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2. Trauma MCQs

Practice Set 310 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 6181

Topic: 2. Trauma

Figure 29 shows the radiograph of a 10-year-old boy who injured his knee playing football. What is the most appropriate initial treatment?

General Orthopedics Board Review 2026: High-Yield MCQs (Set 12) - Figure 54

. Closed reduction and casting
. Flexible nailing
. Blade plate fixation
. Anatomic reduction and smooth pin fixation with supplemental casting
. Open or closed reduction and screw fixation

Correct Answer & Explanation

. Anatomic reduction and smooth pin fixation with supplemental casting

Explanation

Salter type I fractures of the distal femur are quite unstable; therefore, closed reduction and cast immobilization can be expected to result in high rates of redisplacement. Optimal treatment consists of open or closed reduction and smooth pin fixation, and supplemental casting is required to ensure fracture stability. Screw fixation may increase rates of growth plate injury. Blade plate or flexible nail fixation will be challenging to apply and is not necessary. Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659. Thomson JD, Stricker SJ, Williams MM: Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995;15:474-478.

Question 6182

Topic: 2. Trauma

An 86-year-old woman sustained a fracture of the humerus and underwent surgical fixation 8 weeks ago. There was no radial nerve function below the elbow after surgery. Radiographs are shown in Figures 51a and 51b. What is the most appropriate management at this time?

. Nerve conduction velocity studies and electromyography
. Exploration and grafting of the radial nerve
. Tendon transfers
. Observation for another 2 months
. Removal of the plate, neurolysis of the radial nerve, and intramedullary rodding of the humerus

Correct Answer & Explanation

. Observation for another 2 months

Explanation

Most radial nerve palsies associated with closed fractures of the humerus resolve spontaneously, including Holstein-Lewis lesions (radial nerve palsy associated with oblique distal third fractures of the humerus). Initial sign of recovery at the brachioradialis may not occur for 4 months. There has been no evidence of deleterious effects occurring during this observation period. There are advocates of early exploration of the nerve. Exploration in the intermediate period between 1 and 4 months is not supported. As overall alignment of the fracture is acceptable, there is no need for hardware exchange until nonunion is clearly identified. Shao YC, Harwood P, Grotz MR, et al: Radial nerve palsy associated with fractures of the shaft of the humerus: A systematic review. J Bone Joint Surg Br 2005;87:1647-1652.

Question 6183

Topic: 2. Trauma

A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient's mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?

. Emergent four compartment fasciotomies
. Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture
. Elevation of the limb overnight and four compartment fasciotomies in the morning
. Elevation of the limb overnight and a recheck of compartment pressures in the morning
. Emergent MRI of the knee and leg

Correct Answer & Explanation

. Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture

Explanation

The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.

Question 6184

Topic: 2. Trauma

A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure 62. Based on these findings, what is the most appropriate treatment?

. Electrical stimulation
. Bone grafting
. No weight bearing
. Bone grafting and compression plating
. Free vascularized bone transport

Correct Answer & Explanation

. Bone grafting and compression plating

Explanation

Nonunions after intramedullary nails are often treated with exchange reamed nailing. In a recent study, this resulted in a union rate of 53%. After failed exchange nailing, bone grafting and compression plating should be used. The other options resulted in less satisfactory results as compared to bone grafting and compression plating. Weresh MJ, Hakanson R, Stover MD, et al: Failure of exchange reamed intramedullary nails for ununited femoral shaft fractures. J Orthop Trauma 2000;14:335-338.

Question 6185

Topic: 2. Trauma

A 25-year-old male polytrauma patient undergoes initial temporary external fixation for a femoral shaft fracture. He is converted to a femoral nail at 7 days. This management can be expected to result in

. higher infection rates.
. higher nonunion rates.
. equal union and infection rates.
. higher rate of ARDS.
. higher mortality rate.

Correct Answer & Explanation

. equal union and infection rates.

