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2. Trauma MCQs

Practice Set 319 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 6361

Topic: 2. Trauma

A 50-year-old male undergoes a dual-incision four-compartment fasciotomy for acute compartment syndrome associated with a Schatzker VI tibial plateau fracture. Despite the procedure, he continues to have progressive ischemic pain and toe flexion contractures. Incomplete release of which compartment is the most likely cause of his ongoing symptoms?

. 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 incompletely released compartment during a lower leg fasciotomy. This is often due to an inadequate surgical release of the fascial attachments of the soleus bridge.

Question 6362

Topic: 2. Trauma
A 40-year-old male sustains an APC-III (Anteroposterior Compression type III) pelvic ring injury and is profoundly hypotensive. In the setting of severe pelvic trauma, which of the following is statistically the most common source of major pelvic hemorrhage?
. Superior gluteal artery laceration
. Internal pudendal artery laceration
. Tears of the pelvic venous plexus and bleeding from fractured cancellous bone
. External iliac artery avulsion
. Obturator artery laceration

Correct Answer & Explanation

. Tears of the pelvic venous plexus and bleeding from fractured cancellous bone

Explanation

Although arterial bleeding can be catastrophic and require embolization, approximately 80-90% of significant pelvic hemorrhage originates from the presacral venous plexus and exposed cancellous bone surfaces.

Question 6363

Topic: 2. Trauma

According to the Lauge-Hansen classification, what is the sequential order of anatomic structures injured in a Supination-External Rotation (SER) ankle fracture?

. Anterior inferior tibiofibular ligament (AITFL), medial malleolus, posterior inferior tibiofibular ligament (PITFL), fibula
. Anterior inferior tibiofibular ligament (AITFL), lateral short oblique fibula fracture, posterior inferior tibiofibular ligament (PITFL), medial malleolus/deltoid ligament
. Medial malleolus, AITFL, fibula, PITFL
. Fibula, AITFL, PITFL, medial malleolus
. PITFL, fibula, AITFL, medial malleolus

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL), lateral short oblique fibula fracture, posterior inferior tibiofibular ligament (PITFL), medial malleolus/deltoid ligament

Explanation

The SER sequence progresses anterolaterally to posteromedially: Stage 1 is AITFL rupture; Stage 2 is an oblique/spiral distal fibula fracture; Stage 3 is PITFL rupture or posterior malleolus fracture; Stage 4 is a medial malleolus fracture or deltoid ligament rupture.

Question 6364

Topic: 2. Trauma

A 22-year-old unrestrained passenger presents after a head-on motor vehicle collision with severe hip pain. Radiographs demonstrate a posterior dislocation of the hip without an associated fracture. In what position is the injured lower extremity classically held upon clinical presentation?

. Flexed, abducted, and externally rotated
. Extended, abducted, and externally rotated
. Flexed, adducted, and internally rotated
. Extended, adducted, and internally rotated
. Flexed, adducted, and externally rotated

Correct Answer & Explanation

. Flexed, adducted, and internally rotated

Explanation

Patients with a posterior hip dislocation classically present with the affected lower extremity in a flexed, adducted, and internally rotated position. Conversely, anterior dislocations typically present externally rotated and abducted.

Question 6365

Topic: 2. Trauma

A 25-year-old competitive cyclist falls directly onto his shoulder and sustains a closed, isolated midshaft clavicle fracture. Which of the following radiographic findings represents the strongest indication for operative fixation (ORIF) over nonoperative management?

. 1 cm of shortening with cortical contact
. An undisplaced transverse fracture line
. 100% fracture displacement with greater than 2 cm of shortening
. An associated nondisplaced greenstick fracture
. Presence of an intact periosteal hinge

Correct Answer & Explanation

. 100% fracture displacement with greater than 2 cm of shortening

Explanation

A midshaft clavicle fracture with complete (100%) displacement and shortening greater than 2 cm is strongly associated with higher rates of nonunion, symptomatic malunion, and poorer functional outcomes if treated nonoperatively.

