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2. Trauma MCQs

Practice Set 384 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 7661

Topic: 2. Trauma

A 25-year-old male is undergoing antegrade intramedullary nailing of a femoral shaft fracture via a piriformis fossa entry portal. If the starting point is placed too far anteriorly, what is the most likely iatrogenic complication?

. Proximal femur burst fracture
. Iatrogenic femoral neck fracture
. Anterior cortical perforation of the proximal femur
. Varus malalignment of the fracture
. Damage to the medial femoral circumflex artery

Correct Answer & Explanation

. Proximal femur burst fracture

Explanation

An anterior starting point in the piriformis fossa forces the rigid nail to course posteriorly, which significantly increases the risk of anterior cortical perforation or blowout of the proximal femur. A strictly colinear starting point on the lateral view is crucial.

Question 7662

Topic: 2. Trauma

In the initial resuscitation of a polytrauma patient with a suspected hemodynamically unstable pelvic ring injury, at what anatomic level should a pelvic binder or circumferential sheet be applied?

. Iliac crests
. Anterior superior iliac spines
. Greater trochanters
. Pubic symphysis strictly
. Mid-thigh

Correct Answer & Explanation

. Iliac crests

Explanation

A pelvic binder should be centered precisely over the greater trochanters to generate optimal compressive forces across the pelvic ring, particularly to close an open-book (APC) injury. Placement over the iliac crests is ineffective and can paradoxically widen the true pelvis.

Question 7663

Topic: 2. Trauma

A 22-year-old male with bilateral femoral shaft fractures develops hypoxia, confusion, and a petechial rash on his chest 48 hours after injury. Which of the following is considered a major criterion for the clinical diagnosis of Fat Embolism Syndrome (FES) according to Gurd and Wilson?

. Tachycardia > 120 bpm
. Petechial rash
. Fever > 39°C
. Jaundice
. Retinal changes

Correct Answer & Explanation

. Tachycardia > 120 bpm

Explanation

Gurd and Wilson's major criteria for Fat Embolism Syndrome (FES) include a petechial rash, respiratory insufficiency, and cerebral involvement. Tachycardia, fever, and retinal changes are considered minor criteria.

Question 7664

Topic: 2. Trauma

A 42-year-old male sustains a highly comminuted, closed distal tibia (pilon) fracture with severe soft tissue swelling and fracture blisters, similar to the injury pattern shown.

What is the current standard of care regarding the timing and sequence of definitive treatment?

. Immediate definitive ORIF within 12 hours
. Immediate primary arthrodesis of the ankle
. Application of a spanning external fixator with delayed definitive ORIF
. Closed reduction and casting for 6 weeks, followed by ORIF
. Early limited internal fixation of the tibia, leaving the fibula unfixed

Correct Answer & Explanation

. Immediate definitive ORIF within 12 hours

Explanation

Severe pilon fractures with compromised soft tissues require a staged approach. Initial management utilizes a joint-spanning external fixator to restore length and alignment, followed by definitive ORIF once soft tissue swelling resolves (typically 1-3 weeks).

Question 7665

Topic: 2. Trauma

A 30-year-old male who underwent intramedullary nailing for a tibial shaft fracture 18 months ago presents with chronic anterior knee pain. Fracture healing is complete. What is the most commonly cited etiology for anterior knee pain after this procedure?

. Deep subclinical infection
. Prominent proximal locking screws
. Patellar tendon injury or irritation from the surgical approach
. Unrecognized iatrogenic patella fracture
. Degenerative meniscal root tear

Correct Answer & Explanation

. Deep subclinical infection

Explanation

Anterior knee pain is the most common complication following intramedullary nailing of the tibia. It is primarily attributed to the surgical approach, including patellar tendon trauma, fat pad fibrosis, or incision placement, regardless of a transtendinous or paratendinous technique.

Question 7666

Topic: 2. Trauma

A 26-year-old male sustains a vertically oriented (Pauwels type III) femoral neck fracture during a motor vehicle accident. Which fixation construct provides the most biomechanical stability for this specific fracture pattern?

. Three parallel cancellous lag screws
. Sliding hip screw (SHS) with a derotation screw
. Cephalomedullary nail
. Dynamic condylar screw
. Bipolar hemiarthroplasty

Correct Answer & Explanation

. Three parallel cancellous lag screws

Explanation

Pauwels type III femoral neck fractures in young adults are highly vertically oriented and experience high shear forces. Biomechanical studies demonstrate that a Sliding Hip Screw (SHS) combined with a derotation screw provides superior stability against vertical shear compared to multiple cancellous screws.

