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2. Trauma MCQs

Practice Set 449 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 8961

Topic: 2. Trauma
A 30-year-old farmer sustains a Gustilo-Anderson type IIIB open tibia fracture from a tractor rollover in a muddy field. In addition to thorough surgical debridement, which antibiotic regimen is most appropriate for initial management?
. First-generation cephalosporin only
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin
. Fluoroquinolone monotherapy
. Vancomycin only

Correct Answer & Explanation

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

Explanation

For severe open fractures (type III) with gross soil or agricultural contamination, coverage for Clostridium species is mandated. The standard regimen includes a first-generation cephalosporin, an aminoglycoside, and high-dose penicillin.

Question 8962

Topic: 2. Trauma

A 29-year-old polytrauma patient with a closed femoral shaft fracture, multiple rib fractures, and bilateral pulmonary contusions is being evaluated for "Damage Control Orthopedics" (DCO) versus "Early Total Care" (ETC). Which of the following physiologic parameters is a strong indication to proceed with DCO (external fixation) rather than primary intramedullary nailing?

. Base deficit < 2.0 mEq/L
. Serum lactate > 2.5 mmol/L
. Platelet count of 150,000/mcL
. Core body temperature of 36.5°C
. Systolic blood pressure > 110 mm Hg

Correct Answer & Explanation

. Serum lactate > 2.5 mmol/L

Explanation

Elevated serum lactate (> 2.5 mmol/L), base deficit (> 6.0 mEq/L), hypothermia, and coagulopathy indicate an unresuscitated or borderline patient. These are clear triggers for Damage Control Orthopedics to prevent a fatal second hit.

Question 8963

Topic: 2. Trauma

A 40-year-old man sustains an ipsilateral midshaft clavicle fracture and a scapular neck fracture (floating shoulder). Which of the following is a recognized radiographic indication for operative intervention of the scapula in this injury pattern?

. A glenopolar angle of 45 degrees
. Medial translation of the glenoid fragment greater than 10-20 mm
. Any degree of displacement of the clavicle fracture
. Scapular body fracture extending to the inferior angle
. Presence of a superficial chest wall abrasion

Correct Answer & Explanation

. Medial translation of the glenoid fragment greater than 10-20 mm

Explanation

Indications for surgery in a floating shoulder (or isolated scapular neck fracture) include a glenopolar angle < 22 degrees, medial translation > 10-20 mm, or severe angular displacement > 40 degrees, as these alter rotator cuff mechanics.

Question 8964

Topic: 2. Trauma

A 25-year-old man sustains a spiral fracture of the distal third of the humerus (Holstein-Lewis fracture). In the emergency department, he has normal radial nerve function. Following closed reduction and splint application, he is noted to have a complete radial nerve palsy. What is the most appropriate next step?

. Schedule an EMG/NCS in 3 to 4 weeks
. Immediate surgical exploration of the radial nerve
. Observation, as 90% resolve spontaneously
. Ultrasound of the arm to look for a hematoma
. Administer high-dose intravenous steroids

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve

Explanation

A secondary (post-reduction) radial nerve palsy is an absolute indication for immediate surgical exploration, as the nerve is likely entrapped within the fracture site during the reduction maneuver.

Question 8965

Topic: 2. Trauma

A 19-year-old man sustains a low-velocity gunshot wound to the thigh, resulting in a comminuted midshaft femur fracture. Clinical examination reveals normal distal pulses and intact neurological function. There is no active bleeding from the entry or exit wounds. What is the most widely accepted definitive management?

. Immediate open debridement of the entire bullet tract followed by plating
. Application of a bridging external fixator only
. Local wound care, tetanus prophylaxis, and locked intramedullary nailing
. Non-operative treatment with skeletal traction for 6 weeks
. Arteriography prior to any surgical intervention

Correct Answer & Explanation

. Local wound care, tetanus prophylaxis, and locked intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without neurovascular compromise or massive contamination do not require formal tract debridement. They are best managed with local wound care, tetanus prophylaxis, IV antibiotics, and standard intramedullary nailing.

