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2. Trauma MCQs

Practice Set 344 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 6861

Topic: 2. Trauma

A 40-year-old male sustains a high-energy Schatzker VI tibial plateau fracture. He presents with severe, unrelenting leg pain out of proportion to the injury, pain on passive stretch of the toes, and tense compartments. What is the most critical diagnostic step prior to surgical intervention?

. CT angiogram of the lower extremity
. Magnetic Resonance Imaging of the knee
. Measurement of intracompartmental pressures
. Doppler ultrasound of deep veins
. No diagnostic testing is needed; proceed directly to fasciotomy

Correct Answer & Explanation

. No diagnostic testing is needed; proceed directly to fasciotomy

Explanation

The clinical presentation is classic and unequivocal for acute compartment syndrome. When the clinical diagnosis is clear based on physical exam, time should not be wasted on measuring compartment pressures; emergent four-compartment fasciotomy is indicated.

Question 6862

Topic: 2. Trauma

A 65-year-old woman taking alendronate for 10 years presents with a low-energy transverse subtrochanteric femur fracture. Radiographs show cortical thickening of the lateral cortex. What is the most appropriate management of the contralateral, asymptomatic femur if radiographs show lateral cortical beaking?

. Stop alendronate and start teriparatide only
. Stop alendronate and observe with serial radiographs
. Prophylactic intramedullary nailing
. Core decompression of the subtrochanteric region
. Prophylactic plating of the lateral cortex

Correct Answer & Explanation

. Prophylactic intramedullary nailing

Explanation

Patients with bisphosphonate-related atypical femur fractures often have bilateral involvement. If the asymptomatic side demonstrates radiographic changes such as lateral cortical "beaking" or a stress line, prophylactic intramedullary nailing is indicated to prevent completion of the fracture.

Question 6863

Topic: 2. Trauma

A 45-year-old smoker is 9 months out from a reamed intramedullary nailing of a closed midshaft tibia fracture. He reports continued pain with weight-bearing. Radiographs show an oligotrophic nonunion with a broken distal locking screw. What is the most successful surgical intervention?

. Removal of the broken screw to allow dynamization
. Exchange intramedullary nailing with a larger diameter reamed nail
. Open reduction and internal fixation with a compression plate
. Fibular osteotomy alone
. Bone marrow aspirate concentrate injection

Correct Answer & Explanation

. Exchange intramedullary nailing with a larger diameter reamed nail

Explanation

Exchange intramedullary nailing with reaming to a larger diameter is the treatment of choice for an oligotrophic or hypertrophic nonunion of the tibial shaft. It provides both biological stimulation through reaming and increased mechanical stability.

Question 6864

Topic: 2. Trauma

A 30-year-old driver presents after a dashboard injury with a swollen knee. Radiographs reveal a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). What is the most appropriate fixation strategy for this specific fracture pattern?

. Anterior-to-posterior directed lag screws
. Posterior-to-anterior directed lag screws
. Lateral-to-medial directed lag screws
. A lateral locking plate alone without lag screws
. Retrograde intramedullary nailing

Correct Answer & Explanation

. Anterior-to-posterior directed lag screws

Explanation

A Hoffa fracture is a coronal plane fracture of the femoral condyle. Biomechanically, anterior-to-posterior (AP) directed lag screws placed perpendicular to the fracture plane provide the best compression and stability for this intra-articular fracture.

Question 6865

Topic: 2. Trauma

A 50-year-old man falls from a height, sustaining a highly comminuted, displaced intra-articular distal tibia fracture (OTA/AO 43-C3) with severe soft tissue swelling and fracture blisters. What is the most appropriate initial step in the operative sequence?

. Immediate open reduction and internal fixation of the tibia
. Spanning external fixation and fibular fixation if required
. Definitive circular fine-wire external fixation
. Percutaneous screw fixation of the articular surface
. Immediate bone grafting of the metaphyseal defect

Correct Answer & Explanation

. Spanning external fixation and fibular fixation if required

Explanation

High-energy pilon fractures with severe soft tissue compromise require a staged approach. Initial management involves a spanning external fixator across the ankle joint to restore length and alignment while allowing soft tissue swelling to subside before definitive fixation.

Question 6866

Topic: 2. Trauma

A patient sustained the injuries shown in the radiographs and clinical photograph seen in Figures 10a through 10c. The neurovascular examination is normal. The first step in emergent management of the extremity injuries should consist of

. application of a femoral traction pin.
. intramedullary nailing of the femur and tibia.
. surgical irrigation and debridement.
. external fixation of the femoral fracture.
. reduction of the femoral head.

Correct Answer & Explanation

. reduction of the femoral head.

Explanation

The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation. Sahin V, Karakas ES, Aksu S, et al: Traumatic dislocation and fracture-dislocation of the hip: A long-term follow-up study. J Trauma 2003;54:520-529.