Explanation

Recently Harwood and associates investigated the principles of damage control orthopaedics (DCO) as they apply to patients with femoral shaft fractures. When they compared those who underwent initial external fixation of femoral shaft fractures with conversion to an intramedullary nail to those who underwent intramedullary nailing as their initial treatment, they found the following: overall infection rates were comparable in patients receiving DCO versus primary intramedullary fixation; open fracture was an independent risk factor for infection regardless of the treatment method; contamination rates in external fixator pin sites rose considerably when left in place more than 2 weeks and logistic regression analysis suggests that infection rates may increase when conversion to an intramedullary nail occurs after 2 weeks following external fixation; and there was no significant difference in time to union among treatment groups. Harwood PJ, Giannoudis PV, Probst C, et al: The risk of local infective complications after damage control procedures for femoral shaft fracture. J Orthop Trauma 2006;20:181-189.

Question 6186

Topic: Pelvic & Acetabular Trauma

A 45-year-old male presents in hemorrhagic shock following a crush injury. A pelvic binder is applied. Secondary survey reveals blood at the urethral meatus and a high-riding prostate on digital rectal examination. Pelvic radiographs show a displaced pubic symphysis diastasis. Which of the following is the most appropriate next step in the urologic management of this patient?

. Immediate blind placement of a 16-French Foley catheter
. Immediate suprapubic catheter placement in the trauma bay
. Retrograde urethrogram
. CT cystogram
. Flexible cystoscopy

Correct Answer & Explanation

. Retrograde urethrogram

Explanation

Blood at the urethral meatus, scrotal/perineal ecchymosis, and a high-riding prostate are classic signs of a posterior urethral injury, which is highly associated with anterior pelvic ring injuries (e.g., APC patterns). Blind insertion of a Foley catheter is contraindicated as it may convert a partial urethral tear into a complete tear. A retrograde urethrogram (RUG) is the gold standard diagnostic study and must be performed prior to any attempt at transurethral catheterization.

Question 6187

Topic: 2. Trauma

A 32-year-old male sustains a closed comminuted tibial shaft fracture. Twelve hours post-injury, he develops increasing pain out of proportion to his injury and severe pain with passive stretch of his toes. You suspect acute compartment syndrome and obtain compartment pressure measurements. Which of the following criteria is generally considered the most reliable threshold for performing a four-compartment fasciotomy?

. Absolute compartment pressure > 20 mm Hg
. Absolute compartment pressure > 30 mm Hg
. Delta pressure (Diastolic BP minus Compartment Pressure) < 30 mm Hg
. Delta pressure (Mean Arterial Pressure minus Compartment Pressure) < 40 mm Hg
. Delta pressure (Systolic BP minus Compartment Pressure) < 30 mm Hg

Correct Answer & Explanation

. Delta pressure (Diastolic BP minus Compartment Pressure) < 30 mm Hg

Explanation

Acute compartment syndrome is primarily a clinical diagnosis, but in equivocal cases or in obtunded patients, compartment pressure measurements are critical. The delta pressure, calculated as Diastolic Blood Pressure minus Compartment Pressure, is considered the most reliable indicator for tissue perfusion. A delta pressure of less than 30 mm Hg indicates inadequate perfusion and is an absolute indication for emergency fasciotomy. Absolute pressures can be misleading, particularly in hypotensive or hypertensive patients.

Question 6188

Topic: 2. Trauma

A 25-year-old multiple trauma patient with a closed head injury (GCS 7), bilateral pulmonary contusions, and bilateral femoral shaft fractures presents to the trauma bay. Initial labs show a lactate of 4.5 mmol/L and a base deficit of -8. After initial fluid resuscitation, his vitals are HR 115 and BP 90/60. What is the most appropriate initial orthopedic management of his bilateral femur fractures?

. Immediate bilateral reamed intramedullary nailing
. Immediate bilateral unreamed intramedullary nailing
. Bilateral external fixation
. Skeletal traction for 3 weeks followed by definitive nailing
. Open reduction and internal fixation with dynamic compression plates

Correct Answer & Explanation

. Bilateral external fixation

Explanation

This patient is physiologically unstable ('borderline' or 'in extremis') with a severe head injury, chest trauma, hypoperfusion (lactate 4.5, base deficit -8), and hemodynamic instability. The concept of Damage Control Orthopedics (DCO) dictates that early definitive fracture care (like reamed IM nailing) can cause a second hit, leading to ARDS or exacerbation of traumatic brain injury. The most appropriate initial management is rapid temporary stabilization with bilateral external fixation until the patient's physiology optimizes.

