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2. Trauma MCQs

Practice Set 397 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 7921

Topic: 2. Trauma

A 38-year-old male develops acute compartment syndrome of the lower leg following a tibial plateau fracture. The surgeon performs a dual-incision, four-compartment fasciotomy. Which compartment is historically the most frequently inadequately released or missed during this procedure?

. Anterior compartment
. Lateral compartment
. Superficial posterior compartment
. Deep posterior compartment
. Peroneal compartment

Correct Answer & Explanation

. Anterior compartment

Explanation

The deep posterior compartment is the most frequently missed or incompletely released compartment during a standard fasciotomy of the leg. This often occurs because the surgeon fails to adequately detach the soleus bridge from the posteromedial tibia.

Question 7922

Topic: 2. Trauma

A 75-year-old female presents with a periprosthetic distal femur fracture (Lewis and Rorabeck Type II) above a stable, well-fixed posterior-stabilized total knee arthroplasty component. Which of the following is the most appropriate definitive management?

. Revision to a distal femoral replacement
. Hinged knee brace and restricted weight-bearing for 12 weeks
. ORIF with a lateral locking plate or retrograde intramedullary nail
. Knee arthrodesis using a long intramedullary nail
. Above-knee amputation due to poor bone stock

Correct Answer & Explanation

. Revision to a distal femoral replacement

Explanation

A Lewis and Rorabeck Type II periprosthetic distal femur fracture involves a fracture around a well-fixed, stable component. The standard of care is surgical fixation with either a lateral locking plate or a retrograde intramedullary nail (if the femoral component box allows).

Question 7923

Topic: 2. Trauma

A 45-year-old man sustains a closed isolated scapular body fracture after an all-terrain vehicle accident. Radiographs demonstrate a displaced scapular body fracture with 10 mm of medialization and 15 degrees of angular deformity. The glenoid is not involved. What is the most appropriate management?

. Open reduction internal fixation of the scapula
. Closed reduction and spica casting
. Sling immobilization and early range of motion
. Shoulder hemiarthroplasty
. Latissimus dorsi transfer

Correct Answer & Explanation

. Open reduction internal fixation of the scapula

Explanation

Sling immobilization and early range of motion is the standard of care for most extra-articular scapular body fractures. Operative intervention is typically reserved for extreme displacement, such as medialization greater than 25 mm or angulation exceeding 45 degrees.

Question 7924

Topic: 2. Trauma

A 25-year-old man sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). Upon initial emergency department evaluation, he is unable to actively extend his wrist or fingers. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and ORIF
. Functional bracing and observation
. External fixation
. Intramedullary nailing
. Immediate electromyography (EMG) and nerve conduction studies

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve and ORIF

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture is generally managed expectantly with functional bracing and observation. The vast majority of these nerve injuries are neuropraxias that will spontaneously recover within 3 to 4 months.

Question 7925

Topic: 2. Trauma

A 75-year-old woman with a history of rheumatoid arthritis sustains an intra-articular, bicolumnar distal humerus fracture (OTA/AO 13-C3) with severe comminution and osteopenia. What treatment option provides the best chance for early functional recovery and reliable pain relief?

. Cast immobilization
. Open reduction and internal fixation with orthogonal dual plates
. Total elbow arthroplasty (TEA)
. Hemiarthroplasty of the elbow
. Spanning external fixation

Correct Answer & Explanation

. Cast immobilization

Explanation

Total elbow arthroplasty is the preferred treatment for highly comminuted, intra-articular distal humerus fractures in low-demand, elderly patients with poor bone quality or pre-existing inflammatory arthritis. It allows for immediate range of motion and has reliable outcomes compared to the high failure rate of ORIF in this population.

Question 7926

Topic: 2. Trauma

A 28-year-old man is involved in a motorcycle collision and sustains a displaced, vertically oriented (Pauwels type III) femoral neck fracture. To minimize the risk of mechanical failure and nonunion, which of the following is the most biomechanically stable fixation construct?

