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2. Trauma MCQs

Practice Set 314 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 6261

Topic: Pelvic & Acetabular Trauma
A 35-year-old male is brought to the trauma bay after a motorcycle collision. He is hypotensive (BP 75/40 mmHg) and tachycardic (HR 130 bpm). A FAST exam is negative. A pelvic radiograph shows an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is applied, and he receives 2 units of uncrossmatched blood, but his hemodynamics remain unstable. What is the most appropriate next step in management?
. CT scan of the abdomen and pelvis
. Retrograde urethrogram
. Pelvic angiography and embolization
. Exploratory laparotomy
. Application of a supra-acetabular external fixator

Correct Answer & Explanation

. Pelvic angiography and embolization

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam (excluding intra-abdominal hemorrhage), the source of bleeding is presumed to be the pelvis. After application of a pelvic binder and initial fluid/blood resuscitation, pelvic angiography with embolization (or preperitoneal pelvic packing, depending on institutional protocol) is the most appropriate next step to address life-threatening arterial bleeding.

Question 6262

Topic: 2. Trauma

A 45-year-old male sustains a bicondylar tibial plateau fracture.

Preoperative computed tomography (CT) scan reveals a large, displaced posteromedial coronal shear fragment. What is the most appropriate surgical approach to anatomically reduce and buttress this specific fragment?

. Standard anterolateral approach
. Anteromedial approach
. Posteromedial approach
. Direct posterior approach
. Lateral approach with a posterolateral window

Correct Answer & Explanation

. Posteromedial approach

Explanation

A posteromedial coronal shear fragment in a bicondylar tibial plateau fracture cannot be adequately addressed or buttressed through standard anterolateral or pure anteromedial approaches. A posteromedial approach allows direct visualization, anatomic reduction, and optimal anti-glide or buttress plating of the fragment at the apex of the deformity.

Question 6263

Topic: 2. Trauma
A 30-year-old male sustains a severe open tibial shaft fracture (Gustilo-Anderson Type IIIB) following a high-speed motor vehicle collision. He is brought to the trauma center 45 minutes after the injury. According to current evidence, which of the following interventions has the greatest impact on reducing his risk of deep infection?
. Surgical debridement within 6 hours
. Immediate administration of intravenous antibiotics
. High-pressure pulsatile lavage during debridement
. Definitive skeletal fixation within 24 hours
. Primary wound closure

Correct Answer & Explanation

. Immediate administration of intravenous antibiotics

Explanation

Extensive literature review has demonstrated that early administration of intravenous antibiotics is the single most critical factor in reducing the risk of deep infection following open fractures. While early surgical debridement is important, the strict '6-hour rule' has not been substantiated as an independent predictor of infection risk when compared to the timing of antibiotic administration.

Question 6264

Topic: 2. Trauma
A 28-year-old male sustains a displaced, vertically oriented (Pauwels type III) femoral neck fracture. Which of the following fixation constructs provides the most biomechanical stability for this specific fracture pattern?
. Three parallel cancellous screws in an inverted triangle
. A dynamic hip screw (DHS) with a derotational screw
. Two fully threaded cortical screws
. A flexible intramedullary nail
. A bipolar hemiarthroplasty

Correct Answer & Explanation

. A dynamic hip screw (DHS) with a derotational screw

Explanation

Pauwels type III femoral neck fractures are characterized by a highly vertical orientation, making them subjected to extremely high shear forces. Biomechanical studies have shown that a fixed-angle construct, such as a sliding hip screw (DHS) combined with a derotational screw, provides significantly superior biomechanical stability and lowers the risk of fixation failure compared to multiple parallel cancellous screws.

Question 6265

Topic: 2. Trauma
A 45-year-old farmer sustains a highly contaminated open fracture of the tibial shaft after his leg is caught in a tractor mechanism. The wound is 12 cm long with extensive soft tissue stripping, but adequate soft tissue coverage is achievable. According to the Gustilo-Anderson classification, what is the most appropriate initial intravenous antibiotic regimen?
. First-generation cephalosporin alone
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin, an aminoglycoside, and penicillin
. Ciprofloxacin alone
. Vancomycin and piperacillin-tazobactam

Correct Answer & Explanation

. First-generation cephalosporin, an aminoglycoside, and penicillin

Explanation

This is a Gustilo-Anderson Type IIIA open fracture (high energy, >10 cm wound, extensive soft tissue damage but adequate coverage). Because it is a farm injury, there is a high risk of anaerobic infection, specifically Clostridium species. The standard recommendation for farm injuries or highly contaminated open fractures is a first-generation cephalosporin (for Gram-positives), an aminoglycoside (for Gram-negatives), and penicillin (for anaerobes).

