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2. Trauma MCQs

Practice Set 323 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 6441

Topic: 2. Trauma

A 40-year-old man sustains a trimalleolar ankle fracture. The posterior malleolus fragment involves 35% of the articular surface and remains displaced 3 mm superiorly after anatomic fibular and medial malleolar fixation. What is the most appropriate management of the posterior malleolus?

. Cast immobilization
. Open reduction and internal fixation
. Syndesmotic screw fixation only
. Excision of the fragment
. Delayed reconstruction

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Posterior malleolar fractures involving >25% to 33% of the articular surface or with persistent displacement >2 mm require open reduction and internal fixation to restore articular congruity and posterior stability.

Question 6442

Topic: 2. Trauma

A 42-year-old woman sustains a supination-external rotation ankle fracture. CT scan reveals a posterolateral tibial (posterior malleolar) fragment involving 30% of the articular surface with 3 mm of superior displacement. What is the most appropriate management for the posterior malleolus?

. Nonoperative management as it will remodel over time.
. Closed reduction and casting.
. Fixation with an anterior-to-posterior lag screw.
. Direct open reduction and internal fixation via a posterolateral approach.
. Arthroscopic debridement of the fracture site.

Correct Answer & Explanation

. Direct open reduction and internal fixation via a posterolateral approach.

Explanation

A displaced posterior malleolar fracture involving >25% of the articular surface warrants fixation. A posterolateral approach allows direct visualization and stable buttress plating of the fragment, which is biomechanically superior to anterior-to-posterior lag screws.

Question 6443

Topic: 2. Trauma

A 32-year-old man sustains an ankle fracture. Radiographs demonstrate a vertical fracture of the medial malleolus and a transverse fracture of the fibula at the level of the tibial plafond. According to the Lauge-Hansen classification, what is the mechanism of this injury?

. Supination-External Rotation
. Pronation-External Rotation
. Supination-Adduction
. Pronation-Abduction
. Axial compression

Correct Answer & Explanation

. Supination-Adduction

Explanation

A vertical medial malleolus fracture combined with a transverse lateral malleolus fracture at or below the joint line is the hallmark of a Supination-Adduction (SAD) injury.

Question 6444

Topic: 2. Trauma

A 28-year-old rugby player sustains an ankle injury. Closed reduction in the emergency department is unsuccessful. Radiographs show a posterior fracture-dislocation of the fibula, with the proximal fibular fragment trapped behind the tibia. What specific anatomical structure blocks the reduction in this Bosworth fracture-dislocation?

. Anterior tibial tubercle
. Posterior lateral ridge (posterior tubercle) of the distal tibia
. Peroneal tendons
. Flexor hallucis longus tendon
. Deltoid ligament

Correct Answer & Explanation

. Posterior lateral ridge (posterior tubercle) of the distal tibia

Explanation

A Bosworth fracture is a rare fracture-dislocation where the proximal fibular fragment becomes incarcerated behind the posterior lateral ridge (posterior tubercle) of the distal tibia, making closed reduction nearly impossible.

Question 6445

Topic: 2. Trauma

A 62-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus undergoes open reduction and internal fixation for a displaced bimalleolar equivalent ankle fracture. Which of the following postoperative regimens is most appropriate to minimize complications in this specific patient?

. Immediate weight-bearing in a standard walking boot
. Standard non-weight-bearing for 6 weeks followed by immediate transition to regular shoes
. Prolonged non-weight-bearing for 8 to 12 weeks followed by protected weight-bearing in a total contact cast or Charcot restraint orthotic walker
. Early active range of motion at 2 weeks with progression to full weight-bearing at 4 weeks
. Removal of all hardware at 6 weeks to prevent deep infection

Correct Answer & Explanation

. Prolonged non-weight-bearing for 8 to 12 weeks followed by protected weight-bearing in a total contact cast or Charcot restraint orthotic walker

Explanation

Diabetic patients with ankle fractures have a significantly higher risk of complications, including Charcot neuroarthropathy, hardware failure, and delayed union. Current AAOS/ABOS guidelines recommend prolonged non-weight-bearing (up to 3 months) followed by protected weight-bearing (TCC or CROW) to mitigate these risks.

