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2. Trauma MCQs

Practice Set 501 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 10001

Topic: 2. Trauma

A 78-year-old female undergoes cephalomedullary nailing for an unstable intertrochanteric femur fracture. Postoperatively, she develops a progressively expanding pulsatile mass in the medial thigh and unexplained tachycardia. Injury to which vessel is most likely responsible, and what is the typical iatrogenic mechanism?

. Superficial femoral artery; over-penetration of the guidewire during distal locking.
. Profunda femoris artery; over-plunging of the drill bit during insertion of the distal interlocking screw.
. Medial circumflex femoral artery; malpositioning of the helical blade in the femoral head.
. Lateral circumflex femoral artery; aggressive reaming of the proximal femoral metaphysis.
. Obturator artery; errant placement of the distal locking screw from anterior to posterior.

Correct Answer & Explanation

. Profunda femoris artery; over-plunging of the drill bit during insertion of the distal interlocking screw.

Explanation

Pseudoaneurysm of the profunda femoris artery is a classic vascular complication of cephalomedullary nailing for intertrochanteric fractures. It is most commonly caused by over-plunging of the drill bit or using screws that are too long during the placement of distal interlocking screws.

Question 10002

Topic: 2. Trauma

A 30-year-old male presents with a displaced intracapsular femoral neck fracture. The decision is made to perform urgent open reduction and internal fixation. A capsulotomy is planned to decompress the intracapsular hematoma. To avoid compromising the remaining blood supply to the femoral head, what is the recommended orientation and location of the capsulotomy?

. T-shaped incision with the vertical limb along the anterior femoral neck, preserving the posterior and superior capsule.
. I-shaped incision along the posterior femoral neck, releasing the piriformis tendon.
. Circumferential release of the capsule at the base of the femoral neck.
. Z-shaped incision extending from the lateral trochanter to the inferior capsule.
. Vertical incision directly through the zona orbicularis on the superior neck.

Correct Answer & Explanation

. T-shaped incision with the vertical limb along the anterior femoral neck, preserving the posterior and superior capsule.

Explanation

A T-shaped or longitudinal capsulotomy along the anterior femoral neck allows for adequate hematoma decompression and direct visualization for fracture reduction. This approach safely avoids the critical lateral epiphyseal vessels, which are terminal branches of the medial circumflex femoral artery located in the posterosuperior retinaculum.

Question 10003

Topic: 2. Trauma

A 32-year-old woman presents with a pathologic fracture of her proximal phalanx through a previously asymptomatic lytic lesion with stippled calcifications. What is the most appropriate initial management?

. Immediate intralesional curettage, bone grafting, and internal fixation
. Immediate wide local excision and ray amputation
. Immobilization to allow fracture healing, followed by elective curettage and bone grafting
. Neoadjuvant chemotherapy followed by curettage
. Radiation therapy followed by internal fixation

Correct Answer & Explanation

. Immobilization to allow fracture healing, followed by elective curettage and bone grafting

Explanation

Pathologic fractures through enchondromas in the hand should initially be allowed to heal with conservative immobilization. Curettage and bone grafting are performed electively once the fracture has healed.

Question 10004

Topic: 2. Trauma

A 15-year-old boy presents with knee pain. Radiographs reveal a 2 cm eccentric, purely lytic lesion in the epiphysis of the distal femur. Histology demonstrates mononuclear cells with grooved nuclei and "chicken-wire" calcifications. What is the most common complication following the standard surgical treatment of this lesion?

. Pulmonary metastasis
. Malignant transformation
. Local recurrence
. Pathologic fracture
. Joint space infection

Correct Answer & Explanation

. Local recurrence

Explanation

The diagnosis is chondroblastoma, typically treated with extended intralesional curettage and bone grafting. Despite standard treatment, local recurrence is the most common complication, occurring in up to 15-20% of cases.

Question 10005

Topic: 2. Trauma

A 30-year-old female sustains a closed, non-displaced fracture of her proximal phalanx after minor trauma. Radiographs reveal an underlying expansile, well-circumscribed radiolucent lesion with stippled calcifications.

What is the most appropriate management?