Question 6366

Topic: 2. Trauma

A 30-year-old man sustains a low-velocity civilian gunshot wound to the thigh, resulting in a comminuted midshaft femur fracture. The bullet passed cleanly through the soft tissues without massive tissue destruction. His distal pulses are intact. What is the standard of care for the management of this fracture?

. Application of an external fixator and serial wound debridements
. Immediate intramedullary nailing without formal track debridement
. Nonoperative management with a spica cast
. Open reduction and internal fixation with dual plating
. Prophylactic fasciotomies followed by skeletal traction

Correct Answer & Explanation

. Immediate intramedullary nailing without formal track debridement

Explanation

Low-velocity civilian gunshot fractures of the femur without significant soft tissue devitalization or vascular injury can be safely treated with early intramedullary nailing. Routine formal debridement of the bullet track is not required.

Question 6367

Topic: 2. Trauma

A 40-year-old man sustained a Hawkins Type II talar neck fracture and underwent open reduction and internal fixation. At his 8-week follow-up, an AP radiograph of the ankle reveals 'Hawkins sign'. What does this radiographic finding indicate?

. Sclerosis of the talar dome indicating the onset of avascular necrosis (AVN)
. Subchondral radiolucency of the talar dome indicating intact vascularity
. Early osteophyte formation indicating post-traumatic arthritis
. Resorption of the fracture site indicating a nonunion
. Rapid chondrolysis of the tibiotalar joint

Correct Answer & Explanation

. Subchondral radiolucency of the talar dome indicating intact vascularity

Explanation

Hawkins sign is a subchondral radiolucent band visible in the talar dome 6 to 8 weeks post-injury. It represents subchondral atrophy due to bone resorption, which requires an intact blood supply, thereby indicating a good prognosis against AVN.

Question 6368

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable trauma patient presents with an anterior-posterior compression (APC) type III pelvic ring injury. The trauma team decides to apply a noninvasive pelvic binder. What is the correct anatomical landmark for placing the center of the binder to optimally reduce pelvic volume?
. Anterior superior iliac spines (ASIS)
. Iliac crests
. Greater trochanters
. Pubic symphysis
. Femoral neck

Correct Answer & Explanation

. Greater trochanters

Explanation

A pelvic binder should be centered over the greater trochanters to effectively compress the pelvic ring and reduce volume in open-book injuries. Placement over the iliac crests is incorrect as it can paradoxically widen the pubic symphysis.

Question 6369

Topic: 2. Trauma
A 28-year-old female sustains a Gustilo-Anderson type IIIB open tibia fracture. She has a documented history of anaphylaxis to penicillin. Which of the following intravenous antibiotic regimens is most appropriate in the emergency department?
. Cefazolin and gentamicin
. Clindamycin and gentamicin
. Vancomycin and ciprofloxacin
. Ceftriaxone and vancomycin
. Aztreonam alone

Correct Answer & Explanation

. Clindamycin and gentamicin

Explanation

For type III open fractures, gram-positive and gram-negative coverage is required. In patients with a severe penicillin allergy (anaphylaxis), clindamycin or vancomycin should replace a first-generation cephalosporin, combined with an aminoglycoside or fluoroquinolone.

Question 6370

Topic: 2. Trauma

A 30-year-old man sustains a closed tibial shaft fracture. His blood pressure in the emergency department is 120/80 mm Hg. Compartment pressures are measured as follows: Anterior 45 mm Hg, Lateral 35 mm Hg, Superficial Posterior 40 mm Hg, Deep Posterior 50 mm Hg. What is the Delta P and the most appropriate next step?

. Delta P is 30 mm Hg; emergent four-compartment fasciotomy is indicated
. Delta P is 30 mm Hg; elevate the leg and observe closely
. Delta P is 35 mm Hg; emergent four-compartment fasciotomy is indicated
. Delta P is 70 mm Hg; emergent four-compartment fasciotomy is indicated
. Delta P is 40 mm Hg; observation is appropriate

Correct Answer & Explanation

. Delta P is 30 mm Hg; emergent four-compartment fasciotomy is indicated

Explanation

Delta P is calculated as the diastolic blood pressure minus the highest compartment pressure (80 - 50 = 30 mm Hg). A Delta P of 30 mm Hg or less indicates inadequate capillary perfusion pressure and is an absolute indication for emergency fasciotomy.

