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2. Trauma MCQs

Practice Set 322 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 6421

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture). He wishes to return to play as soon as possible. What is the most appropriate treatment?

. Hard-soled shoe for 4 weeks
. Short leg walking cast for 6 weeks
. Intramedullary screw fixation
. Plate and screw construct
. Non-weight-bearing cast for 8 weeks

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

In elite athletes, acute Jones fractures are best treated with intramedullary screw fixation to minimize the risk of nonunion and allow for an accelerated return to play.

Question 6422

Topic: 2. Trauma

A 28-year-old male sustains a talar neck fracture following a motor vehicle collision. Six weeks post-open reduction and internal fixation, his radiographs demonstrate a subchondral radiolucent band in the dome of the talus. What is the prognostic significance of this finding?

. It indicates impending hardware failure.
. It indicates intact vascularity to the talar body and a low risk of avascular necrosis.
. It confirms the presence of avascular necrosis (AVN) of the talar body.
. It suggests a deep postoperative infection.
. It represents nonunion of the fracture site.

Correct Answer & Explanation

. It indicates intact vascularity to the talar body and a low risk of avascular necrosis.

Explanation

This finding is known as the Hawkins sign, representing subchondral osteopenia. It demonstrates that vascular supply to the talus is intact, as the bone must be vascularized to undergo osteoclastic resorption, indicating a very low risk of AVN.

Question 6423

Topic: 2. Trauma

A 62-year-old female with peripheral neuropathy and uncontrolled diabetes sustains a displaced bimalleolar ankle fracture. Which of the following surgical strategies is most appropriate to minimize her risk of catastrophic failure and Charcot neuroarthropathy?

. Standard ORIF with early range of motion
. Closed reduction and casting for 12 weeks
. Primary below-knee amputation
. External fixation only
. Augmented ORIF utilizing multiple syndesmotic screws or primary tibiotalocalcaneal nailing with prolonged immobilization

Correct Answer & Explanation

. Augmented ORIF utilizing multiple syndesmotic screws or primary tibiotalocalcaneal nailing with prolonged immobilization

Explanation

Diabetic patients with peripheral neuropathy have a high risk of fixation failure, nonunion, and Charcot arthropathy following ankle fractures. They require augmented, rigid fixation (often twice the normal construct strength) and prolonged non-weight-bearing periods.

Question 6424

Topic: 2. Trauma

A 40-year-old female sustains a trimalleolar ankle fracture. Recent literature regarding the posterior malleolus suggests that the indication for internal fixation is primarily based on which of the following factors?

. A posterior fragment involving strictly >25% of the articular surface on a lateral plain film
. The presence of an intact posterior inferior tibiofibular ligament (PITFL)
. Restoration of syndesmotic stability and articular congruity regardless of fragment size
. The age of the patient
. The degree of medial malleolus displacement

Correct Answer & Explanation

. Restoration of syndesmotic stability and articular congruity regardless of fragment size

Explanation

Modern treatment paradigms for posterior malleolar fractures focus on articular congruity and syndesmotic stability, as the PITFL remains attached to the fragment. Fixation is increasingly recommended even for smaller fragments if they contribute to syndesmotic instability.

Question 6425

Topic: 2. Trauma

A 45-year-old construction worker falls 15 feet, sustaining a highly comminuted, displaced intra-articular distal tibia (pilon) fracture. The soft tissues are severely swollen with early fracture blister formation. What is the most appropriate initial management?

. Immediate open reduction and internal fixation of both tibia and fibula
. Application of a short leg cast
. Spanning external fixation with delayed definitive internal fixation
. Primary intramedullary nailing of the tibia
. Amputation

Correct Answer & Explanation

. Spanning external fixation with delayed definitive internal fixation

Explanation

High-energy pilon fractures with compromised soft tissues are best managed with a staged protocol. Initial spanning external fixation maintains length and alignment while allowing the soft tissue envelope to recover before definitive ORIF.

Question 6426

Topic: 2. Trauma

A 21-year-old elite collegiate basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal. Which of the following treatments provides the fastest return to sport with the lowest nonunion rate in this specific patient population?

. Non-weight-bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Excision of the proximal fragment and advancement of the peroneus brevis
. Intramedullary screw fixation
. Plate and screw construct

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone 2 (Jones) fractures in elite athletes are best treated with early intramedullary screw fixation. This approach significantly reduces the time to return to sport and lowers the high risk of nonunion associated with conservative management.

Question 6427

Topic: 2. Trauma

A 40-year-old construction worker falls from a height and sustains a highly comminuted distal tibia injury as shown in the radiograph.

The soft tissues are significantly swollen with hemorrhagic fracture blisters. What is the most appropriate initial management?

