Menu

2. Trauma MCQs

Practice Set 271 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 5401

Topic: 2. Trauma
A 24-year-old man sustained a grade IIIb open tibial fracture and an ipsilateral grade IIIa femoral fracture in a motorcycle accident. He is unresponsive, intubated, and has a Glasgow Coma Scale score of 8. He is resuscitated and taken to the operating room for definitive orthopaedic care. Which of the following intraoperative problems will most likely adversely affect his long-term outcome?
. Blood loss during debridement
. Prolonged tourniquet time
. Failure to stabilize both fractures with intramedullary nails
. Episodic hypotension
. Loss of dorsalis pedis pulse

Correct Answer & Explanation

. Episodic hypotension

Explanation

Traumatic brain injury is considered to be either primary or secondary. Primary injury is direct or impact damage to the brain, and secondary injury can have intracranial or systemic causes. While treatment has little impact on primary brain injury, secondary brain injury can be avoided. There are many causes of systemic secondary brain injury, but none has a greater impact on outcome than hypotension or hypoxia. In fact, the occurrence of hypotension postinjury causes a 10- to 15-fold increase in mortality. Efforts to avoid hypotension postinjury and especially during surgery should be of primary importance.

Question 5402

Topic: 2. Trauma

Radiographs of an 80-year-old woman with back pain reveal a compression fracture. Which of the following imaging studies best evaluates the acuity of the fracture?

. Triple phase bone scan
. T1-weighted MRI scan
. Short tau inversion recovery (STIR)-weighted MRI scan
. CT
. Standing lateral radiograph

Correct Answer & Explanation

. Short tau inversion recovery (STIR)-weighted MRI scan

Explanation

The best method of evaluating the acuity of osteoporotic compression fractures is to look for edema in the vertebral body. This is best accomplished with a STIR-weighted MRI scan. Bone scans can show increased uptake at the site of fracture for many months after the fracture. T1-weighted MRI scans show loss of normal marrow fat that may not necessarily correspond with acuity of the fracture. CT scans and radiographs show fracture deformity but cannot be used to judge acuity. Phillips FM: Minimally invasive treatments of osteoporotic vertebral compression fractures. Spine 2003;28:S45-S53.

Question 5403

Topic: 2. Trauma

A 60-year-old woman has activity-related hip pain after undergoing arthroplasty 5 years ago. She has severe Parkinsonism and denies fevers or chills. Radiographs are shown in Figures 45a and 45b. What is the most likely cause of her pain?

. Chronic deep infection
. Heterotopic bone
. Femoral loosening
. Parkinsonism
. Acetabular loosening

Correct Answer & Explanation

. Femoral loosening

Explanation

The radiographs reveal both cement debonding at the lateral shoulder of the prosthesis and a cement mantle fracture. Both of these indicate a loose femoral component. The radiographs show a stress fracture with reactive bone on the lateral femoral cortex in conjunction with the cement mantle fracture. The acetabular component shows no evidence of loosening. Heterotopic bone usually is not a source of pain when it is Brooker grade I, as in this case. Parkinsonism generally is not associated with hip pain. Harris WH, McCarthy JC, O'Neill DA: Femoral component loosening using contemporary techniques of femoral cement fixation. J Bone Joint Surg Am 1982;64:1063-1067. Callaghan JJ, Rosenberg AG, Rubash H (eds): The Adult Hip. Philadelphia, PA, Lippincott-Raven, 1998, pp 960, 1228-1229.

Question 5404

Topic: 2. Trauma

A 40-year-old unrestrained passenger reports chest wall pain after a motor vehicle accident. Which of the following structures is most important in preventing the injury shown in Figure 33?

Upper Extremity 2008 Practice Questions: Set 3 (Solved) - Figure 23

. First rib
. Intra-articular disk ligament
. Costoclavicular ligament
. Interclavicular ligament
. Posterior sternoclavicular joint capsule

Correct Answer & Explanation

. Posterior sternoclavicular joint capsule

Explanation

Through cadaveric study, Spencer and associates measured anterior and posterior translation of the sternoclavicular joint. The study demonstrated that the posterior sternoclavicular joint capsule is the most important structure for preventing both anterior and posterior translation of the sternoclavicular joint. Gilot GJ, Wirth MA, Rockwood CA: Injuries to the sternoclavicular joint, in Bucholz RW, Heckman JD, Court-Brown C (eds): Fractures in Adults. Philadelphia, PA, Lippincott, Williams and Wilkins, 2006, vol 2, pp 1373-1374.

