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2. Trauma MCQs

Practice Set 401 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 8001

Topic: 2. Trauma

A 35-year-old male sustains a severely comminuted open tibial shaft fracture with a 12 cm soft tissue laceration and stripped periosteum. A segmental bone defect is noted, but pedal pulses are palpable and symmetrical. According to the Gustilo-Anderson classification, what is the appropriate classification and definitive soft tissue coverage strategy?

. Type II; primary closure
. Type IIIA; split-thickness skin graft
. Type IIIB; local or free flap coverage
. Type IIIC; amputation
. Type IIIB; healing by secondary intention

Correct Answer & Explanation

. Type II; primary closure

Explanation

This is a Gustilo-Anderson Type IIIB fracture due to extensive soft tissue injury, periosteal stripping, and adequate vascularity. Standard management requires skeletal stabilization and local (e.g., gastrocnemius) or free flap coverage.

Question 8002

Topic: 2. Trauma

A 28-year-old man presents with a closed midshaft tibia fracture. He complains of pain out of proportion to his injury that is exacerbated by passive stretch of his great toe. Compartment pressure monitoring reveals a diastolic blood pressure of 70 mmHg and a tissue pressure of 45 mmHg in the anterior compartment. What is the most appropriate next step?

. Elevate the leg and apply ice
. Administer intravenous analgesics and reassess in 2 hours
. Immediate 4-compartment fasciotomy
. Immediate 2-compartment fasciotomy
. Bivalve the splint and recheck pressures in 1 hour

Correct Answer & Explanation

. Elevate the leg and apply ice

Explanation

A delta pressure (diastolic BP minus compartment pressure) of less than 30 mmHg is highly indicative of acute compartment syndrome. The definitive and emergent treatment for tibial compartment syndrome is a four-compartment fasciotomy.

Question 8003

Topic: Pelvic & Acetabular Trauma

A 45-year-old hypotensive male presents after a motorcycle crash. Pelvic radiographs demonstrate a symphyseal diastasis of 4 cm and widening of both sacroiliac joints. A pelvic binder was applied in the field. He remains hemodynamically unstable despite 2 units of uncrossmatched blood. FAST exam is negative. What is the most appropriate next intervention?

. Retrograde urethrogram
. Pre-peritoneal pelvic packing and/or angioembolization
. Definitive open reduction internal fixation of the pelvis
. Exploratory laparotomy
. Administration of tranexamic acid and observation

Correct Answer & Explanation

. Retrograde urethrogram

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST, the source of bleeding is primarily the presacral venous plexus or internal iliac arterial branches. Pre-peritoneal pelvic packing and/or angiography with embolization are the required emergent interventions.

Question 8004

Topic: 2. Trauma

A 30-year-old female sustains a vertically oriented (Pauwels Type III) displaced femoral neck fracture. She is taken to the OR for closed reduction and percutaneous pinning. Which of the following biomechanical constructs provides the most stable fixation for this specific fracture pattern?

. Three parallel cannulated screws placed in an inverted triangle
. A sliding hip screw with a derotational screw
. Two crossed cannulated screws
. A cephalomedullary nail
. Hemiarthroplasty

Correct Answer & Explanation

. Three parallel cannulated screws placed in an inverted triangle

Explanation

Pauwels Type III fractures have a high shear angle, leading to increased failure rates with standard parallel cannulated screws. A sliding hip screw (fixed-angle device) with a derotational screw provides superior biomechanical stability against vertical shear forces.

Question 8005

Topic: 2. Trauma

A 25-year-old snowboarder sustains a displaced talar neck fracture treated with open reduction and internal fixation. At 8 weeks postoperatively, AP ankle radiographs demonstrate a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

. Nonunion of the talar neck
. Avascular necrosis of the talar body
. Revascularization and intact blood supply to the talus
. Early post-traumatic osteoarthritis
. Septic arthritis of the ankle joint

Correct Answer & Explanation

. Nonunion of the talar neck

Explanation

The subchondral radiolucent band is known as Hawkins sign. It represents subchondral osteopenia, which requires an intact vascular supply to occur, effectively indicating viability and ruling out avascular necrosis.

