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2. Trauma MCQs

Practice Set 418 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 8341

Topic: 2. Trauma

A 38-year-old male requires open reduction and internal fixation of a posterior wall acetabular fracture via a Kocher-Langenbeck approach. During the deep exposure, what is the proper anatomical management of the short external rotators to protect the medial femoral circumflex artery (MFCA)?

. Release the piriformis tendon only and retract the remaining rotators inferiorly
. Release the short external rotators at their tendinous insertion, sparing the quadratus femoris
. Release the obturator externus only
. Transect the quadratus femoris muscle belly at its midpoint
. Release the short external rotators at their pelvic origin

Correct Answer & Explanation

. Release the short external rotators at their tendinous insertion, sparing the quadratus femoris

Explanation

During the Kocher-Langenbeck approach, releasing the short external rotators (piriformis, obturator internus, and gemelli) close to their greater trochanter insertion while preserving the quadratus femoris muscle protects the main ascending branch of the medial femoral circumflex artery (MFCA), which provides the critical blood supply to the femoral head.

Question 8342

Topic: 2. Trauma

A 29-year-old male sustained a Hawkins type II talar neck fracture and underwent open reduction and internal fixation. At 8 weeks postoperatively, an AP radiograph of the ankle

demonstrates a subchondral radiolucent band in the talar dome. This radiographic finding most accurately indicates:

. Early onset of avascular necrosis (AVN) of the talar body
. Impending nonunion of the talar neck fracture
. Intact vascular supply to the talar body
. Septic arthritis of the tibiotalar joint
. Failure of internal fixation hardware

Correct Answer & Explanation

. Intact vascular supply to the talar body

Explanation

A subchondral radiolucent band in the talar dome visible on AP mortise radiographs at 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to disuse and hyperemia. The presence of this hyperemia indicates that the vascular supply to the talar body is intact, thus avascular necrosis (AVN) is highly unlikely.

Question 8343

Topic: 2. Trauma

A 35-year-old male involved in a high-speed collision presents with bilateral closed femoral shaft fractures, a grade IV liver laceration, and a severe closed head injury (GCS 7). His initial laboratory values show a lactate of 6.5 mmol/L, pH of 7.15, and his core temperature is 34.5°C. According to Damage Control Orthopedics (DCO) principles, what is the most appropriate initial orthopedic management for his femur fractures?

. Immediate bilateral reamed intramedullary nailing
. Bilateral external fixation
. Unreamed intramedullary nailing of the right femur and external fixation of the left
. Skeletal traction and delayed internal fixation at 2 weeks
. Open reduction and internal fixation with locking plates

Correct Answer & Explanation

. Bilateral external fixation

Explanation

This polytrauma patient is physiologically unstable ('in extremis') with a severe head injury, hypothermia, acidosis, and elevated lactate, fulfilling the lethal triad. Damage Control Orthopedics (DCO) dictates that prolonged, physiologically demanding surgeries (like reamed IM nailing) should be avoided to prevent a 'second hit' of systemic inflammation. Rapid stabilization with bilateral external fixators is indicated.

Question 8344

Topic: 2. Trauma

A 24-year-old female sustains a closed spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture).

On initial evaluation in the emergency department, she is unable to extend her wrist or digits, and has decreased sensation in the first dorsal web space. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve and ORIF of the humerus
. Closed reduction, functional bracing, and clinical observation of nerve function
. EMG and nerve conduction studies prior to deciding on definitive treatment
. Open reduction and internal fixation with prophylactic nerve grafting
. External fixation to distract the fracture site and relieve nerve compression

Correct Answer & Explanation

. Closed reduction, functional bracing, and clinical observation of nerve function

Explanation

A primary radial nerve palsy associated with a closed humeral shaft fracture (including the Holstein-Lewis type) is typically a neuropraxia. The standard of care is expectant management with closed reduction and functional fracture bracing (Sarmiento brace). Surgical exploration is generally indicated only if the palsy occurs after closed reduction, in open fractures, or if there is no clinical or electromyographic sign of recovery after 3 to 6 months.

