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2. Trauma MCQs

Practice Set 289 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 5761

Topic: 2. Trauma
A 38-year-old male sustains a severe open pilon fracture (distal tibia articular surface) with significant soft tissue damage, classified as Gustilo-Anderson Type IIIB. Which of the following principles guides the initial surgical management?
. Immediate definitive open reduction and internal fixation.
. Primary ankle arthrodesis.
. Thorough debridement and external fixation, followed by planned staged reconstruction.
. Primary amputation due to the severe soft tissue injury.
. Placement of a circular external fixator only, with no debridement.

Correct Answer & Explanation

. Thorough debridement and external fixation, followed by planned staged reconstruction.

Explanation

For severe open pilon fractures, especially Gustilo-Anderson Type IIIB, the initial management focuses on damage control principles. This involves thorough surgical debridement of all contaminated and non-viable tissue to prevent infection, followed by stabilization of the fracture with an external fixator (often spanning the ankle joint). This allows the soft tissues to recover and reduces swelling. Definitive reconstruction (e.g., plate and screw fixation) is typically performed in a staged manner once the soft tissue envelope has improved and the risk of infection is minimized, usually 7-14 days later. Immediate definitive ORIF carries a high risk of infection and wound complications in the presence of severe soft tissue injury. Primary ankle arthrodesis is a salvage procedure, not an initial approach. Primary amputation is only considered for unsalvageable limbs. Placement of an external fixator without debridement is inadequate and increases infection risk.

Question 5762

Topic: 2. Trauma

A 22-year-old male sustains a high-energy posterior hip dislocation. After successful closed reduction, what is the most critical immediate post-reduction investigation to assess for associated injuries?

. Repeat plain radiographs of the hip.
. CT scan of the hip and pelvis.
. MRI of the hip.
. Angiogram to rule out vascular injury.
. Electromyography (EMG) of the lower limb.

Correct Answer & Explanation

. CT scan of the hip and pelvis.

Explanation

After successful closed reduction of a posterior hip dislocation, the most critical immediate post-reduction investigation is a CT scan of the hip and pelvis. This is essential to rule out occult intra-articular fragments (e.g., osteochondral fragments from the femoral head or acetabulum), assess for acetabular fractures (especially posterior wall fractures), and confirm the concentric reduction. Undetected fragments or unstable acetabular fractures can lead to early post-traumatic arthritis, avascular necrosis, or recurrent dislocation. Repeat plain radiographs are necessary to confirm reduction but are insufficient to detect intra-articular fragments or subtle fractures. MRI is useful for soft tissue injuries (labrum, cartilage) and avascular necrosis but is not typically the first-line post-reduction imaging due to accessibility and time. Angiogram is reserved for suspected vascular injury (rarely seen acutely) and EMG is for nerve injury assessment, neither is the immediate priority after reduction itself.

Question 5763

Topic: 2. Trauma

A 60-year-old female experiences acute onset of severe shoulder pain after a fall. Radiographs show a three-part proximal humerus fracture (surgical neck and greater tuberosity). She has good bone quality. Which surgical option offers the best chance for functional recovery in this active patient?

. Non-operative management with a sling.
. Tension band wiring of the greater tuberosity and surgical neck pinning.
. Humeral head replacement (hemiarthroplasty).
. Reverse shoulder arthroplasty (RSA).
. Open reduction and internal fixation (ORIF) with a locking plate.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with a locking plate.

Explanation

For a three-part proximal humerus fracture in an active 60-year-old with good bone quality, open reduction and internal fixation (ORIF) with a locking plate is often considered the gold standard. Locking plates provide stable fixation, allowing for early mobilization and preserving the patient's own humeral head, which typically yields better functional outcomes than prosthetic replacement if healing occurs. Non-operative management is generally reserved for minimally displaced or two-part fractures. Tension band wiring is typically used for two-part surgical neck fractures or tuberosity fractures, not complex three-part injuries. Hemiarthroplasty is considered for patients with poor bone quality, highly comminuted fractures where ORIF is not feasible, or older, less active patients. RSA is usually reserved for older patients with irreparable rotator cuff tears, failed hemiarthroplasties, or complex fracture-dislocations, as it alters shoulder biomechanics significantly.

