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2. Trauma MCQs

Practice Set 345 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 6881

Topic: 2. Trauma

A 35-year-old woman is evaluated 6 weeks after sustaining a talar neck fracture treated with open reduction and internal fixation. A mortise radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome (Hawkins sign). What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Impending nonunion of the fracture
. Intact vascularity to the talar body
. Post-traumatic osteoarthritis
. Infection of the talar dome

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6-8 weeks post-injury in talar neck fractures. It represents subchondral atrophy, which requires an intact blood supply, thereby ruling out avascular necrosis.

Question 6882

Topic: 2. Trauma

In the staged management of severe pilon fractures (OTA/AO 43-C), what is the primary rationale for initial application of a spanning external fixator and fibular fixation, followed by delayed definitive tibial articular reconstruction?

. To allow for union of the fibula prior to tibial reduction
. To permit resolution of soft tissue swelling and decrease the risk of wound complications
. To prevent the development of compartment syndrome
. To allow time for the bone to become osteopenic for easier reduction
. To definitively treat the fracture without further surgery

Correct Answer & Explanation

. To permit resolution of soft tissue swelling and decrease the risk of wound complications

Explanation

Severe pilon fractures typically present with significant soft tissue compromise. Initial spanning external fixation stabilizes the fracture while allowing the soft tissue envelope to recover, reducing the high risk of wound necrosis and infection associated with immediate ORIF.

Question 6883

Topic: 2. Trauma

A 42-year-old woman is struck by a motor vehicle and sustains a closed Schatzker VI bicondylar tibial plateau fracture. Severe soft tissue swelling and fracture blisters are present. What is the most appropriate initial management?

. Immediate open reduction and dual plate osteosynthesis
. Spanning external fixation across the knee
. Placement of a long leg cast
. Immediate intramedullary nailing
. Primary total knee arthroplasty

Correct Answer & Explanation

. Spanning external fixation across the knee

Explanation

Bicondylar tibial plateau fractures with severe soft tissue injury (blisters, extreme swelling) should be managed with staged treatment. Immediate application of a spanning external fixator allows the soft tissues to heal before definitive internal fixation is performed.

Question 6884

Topic: 2. Trauma

A 50-year-old polytrauma patient develops petechial hemorrhages over the axillae and chest, progressive hypoxemia, and confusion 36 hours after sustaining bilateral femoral shaft fractures. What is the most likely diagnosis?

. Pulmonary embolism
. Fat embolism syndrome
. Acute respiratory distress syndrome (ARDS)
. Disseminated intravascular coagulation (DIC)
. Septic shock

Correct Answer & Explanation

. Fat embolism syndrome

Explanation

Fat embolism syndrome classic triad includes petechial rash, hypoxemia, and neurologic abnormalities (confusion). It commonly occurs 24-72 hours after long bone fractures.

Question 6885

Topic: Pelvic & Acetabular Trauma

Where is the optimal anatomical location to place a pelvic binder in a hemodynamically unstable patient with an anteroposterior compression pelvic ring injury?

. Over the iliac crests
. Over the greater trochanters
. Over the pubic symphysis
. Mid-thigh bilaterally
. Just superior to the umbilicus

Correct Answer & Explanation

. Over the greater trochanters

Explanation

Pelvic binders are most effective at reducing pelvic volume when centered directly over the greater trochanters. Placement over the iliac crests can paradoxically open the true pelvis further in some fracture patterns.

Question 6886

Topic: 2. Trauma
A 25-year-old farmer sustains an open tibial shaft fracture with massive soft tissue stripping and heavy soil contamination. In addition to a first-generation cephalosporin and an aminoglycoside, which of the following antibiotics should be added for appropriate prophylaxis?
. Clindamycin
. Vancomycin
. Penicillin
. Metronidazole
. Doxycycline

Correct Answer & Explanation

. Penicillin

Explanation

Farm-related or heavily soil-contaminated injuries carry a high risk of Clostridium infection. High-dose Penicillin should be added to the standard regimen of a first-generation cephalosporin and an aminoglycoside for these Gustilo Type III open fractures.

Question 6887

Topic: 2. Trauma

A 32-year-old man presents with a closed diaphyseal tibia fracture and is intubated in the ICU. Intracompartmental pressure measurements show a diastolic blood pressure of 70 mm Hg and an anterior compartment pressure of 45 mm Hg. What is the most appropriate next step in management?

. Observation and elevate the leg
. Bivalve the cast and reassess in 1 hour
. Four-compartment fasciotomy
. Administer IV mannitol
. Immediate open reduction and internal fixation

Correct Answer & Explanation

. Four-compartment fasciotomy

Explanation

The diagnosis of compartment syndrome in an obtunded patient is confirmed when the Delta P (diastolic blood pressure minus compartment pressure) is less than 30 mm Hg. In this patient, Delta P is 25 mm Hg, necessitating an emergent four-compartment fasciotomy.