. Three parallel cancellous lag screws
. Sliding hip screw (SHS) with a derotational screw
. Bipolar hemiarthroplasty
. Total hip arthroplasty
. Proximal femoral locking plate

Correct Answer & Explanation

. Three parallel cancellous lag screws

Explanation

In young adults with high shear angle (Pauwels III) femoral neck fractures, a fixed-angle construct such as a sliding hip screw (DHS) with an adjunctive derotational screw provides superior biomechanical stability. This construct resists vertical shear forces better than parallel cancellous screws.

Question 7927

Topic: 2. Trauma

A 35-year-old man presents with a high-energy Schatzker VI tibial plateau fracture. Which of the following physical examination findings is the earliest and most reliable clinical indicator of acute compartment syndrome?

. Absence of pedal pulses
. Pallor of the foot
. Pain out of proportion to the injury and exacerbated by passive stretch
. Paralysis of the extensor hallucis longus
. Paresthesias in the first web space

Correct Answer & Explanation

. Absence of pedal pulses

Explanation

Pain out of proportion to the apparent injury, which is classically exacerbated by passive stretch of the muscles in the involved compartment, is the most sensitive and earliest clinical sign of acute compartment syndrome. Pulselessness and paralysis are late, often irreversible signs.

Question 7928

Topic: 2. Trauma

A 42-year-old man undergoes intramedullary nailing of a proximal third tibial shaft fracture. Which of the following intraoperative techniques is most effective in preventing the common apex anterior (procurvatum) and valgus deformity associated with this injury?

. Using a medial parapatellar approach in hyperflexion
. Employing a semi-extended or suprapatellar nailing technique
. Using a narrower diameter intramedullary nail
. Starting the awl anterior to the designated safe zone
. Reaming the medullary canal in full knee flexion

Correct Answer & Explanation

. Using a medial parapatellar approach in hyperflexion

Explanation

Proximal third tibial fractures frequently malalign into procurvatum and valgus during traditional hyperflexed nailing due to the unresisted pull of the patellar tendon. A semi-extended (suprapatellar) approach relaxes the extensor mechanism, facilitating anatomic reduction and proper nail trajectory.

Question 7929

Topic: 2. Trauma

A 48-year-old construction worker sustains a severe, comminuted tibial pilon fracture with massive soft tissue swelling and hemorrhagic fracture blisters around the ankle. What is the most appropriate initial management strategy?

. Immediate open reduction and internal fixation with plates and screws
. Closed reduction and application of a snug short leg cast
. Application of a spanning external fixator and limb elevation
. Primary tibiotalar arthrodesis
. Intramedullary nailing of the tibia with distal locking screws

Correct Answer & Explanation

. Immediate open reduction and internal fixation with plates and screws

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with a staged protocol. Initial management consists of a spanning external fixator and elevation until the soft tissues recover (the "wrinkle sign" appears), typically followed by definitive ORIF 10 to 21 days later.

Question 7930

Topic: 2. Trauma

A 35-year-old man sustains a high-energy distal femur fracture. CT imaging reveals a displaced coronal plane fracture of the lateral femoral condyle. What is the most biomechanically stable method of internal fixation for this specific articular fragment?

. Lateral anatomically contoured locking plate only
. Medial and lateral dual plating
. Anterior-to-posterior (AP) or posterior-to-anterior (PA) interfragmentary lag screws
. Transverse interfragmentary lag screws from lateral to medial
. External fixation spanning the knee

Correct Answer & Explanation

. Lateral anatomically contoured locking plate only

Explanation

A coronal fracture of the femoral condyle is known as a Hoffa fracture. It requires orthogonal fixation with AP or PA interfragmentary lag screws to adequately neutralize the shear forces of the knee.

