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2. Trauma MCQs

Practice Set 424 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 8461

Topic: 2. Trauma
A 32-year-old snowboarder sustains a high-energy hyperdorsiflexion injury to the ankle, resulting in a Hawkins Type III fracture of the talar neck. The fracture is managed with emergent open reduction and internal fixation. At 8 weeks postoperatively, a radiograph is taken. The presence of subchondral radiolucency in the talar dome (Hawkins sign) on the AP view indicates:
. Impending avascular necrosis (AVN) of the talar body
. Post-traumatic arthritis of the tibiotalar joint
. Intact vascularity to the talar body
. Nonunion of the talar neck
. Infection of the subtalar joint

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band visible on the AP or mortise radiograph of the ankle, typically appearing 6 to 8 weeks after a talar neck fracture. It represents subchondral osteopenia secondary to disuse and active bone resorption. Because bone resorption requires an intact blood supply to deliver osteoclasts, a positive Hawkins sign is a highly reliable indicator of intact vascularity to the talar body, suggesting that avascular necrosis is unlikely.

Question 8462

Topic: 2. Trauma

A 22-year-old male is admitted following a motor vehicle collision. He has a severe traumatic brain injury (GCS 6), bilateral pulmonary contusions, and a closed comminuted midshaft femur fracture. His initial lactate is 5.5 mmol/L and base deficit is -8. Based on the principles of Damage Control Orthopedics (DCO), what is the most appropriate management of his femur fracture at this time?

. Early total care with immediate reamed intramedullary nailing
. Application of a Thomas splint and skeletal traction for 6 weeks
. External fixation of the femur, followed by conversion to an intramedullary nail when the patient's physiologic status normalizes
. Immediate open reduction and internal fixation with a dynamic compression plate
. Retrograde intramedullary nailing to avoid the use of a traction table

Correct Answer & Explanation

. External fixation of the femur, followed by conversion to an intramedullary nail when the patient's physiologic status normalizes

Explanation

Damage Control Orthopedics (DCO) is indicated in 'borderline' or 'unstable' polytrauma patients, particularly those with severe head or chest trauma and profound physiologic derangement (e.g., high lactate, base deficit). Early total care (reamed IM nailing) can exacerbate the systemic inflammatory response ('second hit') and worsen pulmonary or cerebral edema. DCO involves rapid, temporary stabilization with an external fixator to control pain and hemorrhage, followed by definitive fixation once the patient is physiologically optimized.

Question 8463

Topic: Pelvic & Acetabular Trauma

A 35-year-old male is brought to the trauma bay after a motorcycle crash. His blood pressure is 75/40 mmHg, and his heart rate is 135 bpm. A FAST scan is negative. Pelvic radiograph shows a widened pubic symphysis of 4 cm and bilateral sacroiliac joint disruptions. A pelvic binder is placed, and he receives 2 units of uncrossmatched blood, but his blood pressure remains 80/45 mmHg. What is the most appropriate next step in management?

. CT abdomen and pelvis
. Exploratory laparotomy
. Preperitoneal pelvic packing and/or angioembolization
. Application of an anterior external fixator
. Zone 3 REBOA placement

Correct Answer & Explanation

. Preperitoneal pelvic packing and/or angioembolization

Explanation

Hemodynamically unstable patients with pelvic ring injuries and a negative FAST scan require immediate intervention for pelvic hemorrhage. Preperitoneal pelvic packing or angioembolization are the treatments of choice for ongoing hemorrhage from the presacral venous plexus or internal iliac arterial branches. Binder or sheet placement is the initial step to reduce pelvic volume. CT scan is contraindicated in a hemodynamically unstable patient.

Question 8464

Topic: 2. Trauma
A 28-year-old man sustains a completely displaced, vertically oriented (Pauwels type III) femoral neck fracture after falling from a height. He is taken to the operating room for closed reduction and internal fixation. Which of the following fixation constructs offers the highest biomechanical stability for this specific fracture pattern?
. Three parallel partially threaded cancellous screws
. Sliding hip screw with a derotation screw
. Two partially threaded cancellous screws
. Cephalomedullary nail
. Bipolar hemiarthroplasty

Correct Answer & Explanation

. Sliding hip screw with a derotation screw

Explanation

Pauwels type III fractures (highly vertical) experience significant shear forces leading to varus collapse and nonunion. A sliding hip screw (fixed-angle device) combined with an anti-rotation cancellous screw provides superior biomechanical stability against shear forces compared to multiple cancellous screws alone in young adults.

