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2. Trauma MCQs

Practice Set 340 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 6781

Topic: 2. Trauma
A 25-year-old man sustains a high-energy Pauwels type III (vertical shear) fracture of the femoral neck. To provide the most biomechanically stable construct against the high shear forces in this young patient, which fixation method is favored?
. Three cancellous screws in an inverted triangle
. Three cancellous screws in a standard triangle
. A dynamic hip screw (sliding hip screw) with an anti-rotation screw
. A cephalomedullary nail
. Hemiarthroplasty

Correct Answer & Explanation

. A dynamic hip screw (sliding hip screw) with an anti-rotation screw

Explanation

Pauwels type III femoral neck fractures have a high degree of vertical orientation, resulting in significant shear forces that predispose to varus collapse and nonunion. A fixed-angle device, such as a sliding hip screw with a derotational screw, provides superior biomechanical stability against vertical shear compared to multiple cancellous screws in young adults.

Question 6782

Topic: 2. Trauma
A 25-year-old male sustains a severe closed femoral shaft fracture, pulmonary contusion, and a grade III splenic laceration in a motor vehicle collision. His initial pH is 7.15, serum lactate is 6.5 mmol/L, and base deficit is 9. What is the most appropriate initial management of his femur fracture?
. Antegrade reamed intramedullary nailing
. Retrograde reamed intramedullary nailing
. External fixation
. Open reduction and plate osteosynthesis
. Distal femoral skeletal traction

Correct Answer & Explanation

. External fixation

Explanation

In a borderline or unstable polytrauma patient with high lactate, severe base deficit, and pulmonary contusion, Damage Control Orthopedics with temporary external fixation is indicated. This prevents the "second hit" phenomenon associated with the physiologic burden of intramedullary nailing.

Question 6783

Topic: 2. Trauma
A 34-year-old farmer sustains an open tibial shaft fracture highly contaminated with soil. According to current guidelines, what is the most appropriate initial intravenous antibiotic regimen?
. Cefazolin alone
. Cefazolin and gentamicin
. Ceftriaxone and vancomycin
. Cefazolin, gentamicin, and penicillin
. Piperacillin-tazobactam

Correct Answer & Explanation

. Cefazolin, gentamicin, and penicillin

Explanation

For Gustilo type III open fractures with gross soil or farm contamination, a first-generation cephalosporin, an aminoglycoside (or third-generation cephalosporin), and penicillin are recommended. Penicillin is added specifically for Clostridium coverage.

Question 6784

Topic: 2. Trauma

A 28-year-old polytrauma patient undergoes early total care with reamed intramedullary nailing for bilateral femur fractures. Postoperatively, he develops petechiae over the axillae, confusion, and severe hypoxemia. What is the primary pathophysiologic mechanism of his current condition?

. Deep vein thrombosis leading to pulmonary embolism
. Embolization of bone marrow fat and subsequent inflammatory cascade
. Undiagnosed closed head injury
. Over-resuscitation causing acute pulmonary edema
. Transfusion-related acute lung injury

Correct Answer & Explanation

. Embolization of bone marrow fat and subsequent inflammatory cascade

Explanation

The patient exhibits Gurd's major criteria for Fat Embolism Syndrome (FES). The pathophysiology involves mechanical embolization of marrow fat during reaming and the subsequent biochemical inflammatory cascade.

Question 6785

Topic: 2. Trauma

A 22-year-old man has a closed tibial shaft fracture treated with a long leg cast. He complains of worsening pain out of proportion to the injury. His diastolic blood pressure is 75 mmHg. Intracompartmental pressure testing yields an anterior compartment pressure of 50 mmHg. What is his delta pressure and the appropriate management?

. 25 mmHg, urgent four-compartment fasciotomy
. 25 mmHg, close observation and pain control
. 50 mmHg, urgent four-compartment fasciotomy
. 50 mmHg, bivalve the cast and observe
. 125 mmHg, immediate single-incision fasciotomy

Correct Answer & Explanation

. 50 mmHg, urgent four-compartment fasciotomy

Explanation

Delta pressure is calculated as diastolic blood pressure minus compartment pressure (75 - 50 = 25 mmHg). A delta pressure less than 30 mmHg is an absolute indication for emergent four-compartment fasciotomies.

Question 6786

Topic: 2. Trauma

A 30-year-old polytrauma patient had an external fixator placed for a femoral shaft fracture as part of damage control orthopedics. He is now hemodynamically stable. What is the safest timeframe to convert the external fixator to an intramedullary nail to minimize infection risk, assuming pin sites are clean?

. Within 3 days
. Between 7 to 14 days
. After 21 days
. After 28 days
. Conversion is contraindicated; definitive plating is required

Correct Answer & Explanation

. Between 7 to 14 days

Explanation

Conversion of a femoral external fixator to an intramedullary nail is safest within 14 days of initial application. Conversion after 2 to 3 weeks is associated with a significantly higher risk of deep infection.

Question 6787

Topic: 2. Trauma

A 19-year-old male sustains an isolated low-velocity gunshot wound to the thigh resulting in a comminuted midshaft femur fracture. There is no expanding hematoma or distal pulse deficit. Following local wound care and tetanus prophylaxis, what is the best definitive orthopedic management?