. Immediate definitive open reduction and internal fixation of the tibia and fibula
. Primary tibiotalar arthrodesis
. Spanning external fixation of the ankle joint and delayed definitive fixation
. Closed reduction and application of a short leg cast
. Immediate intramedullary nailing of the tibia

Correct Answer & Explanation

. Spanning external fixation of the ankle joint and delayed definitive fixation

Explanation

High-energy pilon fractures with severe soft tissue compromise (e.g., hemorrhagic blisters) are best managed with a staged protocol. Initial spanning external fixation allows for soft tissue recovery, significantly decreasing wound complications prior to delayed definitive ORIF (typically 10-14 days later).

Question 6428

Topic: 2. Trauma

A 65-year-old male with poorly controlled type II diabetes and severe peripheral neuropathy sustains a closed bimalleolar ankle fracture. Which of the following fixation strategies is most appropriate to minimize his elevated risk of Charcot arthropathy and hardware failure?

. Standard single-plate fibula fixation and medial malleolar screws with 6 weeks of casting
. Enhanced fixation utilizing a locking fibular plate, multiple syndesmotic screws, and prolonged immobilization
. Primary tibiotalocalcaneal arthrodesis with an intramedullary nail
. Closed reduction and total contact casting for 12 weeks
. External fixation until fracture consolidation is radiographically evident

Correct Answer & Explanation

. Enhanced fixation utilizing a locking fibular plate, multiple syndesmotic screws, and prolonged immobilization

Explanation

Diabetic patients with neuropathy are at a high risk for hardware failure and Charcot arthropathy following ankle fractures. Enhanced fixation, often involving locking plates, quad-cortical syndesmotic screws, and prolonged non-weight-bearing (at least 8-12 weeks), is recommended to prevent these complications.

Question 6429

Topic: 2. Trauma

A 30-year-old female presents to the emergency department after a twisting injury to her ankle. Radiographs demonstrate a fracture-dislocation with the proximal fibular shaft trapped posterior to the posterior tubercle of the distal tibia. Closed reduction is unsuccessful. What is the pathognomonic name and required management for this specific injury pattern?

. Tillaux fracture; delayed open reduction
. Maisonneuve fracture; isolated syndesmotic fixation
. Bosworth fracture-dislocation; urgent open reduction
. Dupuytren fracture; closed reduction and casting
. Wagstaffe fracture; primary fragment excision

Correct Answer & Explanation

. Bosworth fracture-dislocation; urgent open reduction

Explanation

A Bosworth fracture-dislocation involves entrapment of the intact or fractured fibula behind the posterior tubercle of the tibia. Closed reduction is typically unsuccessful, necessitating urgent open reduction to release the entrapped fibula and prevent skin necrosis or compartment syndrome.

Question 6430

Topic: 2. Trauma

A 22-year-old elite basketball player sustains a fifth metatarsal base fracture located at the metaphyseal-diaphyseal junction (Zone 2). What is the recommended treatment to ensure the fastest safe return to play?

. Hard-soled shoe with full weight-bearing as tolerated
. Short leg cast non-weight-bearing for 6-8 weeks
. Intramedullary screw fixation
. Excision of the proximal fragment and peroneus brevis advancement
. Closed reduction and percutaneous K-wire fixation

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone 2 (Jones) fractures occur in a vascular watershed area and have a high risk of nonunion. In elite athletes, early intramedullary screw fixation is recommended to decrease nonunion rates and expedite return to play.

Question 6431

Topic: 2. Trauma

A patient undergoes open reduction and internal fixation of a pronation-external rotation ankle fracture, which includes placement of two quadricortical syndesmotic screws. According to the current orthopedic consensus, when should these screws be routinely removed?

. At 6 weeks, prior to initiating weight-bearing
. At 12 weeks, regardless of symptoms
. Routine removal is not required unless the screws become symptomatic
. Only after radiographic evidence of syndesmotic ossification
. At 1 year postoperatively for all patients

Correct Answer & Explanation

. Routine removal is not required unless the screws become symptomatic

Explanation

Current evidence suggests that routine removal of syndesmotic screws is unnecessary. Retained, broken, or loose screws do not significantly worsen functional outcomes, and removal should be reserved for symptomatic patients to avoid unnecessary secondary surgery.

Question 6432

Topic: 2. Trauma

A 24-year-old elite track athlete complains of vague, aching dorsal midfoot pain. A CT scan confirms a non-displaced stress fracture of the tarsal navicular. The relative avascularity of the central third of the navicular predisposes this area to nonunion. Which arteries supply the margins of this avascular zone?

. Anterior tibial and posterior tibial arteries
. Dorsalis pedis and medial plantar arteries
. Peroneal and dorsalis pedis arteries
. Lateral plantar and medial plantar arteries
. Sural and saphenous arteries

Correct Answer & Explanation

. Dorsalis pedis and medial plantar arteries

Explanation

The navicular is supplied radially by branches of the dorsalis pedis and medial plantar arteries. This leaves a central avascular zone that is highly prone to stress fractures and delayed unions.