Question 6189

Topic: 2. Trauma
A 40-year-old agricultural worker sustains a Grade IIIb open tibia fracture after his leg is caught in a tractor mechanism, resulting in heavy soil and manure contamination. In addition to a first-generation cephalosporin and an aminoglycoside, what additional intravenous antibiotic coverage is strictly indicated?
. Clindamycin
. Vancomycin
. Penicillin
. Metronidazole
. Ciprofloxacin

Correct Answer & Explanation

. Penicillin

Explanation

Farm injuries, especially those contaminated with soil, feces, or standing water, carry a high risk of infection with anaerobic organisms, most notably Clostridium perfringens, which can cause devastating gas gangrene. The standard prophylactic antibiotic regimen for a Gustilo-Anderson Grade III open fracture is a first-generation cephalosporin (for Gram-positives) plus an aminoglycoside (for Gram-negatives). High-dose Penicillin is added specifically for farm-related or heavily soil-contaminated injuries to provide adequate Clostridial coverage.

Question 6190

Topic: 2. Trauma

A 35-year-old male sustains a closed, low-energy transverse fracture of the middle third of the humeral shaft. In the emergency department, he exhibits a complete wrist drop and absent sensation in the first dorsal web space of the hand. His skin is intact. What is the most appropriate initial management of the nerve injury?

. Immediate surgical exploration and repair of the nerve
. Application of a coaptation splint/functional brace and clinical observation
. Surgical fixation of the fracture and concurrent nerve exploration
. Immediate Electromyography (EMG) and Nerve Conduction Studies
. Primary nerve grafting

Correct Answer & Explanation

. Application of a coaptation splint/functional brace and clinical observation

Explanation

Radial nerve palsy associated with a closed humeral shaft fracture occurs in up to 18% of cases, most commonly neuropraxia. The standard of care for a primary radial nerve palsy in the setting of a closed humeral shaft fracture is expectant management, as spontaneous recovery occurs in >70-85% of cases. Immediate surgical exploration is generally reserved for open fractures, severe vascular injuries, or secondary palsies (nerve function lost after a closed reduction attempt). An EMG is typically ordered if there is no clinical sign of recovery by 3 to 4 months.

Question 6191

Topic: 2. Trauma

A 28-year-old male sustains a low-velocity civilian gunshot wound to the right thigh, resulting in a comminuted femoral shaft fracture. The bullet passed cleanly through the thigh, leaving isolated 1 cm entry and exit wounds. Examination reveals a neurologically intact extremity with strong distal pulses. Which of the following is the most appropriate management strategy?

. Extensive formal operative debridement of the missile tract followed by external fixation
. Reamed intramedullary nailing within 24 hours with superficial local wound care
. Nonoperative management in 90-90 skeletal traction for 6 weeks
. Immediate open reduction and internal plating with autologous bone grafting
. Prophylactic four-compartment fasciotomies followed by unreamed intramedullary nailing

Correct Answer & Explanation

. Reamed intramedullary nailing within 24 hours with superficial local wound care

Explanation

Low-velocity civilian gunshot wounds (GSWs) causing femoral shaft fractures are generally treated as closed fractures in terms of internal fixation timing and methodology. Extensive formal debridement of the entire missile tract is unnecessary and increases morbidity. Superficial local debridement/wound care followed by early reamed intramedullary nailing provides excellent clinical outcomes, comparable to those of closed fractures. Plating or traction are not standard for diaphyseal femur fractures in this setting.

Question 6192

Topic: 2. Trauma

A 35-year-old man is involved in a high-speed motorcycle collision. Radiographs demonstrate a comminuted bicondylar tibial plateau fracture with metaphyseal-diaphyseal dissociation.


On examination, the leg is extremely tense, and he has agonizing pain with passive extension of the hallux. If a four-compartment fasciotomy of the leg is performed using a standard two-incision technique, which compartment is most at risk for inadequate decompression?