Question 6446

Topic: 2. Trauma

According to the Lauge-Hansen classification system, what is the third stage of injury in a Supination-External Rotation (SER) ankle fracture?

. Rupture of the anterior inferior tibiofibular ligament
. Spiral fracture of the lateral malleolus
. Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus
. Transverse fracture of the medial malleolus or rupture of the deltoid ligament
. Rupture of the interosseous membrane

Correct Answer & Explanation

. Rupture of the anterior inferior tibiofibular ligament

Explanation

The sequence for SER injuries is: 1) Anterior inferior tibiofibular ligament (AITFL), 2) Short oblique/spiral fibula fracture, 3) Posterior inferior tibiofibular ligament (PITFL) or posterior malleolus fracture, 4) Medial malleolus fracture or deltoid ligament tear.

Question 6447

Topic: 2. Trauma

A 32-year-old man presents with a closed ankle fracture-dislocation after a fall. Closed reduction in the emergency department is unsuccessful. Radiographs reveal a severe fracture-dislocation where the proximal fragment of the fibula is locked behind the posterior tubercle of the tibia. What is the eponymous name of this specific injury?

. Maisonneuve fracture
. Bosworth fracture
. Tillaux fracture
. Chaput fracture
. Wagstaffe fracture

Correct Answer & Explanation

. Bosworth fracture

Explanation

A Bosworth fracture-dislocation is a rare injury where the proximal fragment of the fractured fibula becomes irreducibly trapped behind the posterior aspect of the tibia. This invariably requires open reduction to free the fibula.

Question 6448

Topic: 2. Trauma

A 65-year-old patient with poorly controlled type 2 diabetes mellitus and peripheral neuropathy sustains a displaced bimalleolar ankle fracture. Which of the following modifications to the surgical plan is most appropriate to minimize complications?

. Use of a single lag screw for the fibula
. Early weight-bearing at 2 weeks postoperatively
. Enhanced rigid fixation with multiple syndesmotic screws or tibiotalar transfixation pins and prolonged non-weight-bearing
. Casting without surgical intervention regardless of displacement
. Primary below-knee amputation

Correct Answer & Explanation

. Enhanced rigid fixation with multiple syndesmotic screws or tibiotalar transfixation pins and prolonged non-weight-bearing

Explanation

Diabetic patients with neuropathy are at a significantly higher risk for Charcot arthropathy, wound complications, and hardware failure. Enhanced rigid construct fixation and at least doubling the standard non-weight-bearing period are highly recommended.

Question 6449

Topic: 2. Trauma

A 45-year-old man presents with an ankle fracture. Radiographs show a transverse fracture of the medial malleolus and a short oblique fracture of the fibula starting at the level of the mortise and extending proximally. Based on the Lauge-Hansen classification, what is the mechanism of injury?

. Supination-External Rotation
. Supination-Adduction
. Pronation-Abduction
. Pronation-External Rotation
. Axial compression

Correct Answer & Explanation

. Pronation-Abduction

Explanation

A transverse medial malleolus fracture (or deltoid rupture) followed by a short oblique/transverse fibula fracture at or slightly above the joint line represents a Pronation-Abduction mechanism.

Question 6450

Topic: 2. Trauma

A 32-year-old man sustains a Hawkins type II talar neck fracture. At 8 weeks postoperatively, an AP radiograph shows a subchondral radiolucent band in the talar dome. What does this finding indicate?

. Impending avascular necrosis
. Intact vascularity to the talar body
. Nonunion of the talar neck
. Post-traumatic osteoarthritis
. Osteochondral defect of the talar dome

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6 to 8 weeks after a talus fracture, indicating resorption of subchondral bone. This requires an intact vascular supply, essentially ruling out avascular necrosis of the talar body.

