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2. Trauma MCQs

Practice Set 341 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 6801

Topic: 2. Trauma
A 40-year-old man sustains a Gustilo-Anderson IIIB open tibial shaft fracture. Following urgent thorough debridement and application of an external fixator, what is the optimal timeframe for definitive soft tissue coverage to minimize the risk of deep infection?
. Within 24 hours
. Within 5 to 7 days
. Between 14 and 21 days
. After complete bone union has occurred
. Once healthy granulation tissue covers the entire bone

Correct Answer & Explanation

. Within 5 to 7 days

Explanation

Current orthopedic literature and guidelines strongly recommend achieving definitive soft tissue coverage for Gustilo IIIB open fractures within 5 to 7 days (or classically within 72 hours) to significantly reduce the rate of deep infection and flap failure.

Question 6802

Topic: Pelvic & Acetabular Trauma

In a hemodynamically unstable trauma patient with an anteroposterior compression (APC) pelvic ring injury, where is the optimal anatomical location for the application of a circumferential pelvic binder?

. Directly over the iliac crests
. Directly over the greater trochanters
. Directly over the anterior superior iliac spines
. Directly over the pubic symphysis
. Centered over the lumbar spine and lower abdomen

Correct Answer & Explanation

. Directly over the greater trochanters

Explanation

A pelvic binder must be positioned directly over the greater trochanters to effectively close the pelvic volume and provide maximum compressive tamponade on the bleeding presacral venous plexus.

Question 6803

Topic: 2. Trauma

A 28-year-old man presents with a severe traumatic brain injury (GCS 6) and a concomitant closed femoral shaft fracture. In terms of preventing secondary brain injury, which intraoperative systemic derangements are the primary concern during intramedullary nailing?

. Hypercapnia and systemic hypertension
. Hypoxia and systemic hypotension
. Hypothermia and hyperglycemia
. Hypoxia and systemic hypertension
. Hypercapnia and hyperthermia

Correct Answer & Explanation

. Hypoxia and systemic hypotension

Explanation

Secondary brain injury in polytrauma patients is profoundly exacerbated by episodes of hypoxia and systemic hypotension, both of which severely compromise cerebral perfusion pressure and oxygen delivery to the injured brain tissue.

Question 6804

Topic: 2. Trauma

A 45-year-old man complains of persistent leg pain 9 months after intramedullary nailing of a tibial shaft fracture. Radiographs reveal a nonunion with abundant "elephant foot" callus formation and a persistent fracture line. What is the primary etiology and the gold standard treatment for this condition?

. Biological failure; treat with autologous bone grafting
. Biological failure; treat with exchange intramedullary nailing
. Mechanical instability; treat with exchange intramedullary nailing
. Mechanical instability; treat with autologous bone grafting
. Subclinical infection; treat with hardware removal and systemic antibiotics

Correct Answer & Explanation

. Mechanical instability; treat with exchange intramedullary nailing

Explanation

The presence of abundant bridging callus signifies a hypertrophic nonunion, which implies excellent biology but inadequate mechanical stability. The gold standard treatment is improving stability via exchange intramedullary nailing with a larger diameter nail.

Question 6805

Topic: 2. Trauma

A 25-year-old man sustains a low-velocity gunshot wound to the thigh, resulting in a comminuted femoral shaft fracture without neurovascular deficit. The bullet exited the lateral thigh. Which of the following is the most appropriate management?

. Formal surgical debridement of the bullet track followed by external fixation
. Local wound care, tetanus prophylaxis, antibiotics, and prompt intramedullary nailing
. Formal surgical debridement of the entire bullet track followed by intramedullary nailing
. Local wound care and definitive treatment with skeletal traction for 6 weeks
. Immediate plate osteosynthesis with structural allograft

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, antibiotics, and prompt intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without gross contamination or neurovascular injury are treated similarly to closed fractures. They do not require formal track debridement and safely undergo early intramedullary nailing.

Question 6806

Topic: 2. Trauma

A 20-year-old male falls directly on his shoulder and sustains a midshaft clavicle fracture. Which of the following physical examination findings is an absolute indication for operative fixation?

