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2. Trauma MCQs

Practice Set 377 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 7521

Topic: 2. Trauma

When applying a delta-frame spanning external fixator for a severe pilon fracture, what is the optimal placement technique for the transfixing calcaneal pin to minimize the risk of neurovascular injury?

. From anterior to posterior, targeting the sustentaculum tali
. From lateral to medial, passing directly through the sinus tarsi
. From medial to lateral, 2-3 cm posterior and inferior to the medial malleolus
. From lateral to medial, exiting anterior to the medial malleolus
. From medial to lateral, aiming anteriorly through the talar neck

Correct Answer & Explanation

. From anterior to posterior, targeting the sustentaculum tali

Explanation

Transfixing calcaneal pins should be placed from medial to lateral to protect the posterior tibial neurovascular bundle, which can be injured if the pin exits medially. The safe zone is typically 2-3 cm posterior and inferior to the medial malleolus.

Question 7522

Topic: 2. Trauma

A 42-year-old polytrauma patient with a severe closed head injury (GCS 7) and a closed diaphyseal femur fracture is evaluated in the trauma bay. He is hemodynamically stable, but his intracranial pressure (ICP) remains elevated despite medical management. What is the most appropriate management of his femur fracture?

. Immediate reamed intramedullary nailing
. Immediate unreamed intramedullary nailing
. Damage control external fixation
. Skeletal traction for 6 weeks
. Plate osteosynthesis within 24 hours

Correct Answer & Explanation

. Immediate reamed intramedullary nailing

Explanation

In a patient with a severe traumatic brain injury and elevated ICP, damage control orthopedics (DCO) with external fixation avoids the secondary hits of prolonged surgery and reaming, which can further elevate ICP.

Question 7523

Topic: 2. Trauma

A 35-year-old man sustains a severe, high-energy distal tibia fracture extending into the ankle joint (pilon fracture) with significant soft tissue swelling and fracture blisters. What is the standard protocol for initial management?

. Immediate open reduction and internal fixation through dual incisions
. Spanning external fixation with fibular fixation if necessary, followed by delayed definitive fixation
. Primary arthrodesis of the ankle joint
. Closed reduction and long leg cast application
. Immediate minimally invasive plate osteosynthesis (MIPO)

Correct Answer & Explanation

. Immediate open reduction and internal fixation through dual incisions

Explanation

The standard of care for high-energy pilon fractures with severe soft tissue compromise is a staged protocol utilizing an initial spanning external fixator until soft tissues recover (usually 10-21 days), followed by definitive fixation.

Question 7524

Topic: 2. Trauma

A 28-year-old woman sustains a Schatzker IV tibial plateau fracture. Which of the following mechanisms and associated injuries is most characteristic of this fracture pattern?

. Valgus force; lateral meniscal tear
. Varus force; common peroneal nerve injury
. Varus force; popliteal artery injury and knee subluxation
. Axial load; patellar tendon rupture
. Hyperextension; popliteus avulsion

Correct Answer & Explanation

. Valgus force; lateral meniscal tear

Explanation

Schatzker IV fractures (medial plateau) result from a high-energy varus and axial loading mechanism. They are frequently associated with knee subluxation or dislocation, carrying a high risk of popliteal artery and peroneal nerve injuries.

Question 7525

Topic: 2. Trauma

During an anterolateral approach to the distal tibia for a pilon fracture, the skin incision is made in line with the fourth ray. Which nerve is at greatest risk of injury during the superficial dissection?

. Deep peroneal nerve
. Superficial peroneal nerve
. Sural nerve
. Saphenous nerve
. Medial plantar nerve

Correct Answer & Explanation

. Deep peroneal nerve

Explanation

The superficial peroneal nerve is at significant risk during the superficial dissection of the anterolateral approach to the distal tibia and must be carefully identified and protected.

Question 7526

Topic: 2. Trauma

A polytrauma patient presents with bilateral femur fractures and a pelvic ring injury. Initial labs show a serum lactate of 5.5 mmol/L and base excess of -8. After initial resuscitation in the ICU, at what threshold is it considered physiologically safe to proceed with early total care (ETC) rather than damage control orthopedics (DCO)?