Question 6266

Topic: 2. Trauma

A 35-year-old man involved in a high-speed motor vehicle collision sustains a closed subtrochanteric femur fracture. During closed reduction and intramedullary nailing, the proximal fragment is noted to be highly displaced. Which of the following muscles is primarily responsible for the flexion and external rotation of the proximal fracture fragment?

. Gluteus medius
. Iliopsoas
. Adductor longus
. Tensor fascia lata
. Rectus femoris

Correct Answer & Explanation

. Iliopsoas

Explanation

In subtrochanteric femur fractures, the proximal fragment is subjected to strong deforming forces. The iliopsoas attaches to the lesser trochanter and causes flexion and external rotation of the proximal fragment. The gluteus medius and minimus attach to the greater trochanter and cause abduction. The adductors pull the distal fragment medially.

Question 6267

Topic: 2. Trauma
A 25-year-old man sustains a completely displaced Pauwels type III (vertical shear) fracture of the femoral neck. He is otherwise healthy. To minimize the risk of nonunion and avascular necrosis, what is the most biomechanically sound surgical construct for this patient?
. Bipolar hemiarthroplasty
. Total hip arthroplasty
. Closed reduction and percutaneous pinning with three parallel cancellous screws
. Open reduction and internal fixation with a sliding hip screw and a derotational screw
. Nonoperative management with skeletal traction

Correct Answer & Explanation

. Open reduction and internal fixation with a sliding hip screw and a derotational screw

Explanation

In young patients, joint-preserving surgery is mandated for femoral neck fractures. Pauwels type III fractures have a highly vertical fracture line (>50 degrees), subjecting them to significant shear forces. Three parallel cancellous screws offer poor biomechanical stability against shear in this pattern. A fixed-angle device, such as a sliding hip screw (with an additional derotational screw), provides superior biomechanical resistance to vertical shear forces and decreases the rate of nonunion and displacement.

Question 6268

Topic: Pelvic & Acetabular Trauma
A 40-year-old man is brought to the trauma bay after a motorcycle crash. His blood pressure is 80/40 mmHg and heart rate is 130 bpm. Pelvic radiographs demonstrate an anteroposterior compression type III (APC-III) pelvic ring injury with marked symphyseal diastasis. A FAST exam is negative. What is the most appropriate initial step to acutely reduce pelvic volume and aid hemodynamic stability?
. Immediate open reduction and internal fixation of the pubic symphysis
. Application of a pelvic binder centered over the iliac crests
. Application of a pelvic binder centered over the greater trochanters
. Emergent pelvic angiography and embolization
. Exploratory laparotomy and preperitoneal packing

Correct Answer & Explanation

. Application of a pelvic binder centered over the greater trochanters

Explanation

In an unstable patient with an open-book pelvic fracture (APC injury), the initial mechanical intervention is to reduce pelvic volume. A pelvic binder or sheet must be applied centered directly over the greater trochanters. Placing it over the iliac crests is incorrect and can paradoxically open the pelvis further or fail to provide adequate mechanical advantage to close the posterior ring.

Question 6269

Topic: 2. Trauma

A 30-year-old man sustains a closed midshaft humerus fracture after a fall. On examination in the emergency department, he exhibits a complete wrist drop and inability to actively extend his metacarpophalangeal joints, but has palpable distal pulses. What is the most appropriate initial management of his neurologic deficit?

. Immediate surgical exploration of the radial nerve
. Application of a functional brace and clinical observation of the nerve deficit
. Open reduction and internal fixation of the humerus with concomitant nerve exploration
. Immediate electromyography (EMG) and nerve conduction studies
. External fixation of the humerus

Correct Answer & Explanation

. Application of a functional brace and clinical observation of the nerve deficit

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture (without vascular injury or severe soft tissue compromise) is generally treated nonoperatively. Most primary radial nerve palsies are neuropraxias or axonotmeses that spontaneously recover. Functional bracing of the fracture and supportive splinting of the wrist/hand is the standard of care. Surgical exploration is indicated for open fractures, associated vascular injuries, or a secondary palsy that develops after a closed reduction.

Question 6270

Topic: 2. Trauma

A 45-year-old man sustains a complex tibial plateau fracture. CT imaging demonstrates a large, displaced posteromedial shear fragment. To adequately visualize and anatomically reduce this fragment using a buttress plate, which surgical approach is most appropriate?

. Anterolateral approach
. Direct medial approach
. Posteromedial approach
. Posterolateral approach
. Midline transpatellar approach

Correct Answer & Explanation

. Posteromedial approach

Explanation

A posteromedial shear fragment of the tibial plateau cannot be adequately reduced or buttressed from an anterolateral or direct medial approach. The posteromedial approach utilizes the interval between the medial head of the gastrocnemius and the pes anserinus. This allows direct access to the posterior aspect of the medial tibial plateau for application of an anti-glide or buttress plate to counteract vertical shear forces.

