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2. Trauma MCQs

Practice Set 394 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 7861

Topic: 2. Trauma

A 22-year-old male sustains a hyperdorsiflexion injury to his right foot during a fall from a height. Radiographs demonstrate a displaced fracture of the talar neck with subluxation of the subtalar joint, while the tibiotalar joint remains reduced. According to the Hawkins classification, what is the risk of avascular necrosis (AVN) of the talar body?

. 0 - 10%
. 20 - 50%
. 70 - 100%
. 100% with inevitable collapse
. The risk cannot be determined from the fracture pattern

Correct Answer & Explanation

. 0 - 10%

Explanation

This is a Hawkins Type II fracture (talar neck fracture with subtalar subluxation/dislocation). The risk of AVN for a Type II fracture is historically reported as 20% to 50%, whereas Type III fractures have a much higher risk (up to 100%).

Question 7862

Topic: 2. Trauma

A 40-year-old male presents with a high-energy, severe soft-tissue-compromising fracture of the distal tibial plafond (Pilon fracture). There is significant swelling and fracture blisters. What is the standard of care for initial management?

. Immediate open reduction and internal fixation with dual plating
. Immediate intramedullary nailing
. Spanning external fixation and delayed definitive internal fixation
. Primary arthrodesis of the tibiotalar joint
. Application of a long leg cast

Correct Answer & Explanation

. Immediate open reduction and internal fixation with dual plating

Explanation

The standard of care for high-energy pilon fractures with severe soft tissue compromise is a staged approach. Initial spanning external fixation allows soft tissues to recover, followed by definitive internal fixation 10-21 days later to minimize wound complications.

Question 7863

Topic: 2. Trauma

A 29-year-old female sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture after a fall from a horse. What is the preferred surgical construct to maximize biomechanical stability and reduce the risk of nonunion and avascular necrosis?

. Three parallel cancellous screws
. Sliding hip screw (fixed-angle device) with or without a derotational screw
. Hemiarthroplasty
. Total hip arthroplasty
. Cephalomedullary nail

Correct Answer & Explanation

. Three parallel cancellous screws

Explanation

In young adults, vertically oriented, high-shear femoral neck fractures (Pauwels III) are highly unstable. A sliding hip screw (fixed-angle construct) provides superior biomechanical stability against vertical shear forces compared to multiple cancellous screws.

Question 7864

Topic: 2. Trauma

A 55-year-old male sustains a distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle. What is the primary deforming force on this specific articular fragment?

. Quadriceps tendon
. Patellar tendon
. Medial collateral ligament
. Lateral collateral ligament
. Gastrocnemius muscle

Correct Answer & Explanation

. Quadriceps tendon

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture. The primary deforming force causing posterior and proximal displacement of this fragment is the origin of the gastrocnemius muscle.

Question 7865

Topic: 2. Trauma

A 45-year-old male sustains a subtrochanteric femur fracture. During closed reduction for intramedullary nailing, the proximal fragment is noted to be flexed, abducted, and externally rotated. Which muscle is primarily responsible for the external rotation of the proximal fragment?

. Iliopsoas
. Gluteus medius
. Gluteus minimus
. Short external rotators (e.g., piriformis)
. Adductor longus

Correct Answer & Explanation

. Iliopsoas

Explanation

In subtrochanteric femur fractures, the proximal fragment is deformed by the iliopsoas (flexion), gluteus medius/minimus (abduction), and the short external rotators (external rotation). The adductors primarily pull the distal fragment medially.

Question 7866

Topic: 2. Trauma

A 32-year-old female is admitted after a crush injury with an open, bleeding pelvic ring disruption. Massive transfusion protocol (MTP) is initiated. What is the optimal ratio of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets to prevent trauma-induced coagulopathy?

. 1:1:1
. 3:1:1
. 1:3:1
. 2:1:1
. 1:1:2

Correct Answer & Explanation

. 1:1:1

Explanation

The PROPPR trial and current trauma guidelines support a 1:1:1 ratio of PRBCs, FFP, and platelets for patients requiring massive transfusion. This ratio most closely mimics whole blood and mitigates trauma-induced coagulopathy.

Question 7867

Topic: 2. Trauma

A 50-year-old female sustains a posteromedial shear fracture of the tibial plateau. Attempting to fix this fragment from a standard anterolateral approach will likely result in failure. What is the most appropriate surgical approach for direct visualization and buttress plating of this fragment?

. Anteromedial approach
. Posteromedial approach
. Direct posterior (popliteal) approach
. Lateral parapatellar approach
. Extensile anterior approach with tibial tubercle osteotomy

Correct Answer & Explanation

. Anteromedial approach

Explanation

Posteromedial shear fragments of the tibial plateau require a posteromedial approach (between the medial gastrocnemius and pes anserinus). This allows for proper posterior-to-anterior buttress plating, effectively neutralizing the shear forces.

Question 7868

Topic: 2. Trauma

According to the Lower Extremity Assessment Project (LEAP) study, which of the following factors at the time of injury is the most reliable predictor of eventual amputation or poor functional outcome in severe lower extremity trauma?

