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 701
Topic: 2. Trauma
A 28-year-old man sustains a vertically oriented, displaced femoral neck fracture (Pauwels type III) after a motor vehicle collision. Which of the following fixation constructs provides the greatest biomechanical stability for this specific fracture pattern?
Correct Answer & Explanation
. Sliding hip screw with an anti-rotation screw
Explanation
Pauwels type III fractures are subject to high vertical shear forces. A sliding hip screw (fixed-angle device) with an anti-rotation screw provides superior biomechanical stability against shear stress compared to parallel cancellous screws.
Question 702
Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable 30-year-old man is brought in after a motorcycle accident. Pelvic radiograph shows a pubic symphysis diastasis of 4 cm and widening of the sacroiliac joints. After initiating massive transfusion protocols, what is the most appropriate immediate orthopedic intervention?
Correct Answer & Explanation
. Application of a pelvic binder or sheet
Explanation
In a hemodynamically unstable patient with an anteroposterior compression (APC) pelvic ring injury, the immediate priority is closing the pelvic volume using a pelvic binder to tamponade venous bleeding.
Question 703
Topic: 2. Trauma
A 35-year-old man sustains a high-energy Schatzker VI tibial plateau fracture.
Twelve hours post-admission, he develops severe pain out of proportion to the injury, exacerbated by passive stretch of his toes. His pedal pulses are palpable. What is the most appropriate next step in management?
Correct Answer & Explanation
. Immediate four-compartment fasciotomy of the leg
Explanation
Severe pain out of proportion and pain with passive stretch in the setting of a high-energy tibial plateau fracture are classic signs of acute compartment syndrome. Intact pulses do not rule out compartment syndrome, and immediate fasciotomy is the definitive treatment to prevent irreversible muscle necrosis.
Question 704
Topic: 2. Trauma
A 19-year-old soccer player sustains a twisting injury to her knee. Radiographs reveal an avulsion fracture of the anterolateral proximal tibia (Segond fracture). Which of the following examination findings is most likely to be present?
Correct Answer & Explanation
. Positive pivot shift test
Explanation
A Segond fracture is an avulsion of the anterolateral ligament complex and is highly correlated with an anterior cruciate ligament (ACL) tear. Therefore, the patient is likely to have a positive pivot shift test, which assesses anterolateral rotatory instability.
Question 705
Topic: 2. Trauma
A 42-year-old man is brought to the trauma bay after a motorcycle collision. He is hypotensive with a mechanically unstable pelvis. The trauma team decides to apply a pelvic binder. To be maximally effective in reducing pelvic volume, where should the binder be centered?
Correct Answer & Explanation
. Over the greater trochanters
Explanation
To effectively reduce pelvic volume and stabilize the pelvic ring in the acute trauma setting, a pelvic binder must be centered directly over the greater trochanters. Placing it over the iliac crests is a common error and can paradoxically widen certain pelvic ring injuries.
Question 706
Topic: 2. Trauma
A 27-year-old male athlete presents with a 2-month history of pain along the posteromedial ankle. Swelling is present posteriomedially. The pain is exacerbated with resisted plantarflexion and inversion of the foot. This condition is likely to be associated with:
Correct Answer & Explanation
. Seronegative arthritis
Explanation
The presence of posterior tibial tendonitis in a young individual should raise the concern for seronegative arthritis. Although a stress fracture of the medial malleolus may be present, pain is not exacerbated with resisted inversion.
Question 707
Topic: 2. Trauma
A patient presents for treatment in your emergency department following an injury that he sustained 4 hours earlier. His foot was run over by a piece of heavy industrial equipment. On examination, he has pain in the foot, a displaced fracture of the second metatarsal, a 3-cm area of severe contusion over the forefoot, and numbness of the dorsal surface of the foot. The next examination that you recommend is:
Correct Answer & Explanation
. Measurement of compartment pressures in the foot
Explanation
Because of his history, this patient may have a compartment syndrome of the foot. Although other studies may be relevant as part of his evaluation, a compartment syndrome mandates emergency treatment. Vascular evaluation, including laser Doppler flowmetry is unreliable in diagnosing compartment syndrome. Imaging studies may be performed as part of the surgical work-up, but they are not indicated at this time.
