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2. Trauma MCQs

Practice Set 342 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 6821

Topic: 2. Trauma
A 25-year-old man sustains a high-energy trauma resulting in a vertically oriented (Pauwels Type III) displaced femoral neck fracture. To resist the severe shear forces inherent to this fracture pattern, which fixation construct provides the greatest biomechanical stability?
. Three parallel fully threaded cancellous screws
. Two divergent cannulated screws
. A sliding hip screw with a derotational cancellous screw
. An unreamed standard trochanteric entry antegrade nail
. A dynamic condylar screw (DCS) system

Correct Answer & Explanation

. A sliding hip screw with a derotational cancellous screw

Explanation

Pauwels Type III femoral neck fractures feature a highly vertical fracture line, resulting in massive shear forces and a high risk of varus collapse. A fixed-angle device such as a sliding hip screw, combined with a derotational cancellous screw, provides superior biomechanical stability compared to multiple cancellous screws alone.

Question 6822

Topic: 2. Trauma

A 28-year-old man undergoes closed reduction and reamed intramedullary nailing for a closed transverse midshaft tibia fracture. Four hours postoperatively, he requires escalating doses of intravenous opioids and complains of severe, burning leg pain. What is the most reliable clinical indicator mandating immediate surgical intervention?

. Loss of palpable dorsalis pedis and posterior tibial pulses
. Capillary refill time greater than 3 seconds in the toes
. Severe pain exacerbated by passive stretch of the hallux
. Decreased sensation in the sural nerve distribution
. Visible tense swelling over the anterior compartment

Correct Answer & Explanation

. Severe pain exacerbated by passive stretch of the hallux

Explanation

Pain out of proportion to the injury that is worsened by passive stretch of the ischemic muscles is the earliest and most sensitive clinical sign of acute compartment syndrome. The loss of distal pulses and prolonged capillary refill are late, unreliable signs that often do not occur until irreversible ischemia has set in.

Question 6823

Topic: 2. Trauma

A 25-year-old man sustains a subtrochanteric femur fracture. During closed reduction for intramedullary nailing, the proximal fragment typically assumes which of the following positions?

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

Correct Answer & Explanation

. Flexed, abducted, 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 6824

Topic: 2. Trauma

A 30-year-old male is involved in a high-speed MVC and sustains an ipsilateral femoral neck and shaft fracture. Which of the following is the most appropriate management strategy?

. Retrograde IM nail followed by cannulated screws for the neck
. Fixation of the femoral neck with cannulated screws followed by retrograde IM nail
. Plate fixation of the shaft followed by dynamic hip screw
. Antegrade reconstruction nail addressing both fractures simultaneously
. Dynamic hip screw addressing both fractures

Correct Answer & Explanation

. Fixation of the femoral neck with cannulated screws followed by retrograde IM nail

Explanation

In ipsilateral femoral neck and shaft fractures, anatomic reduction and fixation of the femoral neck should be prioritized to minimize the risk of avascular necrosis and nonunion. A common construct is provisional or definitive neck fixation followed by retrograde shaft nailing.

Question 6825

Topic: 2. Trauma

A 65-year-old woman with a 10-year history of alendronate use presents with right thigh pain. Radiographs reveal localized lateral cortical thickening and a transverse radiolucent line in the proximal third of the femoral shaft. What is the most appropriate next step in management?

. Discontinue alendronate and prescribe teriparatide
. Discontinue alendronate, protected weight-bearing, and prophylactic intramedullary nailing
. Core decompression of the lesion
. Open biopsy to rule out malignancy
. Plate osteosynthesis

Correct Answer & Explanation

. Discontinue alendronate, protected weight-bearing, and prophylactic intramedullary nailing

Explanation

Atypical femoral fractures are associated with prolonged bisphosphonate use. Patients with symptomatic incomplete fractures (thigh pain and lateral cortical radiolucency) should undergo prophylactic intramedullary nailing to prevent completion of the fracture.

Question 6826

Topic: 2. Trauma

A 35-year-old man undergoes intramedullary nailing of a proximal third tibial shaft fracture. Postoperatively, the most common malalignment seen is:

. Apex posterior (recurvatum) and varus
. Apex anterior (procurvatum) and valgus
. Apex posterior and valgus
. Apex anterior and varus
. Rotational malalignment

Correct Answer & Explanation

. Apex anterior (procurvatum) and valgus

Explanation

Intramedullary nailing of proximal third tibial fractures often results in an apex anterior (procurvatum) and valgus deformity. This is due to the pull of the patellar tendon and an anterior starting point.

Question 6827

Topic: 2. Trauma

A 28-year-old man sustains a closed midshaft tibial fracture. He develops severe leg pain out of proportion to the injury. Which of the following pressure measurements is most diagnostic for acute compartment syndrome requiring immediate fasciotomy?

