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2. Trauma MCQs

Practice Set 40 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 781

Topic: 2. Trauma

A 40-year-old healthy male presents 9 months after sustaining a closed midshaft tibial fracture initially treated with a long leg cast. Radiographs demonstrate an "elephant foot" appearance with abundant callus formation but persistent radiolucency at the fracture site. What is the optimal surgical management for this specific type of nonunion?

. Reamed intramedullary nailing to provide mechanical stability
. Autologous iliac crest bone grafting only
. Application of a circular ring fixator for bone transport
. Administration of systemic teriparatide (Forteo)
. Pulsed electromagnetic field therapy

Correct Answer & Explanation

. Reamed intramedullary nailing to provide mechanical stability

Explanation

The patient has a hypertrophic nonunion ("elephant foot"), which is characterized by adequate biological healing potential (abundant callus) but insufficient mechanical stability. The treatment of choice is rigid stabilization, typically achieved with reamed intramedullary nailing.

Question 782

Topic: 2. Trauma

A 25-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He has bilateral femur fractures and a closed head injury. His vitals are HR 125, BP 85/50 mmHg, RR 24. Initial labs reveal a lactate of 4.8 mmol/L, a base deficit of -9, and an IL-6 level of 700 pg/mL. Which of the following is the most appropriate initial orthopedic management of his femoral fractures?

. Bilateral antegrade reamed intramedullary nailing
. Bilateral retrograde unreamed intramedullary nailing
. Bilateral external fixation
. Open reduction and internal fixation with locked plating
. Skeletal traction with delayed definitive fixation at 2 weeks

Correct Answer & Explanation

. Bilateral external fixation

Explanation

This patient is hemodynamically unstable with a high lactate and severe base deficit, indicating physiological exhaustion. Under the principles of Damage Control Orthopedics (DCO), rapid temporary stabilization with bilateral external fixation is indicated to minimize the 'second hit' phenomenon from definitive surgery.

Question 783

Topic: 2. Trauma

A 32-year-old male presents with a severe crush injury to his right lower leg. Due to a prolonged extrication, he arrives at the emergency department 36 hours after the injury. The leg is tensely swollen, woody, and he has absent motor function and no sensation below the knee. Pulses are palpable via Doppler. Which of the following is the most appropriate management regarding the fascial compartments?

. Emergent four-compartment fasciotomy
. Observation and supportive care, with consideration for delayed amputation
. Intracompartmental pressure monitoring
. Hyperbaric oxygen therapy followed by fasciotomy
. Prophylactic antibiotics and immediate intramedullary nailing

Correct Answer & Explanation

. Observation and supportive care, with consideration for delayed amputation

Explanation

This is a late presentation of compartment syndrome (>24-36 hours) with established irreversible nerve and muscle necrosis. Performing a fasciotomy in this setting is contraindicated as it exposes dead tissue to infection without functional benefit, often necessitating delayed amputation.

Question 784

Topic: 2. Trauma

A 45-year-old male sustains a closed proximal third tibial shaft fracture. You plan to perform an intramedullary nailing. Due to the wide medullary canal in this region, there is a high risk of apex anterior (procurvatum) and valgus malalignment. To mechanically prevent this specific deformity, where should Poller (blocking) screws be placed relative to the intramedullary nail in the proximal fragment?

. Anterior and medial to the nail
. Posterior and lateral to the nail
. Anterior and lateral to the nail
. Posterior and medial to the nail
. Directly distal to the fracture site only

Correct Answer & Explanation

. Posterior and lateral to the nail

Explanation

Blocking screws should be placed on the concave side of the expected deformity to narrow the intramedullary canal and direct the nail. To prevent procurvatum (apex anterior) and valgus (apex medial) deformities, the screws are placed posterior and lateral to the nail in the proximal fragment.

Question 785

Topic: 2. Trauma

A patient with a complex lower extremity trauma is being evaluated for potential amputation versus limb salvage. According to the findings of the Lower Extremity Assessment Project (LEAP) study, which of the following statements regarding the long-term outcomes at 2 years is most accurate?

. Amputation yields significantly lower Sickness Impact Profile (SIP) scores than limb salvage.
. Limb salvage yields significantly lower Sickness Impact Profile (SIP) scores than amputation.
. There is no significant difference in functional outcomes (SIP scores) between amputation and limb salvage.
. The presence of plantar sensation is the most reliable predictor of successful limb salvage.
. The Mangled Extremity Severity Score (MESS) highly correlates with functional outcomes in salvaged limbs.

Correct Answer & Explanation

. There is no significant difference in functional outcomes (SIP scores) between amputation and limb salvage.