Question 6451

Topic: 2. Trauma

A 42-year-old man sustains a high-energy closed right tibial pilon fracture (OTA 43-C3) with severe fracture blisters and massive soft tissue swelling. What is the most appropriate initial management to minimize soft tissue complications while maintaining alignment?

. Immediate open reduction and internal fixation (ORIF) of the tibia and fibula
. Spanning external fixation and delayed ORIF once swelling subsides
. Application of a long-leg cast
. Intramedullary nailing of the tibia
. Circular frame external fixation as definitive treatment

Correct Answer & Explanation

. Spanning external fixation and delayed ORIF once swelling subsides

Explanation

High-energy pilon fractures are associated with significant soft-tissue compromise. The standard of care is a staged approach utilizing a spanning external fixator for initial length and alignment, followed by delayed ORIF when the "wrinkle sign" appears.

Question 6452

Topic: 2. Trauma

A 40-year-old construction worker falls from a ladder, sustaining a closed intra-articular calcaneus fracture. Which of the following is considered an absolute contraindication to utilizing an extensile lateral approach for open reduction and internal fixation?

. Poorly controlled Type 1 diabetes mellitus
. Smoking 1 pack of cigarettes per day
. Peripheral artery disease with absent pedal pulses
. Fracture blisters present strictly over the medial hindfoot
. Time from injury greater than 14 days

Correct Answer & Explanation

. Peripheral artery disease with absent pedal pulses

Explanation

Peripheral artery disease with compromised vascularity (absent pedal pulses) is an absolute contraindication to the extensile lateral approach due to the unacceptably high risk of wound necrosis and deep infection. Smoking and diabetes are considered relative contraindications.

Question 6453

Topic: 2. Trauma

A 45-year-old man sustains a severe, high-energy, closed tibial pilon fracture with significant soft tissue swelling and fracture blisters. What is the most appropriate staged treatment protocol to minimize soft tissue complications in this injury?

. Immediate definitive ORIF of the tibia and fibula through dual incisions
. Immediate fibular ORIF and definitive tibial ORIF at 7 days
. Application of a spanning external fixator, followed by definitive tibial ORIF once soft tissue swelling subsides
. Primary arthrodesis of the tibiotalar joint using an intramedullary nail
. Intramedullary nailing of the tibia with limited percutaneous screws for the articular surface

Correct Answer & Explanation

. Application of a spanning external fixator, followed by definitive tibial ORIF once soft tissue swelling subsides

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with a staged approach. Immediate spanning external fixation restores length and alignment, followed by definitive ORIF 10-21 days later when the soft tissue envelope has recovered.

Question 6454

Topic: Lower Extremity Trauma

A 28-year-old soccer player sustains a twisting ankle injury. Radiographs show a widened medial clear space on the gravity stress view, consistent with a syndesmotic injury. During operative fixation, what is the most important factor in achieving a good long-term clinical outcome?

. Use of suture-button fixation instead of metallic screw fixation
. Placement of the fixation exactly 2 cm above the joint line
. Anatomic reduction of the distal tibiofibular joint within the incisura
. Routine removal of the syndesmotic screws at exactly 8 weeks postoperatively
. Fixing the fibula in relative internal rotation to tighten the complex

Correct Answer & Explanation

. Anatomic reduction of the distal tibiofibular joint within the incisura

Explanation

The most critical factor determining clinical outcomes in syndesmotic injuries is the anatomic reduction of the fibula within the incisura. Malreduction is highly associated with poor functional outcomes and early post-traumatic ankle arthritis.

Question 6455

Topic: 2. Trauma

A 28-year-old professional basketball player suffers an acute transverse fracture of the fifth metatarsal base, 1.5 cm distal to the tuberosity (Zone II). What is the recommended treatment to minimize the risk of nonunion?