Question 8345

Topic: Pelvic & Acetabular Trauma
A 35-year-old male is brought to the ED after a motorcycle collision. He is hypotensive (BP 75/40 mmHg) and tachycardic (HR 130). AP pelvis radiograph shows a widened pubic symphysis of 4 cm and widened bilateral sacroiliac joints. A pelvic binder has been applied appropriately but he remains hemodynamically unstable after 2 liters of crystalloid and 2 units of packed red blood cells. What is the most appropriate next step in management?
. Emergent CT abdomen and pelvis
. External fixation of the pelvis in the emergency department
. Preperitoneal pelvic packing and/or angioembolization
. Exploratory laparotomy with internal fixation of the pelvis
. Re-application of the pelvic binder and observation

Correct Answer & Explanation

. Preperitoneal pelvic packing and/or angioembolization

Explanation

In a hemodynamically unstable patient with an unstable pelvic ring injury (such as an APC-III), if the patient remains unstable despite initial resuscitation and pelvic binder application, emergent hemorrhage control is indicated. This is typically achieved via preperitoneal pelvic packing, pelvic angiography with embolization, or a combination of both. Exploratory laparotomy is generally reserved for intraperitoneal bleeding (e.g., positive FAST). External fixation takes time and does not stop venous bleeding as effectively as packing, nor arterial bleeding as well as embolization.

Question 8346

Topic: 2. Trauma

A 42-year-old skier presents with a complex bicondylar tibial plateau fracture (Schatzker VI). Radiographs and CT scan reveal a large, displaced posteromedial fragment in addition to lateral plateau depression. When planning surgical fixation, which of the following approaches and patient positioning is most appropriate to optimally address the posteromedial fragment?

. Supine position, anterolateral approach alone
. Supine position, medial parapatellar approach
. Prone or lateral position, posteromedial approach
. Supine position, single midline incision
. Supine position, posterolateral approach

Correct Answer & Explanation

. Prone or lateral position, posteromedial approach

Explanation

A displaced posteromedial fragment in a bicondylar tibial plateau fracture cannot be adequately visualized or reduced through a standard anterolateral approach and is biomechanically unstable if not buttressed. A posteromedial approach, often performed with the patient in a prone or lateral position (or 'floppy lateral'), allows direct visualization, reduction, and application of a posterior buttress plate. This counteracts the shear forces and prevents settling of the medial condyle into varus.

Question 8347

Topic: 2. Trauma
A 25-year-old man sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture after a fall from a height. Which of the following fixation constructs provides the most biomechanically stable fixation for this specific fracture pattern?
. Three parallel cancellous lag screws
. Sliding hip screw with a derotation screw
. Dynamic condylar screw
. Cephalomedullary nail
. Bipolar hemiarthroplasty

Correct Answer & Explanation

. Sliding hip screw with a derotation screw

Explanation

Pauwels type III fractures are highly vertical and subjected to significant shear forces rather than compressive forces, leading to higher rates of nonunion and varus collapse. Biomechanical studies have shown that a sliding hip screw (a fixed-angle device) supplemented with a derotation screw provides superior resistance to vertical shear forces and better clinical outcomes for vertical femoral neck fractures in young adults compared to three parallel cancellous screws.

Question 8348

Topic: 2. Trauma

A 38-year-old male sustains a comminuted distal femur fracture. CT scan reveals a coronal plane fracture of the lateral femoral condyle (Hoffa fragment). Which of the following principles is most critical when fixing this specific coronal fragment?

. Excision of the fragment and advancement of the lateral collateral ligament
. Fixation with anterior-to-posterior directed lag screws
. Fixation with posterior-to-anterior directed lag screws
. Spanning external fixation without internal fixation
. Application of a medial buttress plate

Correct Answer & Explanation

. Fixation with anterior-to-posterior directed lag screws

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle, most commonly the lateral condyle. The standard and biomechanically most robust method of fixation involves anterior-to-posterior directed lag screws placed perpendicular to the fracture plane. Due to the intra-articular nature of the injury, the screw heads should be countersunk if placed through the articular cartilage, or placed just proximal to the articular surface.

