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2. Trauma MCQs

Practice Set 290 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 5781

Topic: 2. Trauma

A 35-year-old male sustains a high-energy trauma with a closed Schatzker Type VI tibial plateau fracture. The patient is hemodynamically stable. Which of the following is the most appropriate initial surgical approach?

. Immediate definitive open reduction and internal fixation.
. External fixation spanning the knee joint.
. Non-operative management with a long leg cast.
. Primary knee arthrodesis.
. Arthroscopic reduction and percutaneous fixation.

Correct Answer & Explanation

. Immediate definitive open reduction and internal fixation.

Explanation

A Schatzker Type VI tibial plateau fracture involves a dissociation of the metaphysis from the diaphysis and often extends into the articular surface, representing a highly unstable, complex injury. For a hemodynamically stable patient, immediate definitive open reduction and internal fixation (ORIF) is often the preferred treatment. This involves restoring the articular surface, buttressing the metaphysis, and fixing the diaphyseal dissociation. While temporary external fixation can be used for damage control in polytrauma or for swelling, definitive ORIF is typically pursued as early as soft tissue conditions allow. Non-operative management is unsuitable for such unstable fractures. Primary knee arthrodesis is a salvage procedure. Arthroscopic reduction is typically for less complex, well-contained fractures (e.g., Schatzker Type I or II non-depressed fractures).

Question 5782

Topic: 2. Trauma

A 78-year-old female with severe dementia and multiple comorbidities sustains a stable, non-displaced pubic rami fracture after a ground-level fall. She is otherwise neurologically intact. What is the most appropriate management?

. Immediate surgical stabilization with plate and screws.
. Strict bed rest for 6 weeks.
. Analgesia and early mobilization as tolerated.
. External fixation of the pelvis.
. MRI of the pelvis to rule out occult instability.

Correct Answer & Explanation

. Analgesia and early mobilization as tolerated.

Explanation

For a stable, non-displaced pubic rami fracture, especially in an elderly patient with comorbidities, the management is almost always non-operative. The primary goal is pain control to allow for early mobilization as tolerated. Prolonged bed rest is associated with significant complications in the elderly (e.g., pneumonia, DVT, pressure ulcers, deconditioning). Surgical stabilization or external fixation are reserved for unstable pelvic fractures. MRI is not necessary for a confirmed stable fracture without suspicion of neurological injury or occult instability.

Question 5783

Topic: 2. Trauma

A 5-year-old child sustains a displaced femoral shaft fracture. Which of the following is the most appropriate definitive management option given the child's age?

. Spica cast.
. Flexible intramedullary nailing.
. Rigid intramedullary nailing.
. External fixation.
. Open reduction and plate fixation.

Correct Answer & Explanation

. Spica cast.

Explanation

For a displaced femoral shaft fracture in a 5-year-old, a spica cast is a highly effective and widely used definitive treatment. Children in this age group have excellent remodeling potential, and a spica cast provides stable immobilization allowing for good functional outcomes. Flexible intramedullary nailing is typically reserved for children aged 6 to 12 years. Rigid intramedullary nailing is for older adolescents/adults due to growth plate risk. External fixation is usually for open fractures or polytrauma. Open reduction and plate fixation are less common for this age group unless other methods are contraindicated or fail.

Question 5784

Topic: 2. Trauma

A 32-year-old male sustains a proximal humerus fracture after a motorcycle accident. Radiographs show a displaced two-part surgical neck fracture. What is the most appropriate management in this young, active patient?

. Non-operative management with a sling.
. Hemiarthroplasty.
. Reverse shoulder arthroplasty.
. Open reduction and internal fixation (ORIF) with a locking plate.
. Intramedullary nailing.

Correct Answer & Explanation

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

Explanation

For a displaced two-part surgical neck fracture of the humerus in a young, active patient, open reduction and internal fixation (ORIF) with a locking plate is the preferred treatment. This approach aims to achieve anatomical reduction and stable fixation, preserving the native humeral head and allowing for early rehabilitation to restore function. Non-operative management is typically for minimally displaced or impacted fractures. Hemiarthroplasty or reverse shoulder arthroplasty are prosthetic replacements usually reserved for older patients, poor bone quality, or complex fractures where ORIF is not feasible or likely to fail. Intramedullary nailing can be used for certain surgical neck fractures, but locking plates offer good stability, especially for two-part surgical neck fractures.

Question 5785

Topic: 2. Trauma
A 10-year-old child sustains a Salter-Harris Type IV fracture of the distal tibia. The fracture is displaced. Which of the following is the most significant concern regarding potential complications?
. Risk of vascular injury.
. High likelihood of non-union.
. Associated nerve damage.
. Growth arrest and angular deformity.
. Development of compartment syndrome.