Question 7667

Topic: 2. Trauma

You are evaluating a polytrauma patient with a femur fracture to decide between Early Total Care (ETC) and Damage Control Orthopedics (DCO). According to the clinical grading of polytrauma, which of the following parameters classifies a patient as 'borderline' rather than 'stable' or 'unstable'?

. Systolic BP > 100 mmHg throughout resuscitation
. Initial Lactate of 2.0 mmol/L
. Base deficit between -2 and -5
. Platelet count < 50,000
. Estimated pulmonary artery pressure > 24 mmHg

Correct Answer & Explanation

. Systolic BP > 100 mmHg throughout resuscitation

Explanation

Polytrauma clinical grading often utilizes Pape's criteria. A 'borderline' patient may have an estimated pulmonary artery pressure > 24 mmHg, ISS > 20 with a thoracic injury, or multiple injuries requiring careful reassessment before committing to prolonged procedures like ETC.

Question 7668

Topic: 2. Trauma

A 55-year-old female presents with a distal femur nonunion 8 months after locked plating for a supracondylar femur fracture. Radiographs show failure of the plate at the level of the fracture. Which technical error during the index surgery most likely contributed to this failure?

. Leaving a large segment of the plate empty over the fracture site (long working length)
. Using entirely locking screws in a construct with adequate bone contact
. Placing locking screws immediately adjacent to the fracture site, resulting in a short working length
. Failing to use a dual-plate construct
. Using a titanium rather than a stainless steel plate

Correct Answer & Explanation

. Leaving a large segment of the plate empty over the fracture site (long working length)

Explanation

Placing locking screws immediately adjacent to a comminuted fracture site creates a 'short working length', which makes the construct too rigid. This concentrates stress over a short segment of the plate, preventing interfragmentary motion (callus formation) and leading to early fatigue failure.

Question 7669

Topic: 2. Trauma

A 25-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He has a GCS of 8, a closed head injury, and bilateral closed femoral shaft fractures. His vital signs show a blood pressure of 85/50 mmHg, heart rate of 125 bpm, and a core temperature of 34°C. Laboratory results demonstrate a serum lactate of 5.5 mmol/L and a pH of 7.15. What is the most appropriate initial orthopedic management for his femur fractures?

. Bilateral reamed intramedullary nailing
. Bilateral external fixation
. Unreamed intramedullary nailing
. Open reduction and internal fixation with locking plates
. Skeletal traction until neurologic status improves

Correct Answer & Explanation

. Bilateral reamed intramedullary nailing

Explanation

This patient is 'in extremis' with the lethal triad of hypothermia, acidosis, and coagulopathy (implied by shock). Damage control orthopedics (DCO) with rapid external fixation is indicated to minimize additional physiologic hits while providing temporary skeletal stability.

Question 7670

Topic: 2. Trauma

A 30-year-old male sustains a high-energy trauma resulting in an ipsilateral displaced midshaft femoral fracture and a displaced basicervical femoral neck fracture. What is the priority regarding the surgical sequence and fixation strategy?

. Immediate reamed antegrade intramedullary nailing of the shaft, followed by percutaneous pinning of the neck
. Fixation with a single reconstruction-type intramedullary nail using a piriformis start point
. Anatomic reduction and definitive stabilization of the femoral neck fracture prior to addressing the shaft
. Retrograde intramedullary nailing of the shaft first to facilitate subsequent closed reduction of the neck
. Simultaneous bilateral traction and external fixation of both fractures

Correct Answer & Explanation

. Immediate reamed antegrade intramedullary nailing of the shaft, followed by percutaneous pinning of the neck

Explanation

In ipsilateral femoral neck and shaft fractures, anatomic reduction and rigid fixation of the femoral neck fracture is the absolute priority to minimize the risk of nonunion and avascular necrosis.

Question 7671

Topic: 2. Trauma

A 45-year-old female undergoes intramedullary nailing for a proximal third tibial shaft fracture using an infrapatellar approach with the knee in extension. Postoperative radiographs reveal a coronal and sagittal plane deformity. Which deformity pattern is most commonly associated with this technique?