Question 5764

Topic: 2. Trauma

A 48-year-old male sustains a fall directly onto his knee, resulting in a patellar fracture. Radiographs show a transverse patellar fracture with 5mm of displacement and 3mm of articular step-off. He is able to actively extend his knee against gravity. Which of the following is the most appropriate management?

. Non-operative management with a knee immobilizer.
. Open reduction and internal fixation with tension band wiring.
. Partial patellectomy.
. Total patellectomy.
. External fixation.

Correct Answer & Explanation

. Open reduction and internal fixation with tension band wiring.

Explanation

A transverse patellar fracture with 5mm displacement and 3mm articular step-off, even with intact active knee extension (which suggests an intact extensor mechanism, but the displacement is significant), typically requires surgical intervention to restore articular congruity and reconstruct the extensor mechanism. Open reduction and internal fixation (ORIF) with tension band wiring is the gold standard for displaced transverse patellar fractures. This technique converts tensile forces into compressive forces across the fracture site, promoting healing and restoring the extensor mechanism. Non-operative management is reserved for non-displaced fractures with an intact extensor mechanism. Partial or total patellectomy are salvage procedures for highly comminuted fractures or non-unions, usually avoided if reconstruction is possible. External fixation is not standard for patellar fractures.

Question 5765

Topic: 2. Trauma

A 40-year-old male sustains a right femoral shaft fracture in a motor vehicle accident. He is taken to the operating theatre for intramedullary nailing. During reaming, he suddenly becomes hypotensive, hypoxic, and develops petechial rash. Which of the following is the most likely diagnosis?

. Anaphylactic reaction to antibiotics.
. Pulmonary embolism.
. Cardiac tamponade.
. Fat embolism syndrome.
. Sepsis.

Correct Answer & Explanation

. Fat embolism syndrome.

Explanation

The classic triad of symptoms (hypotension, hypoxia, and petechial rash) occurring during or shortly after intramedullary nailing of a long bone fracture, particularly the femur, is highly characteristic of fat embolism syndrome (FES). The release of fat globules from the bone marrow into the circulation during reaming is thought to be a key mechanism. Anaphylactic reactions would typically involve bronchospasm, urticaria, and angioed, and less likely petechiae. Pulmonary embolism would present with hypoxia and hypotension but petechiae are not a typical feature. Cardiac tamponade is unlikely in this context without specific chest trauma. Sepsis would have a slower onset and fever.

Question 5766

Topic: 2. Trauma

A 75-year-old male with multiple comorbidities presents with a painful, swollen ankle after a fall. Radiographs show a trimalleolar ankle fracture (medial, lateral, and posterior malleolus involved). He is deemed high-risk for surgery due to cardiac and respiratory issues. Which of the following is the most appropriate management strategy?

. Immediate open reduction and internal fixation (ORIF).
. Attempt closed reduction and external fixation as definitive treatment.
. Non-operative management with a short leg cast and early mobilization.
. Attempt closed reduction and apply a short leg cast with strict non-weight-bearing.
. Primary ankle arthrodesis.

Correct Answer & Explanation

. Attempt closed reduction and apply a short leg cast with strict non-weight-bearing.

Explanation

For a trimalleolar ankle fracture in a high-risk patient unfit for definitive ORIF, the priority is to achieve and maintain a reasonable reduction to prevent skin breakdown and future severe arthritis, while minimizing surgical risks. The most appropriate approach is to attempt a closed reduction. If successful, the ankle is then immobilized in a short leg cast or removable boot with strict non-weight-bearing. The goal is often to obtain a 'best possible' reduction rather than an anatomical one, accepting a slightly less perfect outcome to avoid high surgical risks. External fixation can be used as a temporary measure or sometimes as a definitive measure for extremely high-risk patients, but a well-reduced casted ankle is often preferred if stable. Immediate ORIF is contraindicated due to medical comorbidities. Non-operative management with early mobilization is inappropriate for an unstable trimalleolar fracture. Primary ankle arthrodesis is a salvage procedure.