Question 8349

Topic: 2. Trauma

A 65-year-old woman undergoes open reduction and internal fixation of a 3-part proximal humerus fracture with a locked plating system. Which of the following technical factors is most strongly associated with failure of fixation and subsequent varus collapse?

. Use of an excessively long plate
. Failure to place medial calcar support screws
. Placement of the plate posterior to the bicipital groove
. Non-absorbable suture fixation of the tuberosities
. Postoperative immobilization for 2 weeks

Correct Answer & Explanation

. Failure to place medial calcar support screws

Explanation

In locked plating of proximal humerus fractures, the medial hinge is often disrupted. Failure to restore medial cortical contact or, more importantly, failure to place inferiorly directed 'calcar' screws into the inferomedial quadrant of the humeral head, significantly increases the risk of varus collapse, screw cut-out, and overall fixation failure. Medial calcar screws act as a rigid biomechanical buttress.

Question 8350

Topic: 2. Trauma

A 22-year-old motorcyclist sustains severe high-energy right shoulder trauma. Radiographs reveal lateral displacement of the scapula, a completely displaced clavicle fracture, and acromioclavicular joint separation. His right upper extremity is pulseless, and he has a complete motor and sensory deficit of the right arm. What is the most likely long-term functional outcome for the injured extremity despite optimal initial management?

. Full functional recovery after vascular repair
. Flail, insensate arm due to complete brachial plexus avulsion
. Return of motor function with residual sensory deficits
. Good functional outcome following nerve grafting
. Spontaneous recovery of neurological deficits within 6 months

Correct Answer & Explanation

. Flail, insensate arm due to complete brachial plexus avulsion

Explanation

Scapulothoracic dissociation is a massive injury characterized by disruption of the scapulothoracic articulation, lateral displacement of the scapula, and severe associated neurovascular injuries. The neurological injury is nearly always a complete preganglionic brachial plexus avulsion. Even with successful vascular repair to save the limb from ischemia, complete preganglionic avulsions portend a dismal prognosis for function, often resulting in a flail, insensate limb that frequently requires late amputation.

Question 8351

Topic: 2. Trauma
A 28-year-old male sustains a Hawkins Type III fracture of the talar neck. What is the approximate risk of developing avascular necrosis (AVN) of the talar body, and what is the characteristic finding of the Hawkins sign?
. 10-20%; subchondral sclerosis on AP radiograph at 6-8 weeks indicating AVN
. 20-40%; subchondral radiolucency on AP radiograph at 6-8 weeks indicating intact vascularity
. 70-100%; subchondral radiolucency on AP radiograph at 6-8 weeks indicating intact vascularity
. 70-100%; subchondral sclerosis on AP radiograph at 6-8 weeks indicating intact vascularity
. 0-10%; fragmentation of the talar dome indicating AVN

Correct Answer & Explanation

. 70-100%; subchondral radiolucency on AP radiograph at 6-8 weeks indicating intact vascularity

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body from both the subtalar and tibiotalar joints, disrupting all three major blood supplies. The risk of AVN is exceptionally high, ranging from 70% to 100%. The Hawkins sign is a subchondral radiolucent band seen in the talar dome on an AP radiograph 6 to 8 weeks post-injury. It represents subchondral osteopenia secondary to disuse atrophy. For osteopenia to occur, there must be active bone resorption, which requires an intact blood supply; thus, a positive Hawkins sign indicates intact vascularity.