. Absolute compartment pressure of 20 mm Hg
. Diastolic blood pressure minus compartment pressure < 30 mm Hg
. Systolic blood pressure minus compartment pressure > 30 mm Hg
. Mean arterial pressure minus compartment pressure < 40 mm Hg
. Absolute compartment pressure of 25 mm Hg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure < 30 mm Hg

Explanation

Acute compartment syndrome is a clinical diagnosis, but when utilizing intracompartmental pressures, a Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mm Hg is an accepted threshold for performing a four-compartment fasciotomy.

Question 6828

Topic: 2. Trauma

A 45-year-old man sustains a distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). This specific fracture pattern is best treated with:

. Cast immobilization
. Anatomic reduction and lag screw fixation placed perpendicular to the fracture line
. Excision of the osteochondral fragment
. Primary total knee arthroplasty
. Intramedullary nailing

Correct Answer & Explanation

. Anatomic reduction and lag screw fixation placed perpendicular to the fracture line

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle. It requires anatomic reduction and rigid fixation, typically with anterior-to-posterior or posterior-to-anterior lag screws placed perpendicular to the fracture line to allow early range of motion.

Question 6829

Topic: 2. Trauma

A 25-year-old polytrauma patient presents with a closed femoral shaft fracture, bilateral pulmonary contusions, and a Glasgow Coma Scale score of 7. His serum lactate is 4.5 mmol/L and base deficit is -8. What is the most appropriate initial management of the femur fracture?

. Reamed intramedullary nailing
. Unreamed intramedullary nailing
. External fixation
. Plate osteosynthesis
. Skeletal traction only

Correct Answer & Explanation

. External fixation

Explanation

In an unstable or borderline polytrauma patient with severe chest and head injuries (elevated lactate and base deficit), Damage Control Orthopedics (DCO) is indicated. External fixation of the femur minimizes the 'second hit' phenomenon and systemic inflammatory response.

Question 6830

Topic: 2. Trauma

When treating an extra-articular distal third tibial shaft fracture with an intramedullary nail, which of the following postoperative malalignments is most frequently observed?

. Varus and recurvatum
. Valgus and procurvatum
. Valgus and recurvatum
. Varus and procurvatum
. Shortening and external rotation

Correct Answer & Explanation

. Valgus and procurvatum

Explanation

Intramedullary nailing of distal tibia fractures is notoriously complicated by valgus and procurvatum (apex anterior) deformities. This is due to the mismatch between the nail and the widening metaphysis, along with muscular deforming forces.

Question 6831

Topic: 2. Trauma

A 30-year-old man sustains a closed high-energy tibial shaft fracture. Within 12 hours, he develops out-of-proportion pain and pain with passive toe flexion. Which compartment of the lower leg is most frequently involved in acute compartment syndrome following this injury?

. Anterior compartment
. Lateral compartment
. Superficial posterior compartment
. Deep posterior compartment
. Peroneal compartment

Correct Answer & Explanation

. Anterior compartment

Explanation

The anterior compartment of the leg is the most commonly affected compartment in acute compartment syndrome following a tibial shaft fracture. Diagnosis is confirmed clinically and with compartment pressure measurements.

Question 6832

Topic: 2. Trauma
A 28-year-old sustains a displaced, vertically oriented (Pauwels III) femoral neck fracture. To maximize biomechanical stability and resist the high shear forces inherent to this fracture pattern, which fixation construct is preferred?
. Three parallel cancellous screws
. Sliding hip screw with an anti-rotation screw
. Dynamic condylar screw
. Cephalomedullary nail with a single lag screw
. Multiple fully threaded pins

Correct Answer & Explanation

. Sliding hip screw with an anti-rotation screw

Explanation

In young patients with vertical (Pauwels III) femoral neck fractures, shear forces are high. A sliding hip screw coupled with a derotation screw provides superior biomechanical stability against vertical shear compared to multiple cancellous screws.

Question 6833

Topic: 2. Trauma
A 40-year-old patient presents with an open type IIIB tibia fracture with a 6 cm soft tissue defect directly over the middle third of the tibia. Following adequate debridement, which flap is the most appropriate choice for local soft tissue coverage?
. Gastrocnemius rotational flap
. Soleus rotational flap
. Sural artery cross-leg flap
. Free latissimus dorsi flap
. Reverse sural flap

Correct Answer & Explanation

. Soleus rotational flap

Explanation

The soleus muscle flap is the primary workhorse for soft tissue defects over the middle third of the tibia. The gastrocnemius flap is typically utilized for proximal third defects, while distal third defects often require free flaps.

Question 6834

Topic: 2. Trauma

A 32-year-old sustains a high-energy femoral shaft fracture. Upon secondary survey, a non-displaced ipsilateral femoral neck fracture is discovered. Which of the following surgical strategies represents an optimal approach to manage both injuries?