. Immediate curettage and bone grafting
. Amputation of the affected digit
. Immobilization until fracture healing, followed by curettage and grafting
. Wide local excision and strut grafting
. Neoadjuvant chemotherapy followed by curettage

Correct Answer & Explanation

. Immobilization until fracture healing, followed by curettage and grafting

Explanation

This is a pathologic fracture through an enchondroma of the hand. The standard of care is to allow the fracture to heal with immobilization first, then perform intralesional curettage and bone grafting to prevent recurrence.

Question 10006

Topic: Upper Extremity Trauma

A 45-year-old woman is evaluated for a new painful mass in her proximal humerus. She has a known history of Ollier disease. Radiographs show a destructive lesion arising from a pre-existing calcified intramedullary tumor. Which of the following genetic mutations is most strongly associated with her underlying syndrome?

. EXT1
. GNAS
. IDH1
. RB1
. USP6

Correct Answer & Explanation

. IDH1

Explanation

Ollier disease (multiple enchromatosis) and Maffucci syndrome are strongly associated with somatic mutations in the IDH1 or IDH2 genes. EXT1 mutations are associated with hereditary multiple exostoses.

Question 10007

Topic: Lower Extremity Trauma

In evaluating an intramedullary cartilaginous lesion of the distal femur, which MRI finding best distinguishes a bone infarct from an enchondroma?

. High signal intensity on T2-weighted images
. Lobular internal architecture
. A serpiginous margin of low signal intensity on T1 and T2 images
. Endosteal scalloping
. Presence of calcified matrix

Correct Answer & Explanation

. A serpiginous margin of low signal intensity on T1 and T2 images

Explanation

A bone infarct is classically characterized by a serpiginous rim of low signal on T1 and T2-weighted images (the double-line sign). Enchondromas typically show a lobulated, hyperintense pattern on T2-weighted images corresponding to their high water content.

Question 10008

Topic: 2. Trauma

A 34-year-old male presents with acute pain in his ring finger after a minor jamming injury. Radiographs show a pathologic fracture through a central lytic lesion with stippled calcifications in the proximal phalanx.

What is the most appropriate management?

. Immediate curettage and bone grafting
. Amputation of the affected digit
. Immobilization until fracture healing, followed by curettage and grafting
. Wide local excision and strut allograft
. Intravenous bisphosphonates

Correct Answer & Explanation

. Immobilization until fracture healing, followed by curettage and grafting

Explanation

Enchondromas are the most common primary bone tumors of the hand. When presenting with a pathologic fracture, the standard treatment is to immobilize the digit to allow the fracture to heal, followed later by curettage and bone grafting to prevent recurrence.

Question 10009

Topic: Upper Extremity Trauma

A 22-year-old male presents with a slow-growing, painless mass on his proximal humerus.

Imaging reveals a 2.5 cm surface lesion causing saucerization of the underlying cortex with a sclerotic margin. What is the definitive treatment to minimize local recurrence?

. Observation with serial radiographs
. Intralesional curettage and bone grafting
. Marginal excision including the underlying sclerotic cortical bone
. Wide en bloc resection with 2 cm margins
. Neoadjuvant radiation followed by excision

Correct Answer & Explanation

. Marginal excision including the underlying sclerotic cortical bone

Explanation

The clinical and radiographic presentation is classic for a periosteal chondroma. To minimize recurrence, treatment requires marginal excision that includes the underlying sclerotic cortex.

Question 10010

Topic: Lower Extremity Trauma

A 60-year-old female undergoes an MRI of her knee for a suspected meniscal tear. An incidental intramedullary distal femur lesion is identified. Which of the following MRI findings best distinguishes a bone infarct from an enchondroma?

. Lobulated, bright high-signal intensity on T2-weighted images
. A serpiginous border with a 'double-line' sign
. Endosteal scalloping greater than two-thirds of cortical thickness
. Enhancement of the central matrix after gadolinium administration
. Presence of soft tissue extension

Correct Answer & Explanation

. A serpiginous border with a 'double-line' sign

Explanation

Bone infarcts are distinguished on MRI by a serpiginous, well-defined border frequently demonstrating the 'double-line' sign (hyperintense inner ring, hypointense outer ring on T2). Enchondromas typically show characteristic lobulated T2 hyperintensity.

Question 10011

Topic: 2. Trauma

A 30-year-old man presents with acute hand pain after a minor low-energy twisting injury. Radiographs show a pathologic fracture through a well-circumscribed, lucent lesion with central calcifications in the proximal phalanx, consistent with an enchondroma.