. 1.5 cm of shortening
. 100% vertical displacement of the fracture fragments
. An associated open wound exposing the fracture site
. Presence of a comminuted butterfly fragment
. Patient desire to return to contact sports within 4 weeks

Correct Answer & Explanation

. An associated open wound exposing the fracture site

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, associated neurovascular compromise, and severe skin tenting that threatens to become an open fracture. Shortening and displacement are considered relative indications.

Question 6807

Topic: 2. Trauma

A 28-year-old polytrauma patient sustains multiple long bone fractures. He is intubated in the intensive care unit. Which of the following physiologic markers is the most reliable indicator of adequate end-organ resuscitation prior to proceeding with definitive intramedullary nailing of his bilateral femur fractures?

. Urine output greater than 30 mL/hr
. Systolic blood pressure consistently above 100 mmHg
. Base deficit less than 2.0 mmol/L
. Heart rate less than 100 beats per minute
. Central venous pressure of 8 mmHg

Correct Answer & Explanation

. Base deficit less than 2.0 mmol/L

Explanation

Base deficit and serum lactate are the most sensitive and reliable indicators of global tissue perfusion and adequate resuscitation. Normalization of these values indicates clearance of occult hypoperfusion, making it safer to proceed with Early Total Care. Vital signs and urine output can normalize while occult shock persists.

Question 6808

Topic: 2. Trauma

A 40-year-old man presents with bilateral femur fractures and a severe pulmonary contusion after a high-speed motor vehicle collision. The decision is made to proceed with Damage Control Orthopedics (DCO) rather than Early Total Care (ETC). Which of the following intraoperative parameters represents an absolute trigger to abort definitive fixation and switch to a DCO strategy?

. Intraoperative blood loss of 500 mL
. Core body temperature drop to 32 degrees Celsius
. Rise in peak airway pressure by 2 cmH2O
. Heart rate increase to 110 beats per minute
. Serum lactate of 1.8 mmol/L

Correct Answer & Explanation

. Core body temperature drop to 32 degrees Celsius

Explanation

The lethal triad of trauma consists of hypothermia, coagulopathy, and acidosis. A core temperature dropping to 32 degrees Celsius is an absolute indication for damage control orthopedics, as severe hypothermia leads to irreversible coagulopathy and physiological exhaustion.

Question 6809

Topic: 2. Trauma

A 32-year-old man sustains a severe open midshaft humerus fracture resulting from a motorcycle crash. Physical examination in the emergency department reveals a complete radial nerve palsy. What is the most appropriate management regarding the radial nerve?

. Observation and electromyography (EMG) at 6 weeks
. Primary nerve grafting during initial presentation
. Nerve exploration concurrently during the required surgical debridement
. Tendon transfers after definitive fracture union
. Immediate amputation due to loss of nerve function

Correct Answer & Explanation

. Nerve exploration concurrently during the required surgical debridement

Explanation

While closed humerus fractures with radial nerve palsy are generally observed, an open fracture with an associated radial nerve palsy is an absolute indication for nerve exploration. The exploration should be performed during the operative debridement and stabilization of the open fracture.

Question 6810

Topic: 2. Trauma
A 42-year-old man sustains a Gustilo-Anderson IIIB open tibial shaft fracture. He undergoes initial debridement and external fixation. To minimize the risk of deep infection and flap failure, definitive soft-tissue coverage with a free tissue transfer should ideally be performed within what timeframe?
. Within 12 hours
. Within 3 to 5 days
. Within 10 to 14 days
. Within 3 to 4 weeks
. Only after radiographic evidence of callus formation

Correct Answer & Explanation

. Within 3 to 5 days

Explanation

Classic and modern literature demonstrates that early soft tissue coverage of severe open fractures, ideally within 72 hours and certainly within 3 to 5 days, significantly reduces the rates of deep infection and flap failure. Delaying coverage beyond 7 days drastically increases complication rates.

Question 6811

Topic: 2. Trauma

A 22-year-old man with an isolated, closed femoral shaft fracture develops hypoxia, tachypnea, confusion, and a petechial rash over his axilla 36 hours post-injury. Which of the following interventions has been proven to be the most effective in preventing this specific syndrome?