. Mangled Extremity Severity Score (MESS) > 7
. Absence of plantar sensation
. Extent of soft-tissue and muscle injury
. Bone loss > 5 cm
. Prolonged ischemia time (> 6 hours)

Correct Answer & Explanation

. Mangled Extremity Severity Score (MESS) > 7

Explanation

The LEAP study demonstrated that the severity of the soft-tissue and muscle injury is the most significant determinant of outcome in severe lower extremity trauma. Scoring systems like MESS and initial loss of plantar sensation were found to be poor predictors.

Question 7869

Topic: 2. Trauma

A 22-year-old elite soccer player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture). Why is this specific fracture highly prone to delayed union or nonunion?

. Excessive pull from the peroneus brevis tendon
. Interposition of the plantar fascia
. It occurs in a vascular watershed area
. It is an intra-articular fracture
. Constant weight-bearing forces prevent callus formation

Correct Answer & Explanation

. Excessive pull from the peroneus brevis tendon

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction of the fifth metatarsal. This region is a vascular watershed area between the metaphyseal and diaphyseal blood supplies, leading to a high risk of delayed union or nonunion.

Question 7870

Topic: 2. Trauma

A 28-year-old male is brought to the ED after a high-speed MVC. He has a severe closed head injury, pulmonary contusions, and a closed midshaft femur fracture. His blood pressure is 85/50 mmHg after 2 liters of crystalloid and 2 units of PRBCs. Arterial blood gas shows a base deficit of 9 and lactate of 4.5. What is the most appropriate management of the femur fracture?

. Immediate reamed intramedullary nailing
. Retrograde intramedullary nailing
. Skeletal traction and delayed internal fixation
. External fixation of the femur
. Open reduction and plate osteosynthesis

Correct Answer & Explanation

. Immediate reamed intramedullary nailing

Explanation

The patient is hemodynamically unstable ('in extremis') with a concurrent head injury and pulmonary contusions. Damage control orthopedics with rapid external fixation is indicated to stabilize the fracture while minimizing the 'second hit' inflammatory phenomenon.

Question 7871

Topic: 2. Trauma

A 35-year-old male sustains a Gustilo-Anderson type IIIB open tibia fracture. He undergoes appropriate initial irrigation and debridement. What is the optimal timeframe for definitive soft tissue flap coverage to minimize deep infection rates?

. Within 24 hours of injury
. Within 10 to 14 days after repeated debridements
. Within 72 hours to 7 days
. At 3 weeks, once healthy granulation tissue has formed
. Once bone union is radiographically evident

Correct Answer & Explanation

. Within 24 hours of injury

Explanation

Definitive soft tissue coverage for type IIIB open tibia fractures is ideally performed within 3 to 7 days of the injury. This protocol significantly decreases the risk of deep infection and improves long-term functional outcomes.

Question 7872

Topic: 2. Trauma

A 68-year-old female presents with low-energy thigh pain. She has been taking alendronate for 8 years. Radiographs demonstrate lateral cortical thickening and a transverse fracture through the lateral cortex with a medial spike. What is the most appropriate surgical management?

. Discontinue bisphosphonates and initiate protected weight bearing only
. Open reduction and internal fixation with a lateral locking plate
. Cephalomedullary nailing using a full-length implant
. Retrograde intramedullary nailing with a short nail
. Proximal femoral replacement

Correct Answer & Explanation

. Discontinue bisphosphonates and initiate protected weight bearing only

Explanation

Bisphosphonate-associated atypical femur fractures are notoriously slow to heal and carry a high risk of subsequent fracture. They are best treated prophylactically or definitively with full-length cephalomedullary or antegrade reconstruction nailing to span the entire bone.

Question 7873

Topic: 2. Trauma

A 45-year-old male sustains a severe Schatzker VI tibial plateau fracture. During the initial ED evaluation, he complains of severe leg pain out of proportion to the injury. Which of the following physical examination findings is the most sensitive early clinical indicator of acute compartment syndrome?

. Loss of the dorsalis pedis pulse
. Pallor of the foot and distal extremity
. Pain with passive stretch of the toes
. Paresthesias in the first web space
. Tense compartments on deep palpation

Correct Answer & Explanation

. Loss of the dorsalis pedis pulse

Explanation

Pain with passive stretch of the ischemic muscles is considered the earliest and most sensitive clinical sign of acute compartment syndrome in an awake patient. Pulselessness and pallor are very late signs indicating irreversible damage.

Question 7874

Topic: 2. Trauma

A 30-year-old male falls from a height and sustains a displaced, vertically oriented, Pauwels type III femoral neck fracture. Which fixation construct provides the most biomechanically stable fixation against shear forces for this specific fracture pattern?

. Three parallel cancellous screws
. Dynamic condylar screw
. Proximal femoral locking plate
. Sliding hip screw with an anti-rotation screw
. Standard cephalomedullary nail

Correct Answer & Explanation

. Three parallel cancellous screws

Explanation

For vertically oriented (Pauwels type III) femoral neck fractures in young adults, shear forces at the fracture site are extremely high. A sliding hip screw supplemented with a derotational screw provides superior biomechanical stability compared to multiple cancellous screws.