Correct Answer & Explanation

. Growth arrest and angular deformity.

Explanation

A Salter-Harris Type IV fracture involves a fracture line extending through the epiphysis, physis, and metaphysis. This type of fracture directly violates the growth plate and involves the germinal cells, carrying a significantly high risk of growth arrest and angular deformity if not anatomically reduced and stably fixed. The risk of growth arrest is higher than Type I, II, or III fractures. While vascular or nerve injury and compartment syndrome are general trauma concerns, they are not specific to Type IV Salter-Harris in the way growth arrest is. Non-union is less of a concern than growth arrest in this particular fracture type.

Question 5786

Topic: 2. Trauma

A 40-year-old male sustains a comminuted fracture of the distal humerus (AO Type C3) with significant articular involvement. Which of the following is the most important principle for surgical management to optimize functional outcome?

. Early immobilization in a long arm cast.
. External fixation spanning the elbow joint.
. Anatomical reduction of the articular surface and stable internal fixation.
. Excision of comminuted fragments to facilitate motion.
. Radial head replacement.

Correct Answer & Explanation

. Anatomical reduction of the articular surface and stable internal fixation.

Explanation

A comminuted distal humerus fracture with significant articular involvement (AO Type C3) is a challenging injury. The most important principle for optimizing functional outcome is anatomical reduction of the articular surface and stable internal fixation. This typically involves dual plating (medial and lateral) to restore the column integrity and reconstruct the articular surface, allowing for early range of motion. Early immobilization leads to severe stiffness. External fixation may be used temporarily but not as a definitive treatment for articular reconstruction. Excision of fragments sacrifices bone and can lead to instability. Radial head replacement is for radial head fractures, not the distal humerus itself.

Question 5787

Topic: 2. Trauma

A 65-year-old female presents with acute pain and swelling in her distal forearm after a fall. Radiographs show a distal radius fracture (Colles' type) with significant dorsal displacement and shortening. She has good bone quality. What is the most appropriate management strategy for this active patient?

. Closed reduction and casting.
. External fixation.
. Percutaneous pinning.
. Volar locking plate fixation.
. Sugar tong splint for 2 weeks followed by cast.

Correct Answer & Explanation

. Volar locking plate fixation.

Explanation

For a displaced distal radius fracture with significant dorsal displacement and shortening in an active 65-year-old with good bone quality, volar locking plate fixation is generally considered the preferred management. It allows for anatomical reduction and stable internal fixation, permitting early range of motion and leading to better functional outcomes compared to casting, external fixation, or percutaneous pinning for significantly displaced fractures. Closed reduction and casting may not maintain reduction for unstable fractures. External fixation or percutaneous pinning are options, but locking plates often provide superior stability and earlier return to function for this type of injury in active patients.

Question 5788

Topic: 2. Trauma

A 24-year-old male sustains a closed, spiral fracture of the distal third of his humerus (Holstein-Lewis fracture). On examination, he has a complete radial nerve palsy that was present immediately after the injury. What is the most appropriate initial management of the radial nerve?

. Immediate surgical exploration and nerve repair
. Functional bracing and observation for spontaneous recovery
. Open reduction internal fixation (ORIF) with simultaneous nerve exploration
. EMG and nerve conduction studies at 1 week
. External fixation followed by delayed nerve grafting

Correct Answer & Explanation

. Functional bracing and observation for spontaneous recovery

Explanation

Closed humeral shaft fractures with immediate radial nerve palsy are generally managed non-operatively with bracing, as up to 90% resolve spontaneously. Surgical exploration is indicated for open fractures, penetrating trauma, or secondary palsy after closed manipulation.

Question 5789

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable 35-year-old male arrives in the trauma bay after a motorcycle collision. Radiographs show an Anteroposterior Compression (APC) Type III pelvic ring injury. A pelvic binder has been applied but he remains hypotensive despite aggressive fluid resuscitation. FAST scan is negative. What is the most appropriate next step?
. CT abdomen and pelvis with IV contrast
. Application of an external fixator and transfer to ICU
. Preperitoneal pelvic packing and/or angioembolization
. Exploratory laparotomy with bowel run
. Administration of tranexamic acid and wait for response

Correct Answer & Explanation

. Preperitoneal pelvic packing and/or angioembolization

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and negative FAST, retroperitoneal hemorrhage is the most likely cause. Preperitoneal pelvic packing and angioembolization are the primary life-saving interventions to control this bleeding.