Explanation

The LEAP study demonstrated that there is no significant difference in functional outcomes (as measured by the Sickness Impact Profile) between patients undergoing amputation and those undergoing limb salvage at 2 years post-injury. Additionally, the lack of initial plantar sensation was found not to be an absolute indication for amputation.

Question 786

Topic: 2. Trauma
A 22-year-old male sustains an open Gustilo-Anderson Type IIIA tibial shaft fracture. According to current literature and guidelines, which of the following is the single most critical factor in reducing the risk of deep infection in this patient?
. Performing definitive soft tissue coverage within 24 hours
. Time to administration of systemic antibiotics
. Use of high-pressure pulsatile lavage during debridement
. Addition of local antibiotic beads at the time of initial debridement
. Delaying intramedullary nailing until the wound is clean

Correct Answer & Explanation

. Time to administration of systemic antibiotics

Explanation

The most critical factor in preventing infection in open fractures is the early administration of systemic antibiotics, ideally within 1 hour of injury. High-pressure pulsatile lavage is no longer routinely recommended due to the risk of driving debris deeper into tissues.

Question 787

Topic: Pelvic & Acetabular Trauma

A 28-year-old female presents to the trauma center after a motorcycle crash. She is hypotensive (BP 75/40 mmHg) and has an obvious pelvic deformity. Radiographs demonstrate a widened symphysis pubis and disrupted anterior sacroiliac ligaments with intact posterior ligaments (APC II). A pelvic binder is immediately applied. Which of the following is the correct anatomical landmark for optimal placement of the pelvic binder?

. Over the anterior superior iliac spines (ASIS)
. Over the iliac crests
. Centered over the greater trochanters
. At the level of the umbilicus
. Directly over the lower lumbar spine

Correct Answer & Explanation

. Centered over the greater trochanters

Explanation

For optimal mechanical advantage and maximal reduction of pelvic volume, a pelvic binder or sheet must be centered directly over the greater trochanters. Placement over the iliac crests or ASIS can exacerbate the deformity or cause inadequate reduction.

Question 788

Topic: 2. Trauma

During a massive transfusion protocol for an unstable polytrauma patient with a severe pelvic ring injury and bilateral femur fractures, the trauma team aims for a 1:1:1 ratio of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelets. What is the primary pathophysiologic rationale for utilizing this specific transfusion ratio?

. It provides superior oxygen-carrying capacity compared to whole blood.
. It prevents the dilutional coagulopathy and treats trauma-induced coagulopathy.
. It reduces the risk of transfusion-related acute lung injury (TRALI).
. It minimizes the risk of hyperkalemia and hypocalcemia.
. It ensures adequate volume resuscitation without utilizing crystalloids.

Correct Answer & Explanation

. It prevents the dilutional coagulopathy and treats trauma-induced coagulopathy.

Explanation

Massive transfusion protocols using a 1:1:1 ratio of pRBCs, FFP, and platelets aim to mimic whole blood to prevent dilutional coagulopathy and directly address trauma-induced coagulopathy, a critical arm of the lethal triad in trauma.

Question 789

Topic: 2. Trauma

A 19-year-old male football player undergoes operative fixation of a severe tibial plateau fracture. Postoperatively, he reports severe, escalating pain in the leg despite adequate narcotic analgesia. Pain is exacerbated by passive dorsiflexion of the toes. You suspect compartment syndrome. Which of the following compartments of the leg is statistically the most frequently missed during physical examination and surgical release?

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

Correct Answer & Explanation

. Deep posterior compartment

Explanation

The deep posterior compartment is the most commonly missed compartment in both clinical evaluation and during surgical release (fasciotomy) of the lower leg. It contains the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles.

Question 790

Topic: 2. Trauma

A 34-year-old construction worker sustains a severe crush injury to his left forearm. He complains of excruciating pain. On examination, there is marked pain with passive extension of the fingers and thumb. If compartment syndrome is present, which muscular compartment in the forearm is typically the most severely affected due to its deep anatomical position?

. Mobile wad of Henry
. Superficial volar compartment
. Deep volar compartment
. Dorsal compartment
. Pronator compartment

Correct Answer & Explanation

. Deep volar compartment

Explanation

The deep volar compartment of the forearm, containing the flexor digitorum profundus and flexor pollicis longus, is the most frequently and severely affected compartment in forearm compartment syndrome.

