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2. Trauma MCQs

Practice Set 395 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 7881

Topic: 2. Trauma

A 42-year-old man sustains a closed posterior wall acetabular fracture. Examination reveals a large, fluctuant swelling over the greater trochanter with overlying skin bruising. What is the most appropriate initial management of this soft-tissue injury to minimize perioperative complications?

. Immediate open debridement and primary closure
. Aspiration of the fluid collection and compression dressing
. Immediate surgical fixation of the acetabulum through the lesion
. Incision and drainage with application of a wound vac
. Observation without intervention

Correct Answer & Explanation

. Immediate open debridement and primary closure

Explanation

A Morel-Lavallée lesion is a closed degloving injury often associated with pelvic or acetabular trauma. Initial management typically involves aspiration or percutaneous drainage combined with compressive dressings to resolve the seroma and assess skin viability prior to definitive fracture surgery.

Question 7882

Topic: 2. Trauma

A 30-year-old male presents with a midshaft tibia fracture. He complains of pain out of proportion to the injury. Which of the following continuous compartment pressure monitoring findings is most indicative of acute compartment syndrome requiring emergent fasciotomy?

. Absolute compartment pressure of 20 mmHg
. Delta pressure (Diastolic blood pressure minus compartment pressure) < 30 mmHg
. Delta pressure (Systolic blood pressure minus compartment pressure) < 40 mmHg
. Mean arterial pressure (MAP) minus compartment pressure > 40 mmHg
. Absolute compartment pressure of 25 mmHg

Correct Answer & Explanation

. Absolute compartment pressure of 20 mmHg

Explanation

Acute compartment syndrome is best diagnosed using the delta pressure, calculated as diastolic blood pressure minus compartment pressure. A delta pressure of less than 30 mmHg is highly specific for acute compartment syndrome and warrants emergent fasciotomy.

Question 7883

Topic: 2. Trauma

A 50-year-old man sustains a high-energy closed pilon fracture (OTA 43-C3) with severe fracture blisters and massive soft-tissue swelling. What is the most appropriate initial management?

. Immediate open reduction and internal fixation of the tibia and fibula
. Fibular fixation and spanning external fixation of the tibia
. Application of a circular frame (Ilizarov) definitively in the acute setting
. Nonoperative treatment in a long leg cast
. Immediate intramedullary nailing of the tibia

Correct Answer & Explanation

. Immediate open reduction and internal fixation of the tibia and fibula

Explanation

High-energy pilon fractures with severe soft-tissue compromise are best managed with a staged protocol. Initial management consists of spanning external fixation, followed by delayed definitive fixation once the soft-tissue swelling and blisters resolve.

Question 7884

Topic: 2. Trauma

During the intramedullary nailing of a subtrochanteric femur fracture, the proximal fragment is typically displaced into flexion, abduction, and external rotation. Which muscle is primarily responsible for the flexion deformity of the proximal fragment?

. Gluteus medius
. Gluteus maximus
. Iliopsoas
. Adductor longus
. Piriformis

Correct Answer & Explanation

. Gluteus medius

Explanation

In subtrochanteric fractures, the proximal fragment is driven into flexion by the iliopsoas, which attaches to the lesser trochanter. Abduction is driven by the gluteus medius and minimus, while external rotation is caused by the short external rotators.

Question 7885

Topic: 2. Trauma

A 28-year-old polytrauma patient with a closed femoral shaft fracture has a serum lactate of 4.5 mmol/L, a base deficit of -8 mEq/L, and a platelet count of 85,000/mcL. What is the most appropriate management of the femur fracture?

. Antegrade reamed intramedullary nailing
. Retrograde unreamed intramedullary nailing
. Damage control external fixation
. Skeletal traction and delayed definitive fixation
. Plate osteosynthesis

Correct Answer & Explanation

. Antegrade reamed intramedullary nailing

Explanation

This patient is in a "borderline" or "in extremis" physiologic state based on elevated lactate, base deficit, and thrombocytopenia. Damage control orthopedics (DCO) with rapid temporary external fixation is indicated to minimize the systemic inflammatory "second hit" phenomenon.