Question 8465

Topic: 2. Trauma

A 45-year-old woman presents with a complex bicondylar tibial plateau fracture (Schatzker VI). Preoperative CT scan demonstrates a displaced posteromedial articular fragment. To adequately visualize and reduce this specific fragment, which of the following surgical approaches is most appropriate?

. Anterolateral approach alone
. Direct anterior approach with tibial tubercle osteotomy
. Posteromedial approach with the patient supine and hip externally rotated
. Posterolateral approach with fibular osteotomy
. Medial parapatellar approach

Correct Answer & Explanation

. Posteromedial approach with the patient supine and hip externally rotated

Explanation

A displaced posteromedial fragment in a bicondylar tibial plateau fracture cannot be adequately reduced or stabilized through a standard anterolateral approach alone. A posteromedial approach allows direct visualization, reduction, and application of a buttress plate to counteract the typical apex-posterior and distal displacement of the fragment.

Question 8466

Topic: 2. Trauma

A 40-year-old male falls from a ladder and sustains a severely displaced closed distal tibia pilon fracture with significant soft tissue swelling and fracture blisters. He is initially managed with a joint-spanning external fixator. What is the most appropriate timing for definitive open reduction and internal fixation?

. Within 24 hours of injury to prevent cartilage necrosis
. Once the fracture blisters have ruptured and dried completely
. Upon the appearance of the 'wrinkle sign' and resolution of pitting edema
. 6 weeks post-injury, after ex-fix removal
. Immediate internal fixation is indicated despite soft tissue status

Correct Answer & Explanation

. Upon the appearance of the 'wrinkle sign' and resolution of pitting edema

Explanation

Standard of care for severe pilon fractures involves a staged protocol. Initial management includes a spanning external fixator to stabilize bone and allow soft tissue rest. Definitive ORIF is delayed until the soft tissues are amenable, typically indicated by the presence of skin wrinkling (the 'wrinkle sign') and resolution of significant edema, usually 10-21 days post-injury.

Question 8467

Topic: 2. Trauma
A 30-year-old male sustains a Hawkins Type III fracture of the talar neck. Six weeks after open reduction and internal fixation, an AP radiograph of the ankle shows a subchondral radiolucent band in the talar dome. What is the clinical significance of this radiographic finding?
. It indicates impending avascular necrosis (AVN) of the talar body.
. It represents early post-traumatic osteoarthritis.
. It denotes nonunion of the talar neck.
. It indicates intact vascularity to the talar body.
. It is an indication for immediate subtalar arthrodesis.

Correct Answer & Explanation

. It indicates intact vascularity to the talar body.

Explanation

A subchondral radiolucent band in the talar dome on an AP or mortise radiograph 6 to 8 weeks post-injury is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia and disuse, which confirms that the talar body has an intact vascular supply. Its presence is highly predictive that avascular necrosis will not occur.

Question 8468

Topic: 2. Trauma
A 25-year-old man sustains a Gustilo-Anderson Type IIIA open tibia fracture in a farming accident. The wound is heavily contaminated with soil. In addition to prompt surgical debridement, what is the most appropriate initial intravenous antibiotic regimen?
. Cefazolin alone
. Cefazolin and Gentamicin
. Cefazolin, Gentamicin, and Penicillin
. Vancomycin and Piperacillin/Tazobactam
. Ciprofloxacin alone

Correct Answer & Explanation

. Cefazolin, Gentamicin, and Penicillin

Explanation

For severe open fractures (Type III) occurring in farm environments, there is a high risk of clostridial infection due to soil contamination. The recommended prophylactic antibiotic regimen includes a first-generation cephalosporin (to cover Gram-positives), an aminoglycoside (to cover Gram-negatives), and Penicillin to cover anaerobes, specifically Clostridium species.