Question 5405

Topic: 2. Trauma
A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?
. First-generation cephalosporin
. Cephalosporin, penicillin, and quinolone
. Cephalosporin and aminoglycoside
. Quinolones
. Synthetic penicillin and aminoglycoside

Correct Answer & Explanation

. Cephalosporin, penicillin, and quinolone

Explanation

Patients who sustain grade III open fractures that are related to a farm environment require ampicillin or penicillin for Clostridium coverage.

Question 5406

Topic: 2. Trauma

Figures 35a through 35c show the clinical photograph and radiographs of a 15-year-old boy who stubbed his toe 1 day ago while walking barefoot in the yard. Management should consist of

. buddy taping of the great toe to the second toe for 3 weeks and use of a hard-soled shoe.
. buddy taping of the great toe to the second toe for 3 weeks and application of a short leg cast.
. buddy taping of the great toe to the second toe for 3 weeks, use of a hard-soled shoe, and a short course of antibiotics.
. nail removal in the emergency department, buddy taping of the great toe to the second toe for 3 weeks, and use of a hard-soled shoe.
. irrigation and open reduction, with or without fixation, and a short course of antibiotics.

Correct Answer & Explanation

. irrigation and open reduction, with or without fixation, and a short course of antibiotics.

Explanation

The patient has an open fracture of the physis of the distal phalanx with a portion of the nail bed interposed in the physis. Seymour initially described this injury in the distal phalanges of fingers. Optimal treatment consists of removing the interposed tissue, irrigating the fracture, and a short course of antibiotics. The nail should be preserved to provide stability. Kensinger DR, Guille JT, Horn BD, et al: The stubbed great toe: Importance of early recognition and treatment of open fractures of the distal phalanx. J Pediatr Orthop 2001;21:31-34. Pinckney LE, Currarino G, Kennedy LA: The stubbed great toe: A cause of occult compound fracture and infection. Radiology 1981;138:375-377.

Question 5407

Topic: 2. Trauma

A 26-year-old man sustained an isolated injury to his left hip joint in a motor vehicle accident. Closed reduction was performed, and the postreduction radiograph is shown in Figure 29. Management should now consist of

Trauma 2006 Practice Questions: Set 3 (Solved) - Figure 7

. emergent open reduction and fixation of the fracture.
. skeletal traction and expedient open reduction and fixation of the fracture.
. skeletal traction for 6 weeks, followed by physical therapy.
. crutches and no weight bearing for 6 weeks.
. bed rest for 1 week and follow-up radiographs to see if the fragment has moved.

Correct Answer & Explanation

. skeletal traction and expedient open reduction and fixation of the fracture.

Explanation

The patient has a posterior fracture-dislocation of the hip and following reduction, an incarcerated fragment of bone resulted in an incongruent reduction. Whereas expedient removal of the fragment is required to limit articular cartilage damage, this situation is not an emergency and the procedure may be performed when the appropriate surgical team is available and the patient is stabilized. Skeletal traction through either the femur or tibia may relieve some pressure on the joint and prevent articular damage. Nonsurgical care for incarcerated fragments is contraindicated. Tile M, Olson SA: Decision making: Non operative and operative indications for acetabular fractures, in Tile M, Helfet DL, Kellam JF (eds): Fractures of the Pelvis and Acetabulum. Philadelphia, PA, Lippincott Williams and Wilkins, 2003, pp 496-532.

Question 5408

Topic: 2. Trauma

A 45-year-old woman sustains an injury to her lower leg. Examination reveals that there is a deformity with no neurologic or vascular problems. The skin is intact. Radiographs are shown in Figures 46a and 46b. Which of the following factors would make closed management the least appropriate choice for this injury?

. Spiral fracture pattern
. Low-energy mechanism
. Amount of shortening
. Fracture of the fibula at a different level
. Ipsilateral femoral fracture

Correct Answer & Explanation

. Ipsilateral femoral fracture

Explanation

All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures. Trafton PG: Tibial shaft fractures, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 2153-2169.

