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2. Trauma MCQs

Practice Set 346 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 6901

Topic: 2. Trauma
A 24-year-old male sustains a vertically oriented (Pauwels type III) displaced femoral neck fracture. To maximize biomechanical stability and minimize shear forces, what is the preferred fixation construct?
. Three parallel cancellous screws placed in an inverted triangle
. A sliding hip screw with a derotational screw
. A fixed-angle blade plate
. Bipolar hemiarthroplasty
. Intramedullary nail with cephalomedullary fixation

Correct Answer & Explanation

. A sliding hip screw with a derotational screw

Explanation

Vertically oriented (Pauwels type III) fractures experience high shear forces. A sliding hip screw paired with a derotational screw provides superior biomechanical stability against shear compared to multiple cancellous screws.

Question 6902

Topic: 2. Trauma

A 45-year-old construction worker falls from a height, sustaining a closed, highly comminuted distal tibia (Pilon) fracture with significant soft tissue swelling and fracture blisters. What is the most appropriate initial management?

. Immediate open reduction and internal fixation with dual plating
. Application of a spanning external fixator and delayed definitive fixation
. Closed reduction and long leg cast application
. Primary tibiotalar arthrodesis
. Open reduction and internal fixation of the fibula only

Correct Answer & Explanation

. Application of a spanning external fixator and delayed definitive fixation

Explanation

In high-energy Pilon fractures with significant soft tissue compromise, immediate ORIF carries an unacceptably high rate of wound necrosis and infection. The standard of care is a staged approach using a spanning external fixator until the soft tissue envelope recovers.

Question 6903

Topic: 2. Trauma
A 32-year-old female sustains a Hawkins Type III talar neck fracture. Which of the following statements regarding her risk of avascular necrosis (AVN) and the presence of a positive Hawkins sign is correct?
. A positive Hawkins sign indicates complete avascular necrosis of the talar body.
. The risk of AVN in this injury pattern is approximately 10-20 percent.
. A positive Hawkins sign at 6-8 weeks represents subchondral radiolucency and indicates intact vascularity.
. The injury involves a fracture of the talar neck with subtalar but intact tibiotalar joints.
. Immediate weight-bearing is recommended to stimulate revascularization.

Correct Answer & Explanation

. A positive Hawkins sign at 6-8 weeks represents subchondral radiolucency and indicates intact vascularity.

Explanation

A Hawkins Type III fracture carries a nearly 100 percent risk of AVN. A positive Hawkins sign (subchondral osteopenia in the talar dome on AP/mortise views at 6-8 weeks) indicates active bone resorption, which confirms an intact vascular supply.

Question 6904

Topic: 2. Trauma

A 25-year-old male sustains a high-energy knee dislocation. After reduction, his foot is warm and pink, but pedal pulses are asymmetric. The Ankle-Brachial Index (ABI) is measured at 0.85. What is the most appropriate next step?

. Discharge with close outpatient follow-up
. Immediate operative exploration of the popliteal artery
. CT angiography or conventional arteriography
. Fasciotomy of the lower leg
. Serial ABI measurements every 8 hours

Correct Answer & Explanation

. CT angiography or conventional arteriography

Explanation

An ABI less than 0.90 following a knee dislocation is highly sensitive for a clinically significant vascular injury. The patient requires emergent vascular imaging (CT angiography) to delineate the injury before any potential surgical intervention.

Question 6905

Topic: 2. Trauma

A 35-year-old polytrauma patient presents with closed bilateral femur fractures, multiple rib fractures, and pulmonary contusions. His serum lactate is 4.5 mmol/L, pH is 7.20, and base excess is -8. What is the most appropriate initial management of his femur fractures?

. Immediate reamed intramedullary nailing of both femurs
. Immediate unreamed intramedullary nailing of both femurs
. Application of bilateral spanning external fixators
. Open reduction and internal fixation with plates
. Nonoperative management in skeletal traction until union

Correct Answer & Explanation

. Application of bilateral spanning external fixators

Explanation

This patient is physiologically unstable (acidotic, elevated lactate, base excess less than -4), meeting indications for Damage Control Orthopedics (DCO). Rapid provisional stabilization with external fixation avoids the systemic inflammatory "second hit" associated with definitive intramedullary nailing.