Question 8469

Topic: Pelvic & Acetabular Trauma
A 45-year-old male is brought to the trauma bay following a high-speed motor vehicle collision. His blood pressure is 70/40 mm Hg and heart rate is 130 bpm. A pelvic radiograph demonstrates an anteroposterior compression type III (APC III) pelvic ring injury. A pelvic binder is applied correctly, and 2 units of uncrossmatched whole blood are administered. A FAST exam is negative for intraperitoneal fluid. His hemodynamics do not improve despite resuscitation. What is the most appropriate next step in management?
. Application of a pelvic external fixator
. Preperitoneal pelvic packing
. CT angiography of the abdomen and pelvis
. Exploratory laparotomy
. Immediate open reduction and internal fixation of the pubic symphysis

Correct Answer & Explanation

. Preperitoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam, the primary source of bleeding is assumed to be the pelvic retroperitoneum (venous plexus and cancellous bone). Once a pelvic binder is applied to reduce pelvic volume and stabilize the fracture, if the patient remains unstable, immediate preperitoneal pelvic packing (PPP) and/or pelvic angioembolization is indicated. Sending a hemodynamically unstable patient to the CT scanner is contraindicated. Since the binder is already applied, exchanging it for an external fixator will not provide significantly better immediate hemorrhage control in a patient in extremis.

Question 8470

Topic: 2. Trauma
A 32-year-old male sustains a vertically oriented, displaced basicervical femoral neck fracture (Pauwels type III). He is treated with open reduction and internal fixation using a sliding hip screw combined with a derotational cancellous screw. Compared to fixation with three parallel cancellous screws, what is the primary biomechanical advantage of this construct?
. Decreased resistance to varus collapse
. Increased shear strain at the fracture site
. Increased construct stiffness and ultimate failure load
. Lower resistance to axial loading
. Increased reliance on secondary bone healing

Correct Answer & Explanation

. Increased construct stiffness and ultimate failure load

Explanation

Pauwels type III femoral neck fractures have a high shear angle, predisposing them to varus collapse and nonunion. Biomechanical studies have consistently shown that fixed-angle constructs, such as a sliding hip screw (SHS) with an anti-rotation screw, provide greater construct stiffness, higher ultimate load to failure, and superior resistance to shear stress compared to standard fixation with three parallel cancellous screws. This makes the SHS construct particularly advantageous for high-angle, vertically oriented fractures in young adults.

Question 8471

Topic: 2. Trauma

A 65-year-old female with osteoporosis undergoes minimally invasive plate osteosynthesis (MIPO) using a lateral locked plate for an extra-articular distal femur fracture. Six months postoperatively, she presents with persistent thigh pain and radiographs demonstrate an atrophic nonunion with intact hardware. Which of the following technical errors during the initial fixation most likely contributed to this complication?

. Utilizing a plate that spans the entire diaphysis
. Decreasing the working length by placing locking screws immediately adjacent to the fracture
. Leaving the fracture in 5 degrees of valgus alignment
. Using an excessively long working length
. Using a titanium rather than a stainless steel plate

Correct Answer & Explanation

. Decreasing the working length by placing locking screws immediately adjacent to the fracture

Explanation

Bridge plating relies on relative stability to promote secondary bone healing via callus formation. This requires interfragmentary micromotion. If locking screws are placed too close to the fracture site, the working length (the distance between the two closest screws on either side of the fracture) is significantly decreased. This renders the construct overly rigid, which suppresses interfragmentary strain and callus formation, ultimately leading to an atrophic or oligotrophic nonunion.

Question 8472

Topic: Lower Extremity Trauma

A 40-year-old man sustains a severe bicondylar tibial plateau fracture (Schatzker VI) with severe soft tissue swelling. A spanning external fixator is placed. Two weeks later, the soft tissue envelope has recovered (positive wrinkle test), and the patient undergoes definitive open reduction and internal fixation using dual plates. Which of the following surgical strategies historically carries the highest risk of devastating soft tissue complications and deep infection?

. Utilizing a single midline longitudinal incision to expose both medial and lateral sides
. Delaying definitive surgery until the soft tissue swelling has completely resolved
. Using an anterolateral approach combined with a separate posteromedial approach
. Elevating full-thickness fasciocutaneous flaps during the surgical approach
. Performing minimally invasive percutaneous plate osteosynthesis (MIPPO) for the medial side

Correct Answer & Explanation

. Utilizing a single midline longitudinal incision to expose both medial and lateral sides

Explanation

Historically, utilizing a single, extensive anterior midline incision to plate both the medial and lateral columns of the tibial plateau required massive subcutaneous stripping. This severely compromises the vascular supply to the skin flaps, leading to unacceptably high rates of wound edge necrosis, breakdown, and deep infection. Standard modern management requires either dual incisions (e.g., anterolateral and posteromedial with a wide skin bridge) or minimally invasive techniques to respect the vulnerable soft tissue envelope.