Question 7875

Topic: Pelvic & Acetabular Trauma

A 40-year-old female arrives after a pedestrian-versus-auto collision. Her blood pressure is 70/40 mmHg. A pelvic binder is applied and the FAST exam is negative. Pelvic radiograph shows an APC-III pelvic ring injury. Despite aggressive fluid resuscitation, she remains hypotensive. What is the most appropriate next step?

. Retrograde urethrogram to assess for urologic injury
. CT scan of the abdomen and pelvis
. Laparotomy with preperitoneal pelvic packing or pelvic angioembolization
. Application of a supra-acetabular external fixator in the ED
. Zone 3 REBOA placement followed by observation

Correct Answer & Explanation

. Retrograde urethrogram to assess for urologic injury

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam, the source of bleeding is primarily pelvic. Preperitoneal pelvic packing or immediate pelvic angiography with embolization is urgently indicated.

Question 7876

Topic: 2. Trauma

Radiographs and CT scans of a 35-year-old male involved in a high-speed MVC demonstrate a fracture pattern involving both the anterior and posterior columns of the acetabulum. A characteristic 'spur sign' is visible on the obturator oblique radiograph. What Letournel fracture classification is present?

. Transverse fracture
. T-type fracture
. Anterior column posterior hemi-transverse fracture
. Both-column fracture
. Posterior column fracture

Correct Answer & Explanation

. Transverse fracture

Explanation

The 'spur sign' on an obturator oblique radiograph represents the intact portion of the ilium remaining attached to the axial skeleton above the fracture line. It is pathognomonic for a both-column acetabular fracture.

Question 7877

Topic: 2. Trauma

A 28-year-old polytrauma patient presents with bilateral femur fractures and a severe closed head injury. He has been resuscitated in the ICU. Which of the following parameters suggests he is adequately resuscitated and safe to proceed with definitive early total care (ETC) via intramedullary nailing of his femurs?

. Serum lactate of 4.5 mmol/L
. Base deficit of -6
. Serum lactate < 2.0 mmol/L and normalizing base deficit
. INR 1.8
. Platelet count 80,000

Correct Answer & Explanation

. Serum lactate of 4.5 mmol/L

Explanation

In polytrauma, early total care (ETC) is safe when the patient is adequately resuscitated. A serum lactate < 2.0 mmol/L, base deficit > -2, and normal coagulation profiles indicate adequate resuscitation and a transition to a stable physiological state.

Question 7878

Topic: 2. Trauma

A 45-year-old man sustains a Gustilo-Anderson IIIB open tibia fracture. Following initial thorough debridement and spanning external fixation, what is the optimal timeframe for achieving definitive soft-tissue coverage to minimize the risk of deep infection?

. Within 24 hours
. Within 72 hours to 7 days
. Between 10 and 14 days
. At 3 weeks, once granulation tissue forms
. Concurrently with delayed bone grafting at 6 weeks

Correct Answer & Explanation

. Within 24 hours

Explanation

Definitive soft-tissue coverage for open tibia fractures (Gustilo IIIB) should ideally be performed within 72 hours to 7 days after injury. Early coverage within this window significantly reduces the risk of deep infection and promotes fracture healing.

Question 7879

Topic: Pelvic & Acetabular Trauma

A 35-year-old male is brought to the ED after a motorcycle crash. He is tachycardic (130 bpm) and hypotensive (80/40 mmHg). A pelvic radiograph (similar to

) shows an AP compression type III (APC-III) pelvic ring injury. After massive transfusion protocol is initiated, his blood pressure remains 85/45 mmHg. A pelvic binder is correctly applied. Extended FAST is negative. What is the most appropriate next step?

. CT abdomen and pelvis
. Definitive anterior and posterior pelvic ring fixation
. Preperitoneal pelvic packing and/or angioembolization
. Application of an external fixator in the ED
. Exploratory laparotomy

Correct Answer & Explanation

. CT abdomen and pelvis

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and negative FAST, retroperitoneal hemorrhage is the likely source. Interventions such as preperitoneal pelvic packing and/or pelvic angiography with embolization are critical to control venous and arterial bleeding.

Question 7880

Topic: 2. Trauma

A 25-year-old man sustains a Pauwels type III femoral neck fracture. To maximize biomechanical stability and reduce the risk of varus collapse, which fixation construct is most appropriate?

. Three parallel cancellous screws in an inverted triangle
. A dynamic hip screw (DHS) with a derotational screw
. A proximal femoral intramedullary nail
. A sliding hip screw without a derotational screw
. Hemiarthroplasty

Correct Answer & Explanation

. Three parallel cancellous screws in an inverted triangle

Explanation

Pauwels type III femoral neck fractures have a highly vertical fracture line, exposing them to significant shear forces. A dynamic hip screw (length and angle stable) supplemented with a derotational screw provides superior biomechanical resistance to varus collapse compared to multiple cancellous screws.

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