Question 6433

Topic: 2. Trauma

A 28-year-old skier presents with acute lateral ankle pain and swelling after a fall. Radiographs demonstrate a small cortical avulsion fracture off the posterolateral aspect of the distal fibula (a "fleck sign"). This radiographic finding is pathognomonic for an injury to which of the following structures?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Peroneus brevis tendon

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The "fleck sign" on an ankle radiograph represents an avulsion of the superior peroneal retinaculum from the posterolateral fibula, strongly indicating peroneal tendon subluxation or dislocation.

Question 6434

Topic: 2. Trauma

A 22-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (Zone 2) after a sudden pivot. To minimize the risk of nonunion and expedite his return to play, what is the best management strategy?

. Hard-soled shoe with weight-bearing as tolerated for 4 weeks
. Short leg non-weight-bearing cast for 6-8 weeks
. Early intramedullary screw fixation
. Plate and screw fixation
. Primary excision of the proximal fragment

Correct Answer & Explanation

. Early intramedullary screw fixation

Explanation

Zone 2 (Jones) fractures in competitive athletes are optimally treated with early intramedullary screw fixation. This provides a lower rate of nonunion and a faster return to sport compared to conservative management.

Question 6435

Topic: 2. Trauma

A trauma surgeon utilizes an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture. Which of the following nerves is at greatest risk of iatrogenic injury during the creation of the full-thickness flap?

. Deep peroneal nerve
. Superficial peroneal nerve
. Sural nerve
. Medial plantar nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus places the sural nerve at high risk. The nerve is typically elevated within the full-thickness subperiosteal anterior flap to protect it during retraction.

Question 6436

Topic: 2. Trauma

A 32-year-old male sustains a Hawkins type II talar neck fracture following a motor vehicle accident and undergoes open reduction internal fixation. At his 8-week postoperative visit, AP and lateral ankle radiographs reveal a subchondral radiolucent band in the talar dome. What does this finding indicate?

. Impending avascular necrosis of the talar body
. Nonunion of the talar neck
. Intact vascularity to the talar body
. Osteochondral defect of the talar dome
. Early post-traumatic arthritis of the tibiotalar joint

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

This finding describes the Hawkins sign, which is subchondral osteopenia seen 6-8 weeks after a talar neck fracture. It indicates that blood supply to the talar body is intact, as the bone must be vascularized to resorb bone and show osteopenia.

Question 6437

Topic: 2. Trauma

A 20-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. To minimize the risk of nonunion and facilitate an accelerated return to play, what is the recommended treatment?

. Short leg non-weight-bearing cast for 6 weeks
. Hard-soled shoe with weight-bearing to tolerance
. Open reduction and plate fixation
. Intramedullary screw fixation
. Excision of the proximal fragment with peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This describes a Zone 2 (Jones) fracture. In high-level or elite athletes, intramedullary screw fixation is recommended to reduce the significantly high risk of nonunion associated with conservative management in this vascular watershed area.

Question 6438

Topic: 2. Trauma

A 20-year-old athlete sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the fourth-fifth intermetatarsal articulation. Why does this specific fracture pattern carry a high risk of delayed union or nonunion?

. Disruption of the insertion of the peroneus brevis tendon.
. Distracting forces from the lateral band of the plantar fascia.
. It occurs in a vascular watershed area.
. High incidence of associated covert Lisfranc injuries.
. Complete disruption of the nutrient artery entering the distal diaphysis.

Correct Answer & Explanation

. It occurs in a vascular watershed area.

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction and extends into the 4-5 intermetatarsal joint. This region represents a vascular watershed area between the metaphyseal blood supply and the diaphyseal nutrient artery, predisposing it to poor healing and nonunion.

Question 6439

Topic: 2. Trauma

In evaluating a supination-external rotation ankle fracture, which of the following is the most reliable radiographic parameter indicating a syndesmotic injury on a standard AP view of the ankle?

. Tibiofibular overlap less than 10 mm
. Medial clear space greater than 4 mm
. Tibiofibular clear space greater than 5 mm
. Talar tilt greater than 5 degrees
. Lateral clear space greater than 3 mm

Correct Answer & Explanation

. Tibiofibular clear space greater than 5 mm

Explanation

The tibiofibular clear space, measured 1 cm above the joint line on AP and mortise views, should be less than 5 mm. It is the most reliable radiographic parameter for assessing syndesmotic widening, as it is relatively unaffected by leg rotation.

Question 6440

Topic: 2. Trauma

A 35-year-old man sustains a severe fracture-dislocation of the ankle. Closed reduction in the emergency department is completely unsuccessful. Radiographs show a displaced fracture of the lateral malleolus, and the proximal fibular fragment appears incarcerated behind the posterior tubercle of the tibia. What is this specific injury pattern called?

. Tillaux fracture
. Maisonneuve fracture
. Bosworth fracture-dislocation
. Wagstaffe-Le Fort fracture
. Chaput fracture

Correct Answer & Explanation

. Bosworth fracture-dislocation

Explanation

A Bosworth fracture-dislocation involves irreducible posterior dislocation of the fibula behind the posterior lateral ridge of the tibia. It requires immediate open reduction to prevent skin necrosis and definitive fixation.

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