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2. Trauma MCQs

Practice Set 320 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 6381

Topic: 2. Trauma

A 35-year-old male is admitted with a closed tibial shaft fracture following a motor vehicle collision. He is intubated for an associated head injury. Intracompartmental pressure monitoring is initiated. Which of the following thresholds is the most widely accepted absolute indication for a four-compartment fasciotomy?

. Absolute compartment pressure > 30 mmHg
. Absolute compartment pressure > 45 mmHg
. Delta P (Diastolic BP minus Compartment Pressure) < 30 mmHg
. Delta P (Mean Arterial BP minus Compartment Pressure) < 30 mmHg
. Delta P (Systolic BP minus Compartment Pressure) < 30 mmHg

Correct Answer & Explanation

. Delta P (Diastolic BP minus Compartment Pressure) < 30 mmHg

Explanation

A Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is the most reliable threshold for diagnosing acute compartment syndrome. Absolute pressure alone is less accurate, especially in hypotensive trauma patients.

Question 6382

Topic: Pelvic & Acetabular Trauma

A 45-year-old male presents in hemorrhagic shock following a motorcycle collision. An anteroposterior pelvic radiograph demonstrates a symphyseal diastasis of 4 cm. What is the most appropriate anatomic landmark for the placement of a circumferential pelvic sheet or commercial binder to ensure optimal mechanical reduction?

. Anterior superior iliac spines (ASIS)
. Iliac crests
. Greater trochanters
. Symphysis pubis
. Ischial tuberosities

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders should be centered over the greater trochanters to effectively close an anterior ring disruption. Placement over the iliac crests is less mechanically efficient and can inadvertently worsen the displacement.

Question 6383

Topic: 2. Trauma
A 28-year-old female sustains a Grade IIIb open tibial shaft fracture with heavy farm soil contamination. According to current evidence-based guidelines, what is the most appropriate initial intravenous antibiotic regimen to administer in the emergency department?
. First-generation cephalosporin alone
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin
. Third-generation cephalosporin alone
. Fluoroquinolone alone

Correct Answer & Explanation

. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin

Explanation

For severe open fractures with heavy contamination (e.g., farm injuries), a first-generation cephalosporin, an aminoglycoside, and penicillin are recommended to cover Gram-positive, Gram-negative, and anaerobic organisms. Early administration is critical in reducing infection rates.

Question 6384

Topic: 2. Trauma

A 22-year-old male sustains a closed femoral shaft fracture and severe bilateral pulmonary contusions. Which of the following physiologic parameters strongly suggests that Damage Control Orthopedics (DCO) via external fixation is favored over Early Total Care (ETC) with intramedullary nailing?

. Arterial lactate of 1.5 mmol/L
. Base deficit of 2.0 mEq/L
. Platelet count of 150,000/mcL
. Arterial pH of 7.36
. Arterial lactate > 4.0 mmol/L and base deficit > 6.0 mEq/L

Correct Answer & Explanation

. Arterial lactate > 4.0 mmol/L and base deficit > 6.0 mEq/L

Explanation

Damage Control Orthopedics (DCO) is indicated in borderline or unstable polytrauma patients. Indicators of inadequate resuscitation and high risk for "second hit" complications include an arterial lactate > 4.0 mmol/L, base deficit > 6.0 mEq/L, and severe lung injury.

Question 6385

Topic: 2. Trauma
A 40-year-old male sustains a Grade IIIa open tibia fracture. He receives appropriate intravenous antibiotics and tetanus prophylaxis in the emergency department. Based on current literature, what is the single most critical factor in decreasing his risk of deep infection?
. Immediate wound closure in the emergency department
. High-pressure pulsatile lavage with antibiotic solution
. Early systemic administration of antibiotics
. Application of a vacuum-assisted closure (VAC) dressing
. Surgical debridement delayed until 24 hours

Correct Answer & Explanation

. Early systemic administration of antibiotics

Explanation

The early administration of systemic antibiotics (ideally within 1 to 3 hours of injury) is the most critical factor in decreasing the rate of infection in open fractures. Thorough surgical debridement is also essential.

