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 901
Topic: 2. Trauma
A 40-year-old construction worker falls 20 feet from scaffolding, landing on both heels. He sustains bilateral intra-articular calcaneus fractures. Which of the following concomitant injuries is most critical to rule out during the primary and secondary surveys?
Correct Answer & Explanation
. Lumbar spine burst fracture
Explanation
High-energy axial load injuries, such as falls from a height resulting in calcaneus fractures, are classically associated with spinal fractures, most commonly in the thoracolumbar junction (e.g., lumbar burst fractures). A thorough spinal assessment is mandatory.
Question 902
Topic: 2. Trauma
A surgeon chooses a sinus tarsi approach instead of an extensile lateral approach for ORIF of a displaced intra-articular calcaneus fracture. Which of the following is the primary established advantage of the sinus tarsi approach?
Correct Answer & Explanation
. Decreased rate of wound complications and infection
Explanation
The sinus tarsi approach is a minimally invasive technique that significantly reduces the incidence of wound healing complications and deep infection compared to the traditional extensile lateral approach. However, it provides limited exposure to the entire lateral wall.
Question 903
Topic: 2. Trauma
A 32-year-old female sustains a twisting injury to her ankle. Non-weight-bearing radiographs show a distal fibula fracture with an intact medial malleolus. A gravity stress view is obtained. What measurement of the medial clear space on the stress view is generally accepted as diagnostic for deltoid ligament incompetence?
Correct Answer & Explanation
. Greater than 4 mm
Explanation
A medial clear space greater than 4 mm (or greater than the superior clear space) on a gravity or external rotation stress view is indicative of deltoid ligament incompetence in the setting of a lateral malleolus fracture, defining it as an unstable bimalleolar equivalent injury.
Question 904
Topic: 2. Trauma
The Sanders classification for intra-articular calcaneal fractures is based on the number of articular fracture lines extending through the posterior facet. Which of the following imaging modalities and views is strictly utilized to determine this classification?
Correct Answer & Explanation
. Coronal CT reconstruction through the widest portion of the posterior facet
Explanation
The Sanders classification is determined using a coronal CT slice at the widest portion of the posterior facet. It categorizes fractures based on the number and location of primary fracture lines extending through the posterior articular surface.
Question 905
Topic: 2. Trauma
Which of the following imaging planes and landmarks is strictly utilized to determine the Sanders classification of an intra-articular calcaneus fracture?
Correct Answer & Explanation
. Coronal CT at the widest point of the posterior facet
Explanation
The Sanders classification relies on coronal CT images through the widest point of the posterior facet of the calcaneus. It categorizes fractures based on the number and location of articular fragments, guiding the surgical approach and prognosis.
Question 906
Topic: 2. Trauma
Which of the following patients presenting with a closed, displaced intra-articular calcaneus fracture is the most appropriate candidate for definitive non-operative management?
Correct Answer & Explanation
. A 50-year-old diabetic patient with severe peripheral neuropathy and a Sanders Type II fracture
Explanation
Patients with severe peripheral neuropathy, poor vascular supply, or uncontrolled systemic diseases are extremely poor candidates for surgical fixation due to catastrophic rates of wound breakdown and infection. Non-operative management is strongly favored in this demographic despite articular displacement.
Question 907
Topic: 2. Trauma
During open reduction and internal fixation of a transverse medial malleolus fracture, the surgeon elects to use two partially threaded cancellous lag screws. To achieve optimal interfragmentary compression and avoid joint penetration, what is the recommended trajectory of the screws?
Correct Answer & Explanation
. Perpendicular to the fracture line directed towards the lateral cortex of the tibia
Explanation
Lag screws for a transverse medial malleolus fracture should be placed perpendicular to the fracture line, typically directed superolaterally towards the lateral tibial cortex. This maximizes biomechanical compression and avoids breaching the tibiotalar joint.