Question 5767

Topic: 2. Trauma

A 58-year-old morbidly obese male sustains a crush injury to his foot. He develops severe pain, swelling, and paresthesias in the forefoot. Dorsalis pedis and posterior tibial pulses are present. Pain is exacerbated by passive stretch of the toes. What is the most appropriate next step?

. Elevate the limb and apply ice.
. Administer IV fluids and analgesia.
. Measure compartment pressures in the foot.
. Perform a CT scan of the foot.
. Order arterial Doppler studies.

Correct Answer & Explanation

. Measure compartment pressures in the foot.

Explanation

The patient's symptoms (severe pain, swelling, paresthesias, pain on passive toe stretch) following a crush injury, despite palpable pulses, are classic for acute foot compartment syndrome. The presence of pulses does not rule out compartment syndrome. Elevation and ice are contraindicated as they can worsen perfusion. IV fluids and analgesia are supportive but do not address the underlying compartment syndrome. A CT scan may show bony injury but not compartment pressures. Arterial Doppler studies are not the primary investigation for compartment syndrome. Urgent measurement of compartment pressures is indicated, and if elevated, emergent fasciotomy of the foot compartments is required to prevent ischemic damage and tissue necrosis.

Question 5768

Topic: 2. Trauma
A 28-year-old male sustains an open tibia fracture (Gustilo-Anderson Type IIIA). He is brought to the emergency department. Which of the following is the highest priority in the initial management of this injury?
. Administer IV antibiotics and tetanus prophylaxis.
. Debridement and irrigation in the operating theatre.
. Apply a sterile dressing and splint the limb.
. Obtain plain radiographs and CT scan of the limb.
. Prepare for immediate open reduction and internal fixation.

Correct Answer & Explanation

. Administer IV antibiotics and tetanus prophylaxis.

Explanation

For an open fracture, prompt administration of broad-spectrum intravenous antibiotics (e.g., a cephalosporin and an aminoglycoside, plus penicillin for Type III or grossly contaminated wounds) and tetanus prophylaxis are the highest initial priorities. This significantly reduces the risk of infection. While debridement is critical, it typically occurs in the operating theatre after antibiotics have been initiated and resuscitation is underway. Applying a sterile dressing and splinting are important for temporary care. Imaging is necessary but does not take precedence over infection control. Immediate definitive ORIF is not typically performed for open fractures; damage control (debridement and external fixation) is usually the first surgical step, followed by definitive fixation in a staged approach.

Question 5769

Topic: 2. Trauma

A 6-year-old girl falls onto her elbow and presents with a minimally displaced lateral condyle fracture of the humerus. Which of the following is a significant concern specific to this fracture in children?

. Risk of Volkmann's ischaemic contracture.
. High incidence of non-union or malunion if not anatomically reduced.
. Associated nerve injury (ulnar nerve).
. Compartment syndrome.
. Development of cubitus varus deformity.

Correct Answer & Explanation

. High incidence of non-union or malunion if not anatomically reduced.

Explanation

Lateral condyle fractures in children, even if minimally displaced, have a high incidence of non-union or malunion if not anatomically reduced and stably fixed. This is due to the cartilaginous nature of the condyle, which makes accurate assessment and fixation challenging, and the pull of the common extensor muscles. Non-union can lead to progressive valgus deformity, secondary ulnar nerve palsy, and stiffness. While Volkmann's ischaemic contracture and compartment syndrome are concerns for supracondylar fractures, they are less common for lateral condyle fractures. Ulnar nerve injury is a concern with medial epicondyle or supracondylar fractures. Cubitus varus is typically associated with malunited supracondylar fractures.

Question 5770

Topic: 2. Trauma

A 35-year-old male sustains a fall from a height, landing on his feet. He complains of bilateral heel and back pain. Radiographs confirm bilateral calcaneal fractures. What additional injury must be specifically evaluated given the mechanism of injury?

. Pelvic ring injury.
. Ankle sprain.
. Talus fracture.
. Spinal compression fracture.
. Knee ligamentous injury.

Correct Answer & Explanation

. Spinal compression fracture.

