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2. Trauma MCQs

Practice Set 398 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 7941

Topic: 2. Trauma

A 26-year-old man is brought to the trauma bay with an Injury Severity Score (ISS) of 42, bilateral pulmonary contusions, and a closed right femoral shaft fracture. His initial lactate is 4.5 mmol/L. According to the principles of Damage Control Orthopedics (DCO), what is the most appropriate initial management for his femur fracture?

. Immediate reamed intramedullary nailing
. Immediate unreamed intramedullary nailing
. Plate osteosynthesis
. Spanning external fixation
. Skeletal traction only

Correct Answer & Explanation

. Immediate reamed intramedullary nailing

Explanation

In an unstable polytrauma patient with severe chest injury and metabolic acidosis (elevated lactate), early total care (IM nailing) can exacerbate systemic inflammation (Second Hit phenomenon). Damage Control Orthopedics dictates rapid, provisional stabilization with spanning external fixation.

Question 7942

Topic: 2. Trauma

A 68-year-old woman on long-term alendronate therapy presents with thigh pain and sustains a low-energy transverse fracture of the subtrochanteric femur with lateral cortical thickening. Which surgical implant is considered the gold standard for treating this specific type of atypical femur fracture?

. Lateral locking plate
. Dynamic hip screw
. Standard retrograde intramedullary nail
. Multiple cannulated screws
. Prophylactic or therapeutic full-length cephalomedullary nail

Correct Answer & Explanation

. Lateral locking plate

Explanation

Atypical femur fractures associated with bisphosphonate use are inherently prone to delayed healing and stress propagation. A full-length cephalomedullary nail is the gold standard as it spans the entire bone and mechanically protects the femur while it heals.

Question 7943

Topic: 2. Trauma

A 28-year-old male sustains a high-energy lateral Hoffa fracture (coronal shear fracture of the lateral femoral condyle). If lag screw fixation is chosen, biomechanical studies suggest which of the following screw configurations provides the most stable fixation and highest pullout strength?

. Two anterior-to-posterior (AP) directed lag screws
. Two posterior-to-anterior (PA) directed lag screws
. One AP and one PA directed lag screw
. A laterally applied neutralization plate alone
. Two divergent PA directed lag screws

Correct Answer & Explanation

. Two anterior-to-posterior (AP) directed lag screws

Explanation

Biomechanical studies have demonstrated that anterior-to-posterior (AP) directed lag screws provide significantly greater pullout strength and construct stiffness for Hoffa fractures compared to posterior-to-anterior (PA) screws. AP screws engage the denser bone of the posterior condyle more effectively.

Question 7944

Topic: 2. Trauma

A 38-year-old male sustains a bicondylar tibial plateau fracture featuring a large, displaced posteromedial coronal shear fragment. Which surgical approach and fixation strategy is most appropriate for addressing this specific fragment?

. Anterolateral approach with locking screws directed posteriorly
. Medial parapatellar approach with anterior-to-posterior lag screws
. Posteromedial approach with an under-contoured buttress plate
. Direct posterior approach with an over-contoured bridging plate
. Anteromedial approach with a spanning external fixator

Correct Answer & Explanation

. Anterolateral approach with locking screws directed posteriorly

Explanation

Posteromedial coronal shear fragments in tibial plateau fractures cannot be adequately reduced or stabilized via standard anterior approaches. A posteromedial approach with an under-contoured buttress plate (creating a spring-like anti-glide effect) provides superior biomechanical resistance to vertical shear forces.

Question 7945

Topic: 2. Trauma

A 35-year-old male with a high-energy, highly comminuted distal tibia pilon fracture (OTA/AO 43-C3) is treated with a spanning external fixator. Why might a surgeon purposefully delay open reduction and internal fixation of the associated comminuted fibula fracture during this index procedure?