Question 7886

Topic: Pelvic & Acetabular Trauma

A 35-year-old man presents with a hemodynamically unstable anteroposterior compression (APC-III) pelvic ring injury. A non-invasive pelvic binder is applied in the trauma bay. Over which anatomical landmarks should the binder be centered for optimal reduction and hemorrhage control?

. Anterior superior iliac spines
. Iliac crests
. Greater trochanters
. Pubic symphysis
. Sacral promontory

Correct Answer & Explanation

. Anterior superior iliac spines

Explanation

Pelvic binders must be centered directly over the greater trochanters to effectively close the pelvic ring and reduce intrapelvic volume. Placement over the ASIS or iliac crests is biomechanically less effective and can paradoxically open the pelvis in certain fracture patterns.

Question 7887

Topic: 2. Trauma

A 42-year-old man sustains a high-energy Schatzker VI tibial plateau fracture.

Four hours post-injury, he requires increasing doses of opioids and exhibits severe pain with passive toe extension. What is the most reliable objective parameter to confirm the suspected diagnosis?

. Absolute compartment pressure greater than 30 mmHg
. Delta pressure (diastolic minus compartment pressure) less than 30 mmHg
. Loss of dorsalis pedis pulse
. Capillary refill greater than 3 seconds
. Loss of two-point discrimination on the dorsum of the foot

Correct Answer & Explanation

. Absolute compartment pressure greater than 30 mmHg

Explanation

A delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is the most reliable and specific indicator for acute compartment syndrome. Pulselessness and sensory loss are late, unreliable signs that often precede irreversible ischemia.

Question 7888

Topic: 2. Trauma

A 29-year-old sustains a Gustilo-Anderson Type IIIB open tibia fracture. Following initial aggressive surgical debridement, negative pressure wound therapy is applied. According to current evidence, soft tissue coverage should ideally be performed within what timeframe to minimize deep infection rates?

. 24 hours
. 72 hours
. 7 days
. 14 days
. 21 days

Correct Answer & Explanation

. 24 hours

Explanation

Historically, coverage within 5-7 days was considered standard. However, modern evidence strongly supports performing soft tissue flap coverage within 72 hours to significantly decrease infection rates in Type IIIB open tibia fractures.

Question 7889

Topic: 2. Trauma

Six weeks following open reduction and internal fixation of a Hawkins type III talar neck fracture, an AP radiograph of the ankle reveals subchondral radiolucency in the talar dome. What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Revascularization and viability of the talar body
. Osteomyelitis of the talus
. Nonunion of the fracture site
. Post-traumatic osteoarthritis

Correct Answer & Explanation

. Avascular necrosis of the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band seen 6-8 weeks post-injury, indicating active bone resorption. It signifies intact vascularity to the talus and essentially rules out avascular necrosis of the talar body.

Question 7890

Topic: 2. Trauma

A 50-year-old man presents with a highly comminuted, displaced OTA 43-C3 pilon fracture characterized by severe soft tissue swelling and fracture blisters. What is the standard of care regarding the sequencing of surgical management?

. Immediate ORIF of the fibula and tibia
. Immediate fibular plating, followed by delayed tibial ORIF
. Spanning external fixation, followed by definitive ORIF in 10-14 days
. Primary arthrodesis of the tibiotalar joint
. Immediate intramedullary nailing of the tibia

Correct Answer & Explanation

. Immediate ORIF of the fibula and tibia

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with a staged protocol. Immediate spanning external fixation restores length and alignment, followed by definitive ORIF once the soft tissue envelope adequately recovers (usually 10-14 days).

Question 7891

Topic: 2. Trauma

A 26-year-old male sustains a vertically oriented (Pauwels Type III) femoral neck fracture. Which of the following fixation constructs offers the greatest biomechanical stability against vertical shear forces for this specific fracture pattern?

. Three parallel cancellous lag screws
. A sliding hip screw with a supplemental derotational screw
. A fixed-angle 130-degree blade plate
. Standard reconstruction cephalomedullary nail
. Dynamic condylar screw

Correct Answer & Explanation

. Three parallel cancellous lag screws

Explanation

Pauwels Type III fractures are characterized by high vertical shear forces. Biomechanically, a sliding hip screw construct (often supplemented with a derotational screw) provides superior resistance to vertical shear compared to standard multiple parallel cancellous screws.