. Lactate < 2.5 mmol/L
. Base excess > 2
. Lactate > 4.0 mmol/L
. Systolic blood pressure > 90 mmHg
. Urine output > 0.5 mL/kg/hr only

Correct Answer & Explanation

. Lactate < 2.5 mmol/L

Explanation

A serum lactate of < 2.5 mmol/L and an improving base excess indicate adequate tissue perfusion and clearance of shock, favoring a safe transition to early total care in borderline polytrauma patients.

Question 7527

Topic: 2. Trauma

A 40-year-old man falls from a height and sustains a highly comminuted Schatzker VI tibial plateau fracture. He undergoes a two-incision dual plating technique. To minimize the risk of wound complications and skin necrosis, what is the minimum recommended width of the skin bridge between the anterolateral and posteromedial incisions?

. 3 cm
. 5 cm
. 7 cm
. 9 cm
. 11 cm

Correct Answer & Explanation

. 3 cm

Explanation

When performing dual incisions for complex tibial plateau fractures, a minimum skin bridge of 7 cm is highly recommended to preserve adequate vascularity and minimize the risk of wound necrosis.

Question 7528

Topic: 2. Trauma

You are managing a 55-year-old man with a displaced Schatzker II tibial plateau fracture. Preoperative MRI indicates a peripheral tear of the anterior horn of the lateral meniscus that is trapped within the fracture site. Which of the following is the most appropriate management?

. Lateral meniscectomy prior to fracture reduction
. Submeniscal arthrotomy, meniscal elevation, fracture reduction, and meniscal repair
. Fracture reduction without addressing the meniscus
. Conservative management with a hinged knee brace
. Immediate total knee arthroplasty

Correct Answer & Explanation

. Lateral meniscectomy prior to fracture reduction

Explanation

A submeniscal arthrotomy allows clear visualization of the joint surface and accurate reduction of the fracture. The entrapped meniscus should be elevated, preserved, and repaired to prevent early post-traumatic arthritis.

Question 7529

Topic: 2. Trauma

A 25-year-old male sustains a high-energy polytrauma including bilateral pulmonary contusions and a femur fracture. On day 2, he develops a petechial rash, hypoxemia, and confusion. Which of the following pathophysiological mechanisms primarily drives this specific syndrome?

. Thromboembolism from deep vein thrombosis
. Release of marrow fat into the venous circulation and systemic inflammatory response
. Direct bacterial invasion of the lung parenchyma
. Hypovolemic shock due to acute blood loss
. Neurogenic shock from spinal cord injury

Correct Answer & Explanation

. Thromboembolism from deep vein thrombosis

Explanation

Fat embolism syndrome is characterized by the classic triad of hypoxemia, neurologic abnormalities, and a petechial rash. It is primarily driven by the systemic release of marrow fat from long bone fractures and the subsequent severe inflammatory cascade.

Question 7530

Topic: 2. Trauma

During the application of a knee-spanning external fixator for a highly comminuted proximal tibia fracture, pins are placed in the distal femur. To avoid intra-articular placement of the femoral pins, how far proximal to the knee joint line should the pins be placed?

. 1 cm
. 3 cm
. At least 6-8 cm
. 15 cm
. Intra-articular placement is preferred for stability

Correct Answer & Explanation

. 1 cm

Explanation

The suprapatellar pouch reflects proximally about 4-6 cm from the knee joint line. To avoid intra-articular pin placement and the catastrophic complication of septic arthritis, femoral pins must be placed at least 6-8 cm proximal to the joint.

Question 7531

Topic: 2. Trauma

In the management of a high-energy pilon fracture, axial CT imaging reveals a large anterolateral articular fragment still attached to the anterior inferior tibiofibular ligament (AITFL). This specific fracture fragment is classically known as the:

. Volkmann fragment
. Chaput fragment
. Wagstaffe fragment
. Earle fragment
. Die-punch fragment

Correct Answer & Explanation

. Volkmann fragment

Explanation

The Chaput fragment is the anterolateral corner of the distal tibia, which serves as the strong tibial attachment site for the anterior inferior tibiofibular ligament (AITFL).

Question 7532

Topic: 2. Trauma

A polytraumatized patient is classified as "borderline" based on initial physiological parameters. According to the concepts of Damage Control Orthopedics (DCO), which of the following intraoperative developments is an absolute indication to abandon early total care and immediately proceed with DCO?