Question 7931

Topic: 2. Trauma

A 40-year-old woman is undergoing open reduction and internal fixation of a bicondylar tibial plateau fracture with a large posteromedial shear fragment. Which anatomic interval is utilized for the classic posteromedial approach to the knee?

. Between the semimembranosus and the medial collateral ligament
. Between the medial head of the gastrocnemius and the pes anserinus
. Between the lateral head of the gastrocnemius and the biceps femoris
. Between the medial collateral ligament and the anterior tibialis
. Between the popliteus and the soleus

Correct Answer & Explanation

. Between the semimembranosus and the medial collateral ligament

Explanation

The classic posteromedial approach to the tibial plateau uses the interval between the medial head of the gastrocnemius (retracted laterally) and the pes anserinus tendons (retracted anteriorly/medially). This protects the neurovascular bundle while providing direct access to the posteromedial fragment.

Question 7932

Topic: 2. Trauma

A 25-year-old man sustains a Hawkins Type II talar neck fracture. At his 6-week follow-up radiograph, a subchondral radiolucent band is observed in the talar dome. What does this radiographic finding indicate?

. Onset of avascular necrosis (AVN) of the talar body
. Post-traumatic osteoarthritis of the tibiotalar joint
. Nonunion of the talar neck
. Intact vascularity to the talar body
. Infection of the tibiotalar joint

Correct Answer & Explanation

. Onset of avascular necrosis (AVN) of the talar body

Explanation

This finding is the Hawkins sign, which represents subchondral atrophy secondary to hyperemia. Its presence indicates intact vascularity to the talar body and makes the development of avascular necrosis highly unlikely.

Question 7933

Topic: 2. Trauma

A 28-year-old man sustains a closed midshaft clavicle fracture. Non-operative management is initially chosen. Which of the following initial radiographic findings is the most reliable predictor of subsequent nonunion?

. Displacement greater than 100% and shortening greater than 2 cm
. Presence of a single butterfly fragment
. Inferior displacement of the medial fragment
. Angulation greater than 15 degrees
. Fracture comminution involving less than 50% of the shaft

Correct Answer & Explanation

. Displacement greater than 100% and shortening greater than 2 cm

Explanation

The most reliable predictors of nonunion in midshaft clavicle fractures treated non-operatively are completely displaced fractures (no cortical contact) with shortening greater than 2 cm.

Question 7934

Topic: 2. Trauma

During surgical approach for internal fixation of a severe proximal humerus fracture, the surgeon attempts to preserve the primary blood supply to the humeral head. Which vessel supplies the majority of the blood to the humeral head?

. Anterior circumflex humeral artery
. Thoracoacromial artery
. Posterior circumflex humeral artery
. Profunda brachii artery
. Suprascapular artery

Correct Answer & Explanation

. Anterior circumflex humeral artery

Explanation

Historically, the anterior circumflex humeral artery (via the arcuate branch) was thought to be the primary supply. However, recent quantitative studies have proven that the posterior circumflex humeral artery provides the dominant blood supply to the humeral head.

Question 7935

Topic: 2. Trauma

A 22-year-old man sustains a vertically oriented (Pauwels Type III) femoral neck fracture. Which of the following fixation constructs provides the most biomechanical stability against the high shear forces seen in this fracture pattern?

. Three parallel cannulated screws placed in an inverted triangle
. Two parallel cannulated screws placed vertically
. A sliding hip screw (fixed-angle device) combined with a derotational screw
. A cephalomedullary nail with a single head screw
. A dynamic condylar screw

Correct Answer & Explanation

. Three parallel cannulated screws placed in an inverted triangle

Explanation

Pauwels Type III fractures are highly unstable due to vertical shear forces. A fixed-angle device like a sliding hip screw combined with a derotational screw provides superior biomechanical stability compared to multiple cannulated screws.

Question 7936

Topic: 2. Trauma

In a complete subtrochanteric femur fracture, the proximal fracture fragment is characteristically displaced by strong muscular forces. What is the typical position of the proximal fragment, and which muscles are responsible?