Question 8352

Topic: 2. Trauma
A 45-year-old farmer sustains a severe open tibia fracture after his leg was caught in a tractor. The wound is 12 cm long with extensive muscle damage and gross agricultural contamination. The foot is well-perfused with palpable pulses. According to current evidence-based guidelines, what is the most appropriate initial antibiotic regimen?
. First-generation cephalosporin alone
. First-generation cephalosporin and an aminoglycoside
. Broad-spectrum Gram-negative/Gram-positive coverage plus high-dose Penicillin
. Oral ciprofloxacin and clindamycin
. First-generation cephalosporin and vancomycin

Correct Answer & Explanation

. Broad-spectrum Gram-negative/Gram-positive coverage plus high-dose Penicillin

Explanation

This is a Gustilo-Anderson Type IIIA open fracture heavily contaminated with agricultural debris. Patients with farm injuries or gross soil contamination are at exceptionally high risk for Clostridium perfringens (gas gangrene) and other virulent anaerobes. Current guidelines recommend broad-spectrum coverage (often a 3rd-generation cephalosporin, or 1st-generation cephalosporin plus an aminoglycoside) and the essential addition of high-dose Penicillin specifically for targeted anaerobic coverage.

Question 8353

Topic: 2. Trauma

A 30-year-old male undergoes intramedullary nailing of a closed diaphyseal tibia fracture. In the recovery room, he complains of severe leg pain out of proportion to the injury, unrelieved by IV opioids. On examination, he has pain with passive stretch of the hallux and paresthesias in the first web space. Absolute compartment pressures are measured at 35 mmHg, and his diastolic blood pressure is 60 mmHg. What is the most appropriate next step?

. Elevate the leg above the level of the heart and apply ice
. Administer additional opioids and reassess in 2 hours
. Perform a localized fasciotomy of the anterior compartment only
. Perform urgent four-compartment fasciotomy of the leg
. Obtain a stat CT angiogram of the lower extremity

Correct Answer & Explanation

. Perform urgent four-compartment fasciotomy of the leg

Explanation

The clinical presentation is classic for acute compartment syndrome. The diagnosis is confirmed by a Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg. In this patient, Delta P = 60 - 35 = 25 mmHg, which dictates immediate surgical intervention. The definitive treatment is urgent four-compartment fasciotomy of the leg. Elevating the leg above the heart decreases local arterial perfusion pressure and exacerbates ischemia.

Question 8354

Topic: 2. Trauma
A 40-year-old roofer falls 15 feet, sustaining a closed, displaced intra-articular calcaneus fracture (Sanders Type III) with significant blistering over the lateral heel. Surgery via an extensile lateral approach is planned. Which of the following factors is most predictive of wound healing complications following this surgical approach?
. Time to surgery of less than 3 days
. Smoking history
. Preoperative Bohler's angle of less than 0 degrees
. Type of internal fixation plate used
. Patient age less than 50 years

Correct Answer & Explanation

. Smoking history

Explanation

Wound complications are a major and potentially devastating concern with the extensile lateral approach for calcaneus fractures. While operating through blistered, swollen tissue increases risk, smoking is widely recognized as the single most significant modifiable patient risk factor for postoperative wound edge necrosis and deep infection following this approach. Patients who smoke have complication rates exponentially higher than non-smokers.

Question 8355

Topic: 2. Trauma

A 28-year-old polytrauma patient presents with a hemodynamically unstable pelvic ring injury. A pelvic binder is applied in the trauma bay. To be maximally effective in reducing pelvic volume and controlling hemorrhage, the binder should be centered over which of the following anatomic landmarks?

. Iliac crests
. Anterior superior iliac spines
. Greater trochanters
. Symphysis pubis
. Sacral ala

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders are most effective in reducing pelvic volume when centered over the greater trochanters. Placement over the iliac crests or higher can paradoxically open the true pelvis in certain fracture patterns and is less effective at achieving symphyseal reduction.

Question 8356

Topic: 2. Trauma

A 40-year-old female sustains an isolated closed midshaft tibia fracture treated with a reamed intramedullary nail. Twelve hours postoperatively, she requires escalating doses of IV pain medication and reports severe pain with passive stretch of her hallux. Which compartment of the lower leg is most commonly affected in this scenario?