Question 6386

Topic: 2. Trauma

A 25-year-old male presents with a gunshot wound to the right distal thigh, an expanding hematoma, and an absent dorsalis pedis pulse. Radiographs reveal a comminuted distal femur fracture. What is the most appropriate sequence of operative management?

. Skeletal stabilization followed by vascular repair
. Vascular shunting, skeletal stabilization, then definitive vascular repair
. Definitive vascular repair followed by intramedullary nailing
. Amputation
. External fixation alone

Correct Answer & Explanation

. Vascular shunting, skeletal stabilization, then definitive vascular repair

Explanation

In the setting of a complex mangled extremity with profound ischemia, temporary vascular shunting is typically performed first to restore perfusion. This is followed by rapid skeletal stabilization (e.g., external fixation) and then definitive vascular repair.

Question 6387

Topic: 2. Trauma

A 35-year-old man sustains a closed tibial shaft fracture in a motor vehicle collision. Six hours after admission, he complains of severe, unrelenting leg pain that is poorly controlled with intravenous narcotics. His leg is tense and markedly swollen. Blood pressure is 110/70 mm Hg. A compartment pressure monitor reveals an absolute anterior compartment pressure of 45 mm Hg. What is the most appropriate next step in management?

. Elevate the leg above the level of the heart
. Administer intravenous dexamethasone and observe
. Perform immediate four-compartment fasciotomy
. Re-measure compartment pressures in 2 hours
. Bivalve the splint and apply ice packs

Correct Answer & Explanation

. Perform immediate four-compartment fasciotomy

Explanation

The patient has acute compartment syndrome. A Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mm Hg (70 - 45 = 25 mm Hg) is an absolute indication for immediate fasciotomy.

Question 6388

Topic: 2. Trauma
A 40-year-old man is brought to the trauma bay after a high-speed motorcycle crash. He has an anteroposterior compression (APC) type III pelvic ring injury. His initial blood pressure is 80/40 mm Hg. A pelvic binder is applied correctly, but he remains hypotensive despite initial blood transfusion. Focused assessment with sonography for trauma (FAST) is negative. What is the next most appropriate step?
. Exploratory laparotomy
. Pelvic angiography or pre-peritoneal pelvic packing
. Removal of the pelvic binder to assess for retroperitoneal hematoma
. Application of a halo-femoral traction system
. Administration of high-dose intravenous tranexamic acid and discharge to ICU

Correct Answer & Explanation

. Pelvic angiography or pre-peritoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, the bleeding is likely retroperitoneal from the pelvic fracture. Pre-peritoneal pelvic packing or pelvic angiography with embolization is the appropriate next step.

Question 6389

Topic: 2. Trauma

A 28-year-old man sustains a closed distal third spiral fracture of the humerus (Holstein-Lewis fracture). On initial examination in the emergency department, his radial nerve function is intact. Following a closed reduction and application of a coaptation splint, he is unable to extend his wrist or fingers, and lacks sensation in the first dorsal web space. What is the most appropriate management?

. Obtain an urgent EMG/NCS
. Immediate surgical exploration of the radial nerve
. Observation and clinical re-evaluation in 6 weeks
. Administer a systemic corticosteroid taper
. Remove the splint and apply a dynamic extension brace

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve

Explanation

Loss of radial nerve function following closed reduction of a humeral shaft fracture suggests nerve entrapment within the fracture site. This is an absolute indication for immediate surgical exploration.

Question 6390

Topic: 2. Trauma
A 32-year-old farmer sustains an open fracture of the left tibia after being pinned by a tractor in a muddy field. The wound is 12 cm long with extensive soft tissue stripping and visible bone, but vascularity is intact. Which of the following intravenous antibiotic regimens is most appropriate in the emergency setting?
. Cefazolin monotherapy
. Cefazolin and Gentamicin
. Cefazolin, Gentamicin, and Penicillin
. Vancomycin and Piperacillin-Tazobactam
. Clindamycin monotherapy

Correct Answer & Explanation

. Cefazolin, Gentamicin, and Penicillin

Explanation

This is a Gustilo-Anderson Type IIIb fracture sustained in a highly contaminated agricultural environment. High-dose Penicillin is added to the standard Cefazolin and Aminoglycoside regimen to cover Clostridium species.

