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2. Trauma MCQs

Practice Set 382 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 7621

Topic: 2. Trauma

A 28-year-old male presents as a polytrauma following a high-speed motor vehicle collision. He sustains a closed comminuted midshaft femur fracture and bilateral pulmonary contusions. Initial laboratories demonstrate a serum lactate of 4.8 mmol/L, a pH of 7.21, and a base excess of -8. According to the principles of damage control orthopedics, what is the most appropriate initial management of his femur fracture?

. Reamed antegrade intramedullary nailing
. Unreamed antegrade intramedullary nailing
. Open reduction and internal fixation with a broad locking plate
. Spanning external fixation
. Distal femoral skeletal traction with definitive fixation planned at 3 weeks

Correct Answer & Explanation

. Reamed antegrade intramedullary nailing

Explanation

This patient is considered "borderline" or "unstable" due to his elevated lactate, significant acidosis, and pulmonary contusions, precluding Early Total Care. Damage Control Orthopedics with rapid external fixation is indicated to provide skeletal stability while avoiding the "second hit" phenomenon associated with intramedullary nailing.

Question 7622

Topic: 2. Trauma

A 25-year-old male presents following an MVC. He has a closed femur fracture, bilateral rib fractures, and a pulmonary contusion. His initial lactate is 4.5 mmol/L and pH is 7.21. After initial resuscitation, his lactate is 3.8 mmol/L. Which of the following is the most appropriate management of his femur fracture?

. Early total care with reamed antegrade intramedullary nailing
. Early total care with unreamed retrograde intramedullary nailing
. Damage control orthopedics with external fixation
. Skeletal traction and delayed internal fixation
. Plate osteosynthesis

Correct Answer & Explanation

. Early total care with reamed antegrade intramedullary nailing

Explanation

Patients with persistent acidosis (pH < 7.25), elevated lactate (> 2.5 mmol/L), or a base deficit worse than -5.5 are inadequately resuscitated. They should undergo damage control orthopedics (external fixation) to minimize the systemic inflammatory response and avoid the "second hit" phenomenon.

Question 7623

Topic: 2. Trauma

A 32-year-old male undergoes reamed antegrade intramedullary nailing of a left femoral shaft fracture on a fracture table. Postoperatively, he complains of perineal numbness and erectile dysfunction. Which of the following is the most likely cause?

. Direct injury to the sciatic nerve during portal creation
. Prolonged traction against the perineal post
. Undiagnosed pelvic ring injury
. Fat embolism syndrome
. Retractor placement during reduction

Correct Answer & Explanation

. Direct injury to the sciatic nerve during portal creation

Explanation

Pudendal nerve palsy is a well-documented complication of fracture table use due to prolonged compression against the perineal post. It typically resolves spontaneously over a period of weeks to months.

Question 7624

Topic: 2. Trauma

During surgical planning for a highly comminuted intra-articular distal femur fracture (AO/OTA 33-C3), a coronal plane fracture of the lateral femoral condyle is identified. Which of the following is the most appropriate fixation strategy for this specific fragment?

. Anterior-to-posterior lag screws
. Posterior-to-anterior lag screws
. Medial-to-lateral lag screws
. Lateral-to-medial lag screws
. Spanning external fixation

Correct Answer & Explanation

. Anterior-to-posterior lag screws

Explanation

A Hoffa fracture is a coronal plane fracture of the femoral condyle. It is best stabilized with anterior-to-posterior oriented lag screws placed perpendicular to the fracture plane to provide optimal compression.

Question 7625

Topic: 2. Trauma

A 28-year-old male sustains an ipsilateral femoral neck and shaft fracture. Which of the following statements regarding this injury pattern is true?

. The femoral neck fracture is typically displaced and easily seen on AP pelvis radiograph.
. Delayed fixation of the femoral neck fracture is recommended.
. A dedicated CT scan of the hip should be obtained in all high-energy femoral shaft fractures.
. The shaft fracture should always be fixed before the neck fracture.
. Retrograde nailing with a single construct is the gold standard.