Question 6888

Topic: 2. Trauma

Which of the following physiologic parameters is an absolute indication for 'Damage Control Orthopedics' (provisional external fixation) rather than Early Total Care for a displaced femoral shaft fracture?

. Base deficit of 4 mEq/L
. Lactate of 2.0 mmol/L
. Core body temperature of 33°C
. Platelet count of 150,000
. Heart rate of 100 beats per minute

Correct Answer & Explanation

. Core body temperature of 33°C

Explanation

Damage Control Orthopedics (DCO) is indicated in 'in extremis' or borderline trauma patients. Severe hypothermia (temperature < 35°C), severe coagulopathy, and profound acidosis are absolute indications to proceed with DCO to avoid a fatal second hit.

Question 6889

Topic: 2. Trauma

A 28-year-old man with bilateral femur fractures develops confusion, a petechial rash on the axilla, and hypoxemia 48 hours after injury. Which of the following is the most effective management strategy for the underlying syndrome?

. High-dose intravenous corticosteroids
. Heparin infusion
. Early fracture fixation and supportive pulmonary care
. Prophylactic intravenous antibiotics
. Emergent hyperbaric oxygen therapy

Correct Answer & Explanation

. Early fracture fixation and supportive pulmonary care

Explanation

The patient has Fat Embolism Syndrome, characterized by the triad of hypoxemia, neurologic compromise, and petechial rash. The most effective treatment is prevention via early fracture stabilization, followed by meticulous supportive respiratory care.

Question 6890

Topic: 2. Trauma
A 40-year-old man presents with a boggy, fluctuant mass over his greater trochanter following a high-speed motorcycle collision. Radiographs show no underlying fracture. What is the pathophysiology of this clinical finding?
. Intramuscular hematoma within the gluteus medius
. Subfascial abscess formation
. Closed degloving injury separating skin and subcutaneous tissue from deep fascia
. Primary lymphatic malformation
. Ruptured adventitial bursa

Correct Answer & Explanation

. Closed degloving injury separating skin and subcutaneous tissue from deep fascia

Explanation

A Morel-Lavallée lesion is a traumatic closed degloving injury where the skin and subcutaneous tissue are separated from the underlying fascia. This creates a potential space that fills with a mixture of blood, lymph, and necrotic fat.

Question 6891

Topic: 2. Trauma
A 25-year-old man sustains a completely displaced, vertically oriented femoral neck fracture (Pauwels Type III). What is the optimal surgical management to minimize the risk of fixation failure?
. Bipolar hemiarthroplasty
. Total hip arthroplasty
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with multiple cancellous screws
. Open reduction and internal fixation with a fixed-angle sliding hip screw

Correct Answer & Explanation

. Open reduction and internal fixation with a fixed-angle sliding hip screw

Explanation

In young adults, joint preservation with anatomic reduction and stable internal fixation is mandatory. Pauwels Type III fractures experience massive vertical shear forces, making a fixed-angle device like a sliding hip screw biomechanically superior to cancellous screws alone.

Question 6892

Topic: 2. Trauma

Blood supply to the scaphoid primarily enters through the dorsal ridge and supplies the proximal pole in a retrograde fashion. Which artery provides this dominant intraosseous supply?

. Radial artery
. Ulnar artery
. Anterior interosseous artery
. Posterior interosseous artery
. Deep palmar arch

Correct Answer & Explanation

. Radial artery

Explanation

The primary blood supply to the scaphoid arises from dorsal branches of the radial artery entering at the dorsal ridge. This leaves the proximal pole highly reliant on fragile retrograde flow, explaining the high rate of nonunion and AVN in proximal pole fractures.

Question 6893

Topic: 2. Trauma

Which of the following scenarios is considered an absolute indication for operative fixation of an acute midshaft clavicle fracture?

. 15 mm of fracture shortening
. 100% cortical displacement
. Z-type fracture pattern in the dominant arm of a manual laborer
. Open fracture
. Patient is a professional overhead athlete

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, vascular injury requiring repair, and progressive neurologic deficit. Shortening, displacement, and athletic status are relative indications.

Question 6894

Topic: 2. Trauma

A 22-year-old man sustains a low-velocity civilian gunshot wound to the thigh, resulting in a comminuted midshaft femur fracture. The 1 cm wounds are clean, with no active bleeding or neurovascular deficit. Which of the following is the most appropriate initial management?

. Formal irrigation and debridement of the wound track in the OR followed by IM nailing
. Local wound care in the ED, tetanus prophylaxis, and standard immediate IM nailing
. Immediate spanning external fixation
. Application of a hip spica cast
. Administration of IV antibiotics for 7 days before definitive fixation

Correct Answer & Explanation

. Local wound care in the ED, tetanus prophylaxis, and standard immediate IM nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without gross contamination or vascular injury can safely undergo local wound debridement in the ED, tetanus prophylaxis, and immediate intramedullary nailing. Formal operative tract debridement is unnecessary.