. Formal open debridement of the bullet track followed by external fixation
. Immediate reamed intramedullary nailing
. Skeletal traction for 6 weeks followed by bracing
. Open reduction and plate osteosynthesis
. Observation in a long leg cast

Correct Answer & Explanation

. Immediate reamed intramedullary nailing

Explanation

Low-velocity civilian gunshot wounds to the femur without vascular compromise or massive contamination can be safely treated with early reamed intramedullary nailing without formal bullet track debridement.

Question 6788

Topic: 2. Trauma



A 45-year-old woman sustains a high-energy distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle. What is the optimal fixation strategy for this specific fragment?

. Lateral locked plating with unicortical screws
. Anterior-to-posterior oriented lag screws
. Posterior-to-anterior oriented lag screws
. Retrograde intramedullary nailing
. Medial locked plating

Correct Answer & Explanation

. Posterior-to-anterior oriented lag screws

Explanation

A coronal fracture of the femoral condyle is a Hoffa fracture. Fixation is best achieved with anterior-to-posterior (or ideally posterior-to-anterior) directed lag screws to provide compression across the coronal fracture plane.

Question 6789

Topic: 2. Trauma

A 40-year-old heavy smoker presents 9 months after intramedullary nailing of a tibial shaft fracture with persistent pain with ambulation. Radiographs show no bridging callus, rounding of the fracture edges, and an intact intramedullary nail. What is the most appropriate surgical management?

. Dynamization of the nail by removing locking screws
. Exchange nailing to a larger diameter nail
. Plate osteosynthesis with autologous bone grafting
. Ultrasound bone stimulation
. Observation and aggressive smoking cessation program

Correct Answer & Explanation

. Plate osteosynthesis with autologous bone grafting

Explanation

The patient has an atrophic nonunion, indicating poor vascularity and healing potential. Treatment requires improving the biology, typically with autologous bone grafting, often combined with stable fixation like plating or exchange nailing.

Question 6790

Topic: 2. Trauma

In managing a multiply injured patient with long bone fractures, which of the following is the most reliable clinical indicator that the patient is adequately resuscitated and physiologically optimized for definitive Early Total Care?

. Systolic blood pressure > 100 mmHg for 2 consecutive hours
. Urine output of 0.5 mL/kg/hr
. Normalization of serum lactate to < 2.0 mmol/L
. Heart rate < 100 beats per minute
. Oxygen saturation > 92% on room air

Correct Answer & Explanation

. Normalization of serum lactate to < 2.0 mmol/L

Explanation

Serum lactate clearance and normalization of base deficit are the most reliable markers of adequate tissue perfusion and successful resuscitation in a polytrauma patient prior to undertaking definitive fracture care.

Question 6791

Topic: 2. Trauma

A 25-year-old man sustains a closed spiral fracture of the distal third of the humeral shaft. On presentation, he has a complete radial nerve palsy. Closed reduction is performed, but post-reduction radiographs show significant fracture distraction, and the nerve palsy persists. What is the next best step?

. Immediate surgical exploration of the radial nerve and fracture fixation
. Application of a functional fracture brace and observation
. Electromyography and nerve conduction studies
. Skeletal traction via an olecranon pin
. Perform an immediate tendon transfer

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve and fracture fixation

Explanation

While initial radial nerve palsies are typically observed, a Holstein-Lewis fracture that shows significant distraction or entrapment signs after closed reduction is an indication for immediate surgical exploration.

Question 6792

Topic: 2. Trauma

A 33-year-old motorcyclist sustains a floating knee injury, defined as ipsilateral fractures of the femur and tibia. What is the most common long-term complication associated with the operative management of these combined injuries?

. Knee stiffness and decreased range of motion
. Arterial occlusion requiring delayed amputation
. Chronic deep vein thrombosis
. Atrophic nonunion of the tibia
. Recurrent fat embolism syndrome

Correct Answer & Explanation

. Knee stiffness and decreased range of motion

Explanation

The floating knee is notoriously associated with poor functional outcomes. The most frequent long-term complication is severe knee stiffness and decreased range of motion following fixation.

Question 6793

Topic: 2. Trauma



A 41-year-old male presents with a subtrochanteric femur fracture. During closed reduction for intramedullary nailing, the proximal fragment is typically deformed in which position due to prevailing muscle forces?

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

Correct Answer & Explanation

. Flexed, abducted, and externally rotated

Explanation

In subtrochanteric fractures, the proximal fragment is pulled into flexion by the iliopsoas, abduction by the gluteus medius and minimus, and external rotation by the short external rotators.

Question 6794

Topic: 2. Trauma
A 27-year-old sustains a Gustilo-Anderson IIIB open tibia fracture. Following initial aggressive debridement and application of an external fixator, what is the optimal timeframe for definitive soft-tissue coverage with a free flap to minimize the risk of infection?
. Within 24 hours
. Within 72 hours to 7 days
. Between 2 to 3 weeks
. After 4 weeks when granulation tissue is robust
. Timing of coverage does not independently affect infection rates

Correct Answer & Explanation

. Within 72 hours to 7 days

Explanation

Definitive soft-tissue coverage for Gustilo type IIIB open tibia fractures should ideally be performed within 3 to 7 days. Delaying beyond this window significantly increases the risk of deep infection and flap failure.