Question 8006

Topic: 2. Trauma

An 85-year-old community-ambulating female with severe pre-existing knee osteoarthritis sustains a comminuted distal femur fracture (AO/OTA 33-C2). She has severely osteopenic bone. What is the most reliable surgical option to allow immediate weight-bearing?

. Retrograde intramedullary nailing
. Bridge plating with a lateral locking plate
. Distal femoral replacement (megaprosthesis)
. External fixation
. Non-operative management in a hinged knee brace

Correct Answer & Explanation

. Retrograde intramedullary nailing

Explanation

In elderly patients with osteoporotic bone, comminuted distal femur fractures, and severe osteoarthritis, distal femoral replacement offers immediate stability. It allows early weight-bearing and addresses the arthritic joint, avoiding the high failure rates of internal fixation.

Question 8007

Topic: 2. Trauma

A 22-year-old cyclist sustains a completely displaced midshaft clavicle fracture with 2.5 cm of shortening and no cortical contact. What is the most significant advantage of operative fixation compared to non-operative management for this specific injury?

. Decreased risk of major neurovascular injury
. Lower rate of symptomatic nonunion
. Decreased risk of infection
. Improved final shoulder range of motion
. Elimination of the need for post-operative immobilization

Correct Answer & Explanation

. Decreased risk of major neurovascular injury

Explanation

Displaced midshaft clavicle fractures with greater than 2 cm of shortening or no cortical contact have a significantly higher nonunion rate when treated non-operatively. Operative fixation reduces the rate of symptomatic nonunion and improves early functional outcomes.

Question 8008

Topic: 2. Trauma

A 38-year-old man sustains a pelvic injury. CT imaging demonstrates a fracture line involving both columns of the acetabulum, with a 'spur sign' seen on the obturator oblique radiograph. No part of the articular surface remains attached to the intact ilium. What is the diagnosis?

. Transverse fracture
. T-type fracture
. Anterior column posterior hemitransverse fracture
. Both-column fracture
. Posterior column fracture

Correct Answer & Explanation

. Transverse fracture

Explanation

A both-column acetabular fracture detaches all articular segments from the intact axial skeleton. The 'spur sign' represents the intact strut of the ilium protruding above the medially displaced articular segments, pathognomonic for a both-column fracture.

Question 8009

Topic: 2. Trauma

A 24-year-old male presents with a closed middle-third spiral humeral shaft fracture. He develops an inability to extend his wrist or fingers immediately following a closed reduction attempt in the ED. What is the most appropriate management?

. Immediate surgical exploration and nerve repair/release
. Observation with serial clinical exams and EMG at 6 weeks
. Immediate MRI of the humerus
. Application of a functional fracture brace and early motion
. Nerve grafting within 72 hours

Correct Answer & Explanation

. Immediate surgical exploration and nerve repair/release

Explanation

A secondary radial nerve palsy that develops after a closed reduction attempt of a humeral shaft fracture is an absolute indication for surgical exploration. The nerve is highly likely to be entrapped in the fracture site.

Question 8010

Topic: 2. Trauma

A 20-year-old male sustains a low-velocity gunshot wound to the mid-thigh, resulting in a comminuted midshaft femur fracture. He is neurovascularly intact with no exit wound. What is the most appropriate initial management?

. Extensive surgical debridement of the entire bullet track
. Local wound care, systemic antibiotics, and antegrade intramedullary nailing
. Immediate exploration to retrieve the retained bullet fragment
. External fixation to avoid passing a nail through a contaminated track
. Primary closure of the entry wound with non-absorbable suture

Correct Answer & Explanation

. Extensive surgical debridement of the entire bullet track

Explanation

Low-velocity gunshot wounds causing femur fractures without neurovascular compromise do not require formal tract debridement or bullet retrieval. Local wound care, IV antibiotics, and standard intramedullary nailing demonstrate excellent outcomes.