Question 6391

Topic: 2. Trauma

A 22-year-old man is brought in after an ejection from a vehicle. He has bilateral closed femoral shaft fractures, a pulmonary contusion, and a Glasgow Coma Scale (GCS) of 7. His initial lactate is 4.5 mmol/L, and his pH is 7.15. Which of the following is the most appropriate initial orthopedic management of his femur fractures?

. Bilateral reamed intramedullary nailing
. Bilateral unreamed intramedullary nailing
. Bilateral external fixation
. Skeletal traction only until discharge
. Bilateral open reduction and internal fixation with plates

Correct Answer & Explanation

. Bilateral external fixation

Explanation

This patient is physiologically unstable (acidosis, high lactate, head injury, pulmonary contusion). Damage Control Orthopedics (DCO) using temporary bilateral external fixation is indicated to minimize the second hit of surgical trauma.

Question 6392

Topic: 2. Trauma
A 30-year-old man falls from a height and sustains a displaced, completely vertical (Pauwels type III) femoral neck fracture. To maximize biomechanical stability and minimize the risk of nonunion and avascular necrosis, what is the most appropriate surgical construct?
. Three parallel partially threaded cannulated screws
. A sliding hip screw (fixed-angle device) with a derotational screw
. Bipolar hemiarthroplasty
. Total hip arthroplasty
. Core decompression

Correct Answer & Explanation

. A sliding hip screw (fixed-angle device) with a derotational screw

Explanation

In young patients with vertical, high-shear femoral neck fractures (Pauwels III), a fixed-angle construct like a sliding hip screw offers superior biomechanical stability against vertical shear forces compared to parallel cannulated screws.

Question 6393

Topic: 2. Trauma

A 50-year-old roofer falls 15 feet and sustains a displaced, intra-articular calcaneus fracture. It is treated with open reduction and internal fixation via a classic extensile lateral approach. Which of the following is the most common complication associated with this specific surgical approach?

. Superficial peroneal nerve entrapment
. Medial plantar nerve neuropraxia
. Wound healing complications and dehiscence
. Nonunion of the calcaneal body
. Injury to the flexor hallucis longus tendon

Correct Answer & Explanation

. Wound healing complications and dehiscence

Explanation

The extensile lateral approach to the calcaneus is notorious for soft tissue complications, with wound margin necrosis and dehiscence occurring in up to 10-25% of cases due to the precarious blood supply of the L-shaped flap.

Question 6394

Topic: 2. Trauma

A 65-year-old woman on long-term oral bisphosphonate therapy presents with thigh pain and sustains a low-energy transverse fracture of the subtrochanteric femur. Radiographs reveal lateral cortical thickening and a transverse fracture with a medial spike. What is the most appropriate surgical management?

. Open reduction and internal fixation with a dynamic hip screw
. Prophylactic internal fixation of the contralateral femur followed by cast bracing
. Full-length cephalomedullary nailing of the affected femur
. Short intramedullary nailing of the affected femur
. Lateral locking plate fixation

Correct Answer & Explanation

. Full-length cephalomedullary nailing of the affected femur

Explanation

Atypical bisphosphonate-related femur fractures require full-length intramedullary nailing to protect the entire femur, as the bone remodeling defect affects the whole diaphysis and places it at risk for future fractures.

Question 6395

Topic: 2. Trauma

A 27-year-old man is brought to the emergency room with a gunshot wound to the mid-thigh. Radiographs show a highly comminuted midshaft femur fracture with retained bullet fragments. The weapon was a low-velocity civilian handgun. The patient has no vascular deficits or expanding hematoma. What is the standard of care for this injury?

. Immediate extensive formal surgical debridement of the bullet tract followed by external fixation
. Local wound care, tetanus prophylaxis, and standard reamed intramedullary nailing
. Primary above-knee amputation
. Skeletal traction and intravenous antibiotics for 6 weeks
. Immediate open reduction and internal fixation with dual plating

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and standard reamed intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without neurovascular compromise do not require formal operative debridement of the bullet tract. They are treated safely with superficial wound care, tetanus, antibiotics, and standard intramedullary nailing.