What is the most appropriate initial management for this pathologic fracture?

. Immediate intralesional curettage, bone grafting, and internal fixation
. Allow the fracture to heal with immobilization, followed by curettage and bone grafting
. Ray amputation of the affected digit
. Neoadjuvant radiation followed by wide local excision
. Aspiration and corticosteroid injection

Correct Answer & Explanation

. Allow the fracture to heal with immobilization, followed by curettage and bone grafting

Explanation

Most pathologic fractures through a benign enchondroma in the hand should be managed by allowing the fracture to heal first with conservative care. Once healed, definitive intralesional curettage and bone grafting can be performed to restore structural integrity.

Question 10012

Topic: 2. Trauma

A 30-year-old male involved in a high-speed motor vehicle accident presents with a hemodynamically unstable pelvic fracture. Initial resuscitation is underway. What is the most critical next step in managing hemorrhage from the pelvis after initial ABCs?

. Application of external fixator
. Angiography with embolization
. Pelvic binder application
. Exploratory laparotomy
. Transfusion of blood products

Correct Answer & Explanation

. Pelvic binder application

Explanation

In a hemodynamically unstable patient with a suspected pelvic ring injury, immediate pelvic binder application (or sheet wrapping) is a critical initial step to reduce the pelvic volume and tamponade venous bleeding, which is the most common source of significant hemorrhage in these injuries. While angiography with embolization is crucial for arterial bleeding, and external fixation provides definitive stabilization, these typically follow immediate mechanical stabilization. Transfusion is supportive, not a definitive hemorrhage control measure. Laparotomy is indicated for suspected intra-abdominal hemorrhage, not primarily pelvic bone bleeding.

Question 10013

Topic: 2. Trauma

A 35-year-old male sustains a closed comminuted tibia shaft fracture. What is the most common early complication of this injury requiring urgent intervention?

. Nonunion
. Compartment syndrome
. Deep vein thrombosis
. Infection
. Malunion

Correct Answer & Explanation

. Compartment syndrome

Explanation

Compartment syndrome is a critical and common early complication of high-energy tibia shaft fractures due to the confined compartments of the lower leg. It requires urgent recognition and surgical intervention (fasciotomy) to prevent irreversible muscle and nerve damage. Nonunion and malunion are late complications. DVT can occur but is not as acutely limb-threatening as compartment syndrome. Infection is a risk, particularly with open fractures, but compartment syndrome is a more immediate concern for closed comminuted fractures.

Question 10014

Topic: 2. Trauma

Which of the following is considered an absolute contraindication to closed reduction for a fracture-dislocation?

. Open fracture
. Severe comminution of the fracture
. Neurovascular compromise
. Pathologic fracture
. Associated ligamentous injury

Correct Answer & Explanation

. Open fracture

Explanation

An open fracture is an absolute contraindication to closed reduction of a fracture-dislocation. Open fractures require urgent surgical debridement and stabilization to prevent infection. While neurovascular compromise is an emergency requiring prompt reduction, it is not a contraindication to attempted closed reduction; rather, it's an indication for it. Severe comminution might make closed reduction difficult or unstable, but it's not an absolute contraindication. Pathologic fractures and associated ligamentous injuries generally don't contraindicate closed reduction.

Question 10015

Topic: 2. Trauma

What is the primary goal of surgical management for unstable intertrochanteric hip fractures in an elderly patient?

. Achieve anatomic reduction at all costs
. Preserve the femoral head viability
. Allow early mobilization and weight-bearing
. Minimize operative time regardless of implant choice
. Perform a total hip arthroplasty

Correct Answer & Explanation

. Allow early mobilization and weight-bearing

Explanation

For unstable intertrochanteric hip fractures in elderly patients, the primary goal of surgical management (typically with an intramedullary nail or sliding hip screw) is to provide stable fixation that allows for early mobilization and weight-bearing. This helps to prevent complications associated with prolonged immobility, such as pneumonia, DVT, and decubitus ulcers. While anatomic reduction is desired, it is often secondary to stability for early mobilization in this population. Preservation of femoral head viability is more critical for femoral neck fractures. Total hip arthroplasty is generally not indicated for intertrochanteric fractures unless there is pre-existing severe arthritis or nonunion.