Question 6906

Topic: 2. Trauma

A 22-year-old cyclist falls onto his left shoulder, sustaining a midshaft clavicle fracture. Which of the following is an absolute indication for operative fixation of this injury?

. Shortening greater than 2 centimeters
. Comminution with a Z-deformity
. Open fracture
. 100 percent displacement of the fracture fragments
. Patient preference for faster return to sports

Correct Answer & Explanation

. Open fracture

Explanation

Absolute indications for operative fixation of clavicle fractures include open fractures, vascular compromise, progressive neurologic deficit, and skin tenting causing impending necrosis. Displacement and shortening are relative indications.

Question 6907

Topic: 2. Trauma

A 50-year-old male presents with a posterior hip dislocation and an associated posterior wall acetabular fracture following an MVC. Post-reduction CT reveals a posterior wall fragment comprising 45 percent of the posterior articular surface. The joint is congruent. What is the definitive management?

. Skeletal traction for 6 weeks
. Touch-down weight-bearing and early mobilization
. Open reduction and internal fixation of the posterior wall
. Total hip arthroplasty
. Closed reduction and spica casting

Correct Answer & Explanation

. Open reduction and internal fixation of the posterior wall

Explanation

Posterior wall fractures involving greater than 40 percent of the articular surface are biomechanically unstable. Operative fixation (ORIF) is required to restore joint stability, prevent recurrent dislocation, and minimize post-traumatic arthrosis.

Question 6908

Topic: 2. Trauma

A 29-year-old male sustains a low-velocity gunshot wound to the right thigh, resulting in a minimally displaced diaphyseal femur fracture. The entry and exit wounds are small and clean. Neurovascular exam is normal. What is the most appropriate initial management?

. Extensive operative debridement of the bullet track followed by intramedullary nailing
. Local wound care, tetanus prophylaxis, and intramedullary nailing
. Immediate external fixation and planned delayed nailing
. Operative extraction of the retained bullet fragments without fracture fixation
. Skeletal traction for 4 weeks

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without gross contamination or vascular injury do not require formal operative track debridement. They are managed safely with local wound care, tetanus prophylaxis, and standard intramedullary nailing.

Question 6909

Topic: 2. Trauma

A 42-year-old male is involved in a motorcycle collision and sustains a severe crush injury to his right lower leg. Clinical exam shows a tense, swollen leg with severe pain on passive stretch of the toes. Which of the following is the most accurate parameter for diagnosing acute compartment syndrome?

. Diastolic blood pressure minus intracompartmental pressure less than 30 mm Hg
. Absolute intracompartmental pressure greater than 20 mm Hg
. Mean arterial pressure minus intracompartmental pressure less than 40 mm Hg
. Loss of palpable dorsalis pedis and posterior tibial pulses
. Systolic blood pressure minus intracompartmental pressure less than 30 mm Hg

Correct Answer & Explanation

. Diastolic blood pressure minus intracompartmental pressure less than 30 mm Hg

Explanation

The delta pressure (diastolic blood pressure minus intracompartmental pressure) is the most reliable parameter for diagnosing acute compartment syndrome. A delta pressure less than 30 mm Hg is a standard threshold indicating the need for emergent fasciotomy.

Question 6910

Topic: Pelvic & Acetabular Trauma
A 30-year-old trauma patient arrives with an anterior-posterior compression (APC-III) pelvic ring injury and is hemodynamically unstable. Where is the most biomechanically effective anatomical location to apply a noninvasive pelvic circumferential compression device (pelvic binder)?
. Iliac crests
. Level of the umbilicus
. Greater trochanters
. Anterior superior iliac spines
. Proximal femurs

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders are most effective at reducing pelvic volume and controlling hemorrhage when centered directly over the greater trochanters. Application higher up over the iliac crests or abdomen is less effective and can potentially worsen certain pelvic ring displacements.