. Single antegrade trochanteric entry nail
. Antegrade piriformis entry nail for both
. Retrograde intramedullary nail for the shaft and cancellous screws for the neck
. Plate fixation for the shaft and dynamic hip screw for the neck
. Nonoperative management of the neck with external fixation of the shaft

Correct Answer & Explanation

. Retrograde intramedullary nail for the shaft and cancellous screws for the neck

Explanation

Using a retrograde intramedullary nail for the femoral shaft combined with cancellous screws for the femoral neck allows optimal, independent fixation of both fractures. Crucially, it prioritizes anatomic fixation of the neck and avoids displacement during shaft nailing.

Question 6835

Topic: 2. Trauma

A 45-year-old sustains a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). Which of the following statements regarding the surgical fixation of this injury is true?

. It requires non-operative management if nondisplaced
. Anterior-to-posterior directed screws are biomechanically superior to posterior-to-anterior screws
. Posterior-to-anterior directed screws are biomechanically superior to anterior-to-posterior screws
. A single 6.5mm screw provides adequate rotational stability
. It is best treated with a retrograde intramedullary nail

Correct Answer & Explanation

. Posterior-to-anterior directed screws are biomechanically superior to anterior-to-posterior screws

Explanation

Biomechanical studies have demonstrated that posterior-to-anterior (PA) directed lag screws provide superior fixation and stability for Hoffa fractures compared to anterior-to-posterior (AP) screws. At least two screws are required to control rotation.

Question 6836

Topic: 2. Trauma

When treating a proximal third tibial shaft fracture with an intramedullary nail using a standard infrapatellar approach, the most commonly encountered post-operative malalignment is:

. Valgus and recurvatum
. Varus and procurvatum
. Valgus and procurvatum
. Varus and recurvatum
. Shortening and internal rotation

Correct Answer & Explanation

. Valgus and procurvatum

Explanation

The classic deformity associated with standard intramedullary nailing of proximal third tibia fractures is apex anterior (procurvatum) and valgus. This is primarily driven by the pull of the patellar tendon and the anatomical widening of the metaphysis.

Question 6837

Topic: 2. Trauma

A 35-year-old man sustains a severe, closed, highly comminuted tibial pilon fracture with massive soft tissue swelling and impending fracture blisters. What is the most appropriate management strategy?

. Immediate open reduction and internal fixation of the tibia and fibula
. Spanning external fixation with delayed definitive ORIF
. Immediate definitive intramedullary nailing
. Application of a rigid short leg cast
. Immediate primary below-knee amputation

Correct Answer & Explanation

. Spanning external fixation with delayed definitive ORIF

Explanation

For high-energy pilon fractures with significantly compromised soft tissues, the standard of care is a staged protocol. Initial spanning external fixation allows the soft tissue envelope to recover, followed by delayed definitive ORIF typically 10-21 days later.

Question 6838

Topic: 2. Trauma
According to the Winquist-Hansen classification of femoral shaft fractures, how is a Type III fracture defined?
. A small butterfly fragment with >50% cortical contact between major fragments
. Comminution with <50% cortical contact between the proximal and distal fragments
. Segmental comminution with no cortical contact between major fragments
. A simple transverse fracture with a spiral wedge
. A spiral fracture with an intact medial hinge

Correct Answer & Explanation

. Comminution with <50% cortical contact between the proximal and distal fragments

Explanation

In the Winquist-Hansen classification, Type III fractures feature a large butterfly fragment with less than 50% cortical contact between the major proximal and distal fragments. These fractures are considered highly unstable regarding length and rotation.

Question 6839

Topic: 2. Trauma
A 42-year-old pedestrian is struck by a motor vehicle and sustains an isolated medial tibial plateau fracture. According to the Schatzker classification system, what type of fracture is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

A Schatzker Type IV fracture is an isolated fracture of the medial tibial plateau. It is typically the result of a high-energy trauma and is highly associated with varus instability, as well as peroneal nerve and popliteal artery injuries.

Question 6840

Topic: 2. Trauma

A 25-year-old man sustains a high-energy femoral shaft fracture. What is the most commonly missed associated ipsilateral injury, and what is the best imaging modality to rule it out during the initial trauma evaluation?

. Femoral neck fracture; dedicated AP and lateral hip radiographs or thin-cut CT
. Posterior hip dislocation; standard pelvic radiograph
. Anterior cruciate ligament tear; MRI of the knee
. Popliteal artery injury; CT angiography
. Acetabular fracture; Judet views

Correct Answer & Explanation

. Femoral neck fracture; dedicated AP and lateral hip radiographs or thin-cut CT

Explanation

Ipsilateral femoral neck fractures occur in 2-9% of femoral shaft fractures and are frequently missed initially. A dedicated CT or high-quality AP/lateral hip radiographs are mandatory to rule out this injury.

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