. Flexed, abducted, and externally rotated (iliopsoas, gluteus medius/minimus, short external rotators)
. Extended, adducted, and internally rotated (gluteus maximus, adductor magnus, TFL)
. Flexed, adducted, and internally rotated (iliopsoas, adductor longus, anterior gluteus medius)
. Extended, abducted, and externally rotated (gluteus maximus, gluteus medius, piriformis)
. Flexed, abducted, and internally rotated (rectus femoris, sartorius, TFL)

Correct Answer & Explanation

. Flexed, abducted, and externally rotated (iliopsoas, gluteus medius/minimus, short external rotators)

Explanation

The proximal fragment in a subtrochanteric fracture is classically pulled into flexion (iliopsoas), abduction (gluteus medius/minimus), and external rotation (short external rotators).

Question 7937

Topic: 2. Trauma

A 35-year-old man sustains a severe closed tibial pilon fracture with massive soft tissue swelling. What is the most appropriate initial management strategy to minimize the risk of wound complications?

. Immediate open reduction and internal fixation through a dual incision
. Application of a spanning external fixator and delayed definitive internal fixation in 10 to 14 days
. Immediate intramedullary nailing of the tibia
. Application of a circular frame (Ilizarov) immediately
. Immediate single-incision anterior plating

Correct Answer & Explanation

. Immediate open reduction and internal fixation through a dual incision

Explanation

High-energy pilon fractures are fraught with soft tissue complications. The standard of care is a staged protocol: initial spanning external fixation with fibular fixation (if needed), followed by delayed definitive ORIF once the soft tissue envelope has healed (indicated by the presence of skin wrinkles).

Question 7938

Topic: 2. Trauma

A 24-year-old man sustains a fracture of the proximal pole of the scaphoid. Why is this specific fracture pattern at an exceptionally high risk for developing avascular necrosis (AVN) and nonunion?

. The proximal pole relies entirely on diffusion from the synovial fluid
. The predominant blood supply enters distally and flows retrograde to the proximal pole
. The proximal pole lacks a cartilaginous cap for healing
. The main blood supply arises from the ulnar artery which is often severed
. The palmar carpal branches of the radial artery exclusively supply the distal pole

Correct Answer & Explanation

. The proximal pole relies entirely on diffusion from the synovial fluid

Explanation

The scaphoid has a retrograde blood supply. Branches of the radial artery (the dorsal carpal branch) enter the scaphoid near the waist and distal pole, flowing proximally. Fractures of the proximal pole disrupt this supply, leading to high rates of AVN.

Question 7939

Topic: 2. Trauma

A 32-year-old skier sustains a distal third spiral fracture of the tibial shaft. Which concomitant injury is statistically most likely to be present and must be specifically evaluated with dedicated imaging?

. Proximal fibula fracture (Maisonneuve)
. Posterior malleolus fracture
. Talus fracture
. Medial collateral ligament tear
. Navicular body fracture

Correct Answer & Explanation

. Proximal fibula fracture (Maisonneuve)

Explanation

Distal third spiral tibia fractures are highly associated with occult posterior malleolus fractures. CT scanning is generally recommended to evaluate the posterior malleolus and plan for appropriate internal fixation.

Question 7940

Topic: 2. Trauma

A 19-year-old elite college basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal (Jones fracture). What is the most appropriate management to ensure the fastest return to play and lowest risk of nonunion?

. Intramedullary screw fixation
. Non-weight-bearing cast for 6 weeks
. Weight-bearing as tolerated in a walking boot
. Open reduction and crossed K-wire fixation
. Primary excision of the proximal fragment

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

In elite athletes, acute Jones fractures (Zone 2) are typically treated with early intramedullary screw fixation. This provides the most reliable healing and fastest return to competitive sports, avoiding the high nonunion rates seen with conservative care due to the watershed blood supply.

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