Question 6911

Topic: 2. Trauma

A 45-year-old woman who has been taking alendronate for 8 years presents with a prodrome of lateral thigh pain followed by a low-energy displaced subtrochanteric femur fracture. Her radiograph shows lateral cortical thickening and a transverse fracture with a medial spike. What is the most appropriate surgical management?

. Proximal femoral locking plate
. Sliding hip screw
. Retrograde intramedullary nail
. Cephalomedullary nailing
. Dynamic condylar screw

Correct Answer & Explanation

. Cephalomedullary nailing

Explanation

Atypical femur fractures (AFF) are associated with prolonged bisphosphonate use and exhibit specific radiographic features like lateral cortical thickening. Intramedullary nailing (such as cephalomedullary nailing) is the treatment of choice as it load-shares and protects the entire diseased femoral diaphysis.

Question 6912

Topic: 2. Trauma

A 38-year-old male falls from a roof and sustains a closed, displaced intra-articular calcaneus fracture (Sanders type II). Open reduction and internal fixation via an extensile lateral approach is planned. To minimize severe wound complications, what is the optimal timing for surgery?

. Within 12 hours of injury
. Within 24-48 hours, prior to peak swelling
. 7-14 days, once the "wrinkle sign" appears
. 21-28 days, after soft tissue consolidation
. Immediate emergent surgery

Correct Answer & Explanation

. 7-14 days, once the "wrinkle sign" appears

Explanation

To minimize the high risk of wound dehiscence and deep infection associated with the extensile lateral approach for calcaneus fractures, surgery should be delayed until soft tissue swelling subsides. This is typically indicated by the presence of a positive "wrinkle sign" at 7 to 14 days post-injury.

Question 6913

Topic: 2. Trauma

A 34-year-old woman presents to the ER with an open tibia fracture after a high-speed motor vehicle collision. The wound is 12 cm long with significant periosteal stripping. According to evidence-based guidelines, when should systemic antibiotics be administered?

. Within 1 hour of injury or arrival
. Within 6 hours of injury
. Only postoperatively after initial debridement
. Within 24 hours of injury
. Prior to definitive flap coverage only

Correct Answer & Explanation

. Within 1 hour of injury or arrival

Explanation

Early administration of systemic antibiotics is the single most important factor in reducing infection rates in open fractures. Guidelines strongly recommend administering appropriate intravenous antibiotics within 1 hour of injury or emergency department arrival.

Question 6914

Topic: 2. Trauma

A 40-year-old polytrauma patient with a severe traumatic brain injury (GCS 6), bilateral pulmonary contusions, and a closed right femoral shaft fracture is brought to the trauma bay. His lactate is 4.5 mmol/L and base deficit is -8. What is the most appropriate initial management of his femur fracture?

. Antegrade reamed intramedullary nailing
. Retrograde unreamed intramedullary nailing
. Open reduction and internal fixation with a plate
. External fixation
. Skeletal traction via a proximal tibial pin for 6 weeks

Correct Answer & Explanation

. External fixation

Explanation

In a "borderline" or unstable polytrauma patient (indicated by elevated lactate, negative base deficit, severe TBI, and chest trauma), damage control orthopedics (DCO) is indicated. Rapid temporary stabilization with external fixation avoids the systemic "second hit" associated with early total care like intramedullary nailing.

Question 6915

Topic: 2. Trauma

During the preparation for intramedullary nailing of a diaphyseal femur fracture, the surgeon notices a coronal plane fracture of the lateral femoral condyle extending into the knee joint on the lateral radiograph. This specific articular injury is commonly referred to as a:

. Pipkin fracture
. Hoffa fracture
. Segond fracture
. Tillaux fracture
. Chaput fracture

Correct Answer & Explanation

. Hoffa fracture

Explanation

A Hoffa fracture is an intra-articular coronal plane fracture of the femoral condyle, most commonly involving the lateral condyle. It is frequently associated with distal femur or diaphyseal fractures and requires specific fixation (often anterior-to-posterior lag screws) to restore joint congruity.