. Short leg walking cast for 4 weeks
. Intramedullary screw fixation
. Open reduction and tension band wiring
. Primary excision of the proximal fragment
. Plate and screw fixation

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone II (Jones) fractures occur at the metaphyseal-diaphyseal junction, a vascular watershed area prone to nonunion. Intramedullary screw fixation is recommended for competitive athletes to ensure reliable healing and facilitate a faster return to play.

Question 6456

Topic: 2. Trauma

A 35-year-old construction worker falls from a height and sustains a severely displaced, closed pilon fracture (OTA/AO 43-C3). The ankle is grossly swollen with fracture blisters. What is the preferred initial management strategy?

. Immediate open reduction and internal fixation with dual plates
. Spanning external fixation with delayed definitive fixation
. Primary arthrodesis of the tibiotalar joint
. Closed reduction and long leg cast
. Intramedullary nailing of the tibia

Correct Answer & Explanation

. Spanning external fixation with delayed definitive fixation

Explanation

For severe pilon fractures with significant soft tissue compromise, a staged approach is standard. Spanning external fixation allows for soft tissue recovery before definitive open reduction and internal fixation, minimizing severe wound complications.

Question 6457

Topic: 2. Trauma

A 22-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. He wishes to return to play as soon as possible. Intramedullary screw fixation is planned. What is a critical technical consideration to prevent failure?

. Use of a 3.0 mm fully threaded screw
. Using a solid screw that engages the medullary canal bow completely
. Ensuring the screw threads cross the fracture site and purchase diaphyseal cortical bone
. Placing the screw in a purely plantar-to-dorsal trajectory
. Using a bioabsorbable screw

Correct Answer & Explanation

. Ensuring the screw threads cross the fracture site and purchase diaphyseal cortical bone

Explanation

When fixing a Jones fracture with an intramedullary screw, it is critical that the screw is robust (typically 4.5 mm or larger) and that the threads pass distal to the fracture site to achieve solid purchase in the diaphyseal isthmus.

Question 6458

Topic: 2. Trauma

A 20-year-old track athlete has an insidious onset of midfoot pain. Plain radiographs are normal, but an MRI demonstrates a complete, non-displaced stress fracture in the central third of the navicular. What is the most appropriate initial management?

. Continuing running with a carbon fiber plate shoe
. Non-weight bearing in a short leg cast for 6 to 8 weeks
. Immediate percutaneous screw fixation
. Extracorporeal shockwave therapy
. Bone morphogenetic protein injection

Correct Answer & Explanation

. Non-weight bearing in a short leg cast for 6 to 8 weeks

Explanation

Navicular stress fractures have a high risk of nonunion due to the relatively avascular central third. The initial gold standard for a non-displaced navicular stress fracture is strict non-weight bearing in a cast for 6-8 weeks.

Question 6459

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains a fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction without distal extension. He is eager to return to play this season. Which of the following treatments provides the fastest return to sport with the lowest nonunion rate in this athletic population?

. Non-weight-bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Open reduction and internal fixation with a mini-fragment plate
. Percutaneous intramedullary screw fixation
. Primary excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

In high-level athletes with an acute Jones fracture (Zone 2), intramedullary screw fixation is recommended. This approach yields faster return to play and lower nonunion rates compared to nonoperative management.

Question 6460

Topic: 2. Trauma

A 35-year-old man sustains a Hawkins Type II talar neck fracture and undergoes open reduction and internal fixation. At his 8-week follow-up, 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 indicates the onset of avascular necrosis (AVN).
. It represents a deep postoperative infection.
. It signifies intact vascularity to the talar body.
. It is a sign of impending talar neck nonunion.
. It demonstrates early post-traumatic subtalar arthritis.

Correct Answer & Explanation

. It signifies intact vascularity to the talar body.

Explanation

This finding describes the Hawkins sign, which is subchondral osteopenia in the talar dome following a talar neck fracture. It indicates that there is sufficient vascular supply to the talar body to allow for bone resorption, effectively ruling out complete avascular necrosis.

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