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2. Trauma MCQs

Practice Set 442 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 8821

Topic: 2. Trauma

A 45-year-old patient presents with a Bado Type I Monteggia fracture. Intraoperatively, after achieving rigid plate fixation of the ulna, the radial head remains anteriorly dislocated. What is the most appropriate next step?

. Perform a radial head excision
. Reconstruct the annular ligament
. Re-evaluate and correct ulnar length and alignment
. Cast the arm in full supination
. Perform radiocapitellar transarticular pinning

Correct Answer & Explanation

. Re-evaluate and correct ulnar length and alignment

Explanation

Persistent radial head dislocation after ulnar fixation in a Monteggia fracture is almost always due to malreduction (residual shortening or angulation) of the ulna. The ulnar fixation must be revised to restore appropriate length and bow.

Question 8822

Topic: 2. Trauma

A 42-year-old sustains a posterior wall acetabular fracture. During a dynamic fluoroscopic examination under anesthesia (EUA), the hip subluxates posteriorly. Involvement of what minimum percentage of the posterior wall articular surface typically correlates with this instability?

. Less than 10%
. 10-15%
. Greater than 20-25%
. Greater than 50%
. Greater than 75%

Correct Answer & Explanation

. Greater than 20-25%

Explanation

Posterior wall fractures involving greater than 20-25% of the articular surface generally compromise the structural integrity of the joint, leading to hip instability and serving as an indication for surgical fixation.

Question 8823

Topic: 2. Trauma

A polytrauma patient is diagnosed with a "floating knee" (ipsilateral femoral and tibial shaft fractures). Due to the nature of this specific combination of injuries, the patient is at significantly increased risk for which of the following early systemic complications?

. Deep vein thrombosis
. Fat embolism syndrome
. Disseminated intravascular coagulation
. Acute myocardial infarction
. Pulmonary fibrosis

Correct Answer & Explanation

. Fat embolism syndrome

Explanation

Floating knee injuries expose the marrow of two major long bones simultaneously, drastically increasing the load of marrow fat into the venous system and making Fat Embolism Syndrome highly probable.

Question 8824

Topic: 2. Trauma

A 24-year-old active male has a completely displaced, shortened midshaft clavicle fracture. If he chooses to proceed with nonoperative management, he should be counseled that his risk of nonunion is approximately:

. 1%
. 5%
. 15%
. 35%
. 50%

Correct Answer & Explanation

. 15%

Explanation

While historically thought to heal reliably, modern prospective studies show that completely displaced and shortened midshaft clavicle fractures have a nonunion rate of approximately 15% when treated nonoperatively.

Question 8825

Topic: 2. Trauma

A 22-year-old sustains a low-velocity civilian gunshot wound to the midshaft femur, resulting in a comminuted fracture. There is no neurovascular injury, and the entry/exit wounds are small and clean. What is the optimal surgical management?

. Application of a spanning external fixator
. Formal open debridement, bone grafting, and plating
. Local wound care and immediate amputation
. Intravenous antibiotics and early reamed intramedullary nailing
. Continuous normal saline irrigation for 48 hours prior to fixation

Correct Answer & Explanation

. Intravenous antibiotics and early reamed intramedullary nailing

Explanation

Low-velocity civilian gunshot fractures of the femur without severe soft-tissue contamination can be safely treated with superficial wound care, IV antibiotics, and early intramedullary nailing without formal open debridement of the fracture site.

Question 8826

Topic: 2. Trauma

A 45-year-old smoker presents with a symptomatic aseptic nonunion of a tibial shaft fracture 9 months after initial intramedullary nailing. The implant is intact. What is the most appropriate next step in surgical management?

. Remove the nail and apply a circular Ilizarov frame
. Exchange nailing with a larger diameter reamed nail
. Retain the nail and apply a compression plate
. Noninvasive pulsed electromagnetic field therapy
. Below-knee amputation

Correct Answer & Explanation

. Exchange nailing with a larger diameter reamed nail

Explanation

Exchange nailing with a larger reamed nail provides improved mechanical stability and biological stimulation (autograft generated from reamings), making it the gold standard for aseptic tibial nonunions.

Question 8827

Topic: Pelvic & Acetabular Trauma
A 50-year-old patient presents with a massive, fluctuant Morel-Lavallée lesion over the greater trochanter that has been present for 4 weeks following a blunt trauma. What is the most definitive management?
. Observation and compression dressings
. A single percutaneous aspiration
. A short course of oral antibiotics
. Open excision of the pseudocapsule or percutaneous debridement with sclerodesis
. Primary closure with deep tension sutures

Correct Answer & Explanation

. Open excision of the pseudocapsule or percutaneous debridement with sclerodesis

Explanation

Chronic Morel-Lavallée lesions form an epithelialized pseudocapsule that prevents resorption. Simple aspiration has a very high recurrence rate; therefore, definitive treatment requires open excision or aggressive debridement with sclerodesis.

Question 8828

Topic: 2. Trauma

A 38-year-old falls from a significant height, sustaining a high-energy, severely displaced tibial pilon fracture with massive soft tissue swelling and fracture blisters. What is the most appropriate initial treatment approach?