Question 8966

Topic: 2. Trauma
A 35-year-old male arrives at the trauma bay hypotensive (BP 70/40 mmHg) following a high-speed motorcycle crash. Pelvic radiographs show a widely displaced anteroposterior compression (APC III) fracture. A pelvic binder is applied and he receives 2 units of uncrossmatched blood, but his blood pressure remains 75/45 mmHg. A FAST exam is negative. What is the most appropriate next step in his management?
. Application of a pelvic binder and immediate exploratory laparotomy
. Application of an external fixator and preperitoneal pelvic packing
. Zone 3 REBOA inflation and observation
. Immediate transport to the scanner for CT angiography
. Resuscitative thoracotomy

Correct Answer & Explanation

. Application of an external fixator and preperitoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST, preperitoneal pelvic packing combined with external fixation is a rapid and effective method to control venous and cancellous bone bleeding. Exploratory laparotomy is not indicated with a negative FAST, and CT angiography is unsafe in a profoundly unstable patient.

Question 8967

Topic: 2. Trauma

A 30-year-old male is admitted with a closed, highly comminuted tibia shaft fracture. Twelve hours later, he complains of disproportionate leg pain. His blood pressure is 110/70 mmHg. Intracompartmental pressure monitoring is performed. Which of the following pressure measurements is the generally accepted threshold to indicate an acute compartment syndrome requiring fasciotomy?

. Absolute compartment pressure greater than 20 mm Hg
. Absolute compartment pressure greater than 30 mm Hg
. Diastolic blood pressure minus compartment pressure less than 30 mm Hg
. Mean arterial pressure minus compartment pressure less than 40 mm Hg
. Systolic blood pressure minus compartment pressure less than 30 mm Hg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure less than 30 mm Hg

Explanation

The threshold for diagnosing acute compartment syndrome is a Delta P (diastolic blood pressure minus intracompartmental pressure) of less than 30 mm Hg. This accounts for systemic perfusion pressure better than an absolute pressure value, minimizing unnecessary fasciotomies.

Question 8968

Topic: 2. Trauma

A 45-year-old male presents after a high-speed MVC. Radiographs and CT demonstrate the injury pattern seen in Figure 10. The surgeon plans an isolated Kocher-Langenbeck approach for definitive fixation.

Which of the following acetabular fracture patterns is most appropriate for this specific surgical approach?

. Isolated anterior column fracture
. Anterior column with posterior hemitransverse fracture
. Both-column acetabular fracture
. Isolated posterior wall fracture
. Transverse fracture with an isolated anterior wall component

Correct Answer & Explanation

. Isolated posterior wall fracture

Explanation

The Kocher-Langenbeck approach provides excellent exposure to the posterior column and posterior wall. It is the gold standard surgical approach for isolated posterior wall and posterior column fractures of the acetabulum.

Question 8969

Topic: 2. Trauma

In the management of a high subtrochanteric femur fracture, the proximal fracture fragment is typically displaced into a characteristic deformity. Which combination of deforming forces is responsible for the position of the proximal fragment?

. Flexion, adduction, and internal rotation
. Extension, abduction, and internal rotation
. Flexion, abduction, and external rotation
. Extension, adduction, and external rotation
. Flexion, abduction, and internal rotation

Correct Answer & Explanation

. Flexion, abduction, and external rotation

Explanation

In subtrochanteric femur fractures, the proximal fragment is pulled into flexion by the iliopsoas, abduction by the gluteus medius and minimus, and external rotation by the short external rotators. Understanding these deforming forces is critical for achieving an accurate closed reduction.

Question 8970

Topic: 2. Trauma

A 50-year-old male presents with a highly comminuted, closed distal tibia intra-articular fracture (OTA/AO 43C pilon fracture) with severe soft tissue swelling and multiple fracture blisters. What is the most appropriate initial management?