Question 791

Topic: 2. Trauma
A 40-year-old male sustains an open, middle-third tibial shaft fracture with a 6 cm soft tissue defect over the anterior tibia exposing bone without periosteum (Gustilo IIIB). He has undergone appropriate serial debridements and the wound is now ready for soft tissue coverage. Which of the following is the most appropriate reliable flap for coverage of a defect specifically in the middle third of the tibia?
. Medial gastrocnemius rotational flap
. Lateral gastrocnemius rotational flap
. Soleus rotational flap
. Sural artery fasciocutaneous flap
. Anterolateral thigh (ALT) free flap

Correct Answer & Explanation

. Soleus rotational flap

Explanation

Local muscle flap coverage for the tibia is dictated by the level of the defect. Proximal third defects are typically covered by the gastrocnemius flap, middle third defects by the soleus flap, and distal third defects usually require a free tissue transfer.

Question 792

Topic: 2. Trauma

A 55-year-old male undergoes intramedullary nailing for a closed transverse tibial shaft fracture. Six months postoperatively, he complains of persistent pain at the fracture site. Radiographs demonstrate abundant callus formation around the fracture site but a persistent radiolucent line across the fracture gap. What is the most appropriate next step in management?

. Non-invasive bone stimulation
. Platelet-rich plasma (PRP) injection
. Exchange intramedullary nailing with a larger reamed nail
. Removal of hardware and application of a circular external fixator
. Autologous iliac crest bone grafting without hardware exchange

Correct Answer & Explanation

. Exchange intramedullary nailing with a larger reamed nail

Explanation

This patient has a hypertrophic nonunion, characterized by abundant callus but failure to bridge due to inadequate mechanical stability. The treatment of choice for a hypertrophic nonunion of a long bone is to increase stability, which is best achieved via exchange intramedullary nailing.

Question 793

Topic: 2. Trauma

A 21-year-old male sustains a low-velocity gunshot wound to his right thigh. Radiographs demonstrate a comminuted midshaft femur fracture with retained bullet fragments near the fracture site. There is no expanding hematoma, and distal pulses are intact. Which of the following statements regarding the acute management of this injury is most accurate?

. Formal operative debridement of the bullet track is required prior to fixation.
. The retained bullet fragments must be removed to prevent lead toxicity.
. Intramedullary nailing can be safely performed without formal bullet track debridement.
. External fixation is indicated until the wound is definitively closed.
. Intravenous antibiotics are not required if the wound is superficial.

Correct Answer & Explanation

. Intramedullary nailing can be safely performed without formal bullet track debridement.

Explanation

Low-velocity gunshot wounds resulting in femur fractures without intra-articular extension, gross contamination, or vascular injury do not require formal formal debridement of the bullet track. They can be safely treated with local wound care, a short course of IV antibiotics, and early intramedullary nailing.

Question 794

Topic: 2. Trauma

A 26-year-old male is admitted with a closed diaphyseal femur fracture following a high-energy fall.

Approximately 36 hours after admission, he becomes confused, tachypneic (RR 30), and develops a petechial rash over his axilla and conjunctiva. Arterial blood gas shows a PaO2 of 55 mmHg. What is the primary pathophysiologic mechanism underlying the pulmonary manifestations of this syndrome?

. Direct mechanical obstruction of pulmonary capillaries by large thrombi
. Release of free fatty acids causing toxic endothelial damage in the pulmonary vasculature
. Histamine-mediated bronchospasm and localized anaphylaxis
. Left ventricular failure secondary to severe systemic hypertension
. Pulmonary contusion leading to alveolar hemorrhage

Correct Answer & Explanation

. Release of free fatty acids causing toxic endothelial damage in the pulmonary vasculature

Explanation

This patient presents with Bergman's triad for Fat Embolism Syndrome (FES). The pulmonary manifestations are driven by a biochemical phase where circulating neutral fat droplets are hydrolyzed by lipases into free fatty acids, which cause direct toxic endothelial damage and acute respiratory distress syndrome (ARDS).

Question 795

Topic: 2. Trauma

A patient with multiple rib fractures, pulmonary contusions, and an open femur fracture is intubated in the ICU. To appropriately diagnose compartment syndrome of the leg in an unconscious or obtunded patient, intracompartmental pressure monitoring is utilized. Which of the following pressure criteria is the most reliable absolute indication for performing a fasciotomy?

. An absolute compartment pressure > 20 mmHg
. An absolute compartment pressure > 30 mmHg
. A differential pressure (Delta P) between mean arterial pressure (MAP) and compartment pressure < 45 mmHg
. A differential pressure (Delta P) between diastolic blood pressure and compartment pressure < 30 mmHg
. A differential pressure (Delta P) between systolic blood pressure and compartment pressure < 20 mmHg

Correct Answer & Explanation

. A differential pressure (Delta P) between diastolic blood pressure and compartment pressure < 30 mmHg

Explanation

The delta P (diastolic blood pressure minus intracompartmental pressure) is the most reliable parameter for diagnosing compartment syndrome. A delta P of less than 30 mmHg indicates inadequate tissue perfusion and is an absolute indication for fasciotomy.

