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2. Trauma MCQs

Practice Set 338 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 6741

Topic: 2. Trauma

An orthopedic trauma surgeon is performing antegrade intramedullary nailing of a femoral shaft fracture. The starting point is chosen at the piriformis fossa. If the guide wire is inadvertently placed too anteriorly on the femoral neck, which of the following iatrogenic complications is most likely to occur?

. Anterior cortical blowout of the distal femur
. Iatrogenic femoral neck fracture
. Varus malalignment of the fracture
. Heterotopic ossification of the gluteus medius

Correct Answer & Explanation

. Iatrogenic femoral neck fracture

Explanation

An anterior starting point for a piriformis entry nail misses the central axis of the medullary canal and places excessive stress on the anterior femoral neck during reaming and nail insertion, highly risking an iatrogenic femoral neck fracture.

Question 6742

Topic: 2. Trauma

A 45-year-old woman presents with a medial tibial plateau fracture with extension into the intercondylar eminence (Schatzker type IV). The fracture includes a significantly displaced posteromedial fragment. What is the most appropriate surgical approach and fixation strategy?

. Anterolateral approach with a laterally applied buttress plate
. Posteromedial approach with an anti-glide plate
. Direct anterior approach with percutaneous lag screws
. Lateral approach with dual locking plates

Correct Answer & Explanation

. Posteromedial approach with an anti-glide plate

Explanation

Schatzker IV fractures involve the medial plateau and commonly feature a posteromedial shear fragment. A posteromedial approach allows for direct reduction and placement of an anti-glide plate to effectively neutralize the deforming shear forces.

Question 6743

Topic: 2. Trauma

A 32-year-old man undergoes intramedullary nailing for a closed transverse tibial shaft fracture. In the recovery room, he requires increasing doses of opioids and exhibits severe pain with passive stretch of the hallux. His diastolic blood pressure is 70 mm Hg, and an intracompartmental pressure reading of the anterior compartment is 55 mm Hg. What is the most appropriate immediate management?

. Observation and elevation of the limb above the heart
. Emergent four-compartment fasciotomy
. Removal of the intramedullary nail
. Administration of intravenous dexamethasone

Correct Answer & Explanation

. Emergent four-compartment fasciotomy

Explanation

The patient has clinical acute compartment syndrome confirmed by a delta P (diastolic pressure minus compartment pressure) of less than 30 mm Hg. The standard of care is emergent four-compartment fasciotomy to prevent irreversible muscle and nerve necrosis.

Question 6744

Topic: 2. Trauma

A 25-year-old man sustained a Hawkins type II talar neck fracture and underwent open reduction and internal fixation. At his 6-week follow-up, a mortise radiograph reveals a subchondral radiolucent band across the dome of the talus (Hawkins sign). What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Intact vascularity and subchondral bone resorption
. Impending nonunion of the talar neck fracture
. Osteomyelitis of the talar dome

Correct Answer & Explanation

. Intact vascularity and subchondral bone resorption

Explanation

The Hawkins sign represents subchondral osteopenia resulting from disuse hyperemia. Its presence indicates that the blood supply to the talar body is intact, predicting a very low risk of subsequent avascular necrosis.

Question 6745

Topic: 2. Trauma

A 50-year-old male smoker with poorly controlled diabetes undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following is the most common complication associated with this specific approach?

. Sural nerve neuroma
. Wound edge necrosis and dehiscence
. Flexor hallucis longus entrapment
. Iatrogenic peroneal tendon subluxation

Correct Answer & Explanation

. Wound edge necrosis and dehiscence

Explanation

The extensile lateral approach for calcaneus fractures relies on a full-thickness fasciocutaneous flap supplied by the lateral calcaneal artery. Wound complications, such as edge necrosis and dehiscence, occur in up to 25% of cases, particularly in smokers and diabetics.

Question 6746

Topic: Pelvic & Acetabular Trauma

A 22-year-old construction worker falls from a height and sustains a vertical shear pelvic fracture. Radiographs show superior displacement of the right hemipelvis and avulsion of the right L5 transverse process. Which of the following ligamentous complexes are completely disrupted in this injury pattern?

. Anterior sacroiliac ligaments only
. Sacrotuberous and sacrospinous ligaments only
. Anterior and posterior sacroiliac ligaments
. Anterior and posterior sacroiliac, sacrotuberous, and sacrospinous ligaments

Correct Answer & Explanation

. Anterior and posterior sacroiliac, sacrotuberous, and sacrospinous ligaments

Explanation

A vertical shear fracture pattern involves global instability of the hemipelvis. It necessitates the complete disruption of the anterior and posterior pelvic ring, including both the anterior and posterior sacroiliac ligaments, as well as the pelvic floor (sacrotuberous and sacrospinous ligaments).

Question 6747

Topic: Pelvic & Acetabular Trauma

An anteroposterior (AP) radiograph of the pelvis is obtained for a 60-year-old woman who fell from a ladder. The film demonstrates an isolated disruption of the iliopectineal line with a completely intact ilioischial line. Which acetabular structure is fractured?