Correct Answer & Explanation

. The femoral neck fracture is typically displaced and easily seen on AP pelvis radiograph.

Explanation

Ipsilateral femoral neck fractures occur in 2-6% of femoral shaft fractures and are frequently non-displaced. A dedicated CT protocol of the hip is recommended to avoid missing the diagnosis, and the neck fracture is prioritized for anatomic reduction.

Question 7626

Topic: 2. Trauma

You are treating a 45-year-old male with a proximal third tibial shaft fracture. When performing an intramedullary nailing, what is the most common malalignment deformity expected?

. Varus and recurvatum
. Valgus and procurvatum
. Varus and procurvatum
. Valgus and recurvatum
. Internal rotation and shortening

Correct Answer & Explanation

. Varus and recurvatum

Explanation

Proximal third tibia fractures have a strong tendency to go into valgus and procurvatum (apex anterior). This is primarily due to the pull of the patellar tendon, the anterior start point of the nail, and the unconstrained metaphysis.

Question 7627

Topic: 2. Trauma

According to the SPRINT trial, which of the following is true regarding reamed versus unreamed intramedullary nailing of tibial shaft fractures?

. Reamed nails have a higher rate of compartment syndrome in closed fractures.
. Unreamed nails have a lower rate of nonunion in open fractures.
. Reamed nails have a lower rate of reoperation for closed fractures compared to unreamed nails.
. There is a significantly higher infection rate with reamed nails in open fractures.
. Unreamed nails provide superior biomechanical stability in diaphyseal fractures.

Correct Answer & Explanation

. Reamed nails have a higher rate of compartment syndrome in closed fractures.

Explanation

The SPRINT trial demonstrated that reamed intramedullary nailing significantly reduced the risk of reoperations (primarily for nonunion) in closed tibial shaft fractures compared to unreamed nails. There was no significant difference in outcomes for open fractures.

Question 7628

Topic: 2. Trauma

A 30-year-old male sustains a severe open tibial shaft fracture with extensive soft tissue stripping (Gustilo-Anderson IIIB). He has a documented history of anaphylaxis to penicillin. Which of the following is the most appropriate initial antibiotic regimen?

. Cefazolin and gentamicin
. Clindamycin and gentamicin
. Vancomycin and ceftriaxone
. Ciprofloxacin monotherapy
. Linezolid and aztreonam

Correct Answer & Explanation

. Cefazolin and gentamicin

Explanation

For a Type III open fracture in a patient with a severe penicillin allergy (anaphylaxis), clindamycin is used to cover gram-positives, while an aminoglycoside like gentamicin covers gram-negatives. Cephalosporins are generally avoided if the allergy is anaphylactic.

Question 7629

Topic: 2. Trauma

A 24-year-old male sustains a closed tibial shaft fracture. Twelve hours later, he develops excruciating leg pain out of proportion to the injury. Which of the following clinical findings is the most sensitive early indicator of acute compartment syndrome?

. Loss of dorsalis pedis pulse
. Pain with passive stretch of the toes
. Capillary refill time greater than 3 seconds
. Foot drop
. Pallor of the extremity

Correct Answer & Explanation

. Loss of dorsalis pedis pulse

Explanation

Pain with passive stretch of the muscles in the involved compartment is the most sensitive and earliest clinical sign of acute compartment syndrome. Pulselessness, pallor, and paralysis are late and unreliable signs of irreversible ischemia.

Question 7630

Topic: 2. Trauma

A 22-year-old male with bilateral femoral shaft fractures develops hypoxia, altered mental status, and a petechial rash on his axilla 36 hours after injury. Which of the following is the most appropriate management?

. Immediate administration of high-dose corticosteroids
. Heparin infusion
. Supportive care with adequate oxygenation and ventilation
. Placement of an inferior vena cava filter
. Emergent hyperbaric oxygen therapy

Correct Answer & Explanation

. Immediate administration of high-dose corticosteroids

Explanation

The clinical triad of hypoxia, altered mental status, and a petechial rash is classic for Fat Embolism Syndrome (FES). Management is primarily supportive, focusing on maintaining adequate oxygenation and hemodynamic stability.