. Immediate open reduction and internal fixation of the tibia
. Spanning external fixation across the ankle joint and strict limb elevation
. Immediate primary tibiotalar arthrodesis
. Reamed intramedullary nailing of the tibia
. Application of a tight, short leg cast

Correct Answer & Explanation

. Spanning external fixation across the ankle joint and strict limb elevation

Explanation

High-energy pilon fractures with massive soft tissue compromise require staged management. Initial spanning external fixation allows the vulnerable soft tissues to recover prior to delayed definitive internal fixation.

Question 8829

Topic: 2. Trauma

A 28-year-old woman is evaluated 8 weeks following closed reduction and percutaneous pinning of a Hawkins type II talar neck fracture. An AP radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

. Avascular necrosis of the talar body
. Imminent hardware failure
. Intact vascularity to the talar body
. Nonunion of the talar neck
. Osteomyelitis of the talus

Correct Answer & Explanation

. Intact vascularity to the talar body

Explanation

Hawkins sign is a subchondral radiolucent band seen in the talar dome on an AP or mortise radiograph 6 to 8 weeks post-injury. It indicates subchondral atrophy from disuse, which confirms that the vascular supply to the talar body remains intact.

Question 8830

Topic: 2. Trauma

In the evaluation of a displaced 4-part proximal humerus fracture, which of the following anatomic variables is the strongest predictor of subsequent avascular necrosis of the humeral head?

. Greater tuberosity displacement of 5 mm
. Varus angulation of 20 degrees
. Medial metaphyseal calcar length of less than 8 mm
. Age greater than 65 years
. Associated nondisplaced surgical neck fracture

Correct Answer & Explanation

. Medial metaphyseal calcar length of less than 8 mm

Explanation

A metaphyseal head extension (calcar length) of less than 8 mm, disruption of the medial hinge, and a basicervical fracture pattern are the most reliable predictors of ischemia and subsequent avascular necrosis in proximal humerus fractures.

Question 8831

Topic: 2. Trauma

A 30-year-old man sustains a closed distal third spiral humerus fracture. Examination reveals a complete radial nerve palsy present immediately after the injury. After closed reduction and application of a coaptation splint, the fracture is acceptably aligned but the palsy persists. What is the most appropriate initial management of the nerve injury?

. Immediate surgical exploration and nerve repair
. EMG and nerve conduction studies at 1 week
. Observation and supportive splinting
. Immediate MRI of the arm
. Corticosteroid injection into the spiral groove

Correct Answer & Explanation

. Observation and supportive splinting

Explanation

Primary radial nerve palsies associated with closed humeral shaft fractures should be observed, as 70-90% will spontaneously resolve. Surgical exploration is reserved for open fractures, penetrating injuries, or failure to recover clinically or electromyographically by 3 to 4 months.

Question 8832

Topic: 2. Trauma

A 25-year-old man sustains a subtrochanteric femur fracture. During closed intramedullary nailing, the proximal fragment is typically difficult to reduce due to the deforming forces of local musculature. The proximal fragment is classically pulled into which of the following positions?

. Flexed, adducted, and internally rotated
. Flexed, abducted, and externally rotated
. Extended, abducted, and externally rotated
. Extended, adducted, and internally rotated
. Flexed, abducted, and internally rotated

Correct Answer & Explanation

. Flexed, abducted, and externally rotated

Explanation

The proximal fragment in a subtrochanteric fracture is deformed into flexion by the iliopsoas, abduction by the gluteus medius and minimus, and external rotation by the short external rotators. Proper reduction requires neutralizing these forces before nailing.

Question 8833

Topic: 2. Trauma
A 22-year-old man sustains a vertical, shear-type (Pauwels type III) femoral neck fracture. Which of the following fixation constructs provides the most biomechanically stable fixation for this specific fracture pattern?
. Three parallel cancellous screws placed in an inverted triangle
. Two parallel cancellous screws
. A sliding hip screw with a derotational screw
. A single fully threaded 7.3mm screw
. Non-locking proximal femoral plate

Correct Answer & Explanation

. A sliding hip screw with a derotational screw

Explanation

Pauwels type III fractures are high-angle, vertical fractures with significant shear forces. A sliding hip screw (fixed-angle device) combined with an anti-rotation cancellous screw offers superior biomechanical stability compared to multiple cancellous screws for this pattern.

Question 8834

Topic: 2. Trauma

A 28-year-old man sustains a closed femoral shaft fracture and bilateral pulmonary contusions in a motor vehicle collision. On arrival, his lactate is 4.5 mmol/L, base deficit is 8 mEq/L, and pH is 7.21. After initial fluid resuscitation, his lactate improves to 3.0 mmol/L and base deficit to 6 mEq/L. What is the most appropriate management of his femoral shaft fracture?