. Anterior column
. Posterior column
. Anterior wall
. Posterior wall

Correct Answer & Explanation

. Anterior column

Explanation

On an AP radiograph of the pelvis, the iliopectineal line correlates anatomically with the anterior column of the acetabulum, while the ilioischial line correlates with the posterior column.

Question 6748

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable 45-year-old woman is brought to the trauma bay after a crush injury. Radiographs show an anterior-posterior compression type III (APC-III) pelvic ring injury with complete disruption of the sacroiliac joints. The initial management to stabilize the pelvic volume should be placement of a pelvic binder centered over which of the following anatomic landmarks?
. Iliac crests
. Anterior superior iliac spines
. Greater trochanters
. Symphysis pubis
. Lumbosacral junction

Correct Answer & Explanation

. Greater trochanters

Explanation

A pelvic binder must be centered over the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests is incorrect and can paradoxically worsen the deformity.

Question 6749

Topic: 2. Trauma

An 80-year-old woman presents with a reverse obliquity intertrochanteric femur fracture after a ground-level fall. Which of the following implants is most appropriate to prevent medial shaft displacement and failure?

. Dynamic hip screw (sliding hip screw)
. Long cephalomedullary nail
. Multiple cannulated screws
. Proximal femoral locking plate
. Dynamic condylar screw

Correct Answer & Explanation

. Long cephalomedullary nail

Explanation

Reverse obliquity and fractures with lateral wall incompetence are highly unstable and do poorly with sliding hip screws due to lateral translation. A cephalomedullary nail provides the necessary intramedullary support to prevent this displacement.

Question 6750

Topic: 2. Trauma

A 24-year-old polytrauma patient presents with bilateral closed femoral shaft fractures, severe pulmonary contusions, and an initial lactate of 5.0 mmol/L.

What is the most appropriate initial management of the femoral fractures?

. Immediate bilateral reamed intramedullary nailing
. Immediate bilateral unreamed intramedullary nailing
. Damage control external fixation
. Skeletal traction and bed rest for 7 days
. Open reduction and internal fixation with plates

Correct Answer & Explanation

. Damage control external fixation

Explanation

In a borderline or unstable polytrauma patient with significant pulmonary injury and elevated lactate, damage control orthopedics (temporary external fixation) is indicated. Early total care (intramedullary nailing) increases the risk of ARDS and systemic inflammatory response syndrome (SIRS) in this population.

Question 6751

Topic: 2. Trauma

During open reduction and internal fixation of a distal femur fracture, you identify a separate coronal plane fracture of the lateral femoral condyle (Hoffa fragment). What is the optimal fixation strategy for this specific fragment?

. Lateral to medial lag screws
. Medial to lateral lag screws
. Anterior-to-posterior or posterior-to-anterior lag screws
. A single lateral locking plate bridging the fragment
. Tension band wiring

Correct Answer & Explanation

. Anterior-to-posterior or posterior-to-anterior lag screws

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle. It requires fixation perpendicular to the fracture plane, typically using anterior-to-posterior (AP) or posterior-to-anterior (PA) lag screws.

Question 6752

Topic: 2. Trauma

A 35-year-old man undergoes intramedullary nailing for a proximal-third tibial shaft fracture. Intraoperatively, the fracture demonstrates an apex anterior (procurvatum) and valgus deformity. Which of the following techniques is most effective in preventing this deformity?

. Using an infrapatellar surgical approach in full extension
. Placing a blocking (Poller) screw posterior and lateral to the nail in the proximal segment
. Using a thinner, unreamed nail
. Placing a blocking screw anterior and medial to the nail in the distal segment
. Applying sequential compression through the nail

Correct Answer & Explanation

. Placing a blocking (Poller) screw posterior and lateral to the nail in the proximal segment

Explanation

Proximal-third tibia fractures are notorious for apex anterior and valgus deformities during nailing. Blocking screws placed posterior to the nail (to prevent procurvatum) and lateral to the nail (to prevent valgus) in the proximal fragment help guide the nail and maintain reduction.

Question 6753

Topic: 2. Trauma

A 45-year-old man sustains a Schatzker IV tibial plateau fracture (medial plateau) from a high-energy varus force.

Which of the following approaches is most appropriate for direct visualization and buttressing of this fracture?

. Anterolateral approach
. Midline transpatellar approach
. Posteromedial approach
. Direct medial approach
. Lateral approach with a fibular osteotomy

Correct Answer & Explanation

. Posteromedial approach

Explanation

Schatzker IV fractures typically involve a posteromedial shear fragment. A posteromedial approach allows for an anti-glide or buttress plate to be applied directly over the apex of the fracture, providing stable fixation.

Question 6754

Topic: 2. Trauma

A 30-year-old construction worker falls from a roof, sustaining a closed, highly comminuted tibial pilon fracture with massive soft tissue swelling and fracture blisters. What is the most appropriate definitive management sequence?