Question 708
Topic: Pelvic & Acetabular Trauma
In the setting of a traumatic anterior pelvic ring injury (APC-III), where is the anatomically correct placement of a circumferential pelvic binder to effectively reduce pelvic volume?
Correct Answer & Explanation
. Centered over the greater trochanters
Explanation
To optimally reduce pelvic volume and stabilize the pelvic ring, a pelvic binder must be centered directly over the greater trochanters. Placement higher over the iliac crests is less effective and may worsen the deformity.
Question 709
Topic: 2. Trauma
Primary bone healing occurs without the formation of a visible fracture callus. Which of the following fixation constructs is designed to achieve primary bone healing?
Correct Answer & Explanation
. Compression plating of a transverse radius shaft fracture
Explanation
Primary bone healing requires absolute stability, which is achieved through rigid fixation with interfragmentary compression (e.g., compression plating). Constructs providing relative stability result in secondary bone healing via callus formation.
Question 710
Topic: 2. Trauma
A 25-year-old male sustains a humeral shaft fracture at the junction of the middle and distal thirds (Holstein-Lewis fracture).
Which nerve is most acutely at risk in this specific fracture pattern?
Correct Answer & Explanation
. Radial nerve
Explanation
A Holstein-Lewis fracture is a distal third spiral humerus fracture. The radial nerve is tethered at the lateral intermuscular septum in this region, making it highly susceptible to stretch or entrapment.
Question 711
Topic: 2. Trauma
A 25-year-old male presents with a displaced, vertically oriented femoral neck fracture (Pauwels type III). What is the most biomechanically stable fixation construct to resist the high shear forces inherent in this fracture pattern?
Correct Answer & Explanation
. A sliding hip screw with a derotation screw
Explanation
Pauwels type III fractures have a vertical orientation with high shear forces that can lead to varus collapse. A sliding hip screw (fixed-angle device) combined with an anti-rotation screw provides superior biomechanical stability against vertical shear compared to multiple cancellous screws.
Question 712
Topic: Pelvic & Acetabular Trauma
A 40-year-old male sustains an anteroposterior compression (APC-III) pelvic ring injury. Upon arrival, he is hypotensive and tachycardic. Despite the immediate application of a pelvic binder and administration of 2 units of packed red blood cells, he remains hemodynamically unstable. What is the most appropriate next step in management?
In a hemodynamically unstable patient with a mechanically stabilized pelvic ring (via binder), the source of continued shock is likely retroperitoneal venous or arterial bleeding. Preperitoneal packing and angiography with embolization are the interventions of choice. CT is contraindicated in a hemodynamically unstable patient.
Question 713
Topic: Pelvic & Acetabular Trauma
A 35-year-old male is brought to the trauma bay after an industrial crush injury. He has an open-book pelvic ring disruption (APC-III) and remains hemodynamically unstable despite a massive transfusion protocol. What is the most appropriate next step in management?
Correct Answer & Explanation
. Application of a pelvic binder and preperitoneal pelvic packing
Explanation
In a hemodynamically unstable patient with a mechanically unstable pelvic ring, temporary mechanical stabilization (binder) combined with preperitoneal pelvic packing is the most rapid and effective initial step to control the retroperitoneal venous bleeding, which is the most common hemorrhage source.
Question 714
Topic: 2. Trauma
A 24-year-old male falls on an outstretched hand and sustains a fracture of the scaphoid proximal pole.
Which of the following anatomic factors most significantly increases the risk of avascular necrosis and nonunion in this specific fracture pattern?
Correct Answer & Explanation
. The retrograde blood supply entering the scaphoid distally
Explanation
The major blood supply to the scaphoid is retrograde, entering via the dorsal ridge at the waist and distal pole before perfusing the proximal pole. Proximal pole fractures disrupt this flow, resulting in a very high risk of avascular necrosis.