Question 5409

Topic: 2. Trauma

A 25-year-old laborer sustains a transverse fracture of the proximal 25% of the scaphoid. CT reconstructions reveal a 1-mm fracture gap. What is the most appropriate treatment?

. Above-elbow thumb spica cast
. Short arm thumb spica cast
. Scaphotrapezial-trapezoidal (STT) fusion
. Excision of the proximal pole
. Internal fixation of the fracture with a compression screw

Correct Answer & Explanation

. Internal fixation of the fracture with a compression screw

Explanation

A higher risk of nonunion and the need for prolonged immobilization is seen after nonsurgical management of proximal pole fractures of the scaphoid. Because of the relatively poor blood supply of the proximal pole, surgical treatment with a compression screw is advocated for fractures of the proximal third of the scaphoid. Clay NR, Dias JJ, Costigan PS, et al: Need the thumb be immobilized in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br 1991;73:828-832.

Question 5410

Topic: 2. Trauma

Figure 24 shows the radiograph of a 36-year-old volleyball player with right hip pain. What is the cause of the pain?

Hip & Knee Reconstruction Board Review 2007: High-Yield MCQs (Set 2) - Figure 20

. Osteonecrosis
. Rheumatoid arthritis
. Developmental dysplasia of the acetabulum
. Femoral neck fracture
. Femoral acetabular impingement

Correct Answer & Explanation

. Femoral acetabular impingement

Explanation

Femoral acetabular impingement usually presents in active young adults with the slow onset of groin pain that often starts after a minor trauma. Physical examination reveals limitation of motion with a positive impingement test which consists of forceful internal rotation with flexion and adduction. Femoral acetabular impingement is a mechanism for the development of early osteoarthritis in nondysplastic hips. Surgical debridement of the impinging, nonspherical portion of the femoral head restores offset and improves the clearance of the head, thus preventing abutment of the neck against the acetabular rim. The patient has no evidence of osteonecrosis, developmental dysplasia of the hip, rheumatoid arthritis, or femoral neck fracture. Ganz R, Parvizi J, Beck M, et al: Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop 2003;417:112-120.

Question 5411

Topic: 2. Trauma

A 16-year-old girl was involved in a motorcycle accident that resulted in a significant right tibial fracture with soft-tissue loss over the distal 4 cm of the anterior medial tibia. The patient has had two irrigations and debridements and recently had an intramedullary nail placed for the skeletal injury. Vacuum-assisted closure (VAC) has been used to cover the defect since the injury. The risk of infection developing in the tibia is

. higher than previous reports because of the use of the wound VAC.
. related mainly to the location of the soft-tissue defect.
. related mainly to the timing of soft-tissue coverage.
. lower than previous reports because of the use of the wound VAC.
. lower than previous reports because of the intramedullary nailing.

Correct Answer & Explanation

. related mainly to the timing of soft-tissue coverage.

Explanation

Detailed The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures. Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292. Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.

Question 5412

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?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 6

. 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 patient'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 patient'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 5413

Topic: 2. Trauma
A 32-year-old woman has an isolated left posterior wall acetabular fracture in which about 25% of the wall surface is involved. Which of the following criteria would indicate the need for surgical reduction and fixation?
. Fracture comminution
. Displacement of 1 mm at the fracture site
. Involvement of the ischial facet
. Femoral head subluxation during fluoroscopic examination
. Presence of a bilateral pneumothorax

Correct Answer & Explanation

. Femoral head subluxation during fluoroscopic examination

Explanation

Fractures with a posterior wall fragment that makes up less than one third of the surface generally are stable. Conversely, fractures with a fragment making up more than 50% of the surface are unstable. Patients with an intermediate fracture fragment should undergo a fluoroscopic examination under sedation or anesthesia to determine if the fragment is truly stable. If so, the patient can be treated nonoperatively and safely mobilized.