Question 5790

Topic: 2. Trauma
A 40-year-old farmer sustains an open tibial shaft fracture heavily contaminated with soil (Gustilo-Anderson IIIB). He has a documented history of severe anaphylaxis to penicillin. According to current guidelines, what is the most appropriate initial intravenous antibiotic regimen?
. Cefazolin and Gentamicin
. Clindamycin and Gentamicin
. Vancomycin and Ciprofloxacin
. Ceftriaxone and Metronidazole
. Meropenem alone

Correct Answer & Explanation

. Clindamycin and Gentamicin

Explanation

Farm injuries require coverage for Gram-positive, Gram-negative, and anaerobic organisms (specifically Clostridium). In a patient with an anaphylactic penicillin allergy, Clindamycin provides anaerobic and Gram-positive coverage, while high-dose Gentamicin covers Gram-negative organisms.

Question 5791

Topic: 2. Trauma

A 38-year-old female sustains a Schatzker VI tibial plateau fracture. Post-operatively, she develops increasing pain and paresthesias in the first web space of her foot. Measurement of compartment pressures reveals a deep posterior compartment pressure of 35 mmHg and a diastolic blood pressure of 60 mmHg. What is the most accurate interpretation?

. Immediate four-compartment fasciotomy is indicated.
. The delta pressure is 35 mmHg, which mandates surgical release.
. The delta pressure is 25 mmHg, which is acceptable; continue to observe.
. The findings are consistent with isolated deep peroneal nerve neuropraxia.
. Immediate peroneal nerve release is required.

Correct Answer & Explanation

. The delta pressure is 35 mmHg, which mandates surgical release.

Explanation

Delta pressure is calculated as diastolic blood pressure minus compartment pressure (60 - 35 = 25 mmHg). A delta pressure of less than 30 mmHg in the setting of clinical signs of compartment syndrome is an absolute indication for emergency fasciotomy.

Question 5792

Topic: 2. Trauma

A 45-year-old male sustains a high-energy distal femur fracture. CT imaging reveals a coronal plane fracture of the lateral femoral condyle. What is the standard classification for this specific fracture pattern, and what is the preferred fixation strategy?

. Schatzker fracture; lateral locked plating
. Hoffa fracture; anterior-to-posterior lag screws
. Hoffa fracture; posterior-to-anterior lag screws
. Barton fracture; retrograde intramedullary nail
. Die-punch fracture; buttress plating

Correct Answer & Explanation

. Hoffa fracture; posterior-to-anterior lag screws

Explanation

A coronal shear fracture of the femoral condyle is known as a Hoffa fracture. Fixation is best achieved using posterior-to-anterior lag screws inserted perpendicular to the fracture line to maximize compression and minimize hardware prominence in the joint.

Question 5793

Topic: 2. Trauma

A 28-year-old male is brought in after a motor vehicle accident with a closed bilateral femoral shaft fracture, severe pulmonary contusions, and a GCS of 8. His initial lactate is 5.5 mmol/L. What is the most appropriate management of his femur fractures?

. Immediate bilateral reamed intramedullary nailing (Early Total Care)
. Bilateral external fixation (Damage Control Orthopedics)
. Skeletal traction until mental status improves
. Immediate open reduction and internal fixation with plates
. Single-stage unreamed nailing of both femurs

Correct Answer & Explanation

. Bilateral external fixation (Damage Control Orthopedics)

Explanation

In a polytraumatized patient who is borderline or unstable (pulmonary contusions, high lactate, closed head injury), Damage Control Orthopedics (DCO) with external fixation is indicated. This minimizes the second hit of the systemic inflammatory response associated with prolonged surgery and intramedullary reaming.

Question 5794

Topic: 2. Trauma

A 7-year-old boy falls on an outstretched hand and presents with a swollen, painful forearm. Radiographs demonstrate a fracture of the proximal third of the ulna with an associated anterior dislocation of the radial head. What is the eponym for this injury pattern?

. Galeazzi fracture
. Barton fracture
. Monteggia fracture (Bado Type I)
. Monteggia fracture (Bado Type II)
. Essex-Lopresti injury

Correct Answer & Explanation

. Monteggia fracture (Bado Type I)

Explanation

A Monteggia fracture-dislocation consists of a proximal third ulnar shaft fracture with a radial head dislocation. Bado Type I is characterized by an anterior dislocation of the radial head, which is the most common pattern in the pediatric population.

Question 5795

Topic: 2. Trauma

A 68-year-old female presents with a 4-part proximal humerus fracture. According to Hertel's radiographic criteria, which of the following combinations is the most reliable predictor of subsequent avascular necrosis of the humeral head?

