Menu

2. Trauma MCQs

Practice Set 379 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 7561

Topic: 2. Trauma

While most middle-third clavicle fractures can be managed nonoperatively, certain clinical and radiographic criteria strictly dictate surgical intervention. Which of the following is an absolute indication for operative fixation of an acute clavicle fracture?

. Displacement greater than 100% of the shaft width
. Shortening of more than 2 centimeters
. Impending skin breakdown with severe skin tenting
. The presence of a Z-type comminuted fragment
. A highly active patient who participates in overhead sports

Correct Answer & Explanation

. Displacement greater than 100% of the shaft width

Explanation

Absolute indications for clavicle fracture fixation include open fractures, neurovascular compromise, and impending skin breakdown (severe tenting with blanching). Displacement and shortening are relative indications based on patient activity level and shared decision-making.

Question 7562

Topic: 2. Trauma

A 22-year-old man presents with a closed right femoral shaft fracture and a severe closed head injury with a Glasgow Coma Scale (GCS) score of 6. He is hemodynamically labile. According to the principles of Damage Control Orthopedics (DCO), what is the most appropriate initial management of the femur fracture?

. Early total care with reamed intramedullary nailing
. Plate osteosynthesis of the femur
. External fixation of the femur
. Skeletal traction and observation for 2 weeks in the ICU
. Immediate unreamed intramedullary nailing

Correct Answer & Explanation

. Early total care with reamed intramedullary nailing

Explanation

In severely polytraumatized patients (e.g., severe head injury, hemodynamic instability), prolonged surgeries and the systemic inflammatory hit from reamed nailing can be fatal (second hit phenomenon). Damage Control Orthopedics dictates rapid, temporary stabilization with external fixation.

Question 7563

Topic: 2. Trauma

A 35-year-old man undergoes open reduction and internal fixation of a Hawkins Type II talar neck fracture. At 8 weeks postoperatively, an anteroposterior mortise radiograph reveals a subchondral radiolucent band in the dome of the talus (Hawkins sign). What does this radiographic finding indicate?

. Impending avascular necrosis of the talar body
. Failure of the internal fixation hardware
. Nonunion of the talar neck fracture
. Intact vascular supply to the talar body and a favorable prognosis
. Post-traumatic osteomyelitis of the talus

Correct Answer & Explanation

. Impending avascular necrosis of the talar body

Explanation

The Hawkins sign represents subchondral osteopenia (resorption of bone) seen 6 to 8 weeks after injury. Its presence requires an intact blood supply to the talus, indicating that avascular necrosis is highly unlikely.

Question 7564

Topic: 2. Trauma

A 40-year-old man sustains a high-energy trauma resulting in a distal femur fracture. CT imaging reveals a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). What is the optimal surgical approach and fixation strategy for this specific fragment?

. Medial parapatellar approach with a laterally applied locking plate
. Lateral approach with anterior-to-posterior (AP) oriented lag screws
. Lateral approach with medial-to-lateral oriented lag screws
. Intramedullary nailing through an infrapatellar approach
. Posterior approach with a medial bridging plate

Correct Answer & Explanation

. Medial parapatellar approach with a laterally applied locking plate

Explanation

A Hoffa fracture is a coronal plane fracture of the femoral condyle. It requires anatomic articular reduction and fixation with lag screws oriented perpendicular to the fracture plane, typically placed in an anterior-to-posterior (AP) or posterior-to-anterior (PA) direction.

Question 7565

Topic: 2. Trauma

A 29-year-old motorcyclist sustains a completely displaced, closed midshaft femur fracture and a closed midshaft tibia fracture on the same limb (ipsilateral floating knee). Both fractures are amenable to antegrade intramedullary nailing. Which of the following describes the most universally accepted sequence of definitive stabilization?

. Tibial nailing first, followed by femoral nailing
. Femoral nailing first, followed by tibial nailing
. Simultaneous nailing using a two-surgeon approach
. External fixation of both bones, followed by delayed nailing at 3 weeks
. Plating of the femur, followed by nailing of the tibia

Correct Answer & Explanation

. Tibial nailing first, followed by femoral nailing

Explanation

In a floating knee injury, the femur is generally stabilized first. Stabilizing the femur restores limb alignment and allows the knee to be safely flexed, which is necessary to gain the proper starting trajectory for subsequent tibial intramedullary nailing.