Question 5414

Topic: 2. Trauma
A healthy 25-year-old man sustains a grade IIIB open tibial fracture. Following appropriate debridement, irrigation, and stabilization with an external fixator, the soft-tissue injury is shown in Figure 30. What is the most appropriate definitive soft-tissue coverage procedure?
. Split-thickness skin graft
. Full-thickness skin graft
. Soleus rotation flap
. Medial gastrocnemius rotation flap
. Free latissimus dorsi flap with microvascular anastomosis

Correct Answer & Explanation

. Free latissimus dorsi flap with microvascular anastomosis

Explanation

This is a very large near-circumferential defect with posterior as well as anterior skin and muscle injury. Bone is exposed. The posterior muscles cannot be rotated since they are part of the zone of injury. The bone and other poorly vascularized areas of this wound would not accept a skin graft. The best chance for limb salvage will be to obtain soft-tissue coverage with a free tissue transfer using the latissimus dorsi.

Question 5415

Topic: 2. Trauma

A 34-year-old man sustained a tibial fracture in a motorcycle accident. What perioperative variable is associated with the greatest relative risk for reoperation to achieve bone union?

. Gender
. Delay in initial surgical treatment
. Use of nonsteroidal anti-inflammatory drugs
. Smoking
. Cortical contact of less than or equal to 50%

Correct Answer & Explanation

. Cortical contact of less than or equal to 50%

Explanation

In a recent analysis of 200 patients with tibial fractures, Bhandari and associates attempted to identify variables that were predictive of reoperation. The variables in the study were type of injury (fracture pattern), degree of open injury, mechanism of injury, cortical bone contact, postoperative complications, polytrauma, anti-inflammatory drug use, nail insertion technique (reamed versus nonreamed), smoking history, alcohol use, diabetes mellitus, peripheral vascular disease, age, disability status pre-injury, gender, surgeon, time to surgery, steroid use, phenytoin use, antibiotic use, anticoagulant use, and type of fixation used. Three variables were statistically significant predictors of reoperation to achieve bone union in the first postinjury year: transverse fracture pattern, open fracture, and cortical contact of 50% or less. Using these three variables, four reoperation risk groups were identified based on the number of these three variables present: 0, 1, 2, or 3. The risk for reoperation was 0%, 18%, 47%, and 94%, respectively. The authors concluded that these statistics can provide prognostic information to patients and help identify those high-risk patients where early intervention to achieve union is indicated. In addition, the data highlights the significance of achieving cortical contact at the time of initial fixation.

Question 5416

Topic: 2. Trauma

Figure 36 shows the radiograph of a 28-year-old man who injured his shoulder in a motocross race. Management should consist of

Sports Medicine Board Review 2004: High-Yield MCQs (Set 4) - Figure 6

. sling and swathe immobilization.
. early mobilization and strengthening exercises.
. an airplane abduction orthosis.
. stabilization with percutaneous smooth pins.
. open stabilization with coracoclavicular ligament repair and reconstruction.

Correct Answer & Explanation

. open stabilization with coracoclavicular ligament repair and reconstruction.

Explanation

Fractures of the distal one third of the clavicle have a high incidence of delayed union (45% to 67%) and nonunion (22% to 33%) with nonsurgical management. Surgical stabilization with tension band techniques or a combination of plate and screw techniques is indicated, especially in young, active patients. In this patient, significant displacement of the fracture implies injury to the coracoclavicular ligaments with a higher risk of delayed union or nonunion. Various surgical treatments have been recommended, but the use of smooth wires is not indicated because of the potential for hardware migration. Jupiter JB, Ring D: Fractures of the clavicle, in Ianotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management, ed 1. Philadelphia, PA, Lippincott, Williams and Wilkins, 1999, pp 709-736.

Question 5417

Topic: 2. Trauma

A 13-year-old boy injured his knee playing basketball and is now unable to bear weight. Examination reveals tenderness and swelling at the proximal anterior tibia, with a normal neurologic examination. AP and lateral radiographs are shown in Figures 1a and 1b. Management should consist of

. MRI.
. a long leg cast.
. fasciotomy of the anterior compartment.
. open reduction and internal fixation.
. patellar advancement.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The patient has a displaced intra-articular tibial tuberosity fracture; therefore, the treatment of choice is open reduction and internal fixation. Periosteum is often interposed between the fracture fragments and prevents satisfactory closed reduction. Fortunately, most patients with this injury are close to skeletal maturity and therefore, growth arrest and recurvatum are unusual. Nondisplaced fractures can be treated with a cast, but displaced fractures are best treated with open reduction and internal fixation. Intra-articular fractures can disrupt the joint surface and are sometimes associated with a meniscal tear; therefore, arthroscopy may be needed at the time of open reduction and internal fixation. McKoy BE, Stanitski CL: Acute tibial tubercle avulsion fractures. Orthop Clin North Am 2003;34:397-403.