. Apex posterior (recurvatum) and varus
. Apex anterior (procurvatum) and valgus
. Apex posterior (recurvatum) and valgus
. Apex anterior (procurvatum) and varus
. Neutral sagittal alignment with severe varus

Correct Answer & Explanation

. Apex posterior (recurvatum) and varus

Explanation

Intramedullary nailing of proximal third tibia fractures often leads to apex anterior (procurvatum) and valgus deformity. This is due to the unopposed pull of the patellar tendon and the geometric mismatch between the straight nail and the flared proximal tibia.

Question 7672

Topic: 2. Trauma

A 22-year-old male presents with a severely swollen leg following a closed midshaft tibia fracture. He requires escalating doses of IV narcotics. His blood pressure is 110/65 mmHg. Intracompartmental pressure testing yields a reading of 45 mmHg in the anterior compartment. What is this patient's delta pressure, and what is the standard threshold for fasciotomy?

. Delta pressure is 20 mmHg; fasciotomy is indicated if delta pressure is < 30 mmHg.
. Delta pressure is 65 mmHg; fasciotomy is indicated if delta pressure is > 50 mmHg.
. Delta pressure is 45 mmHg; fasciotomy is indicated if delta pressure is > 30 mmHg.
. Delta pressure is 20 mmHg; fasciotomy is indicated if delta pressure is < 45 mmHg.
. Delta pressure is 110 mmHg; fasciotomy is indicated if delta pressure is < 30 mmHg.

Correct Answer & Explanation

. Delta pressure is 20 mmHg; fasciotomy is indicated if delta pressure is < 30 mmHg.

Explanation

Delta pressure is calculated as diastolic blood pressure minus intracompartmental pressure (65 - 45 = 20 mmHg). A delta pressure of less than 30 mmHg is highly suggestive of compartment syndrome and is an absolute indication for emergency fasciotomy.

Question 7673

Topic: 2. Trauma

A 28-year-old male with an isolated closed femur fracture develops hypoxia, a petechial rash over his axilla, and altered mental status 48 hours after admission. Which pathophysiologic mechanism most accurately explains the classic petechial rash seen in this syndrome?

. Endothelial damage from circulating free fatty acids released from bone marrow
. Microvascular thrombosis triggered by severe systemic inflammatory response
. Direct mechanical occlusion of dermal capillaries by fat macroglobules
. Disseminated intravascular coagulation resulting in thrombocytopenia
. Capillary fragility induced by hypoxemia

Correct Answer & Explanation

. Endothelial damage from circulating free fatty acids released from bone marrow

Explanation

The petechial rash in fat embolism syndrome is caused by the direct embolization of fat macroglobules into the dermal capillaries. This mechanical occlusion leads to erythrocyte extravasation and the characteristic rash.

Question 7674

Topic: 2. Trauma

A 35-year-old male sustains a severely comminuted open tibia fracture from a motorcycle crash. The wound measures 12 cm, features massive contamination, and has exposed bone stripped of its periosteum requiring a rotational muscle flap for coverage. Distal pulses are palpable and symmetric. What is the correct Gustilo-Anderson classification for this injury?

. Type II
. Type IIIA
. Type IIIB
. Type IIIC
. Type IV

Correct Answer & Explanation

. Type II

Explanation

Gustilo-Anderson Type IIIB fractures involve extensive soft-tissue stripping and inadequate bone coverage, necessitating local or free flap coverage. The presence of normal vascularity rules out a Type IIIC injury.

Question 7675

Topic: 2. Trauma

A 40-year-old male is 9 months post-intramedullary nailing for a midshaft femur fracture. He reports persistent pain with weight-bearing. Radiographs show abundant, bridging callus that fails to cross the fracture line (an "elephant shoe" appearance). What is the most appropriate surgical management?

. Removal of the nail and application of a circular external fixator
. Autologous iliac crest bone grafting alone
. Exchange nailing with a larger diameter reamed nail
. Plate augmentation leaving the current nail in place
. Pulsed electromagnetic field therapy

Correct Answer & Explanation

. Removal of the nail and application of a circular external fixator

Explanation

The patient has a hypertrophic nonunion, which indicates adequate biology but insufficient mechanical stability. Exchange nailing with a larger diameter reamed nail provides the necessary stability to allow the already active biological process to bridge the fracture.