Question 8473

Topic: 2. Trauma

A 78-year-old female sustains an acute T12 osteoporotic vertebral compression fracture without neurological deficits. She reports debilitating mechanical pain. According to the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines, what is the recommendation regarding the use of vertebroplasty for this condition?

. It is strongly recommended as first-line therapy within 2 weeks of injury to prevent deformity
. It is moderately recommended to improve long-term functional outcomes and pulmonary capacity
. It is strongly recommended against due to a lack of proven efficacy over a placebo (sham) procedure
. It is recommended only if the patient fails a strict 3-month trial of rigid thoracolumbosacral orthosis (TLSO) bracing
. It is recommended only if performed concomitantly with posterior pedicle screw fixation

Correct Answer & Explanation

. It is strongly recommended against due to a lack of proven efficacy over a placebo (sham) procedure

Explanation

The AAOS Clinical Practice Guidelines strongly recommend against the use of vertebroplasty for patients presenting with osteoporotic spinal compression fractures. High-quality, randomized, double-blind, sham-controlled trials have consistently demonstrated no significant benefit of vertebroplasty over a sham procedure in terms of pain relief or functional improvement.

Question 8474

Topic: 2. Trauma

A 78-year-old man sustains a Type II odontoid fracture after a ground-level fall. He complains of neck pain but is neurologically intact. Computed tomography (CT) shows 2 mm of posterior displacement.

If nonoperative management is selected, what is the most significant disadvantage of utilizing a halo vest orthosis compared to a rigid cervical collar in this specific patient demographic?

. Increased rate of fracture nonunion
. Progressive loss of cervical lordosis
. Significantly increased risk of mortality
. Higher incidence of post-traumatic syringomyelia
. Inability to achieve adequate fracture alignment

Correct Answer & Explanation

. Significantly increased risk of mortality

Explanation

In the elderly population (typically >65-70 years old), halo vest immobilization is associated with significantly increased morbidity and mortality compared to a rigid cervical collar. Complications such as pneumonia, pin-site infections, and respiratory distress are prominent. Multiple studies have shown that while rigid cervical collars have a higher rate of fibrous nonunion for Type II odontoid fractures, the overall survival and complication profile in the elderly strongly favor collar immobilization over halo placement.

Question 8475

Topic: 2. Trauma

Which of the following is considered the strongest risk factor for nonunion of a Type II odontoid fracture treated non-operatively with rigid cervical immobilization?

. Initial fracture displacement greater than 5 mm
. Patient age less than 30 years
. Anterior fracture displacement
. Fracture gap less than 1 mm
. Concomitant C1 ring fracture

Correct Answer & Explanation

. Initial fracture displacement greater than 5 mm

Explanation

Risk factors for nonunion of Type II odontoid fractures treated conservatively include patient age > 50 years, initial fracture displacement > 5 mm, posterior displacement, and a fracture gap > 1 mm. An initial displacement greater than 5 mm is a very strong independent predictor of conservative management failure, often prompting early surgical intervention such as anterior screw fixation or posterior C1-C2 fusion.

Question 8476

Topic: 2. Trauma

An 82-year-old man presents with neck pain after a low-energy fall from a standing height. Neurologic examination is normal. Radiographs and CT scan demonstrate a Type II odontoid fracture with 2 mm of posterior displacement. In considering non-operative management options, which of the following immobilization methods is associated with the highest rate of morbidity and mortality in this age group?

. Rigid cervical collar
. Halo vest immobilization
. Soft cervical collar
. Cervicothoracic orthosis (Minerva)
. Philadelphia collar

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Halo vest immobilization in the elderly (especially patients > 65-70 years) is associated with a significantly increased risk of major complications, including pneumonia, cardiac events, pin-site infections, and a higher mortality rate compared to rigid cervical collar immobilization. Current guidelines often recommend initial treatment with a rigid cervical collar for elderly patients with Type II odontoid fractures if they are deemed poor surgical candidates, accepting the higher risk of nonunion because a stable fibrous nonunion is frequently well-tolerated.