Question 908
Topic: 2. Trauma
A 38-year-old male sustains a closed intra-articular calcaneus fracture. The foot is massively swollen with multiple clear fracture blisters on presentation. What is the most reliable clinical indicator that the soft tissue envelope has recovered sufficiently to safely permit an extensile lateral surgical approach?
Correct Answer & Explanation
. Appearance of the 'wrinkle sign' on the lateral skin of the hindfoot
Explanation
The appearance of skin wrinkles (the 'wrinkle sign') indicates that the severe acute soft tissue edema has subsided enough to allow surgical incision. Operating before this sign appears carries an unacceptably high risk of catastrophic wound dehiscence and necrosis.
Question 909
Topic: 2. Trauma
A surgeon elects to use a minimally invasive sinus tarsi approach rather than a traditional extensile lateral approach for a Sanders Type II calcaneus fracture. Which of the following represents the primary proven advantage of the sinus tarsi approach?
Correct Answer & Explanation
. Significantly decreased incidence of postoperative soft tissue and wound complications
Explanation
The primary advantage of the minimally invasive sinus tarsi approach is a dramatically lower rate of soft tissue necrosis and wound complications compared to the extensile lateral approach. It is ideally suited for simpler fracture patterns (e.g., Sanders Type II) where extensive exposure is not mandatory.
Question 910
Topic: 2. Trauma
A 42-year-old male sustains a high-energy ankle injury. Closed reduction in the emergency department is unsuccessful. Radiographs demonstrate a fracture-dislocation with the proximal fragment of the fractured fibula entrapped posterior to the posterior tubercle of the distal tibia. Which of the following is the most accurate diagnosis and required immediate management?
Correct Answer & Explanation
. Bosworth fracture-dislocation requiring urgent open reduction
Explanation
A Bosworth fracture-dislocation involves the entrapment of the proximal fibular fragment behind the posterior tibial tubercle, making closed reduction impossible. Urgent open reduction and internal fixation are required to relieve tension on the soft tissues and neurovascular structures.
Question 911
Topic: 2. Trauma
A 28-year-old male sustains an ankle fracture involving 30% of the posterior malleolus along with a distal fibula fracture. Biomechanical studies indicate that anatomic reduction and rigid fixation of the posterior malleolus provides superior syndesmotic stability compared to a trans-syndesmotic screw. This stability is primarily achieved through the restoration of which of the following structures?
The posterior inferior tibiofibular ligament (PITFL) remains attached to the posterior malleolar fragment. Anatomic fixation of the posterior malleolus tensions the PITFL, restoring syndesmotic stability often equivalent to or better than a trans-syndesmotic screw.
Question 912
Topic: 2. Trauma
A 32-year-old patient underwent open reduction and internal fixation of a pronation-external rotation ankle fracture, which included the placement of two quadricortical syndesmotic screws. At 4 months post-operatively, the patient is asymptomatic, has full range of motion, and radiographs show intact hardware. Based on current orthopedic evidence, what is the best recommendation regarding the syndesmotic screws?
Correct Answer & Explanation
. Routine removal is not indicated unless the patient becomes symptomatic
Explanation
Current evidence demonstrates no functional benefit to the routine removal of asymptomatic syndesmotic screws. Removal is generally reserved for patients who experience localized pain or prominent hardware irritation.
Question 913
Topic: 2. Trauma
When evaluating a patient with a closed, displaced intra-articular calcaneus fracture, a computed tomography (CT) scan is obtained for pre-operative planning. The Sanders classification system is universally utilized for these fractures. On which specific CT view and anatomic location is the Sanders classification based?
Correct Answer & Explanation
. Coronal view at the widest portion of the posterior facet
Explanation
The Sanders classification for intra-articular calcaneus fractures assesses the number and location of articular fracture lines. It is specifically determined using the coronal CT slice that shows the widest portion of the posterior facet of the calcaneus.