Question 7566

Topic: 2. Trauma

A 25-year-old man with a severe closed head injury (GCS 7) and a closed femoral shaft fracture is admitted to the trauma bay. Initial head CT shows cerebral edema with mass effect. Which of the following is the most appropriate initial management of his femur fracture?

. Immediate reamed intramedullary nailing
. Immediate unreamed intramedullary nailing
. Damage control external fixation
. Open reduction and internal fixation with a dynamic compression plate
. Skeletal traction for 6 weeks

Correct Answer & Explanation

. Immediate reamed intramedullary nailing

Explanation

In a polytrauma patient with a severe head injury and elevated intracranial pressure, early total care (IM nailing) risks a 'second hit' phenomenon, exacerbating brain injury due to embolization and hypotension. Damage control orthopedics with temporary external fixation is the safest initial management.

Question 7567

Topic: 2. Trauma

A 34-year-old man sustains an open humeral shaft fracture (Gustilo-Anderson Type II) after a motorcycle collision. Examination reveals a complete inability to extend the wrist and fingers, which was noted immediately after the injury. What is the most appropriate management of the nerve injury?

. Immediate exploration of the radial nerve during fracture debridement and fixation
. Observation and baseline EMG at 6 weeks
. Observation and early tendon transfers
. Fracture fixation with delayed nerve exploration at 3 months if no recovery
. Primary nerve grafting

Correct Answer & Explanation

. Immediate exploration of the radial nerve during fracture debridement and fixation

Explanation

While radial nerve palsy in a closed humeral shaft fracture is typically observed initially, an open fracture with an associated radial nerve palsy is an absolute indication for immediate nerve exploration during the mandatory surgical debridement and fracture fixation.

Question 7568

Topic: 2. Trauma

A 22-year-old football player sustains a high-energy knee injury resulting in a multi-ligamentous knee dislocation. Upon reduction in the emergency department, his pedal pulses are palpable, but his ankle-brachial index (ABI) is 0.8. What is the most appropriate next step in management?

. Observation and re-evaluation in 24 hours
. Immediate exploration of the popliteal artery
. CT angiography of the lower extremity
. Duplex ultrasonography
. Fasciotomy of the lower leg

Correct Answer & Explanation

. Observation and re-evaluation in 24 hours

Explanation

An ankle-brachial index (ABI) less than 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury, even if pulses are palpable. CT angiography is the gold standard next step to rapidly delineate a popliteal artery intimal tear or occlusion.

Question 7569

Topic: 2. Trauma

A 28-year-old man sustains a completely displaced, high-shear vertical femoral neck fracture (Pauwels Type III). Which of the following internal fixation constructs provides the highest biomechanical stability for this fracture pattern?

. Three parallel cannulated screws placed in an inverted triangle
. A dynamic hip screw (sliding hip screw) with a derotational screw
. Two parallel cannulated screws
. A proximal femoral intramedullary nail
. Multiple divergent cannulated screws

Correct Answer & Explanation

. Three parallel cannulated screws placed in an inverted triangle

Explanation

Pauwels Type III fractures experience extremely high vertical shear forces, making standard parallel cannulated screws prone to failure. A fixed-angle device, such as a sliding hip screw combined with a derotational screw, provides superior biomechanical resistance to vertical shear.

Question 7570

Topic: 2. Trauma

A 40-year-old man sustains a Gustilo-Anderson Type IIIB open tibial shaft fracture. Following initial aggressive debridement and stabilization, within what timeframe should definitive soft-tissue coverage ideally be performed to minimize the risk of deep infection?

. Within 24 hours
. Within 3 to 5 days
. Within 10 to 14 days
. After 3 weeks to allow granulation tissue formation
. Only after complete bone healing has occurred

Correct Answer & Explanation

. Within 24 hours

Explanation

Current evidence suggests that definitive soft-tissue coverage of Type IIIB open tibia fractures within 3 to 7 days (optimally within 5 days) significantly reduces the rate of deep infection and flap failure compared to delayed coverage.