. Deep posterior compartment
. Superficial posterior compartment
. Lateral (peroneal) compartment
. Anterior compartment
. Tibialis posterior compartment

Correct Answer & Explanation

. Anterior compartment

Explanation

Acute compartment syndrome most commonly affects the anterior compartment of the lower leg following tibial shaft fractures. The hallmark physical exam finding is severe pain with passive stretch of the involved muscles; pain with passive stretch of the great toe (extensor hallucis longus) indicates anterior compartment involvement.

Question 8357

Topic: 2. Trauma

In the management of open fractures, current literature demonstrates that the most critical factor in reducing the risk of deep infection is:

. Administration of systemic antibiotics within 1 hour of injury
. Operative debridement strictly within 6 hours of injury
. Initiation of negative pressure wound therapy (NPWT) immediately after debridement
. Use of high-pressure pulsatile lavage during debridement
. Early soft tissue flap coverage within 24 hours

Correct Answer & Explanation

. Administration of systemic antibiotics within 1 hour of injury

Explanation

Evidence consistently demonstrates that the administration of systemic antibiotics as early as possible (ideally within 1 hour of injury) is the single most important factor in reducing infection rates in open fractures. The traditional '6-hour rule' for surgical debridement has been shown to be less critical than the timing of antibiotic administration.

Question 8358

Topic: 2. Trauma
A 22-year-old male sustains a vertically oriented, displaced femoral neck fracture (Pauwels Type III) after a fall from a roof. The plan is for urgent open reduction and internal fixation. To maximize biomechanical stability and resist shear forces in this specific fracture pattern, the optimal fixation construct consists of:
. Three parallel cancellous screws placed in an inverted triangle
. A sliding hip screw (DHS) with an anti-rotation screw
. Three parallel cancellous screws placed in a standard triangle
. A cephalomedullary nail with a single head screw
. Two parallel 7.3mm cannulated screws

Correct Answer & Explanation

. A sliding hip screw (DHS) with an anti-rotation screw

Explanation

Pauwels Type III fractures are highly vertically oriented (>50 degrees), leading to significant shear forces across the fracture site. A fixed-angle device, such as a sliding hip screw (DHS) with a derotational screw, provides superior biomechanical stability against shear forces compared to multiple cancellous screws.

Question 8359

Topic: 2. Trauma

In a patient with multiple severe injuries including bilateral femur fractures and a severe traumatic brain injury (TBI) with elevated intracranial pressure, the concept of Damage Control Orthopedics (DCO) suggests which of the following initial management strategies for the femur fractures?

. Bilateral reamed intramedullary nailing within 24 hours
. Bilateral unreamed intramedullary nailing within 24 hours
. Open reduction and internal fixation with plates
. Skeletal traction followed by definitive fixation at 2 weeks
. External fixation of bilateral femurs

Correct Answer & Explanation

. External fixation of bilateral femurs

Explanation

In polytrauma patients who are physiologically unstable or have a severe TBI with elevated intracranial pressure ('borderline' or 'in extremis'), early total care (reamed IM nailing) can exacerbate systemic inflammation and cause secondary brain injury ('second hit'). Damage control orthopedics with rapid external fixation is indicated to stabilize the fractures rapidly while minimizing physiologic burden.

Question 8360

Topic: 2. Trauma
A 35-year-old male presents with an open diaphyseal tibia fracture with a 12 cm soft tissue defect and exposed bone after a motorcycle crash. The limb is vascularly intact. After initial debridement, what is the most appropriate timing and method for soft tissue coverage?
. Immediate split-thickness skin graft
. Local rotational flap within 24 hours
. Free tissue transfer within 3-7 days
. Healing by secondary intention with vacuum-assisted closure over 6 weeks
. Delayed primary closure at 14 days

Correct Answer & Explanation

. Free tissue transfer within 3-7 days

Explanation

Gustilo-Anderson IIIB open fractures require soft tissue coverage with a rotational or free flap. For large or distal third tibia defects, free tissue transfer (e.g., anterolateral thigh or latissimus dorsi) is the standard of care. Early coverage within 3 to 7 days has been shown to significantly reduce infection rates, minimize flap failure, and improve overall functional outcomes compared to delayed coverage.

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