Question 914
Topic: 2. Trauma
A healthy 30-year-old male undergoes rigid open reduction and internal fixation of an uncomminuted, bimalleolar equivalent ankle fracture. The surgeon considers initiating early active range of motion and early weight-bearing (at 2-3 weeks post-operatively) in a controlled fracture boot. According to recent prospective studies, what is the expected outcome of this rehabilitation protocol compared to 6 weeks of non-weight-bearing cast immobilization?
Correct Answer & Explanation
. Improved early functional scores and earlier return to work, with no difference in late functional outcomes
Explanation
Early weight-bearing and active ROM in compliant, healthy patients with rigidly fixed ankle fractures leads to improved early functional scores, faster return to work, and reduced ankle stiffness, without significantly increasing the risk of hardware failure or loss of reduction.
Question 915
Topic: 2. Trauma
A 42-year-old female presents to the office for follow up after sustaining a minimally displaced radial head fracture 3 months prior. She states she was initially treated in long-arm splint by the ER and did not follow up with an orthopaedic surgeon until now. Per her report, she removed the splint 4 weeks after the injury, but did not move her elbow due to pain. She now has no pain but is unable to reach that hand to her face or head. The remaining history is significant for previous ulnar nerve surgery for which she is unable to provide details. On physical examination, her upper extremity is normal except for limited flexion/extension, measured to be 80 to 50 degrees by goniometer. In addition, she has a well-healed surgical incision about the medial elbow, consistent with a previous surgery on her ulnar nerve. Her images are shown.
What is the diagnosis?
Correct Answer & Explanation
. Early post-traumatic intrinsic joint contracture
Explanation
Correct Answer: AThis patient presents with an 'early post-traumatic intrinsic joint contracture.' The term 'early' is defined as within 6 months of the injury; this patient is 3 months post-injury. 'Intrinsic' causes of elbow stiffness refer to problems within the joint itself, such as articular incongruity, loose bodies, or severe osteoarthritis. In this case, the minimally displaced radial head fracture, even if healed, can lead to subtle incongruity or altered joint mechanics contributing to the stiffness. The prolonged immobilization and subsequent lack of motion due to pain also contribute. 'Extrinsic' causes involve structures outside the joint, such as capsular tightness, muscle contracture, heterotopic ossification, or skin contractures. While capsular tightness is likely present, the primary underlying cause stemming from the intra-articular fracture classifies it as intrinsic. Given the timeframe, it is not 'late' (greater than 6 months), and while there may be extrinsic components, the initial classification based on the radial head fracture points to an intrinsic cause.
Question 916
Topic: 2. Trauma
A 35-year-old male presents to the emergency department after a high-speed motor vehicle collision with a Glasgow Coma Scale of 14, an open tibia fracture, and a clinically unstable pelvis on examination. His blood pressure is 80/40 mmHg, heart rate is 130 bpm, and respiratory rate is 26 bpm. He is pale and diaphoretic. What is the MOST critical immediate intervention after establishing airway and breathing?
Correct Answer & Explanation
. Apply a pelvic binder
Explanation
Correct Answer: BIn a hypotensive trauma patient with a clinically unstable pelvis, immediate application of a pelvic binder is a critical life-saving intervention. An unstable pelvic fracture can lead to massive hemorrhage from venous plexuses and arterial injury, and external compression can significantly reduce blood loss. While fluid resuscitation (crystalloids, blood products), TXA, and diagnostic exams (FAST) are all crucial components of trauma management, controlling the source of hemorrhage from the pelvis takes immediate precedence in this scenario to stabilize the patient's hemodynamics. Rapid IV access and fluid infusion should occur concurrently.
Question 917
Topic: 2. Trauma
A 29-year-old male with a femur fracture undergoes intramedullary nailing. During reaming, the anesthesiologist observes a sudden decrease in SpO2, hypotension (BP 70/40 mmHg), and an increase in end-tidal CO2. The surgical field is free of significant bleeding. What is the most likely cause?