. Immediate open reduction and internal fixation with dual plating
. Primary tibiotalar arthrodesis
. Intramedullary nailing of the tibia
. Immediate application of a definitive circular fine-wire frame
. Spanning external fixation and delayed definitive internal fixation

Correct Answer & Explanation

. Spanning external fixation and delayed definitive internal fixation

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with a staged protocol to minimize wound complications. A spanning external fixator restores length and alignment while allowing the soft tissues to recover for definitive internal fixation typically 10-21 days later.

Question 8971

Topic: 2. Trauma
A 28-year-old man sustains a high-energy trauma resulting in the isolated injury shown in Figure 10. Assuming the radiograph demonstrates a vertically oriented, displaced Pauwels type III femoral neck fracture, what is the most biomechanically sound definitive fixation construct to minimize the risk of varus collapse?
. Three parallel 7.3-mm partially threaded cancellous screws
. Sliding hip screw with an anti-rotation cancellous screw
. Standard cephalomedullary nail
. Cemented bipolar hemiarthroplasty
. Proximal femoral locking plate

Correct Answer & Explanation

. Sliding hip screw with an anti-rotation cancellous screw

Explanation

In young patients with vertically oriented (Pauwels type III) femoral neck fractures, high shear forces predispose the fracture to varus collapse and nonunion. A sliding hip screw with a derotational screw provides superior biomechanical stability against these vertical shear forces compared to multiple parallel cancellous screws.

Question 8972

Topic: 2. Trauma

A 35-year-old man is brought to the emergency department following a high-speed motor vehicle collision. He has closed bilateral femoral shaft fractures and a severe pulmonary contusion. After initial fluid resuscitation, his blood pressure is 105/65 mmHg, heart rate is 110 bpm, serum lactate is 4.8 mmol/L, and base deficit is -9 mEq/L. What is the most appropriate initial orthopaedic management of his femur fractures?

. Immediate bilateral reamed intramedullary nailing
. Immediate bilateral unreamed intramedullary nailing
. Bilateral spanning external fixation
. Open reduction and internal fixation with compression plating
. Distal femoral skeletal traction and delayed definitive fixation for 10 days

Correct Answer & Explanation

. Bilateral spanning external fixation

Explanation

This polytrauma patient is physiologically unstable as indicated by an elevated serum lactate and a severe base deficit. Damage control orthopaedics with rapid bilateral spanning external fixation is indicated to minimize the surgical "second hit" while the patient is aggressively resuscitated in the intensive care unit.

Question 8973

Topic: 2. Trauma

A 75-year-old woman sustains a Type II odontoid fracture after a ground-level fall. Which of the following factors is most strongly associated with a high rate of nonunion if managed nonoperatively with a halo vest?

. Age less than 40 years
. Fracture displacement less than 2 mm
. Fracture gap > 1 mm and displacement > 5 mm
. Concomitant C1 ring fracture
. Anterior tilt of 5 degrees

Correct Answer & Explanation

. Fracture gap > 1 mm and displacement > 5 mm

Explanation

Risk factors for nonunion of Type II odontoid fractures include age > 50 years, displacement > 5 mm, posterior displacement, and a fracture gap > 1 mm. High-risk patients often require primary surgical stabilization.

Question 8974

Topic: 2. Trauma

A 75-year-old woman presents with a displaced Type II odontoid fracture after a fall. What is the major disadvantage of utilizing a halo vest orthosis in this specific patient population compared to a rigid cervical collar?

. High rate of nonunion compared to a soft collar
. High risk of complications and mortality
. Inability to control rotational stability
. Increased incidence of post-traumatic syringomyelia
. High risk of immediate spinal cord injury during application

Correct Answer & Explanation

. High risk of complications and mortality

Explanation

In the elderly population, halo vest immobilization is associated with a significantly increased risk of major complications, including pneumonia and mortality, compared to a rigid cervical collar. Therefore, rigid collars are generally preferred despite a higher nonunion rate.

Question 8975

Topic: 2. Trauma

A 74-year-old man falls and sustains a Type II odontoid fracture. Which of the following factors most significantly increases his risk of fracture nonunion with conservative halo vest management?