Question 6371

Topic: 2. Trauma

A 25-year-old male sustains bilateral femoral shaft fractures in a motor vehicle collision. On post-injury day two, he develops acute respiratory distress. Which of the following represents the classic clinical triad of fat embolism syndrome?

. Hypoxemia, neurologic abnormalities, and a petechial rash
. Tachycardia, hypertension, and diffuse diaphoresis
. Bradycardia, hyperthermia, and an urticarial rash
. Pulmonary hypertension, right heart failure, and jaundice
. Hypotension, coagulopathy, and hypothermia

Correct Answer & Explanation

. Hypoxemia, neurologic abnormalities, and a petechial rash

Explanation

The classic clinical triad of fat embolism syndrome consists of hypoxemia, neurologic abnormalities (such as confusion or altered mental status), and a petechial rash. It typically presents 24 to 72 hours after severe long bone fractures.

Question 6372

Topic: 2. Trauma

In the context of Damage Control Orthopedics (DCO) for a polytraumatized patient, which of the following metabolic parameters best indicates adequate systemic resuscitation, allowing safe conversion from external fixation to definitive intramedullary nailing?

. Serum lactate less than 2.5 mmol/L
. Urine output greater than 0.1 mL/kg/hr
. Hematocrit greater than 30 percent
. Platelet count greater than 50,000
. Systolic blood pressure consistently greater than 90 mm Hg

Correct Answer & Explanation

. Serum lactate less than 2.5 mmol/L

Explanation

Normalization of serum lactate (less than 2.5 mmol/L) and base deficit are the most reliable indicators of adequate tissue perfusion and systemic resuscitation. This normalization implies the patient is physiologically optimized for definitive long surgical procedures.

Question 6373

Topic: 2. Trauma

A 40-year-old man presents with a high-energy posterior knee dislocation. After closed reduction, pedal pulses are palpable but appear asymmetric compared to the uninjured limb. What is the most appropriate next step in evaluation?

. Immediate operative arterial exploration
. Splinting and reassessment in 4 hours
. Measurement of the Ankle-Brachial Index (ABI)
. Prophylactic four-compartment fasciotomy
. Magnetic resonance angiography (MRA)

Correct Answer & Explanation

. Measurement of the Ankle-Brachial Index (ABI)

Explanation

Following reduction of a knee dislocation, if pulses are present but diminished or asymmetric, ABI should be measured. An ABI of less than 0.9 warrants immediate advanced vascular imaging (such as CTA) or surgical consultation.

Question 6374

Topic: 2. Trauma
A 28-year-old trauma patient has an estimated blood loss of 35%. His vitals show a blood pressure of 90/60 mm Hg, heart rate of 130 bpm, and respiratory rate of 30 breaths/min. He is confused and his urine output is 10 mL/hr. According to the ATLS classification, what class of hemorrhagic shock does this represent?
. Class I
. Class II
. Class III
. Class IV
. Class V

Correct Answer & Explanation

. Class III

Explanation

Class III hemorrhagic shock represents 30-40% blood volume loss. It is classically characterized by hypotension, marked tachycardia (HR > 120), tachypnea, decreased urine output, and a change in mental status.

Question 6375

Topic: 2. Trauma

A 35-year-old male sustains a Gustilo-Anderson type II open tibial shaft fracture. Intravenous antibiotics are administered within 30 minutes of arrival. Due to operating room unavailability, surgical debridement is delayed for 10 hours. How does this delay affect his infection risk compared to debridement within 6 hours?

. Significantly higher risk, as the '6-hour rule' is an absolute threshold
. Similar risk, provided appropriate systemic antibiotics are administered promptly
. Significantly lower risk due to the extended period of antibiotic penetration
. Higher risk primarily due to inevitable bone necrosis
. Completely dependent on the eventual method of soft tissue coverage

Correct Answer & Explanation

. Similar risk, provided appropriate systemic antibiotics are administered promptly

Explanation

Recent literature demonstrates that early administration of appropriate intravenous antibiotics is the most critical factor in preventing infection. Delaying surgical debridement up to 24 hours in low-grade open fractures does not significantly increase infection rates if antibiotics were given promptly.