Question 10016

Topic: 2. Trauma

In the context of a tibial plateau fracture, a 'sagging' posterior displacement of the proximal tibia on lateral radiographs suggests injury to which structure?

. Anterior cruciate ligament
. Medial collateral ligament
. Lateral collateral ligament
. Posterior cruciate ligament
. Medial meniscus

Correct Answer & Explanation

. Posterior cruciate ligament

Explanation

A 'sagging' posterior displacement of the proximal tibia relative to the femur on a lateral radiograph (especially when the patient is supine and the knee is flexed) is a classic sign of Posterior Cruciate Ligament (PCL) insufficiency. This often occurs with bicondylar tibial plateau fractures or high-energy trauma affecting the posterior structures. ACL injury would result in anterior translation. MCL and LCL injuries involve valgus and varus stability, respectively. Meniscal injuries do not cause this specific radiographic sign of instability.

Question 10017

Topic: 2. Trauma

A patient presents with pain and swelling around the distal radius after a fall onto an outstretched hand. Radiographs show a fracture of the distal radius with dorsal displacement and angulation. Which eponymous fracture does this describe?

. Galeazzi fracture
. Monteggia fracture
. Colles fracture
. Smith fracture
. Barton's fracture

Correct Answer & Explanation

. Colles fracture

Explanation

A Colles fracture is a fracture of the distal radius with dorsal displacement and dorsal angulation, typically resulting from a fall onto an outstretched hand (FOOSH) with the wrist in extension. A Smith fracture (reverse Colles) involves volar displacement and angulation. A Galeazzi fracture involves a distal radial shaft fracture with associated distal radioulnar joint (DRUJ) dislocation. A Monteggia fracture involves a proximal ulnar shaft fracture with associated radial head dislocation. A Barton's fracture is an intra-articular fracture of the distal radius with dislocation of the carpus, either dorsally or volarly.

Question 10018

Topic: 2. Trauma
Which factor is most crucial in determining the need for operative fixation in a displaced intra-articular calcaneal fracture?
. Patient's age
. Presence of skin tenting
. Extent of articular surface depression
. Degree of calcaneal widening
. Number of associated fractures

Correct Answer & Explanation

. Extent of articular surface depression

Explanation

For displaced intra-articular calcaneal fractures, the extent of articular surface depression (specifically, the depression of the posterior facet) and the involvement of the Bรถhler's angle are crucial for surgical decision-making. Significant articular depression warrants surgical reduction and fixation to restore joint congruity and minimize post-traumatic arthritis. Skin tenting is an indication for immediate reduction but not the primary factor for internal fixation decision. Calcaneal widening and associated fractures are important but secondary to articular involvement for surgical indications.

Question 10019

Topic: 2. Trauma

Which of the following is an absolute indication for surgical intervention in a patient with a scaphoid fracture?

. Non-displaced fracture of the distal pole
. Stable fracture of the waist
. Displaced fracture with greater than 1mm step-off or angulation
. Fracture of the tubercle
. Positive snuffbox tenderness

Correct Answer & Explanation

. Displaced fracture with greater than 1mm step-off or angulation

Explanation

A displaced scaphoid fracture (typically defined as >1mm displacement, angulation >10-15 degrees, or significant humpback deformity) is an absolute indication for surgical intervention due to the high risk of nonunion and avascular necrosis. Non-displaced fractures of the distal pole or stable waist fractures are often treated non-operatively in a cast. Fracture of the tubercle is usually treated symptomatically. Positive snuffbox tenderness indicates suspicion but not a definitive need for surgery alone.

Question 10020

Topic: 2. Trauma

What is the most common complication of a high-energy Pilon fracture of the distal tibia?

. Nonunion
. Malunion
. Post-traumatic arthritis
. Infection
. Compartment syndrome

Correct Answer & Explanation

. Post-traumatic arthritis

Explanation

Pilon fractures (distal tibia intra-articular fractures) are high-energy injuries involving the weight-bearing surface of the ankle. The most common and devastating long-term complication, despite optimal surgical management, is post-traumatic arthritis due to the severe articular damage and often irreparable chondral injury. While nonunion, malunion, and infection can occur, post-traumatic arthritis is the most frequent and significant cause of long-term disability. Compartment syndrome is an acute complication.

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