Explanation

A fall from a height, landing on the feet, imparts axial load through the lower extremities. This mechanism frequently results in associated injuries, classically affecting the calcaneus, tibia, femur, and spine (especially thoracolumbar compression fractures) as the force is transmitted upwards. Therefore, a careful assessment and imaging (e.g., clinical examination and potentially radiographs or CT of the spine) for spinal compression fractures is mandatory in a patient with calcaneal fractures from a fall from height. While other injuries are possible, spinal fractures are a well-recognized and critical association.

Question 5771

Topic: 2. Trauma

A 42-year-old female presents with a chronic non-union of her humeral shaft fracture after 9 months of conservative management. The fracture site is not infected, and there is hypertrophic callus evident on X-ray, but a persistent fracture line. What is the most appropriate next step in management?

. Continue conservative management for another 3 months.
. Bone stimulation (e.g., ultrasound, electromagnetic field).
. Revision open reduction and internal fixation with plate and screws and autogenous bone grafting.
. Conversion to intramedullary nail.
. Debridement and external fixation.

Correct Answer & Explanation

. Revision open reduction and internal fixation with plate and screws and autogenous bone grafting.

Explanation

A chronic non-union with hypertrophic callus but a persistent fracture line (hypertrophic non-union) indicates biological activity but insufficient stability for union. In this scenario, surgical intervention to achieve greater stability is required. Revision open reduction and internal fixation with plate and screws, often augmented with autogenous bone grafting, is a common and effective treatment. Bone grafting provides osteogenic cells, osteoinductive factors, and an osteoconductive scaffold. Bone stimulation can be helpful for atrophic non-unions or as an adjunct, but for hypertrophic non-union requiring increased stability, it's usually insufficient as a standalone treatment. Continuing conservative management is unlikely to succeed. Conversion to an IM nail is an option, but plating with bone graft is also a strong choice, especially in the context of an existing non-union. Debridement and external fixation are less common for a sterile hypertrophic non-union.

Question 5772

Topic: 2. Trauma
A 50-year-old male sustains a severe crush injury to his right forearm, resulting in an open, comminuted radius and ulna fracture. The patient is hemodynamically stable. After initial debridement and external fixation, what is the most appropriate next step in the management of the soft tissue defect?
. Immediate primary closure of the wound.
. Skin grafting within 24 hours.
. Application of a vacuum-assisted closure (VAC) device, followed by delayed definitive soft tissue coverage.
. Repeated debridements every 48 hours until healthy granulation tissue is achieved.
. Amputation due to the severity of the crush injury.

Correct Answer & Explanation

. Application of a vacuum-assisted closure (VAC) device, followed by delayed definitive soft tissue coverage.

Explanation

For severe open fractures with significant soft tissue defects (often Gustilo-Anderson Type IIIB or higher), immediate primary closure or skin grafting is often contraindicated due to contamination and swelling, which would lead to high rates of infection or graft failure. The 'vacuum-assisted closure (VAC) device, followed by delayed definitive soft tissue coverage (e.g., local or free flap)' is a common and effective strategy. The VAC device helps manage exudate, reduces edema, promotes granulation tissue formation, and prepares the wound bed for subsequent definitive soft tissue coverage, which typically occurs within 5-7 days of injury, or after multiple debridements depending on wound status. Repeated debridements are often necessary, but the soft tissue defect needs a plan. Amputation is a last resort for unsalvageable limbs.

Question 5773

Topic: 2. Trauma

A 3-year-old child presents with a spiral fracture of the tibia (toddler's fracture) after a minor fall. He is otherwise healthy. What is the most appropriate treatment?

. Rigid cast immobilization for 6 weeks.
. Elastic intramedullary nailing.
. Short leg walking cast for 3-4 weeks.
. External fixation.
. Surgical exploration and plating.

Correct Answer & Explanation

. Short leg walking cast for 3-4 weeks.

Explanation

A 'toddler's fracture' is a common, often minimally or non-displaced spiral or oblique fracture of the distal tibia in young children (typically 9 months to 3 years old), usually caused by low-energy trauma. The treatment is conservative, typically with a short leg walking cast for 3-4 weeks. These fractures heal reliably well with excellent outcomes. Rigid or long-term casting is unnecessary. Intramedullary nailing, external fixation, or surgical exploration and plating are overly aggressive and inappropriate for this benign fracture.