Question 7676

Topic: 2. Trauma

A 75-year-old female with a primary total knee arthroplasty sustains a closed distal femur fracture just above the femoral component. Radiographs confirm the prosthesis remains well-fixed without evidence of loosening (Lewis-Rorabeck Type II). What is the optimal surgical treatment?

. Distal femoral replacement arthroplasty
. Open reduction and internal fixation with a lateral locking plate or retrograde intramedullary nail
. Revision to a hinged total knee arthroplasty
. Nonoperative management with a hinged knee brace
. External fixation spanning the knee joint

Correct Answer & Explanation

. Distal femoral replacement arthroplasty

Explanation

Lewis-Rorabeck Type II fractures are displaced periprosthetic fractures around a well-fixed implant. They are best treated with internal fixation, commonly using either a lateral locking plate or a retrograde intramedullary nail, preserving the well-fixed components.

Question 7677

Topic: 2. Trauma

A 45-year-old male sustains a bicondylar tibial plateau fracture. CT imaging demonstrates a significant posteromedial shear fragment that is displaced inferiorly. What is the optimal surgical approach and fixation strategy to address this specific fragment?

. Anterolateral approach with a single pre-contoured lateral locking plate
. Posteromedial approach utilizing an antiglide (buttress) plate
. Direct anterior approach with bilateral non-locking plates
. Arthroscopic-assisted percutaneous anterior-to-posterior lag screws
. Spanning external fixation as definitive management

Correct Answer & Explanation

. Anterolateral approach with a single pre-contoured lateral locking plate

Explanation

A posteromedial shear fragment in a tibial plateau fracture requires an open posteromedial approach and buttress (antiglide) plating. Lateral locking plates frequently fail to capture or adequately compress this coronally oriented fragment.

Question 7678

Topic: 2. Trauma

A 32-year-old male is involved in a high-energy collision. Radiographs demonstrate a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). How should this specific fracture pattern be ideally stabilized to optimize articular compression and stability?

. Anterior-to-posterior directed lag screws
. Posterior-to-anterior directed lag screws
. Medial-to-lateral fully threaded positioning screws
. A laterally applied tension band wire construct
. A bridging external fixator alone

Correct Answer & Explanation

. Anterior-to-posterior directed lag screws

Explanation

Hoffa fractures are coronal plane shear fractures of the femoral condyles. They are best stabilized using anterior-to-posterior directed interfragmentary lag screws to provide perpendicular compression across the fracture plane.

Question 7679

Topic: 2. Trauma

A 25-year-old polytrauma patient with a pelvic ring injury and bilateral femur fractures is undergoing resuscitation in the ICU. Which of the following clinical parameters is considered the most reliable indicator of adequate tissue perfusion to safely clear the patient for Early Total Care (ETC)?

. Heart rate consistently < 100 beats per minute
. Systolic blood pressure maintained > 100 mmHg
. Serum lactate < 2.0 mmol/L and normalized base deficit
. Urine output of 0.25 mL/kg/hr for 6 consecutive hours
. Glasgow Coma Scale score > 13

Correct Answer & Explanation

. Heart rate consistently < 100 beats per minute

Explanation

Normalization of serum lactate (< 2.0 mmol/L) and correction of the base deficit are the most reliable markers of adequate cellular resuscitation and tissue perfusion, indicating the patient is physiologically optimized for definitive fracture surgery.

Question 7680

Topic: 2. Trauma

A 25-year-old man presents following a high-speed motor vehicle collision. He has a closed right femoral shaft fracture, bilateral pulmonary contusions, and a grade III spleen laceration. Initial vitals show HR 120 bpm and BP 90/60 mm Hg. Arterial blood gas shows a base deficit of -8 and a serum lactate of 4.5 mmol/L. According to damage control orthopedics (DCO) principles, what is the most appropriate initial management of his femur fracture?

. Early total care with reamed antegrade intramedullary nailing
. Spanning external fixation
. Skeletal traction via a proximal tibial pin
. Retrograde intramedullary nailing
. Minimally invasive plate osteosynthesis

Correct Answer & Explanation

. Early total care with reamed antegrade intramedullary nailing

Explanation

In a hemodynamically unstable polytrauma patient with severe chest injury and elevated lactate (>4.0 mmol/L), early total care with intramedullary nailing risks a 'second hit' phenomenon, potentially triggering ARDS. Damage control external fixation is indicated to stabilize the fracture rapidly while physiology normalizes.

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