Question 6795

Topic: 2. Trauma

An 82-year-old female sustains a distal third spiral femur fracture from a mechanical fall. She has a history of severe COPD and heart failure. Which fixation construct provides the best balance of immediate weight-bearing capability and minimal physiologic insult?

. Retrograde intramedullary nailing
. Open reduction internal fixation with a lateral locking plate
. Distal femoral replacement (megaprosthesis)
. Non-operative management in a hinged knee brace
. Skeletal traction for 6 weeks

Correct Answer & Explanation

. Retrograde intramedullary nailing

Explanation

Retrograde intramedullary nailing involves a smaller surgical exposure and preserves the fracture hematoma compared to locking plates. It allows for more reliable immediate weight-bearing in elderly patients with comorbidities.

Question 6796

Topic: 2. Trauma

A 25-year-old polytraumatized man is brought to the emergency department with a closed femoral shaft fracture and bilateral pulmonary contusions. His initial lactate is 4.5 mmol/L, pH is 7.21, and base deficit is 8. Which of the following is the most appropriate initial management of his femur fracture?

. Early total care with reamed intramedullary nailing
. External fixation
. Skeletal traction
. Plate osteosynthesis
. Unreamed intramedullary nailing

Correct Answer & Explanation

. External fixation

Explanation

This patient is hemodynamically unstable with a significant acid-base disturbance indicating inadequate perfusion. Damage control orthopedics (external fixation) is indicated to rapidly stabilize the fracture and minimize the 'second hit' of prolonged surgery.

Question 6797

Topic: 2. Trauma

A 35-year-old man sustains a proximal third tibial shaft fracture. You plan to treat this with an intramedullary nail. To prevent the most common malalignment deformities (procurvatum and valgus), where should blocking (Poller) screws be placed relative to the fracture and the nail?

. Posterior and lateral in the proximal segment
. Anterior and medial in the proximal segment
. Posterior and medial in the proximal segment
. Anterior and lateral in the proximal segment
. Anterior and lateral in the distal segment

Correct Answer & Explanation

. Posterior and medial in the proximal segment

Explanation

Proximal third tibial fractures tend to fall into procurvatum and valgus when treated with intramedullary nails. Blocking screws placed posterior and lateral in the proximal fragment direct the nail anteriorly and medially, counteracting these deforming forces.

Question 6798

Topic: 2. Trauma

A 22-year-old man with a closed midshaft femur fracture develops hypoxia, petechiae over the axilla, and confusion 36 hours after injury. Which of the following is the most effective intervention for preventing the development of this syndrome?

. Prophylactic administration of high-dose corticosteroids
. Placement of a prophylactic inferior vena cava filter
. Early operative stabilization of the fracture within 24 hours
. Prophylactic administration of low molecular weight heparin
. Empirical administration of broad-spectrum antibiotics

Correct Answer & Explanation

. Early operative stabilization of the fracture within 24 hours

Explanation

The clinical presentation is classic for Fat Embolism Syndrome (FES). Early operative stabilization of long bone fractures (within 24 hours) is the most effective proven method to reduce the incidence and severity of FES.

Question 6799

Topic: 2. Trauma

A 65-year-old woman with an 8-year history of alendronate use presents with a displaced transverse subtrochanteric femur fracture. Radiographs show generalized cortical thickening and a lateral cortical spike. Which of the following is the most appropriate definitive surgical treatment?

. Full-length cephalomedullary nailing
. Dynamic hip screw with a short side plate
. Proximal femoral locking plate
. External fixation
. Conservative management with 6 weeks of skeletal traction

Correct Answer & Explanation

. Full-length cephalomedullary nailing

Explanation

Atypical femur fractures are associated with prolonged bisphosphonate use and abnormal bone remodeling. Full-length cephalomedullary or intramedullary nailing provides a load-sharing construct that protects the entire abnormal femur.

Question 6800

Topic: 2. Trauma

A 30-year-old man sustains a closed spiral fracture of the distal third of the humerus. On initial presentation, he has a complete inability to extend his wrist and fingers. He undergoes closed reduction and splinting. Following reduction, the nerve palsy persists unchanged. What is the most appropriate management of the nerve injury?

. Immediate surgical exploration of the radial nerve
. Observation and obtaining an EMG at 12 weeks if no clinical recovery occurs
. Immediate MRI of the humerus to assess nerve continuity
. Immediate flexor-to-extensor tendon transfers
. Administration of high-dose intravenous methylprednisolone

Correct Answer & Explanation

. Observation and obtaining an EMG at 12 weeks if no clinical recovery occurs

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture (including Holstein-Lewis fractures) is generally treated with observation, as the spontaneous recovery rate is extremely high (>85%). EMG is indicated at 12 weeks if no clinical improvement is noted.

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