Question 6916

Topic: 2. Trauma

A 25-year-old male sustains a low-velocity civilian gunshot wound to the midshaft femur, resulting in a comminuted fracture. The bullet passed cleanly through the thigh. His neurovascular exam is normal, and the wounds are small without gross contamination. What is the most appropriate management?

. Immediate formal open debridement of the bullet track and external fixation
. Local wound care, tetanus prophylaxis, antibiotics, and intramedullary nailing
. Non-operative management in a spica cast
. Immediate open reduction and internal fixation with a dynamic compression plate
. Amputation

Correct Answer & Explanation

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

Explanation

Low-velocity gunshot wounds causing femur fractures without significant contamination or vascular injury are effectively managed similarly to closed fractures. Treatment involves superficial local wound care, appropriate antibiotics, tetanus prophylaxis, and standard intramedullary nailing.

Question 6917

Topic: Pelvic & Acetabular Trauma

In long-segment fusions extending to the pelvis for adult degenerative scoliosis, Sacral-2 Alar-Iliac (S2AI) screws are often utilized instead of traditional iliac screws. Which of the following is an advantage of S2AI screws?

. They require a wider lateral fascial dissection
. They provide a starting point that is directly in-line with the lumbar pedicle screws
. They completely avoid crossing the sacroiliac (SI) joint
. They have a significantly higher rate of hardware prominence
. They require an offset connector for rod linkage

Correct Answer & Explanation

. They provide a starting point that is directly in-line with the lumbar pedicle screws

Explanation

S2AI screws have a starting point medial to traditional iliac screws, placing them directly in-line with the S1 and lumbar pedicle screws. This eliminates the need for bulky offset connectors, requires less lateral dissection, and significantly reduces hardware prominence.

Question 6918

Topic: 2. Trauma

A 25-year-old male is involved in a high-speed motor vehicle collision while wearing only a lap seatbelt. He is diagnosed with a flexion-distraction (Chance) fracture of L2. Which of the following associated injuries must be most carefully evaluated and ruled out?

. Traumatic aortic tear
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Renal artery thrombosis
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries highly associated with lap-belt use. Up to 50% of these patients have concurrent intra-abdominal injuries, particularly perforations of hollow viscous organs (e.g., bowel).

Question 6919

Topic: 2. Trauma

A 16-year-old female wearing a lap belt is involved in a head-on collision. Radiographs demonstrate a horizontal fracture through the spinous process, pedicles, and vertebral body of L2. Which of the following associated injuries must be aggressively ruled out?

. Aortic dissection
. Renal artery thrombosis
. Intra-abdominal hollow viscus injury
. Diaphragmatic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Intra-abdominal hollow viscus injury

Explanation

Chance fractures are flexion-distraction injuries highly associated with lap-belt restraints. They carry an association with intra-abdominal injuries, particularly hollow viscus injuries (e.g., bowel perforation), in up to 50% of cases.

Question 6920

Topic: 2. Trauma

A 55-year-old man with a long-standing history of ankylosing spondylitis presents with severe neck pain after a low-energy fall. Radiographs are inconclusive, but CT reveals a transverse fracture through the C5-C6 intervertebral space extending through the posterior elements. What is the most appropriate management?

. Rigid cervical collar for 12 weeks
. Halo vest immobilization
. Anterior-only cervical plating
. Posterior-only instrumented fusion
. Combined anterior and posterior instrumented fusion

Correct Answer & Explanation

. Combined anterior and posterior instrumented fusion

Explanation

Fractures in ankylosing spondylitis are highly unstable and often behave like long-bone fractures. Due to the high risk of displacement, epidural hematoma, and nonunion, robust long-segment fixation, often combined anteriorly and posteriorly, is recommended.

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