. Prophylactic systemic corticosteroids on admission
. Prophylactic placement of an inferior vena cava filter
. Early operative stabilization of the long bone fracture
. Empiric therapeutic anticoagulation with heparin
. High-dose intravenous Vitamin C therapy

Correct Answer & Explanation

. Early operative stabilization of the long bone fracture

Explanation

The patient is presenting with Fat Embolism Syndrome (FES). Early operative stabilization (within 24 hours) of long bone fractures is the most effective and proven method to prevent the development of FES and pulmonary complications in orthopedic trauma patients.

Question 6812

Topic: 2. Trauma

A 30-year-old man sustains a severe crush injury to his leg. His blood pressure is 100/60 mmHg. Intracompartmental pressure testing of the anterior compartment yields a reading of 45 mmHg. What is the delta pressure and is a fasciotomy indicated?

. Delta pressure is 45 mmHg; fasciotomy is not indicated.
. Delta pressure is 55 mmHg; fasciotomy is indicated.
. Delta pressure is 15 mmHg; fasciotomy is indicated.
. Delta pressure is 15 mmHg; fasciotomy is not indicated.
. Delta pressure is 60 mmHg; fasciotomy is not indicated.

Correct Answer & Explanation

. Delta pressure is 15 mmHg; fasciotomy is indicated.

Explanation

Delta pressure is defined as the diastolic blood pressure minus the intracompartmental pressure (60 - 45 = 15 mmHg). A delta pressure less than 30 mmHg indicates inadequate capillary perfusion and is an absolute indication for emergency fasciotomy.

Question 6813

Topic: 2. Trauma
A 35-year-old man sustains a high-energy, displaced, vertically oriented (Pauwels type III) femoral neck fracture. Which of the following internal fixation constructs provides the highest biomechanical stability for this specific fracture pattern?
. Three parallel cancellous lag screws
. Two parallel cancellous lag screws
. A sliding hip screw with an additional derotational cancellous screw
. A standard trochanteric entry cephalomedullary nail
. Non-locking proximal femoral plate

Correct Answer & Explanation

. A sliding hip screw with an additional derotational cancellous screw

Explanation

Pauwels III fractures are highly unstable due to extreme vertical shear forces. Biomechanical studies demonstrate that a fixed-angle construct, such as a sliding hip screw combined with a derotational screw (or a proximal femoral locking plate), provides superior stability and lower failure rates compared to multiple cancellous screws.

Question 6814

Topic: 2. Trauma

A 45-year-old man presents with persistent thigh pain 9 months after intramedullary nailing of a midshaft femur fracture. Radiographs demonstrate an 'elephant foot' appearance at the fracture site and a broken distal locking screw. What is the most appropriate management?

. Removal of hardware and application of a ring external fixator
. Bone grafting of the nonunion site without hardware revision
. Exchange nailing using a larger-diameter reamed intramedullary nail
. Addition of a compression plate leaving the current nail in situ
. Observation and protected weight bearing for 3 more months

Correct Answer & Explanation

. Exchange nailing using a larger-diameter reamed intramedullary nail

Explanation

The patient has a hypertrophic nonunion, which implies adequate biology but inadequate mechanical stability. Exchange nailing with a larger-diameter reamed nail provides the necessary increased biomechanical stability and stimulates healing via the reaming process.

Question 6815

Topic: 2. Trauma

A 68-year-old woman on long-term alendronate therapy presents with a low-energy, transverse subtrochanteric fracture of the right femur. Radiographs of her uninjured left femur reveal lateral cortical thickening and transverse beaking. She reports a 3-month history of left thigh pain. What is the optimal management for the left femur?

. Discontinuation of bisphosphonates and close observation
. Immediate initiation of teriparatide without surgery
. Prophylactic antegrade intramedullary nailing
. Application of a hip spica cast
. Core decompression of the femoral head

Correct Answer & Explanation

. Prophylactic antegrade intramedullary nailing

Explanation

The patient has a completed atypical femur fracture on the right and an impending atypical fracture on the left. The presence of prodromal thigh pain in the setting of lateral cortical beaking on radiographs is a strong indication for prophylactic intramedullary nailing to prevent displacement.

Question 6816

Topic: 2. Trauma

A 55-year-old man is brought to the trauma bay with a high-energy, closed, bicondylar tibial plateau fracture. Examination reveals massive soft tissue swelling, profound ecchymosis, and early fracture blisters. What is the most appropriate initial orthopedic management?