Question 7631

Topic: 2. Trauma

A 40-year-old male presents with persistent mid-leg pain 8 months after undergoing reamed intramedullary nailing of a closed tibial shaft fracture. Radiographs show a widened fracture line with abundant callus formation ("elephant foot"). Inflammatory markers are normal. What is the most appropriate definitive management?

. Intravenous antibiotics and suppressive therapy
. Bone grafting alone
. Removal of hardware and application of a fine-wire circular fixator
. Exchange nailing with a larger diameter reamed nail
. Pulsed electromagnetic field therapy

Correct Answer & Explanation

. Intravenous antibiotics and suppressive therapy

Explanation

The patient has an aseptic hypertrophic nonunion, indicating adequate biology but inadequate mechanical stability. Exchange intramedullary nailing with a larger diameter reamed nail provides the necessary mechanical stability to allow healing.

Question 7632

Topic: 2. Trauma

Recent literature regarding the timing of surgical debridement for open lower extremity fractures indicates that:

. All open fractures must be debrided within 6 hours to prevent infection.
. Delaying debridement up to 24 hours does not increase infection rates provided early antibiotics are administered.
. Only Gustilo-Anderson Type I fractures can be delayed up to 24 hours.
. Time to debridement is the single most important factor in preventing infection.
. Debridement should be delayed until soft tissue swelling completely subsides.

Correct Answer & Explanation

. All open fractures must be debrided within 6 hours to prevent infection.

Explanation

Multiple studies have shown that if prompt, appropriate intravenous antibiotics are administered, delaying surgical debridement up to 24 hours does not significantly increase the rate of infection in open fractures. Early antibiotic administration remains the most critical factor.

Question 7633

Topic: 2. Trauma

In the management of a polytraumatized patient, which of the following is considered the most reliable indicator of adequate global tissue perfusion and readiness for definitive orthopedic surgery?

. Normalization of heart rate and blood pressure
. Urine output greater than 0.5 mL/kg/hr
. Lactate level less than 2.0 mmol/L
. Glasgow Coma Scale score of 15
. Hematocrit greater than 30%

Correct Answer & Explanation

. Normalization of heart rate and blood pressure

Explanation

Serum lactate clearance to less than 2.0 mmol/L and the correction of the base deficit are the most reliable markers of adequate global tissue perfusion. Normalizing these values indicates the patient is resuscitated and ready for Early Total Care (ETC).

Question 7634

Topic: 2. Trauma

A 26-year-old male presents with a "floating knee" injury (ipsilateral femur and tibia fractures) following an ATV crash. He is hemodynamically stable. Which of the following is the most appropriate sequence of fixation?

. External fixation of the tibia followed by intramedullary nailing of the femur
. Intramedullary nailing of the femur followed by intramedullary nailing of the tibia
. Intramedullary nailing of the tibia followed by intramedullary nailing of the femur
. Plate fixation of the femur followed by external fixation of the tibia
. Simultaneous external fixation of both fractures

Correct Answer & Explanation

. External fixation of the tibia followed by intramedullary nailing of the femur

Explanation

In a hemodynamically stable patient with a floating knee, the standard of care is to stabilize the femur first. This restores the length and axis of the extremity, significantly facilitating the subsequent reduction and fixation of the tibia.

Question 7635

Topic: 2. Trauma

In which of the following scenarios is retrograde intramedullary nailing of a femoral shaft fracture most strongly indicated over antegrade nailing?

. A 25-year-old male with an isolated midshaft femur fracture
. A 30-year-old female who is 12 weeks pregnant
. A 40-year-old morbidly obese male (BMI 45) with an ipsilateral tibial shaft fracture
. A 50-year-old male with a proximal third femoral shaft fracture
. A 20-year-old male with an open midshaft femur fracture

Correct Answer & Explanation

. A 25-year-old male with an isolated midshaft femur fracture

Explanation

Retrograde nailing is particularly advantageous in morbidly obese patients due to easier access to the starting point. It is also ideal for patients with ipsilateral tibial shaft fractures (floating knee) as both fractures can be treated through a single incision without repositioning.