Question 6895

Topic: Pelvic & Acetabular Trauma

A patient with a mechanically unstable pelvic ring injury remains hemodynamically unstable despite a pelvic binder and massive transfusion protocol. A FAST exam is negative. What is the most appropriate next step in management?

. Exploratory laparotomy
. Preperitoneal pelvic packing or angioembolization
. Intravenous tranexamic acid administration and observation
. Removal of the pelvic binder to assess for expansion
. CT scan of the abdomen and pelvis

Correct Answer & Explanation

. Preperitoneal pelvic packing or angioembolization

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, the source of bleeding is typically the retroperitoneal venous plexus or arterial branches. Preperitoneal pelvic packing and/or angioembolization are the treatments of choice.

Question 6896

Topic: 2. Trauma

A 50-year-old man sustains a severe closed tibial pilon fracture with significant fracture blisters and profound soft tissue swelling. What is the preferred initial management strategy?

. Immediate open reduction and internal fixation with a dual plate construct
. Spanning external fixation and delayed definitive internal fixation
. Cast immobilization until fracture union
. Immediate reamed intramedullary nailing
. Primary tibiotalar arthrodesis

Correct Answer & Explanation

. Spanning external fixation and delayed definitive internal fixation

Explanation

High-energy pilon fractures are associated with severe soft tissue compromise that precludes immediate internal fixation. The standard of care is a staged approach: immediate spanning external fixation to restore length, followed by definitive ORIF once soft tissues recover.

Question 6897

Topic: 2. Trauma

Which of the following statements best describes the fundamental pathophysiologic mechanism of acute compartment syndrome?

. Primary arterial occlusion leading to profound distal ischemia
. Lactic acidosis resulting in direct inflammatory muscle necrosis
. Elevated intracompartmental pressure exceeding capillary perfusion pressure, causing venous outflow obstruction
. Direct crush injury to the peripheral nerve fascicles
. Autoimmune destruction of the investing fascial layers

Correct Answer & Explanation

. Elevated intracompartmental pressure exceeding capillary perfusion pressure, causing venous outflow obstruction

Explanation

Compartment syndrome occurs when tissue pressure within a closed fascial space exceeds capillary perfusion pressure. This primarily blocks venous outflow, which exacerbates edema, further increasing pressure until arterial inflow is ultimately compromised.

Question 6898

Topic: 2. Trauma
A 42-year-old male arrives hypotensive after a motorcycle crash. Pelvic radiograph shows an APC-III pelvic ring injury. After ATLS protocol, he remains hemodynamically unstable despite initial fluid resuscitation. What is the most appropriate next step in orthopedic management?
. Application of a pelvic binder over the iliac crests
. Application of a pelvic binder centered over the greater trochanters
. Immediate open reduction and internal fixation of the symphysis pubis
. Placement of a supra-acetabular external fixator in the ER
. Pelvic packing without external fixation

Correct Answer & Explanation

. Application of a pelvic binder centered over the greater trochanters

Explanation

Pelvic binders should be centered over the greater trochanters to effectively reduce pelvic volume in anteroposterior compression injuries. Placement over the iliac crests can inadvertently exacerbate the rotational deformity.

Question 6899

Topic: 2. Trauma
A 28-year-old male sustains a Gustilo-Anderson Type IIIA open tibia fracture. What is the most critical factor in reducing the risk of deep infection in this patient?
. Time to operative debridement within 6 hours
. Administration of intravenous antibiotics as soon as possible
. Use of high-pressure pulsatile lavage
. Immediate wound closure
. Application of a negative pressure wound therapy device

Correct Answer & Explanation

. Administration of intravenous antibiotics as soon as possible

Explanation

The early administration of systemic antibiotics is the single most important factor in decreasing infection rates in open fractures. Recent literature shows the traditional "6-hour rule" for debridement is less critical than the immediate delivery of appropriate antibiotics.

Question 6900

Topic: 2. Trauma

A 30-year-old male presents with a severely comminuted closed tibial shaft fracture and pain out of proportion to his injury. His diastolic blood pressure is 75 mmHg. Intracompartmental pressure testing yields: Anterior 40 mmHg, Lateral 35 mmHg, Superficial posterior 20 mmHg, Deep posterior 45 mmHg. What is the most appropriate management?

. Elevation of the leg above the level of the heart
. Immediate four-compartment fasciotomy
. Observation with repeat pressure measurements in 2 hours
. Application of a short leg cast
. Intravenous administration of mannitol

Correct Answer & Explanation

. Immediate four-compartment fasciotomy

Explanation

The patient has acute compartment syndrome, indicated by a delta pressure (diastolic BP minus compartment pressure) of 30 mmHg or less (75 - 45 = 30 mmHg). Immediate four-compartment fasciotomy is required to prevent irreversible ischemic necrosis.

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