Question 8011

Topic: 2. Trauma

A 24-year-old male presents with persistent wrist pain 8 months after a fall. Imaging reveals a scaphoid waist fracture nonunion with a 'humpback' deformity and proximal pole avascular necrosis. Which surgical intervention is most appropriate?

. Percutaneous retrograde screw fixation
. Non-vascularized iliac crest bone graft and screw fixation
. Vascularized bone graft and internal fixation
. Proximal row carpectomy
. Four-corner arthrodesis

Correct Answer & Explanation

. Percutaneous retrograde screw fixation

Explanation

A scaphoid nonunion with humpback deformity and proximal pole AVN requires restoration of length and robust blood supply. A vascularized bone graft (e.g., 1,2 ICSRA) combined with rigid fixation provides the best chance of union.

Question 8012

Topic: 2. Trauma

A 32-year-old male presents with a comminuted tibial shaft fracture following a crush injury. He complains of severe pain out of proportion to the injury. Clinical examination is highly concerning for acute compartment syndrome. Which of the following pressure measurements is the most reliable threshold for indicating a fasciotomy?

. Absolute compartment pressure > 30 mm Hg
. Absolute compartment pressure > 45 mm Hg
. Diastolic blood pressure minus compartment pressure < 30 mm Hg
. Mean arterial pressure minus compartment pressure < 30 mm Hg
. Systolic blood pressure minus compartment pressure < 30 mm Hg

Correct Answer & Explanation

. Absolute compartment pressure > 30 mm Hg

Explanation

The delta P (diastolic blood pressure minus compartment pressure) is the most reliable indicator for acute compartment syndrome. A threshold of < 30 mm Hg strongly indicates the need for emergent fasciotomy, as absolute pressures can be misleading in hypotensive patients.

Question 8013

Topic: 2. Trauma

A 25-year-old man sustains a low-velocity gunshot wound to the thigh resulting in a comminuted femoral shaft fracture. The bullet passed cleanly through without expanding. Distal pulses are normal, and there is no expanding hematoma. What is the most appropriate initial management?

. Formal operative debridement of the bullet tract followed by IM nailing
. External fixation as a damage control measure
. Local wound care, tetanus prophylaxis, antibiotics, and intramedullary nailing
. Routine arteriography prior to any surgical intervention
. Plate osteosynthesis with a vascularized fibular strut graft

Correct Answer & Explanation

. Formal operative debridement of the bullet tract followed by IM nailing

Explanation

Low-velocity gunshot wounds causing femur fractures without vascular injury or massive contamination do not require formal operative debridement of the bullet tract. They are appropriately treated with local wound care, short-course antibiotics, and standard intramedullary nailing.

Question 8014

Topic: Pelvic & Acetabular Trauma

A 45-year-old male is brought to the trauma bay after a motorcycle crash. He is hypotensive and tachycardic. A pelvic radiograph reveals an APC-III (open-book) pelvic ring injury. What is the correct anatomical landmark for the application of a circumferential pelvic sheet or binder?

. Iliac crests
. Anterior superior iliac spines (ASIS)
. Greater trochanters
. Symphysis pubis
. Ischial tuberosities

Correct Answer & Explanation

. Iliac crests

Explanation

Circumferential pelvic binders should be centered directly over the greater trochanters to effectively reduce pelvic volume in open-book pelvic ring injuries. Placement higher over the iliac crests is biomechanically less effective and restricts abdominal access.

Question 8015

Topic: 2. Trauma

A 30-year-old male falls from a height and sustains a Hawkins type III fracture of the talar neck. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body in this injury pattern?

. Less than 10%
. 15% to 25%
. 30% to 50%
. 70% to 100%
. AVN only occurs in Hawkins type IV fractures

Correct Answer & Explanation

. Less than 10%

Explanation

Hawkins type III fractures involve dislocation of the talar body from both the subtalar and tibiotalar joints, disrupting all three main blood supplies. This results in an AVN rate approaching 70% to 100%.