. Immediate fibula fixation increases the risk of deep vein thrombosis
. Fixing the fibula first consistently leads to over-distraction of the tibiotalar joint
. An incorrectly reconstructed fibula can impede accurate reduction of the tibial articular block
. Fibula fractures associated with severe pilon injuries typically heal without operative intervention
. It prevents the use of a standard anterolateral surgical approach for the tibia

Correct Answer & Explanation

. Immediate fibula fixation increases the risk of deep vein thrombosis

Explanation

In complex, comminuted pilon fractures, early fixation of the fibula can act as a deforming force if length or rotation is slightly off. Delaying fibular fixation allows the surgeon to accurately reduce the critical tibial articular block without being hindered by an arbitrarily fixed fibula.

Question 7946

Topic: 2. Trauma

A 22-year-old male falls onto his shoulder and sustains a completely displaced midshaft clavicle fracture. While many factors influence surgical decision-making, which of the following is considered an absolute indication for acute operative fixation?

. Fracture shortening greater than 2 cm
. 100 percent displacement of the fracture fragments
. Severe butterfly comminution
. An open fracture
. Concomitant nondisplaced scapular body fracture

Correct Answer & Explanation

. Fracture shortening greater than 2 cm

Explanation

While severe shortening, 100 percent displacement, and comminution are strong relative indications for operative fixation to prevent symptomatic malunion or nonunion, an open clavicle fracture is an absolute indication for urgent surgical debridement and stabilization.

Question 7947

Topic: 2. Trauma

A 78-year-old female sustains an unstable reverse obliquity intertrochanteric femur fracture. Which of the following implants is biomechanically optimal to minimize the risk of lateral wall blowout and fixation failure?

. Sliding hip screw with a 2-hole side plate
. Sliding hip screw with a 4-hole side plate and trochanteric stabilizing plate
. Cephalomedullary nail
. Proximal femoral locking plate
. Multiple parallel cancellous lag screws

Correct Answer & Explanation

. Sliding hip screw with a 2-hole side plate

Explanation

Reverse obliquity intertrochanteric fractures are highly unstable because the fracture line parallels the vector of weight-bearing, encouraging medial shaft displacement. A cephalomedullary nail acts as an intramedullary buttress against this displacement, providing vastly superior stability compared to extramedullary sliding hip screws.

Question 7948

Topic: 2. Trauma

A 28-year-old polytrauma patient with bilateral femur fractures, pulmonary contusions, and a closed head injury (GCS 7) is brought to the trauma bay. His initial lactate is 5.2 mmol/L and pH is 7.18. He is hemodynamically stabilized with blood products. What is the most appropriate orthopedic management of his bilateral femur fractures?

. Early total care with bilateral reamed intramedullary nailing
. Bilateral external fixation
. Unreamed intramedullary nailing of both femurs
. Skeletal traction until neurological status improves
. Plating of both femurs

Correct Answer & Explanation

. Early total care with bilateral reamed intramedullary nailing

Explanation

In a borderline or unstable polytrauma patient with severe head injury and acidosis (pH < 7.25, lactate > 4.0), damage control orthopedics (DCO) with external fixation is indicated. Early total care (ETC) increases the risk of 'second hit' phenomena like ARDS or elevated intracranial pressure.

Question 7949

Topic: 2. Trauma

A 35-year-old farmer sustains a Gustilo-Anderson Type IIIA open tibia fracture heavily contaminated with soil. According to the latest guidelines, which of the following is the most appropriate prophylactic antibiotic regimen?

. Cefazolin only
. Cefazolin and gentamicin
. Ceftriaxone and clindamycin
. Ceftriaxone and metronidazole
. Cefazolin and penicillin

Correct Answer & Explanation

. Cefazolin only

Explanation

For Type III open fractures, particularly those with heavy soil contamination or farm injuries, guidelines recommend a broad-spectrum cephalosporin (like ceftriaxone) plus an agent covering anaerobes. Aminoglycosides are less favored due to renal toxicity.

Question 7950

Topic: 2. Trauma

A 22-year-old man presents with a closed midshaft tibia fracture treated with a cast. He has worsening pain and excruciating pain with passive stretch of the hallux. His blood pressure is 100/60 mmHg. Intracompartmental pressure is 40 mmHg in the anterior compartment. Which of the following is true?