. Anterior compartment
. Lateral compartment
. Superficial posterior compartment
. Deep posterior compartment
. Peroneal compartment

Correct Answer & Explanation

. Deep posterior compartment

Explanation

The deep posterior compartment is the most commonly missed or inadequately decompressed compartment during two-incision lower extremity fasciotomies. It is located deep to the superficial posterior compartment and must be accessed by taking the soleus off the posterior aspect of the tibia. Failure to fully decompress this compartment can lead to irreversible muscle necrosis and claw toe deformities.

Question 6193

Topic: 2. Trauma

A 65-year-old woman sustained a supracondylar femur fracture treated with a lateral locked plate. Six months postoperatively, she presents with progressive thigh pain. Radiographs demonstrate a broken plate at the fracture site and a lack of bridging callus. Which technical error during the initial surgery is most strongly associated with this specific mode of implant failure?

. Using a plate that is too long
. Inadequate working length creating an overly stiff construct
. The use of titanium instead of stainless steel implants
. Failure to achieve an anatomical reduction of the articular surface
. Using unicortical rather than bicortical screws in the diaphysis

Correct Answer & Explanation

. Inadequate working length creating an overly stiff construct

Explanation

Locked plating of comminuted metaphyseal/diaphyseal fractures relies on the principle of relative stability and secondary bone healing via callus formation. A construct that is too stiff (e.g., short working length, filling all the screw holes adjacent to the fracture site) suppresses micromotion, inhibiting callus formation. This leads to nonunion and eventual fatigue failure of the implant.

Question 6194

Topic: 2. Trauma
A 28-year-old construction worker sustains a Gustilo-Anderson IIIB open fracture of the middle third of the tibia. After serial debridements, the wound bed is healthy, but there is a 6 cm x 4 cm area of exposed anterior tibia devoid of periosteum. Which of the following soft tissue coverage options is most appropriate for this specific defect?
. Medial gastrocnemius rotational flap
. Soleus rotational flap
. Sural artery fasciocutaneous flap
. Reverse sural artery flap
. Free latissimus dorsi myocutaneous flap

Correct Answer & Explanation

. Soleus rotational flap

Explanation

Local muscle flap coverage for exposed tibia fractures without periosteum depends on the anatomical zone. The proximal third is typically covered by the medial gastrocnemius flap, the middle third by the soleus flap, and the distal third generally requires a free tissue transfer or a distally based reverse sural flap, as local muscle bellies are inadequate.

Question 6195

Topic: 2. Trauma

A 22-year-old snowboarder sustained a Hawkins type II talar neck fracture treated with open reduction and internal fixation. At his 8-week postoperative visit, an anteroposterior radiograph of the ankle reveals a subchondral radiolucent band in the talar dome. What is the clinical significance of this radiographic finding?

. It is an early sign of impending avascular necrosis (AVN)
. It indicates an ongoing deep infection or septic arthritis
. It demonstrates hyperemic revascularization and an intact vascular supply
. It represents a nonunion at the talar neck fracture site
. It is a harbinger of early post-traumatic osteoarthritis

Correct Answer & Explanation

. It demonstrates hyperemic revascularization and an intact vascular supply

Explanation

The subchondral radiolucent band is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia, which proves that the vascular supply to the body of the talus is intact or has been successfully restored. Its presence is highly predictive of the absence of avascular necrosis (AVN).

Question 6196

Topic: 2. Trauma

A 55-year-old woman sustains a severely displaced 4-part proximal humerus fracture.

When considering the risk of avascular necrosis of the humeral head, which of the following arterial branches provides the predominant blood supply to the articular segment?

. Anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Circumflex scapular artery
. Subscapular artery

Correct Answer & Explanation

. Posterior humeral circumflex artery

Explanation

Historically, the anterior humeral circumflex artery (via the arcuate branch) was taught to be the primary blood supply to the humeral head. However, anatomic perfusion studies by Brooks et al. and Hettrich et al. conclusively demonstrated that the posterior humeral circumflex artery provides the vast majority (up to 64%) of the blood supply to the humeral head.