Question 5774

Topic: 2. Trauma
A 30-year-old motorcyclist sustains a pelvic fracture after a high-speed collision. He is hemodynamically unstable, with a systolic blood pressure of 80 mmHg. Initial assessment reveals a widely displaced open book pelvic fracture (APC Type III). What is the immediate life-saving intervention?
. Immediate external fixation of the pelvis.
. Pelvic angiography with embolization.
. Application of a pelvic binder or sheet.
. Volume resuscitation with crystalloids and blood products.
. Urgent transfer to the operating theatre for internal fixation.

Correct Answer & Explanation

. Application of a pelvic binder or sheet.

Explanation

In a hemodynamically unstable patient with a widely displaced open book pelvic fracture (APC Type III), applying a pelvic binder or sheet is the immediate life-saving intervention. This maneuver closes the 'open book,' reduces the pelvic volume, and tamponades bleeding from disrupted venous plexuses and cancellous bone, thus stabilizing the pelvis and reducing ongoing hemorrhage. This should be done concurrently with volume resuscitation (crystalloids and blood products). While external fixation, angiography with embolization, and eventual internal fixation are critical parts of definitive management, they are not the first immediate step. Volume resuscitation is ongoing, but mechanical stabilization of the pelvis is crucial to stemming the source of hemorrhage.

Question 5775

Topic: 2. Trauma

A 60-year-old female sustains a fall directly onto her elbow. Radiographs show a comminuted olecranon fracture with significant displacement and involvement of the articular surface. What is the most appropriate management?

. Long arm cast immobilization for 6 weeks.
. Excision of the olecranon fragment.
. Open reduction and internal fixation (ORIF) with tension band wiring or plate and screws.
. Radial head replacement.
. Skeletal traction.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with tension band wiring or plate and screws.

Explanation

A displaced, comminuted olecranon fracture with articular involvement significantly disrupts the extensor mechanism of the elbow and the joint surface. Open reduction and internal fixation (ORIF) is the standard treatment to restore articular congruity and the extensor mechanism. Tension band wiring is effective for simple transverse fractures, while plate and screw fixation is often preferred for comminuted or oblique fractures to achieve stable fixation and allow early range of motion. Non-operative management is only for non-displaced fractures with an intact extensor mechanism. Excision of the olecranon is considered for very small, highly comminuted fragments or in older, low-demand patients, but typically not for significant articular involvement. Radial head replacement is for radial head fractures. Skeletal traction is not used for olecranon fractures.

Question 5776

Topic: 2. Trauma

A 16-year-old male sustains a fracture through the base of the first metatarsal, extending into the articular surface, with lateral displacement of the metatarsal. Which of the following describes this injury?

. Jones fracture.
. Stress fracture.
. Dancer's fracture.
. Avulsion fracture of the base of the 5th metatarsal.
. Bennett's fracture of the first metatarsal.

Correct Answer & Explanation

. Bennett's fracture of the first metatarsal.

Explanation

A fracture through the base of the first metatarsal, extending into the articular surface, with lateral displacement of the metatarsal, is characteristic of a Bennett's fracture. This is an intra-articular fracture-dislocation of the base of the first metacarpal (typically, the question mistakenly says metatarsal, but Bennett's classically refers to the hand). Assuming the question intended 'first metacarpal,' this is a Bennett's fracture. Jones fracture is a transverse fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal. Stress fractures are typically hairline fractures. Dancer's fracture (or spiral fracture of the fifth metatarsal) is usually a result of inversion and plantarflexion. Avulsion fracture of the base of the 5th metatarsal is due to pull from the peroneus brevis tendon.

Question 5777

Topic: 2. Trauma

A 2-year-old child presents with a femoral shaft fracture. What is the most appropriate initial management for this injury in a healthy child of this age?

. Skeletal traction followed by spica cast.
. Flexible intramedullary nailing.
. External fixation.
. Immediate spica cast.
. Submuscular plating.

Correct Answer & Explanation

. Immediate spica cast.