. Early total care with reamed intramedullary nailing
. Damage control orthopedics with external fixation
. Open reduction and internal fixation with a plate
. Nonoperative management with skeletal traction
. Early total care with retrograde unreamed intramedullary nailing

Correct Answer & Explanation

. Damage control orthopedics with external fixation

Explanation

This polytrauma patient remains 'borderline' or 'unstable' based on elevated lactate (>2.5 mmol/L) and base deficit (>5 mEq/L) despite resuscitation. Damage control orthopedics (external fixation) is favored to minimize the 'second hit' inflammatory response associated with reamed intramedullary nailing in the setting of severe chest trauma.

Question 8835

Topic: 2. Trauma

A 65-year-old woman undergoes evaluation for a 4-part proximal humerus fracture. According to Hertel's criteria, which of the following radiographic findings is the most reliable predictor for the development of humeral head osteonecrosis?

. Displacement of the greater tuberosity > 1 cm
. Metaphyseal head extension (calcar length) < 8 mm
. Angulation of the surgical neck > 45 degrees
. Intra-articular fracture extension
. Comminution of the lesser tuberosity

Correct Answer & Explanation

. Metaphyseal head extension (calcar length) < 8 mm

Explanation

Hertel described specific criteria for predicting ischemia and subsequent avascular necrosis in proximal humerus fractures. The most reliable predictors include a metaphyseal head extension (calcar segment) of less than 8 mm and disruption of the medial hinge.

Question 8836

Topic: 2. Trauma

An extensile lateral approach is planned for open reduction and internal fixation of a displaced intra-articular calcaneus fracture. To prevent wound slough and edge necrosis, the surgeon must be aware that the full-thickness fasciocutaneous flap's viability is primarily dependent on which of the following arteries?

. Medial calcaneal artery
. Lateral calcaneal artery
. Dorsalis pedis artery
. Sural artery
. Anterior tibial artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The extensile lateral approach creates a 'no-touch' full-thickness fasciocutaneous flap containing the sural nerve and peroneal tendons. Its vascular supply is primarily based on the lateral calcaneal artery, a terminal branch of the peroneal artery.

Question 8837

Topic: 2. Trauma

A 42-year-old man sustains a high-energy Schatzker VI tibial plateau fracture. During the initial evaluation, he has a tense, swollen calf and decreased sensation in the first dorsal webspace. Passive plantarflexion of the hallux elicits severe pain. Which compartment of the lower leg is most likely experiencing critically elevated pressures?

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

Correct Answer & Explanation

. Anterior

Explanation

Decreased sensation in the first dorsal webspace (deep peroneal nerve distribution) and severe pain with passive toe plantarflexion (stretching the extensor hallucis longus) are classic signs of anterior compartment syndrome. The deep peroneal nerve and anterior tibial artery reside within this compartment.

Question 8838

Topic: 2. Trauma

A 25-year-old man sustains a displaced midshaft clavicle fracture after being thrown over the handlebars of his bicycle. Which of the following is considered an absolute indication for operative fixation over nonoperative management?

. 100% displacement with 1.5 cm of shortening
. Z-type comminution with a transverse fragment
. Superior displacement of the proximal fragment
. Skin tenting that does not blanch
. Associated open fracture

Correct Answer & Explanation

. Associated open fracture

Explanation

Absolute indications for operative fixation of a clavicle fracture include open fractures, associated vascular injuries requiring repair, and progressive neurologic deficits. Severe shortening (>2 cm) and marked displacement are generally considered relative indications depending on patient activity level.

Question 8839

Topic: 2. Trauma

A 78-year-old female presents with a highly comminuted, intra-articular distal humerus fracture after a fall. Her bone quality is osteoporotic. Which of the following surgical options is associated with the most reliable return to independent activities of daily living in this specific patient demographic?

. Open reduction and internal fixation with dual orthogonal locking plates
. Total elbow arthroplasty
. Closed reduction and percutaneous pinning
. Spanning external fixation
. Hemiarthroplasty of the elbow

Correct Answer & Explanation

. Total elbow arthroplasty

Explanation

Total elbow arthroplasty (TEA) is the preferred treatment for elderly patients with highly comminuted distal humerus fractures and osteoporotic bone. TEA allows for immediate weight-bearing for transfers and early range of motion, providing more reliable functional outcomes than ORIF in this population.

Question 8840

Topic: 2. Trauma

A 30-year-old male with a closed midshaft tibia fracture is treated with intramedullary nailing. Six hours postoperatively, he complains of pain out of proportion to the injury. His blood pressure is 110/70 mmHg. Direct measurement of the anterior compartment pressure reveals a value of 45 mmHg. What is the most appropriate next step in management?

. Elevate the leg above the level of the heart and observe
. Administer intravenous pain medication and reassess in 2 hours
. Bivalve the cast or remove constrictive dressings
. Perform an urgent four-compartment fasciotomy
. Order a stat venous duplex ultrasound

Correct Answer & Explanation

. Perform an urgent four-compartment fasciotomy

Explanation

Compartment syndrome is diagnosed when the Delta P (diastolic blood pressure minus compartment pressure) is less than 30 mmHg. This patient has a Delta P of 25 mmHg (70 - 45), which is a definitive indication for an urgent four-compartment fasciotomy.

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