Question 8016

Topic: 2. Trauma

Which of the following is considered the most important blood supply to the articular segment of the humeral head, making it a critical structure to preserve during proximal humerus fracture fixation?

. Anterior humeral circumflex artery (AHCA)
. Posterior humeral circumflex artery (PHCA)
. Thoracoacromial artery
. Profunda brachii artery
. Suprascapular artery

Correct Answer & Explanation

. Anterior humeral circumflex artery (AHCA)

Explanation

Modern anatomical studies demonstrate that the posterior humeral circumflex artery (PHCA) provides the predominant blood supply (up to 64%) to the humeral head. This contradicts older literature that heavily emphasized the arcuate branch of the AHCA.

Question 8017

Topic: 2. Trauma

A 40-year-old man sustains a Grade IIIB open tibia fracture following an industrial crush injury. According to current evidence-based guidelines, what is the most critical factor in reducing his risk of deep infection?

. Time to operative debridement within exactly 6 hours
. The use of high-pressure pulsatile lavage
. Time to administration of systemic intravenous antibiotics
. Primary closure of the wound at the initial debridement
. The use of a circular external fixator instead of IM nailing

Correct Answer & Explanation

. Time to operative debridement within exactly 6 hours

Explanation

Early administration of intravenous antibiotics (ideally within 1 hour of injury) is the single most critical factor in reducing infection rates in open fractures. The traditional '6-hour rule' for surgical debridement has not been consistently supported by modern literature.

Question 8018

Topic: 2. Trauma

A 24-year-old polytrauma patient with a severe head injury (GCS 7) and bilateral femoral shaft fractures presents to the trauma bay. His initial lactate is 5.5 mmol/L and base excess is -8. What is the most appropriate initial management of his bilateral femur fractures?

. Immediate bilateral antegrade reamed intramedullary nailing
. Immediate bilateral external fixation
. Skeletal traction pins and delayed fixation at 3 weeks
. Bilateral retrograde unreamed intramedullary nailing
. Open reduction and plate fixation

Correct Answer & Explanation

. Immediate bilateral antegrade reamed intramedullary nailing

Explanation

In a hemodynamically unstable or 'borderline' polytrauma patient with elevated lactate and severe traumatic brain injury, Damage Control Orthopedics (DCO) with rapid external fixation is indicated. This minimizes the 'second hit' inflammatory response from a lengthy IM nailing procedure.

Question 8019

Topic: 2. Trauma

A 40-year-old male sustains a posteromedial shear fracture of the tibial plateau. Which of the following surgical approaches is most appropriate for direct visualization and buttress plating of this specific fracture fragment?

. Anterolateral approach
. Posteromedial approach between the medial gastrocnemius and pes anserinus
. Direct posterior approach through the popliteal fossa
. Lateral approach with tibial tubercle osteotomy
. Medial parapatellar approach

Correct Answer & Explanation

. Anterolateral approach

Explanation

The posteromedial approach utilizes the interval between the medial head of the gastrocnemius and the pes anserinus tendons. It allows direct access for anti-glide or buttress plating of posteromedial shear fragments in complex tibial plateau fractures.

Question 8020

Topic: 2. Trauma

A 35-year-old male is brought to the trauma bay after a high-speed motorcycle collision. He is hemodynamically unstable with a suspected anteroposterior compression (APC) pelvic ring injury. A pelvic binder is ordered. To be most biomechanically effective at reducing pelvic volume, at what anatomical level should the binder be centered?

. Greater trochanters
. Iliac crests
. Anterior superior iliac spines (ASIS)
. Symphysis pubis
. Subtrochanteric femur

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders should be centered over the greater trochanters to effectively close an open-book pelvic injury. Placement over the iliac crests or ASIS is less effective and may paradoxically widen the pelvis in some fracture patterns.

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