Question 7892

Topic: 2. Trauma

A 35-year-old woman is struck by a vehicle and sustains a closed pelvic ring injury. She develops a large, fluctuant mass over the greater trochanter with distinct skin hypermobility. Aspiration yields serosanguinous fluid. What is the pathophysiology of this lesion?

. Rupture of the deep fascia causing muscle herniation
. Shearing trauma separating subcutaneous tissue from underlying fascia
. Direct blunt trauma causing a deep intramuscular hematoma
. Avulsion of the gluteus medius insertion
. Arterial laceration of the superior gluteal artery

Correct Answer & Explanation

. Rupture of the deep fascia causing muscle herniation

Explanation

A Morel-Lavallée lesion is a closed degloving injury caused by shearing forces that separate the subcutaneous fat from the underlying fascial plane. This creates a potential space that rapidly fills with blood, lymph, and liquefied necrotic fat.

Question 7893

Topic: 2. Trauma

A 22-year-old polytrauma patient with bilateral femoral shaft fractures develops hypoxia, an axillary petechial rash, and confusion 36 hours post-injury. What is the most effective strategy to decrease the incidence of this specific syndrome in at-risk trauma patients?

. Prophylactic administration of systemic corticosteroids
. Early definitive operative stabilization of the long bone fractures
. Placement of a prophylactic inferior vena cava filter
. Empiric therapeutic anticoagulation with low molecular weight heparin
. Prophylactic administration of broad-spectrum intravenous antibiotics

Correct Answer & Explanation

. Prophylactic administration of systemic corticosteroids

Explanation

This patient exhibits the classic clinical triad of Fat Embolism Syndrome (FES). Early operative stabilization (within 24 hours) of long bone fractures is the single most effective and proven method to reduce the incidence of FES and ARDS in polytrauma patients.

Question 7894

Topic: 2. Trauma

A 40-year-old man presents with a "floating knee" consisting of ipsilateral diaphyseal fractures of the femur and tibia. Both injuries require intramedullary nailing. Which surgical approach combination is most recommended to limit setup changes and operative time?

. Antegrade femur nailing and antegrade tibia nailing on a fracture table
. Retrograde femur nailing and antegrade tibia nailing through a single knee incision
. Antegrade femur nailing followed by external fixation of the tibia
. Plate osteosynthesis for both fractures
. Bilateral skeletal traction followed by delayed antegrade nailing

Correct Answer & Explanation

. Antegrade femur nailing and antegrade tibia nailing on a fracture table

Explanation

A combined retrograde femoral nail and antegrade tibial nail can be efficiently performed through a single midline peripatellar incision with the leg draped free on a radiolucent triangle. This avoids repositioning the patient and decreases overall operative time.

Question 7895

Topic: 2. Trauma

A 30-year-old woman sustains a displaced intra-articular distal femur fracture. CT imaging reveals an associated coronal plane fracture of the lateral femoral condyle. Which surgical strategy is essential for appropriately managing this specific condylar fragment?

. Fixation with anterior-to-posterior oriented lag screws prior to lateral plate application
. Fixation with posterior-to-anterior oriented lag screws after lateral plate application
. Excision of the fragment and advancement of the lateral collateral ligament
. Conservative management with an articulated hinged knee brace
. Fixation using a standard lateral locking plate without independent interfragmentary screws

Correct Answer & Explanation

. Fixation with anterior-to-posterior oriented lag screws prior to lateral plate application

Explanation

Coronal shear fractures of the femoral condyle (Hoffa fractures) require independent fixation with anterior-to-posterior (or PA) lag screws to resist significant shear forces. This must be done before applying a definitive lateral neutralization or bridging plate.

Question 7896

Topic: 2. Trauma

A 45-year-old smoker presents with persistent mid-thigh pain 9 months after antegrade locked intramedullary nailing of a femoral shaft fracture. Radiographs show a distinct "elephant foot" hypertrophic nonunion. What is the most appropriate next step in management?