Question 796

Topic: 2. Trauma

A 45-year-old male presents with a severe closed crush injury to his foot after a forklift ran over it. He has intractable pain and clawing of his toes. You suspect compartment syndrome of the foot. How many distinct fascial compartments exist in the human foot?

. 3
. 4
. 5
. 7
. 9

Correct Answer & Explanation

. 9

Explanation

There are 9 recognized fascial compartments in the foot: medial, lateral, superficial, calcaneal, four interosseous, and the adductor compartment. Ischemia of the calcaneal compartment specifically leads to contracture of the quadratus plantae, causing clawing of the toes.

Question 797

Topic: 2. Trauma

A 50-year-old male undergoes intramedullary nailing for a tibial shaft fracture. The procedure is performed using an infrapatellar approach. At a 1-year follow-up, the fracture is completely healed. What is statistically the most common complication reported by patients following antegrade intramedullary nailing of the tibia?

. Deep infection
. Nonunion
. Anterior knee pain
. Malunion (valgus deformity)
. Hardware failure (nail breakage)

Correct Answer & Explanation

. Anterior knee pain

Explanation

Anterior knee pain is the most frequently reported complication following antegrade intramedullary nailing of the tibia, occurring in a significant percentage of patients regardless of whether a paratendon or tendon-splitting approach is used.

Question 798

Topic: 2. Trauma
A 35-year-old male suffers an open fracture of his right tibia. The wound is 12 cm long, highly contaminated with farm soil, and there is extensive periosteal stripping. Which of the following prophylactic antibiotic regimens is the most appropriate according to the most recent evidence-based orthopaedic trauma guidelines?
. First-generation cephalosporin only
. First-generation cephalosporin plus an aminoglycoside
. Ceftriaxone monotherapy
. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin
. Fluoroquinolone monotherapy

Correct Answer & Explanation

. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin

Explanation

For severe, highly contaminated open fractures (Gustilo Type III, including farm injuries), modern guidelines increasingly support the use of Ceftriaxone (or a broad-spectrum equivalent) with or without Penicillin (if Clostridium is suspected) or a combination of Cefazolin plus a Gram-negative agent. However, high-dose Penicillin is historically added for farm injuries specifically to cover anaerobes, making the classic triple therapy (Cefazolin, Aminoglycoside, Penicillin) a traditional answer, but modern single-agent broad-spectrum regimens or tailored additions are replacing aminoglycosides due to renal toxicity.

Question 799

Topic: 2. Trauma

A 24-year-old male sustains a closed tibial shaft fracture. Upon examination, he complains of severe, escalating leg pain out of proportion to his injury. His blood pressure is 110/70 mmHg. Intracompartmental pressure testing reveals a deep posterior compartment pressure of 45 mmHg. What is the calculated Delta P, and what is the appropriate management?

. Delta P = 25 mmHg; emergent fasciotomy is indicated.
. Delta P = 35 mmHg; emergent fasciotomy is indicated.
. Delta P = 45 mmHg; emergent fasciotomy is indicated.
. Delta P = 25 mmHg; continuous monitoring is indicated without immediate surgery.
. Delta P = 65 mmHg; continuous monitoring is indicated without immediate surgery.

Correct Answer & Explanation

. Delta P = 25 mmHg; emergent fasciotomy is indicated.

Explanation

Delta P is defined as the diastolic blood pressure minus the intracompartmental pressure (70 - 45 = 25 mmHg). A Delta P of 30 mmHg or less is an absolute indication for emergent fasciotomy to prevent irreversible ischemic muscle damage.

Question 800

Topic: 2. Trauma

During a standard two-incision, four-compartment fasciotomy of the lower leg, the deep posterior compartment is released through the medial incision. To safely and completely access this deep compartment, the surgeon must specifically detach which of the following muscles from its bony origin?

. Gastrocnemius from the posterior femoral condyles
. Soleus from the posteromedial crest of the tibia
. Flexor hallucis longus from the posterior fibula
. Tibialis anterior from the interosseous membrane
. Peroneus brevis from the lateral fibular shaft

Correct Answer & Explanation

. Soleus from the posteromedial crest of the tibia

Explanation

To adequately release the deep posterior compartment via a medial incision, the soleus bridge must be taken down from its origin on the posteromedial crest of the tibia. Failure to release this fascial attachment is a common cause of inadequate deep posterior compartment decompression.

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