. Delta P is 20 mmHg, emergency fasciotomy is indicated.
. Delta P is 60 mmHg, emergency fasciotomy is indicated.
. Delta P is 20 mmHg, bivalve the cast and observe.
. Delta P is 40 mmHg, emergency fasciotomy is indicated.
. Delta P is 40 mmHg, bivalve the cast and observe.

Correct Answer & Explanation

. Delta P is 20 mmHg, emergency fasciotomy is indicated.

Explanation

Delta P is calculated as diastolic blood pressure minus compartment pressure (60 - 40 = 20 mmHg). A Delta P of 30 mmHg or less, or an absolute pressure >30 mmHg with strong clinical symptoms, indicates acute compartment syndrome requiring immediate fasciotomy.

Question 7951

Topic: Pelvic & Acetabular Trauma

A 40-year-old man arrives at the trauma center after falling from a 3-story building. He is tachycardic (120 bpm) and hypotensive (80/40 mmHg). Pelvic radiograph shows an anteroposterior compression (APC) III injury. A pelvic binder is applied. To optimize mechanical stability and reduction of pelvic volume, where should the pelvic binder be centered?

. Iliac crests
. Greater trochanters
. Anterior superior iliac spines
. Pubic symphysis directly
. Proximal femurs

Correct Answer & Explanation

. Iliac crests

Explanation

A pelvic binder should be centered precisely over the greater trochanters to effectively close the pelvic ring and reduce intrapelvic volume. Placement over the iliac crests or ASIS can cause a flaring effect, worsening the displacement.

Question 7952

Topic: 2. Trauma

A 78-year-old woman with a well-fixed total knee arthroplasty presents with a comminuted, osteoporotic periprosthetic distal femur fracture. Which of the following fixation constructs offers the most mechanically stable osteosynthesis?

. Single lateral locked plate
. Retrograde intramedullary nail
. Dual plating (lateral and medial locked plates)
. Distal femoral replacement
. Non-locking lateral compression plate

Correct Answer & Explanation

. Single lateral locked plate

Explanation

In osteoporotic periprosthetic distal femur fractures with medial comminution or poor bone stock, dual plating (medial and lateral) provides the most biomechanically stable construct. Single lateral locked plates have a higher risk of varus collapse in severely comminuted fractures.

Question 7953

Topic: 2. Trauma

A 45-year-old man sustains a Schatzker type VI tibial plateau fracture. Which of the following surgical approaches is most commonly necessary to ensure adequate exposure and reduction of both the medial and lateral articular surfaces?

. Single midline incision
. Anterolateral and posteromedial incisions
. Posterolateral incision only
. Direct medial incision
. Extended iliofemoral approach

Correct Answer & Explanation

. Single midline incision

Explanation

A Schatzker VI fracture exhibits bicondylar involvement with metadiaphyseal dissociation. Dual incisions (anterolateral and posteromedial) are preferred to provide adequate visualization of both columns while minimizing the risk of severe soft tissue sloughing.

Question 7954

Topic: 2. Trauma

A 28-year-old male polytrauma patient (ISS 45) presents with bilateral closed femoral shaft fractures, severe closed head injury (GCS 6), and bilateral pulmonary contusions. His serum lactate is 6.5 mmol/L. What is the most appropriate initial management of his bilateral femur fractures?

. Bilateral reamed intramedullary nailing
. Unreamed intramedullary nailing of both femurs
. Bilateral temporary external fixation
. Plate osteosynthesis
. Skeletal traction

Correct Answer & Explanation

. Bilateral reamed intramedullary nailing

Explanation

In a polytrauma patient with high ISS, head injury, and physiological instability, damage control orthopedics (DCO) with temporary external fixation is indicated. This minimizes the "second hit" phenomenon associated with prolonged surgery and marrow reaming.

Question 7955

Topic: 2. Trauma

A 35-year-old polytrauma patient presents with hemodynamic instability and an anteroposterior compression type III pelvic ring injury. A pelvic binder is to be applied. What is the correct anatomical landmark for the optimal placement of the pelvic binder to effectively reduce the pelvic volume?