. Immediate open reduction and internal fixation with dual locking plates
. Application of a knee-spanning external fixator
. Closed reduction and long-leg casting
. Primary placement of an intramedullary nail
. Immediate single lateral locked plating

Correct Answer & Explanation

. Application of a knee-spanning external fixator

Explanation

In high-energy tibial plateau fractures with severely compromised soft tissues (swelling, blisters), immediate open reduction carries an unacceptably high risk of wound breakdown and deep infection. A knee-spanning external fixator provides skeletal stability while allowing the soft tissues to recover prior to definitive internal fixation.

Question 6817

Topic: 2. Trauma

A 40-year-old man sustains a comminuted supracondylar distal femur fracture. A computed tomography (CT) scan identifies an associated coronal plane fracture of the lateral femoral condyle (Hoffa fragment). What is the crucial first step in the sequence of operative fixation?

. Fixation of the supracondylar component with a lateral locked plate first
. Placement of a retrograde intramedullary nail
. Anatomical reduction and lag screw fixation of the coronal (Hoffa) fragment
. Application of a spanning external fixator
. Excision of the Hoffa fragment to prevent nonunion

Correct Answer & Explanation

. Anatomical reduction and lag screw fixation of the coronal (Hoffa) fragment

Explanation

When treating a complex distal femur fracture with an associated Hoffa fragment, the articular block must be reconstructed first. The coronal Hoffa fragment should be anatomically reduced and fixed independently with anterior-to-posterior (or posterior-to-anterior) lag screws before addressing the metaphyseal/diaphyseal components.

Question 6818

Topic: 2. Trauma

A 28-year-old man with an Injury Severity Score (ISS) of 42 presents after a motor vehicle collision. He has bilateral closed femoral shaft fractures, a grade IV splenic laceration, and bilateral pulmonary contusions. His initial lactate is 6.2 mmol/L, and pH is 7.18. Following stabilization of his splenic injury by general surgery, what is the most appropriate initial management for his femur fractures?

. Bilateral reamed intramedullary nailing
. Bilateral external fixation
. Open reduction and internal fixation with plating
. Skeletal traction until pulmonary status improves
. Bilateral unreamed intramedullary nailing

Correct Answer & Explanation

. Bilateral external fixation

Explanation

In a hemodynamically unstable polytrauma patient or one with borderline physiology (high ISS, acidosis, elevated lactate, pulmonary contusions), damage control orthopedics (DCO) with external fixation is preferred. This minimizes the inflammatory 'second hit' and fat embolization associated with early intramedullary nailing.

Question 6819

Topic: 2. Trauma

A 34-year-old man sustains a closed spiral fracture of the middle third of the humerus. On initial examination in the emergency department, he is unable to actively extend his wrist or fingers, though he had full function immediately prior to the injury. What is the most appropriate initial management of this nerve deficit?

. Immediate operative nerve exploration and repair
. Electromyography (EMG) within 48 hours
. Observation and functional bracing of the humerus
. Internal fixation of the humerus with concomitant nerve exploration
. Placement of a skeletal traction pin

Correct Answer & Explanation

. Observation and functional bracing of the humerus

Explanation

Primary radial nerve palsies associated with closed humeral shaft fractures typically represent a neuropraxia and have a high rate of spontaneous recovery. Initial management consists of functional bracing; nerve exploration is reserved for open fractures, secondary palsies after closed reduction, or failure of clinical recovery after 3-4 months.

Question 6820

Topic: 2. Trauma
A 42-year-old man sustains a Gustilo-Anderson Type IIIB open tibia fracture with a 12 cm wound and exposed bone devoid of periosteal coverage. After thorough surgical debridement and application of a spanning external fixator, what is the optimal timeframe for definitive soft tissue coverage?
. Within 24 hours of the initial injury
. Within 3 to 7 days after the injury
. Within 14 to 21 days after the injury
. After complete granulation tissue covers the exposed bone
. Immediately during the index procedure regardless of wound contamination

Correct Answer & Explanation

. Within 3 to 7 days after the injury

Explanation

For severe open tibial fractures requiring flap coverage, definitive soft tissue reconstruction is optimally performed within 3 to 7 days following serial debridement. Early coverage in this window significantly decreases the risk of deep infection and flap failure compared to delayed closure.

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