. Exchange nailing with a larger diameter reamed nail
. Removal of hardware and application of a spanning external fixator
. Addition of a supplemental lateral compression plate leaving the nail in situ
. Autologous iliac crest bone grafting of the nonunion site alone
. Pulsed electromagnetic field therapy

Correct Answer & Explanation

. Exchange nailing with a larger diameter reamed nail

Explanation

Hypertrophic nonunions possess excellent biological activity but lack sufficient mechanical stability. Exchange nailing with reaming and insertion of a larger diameter nail increases construct stiffness and is the gold standard treatment for femoral shaft hypertrophic nonunions.

Question 7897

Topic: 2. Trauma

A 33-year-old man sustains an open APC-II pelvic fracture with a large laceration extending deep into the perineum. There is no grossly visible stool, but rectal sphincter tone is absent. What is the primary indication for performing a diverting colostomy in this setting?

. Prevention of ascending genitourinary infections
. Facilitation of early patient mobilization
. Prevention of sepsis from massive fecal contamination of the pelvic fracture hematoma
. To definitively control intra-abdominal hemorrhage
. To allow for primary tension-free closure of the perineal wound

Correct Answer & Explanation

. Prevention of ascending genitourinary infections

Explanation

Diverting colostomy in severe open pelvic fractures is indicated primarily to prevent mechanical fecal soiling of the massive pelvic fracture hematoma. This significantly reduces the risk of overwhelming pelvic sepsis and mortality associated with perineal wounds.

Question 7898

Topic: 2. Trauma

A 28-year-old man sustains multiple injuries in a motor vehicle collision, including a closed right femoral shaft fracture and bilateral pulmonary contusions. He is currently intubated in the intensive care unit. Which of the following physiologic parameters is an absolute indication for damage control orthopedics (DCO) with temporary external fixation rather than early total care (ETC) with intramedullary nailing?

. Serum lactate level of 1.5 mmol/L
. Arterial pH of 7.32
. Base deficit greater than 8 mEq/L
. Core body temperature of 36.1°C
. Platelet count of 110,000/mcL

Correct Answer & Explanation

. Serum lactate level of 1.5 mmol/L

Explanation

Damage control orthopedics (DCO) is indicated in hemodynamically unstable or 'in extremis' polytrauma patients to avoid the second hit of major surgery. Physiologic parameters favoring DCO over early total care include a base deficit > 8 mEq/L, lactate > 2.5 mmol/L, pH < 7.25, and core body temperature < 35°C.

Question 7899

Topic: 2. Trauma

A 35-year-old man presents with a grossly swollen and deformed lower leg after a motorcycle crash. Radiographs demonstrate a highly comminuted, displaced fracture as seen in Figure 4.

On examination, the soft tissues are tense, and hemorrhagic fracture blisters are developing over the medial ankle. What is the most appropriate initial management?

. Immediate open reduction and internal fixation (ORIF) with dual plating
. Closed reduction and long-leg cast application
. Joint-spanning external fixation and elevation
. Primary ankle arthrodesis
. Immediate minimally invasive percutaneous plate osteosynthesis (MIPPO)

Correct Answer & Explanation

. Immediate open reduction and internal fixation (ORIF) with dual plating

Explanation

High-energy tibial pilon fractures are associated with severe soft tissue compromise, making immediate ORIF highly risky for necrosis and deep infection. The standard of care is a staged protocol starting with joint-spanning external fixation to restore length and alignment while allowing soft tissue swelling to subside before definitive fixation.

Question 7900

Topic: 2. Trauma

A 42-year-old pedestrian is struck by a truck and arrives at the trauma bay with a blood pressure of 75/40 mmHg and a heart rate of 135 bpm. Chest and abdomen FAST exams are negative. Pelvic radiographs show an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is emergently applied. Which of the following is the most appropriate anatomic landmark for the proper placement of the pelvic binder?

. Over the iliac crests
. Centered over the greater trochanters
. Over the anterior superior iliac spines (ASIS)
. Centered over the umbilicus
. Over the proximal femoral shafts

Correct Answer & Explanation

. Over the iliac crests

Explanation

Pelvic binders should be placed centered over the greater trochanters to effectively reduce the pelvic volume and stabilize the pelvic ring in 'open-book' type fractures. Placement higher over the iliac crests or ASIS is less effective and can actually cause paradoxical widening of the pelvic ring.

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