Question 6197

Topic: 2. Trauma
A 25-year-old man presents following a high-speed collision with a closed left femoral shaft fracture, multiple rib fractures, bilateral pulmonary contusions, and a grade III spleen laceration. Initial vitals: BP 85/50 mmHg, HR 120 bpm. Lactate is 4.5 mmol/L. After 2 liters of crystalloid and splenic embolization, his BP is 95/60 mmHg, and repeat lactate is 3.8 mmol/L. What is the most appropriate management of his femur fracture?
. Reamed intramedullary nailing
. Unreamed intramedullary nailing
. Temporizing external fixation
. Open reduction and internal fixation with a dynamic compression plate
. Skeletal traction and bed rest for 2 weeks

Correct Answer & Explanation

. Temporizing external fixation

Explanation

This patient is a 'borderline' or 'unstable' polytrauma patient (persistent hypotension, elevated lactate, severe chest trauma). Damage Control Orthopedics (DCO), consisting of temporizing external fixation, is indicated to limit the systemic inflammatory response ('second hit') associated with prolonged surgery or canal reaming. Early Total Care (e.g., IM nailing) in this setting heavily increases the risk of ARDS, multi-organ failure, and death.

Question 6198

Topic: 2. Trauma

A 35-year-old male is brought into the trauma bay following a high-speed motor vehicle collision. He is hemodynamically unstable with a blood pressure of 80/50 mmHg. Pelvic compression reveals instability, and an anteroposterior pelvic radiograph demonstrates a wide symphyseal diastasis. An emergency responder placed a pelvic binder in the field.

What is the most common anatomical error in the placement of a circumferential pelvic binder?

. Positioning the binder too high over the iliac crests
. Positioning the binder too low over the proximal thighs
. Failing to internally rotate the lower extremities
. Applying the binder prior to ruling out an associated acetabular fracture
. Placing the binder directly over the greater trochanters

Correct Answer & Explanation

. Placing the binder directly over the greater trochanters

Explanation

The most common error in applying a pelvic binder or sheet is placing it too proximally over the iliac crests. This can be ineffective or even paradoxically open the pelvic ring further. To optimally close an open-book pelvic fracture and reduce pelvic volume, the binder must be centered directly over the greater trochanters.

Question 6199

Topic: 2. Trauma
A 30-year-old man is struck by a motor vehicle and sustains a closed Pauwels type III (high shear angle) femoral neck fracture. To minimize the risk of mechanical failure and nonunion, what is the most biomechanically stable fixation construct for this specific fracture pattern?
. Three parallel partially threaded cannulated screws placed in an inverted triangle
. A sliding hip screw (fixed-angle device) with a supplementary anti-rotation screw
. Multiple fully threaded divergent cannulated screws
. Antegrade reamed intramedullary nail with cross-locking screws
. Primary total hip arthroplasty

Correct Answer & Explanation

. A sliding hip screw (fixed-angle device) with a supplementary anti-rotation screw

Explanation

Vertical femoral neck fractures (Pauwels type III) in young adults experience high vertical shear forces. Biomechanical studies have consistently shown that a fixed-angle device, such as a sliding hip screw (often supplemented with a derotation screw), provides superior stability and higher load-to-failure rates compared to three parallel cannulated screws for high-angle shear fractures.

Question 6200

Topic: 2. Trauma

A 25-year-old male is evaluated in the emergency department after sustaining an isolated low-velocity civilian gunshot wound to the right thigh. Radiographs demonstrate a midshaft femur fracture. He is hemodynamically stable, has palpable distal pulses, no sensory deficits, and the entrance and exit wounds are less than 1 cm with minimal contamination. What is the standard of care for definitive management?

. Formal open irrigation and debridement of the fracture site followed by external fixation
. Formal open irrigation and debridement followed by plate osteosynthesis
. Local wound care, antibiotics, and early reamed intramedullary nailing
. Local wound care, antibiotics, and delayed intramedullary nailing at 7-10 days
. Skeletal traction for 6 weeks followed by functional bracing

Correct Answer & Explanation

. Local wound care, antibiotics, and early reamed intramedullary nailing

Explanation

Low-velocity civilian gunshot wounds resulting in femur fractures without neurovascular compromise or massive soft tissue destruction can be treated safely similarly to closed fractures. Local superficial wound care, tetanus prophylaxis, intravenous antibiotics, and early reamed intramedullary nailing yield excellent union rates without an increased risk of deep infection. Formal deep debridement of the fracture site is generally unnecessary.

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