. Isolated closed femur fracture
. Temperature of 36.5 Celsius
. Intraoperative coagulopathy and worsening acidosis
. Urine output of 1.5 mL/kg/hr
. Glasgow Coma Scale of 15

Correct Answer & Explanation

. Isolated closed femur fracture

Explanation

The acute development of intraoperative coagulopathy, worsening acidosis, or hypothermia (the lethal triad) in a borderline patient is an absolute indication to abort definitive fracture fixation and switch immediately to a damage control approach.

Question 7533

Topic: 2. Trauma

A 24-year-old male presents with a Schatzker I tibial plateau fracture. Which of the following patient profiles and mechanisms most closely matches the typical presentation for this specific fracture pattern?

. Young patient with high-energy trauma and normal bone density
. Elderly female with severe osteoporosis and low-energy fall
. Young patient with a bleeding diathesis
. Middle-aged patient with previous knee arthroplasty
. Diabetic patient with Charcot arthropathy

Correct Answer & Explanation

. Young patient with high-energy trauma and normal bone density

Explanation

Schatzker I fractures represent a pure wedge split of the lateral plateau. They typically occur in younger patients with strong cancellous bone that splits rather than depresses under an axial or valgus load.

Question 7534

Topic: 2. Trauma

When planning definitive open reduction and internal fixation for a complex pilon fracture (AO/OTA 43-C), the sequence of reconstruction is critical. Which of the following represents the classic and most widely accepted sequential approach?

. Fibular length/axis, articular surface reconstruction, attachment of articular block to diaphysis, bone grafting of defects
. Bone grafting of defects, fibular fixation, articular reconstruction
. Attachment of articular block to diaphysis, fibular fixation, articular reconstruction
. Articular reconstruction, bone grafting, fibular fixation without metaphyseal attachment
. Intramedullary nailing of the tibia followed by fibular plating

Correct Answer & Explanation

. Fibular length/axis, articular surface reconstruction, attachment of articular block to diaphysis, bone grafting of defects

Explanation

The classic sequence for pilon fracture reconstruction is to first restore fibular length (if fractured), then reconstruct the tibial articular surface, attach the reconstructed articular block to the tibial shaft, and finally bone graft any resulting metaphyseal voids.

Question 7535

Topic: 2. Trauma

A 32-year-old polytrauma patient with a severe chest injury and bilateral femur fractures is initially treated with bilateral damage control external fixators. When converting the femoral external fixators to intramedullary nails, which of the following strategies best minimizes the risk of deep infection?

. Converting the fixator after 4 weeks without a break
. Removing the external fixator, providing a pin-site holiday until tracts heal, then nailing
. Placing the intramedullary nail directly through the external fixator pin tracts
. Using a solid, unreamed nail only without tract debridement
. Performing the conversion in a single stage regardless of active pin site inflammation

Correct Answer & Explanation

. Converting the fixator after 4 weeks without a break

Explanation

To minimize deep infection risk when converting from an external fixator to an intramedullary nail, especially if pin sites are inflamed or the fixator has been on for more than 2 weeks, a staged protocol utilizing a "pin-site holiday" to allow tracts to heal is strongly recommended.

Question 7536

Topic: Lower Extremity Trauma

A 45-year-old male sustains a high-energy Schatzker IV tibial plateau fracture with a significant posteromedial shear fragment. Which of the following describes the most appropriate surgical approach and interval for fixing this specific fragment?

. Anterolateral approach between the iliotibial band and biceps femoris
. Posteromedial approach between the medial head of the gastrocnemius and the pes anserinus
. Posterolateral approach between the lateral head of the gastrocnemius and the soleus
. Direct medial approach elevating the superficial medial collateral ligament
. Anterior midline approach with a medial parapatellar arthrotomy

Correct Answer & Explanation

. Anterolateral approach between the iliotibial band and biceps femoris

Explanation

The posteromedial approach is ideal for direct visualization and buttress plating of a posteromedial shear fragment. The classic surgical interval is between the medial head of the gastrocnemius and the pes anserinus.

Question 7537

Topic: 2. Trauma

A 35-year-old construction worker falls from a height, sustaining a highly comminuted, closed distal tibia pilon fracture. On presentation, the ankle is severely swollen with fracture blisters over the medial and lateral malleoli. What is the most appropriate initial management?