Question 5418

Topic: 2. Trauma

A 68-year-old man reports a 4-week history of progressive left-sided lower back and hip pain. The pain is in the posterior buttock region with radiation to the groin and to the left anterior knee region. The pain is aggravated with walking and improves with rest. There is no history of previous trauma. Radiographs are seen in Figures 14a and 14b, and MRI scans are seen in Figures 14c through 14e. What is the most appropriate treatment option at this time?

. Epidural steroid injection at L4-5
. Outpatient physical therapy for the lower back
. Non-weight-bearing of the left lower extremity
. Home exercise program, analgesics, and limited use of muscle relaxants
. Cortisone injection of the left greater trochanter region

Correct Answer & Explanation

. Non-weight-bearing of the left lower extremity

Explanation

Although the imaging reveals generalized lumbar spondylosis and stenosis, in particular at L4-5, the MRI scan of the left hip clearly reveals a stress fracture of the femoral neck. Therefore, the treatment of choice is non-weight-bearing of the left lower extremity. During the evaluation of acute back pain, clinicians must include other possibilities within the differential diagnosis that may mimic mechanical axial back pain; thus, potential complications from a missed diagnosis can be avoided. Wong DA, Transfeldt E: Macnab's Backache, ed 4. Philadelphia, PA, Lippincott Williams and Wilkins, 2007, pp 339-361.

Question 5419

Topic: Pelvic & Acetabular Trauma

In the treatment of acetabular dysplasia, what type of pelvic osteotomy leaves the "teardrop" in its original position and redirects the acetabulum?

Hip 2004 Practice Questions: Set 1 (Solved) - Figure 26

. Steel
. Chiari
. Ganz periacetabular
. Dial or spherical
. Salter innominate

Correct Answer & Explanation

. Dial or spherical

Explanation

The dial or spherical osteotomy leaves the medial wall or teardrop in its original position and, as a result, is intra-articular. The other pelvic osteotomies (except Chiari) redirect the acetabulum, including the medial wall. The Chiari osteotomy improves coverage without redirecting the acetabulum within the pelvis, and it leaves the teardrop in the same place. Lack W, Windhager R, Kutschera HP, Engel A: Chiari pelvic osteotomy for osteoarthritis secondary to hip dysplasia: Indications and long-term results. J Bone Joint Surg Br 1991;73:229-234. Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results. Clin Orthop 1988;232:26-36.

Question 5420

Topic: 2. Trauma

A 14-year-old boy undergoes application of a circular frame with tibial and fibular osteotomy for gradual limb lengthening. He initiates lengthening 7 days after surgery. During the first week of lengthening, he reports that turning of the distraction devices is becoming increasingly difficult. On the 9th day of lengthening, he is seen in the emergency department after feeling a pop in his leg and noting the acute onset of severe pain. What complication has most likely occurred?

Pediatrics Board Review 2007: High-Yield MCQs (Set 2) - Figure 7

. Joint subluxation and acute ligament rupture
. Incomplete corticotomy at the time of surgery with spontaneous completion and acute distraction
. Premature consolidation of the osteotomy with breakage of bone transfixation wire
. Fracture through the bone regenerate
. Fracture of the tibia through a unicortical half-pin track

Correct Answer & Explanation

. Incomplete corticotomy at the time of surgery with spontaneous completion and acute distraction

Explanation

Incomplete corticotomy may result from osteotomy with limited soft-tissue stripping and exposure. When the patient begins distraction, tension develops at all wire/half-pin and bone interfaces, leading to increasing difficulty in distraction and limb pain. Sudden spontaneous completion of the osteotomy with continued tension applied by the fixator results in acute distraction of the osteotomy with severe pain. Premature consolidation is unlikely this early following the initial surgery. Birch JG, Samchukov ML: Use of the Ilizarov method to correct lower limb deformities in children and adolescents. J Am Acad Orthop Surg 2004;12:144-154.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page