Question 6376

Topic: 2. Trauma

A 22-year-old man presents with a low-velocity civilian gunshot wound to the thigh resulting in a midshaft femur fracture. Vascular examination is normal, with symmetric pulses and an Ankle-Brachial Index (ABI) of 1.1. What is the most appropriate initial management?

. Local wound care, tetanus prophylaxis, and fracture stabilization
. Immediate vascular exploration
. CT angiography of the lower extremity
. Prophylactic two-incision thigh fasciotomy
. Formal open wound debridement in the operating room extending the bullet tracts

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and fracture stabilization

Explanation

Low-velocity gunshot wounds resulting in fractures with a normal vascular examination (ABI > 0.9) do not require routine angiography or immediate operative debridement of the tracts. They are treated with local wound care, tetanus prophylaxis, and appropriate fracture stabilization.

Question 6377

Topic: 2. Trauma

A 34-year-old polytrauma patient presents with a severe closed head injury (GCS 7) and bilateral femoral shaft fractures. Intracranial pressure (ICP) monitoring reveals an ICP of 25 mm Hg. What is the safest initial orthopedic management for the femur fractures?

. Bilateral reamed intramedullary nails
. Bilateral unreamed intramedullary nails
. External fixation of bilateral femurs
. Skeletal traction until head injury resolves
. Open reduction and internal fixation with plates

Correct Answer & Explanation

. External fixation of bilateral femurs

Explanation

In patients with severe traumatic brain injury and elevated intracranial pressure, prolonged physiological insults from reaming and definitive fixation can cause a 'second hit' exacerbating secondary brain injury. Damage control orthopedics with rapid external fixation is indicated.

Question 6378

Topic: 2. Trauma
In the evaluation of a mangled lower extremity, which of the following is considered an absolute indication for primary amputation?
. Posterior tibial nerve transection in an adult
. Total ischemia time greater than 4 hours
. Gustilo-Anderson IIIC tibia fracture
. Unreconstructible vascular injury with irreversible warm ischemia
. Mangled Extremity Severity Score (MESS) of 6

Correct Answer & Explanation

. Unreconstructible vascular injury with irreversible warm ischemia

Explanation

Absolute indications for primary amputation are rare but include anatomically complete transection of the limb or an unreconstructible vascular injury resulting in irreversible warm ischemia. Nerve injury and high MESS scores are relative indications.

Question 6379

Topic: 2. Trauma

Acute compartment syndrome of the thigh is a rare but devastating complication typically associated with severe blunt trauma or femur fractures. Which compartment of the thigh is most frequently involved?

. Anterior compartment
. Posterior compartment
. Medial compartment
. Lateral compartment
. Superficial posterior compartment

Correct Answer & Explanation

. Anterior compartment

Explanation

The anterior compartment of the thigh is the most commonly involved compartment in thigh compartment syndrome. It contains the quadriceps muscle group and the femoral nerve.

Question 6380

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable patient with an anterior-posterior compression (APC) type III pelvic ring injury transiently responds to fluid resuscitation. A pelvic binder has been appropriately placed, but the patient's blood pressure begins to drop again. FAST exam is negative. What is the most appropriate next step in management?
. Emergent exploratory laparotomy
. Preperitoneal pelvic packing and/or pelvic angioembolization
. CT scan of the abdomen and pelvis
. Removal of the pelvic binder and application of an external fixator
. Diagnostic peritoneal lavage (DPL)

Correct Answer & Explanation

. Preperitoneal pelvic packing and/or pelvic angioembolization

Explanation

In a hemodynamically unstable pelvic fracture patient with a negative FAST exam (ruling out massive intra-abdominal hemorrhage), the bleeding is likely retroperitoneal. Preperitoneal pelvic packing or angioembolization is the standard of care to achieve hemostasis.

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