Question 6396

Topic: 2. Trauma

A 38-year-old woman is involved in an MVA. Radiographs and a CT scan of the knee reveal an isolated, displaced coronal plane fracture of the lateral femoral condyle. What is this fracture called, and which screw trajectory is biomechanically superior for its fixation?

. Segond fracture; Anterior-to-posterior screws
. Hoffa fracture; Posterior-to-anterior screws
. Hoffa fracture; Anterior-to-posterior screws
. Tillaux fracture; Medial-to-lateral screws
. Barton fracture; Distal-to-proximal screws

Correct Answer & Explanation

. Hoffa fracture; Posterior-to-anterior screws

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture. Biomechanical studies have demonstrated that posterior-to-anterior directed lag screws provide superior fixation and compression compared to anterior-to-posterior screws.

Question 6397

Topic: 2. Trauma

When applying a commercial pelvic binder to a hypotensive trauma patient with a presumed open-book pelvic ring injury, what anatomic landmark should be used to center the device to ensure optimal mechanical closure of the pelvic volume?

. Iliac crests
. Anterior superior iliac spines (ASIS)
. Greater trochanters
. Umbilicus
. Ischial tuberosities

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders must be centered directly over the greater trochanters to effectively compress the pelvic ring and reduce the retroperitoneal volume. Placement too high (e.g., over the iliac crests) is less effective and can worsen certain fracture patterns.

Question 6398

Topic: 2. Trauma

A 55-year-old man presents with a highly comminuted Schatzker VI tibial plateau fracture. He is complaining of extreme pain. What is considered the most reliable and earliest clinical finding of acute compartment syndrome in a conscious patient?

. Absence of dorsalis pedis and posterior tibial pulses
. Capillary refill greater than 4 seconds
. Pain out of proportion to the injury and pain with passive stretch of the muscles
. Pallor of the distal extremity
. Paresthesias in the first web space

Correct Answer & Explanation

. Pain out of proportion to the injury and pain with passive stretch of the muscles

Explanation

Pain out of proportion to the apparent injury and severe pain exacerbated by passive stretch of the compartments involved are the earliest and most sensitive clinical signs of acute compartment syndrome. Pulselessness and pallor are very late signs.

Question 6399

Topic: 2. Trauma

A 70-year-old man falls and sustains an unstable odontoid fracture (Type II). Non-operative management with a halo vest is considered. Which of the following is an absolute contraindication to the use of a halo vest in an elderly patient?

. Age greater than 65 years
. Concomitant non-displaced clavicle fracture
. Severe kyphotic deformity
. History of deep vein thrombosis
. Severe respiratory disease or poor pulmonary function

Correct Answer & Explanation

. Severe respiratory disease or poor pulmonary function

Explanation

Halo vests restrict chest excursion and can severely compromise pulmonary mechanics. In elderly patients with severe respiratory disease, a halo vest is contraindicated due to the high risk of pneumonia and respiratory failure.

Question 6400

Topic: 2. Trauma

A 45-year-old male falls from a ladder and sustains a high-energy distal tibia fracture.

He presents to the emergency department with massive soft tissue swelling and clear fracture blisters around the ankle. What is the most appropriate initial management to minimize soft tissue complications while providing adequate skeletal stability?

. Immediate open reduction and internal fixation with dual plating
. Application of a spanning external fixator and strict limb elevation
. Closed reduction and long-leg casting in equinus
. Primary arthrodesis of the tibiotalar joint
. Minimally invasive percutaneous plate osteosynthesis (MIPPO)

Correct Answer & Explanation

. Application of a spanning external fixator and strict limb elevation

Explanation

For severe pilon fractures with significant soft tissue compromise (e.g., fracture blisters, massive swelling), the standard of care is a staged protocol. Initial management consists of a spanning external fixator to allow soft tissue recovery, followed by definitive internal fixation 1 to 3 weeks later.

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