. Age younger than 65 years
. Fracture displacement greater than 5 mm
. Anterior displacement of the dens
. Concomitant C1 arch fracture
. Impacted fracture pattern

Correct Answer & Explanation

. Fracture displacement greater than 5 mm

Explanation

Risk factors for nonunion of Type II odontoid fractures include initial displacement greater than 5 mm, posterior displacement, angulation greater than 10 degrees, and patient age older than 65 years. Surgical stabilization is generally favored in these high-risk patients.

Question 8976

Topic: 2. Trauma

A 28-year-old man sustains a flexion-distraction (Chance) fracture of L2 during a high-speed motor vehicle collision. Which of the following injuries is most highly associated with this specific fracture pattern?

. Aortic transection
. Hollow viscus bowel injury
. Renal artery thrombosis
. Pulmonary contusion
. Pelvic ring disruption

Correct Answer & Explanation

. Hollow viscus bowel injury

Explanation

Chance fractures result from a lap-belt mechanism causing severe flexion-distraction forces. They have a known 40% to 50% association with intra-abdominal injuries, most commonly hollow viscus (bowel) injuries.

Question 8977

Topic: 2. Trauma

An 82-year-old female sustains a Type II odontoid fracture after a fall from standing. Which of the following is a recognized risk factor for nonunion if this fracture is treated non-operatively with a rigid cervical collar?

. Age less than 30 years
. Anterior displacement of 2 mm
. Initial fracture displacement greater than 5 mm
. Concomitant C1 posterior arch fracture
. Use of a halo vest instead of a collar

Correct Answer & Explanation

. Initial fracture displacement greater than 5 mm

Explanation

Risk factors for nonunion of a Type II odontoid fracture include advanced age (>50 years), initial displacement > 5 mm, posterior displacement, and angulation > 10 degrees. Elderly patients often tolerate halo vests poorly due to pulmonary and skin complications.

Question 8978

Topic: 2. Trauma

An 82-year-old man falls from a standing height and complains of severe neck pain. CT imaging reveals a Type II odontoid fracture with 2 mm of posterior displacement. His neurologic examination is normal. In considering non-operative management, which of the following strategies carries the highest risk of mortality in this patient population?

. Soft cervical collar
. Rigid cervical collar
. Halo vest immobilization
. Minerva cast
. SOMI (Sternal Occipital Mandibular Immobilizer) brace

Correct Answer & Explanation

. Rigid cervical collar

Explanation

Halo vest immobilization in elderly patients (especially those over 80 years old) is associated with unacceptably high morbidity and mortality rates due to respiratory complications and falls. A rigid cervical collar is generally preferred in this population despite a high nonunion rate.

Question 8979

Topic: Lower Extremity Trauma
A 7-year-old girl presents with torticollis and her head tilted to the right and rotated to the left following an upper respiratory infection. Dynamic CT shows atlantoaxial rotatory subluxation with 4 mm of anterior displacement of C1 on C2. What is the Fielding and Hawkins classification of this injury?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

Fielding and Hawkins Type II atlantoaxial rotatory subluxation is characterized by unilateral anterior displacement of one lateral mass by 3-5 mm. This indicates a deficiency or rupture of the transverse ligament.

Question 8980

Topic: Pelvic & Acetabular Trauma

Which of the following is an essential radiographic criterion for diagnosing Diffuse Idiopathic Skeletal Hyperostosis (DISH) according to Resnick?

. Erosion of the sacroiliac joints
. Flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies
. Severe intervertebral disc space narrowing
. Bilateral facet joint ankylosis
. Positive HLA-B27 antigen test

Correct Answer & Explanation

. Flowing ossification along the anterolateral aspect of at least four contiguous vertebral bodies

Explanation

Resnick's criteria for DISH require flowing ossification of at least four contiguous vertebral bodies. It also requires preservation of intervertebral disc height and the absence of sacroiliac joint erosion or facet ankylosis.

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