. Over the iliac crests
. Over the anterior superior iliac spines
. Centered over the greater trochanters
. Over the symphysis pubis and sacrum directly
. Below the level of the lesser trochanters

Correct Answer & Explanation

. Over the iliac crests

Explanation

Pelvic binders are most effective at reducing pelvic volume and controlling hemorrhage when centered directly over the greater trochanters, directing a medially based force to close the pelvic ring.

Question 7956

Topic: 2. Trauma

A 28-year-old man sustains a closed diaphyseal tibia fracture. Twelve hours post-admission, he complains of severe pain out of proportion to the injury, especially with passive stretch of the hallux. His blood pressure is 110/70 mm Hg. Intracompartmental pressure testing of the anterior compartment is 45 mm Hg. What is the most appropriate next step in management?

. Elevation of the leg and re-evaluation in 2 hours
. Administration of intravenous pain medication and muscle relaxants
. Emergent four-compartment fasciotomy
. Closed reduction and casting
. Intramedullary nailing within 24 hours

Correct Answer & Explanation

. Elevation of the leg and re-evaluation in 2 hours

Explanation

A delta pressure (diastolic blood pressure minus intracompartmental pressure) of less than 30 mm Hg confirms acute compartment syndrome. Emergent four-compartment fasciotomy is definitively indicated.

Question 7957

Topic: 2. Trauma

A 34-year-old woman sustained a Hawkins type II talar neck fracture 8 weeks ago, which was treated with open reduction and internal fixation. A follow-up AP radiograph of the ankle demonstrates a linear subchondral radiolucency in the dome of the talus. What does this radiographic finding indicate?

. Nonunion of the fracture
. Osteonecrosis of the talar body
. Revascularization and preserved blood supply to the talar body
. Post-traumatic osteoarthritis of the tibiotalar joint
. Infection of the talar dome

Correct Answer & Explanation

. Nonunion of the fracture

Explanation

The Hawkins sign is a subchondral radiolucency in the talar dome seen 6 to 8 weeks after injury, indicating subchondral bone resorption due to an intact or re-established blood supply, thereby ruling out avascular necrosis.

Question 7958

Topic: 2. Trauma

Which of the following physiologic parameters is an indication for "damage control orthopedics" (e.g., external fixation of major long bone fractures) rather than early total care in a multiply injured patient?

. Base deficit of 1 mmol/L
. Serum lactate of 1.5 mmol/L
. Platelet count of 150,000/mcL
. Pulmonary contusion with PaO2/FiO2 ratio < 200
. Temperature of 36.5 degrees Celsius

Correct Answer & Explanation

. Base deficit of 1 mmol/L

Explanation

Indications for damage control orthopedics include severe pulmonary injury (PaO2/FiO2 < 200), hypothermia (< 35 degrees Celsius), coagulopathy (platelets < 90,000), acidosis, and refractory shock. Early intramedullary nailing in severe chest trauma can exacerbate ARDS.

Question 7959

Topic: 2. Trauma

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

. Iliopsoas
. Short external rotators
. Gluteus medius and minimus
. Adductor longus
. Vastus lateralis

Correct Answer & Explanation

. Iliopsoas

Explanation

In subtrochanteric fractures, the gluteus medius and minimus abduct the proximal fragment, while the iliopsoas flexes it and the short external rotators externally rotate it. The adductors pull the distal fragment medially.

Question 7960

Topic: 2. Trauma

A 30-year-old man sustains a high-energy distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle. What is the optimal surgical fixation strategy for this specific fracture fragment?

. Anteroposterior targeted lag screws
. Posteroanterior targeted lag screws
. Medial to lateral fully threaded screws
. A single lateral locking plate without lag screws
. Tension band wiring

Correct Answer & Explanation

. Anteroposterior targeted lag screws

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle. The biomechanically superior fixation method utilizes anterior-to-posterior (AP) directed lag screws, often supplemented with an anti-glide plate.

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