of these palsies represent neurapraxia or axonotmesis and will recover spontaneously. The standard of care is a coaptation splint or functional brace. Surgical exploration is indicated if the fracture is open, if there is an associated vascular injury, or if the nerve palsy develops secondarily after closed reduction.

Question 5192

Topic: 2. Trauma

A 24-year-old male is evaluated for severe hand swelling, tense compartments, and pain out of proportion to the injury following an industrial crush injury. If a full hand fasciotomy is indicated, how many distinct fascial compartments in the hand must be released?

. 4
. 7
. 10
. 12
. 14

Correct Answer & Explanation

. 10

Explanation

There are 10 accepted fascial compartments in the hand that require release in the setting of compartment syndrome: 4 dorsal interosseous compartments, 3 volar interosseous compartments, the thenar compartment, the hypothenar compartment, and the adductor pollicis compartment.

Question 5193

Topic: Pelvic & Acetabular Trauma
A 40-year-old male sustains an APC-III pelvic ring injury. In the trauma bay, the decision is made to apply a non-invasive external pelvic binder to reduce pelvic volume. To maximize biomechanical efficacy, the binder should be centered over which of the following anatomic landmarks?
. Iliac crests
. Anterior superior iliac spines (ASIS)
. Greater trochanters
. Symphysis pubis
. Sacral promontory

Correct Answer & Explanation

. Greater trochanters

Explanation

For effective reduction of pelvic volume in anterior-posterior compression injuries, a pelvic binder must be applied directly over the greater trochanters. Placement higher over the iliac crests is incorrect and can paradoxically open the true pelvis further or be less effective in closing the symphyseal diastasis.

Question 5194

Topic: Pelvic & Acetabular Trauma

On a standard anteroposterior (AP) radiograph of the pelvis in a patient with a suspected acetabular fracture, the iliopectineal line serves as the radiographic landmark for which structural component of the acetabulum?

. Anterior wall
. Posterior wall
. Anterior column
. Posterior column
. Quadrilateral plate

Correct Answer & Explanation

. Anterior column

Explanation

In the radiographic evaluation of acetabular fractures (Judet-Letournel principles), the iliopectineal line represents the anterior column. The ilioischial line represents the posterior column. The anterior rim of the acetabulum represents the anterior wall, and the posterior rim represents the posterior wall.

Question 5195

Topic: 2. Trauma
A 25-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III). Compared to a more horizontally oriented Pauwels type I fracture, what is the primary biomechanical disadvantage inherent to the Pauwels type III pattern?
. Increased compressive forces across the fracture site
. Increased shear forces across the fracture site
. Decreased bending moment at the base of the neck
. Increased interdigitation of the fracture ends
. Decreased varus deforming force

Correct Answer & Explanation

. Increased shear forces across the fracture site

Explanation

The Pauwels classification of femoral neck fractures is based on the angle of the fracture line relative to the horizontal plane. A Pauwels type III fracture is highly vertical (>50 degrees). Biomechanically, this steep angle translates axial loading forces into extremely high shear forces across the fracture site, predisposing the fracture to varus displacement and nonunion.

Question 5196

Topic: 2. Trauma

A 38-year-old male develops severe heterotopic ossification (HO) following a complex elbow fracture-dislocation, resulting in profound functional stiffness. Nonoperative management has failed. According to current evidence-based guidelines, what is the most reliable clinical and radiographic indicator that the HO is mature enough for safe surgical excision?

. A mandatory waiting period of strictly 12 months minimum
. Normalization of serum alkaline phosphatase levels
. A negative three-phase technetium bone scan
. A clinical plateau of range of motion and sharp, mature trabecular cortical margins on CT scan
. Normalization of C-reactive protein (CRP)

Correct Answer & Explanation

. A clinical plateau of range of motion and sharp, mature trabecular cortical margins on CT scan

Explanation

Historically, surgeons waited 12 to 18 months or relied on alkaline phosphatase/bone scans before excising heterotopic ossification to prevent recurrence. Modern evidence demonstrates that HO can be safely excised much earlier (often at 6 months) as long as there is a clinical plateau in the recovery of range of motion and CT imaging confirms mature bone with sharp, distinct trabecular and cortical margins.