Question 7571

Topic: 2. Trauma

A 35-year-old male sustained a closed tibial shaft fracture treated with a reamed intramedullary nail 9 months ago. He presents with persistent weight-bearing pain. Radiographs demonstrate an oligotrophic nonunion at the fracture site without hardware failure. Which of the following is the most appropriate definitive management?

. Removal of hardware and application of an Ilizarov frame
. Addition of a fibular osteotomy alone
. Exchange nailing with a larger diameter reamed nail
. Prescription of a pulsed electromagnetic field bone stimulator
. Autologous iliac crest bone grafting without hardware exchange

Correct Answer & Explanation

. Removal of hardware and application of an Ilizarov frame

Explanation

Exchange nailing with a larger reamed nail is the gold standard for aseptic oligotrophic or hypertrophic nonunion of the tibia treated initially with an IM nail. It provides improved mechanical stability and stimulates a biological healing response via reaming.

Question 7572

Topic: 2. Trauma

A 25-year-old male is brought to the emergency department after a high-speed motorcycle collision. He is hemodynamically unstable, intubated for severe bilateral pulmonary contusions, and has bilateral closed femoral shaft fractures. What is the most appropriate initial orthopedic management?

. Bilateral antegrade reamed intramedullary nailing
. Bilateral damage control external fixation
. Bilateral retrograde unreamed intramedullary nailing
. Plate osteosynthesis of both femurs
. Skeletal traction with delayed definitive fixation at 3 weeks

Correct Answer & Explanation

. Bilateral antegrade reamed intramedullary nailing

Explanation

In a polytrauma patient who is hemodynamically unstable ('in extremis') with pulmonary compromise, damage control orthopedics using external fixation is indicated. This minimizes the 'second hit' inflammatory cascade associated with prolonged surgery and intramedullary reaming.

Question 7573

Topic: 2. Trauma

A 31-year-old pedestrian struck by a vehicle sustains ipsilateral fractures of the femoral and tibial shafts (floating knee). What systemic complication is statistically most associated with this specific injury pattern compared to isolated long bone fractures?

. Fat embolism syndrome
. Disseminated intravascular coagulation (DIC)
. Rhabdomyolysis
. Acute respiratory distress syndrome (ARDS) of non-fat origin
. Massive deep vein thrombosis

Correct Answer & Explanation

. Fat embolism syndrome

Explanation

The 'floating knee' involves significant marrow-replacing fractures of two major long bones. These highly energetic injuries carry a significantly elevated risk of fat embolism syndrome due to the large volume of intramedullary fat released into the venous circulation.

Question 7574

Topic: 2. Trauma

An 18-year-old male undergoes closed reduction of a both-bone forearm fracture. He develops severe pain out of proportion to the injury and tense compartments, prompting a volar fasciotomy. To adequately decompress the deep volar compartment, which specific fascial structure MUST be released?

. Bicipital aponeurosis (lacertus fibrosus)
. Fascia of the pronator quadratus
. Transverse carpal ligament
. Mobile wad fascia
. Fascia of the brachioradialis

Correct Answer & Explanation

. Bicipital aponeurosis (lacertus fibrosus)

Explanation

Adequate decompression of the deep volar compartment of the forearm requires incising the fascia overlying the deep muscles, specifically the pronator quadratus, flexor pollicis longus, and flexor digitorum profundus.

Question 7575

Topic: 2. Trauma

A 65-year-old female sustains a severely displaced 4-part proximal humerus fracture. According to recent quantitative anatomical studies, preservation of which artery is most critical for the primary blood supply to the humeral head?

. Anterolateral branch of the anterior humeral circumflex artery
. Posterior humeral circumflex artery
. Thoracoacromial artery
. Profunda brachii artery
. Suprascapular artery

Correct Answer & Explanation

. Anterolateral branch of the anterior humeral circumflex artery

Explanation

While classic teaching (Laing) emphasized the anterior humeral circumflex artery, recent cadaveric studies (Hettrich et al.) demonstrate that the posterior humeral circumflex artery provides the overwhelming majority (up to 64%) of the blood supply to the humeral head.