Question 6271

Topic: 2. Trauma

A 35-year-old driver is involved in a severe motor vehicle collision. Pelvic radiographs and computed tomography (CT) reveal an acetabular fracture. The fracture line disrupts the anterior column and extends inferiorly through the anterior wall. A separate transverse fracture line is noted traversing the posterior column, but the superior portion of the posterior column and the ilium remain solidly attached to the axial skeleton. According to the Judet-Letournel classification, what is the correct diagnosis?

. T-type fracture
. Anterior column with posterior hemitransverse fracture
. Transverse fracture
. Both-column fracture
. Posterior column with posterior wall fracture

Correct Answer & Explanation

. Anterior column with posterior hemitransverse fracture

Explanation

This describes an anterior column and posterior hemitransverse fracture, one of the five associated patterns in the Judet-Letournel classification. It features an anterior column (or anterior wall) fracture associated with a transverse fracture through the posterior half of the acetabulum. It is distinguished from a T-type fracture (which has a true transverse component and a vertical stem splitting the obturator ring) and from a both-column fracture, where no part of the articular surface remains attached to the intact posterior ilium (the 'spur sign').

Question 6272

Topic: Pelvic & Acetabular Trauma

A 35-year-old man is brought to the emergency department after a motorcycle collision. He is hypotensive with a blood pressure of 80/50 mm Hg. A pelvic radiograph shows a widened pubic symphysis consistent with an anteroposterior compression (APC) injury. You decide to apply a pelvic binder to provide temporary stability. To most effectively reduce the pelvic volume, at what anatomical level should the binder be centered?

. Iliac crests
. Greater trochanters
. Anterior superior iliac spines
. Mid-thighs
. Umbilicus

Correct Answer & Explanation

. Greater trochanters

Explanation

The most effective placement of a pelvic binder or sheet to reduce pelvic volume in anteroposterior compression (APC) and open-book pelvic fractures is at the level of the greater trochanters. Placing the binder higher, at the level of the iliac crests, is a common error that is less effective and may inadvertently worsen the pelvic deformity by everting the lower pelvis.

Question 6273

Topic: 2. Trauma

A 28-year-old male sustains an isolated, closed, low-velocity gunshot wound to the midshaft femur. Radiographs reveal a comminuted midshaft femur fracture. He is neurovascularly intact, and there is no evidence of a compartment syndrome. Which of the following is the most appropriate management?

. Excisional debridement of the bullet track, removal of the bullet, and external fixation
. Excisional debridement of the bullet track and plate osteosynthesis
. Local wound care, tetanus prophylaxis, and antegrade intramedullary nailing
. Skeletal traction for 6 weeks
. Irrigation and debridement with retention of the bullet and cast bracing

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and antegrade intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in diaphyseal femur fractures do not typically require extensive debridement of the bullet track. Standard evidence-based treatment includes superficial local wound care, tetanus prophylaxis, and standard reamed intramedullary nailing. Routine bullet removal is not indicated unless the bullet is intra-articular or causing direct neurovascular compromise.

Question 6274

Topic: 2. Trauma

A 45-year-old male falls from a height of 15 feet and sustains a high-energy closed pilon fracture. Clinical examination reveals severe swelling, tense skin, and hemorrhagic fracture blisters over the medial and lateral aspects of the ankle. Which of the following represents the most appropriate initial management?

. Immediate open reduction and internal fixation of the tibia and fibula
. Application of a spanning external fixator
. Closed reduction and long leg casting
. Open reduction and internal fixation of the fibula only
. Elevation and observation until blisters resolve, followed by definitive fixation in 3 weeks without temporary stabilization

Correct Answer & Explanation

. Application of a spanning external fixator

Explanation

High-energy pilon fractures often present with severe soft tissue injury. Immediate open reduction and internal fixation (ORIF) is contraindicated due to high rates of wound breakdown, necrosis, and deep infection. The standard of care is temporary spanning external fixation across the ankle joint to restore length and alignment, allowing the soft tissues to recover before definitive fixation is performed (usually 10-21 days later).

Question 6275

Topic: 2. Trauma

A 22-year-old male is struck by a motor vehicle and sustains a closed transverse midshaft tibia fracture, treated with reamed intramedullary nailing. Postoperatively, he requires rapidly increasing doses of opioids for leg pain. Examination reveals a tense leg, and passive extension of the great toe elicits excruciating pain. Which of the following compartments is most likely experiencing critically elevated pressures?

. Anterior
. Lateral
. Superficial posterior
. Deep posterior
. Plantar

Correct Answer & Explanation

. Deep posterior

Explanation

The deep posterior compartment of the leg contains the tibialis posterior, flexor digitorum longus, and flexor hallucis longus. Passive extension of the hallux stretches the flexor hallucis longus, eliciting severe pain out of proportion to the injury. This clinical finding is a classic hallmark for deep posterior compartment syndrome.