Question 5197

Topic: Pelvic & Acetabular Trauma

A 28-year-old male is involved in a high-speed motorcycle accident and sustains a pelvic ring injury. Radiographs and CT demonstrate a symphysis pubis diastasis of 3.5 cm, with widening of the anterior sacroiliac joints. The posterior sacroiliac ligaments are intact. According to the Young and Burgess classification, what is the injury type and its primary plane of instability?

. Lateral Compression Type 1 (LC-1); internally rotationally unstable
. Lateral Compression Type 2 (LC-2); internally rotationally and vertically unstable
. Anteroposterior Compression Type 2 (APC-2); externally rotationally unstable but vertically stable
. Anteroposterior Compression Type 3 (APC-3); externally rotationally and vertically unstable
. Vertical Shear (VS); vertically and horizontally unstable

Correct Answer & Explanation

. Anteroposterior Compression Type 2 (APC-2); externally rotationally unstable but vertically stable

Explanation

An APC-2 injury is characterized by rupture of the symphysis pubis (>2.5 cm diastasis) and rupture of the anterior sacroiliac, sacrotuberous, and sacrospinous ligaments. The posterior sacroiliac ligaments remain intact. This results in rotational instability (an 'open book' pelvis) but preserves vertical stability. APC-3 involves complete disruption of both anterior and posterior SI ligaments, resulting in both rotational and vertical instability.

Question 5198

Topic: 2. Trauma
A 40-year-old male sustains an isolated vertical femoral neck fracture (Pauwels Type III). He undergoes closed reduction and internal fixation. From a biomechanical perspective, which of the following fixation constructs offers the greatest resistance to vertical shear forces in this fracture pattern?
. Three parallel cannulated screws placed in an inverted triangle configuration
. Two parallel cannulated screws placed inferiorly and superiorly
. A sliding hip screw (dynamic hip screw) with an adjunctive derotational cancellous screw
. A 95-degree angled blade plate
. Multiple fully threaded cortical screws

Correct Answer & Explanation

. A sliding hip screw (dynamic hip screw) with an adjunctive derotational cancellous screw

Explanation

Pauwels Type III (vertical) femoral neck fractures have a fracture angle greater than 50 degrees relative to the horizontal and are highly unstable due to significant vertical shear forces. Traditional multiple parallel cannulated screws have a high failure rate in this pattern because they do not adequately resist shear. A fixed-angle sliding hip screw (DHS) construct, often supplemented with a derotational screw, provides superior biomechanical resistance to shear forces and improved rates of union for vertical femoral neck fractures in young adults.

Question 5199

Topic: 2. Trauma
A 45-year-old male sustains a severe open tibia fracture (Gustilo-Anderson IIIB) to the middle third of his lower leg. After aggressive skeletal stabilization and serial debridement, a soft tissue defect remains that exposes bone devoid of periosteum. Which of the following soft tissue coverage options is most appropriate for a defect in the MIDDLE third of the tibia?
. Medial gastrocnemius rotational flap
. Soleus rotational flap
. Reverse sural artery flap
. Anterolateral thigh free flap
. Local fasciocutaneous rotation flap

Correct Answer & Explanation

. Soleus rotational flap

Explanation

For coverage of soft tissue defects of the lower extremity, rotational muscle flaps are chosen based on the level of the defect. The classic algorithm utilizes the medial gastrocnemius flap for the proximal third, the soleus flap for the middle third, and a free tissue transfer (e.g., anterolateral thigh or latissimus dorsi) for the distal third of the tibia.

Question 5200

Topic: 2. Trauma

A 32-year-old male sustains a high radial nerve palsy following a humerus shaft fracture. Six months later, there is no clinical or EMG evidence of recovery, and tendon transfers are planned. In a standard superficialis (Boyes) transfer, which donor tendon is used to restore wrist extension?

. Pronator Teres (PT)
. Flexor Carpi Radialis (FCR)
. Flexor Carpi Ulnaris (FCU)
. Palmaris Longus (PL)
. Flexor Digitorum Superficialis (FDS)

Correct Answer & Explanation

. Pronator Teres (PT)

Explanation

In tendon transfers for radial nerve palsy, restoring wrist extension is almost universally accomplished by transferring the Pronator Teres (PT) to the Extensor Carpi Radialis Brevis (ECRB). This holds true for both the Boyes (superficialis) transfer and the standard FCR transfer. The Boyes transfer then uses FDS of the middle finger to EDC (finger extension) and FDS of the ring finger to EPL (thumb extension).

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