Question 8477

Topic: 2. Trauma

Figure 22 shows the imaging of an 82-year-old man who fell from a standing height and presents with severe neck pain. He is neurologically intact. If this injury is treated nonoperatively, which of the following factors is most strongly associated with the development of a nonunion?

. Fracture displacement of 2 mm
. Age greater than 65 years
. Anterior displacement of 3 mm
. Concomitant stable C1 ring fracture
. Male sex

Correct Answer & Explanation

. Age greater than 65 years

Explanation

The clinical scenario and (implied) imaging describe a Type II odontoid fracture in a geriatric patient. Type II odontoid fractures have a high nonunion rate when treated nonoperatively. Established risk factors for nonunion include patient age greater than 65 years, initial fracture displacement greater than 5 mm, posterior displacement, and significant comminution. While surgery (e.g., posterior C1-C2 fusion) offers a higher union rate, nonoperative management with a rigid cervical collar is often chosen in elderly patients due to the high morbidity and mortality associated with surgery and halo vest immobilization, provided the patient can tolerate a potential fibrous nonunion.

Question 8478

Topic: 2. Trauma
A 78-year-old male with severe osteoporosis presents to the emergency department after a ground-level fall, reporting severe upper neck pain. He is neurologically intact. Imaging confirms a Type II odontoid fracture. If nonoperative management with a rigid cervical collar is chosen, which of the following radiographic findings is the most significant predictor of subsequent nonunion?
. Initial fracture displacement > 5 mm
. Anterior angulation > 5 degrees
. Concomitant fracture of the posterior arch of C1
. Distance of the fracture line < 1 mm from the base
. Presence of a Type III component

Correct Answer & Explanation

. Initial fracture displacement > 5 mm

Explanation

Risk factors for nonunion of Type II odontoid fractures treated nonoperatively include age > 50 years, initial fracture displacement > 5 mm, fracture angulation > 10 degrees, and delayed presentation (> 4 days). The high nonunion rate in displaced fractures often prompts consideration of surgical stabilization (e.g., posterior C1-C2 fusion), even in elderly populations, though patient comorbidities must be carefully weighed.

Question 8479

Topic: 2. Trauma



A 19-year-old man is brought to the trauma bay after a high-speed motor vehicle collision where he was restrained by a lap belt only. He sustains an L2 flexion-distraction injury (classic Chance-type fracture pattern), as demonstrated in Figure 12. Biomechanically, if the axis of rotation is located at the anterior longitudinal ligament, which of the following best describes the mechanism of failure according to the Denis three-column model?

. Failure of the anterior column in compression, and the middle and posterior columns in tension
. Failure of all three columns in axial compression
. Failure of the anterior column in tension and the posterior column in compression
. Failure of the anterior and middle columns in compression, and the posterior column in tension
. Failure of all three columns in lateral shear

Correct Answer & Explanation

. Failure of the anterior and middle columns in compression, and the posterior column in tension

Explanation

In a flexion-distraction injury where the axis of rotation is at the anterior longitudinal ligament or the anterior aspect of the vertebral body, the biomechanical failure involves compression of the anterior column while the middle and posterior columns fail in tension (distraction). If the axis of rotation is displaced further anteriorly (e.g., at the anterior abdominal wall due to a lap belt), a pure tension failure can occur across all three columns (the classic 'bony' Chance fracture). However, the classic Denis description of a flexion-distraction injury involves anterior compression with middle/posterior tension.

Question 8480

Topic: 2. Trauma

A 24-year-old man is involved in a high-speed motor vehicle collision while wearing a lap belt. Radiographs and CT show a fracture line extending horizontally through the spinous process, pedicles, and vertebral body of L2.

Which of the following associated injuries has the highest incidence in this patient?

. Aortic tear
. Bowel or mesenteric injury
. Renal laceration
. Splenic rupture
. Pelvic ring disruption

Correct Answer & Explanation

. Bowel or mesenteric injury

Explanation

The description and mechanism represent a Chance fracture (flexion-distraction injury), typically caused by a lap belt. There is a high association (up to 40-50%) with intra-abdominal injuries, most commonly involving the hollow viscus (bowel) or mesentery, secondary to the fulcrum effect of the seatbelt during rapid deceleration.

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