Question 6276

Topic: 2. Trauma

A 34-year-old man sustains a pelvic injury following a high-speed motor vehicle collision. An anteroposterior radiograph of the pelvis demonstrates a complex fracture involving the acetabulum. An obturator oblique radiograph clearly demonstrates a 'spur sign'. This radiographic finding is pathognomonic for which of the following acetabular fracture patterns?

. Transverse
. T-type
. Anterior column and posterior hemitransverse
. Both-column
. Isolated posterior column

Correct Answer & Explanation

. Both-column

Explanation

The 'spur sign' is pathognomonic for a both-column fracture of the acetabulum. It represents the intact portion of the ilium that remains attached to the axial skeleton (sacrum), projecting posteriorly relative to the medially displaced articular segment when viewed on the obturator oblique radiograph.

Question 6277

Topic: 2. Trauma
A 30-year-old man sustains a severe open tibia fracture (Gustilo-Anderson IIIB) requiring a free tissue transfer for soft-tissue coverage. To minimize the risk of deep infection and maximize flap survival, the classic study by Godina demonstrated the best outcomes when coverage is performed within what timeframe?
. 24 hours
. 72 hours
. 7 days
. 10 days
. 14 days

Correct Answer & Explanation

. 72 hours

Explanation

The classic principle described by Marko Godina emphasizes that early microsurgical reconstruction of complex lower extremity trauma—specifically within 72 hours of injury—yields significantly lower infection rates, higher flap survival, and better overall bone healing compared to delayed coverage.

Question 6278

Topic: 2. Trauma

A 35-year-old male is involved in a motor vehicle collision and sustains a posterior hip dislocation. Closed reduction is performed in the emergency department within 2 hours. A post-reduction CT scan demonstrates a posterior wall fracture involving 15% of the articular surface. There are no intra-articular fragments, and the joint is congruous. Dynamic fluoroscopic stress examination reveals a stable hip. What is the most appropriate definitive management?

. Immediate open reduction and internal fixation of the posterior wall
. Skeletal traction via a distal femoral pin for 6 weeks
. Touchdown weight-bearing for 6-8 weeks
. Spica cast application
. Total hip arthroplasty

Correct Answer & Explanation

. Touchdown weight-bearing for 6-8 weeks

Explanation

The primary indication for surgical fixation of a posterior wall acetabular fracture is hip instability. The standard evaluation for stability involves a dynamic stress examination under fluoroscopy under anesthesia. If the hip is stable and the posterior wall fragment involves less than 20% of the articular surface with no retained intra-articular loose bodies, non-operative management with protected weight-bearing (touchdown weight-bearing) for 6-8 weeks is appropriate and yields excellent long-term functional results.

Question 6279

Topic: 2. Trauma

A 45-year-old female sustains a closed, midshaft humerus fracture and is treated with a functional brace. At 12 weeks follow-up, she complains of persistent pain and mobility at the fracture site. Radiographs demonstrate no bridging callus formation. Which of the following factors is most strongly associated with nonunion in humeral shaft fractures treated with functional bracing?

. Spiral fracture pattern
. Over-distraction of the fracture fragments
. Early initiation of pendulum exercises
. Distal third fracture location
. Concomitant radial nerve palsy

Correct Answer & Explanation

. Over-distraction of the fracture fragments

Explanation

Functional bracing (Sarmiento bracing) is the gold standard for most closed humeral shaft fractures. Risk factors for nonunion with non-operative management include transverse fracture patterns (which lack the surface area and intrinsic stability of oblique or spiral fractures), soft tissue interposition, and over-distraction. Over-distraction can easily occur if the arm is not properly supported or if gravity pulls the distal fragment inferiorly, leading to a gap that inhibits secondary bone healing.

Question 6280

Topic: 2. Trauma

A 22-year-old healthy male presents with a completely displaced midshaft clavicle fracture. Which of the following is considered a widely accepted relative indication for open reduction and internal fixation to improve functional outcomes and decrease nonunion risk?

. Any displacement greater than 5 mm
. Shortening greater than 20 mm
. Presence of a butterfly fragment
. Patient age greater than 18 years
. Initial pain requiring narcotic analgesia

Correct Answer & Explanation

. Shortening greater than 20 mm

Explanation

Recent high-level evidence has demonstrated that completely displaced, significantly shortened (>2 cm or 20 mm) midshaft clavicle fractures treated non-operatively have a higher rate of nonunion, symptomatic malunion, and decreased long-term shoulder strength/endurance compared to those treated with ORIF. Therefore, >2 cm of shortening and 100% displacement are widely accepted relative indications for operative fixation in young, active patients.

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