Explanation

For a femoral shaft fracture in a healthy child aged 6 months to 5 years (some sources say up to 6 years), an immediate spica cast is the preferred initial management. Children in this age group have excellent remodeling potential, and a spica cast effectively immobilizes the fracture, allows for early discharge, and has high union rates. Skeletal traction followed by a spica cast is a valid older method but is more cumbersome and requires hospitalization. Flexible intramedullary nailing is typically for children aged 6-12 years. External fixation is reserved for open fractures, polytrauma, or significant soft tissue injury. Submuscular plating is also for older children or specific fracture patterns.

Question 5778

Topic: 2. Trauma

A 40-year-old male sustains a direct blow to the lateral aspect of his knee. He has severe pain and inability to bear weight. Radiographs show a depressed lateral tibial plateau fracture (Schatzker Type II). Which of the following is the most critical aspect of surgical management?

. External fixation to span the knee joint.
. Arthroscopic debridement of the joint.
. Elevation of the depressed articular segment and support with bone graft.
. Primary knee arthroplasty.
. Repair of the lateral collateral ligament.

Correct Answer & Explanation

. Elevation of the depressed articular segment and support with bone graft.

Explanation

For a depressed lateral tibial plateau fracture (Schatzker Type II), the critical aspect of surgical management is the elevation of the depressed articular segment and support of the elevated segment with a bone graft (autograft or allograft), followed by stable plate and screw fixation. This aims to restore articular congruity and mechanical alignment of the joint, which is paramount to preventing post-traumatic arthritis. While external fixation might be used temporarily for severe open injuries, it's not the definitive articular management. Arthroscopic debridement alone is insufficient. Primary knee arthroplasty is a salvage procedure for severe arthritis, not acute fractures. Repair of the lateral collateral ligament might be needed if injured, but the primary pathology is the articular depression.

Question 5779

Topic: 2. Trauma

A 6-year-old boy presents with pain and swelling in his forearm after a fall. Radiographs show a greenstick fracture of both the radius and ulna, with apex dorsal angulation. What is the most appropriate management?

. Rigid cast immobilization without reduction.
. Open reduction and internal fixation (ORIF).
. Closed reduction under anesthesia, followed by long arm cast.
. Elastic intramedullary nailing.
. Dynamic splinting.

Correct Answer & Explanation

. Closed reduction under anesthesia, followed by long arm cast.

Explanation

Greenstick fractures are incomplete fractures common in children. While they have excellent remodeling potential, significant angulation (especially apex dorsal) needs to be corrected to prevent malunion and functional impairment, particularly in the forearm where rotation is critical. Closed reduction under anesthesia, followed by a long arm cast, is the standard treatment for displaced greenstick forearm fractures. The intact cortex on the concave side of the fracture must often be completed (broken) during reduction to prevent recurrent angulation. Rigid cast immobilization without reduction is inappropriate for significant angulation. ORIF or elastic nailing are reserved for highly unstable or irreducibility fractures. Dynamic splinting is not sufficient for an acute fracture.

Question 5780

Topic: 2. Trauma

A 25-year-old male sustains a femoral shaft fracture. During reaming for intramedullary nailing, he experiences a sudden drop in end-tidal CO2, hypoxia, and hypotension. The surgical team suspects fat embolism. What is the most appropriate immediate therapeutic intervention?

. Administer vasopressors to maintain blood pressure.
. Increase fractional inspired oxygen (FiO2) and optimize ventilation.
. Administer high-dose corticosteroids.
. Stop reaming and ventilate with 100% oxygen.
. Administer heparin for anticoagulation.

Correct Answer & Explanation

. Stop reaming and ventilate with 100% oxygen.

Explanation

When fat embolism is suspected during intramedullary nailing, the most appropriate immediate therapeutic intervention is to stop reaming and ventilate the patient with 100% oxygen. This stops the ongoing embolization and maximizes oxygen delivery to combat the hypoxia. While vasopressors might be needed to support blood pressure and optimizing ventilation is part of supportive care, stopping the causative factor and addressing hypoxia directly are paramount. High-dose corticosteroids have not shown consistent benefit. Heparin is not indicated for fat embolism syndrome as it's not a thrombotic event.

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