Question 715
Topic: 2. Trauma
During the surgical intervention, a greater trochanteric osteotomy was performed. What is the primary rationale for utilizing a greater trochanteric osteotomy in this specific complex revision total hip arthroplasty?
Correct Answer & Explanation
. To facilitate unparalleled exposure of the femoral canal and acetabulum, especially for cement and component removal.
Explanation
Correct Answer: CThe case states that a 'greater trochanteric osteotomy was performed to facilitate exposure of the femoral canal and removal of the existing cemented stem without compromising precious host bone.' It further emphasizes that reflecting the osteotomized fragment 'greatly improving access.' While it can indirectly help prevent iatrogenic fracture (Option A) by improving access for cement removal, and its reattachment is crucial for abductor function (Option B), the primary and most comprehensive reason in a complex revision is to provide unparalleled access to both the femoral canal (for cement and stem removal) and the acetabulum (for reconstruction of severe defects). Option D is a secondary benefit, and Option E is incorrect as an osteotomy typically increases the surgical dissection and potential for blood loss compared to a standard approach.
Question 716
Topic: 2. Trauma
A 28-year-old male sustains a T11 flexion-distraction injury (Chance fracture) after a motor vehicle accident where he was wearing a lap belt without a shoulder harness. He is neurologically intact. CT scan shows a horizontal fracture through the T11 vertebral body and posterior elements. MRI confirms complete disruption of the posterior ligamentous complex. Based on the surgical anatomy and biomechanics described in the case, which of the following statements accurately describes the primary mechanism of injury and the most appropriate management?
Correct Answer & Explanation
. The injury involves tension failure of the posterior and middle columns, resulting in inherent instability, and typically requires surgical stabilization.
Explanation
Correct Answer: BFlexion-distraction injuries (Chance fractures) are classically associated with lap-belt use and create tension across the posterior and middle columns, leading to bony or ligamentous failure. The case explicitly states that these injuries involve 'tension across the posterior and middle columns, leading to bony or ligamentous failure.' The MRI confirming complete disruption of the posterior ligamentous complex further underscores the instability. Even in neurologically intact patients, these injuries are inherently unstable due to the disruption of the posterior tension band and often require surgical stabilization to prevent progressive deformity and pain.Option A is incorrectbecause flexion-distraction injuries are caused by tension, not axial loading, and primarily affect the posterior and middle columns. They are unstable and not amenable to non-operative management with a brace alone, especially with PLC disruption.Option C is incorrectbecause a flexion-distraction injury with PLC disruption is an unstable injury, not a stable compression fracture, and requires intervention beyond observation.Option D is incorrectbecause while a Chance fracture is unstable, it is a specific type of flexion-distraction injury, not a fracture-dislocation, which involves more complex multi-planar forces and translation. Anterior column reconstruction is not typically the primary requirement unless there's significant anterior column collapse, which is less common in pure Chance fractures.Option E is incorrectbecause retropulsion of bone fragments is characteristic of burst fractures (axial loading), not typically flexion-distraction injuries. Decompression is not the primary indication in a neurologically intact patient with a Chance fracture; stabilization of the tension band is.
Question 717
Topic: 2. Trauma
A 68-year-old female with osteoporosis sustains an L2 compression fracture after a low-energy fall. She is neurologically intact. Radiographs show a wedge compression fracture with 25% loss of anterior vertebral height. MRI shows no evidence of posterior ligamentous complex disruption. According to the AOSpine Thoracolumbar Spine Injury Classification System, as discussed in the case, which classification best describes this injury, and what is the typical management?
Correct Answer & Explanation
. Type A1 (wedge compression); typically managed non-operatively with bracing.