Question 7636

Topic: 2. Trauma

A 25-year-old man sustains a severe closed head injury, a blunt chest injury, and a closed midshaft femur fracture in a motor vehicle collision. Upon arrival, his blood pressure is 90/60 mm Hg, heart rate 120 bpm, and Glasgow Coma Scale score is 7. His base deficit is 9. What is the most appropriate initial management for the femur fracture?

. Antegrade reamed intramedullary nailing
. Retrograde reamed intramedullary nailing
. External fixation
. Open reduction and internal fixation with a plate
. Skeletal traction

Correct Answer & Explanation

. Antegrade reamed intramedullary nailing

Explanation

In a polytrauma patient with 'borderline' or 'in extremis' physiological status (e.g., severe head injury, shock, base deficit >8), Damage Control Orthopedics (DCO) with temporary external fixation is indicated to minimize the 'second hit' of surgery.

Question 7637

Topic: 2. Trauma

A 30-year-old woman is evaluated after a high-speed motor vehicle collision. Radiographs demonstrate a comminuted midshaft femur fracture. Which of the following is the most appropriate imaging modality or protocol to rule out an associated ipsilateral femoral neck fracture?

. AP and lateral plain radiographs of the femur only
. Dedicated CT scan of the pelvis and proximal femur
. Postoperative MRI of the hip
. Intraoperative fluoroscopy of the knee
. Technetium bone scan

Correct Answer & Explanation

. AP and lateral plain radiographs of the femur only

Explanation

Ipsilateral femoral neck fractures occur in 2-9% of femoral shaft fractures and are often non-displaced. A dedicated CT protocol of the pelvis or a fine-cut CT through the proximal femur is considered the gold standard for ruling out these associated injuries.

Question 7638

Topic: 2. Trauma

When performing intramedullary nailing of a proximal third tibial shaft fracture via an infrapatellar approach, there is a tendency for the proximal fragment to displace into which of the following positions?

. Apex anterior and valgus
. Apex posterior and varus
. Apex anterior and varus
. Apex posterior and valgus
. Neutral alignment

Correct Answer & Explanation

. Apex anterior and valgus

Explanation

During infrapatellar IM nailing of proximal third tibia fractures, the pull of the patellar tendon extends the proximal fragment, leading to an apex anterior (procurvatum) and valgus deformity. Blocking screws or a suprapatellar approach can mitigate this.

Question 7639

Topic: 2. Trauma

A 28-year-old man presents with a closed midshaft tibia fracture. He reports excruciating pain in the leg, out of proportion to the injury. Passive stretch of the great toe elicits severe pain. Intracompartmental pressure measurements are obtained. Which of the following values is the most universally accepted threshold to perform a four-compartment fasciotomy?

. Absolute pressure > 20 mm Hg
. Absolute pressure > 30 mm Hg in two compartments
. Delta P (Diastolic blood pressure minus compartment pressure) < 30 mm Hg
. Delta P (Mean arterial pressure minus compartment pressure) < 40 mm Hg
. Absolute pressure > 45 mm Hg in any compartment

Correct Answer & Explanation

. Absolute pressure > 20 mm Hg

Explanation

The most reliable indicator for compartment syndrome is a Delta P (diastolic blood pressure minus the intracompartmental pressure) of less than 30 mm Hg. This accounts for systemic perfusion pressure, which dictates tissue oxygenation.

Question 7640

Topic: 2. Trauma

A 45-year-old woman sustains a displaced intra-articular fracture of the distal femur. CT scan reveals a coronal plane fracture of the lateral femoral condyle. Which of the following biomechanical forces is primarily responsible for the displacement of this specific fragment?

. Pull of the medial collateral ligament
. Pull of the anterior cruciate ligament
. Pull of the gastrocnemius muscle
. Pull of the popliteus tendon
. Pull of the quadriceps muscle

Correct Answer & Explanation

. Pull of the medial collateral ligament

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture, most commonly affecting the lateral condyle. The lateral head of the gastrocnemius muscle and the popliteus exert deforming forces on this fragment, causing posterior and proximal displacement.

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