Question 6867

Topic: Pelvic & Acetabular Trauma
A 25-year-old male is brought to the ED after a motorcycle collision. He is hemodynamically unstable. A pelvic radiograph shows an APC-III pelvic ring injury. Where should a pelvic binder be applied to most effectively reduce the pelvic volume?
. At the level of the iliac crests
. At the level of the anterior superior iliac spines
. At the level of the greater trochanters
. Around the proximal thighs
. At the level of the umbilicus

Correct Answer & Explanation

. At the level of the greater trochanters

Explanation

Pelvic binders should be placed centered over the greater trochanters to effectively reduce the pelvic volume in open-book pelvic fractures. Placement over the iliac crests is less effective and may paradoxically open the pelvis further.

Question 6868

Topic: 2. Trauma
A 42-year-old construction worker sustains a Gustilo-Anderson Type IIIB open tibia fracture. Which of the following factors has been shown to be the most critical in reducing the risk of subsequent infection?
. Time to operative debridement within 6 hours
. Time to administration of intravenous antibiotics
. Use of high-pressure pulsatile lavage
. Immediate soft tissue coverage
. Use of local antibiotic beads

Correct Answer & Explanation

. Time to administration of intravenous antibiotics

Explanation

The single most important factor in reducing infection rates in open fractures is the early administration of systemic antibiotics. Strict adherence to the '6-hour rule' for debridement has not been proven to be as critical as immediate antibiotic delivery.

Question 6869

Topic: 2. Trauma

A 30-year-old male presents with a closed tibial shaft fracture. He complains of severe pain out of proportion to the injury. Which of the following intracompartmental pressure measurements is an absolute indication for fasciotomy?

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

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure < 30 mm Hg

Explanation

A delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mm Hg is widely accepted as a strong indication for urgent fasciotomy. Absolute pressures are less reliable, especially in hypotensive patients.

Question 6870

Topic: 2. Trauma

A 45-year-old polytrauma patient presents with bilateral femoral shaft fractures, severe closed head injury, and pulmonary contusions. Which of the following laboratory values is a specific indication for damage control orthopedics (external fixation) rather than early total care?

. Arterial pH of 7.36
. Serum lactate > 2.5 mmol/L
. Platelet count of 150,000/mcL
. Fibrinogen of 250 mg/dL
. Core temperature of 36.5 degrees Celsius

Correct Answer & Explanation

. Serum lactate > 2.5 mmol/L

Explanation

Indications for Damage Control Orthopedics (DCO) include acidosis (pH < 7.24), hypothermia (< 35 degrees C), coagulopathy, and inadequate perfusion markers such as a serum lactate > 2.5 mmol/L. These patients are at high risk for the 'second hit' phenomenon.

Question 6871

Topic: 2. Trauma

A 19-year-old male with an isolated closed femoral shaft fracture develops confusion, a respiratory rate of 30 breaths/min, and a petechial rash over his axillae 24 hours after injury. What is the most appropriate initial management?

. Intravenous corticosteroids
. Administration of low molecular weight heparin
. Supportive care with supplemental oxygen and mechanical ventilation if needed
. Immediate intramedullary nailing of the femur
. Administration of hypertonic saline

Correct Answer & Explanation

. Supportive care with supplemental oxygen and mechanical ventilation if needed

Explanation

The patient presents with Fat Embolism Syndrome, displaying the classic triad of hypoxemia, neurologic abnormalities, and a petechial rash. The mainstay of treatment is supportive care, primarily focusing on maintaining adequate oxygenation.

Question 6872

Topic: 2. Trauma

A 28-year-old male sustains a low-velocity gunshot wound to the thigh resulting in a comminuted femoral shaft fracture. The entrance and exit wounds are 1 cm clean punctures. He has intact distal pulses and no neurologic deficits. What is the most appropriate definitive management?

. Immediate wide excision of the bullet tract and external fixation
. Local wound care, tetanus prophylaxis, and antegrade intramedullary nailing
. Nonoperative management with skeletal traction
. Immediate plate osteosynthesis
. Angiography followed by surgical debridement

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and antegrade intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without vascular injury or severe contamination can be treated similarly to closed fractures. Local wound care, tetanus prophylaxis, and standard intramedullary nailing yield excellent outcomes without formal tract debridement.

Question 6873

Topic: 2. Trauma

A 35-year-old male sustains a closed spiral fracture of the distal third of the humerus (Holstein-Lewis fracture). On initial examination in the ED, he has a dense radial nerve palsy. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve
. Closed reduction and application of a coaptation splint
. Electromyography (EMG) and nerve conduction studies
. Immediate plating and nerve grafting
. Application of an external fixator

Correct Answer & Explanation

. Closed reduction and application of a coaptation splint

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is typically treated nonoperatively with closed reduction and a coaptation splint, as the majority are neuropraxias that will recover spontaneously. Exploration is indicated if the palsy develops AFTER a reduction attempt.

Question 6874

Topic: 2. Trauma

A 24-year-old cyclist falls onto his shoulder, sustaining a midshaft clavicle fracture. Which of the following is considered an absolute indication for operative fixation?