. Immediate open reduction and internal fixation with dual plating
. Application of a short leg plaster cast
. Joint-spanning external fixation and elevation until soft tissue envelope improves
. Open reduction and internal fixation of the fibula with delayed fixation of the tibia
. Percutaneous pinning of the articular surface followed by circular frame application

Correct Answer & Explanation

. Immediate open reduction and internal fixation with dual plating

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with staged treatment. A joint-spanning external fixator stabilizes the fracture and allows for soft tissue recovery before definitive internal fixation.

Question 7538

Topic: 2. Trauma

In a polytrauma patient with bilateral femoral shaft fractures and a severe pulmonary contusion, which of the following laboratory parameters is the most reliable indicator of adequate global tissue perfusion and the end-point of resuscitation prior to early total care (ETC)?

. Urine output of 0.5 mL/kg/hr
. Heart rate less than 100 beats per minute
. Systolic blood pressure greater than 100 mm Hg
. Serum lactate less than 2.0 mmol/L
. Hemoglobin greater than 8 g/dL

Correct Answer & Explanation

. Urine output of 0.5 mL/kg/hr

Explanation

Serum lactate and base deficit are the most reliable indicators of global tissue perfusion. Normalization of serum lactate (< 2.0 mmol/L) suggests adequate resuscitation, favoring early definitive fixation.

Question 7539

Topic: 2. Trauma

A 45-year-old man sustains a high-energy bicondylar tibial plateau fracture following a motor vehicle collision. CT imaging demonstrates a large, displaced posteromedial coronal shear fragment. Which of the following describes the most appropriate surgical approach and fixation strategy for managing this specific fragment?

. Anterolateral approach with a single laterally applied locking plate capturing the fragment with long locking screws
. Anterior midline approach with dual medial and lateral plating
. Posteromedial approach with an anti-glide plate placed at the fracture apex
. Medial approach with anterior-to-posterior directed lag screws
. Direct posterior approach utilizing a single posterior neutralization plate

Correct Answer & Explanation

. Anterolateral approach with a single laterally applied locking plate capturing the fragment with long locking screws

Explanation

A displaced posteromedial shear fragment in a bicondylar tibial plateau fracture cannot be adequately completely reduced or stabilized with lateral locking screws alone. It requires a dedicated posteromedial approach and placement of a posterior anti-glide (buttress) plate to successfully counteract the vertical shear forces.

Question 7540

Topic: 2. Trauma

Examination of a 41-year-old man who was thrown from a motorcycle reveals that both legs appear externally rotated and there is bruising in the perineal area. He has a blood pressure of 80/40 mm Hg, a pulse rate of 140/min, a respiratory rate of 25/min, and he appears confused. Following administration of 4 L of saline solution and 2 units of packed red blood cells, he has a blood pressure of 80/40 mm Hg, a pulse rate of 160/min, and a respiratory rate of 25/min. The abdominal assessment for intraperitoneal blood is negative. An AP radiograph shows an anteroposterior compression injury with 7 cm of symphysis diastasis but no posterior displacement in the sacroiliac joints. What is the next most appropriate step in management?

. Stabilization of the pelvis through noninvasive methods
. Additional crystalloid solution replacement
. External fixation in the operating room
. Angiographic embolization
. Continuing observation of vital signs

Correct Answer & Explanation

. Stabilization of the pelvis through noninvasive methods

Explanation

Because the patient has sustained a major high-energy injury to the pelvic ring, it can be assumed that there is serious bleeding or hemodynamic instability related to a pelvic vascular injury. The goal of intervention at this time is to assist in the resuscitative effort and to stop the bleeding. All attempts at providing fluid and blood are important, but without cessation of the bleeding continued loss occurs and significant problems can ensue such as coagulopathy and multiple organ failure. Noninvasive methods of stabilizating the pelvic ring should be used to stop the bleeding. These methods include wrapping a sheet around the pelvis or using commercially available belts, vacuum beanbags, or pneumatic shock garments. This will provide time to prepare for arteriography and/or external fixation. The next step is debatable but in view of negative findings for intra-abdominal blood, arteriography performed with the pelvis reduced using noninvasive methods would be ideal. Bassam D, Cephas GA, Ferguson KA, Beard LN, Young JS: A protocol for the initial management for unstable pelvic fractures. Am Surg 1998;64:862-867. Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 217-226.

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