Question 7576

Topic: 2. Trauma

A 32-year-old man sustains multiple injuries in a motorcycle accident including ipsilateral open right femur and comminuted tibia fractures. He has acute abdominal distention and tenderness to palpation. The pelvis is stable to examination. He has a blood pressure of 70/40 mm Hg despite appropriate fluid resuscitation and a pulse rate of 120/min; the pulse is thready. Which of the following procedures is considered the highest priority in the management of this patient?

. Emergent CT of the abdomen and pelvis
. Insertion of a Swan-Ganz catheter to monitor the cardiac index
. Administration of albumin solution
. Emergent laparotomy in the operating room
. Application of a pneumatic antishock garment

Correct Answer & Explanation

. Emergent CT of the abdomen and pelvis

Explanation

The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient's bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer's solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries. Krettek C, Simon RG, Tscherne H: Management priorities in patients with polytrauma. Langenbecks Arch Surg 1998;383:220-227.

Question 7577

Topic: 2. Trauma

A 5-year-old girl sustains an isolated injury to the right shoulder area after falling off the monkey bars. Examination reveals intact neurovascular function in the extremity distally, but she is quite uncomfortable. An AP radiograph of the proximal humerus is shown in Figure 24. Her parents state that she is a very talented gymnast. Considering her age and potential athletic career, management should consist of

. a shoulder spica cast with the upper extremity in the salute position.
. a sling and swathe for 3 weeks, followed by gradual motion and strengthening.
. closed reduction and antegrade intramedullary pinning.
. closed reduction and retrograde intramedullary nailing.
. open reduction and internal fixation with small plates and screws.

Correct Answer & Explanation

. a shoulder spica cast with the upper extremity in the salute position.

Explanation

In this age group, bayonet apposition can produce very good results. Healing occurs rapidly, and remodeling usually is complete in less than 1 year. All of the other methods have significant risks of complications and are unnecessary for this fracture. Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures. New York, NY, Churchill Livingstone, 1994, pp 144-148.

Question 7578

Topic: 2. Trauma

A 45-year-old man sustains a bicondylar tibial plateau fracture with a large posteromedial coronal shear fragment. Which surgical approach is most appropriate for direct visualization and buttressing of this specific fragment?

. Anterolateral approach
. Medial parapatellar approach
. Posteromedial approach
. Direct posterior approach
. Anterior midline approach

Correct Answer & Explanation

. Anterolateral approach

Explanation

A posteromedial approach allows direct visualization, anatomical reduction, and anti-glide plating of a posteromedial shear fragment. These fragments cannot be adequately reduced or buttressed from a standard anterolateral or direct medial approach.

Question 7579

Topic: 2. Trauma

A 25-year-old polytrauma patient with a closed femoral shaft fracture is brought to the emergency department. The patient has an Injury Severity Score (ISS) of 36, an initial serum lactate of 4.5 mmol/L, and a platelet count of 80,000/mcL. Which of the following parameters is the strongest physiological indication to pursue Damage Control Orthopedics (DCO) rather than Early Total Care (ETC)?

. Femur fracture comminution
. Platelet count of 80,000/mcL
. Serum lactate of 4.5 mmol/L
. Injury Severity Score > 15
. Patient age

Correct Answer & Explanation

. Femur fracture comminution

Explanation

Elevated serum lactate (>2.5 mmol/L) indicates inadequate tissue perfusion and oxygen debt. It is a major physiological trigger for Damage Control Orthopedics (DCO) to prevent a secondary inflammatory "hit" that can lead to ARDS and multisystem organ failure.

Question 7580

Topic: 2. Trauma

Which Schatzker classification of tibial plateau fractures is associated with the highest risk of acute compartment syndrome?

. Type I
. Type II
. Type III
. Type IV
. Type VI

Correct Answer & Explanation

. Type I

Explanation

Schatzker Type VI fractures involve bicondylar pathology with complete metaphyseal-diaphyseal dissociation. This high-energy injury causes extensive soft-tissue stripping, bleeding, and swelling, conferring the highest risk of acute compartment syndrome.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page