. Immediate open reduction and internal fixation of the tibia and fibula
. Immediate closed reduction and casting
. Spanning external fixation, followed by definitive ORIF once the 'wrinkle sign' appears
. Primary below-knee amputation
. Immediate intramedullary nailing of the tibia

Correct Answer & Explanation

. Spanning external fixation, followed by definitive ORIF once the 'wrinkle sign' appears

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with staged protocols. Initial spanning external fixation protects the soft tissues, allowing swelling to subside (wrinkle sign) before definitive internal fixation is safely performed.

Question 6755

Topic: 2. Trauma
A 45-year-old man is brought to the trauma bay following a motorcycle collision. He is hypotensive with a blood pressure of 75/40 mm Hg. Radiographs reveal an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is applied, and he receives 2 units of uncrossmatched packed red blood cells, but remains hemodynamically unstable. A FAST exam is negative. What is the most appropriate next step in management?
. Bilateral external fixator placement
. Laparotomy
. Preperitoneal pelvic packing or pelvic angiography
. Fluid resuscitation with 2 liters of crystalloid
. CT scan of the abdomen and pelvis

Correct Answer & Explanation

. Preperitoneal pelvic packing or pelvic angiography

Explanation

In a hemodynamically unstable patient with a pelvic fracture and negative FAST, the source of bleeding is presumed to be the pelvis. Immediate preperitoneal pelvic packing or angiography is indicated to control hemorrhage.

Question 6756

Topic: 2. Trauma

A 65-year-old woman sustains a subtrochanteric femur fracture. During closed reduction prior to intramedullary nailing, the proximal fragment is noted to be severely displaced. Which of the following best describes the typical deforming forces acting on the proximal fragment?

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

Correct Answer & Explanation

. Flexed, abducted, and externally rotated

Explanation

The proximal fragment in a subtrochanteric fracture is flexed by the iliopsoas, abducted by the gluteus medius and minimus, and externally rotated by the short external rotators.

Question 6757

Topic: 2. Trauma

A 40-year-old man presents with a high-energy bicondylar tibial plateau fracture (Schatzker VI). CT imaging reveals a large, displaced posteromedial fragment. Biomechanically, what is the most appropriate surgical strategy for addressing this specific fragment?

. Anteromedial approach with an apex-proximal plate
. Posteromedial approach with an apex-distal buttress plate
. Lateral approach with locking screws directed medially
. Anterior approach with dual lag screws
. External fixation alone without internal fixation

Correct Answer & Explanation

. Posteromedial approach with an apex-distal buttress plate

Explanation

The posteromedial fragment in bicondylar tibial plateau fractures typically has a vertical shear pattern. It is best managed via a posteromedial approach using an apex-distal plate in a buttress mode.

Question 6758

Topic: 2. Trauma

A 24-year-old man undergoes closed reduction and percutaneous pinning for a Hawkins type II talar neck fracture. Radiographs obtained 8 weeks postoperatively demonstrate a distinct subchondral radiolucent band in the dome of the talus. What does this radiographic finding indicate?

. Impending avascular necrosis of the talar body
. Osteomyelitis of the talus
. Nonunion of the talar neck
. Intact vascularity of the talar body
. Post-traumatic osteoarthritis

Correct Answer & Explanation

. Intact vascularity of the talar body

Explanation

A subchondral radiolucent band in the talar dome (Hawkins sign) represents subchondral atrophy from disuse in the setting of an intact blood supply, indicating that the talar body remains viable.

Question 6759

Topic: Pelvic & Acetabular Trauma
A 38-year-old woman is evaluated for a closed pelvic ring injury after a pedestrian-versus-auto accident. Examination reveals a large, fluctuant soft-tissue swelling over the greater trochanter with overlying skin ecchymosis and decreased sensation. What is the pathophysiology of this associated soft-tissue injury?
. Rupture of the deep fascia with muscle herniation
. Shearing of the subcutaneous tissue from the underlying fascia, disrupting perforating vessels
. Acute hematogenous spread of bacteria to a local hematoma
. Direct arterial laceration by a bone spike
. Venous thrombosis of the superficial venous system

Correct Answer & Explanation

. Shearing of the subcutaneous tissue from the underlying fascia, disrupting perforating vessels

Explanation

This describes a Morel-Lavallée lesion, a closed degloving injury where subcutaneous tissue is sheared off the underlying fascia. This disrupts perforating vessels, creating a cavity that fills with blood, lymph, and necrotic fat.

Question 6760

Topic: 2. Trauma
A 26-year-old man sustains a completely displaced, vertically oriented femoral neck fracture (Pauwels type III). Given his young age, joint-preserving surgery is planned. Biomechanically, which of the following construct choices offers the greatest resistance to vertical shear forces?
. Three parallel cancellous screws in an inverted triangle configuration
. Two parallel cancellous screws
. A sliding hip screw with a derotation screw
. A fully threaded 7.3 mm intramedullary screw
. A cephalomedullary nail with a single lag screw

Correct Answer & Explanation

. A sliding hip screw with a derotation screw

Explanation

Pauwels III (vertical) fractures experience high shear forces. A sliding hip screw (fixed-angle device) combined with a derotation screw provides superior biomechanical stability against vertical shear compared to multiple cancellous screws.

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