Correct Answer & Explanation
. Fat embolism syndrome
Explanation
Correct Answer: AFat embolism syndrome (FES) is a classic complication of long bone fractures, particularly during intramedullary reaming, where marrow contents are forced into the circulation. The triad of respiratory insufficiency, neurological symptoms, and petechial rash is characteristic, but acute intraoperative FES can manifest as sudden hypoxemia, hypotension, and an increase in end-tidal CO2. This is due to mechanical obstruction and chemical irritation of the pulmonary vasculature by fat globules. Pulmonary embolism (thrombotic) usually doesn't have the same acute increase in ETCO2, and is less common acutely during reaming. Local anesthetic toxicity typically presents with CNS excitation or depression, and/or cardiovascular collapse with wide QRS or arrhythmias. Venous air embolism is also a possibility but often occurs earlier in the case, and ETCO2 changes can vary. Pneumothorax would cause hypoxemia and hypotension but not typically an increase in ETCO2 unless it led to profound hypoventilation.
Question 918
Topic: 2. Trauma
During cementation of a prosthetic component in a total hip arthroplasty, the patient's blood pressure drops acutely to 70/40 mmHg, and oxygen saturation decreases to 88%. What is the most likely cause?
Correct Answer: BBone cement implantation syndrome (BMIS) is a well-recognized complication during cemented orthopedic procedures, particularly total hip arthroplasty. It is triggered by the absorption of bone cement monomers and release of vasoactive substances and microemboli (fat, air, marrow, cement) into the circulation, especially during reaming, femoral preparation, and cement pressurization. BMIS can manifest as sudden hypotension, hypoxemia, pulmonary hypertension, and cardiac arrhythmias, leading to cardiovascular collapse. While fat embolism syndrome is related, BMIS specifically encompasses the broader constellation of cardiopulmonary changes during cementation. The other options are less likely to occur precisely during cementation.
Question 919
Topic: 2. Trauma
A 45-year-old construction worker sustains a highly comminuted, intra-articular Colles fracture (Frykman Type IV). After closed reduction, radiographs show significant residual articular step-off (>2 mm) and metaphyseal comminution with loss of radial height. He has no neurovascular deficits. What is the most appropriate definitive management strategy?
Correct Answer & Explanation
. Open reduction internal fixation (ORIF) with a volar locking plate
Explanation
For a highly comminuted, intra-articular distal radius fracture with significant articular step-off and metaphyseal comminution in a relatively young, active patient, ORIF with a volar locking plate is generally considered the gold standard. A volar locking plate provides rigid fixation, allows for accurate restoration of articular congruence, and permits early mobilization, which is crucial for functional recovery. External fixation alone might not adequately reduce and maintain articular fragments, and K-wires are often insufficient for highly comminuted or intra-articular patterns. Cast immobilization would predictably result in malunion and severe functional deficit given the instability and articular involvement.
Question 920
Topic: 2. Trauma
A 72-year-old patient undergoes closed reduction and casting for a Colles fracture. Three weeks post-reduction, they develop increasing pain, swelling, skin discoloration, and temperature changes in the affected hand, out of proportion to the injury. Active and passive range of motion of the digits is severely limited. What is the most likely diagnosis?
Correct Answer & Explanation
. Complex regional pain syndrome (CRPS) Type I
Explanation
Correct Answer: DThe constellation of symptoms including increasing pain, swelling, skin discoloration, temperature changes (autonomic dysfunction), and severely limited digital motion, out of proportion to the injury and occurring weeks after reduction, is highly suggestive of Complex Regional Pain Syndrome (CRPS) Type I, also known as Reflex Sympathetic Dystrophy (RSD). This condition is a common complication after distal radius fractures. Compartment syndrome is an acute emergency, typically occurring within hours to days, characterized by severe pain with passive stretching and potentially paresthesias and pallor, which is not the typical presentation here. Median nerve compression usually presents with specific sensory and motor deficits. EPL rupture causes a specific loss of thumb extension, and ulnar styloid nonunion would primarily cause focal pain and possibly DRUJ instability, not generalized hand symptoms.
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