Explanation
Correct Answer: CThe case describes the AOSpine classification, stating it categorizes injuries into Type A (compression), Type B (tension band disruption), and Type C (translation or displacement). The patient has a low-energy L2 compression fracture with 25% loss of anterior vertebral height and an intact posterior ligamentous complex, and is neurologically intact. This morphology is consistent with an AOSpine Type A1 injury (wedge compression). The table in the case indicates that 'Type A1, A2, A3 (without neuro deficit or severe kyphosis)' are indications for non-operative management. Therefore, Type A1, typically managed non-operatively with bracing, is the correct classification and management.Option A is incorrectbecause Type B injuries involve tension band disruption, which is explicitly ruled out by the intact PLC. Type B injuries universally require surgical stabilization.Option B is incorrectbecause Type C injuries involve translation or displacement, which is not described. Type C injuries also universally require surgical stabilization.Option D is incorrectbecause a burst fracture (Type A4) involves failure of both endplates and retropulsion of fragments, which is not described here as only 25% loss of anterior vertebral height is mentioned, typical of a wedge compression. Even if it were a stable A3 burst, it would still be non-operative if neurologically intact and without severe kyphosis.Option E is incorrectbecause a fracture-dislocation is a Type C injury with severe instability and is not consistent with the described injury.
Question 718
Topic: 2. Trauma
A 38-year-old male with a T12 burst fracture and a high Load-Sharing Classification score (7 points) is undergoing surgical stabilization. The surgeon plans a posterior approach. Based on the biomechanical classification models discussed in the case, what is the primary implication of this high Load-Sharing score for surgical planning?
Correct Answer & Explanation
. There is a high risk of anterior column failure with posterior-only fixation, necessitating anterior column reconstruction or long-segment posterior fixation.
Explanation
Correct Answer: CThe case states, 'The Load-Sharing Classification (McCormack) is also critical for surgical decision-making, particularly when determining if a short-segment posterior construct will fail. It evaluates the amount of damaged vertebral body, the spread of the fragments, and the degree of kyphosis correction. A high score (greater than 6) suggests a high risk of anterior column failure with short-segment posterior-only fixation, indicating the need for an anterior column reconstruction or long-segment posterior fixation.' A score of 7 points is a high Load-Sharing score, directly indicating this risk and the need for additional anterior support or extended posterior fixation.Option A is incorrectbecause a high Load-Sharing score indicates significant anterior column damage and instability, making non-operative management inappropriate.Option B is incorrectbecause a high Load-Sharing score specifically warns against the failure of short-segment posterior fixation due to inadequate anterior column support.Option D is incorrectbecause while PLC disruption is important for overall stability (TLICS), the Load-Sharing Classification specifically addresses the integrity of the anterior column and the risk of posterior hardware failure due to insufficient anterior support, not just PLC repair.Option E is incorrectbecause a burst fracture with a high Load-Sharing score is a severe injury, not a Type A1 compression fracture, which implies minimal instability.
Question 719
Topic: 2. Trauma
A 50-year-old male has an L2 burst fracture with severe anterior bone comminution, 80% canal compromise, and incomplete paraplegia. The posterior ligamentous complex is intact. Which surgical approach provides the most direct decompression and mechanical support?
Correct Answer & Explanation
. Anterior corpectomy, decompression, and strut grafting with plating
Explanation
An anterior approach allows direct decompression of the retropulsed bone fragment and robust anterior column reconstruction. This is ideal for severe anterior comminution with an incomplete neurologic deficit.
Question 720
Topic: 2. Trauma
According to the Denis three-column theory of spinal stability, an injury involving the anterior longitudinal ligament, anterior two-thirds of the vertebral body, and the anterior annulus fibrosus isolated to these structures represents an injury to which column, and what fracture type?
Correct Answer & Explanation
. Anterior column; Compression fracture
Explanation
The anterior column comprises the ALL, anterior annulus, and anterior two-thirds of the vertebral body. Isolated failure of the anterior column under compression results in a stable wedge compression fracture.
Test Yourself
Switch to an interactive, timed exam simulation to truly master this topic.