. Shortening of 1.5 cm
. Displacement of 100 percent with no cortical contact
. Skin tenting with progressive skin ischemia and blanching
. Presence of a comminuted butterfly fragment
. Patient desire for a faster return to sports

Correct Answer & Explanation

. Skin tenting with progressive skin ischemia and blanching

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, neurovascular compromise, and impending skin compromise (severe skin tenting with blanching/ischemia). Shortening and 100% displacement are relative indications.

Question 6875

Topic: 2. Trauma
A 45-year-old man presents with a hemodynamically unstable APC-III pelvic ring injury. A pelvic binder is applied in the trauma bay. To optimally reduce pelvic volume and stabilize the fracture, the binder should be centered over which of the following anatomic landmarks?
. Anterior superior iliac spines
. Iliac crests
. Greater trochanters
. Symphysis pubis
. Umbilicus

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders should be placed at the level of the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests is less effective and may exacerbate certain fracture patterns.

Question 6876

Topic: 2. Trauma

A 25-year-old polytrauma patient sustains bilateral closed femoral shaft fractures and pulmonary contusions. His initial lactate is 5.2 mmol/L, pH is 7.21, and base excess is -8. What is the most appropriate initial management of his bilateral femur fractures?

. Early total care with bilateral reamed intramedullary nailing
. Bilateral damage control external fixation
. Early total care with bilateral unreamed intramedullary nailing
. Early total care with plate osteosynthesis
. Skeletal traction and delayed internal fixation

Correct Answer & Explanation

. Bilateral damage control external fixation

Explanation

In a polytraumatized patient with physiologic instability (acidosis, elevated lactate), Damage Control Orthopedics (DCO) is indicated. Bilateral external fixation provides rapid stabilization while minimizing additional physiologic surgical burden.

Question 6877

Topic: 2. Trauma
A 30-year-old man sustains a Gustilo-Anderson Type IIIA open tibial shaft fracture following a motorcycle collision. What is the standard antibiotic prophylaxis recommended?
. First-generation cephalosporin alone
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin and penicillin
. Fluoroquinolone alone
. Vancomycin alone

Correct Answer & Explanation

. First-generation cephalosporin and an aminoglycoside

Explanation

Current guidelines recommend a first-generation cephalosporin and an aminoglycoside (or a third-generation cephalosporin alone) for Gustilo-Anderson Type III open fractures to cover both Gram-positive and Gram-negative organisms. Penicillin is typically added only for gross agricultural contamination.

Question 6878

Topic: 2. Trauma

A 28-year-old man presents with a closed midshaft tibia fracture. Four hours post-admission, he complains of severe leg pain out of proportion to the injury, exacerbated by passive toe stretch. His diastolic blood pressure is 70 mm Hg. What intracompartmental pressure reading strongly indicates the need for an emergent four-compartment fasciotomy?

. Absolute pressure of 15 mm Hg
. Absolute pressure of 25 mm Hg
. Delta pressure (Diastolic BP minus Compartment Pressure) of 45 mm Hg
. Delta pressure (Diastolic BP minus Compartment Pressure) of 20 mm Hg
. Delta pressure (Mean Arterial BP minus Compartment Pressure) of 50 mm Hg

Correct Answer & Explanation

. Delta pressure (Diastolic BP minus Compartment Pressure) of 20 mm Hg

Explanation

Compartment syndrome is clinically diagnosed, but when measuring pressures, a delta pressure (Diastolic Blood Pressure minus Compartment Pressure) of less than 30 mm Hg is a strong indication for fasciotomy. Absolute pressure alone is less reliable than delta pressure.

Question 6879

Topic: 2. Trauma

A 60-year-old woman with a history of severe osteoporosis sustains a comminuted distal femur fracture (OTA/AO 33-C2). She has a well-fixed total knee arthroplasty in place. The fracture involves the bone immediately proximal to the prosthesis. What is the preferred surgical treatment?

. Nonoperative management in a hinged knee brace
. Open reduction and internal fixation with a lateral locking plate
. Revision to a distal femoral replacement (megaprosthesis)
. Retrograde intramedullary nailing through the TKA
. External fixation until fracture union

Correct Answer & Explanation

. Open reduction and internal fixation with a lateral locking plate

Explanation

For a periprosthetic distal femur fracture around a well-fixed total knee arthroplasty, open reduction and internal fixation with a lateral locking plate is the standard of care. Distal femoral replacement is reserved for loose components or unsalvageable bone stock.

Question 6880

Topic: 2. Trauma

A 22-year-old man sustains a low-velocity gunshot wound to the thigh resulting in a closed, midshaft spiral femoral fracture. Neurovascular exam is normal. What is the most appropriate management?

. Immediate formal debridement of the bullet track and external fixation
. Local wound care, tetanus prophylaxis, and early antegrade intramedullary nailing
. Intravenous antibiotics for 7 days followed by delayed intramedullary nailing
. Extraction of the bullet followed by plate osteosynthesis
. Skeletal traction for 6 weeks

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and early antegrade intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without neurovascular compromise are treated as closed fractures. Local wound care, tetanus prophylaxis, and early intramedullary nailing yield excellent outcomes without the need for formal bullet track debridement.

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