. Medial hinge disruption < 2 mm and long calcar segment
. Surgical neck fracture with isolated greater tuberosity displacement
. Anatomical neck fracture, short calcar segment (< 8 mm), and medial hinge disruption (> 2 mm)
. Valgus impacted fracture with an intact medial hinge
. Isolated lesser tuberosity fracture with medial extension

Correct Answer & Explanation

. Anatomical neck fracture, short calcar segment (< 8 mm), and medial hinge disruption (> 2 mm)

Explanation

Hertel identified specific predictors of ischemia in proximal humerus fractures. The combination of an anatomical neck fracture pattern, a short calcar segment attached to the articular surface (< 8 mm), and a disrupted medial hinge (> 2 mm) has a positive predictive value of 97% for ischemia.

Question 5796

Topic: 2. Trauma

A 55-year-old female presents with a distal radius fracture characterized by a volar marginal articular fragment with palmar displacement of the carpus. This injury is best classified as a:

. Colles fracture
. Smith fracture
. Volar Barton fracture
. Chauffeur fracture
. Die-punch fracture

Correct Answer & Explanation

. Volar Barton fracture

Explanation

A Volar Barton fracture is an intra-articular shear fracture of the volar lip of the distal radius, typically accompanied by subluxation of the radiocarpal joint. It represents a highly unstable pattern requiring open reduction and buttress plating.

Question 5797

Topic: 2. Trauma

A 70-year-old female on long-term alendronate therapy presents with acute thigh pain after stepping off a curb. Radiographs show a transverse subtrochanteric fracture with lateral cortical thickening and a medial spike. Which of the following is an essential step in her management?

. Immediate initiation of high-dose corticosteroids
. Prophylactic intramedullary nailing of the contralateral femur regardless of symptoms
. Discontinuation of bisphosphonates and obtaining full-length radiographs of the contralateral femur
. Treatment with an external fixator to avoid medullary canal disturbance
. Conservative management with a spica cast

Correct Answer & Explanation

. Discontinuation of bisphosphonates and obtaining full-length radiographs of the contralateral femur

Explanation

Bisphosphonate-associated atypical femur fractures require immediate cessation of the medication and evaluation of the contralateral femur, as bilateral involvement occurs in up to 30% of patients. Fixation of the symptomatic fractured side is typically achieved with an intramedullary nail.

Question 5798

Topic: 2. Trauma
A 40-year-old male polytrauma patient presents with a blood pressure of 70/40 mmHg. Pelvic radiographs reveal an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is applied, and 2 units of PRBCs are administered, but his blood pressure remains 75/45 mmHg. A FAST exam is negative. What is the most appropriate next step in management?
. Immediate CT scan of the abdomen and pelvis
. Pelvic angiography with embolization
. Exploratory laparotomy
. Application of an anterior external fixator
. Skeletal traction of the lower extremities

Correct Answer & Explanation

. Pelvic angiography with embolization

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, the bleeding is likely from the retroperitoneal venous plexus or arterial sources. After mechanical stabilization with a binder, pelvic angiography with embolization is the intervention of choice for persistent arterial hemorrhage.

Question 5799

Topic: 2. Trauma

A 25-year-old male polytrauma patient presents with bilateral closed femoral shaft fractures and severe pulmonary contusions. His initial lactate is 5.0 mmol/L, and his core temperature is 34.5°C. According to Damage Control Orthopedics (DCO) principles, what is the best management for his femur fractures?

. Bilateral reamed antegrade intramedullary nails
. Bilateral unreamed antegrade intramedullary nails
. Bilateral temporary external fixation
. Open reduction and internal fixation with plates
. Bilateral distal femoral skeletal traction for 6 weeks

Correct Answer & Explanation

. Bilateral temporary external fixation

Explanation

This patient is physiologically unstable with "borderline" or "in extremis" criteria, including coagulopathy, hypothermia, and severe chest trauma. Damage Control Orthopedics (DCO) dictates the use of temporary external fixation to minimize the inflammatory "second hit" associated with early intramedullary nailing.

Question 5800

Topic: 2. Trauma

A 45-year-old female sustains a high-energy intra-articular distal femur fracture. A CT scan reveals a coronal plane shear fracture of the lateral femoral condyle. What is the eponym for this specific fracture pattern?

. Barton fracture
. Segond fracture
. Hoffa fracture
. Stieda fracture
. Tillaux fracture

Correct Answer & Explanation

. Hoffa fracture

Explanation

A Hoffa fracture is a coronal plane shear fracture of the distal femoral condyle, most commonly affecting the lateral condyle. It is often hidden on standard AP radiographs and requires independent anterior-to-posterior or posterior-to-anterior lag screw fixation.

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