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 10081
Topic: 2. Trauma
A 4-year-old child presents with a 'toddler's fracture' of the tibia. What is the characteristic radiographic finding?
Correct Answer & Explanation
. Oblique or spiral non-displaced fracture of the tibial shaft.
Explanation
A 'toddler's fracture' is a common, non-displaced or minimally displaced, spiral or oblique fracture of the distal or mid-tibial shaft in ambulatory young children (typically 9 months to 3 years old). It often occurs with minimal or unrecognized trauma. Radiographs can sometimes be subtle, showing only a hairline lucency or just periosteal reaction after a week or two. The other options describe different fracture patterns that are not characteristic of a toddler's fracture.
Question 10082
Topic: 2. Trauma
Which type of fracture is most commonly associated with a high incidence of non-union due to its inherently poor blood supply?
Correct Answer & Explanation
. Scaphoid waist fracture.
Explanation
The scaphoid waist fracture is classically associated with a high incidence of non-union and avascular necrosis (AVN) due to its retrograde blood supply. The blood supply to the proximal pole of the scaphoid enters distally, meaning a fracture through the waist can compromise the blood supply to the proximal fragment. This makes scaphoid waist fractures notoriously slow to heal and prone to complications. Other fractures listed have better inherent blood supplies and lower non-union rates.
Question 10083
Topic: 2. Trauma
Which classification system is primarily used to assess the severity of acetabular fractures and guide surgical approach?
Correct Answer & Explanation
. Letournel and Judet classification.
Explanation
The Letournel and Judet classification system is the universally recognized and most commonly used system to assess the severity and morphology of acetabular fractures. It divides fractures into elementary patterns (e.g., anterior wall, posterior column, transverse) and associated patterns (e.g., T-type, posterior column and wall). This classification guides the choice of surgical approach and predicts prognosis. Gustilo-Anderson is for open fractures. AO/OTA is a general system for all fractures but less specific for acetabulum. Mason is for radial head fractures. Denis is for thoracolumbar spine fractures.
Question 10084
Topic: 2. Trauma
A 30-year-old male sustains a severe open pilon fracture (distal tibia intra-articular) with significant soft tissue compromise. After initial debridement and external fixation, the soft tissue condition remains precarious. What is the optimal timing for definitive internal fixation of the fracture?
Correct Answer & Explanation
. When the soft tissue envelope has recovered, often 7-21 days later (the 'wrinkle sign').
Explanation
For severe open pilon fractures with significant soft tissue compromise, the optimal timing for definitive internal fixation is when the soft tissue envelope has recovered. This often means waiting 7-21 days (or even longer) after the initial injury and external fixation, until the 'wrinkle sign' is present (indicating decreased soft tissue edema and skin laxity). Operating too early in the presence of severe soft tissue swelling significantly increases the risk of wound complications, infection, and non-union. Immediate fixation is reserved for pristine soft tissues, and 3-5 days is still too early for severe compromise. Waiting 6 weeks might risk malunion. While external fixation can be definitive, internal fixation is generally preferred for optimal articular reconstruction if soft tissues allow.
Question 10085
Topic: 2. Trauma
Which classification system is used to assess the severity of proximal humerus fractures?
Correct Answer & Explanation
. Neer classification.
Explanation
The Neer classification system is the most widely recognized and commonly used system for classifying proximal humerus fractures. It categorizes fractures based on the number of displaced 'parts' (anatomical neck, surgical neck, greater tuberosity, lesser tuberosity) by more than 1 cm displacement or 45 degrees angulation. Gustilo-Anderson is for open fractures. AO/OTA is a general fracture classification. Hawkins is for talar neck fractures. Salter-Harris is for physeal (growth plate) fractures in children.
Question 10086
Topic: 2. Trauma
In the management of pediatric femoral shaft fractures, what is the generally accepted threshold for surgical intervention (e.g., intramedullary nailing) in a school-aged child (6-12 years old)?
Correct Answer & Explanation
. Age-dependent guidelines, but typically above 6 years old for unstable or displaced fractures.
Explanation
For school-aged children (6-12 years old) with displaced or unstable femoral shaft fractures, surgical management, typically with flexible or rigid intramedullary nailing, is the generally accepted threshold. While younger children (0-5 years) often do well with spica casting and older adolescents (12+) are treated more like adults with rigid nailing, the 6-12 year age group represents a transition where surgical fixation often provides better stability, allows for earlier mobilization, and reduces the risk of malunion or refracture compared to prolonged casting. The specific amount of shortening or angulation that mandates surgery can vary slightly, but unstable or significantly displaced fractures in this age group are usually surgical. Open fractures or polytrauma are always indications for surgical intervention regardless of age.
Question 10087
Topic: 2. Trauma
A 70-year-old male is admitted for a hip fracture after a fall. He has a history of benign prostatic hyperplasia (BPH) and is scheduled for surgery. To minimize the risk of postoperative urinary retention, what is the most appropriate preoperative consideration?
Correct Answer & Explanation
. Assess for baseline urinary symptoms and consider a trial of voiding or catheterization.
Explanation
Patients with BPH are at increased risk for postoperative urinary retention due to multifactorial reasons including anesthesia, pain medications, and immobility. The most appropriate preoperative consideration is to assess their baseline urinary symptoms (e.g., frequency, nocturia, hesitancy, incomplete emptying). For those with significant symptoms, a trial of voiding before surgery or even prophylactic catheterization might be considered, or careful monitoring post-op. Delaying urgent hip fracture surgery or performing a prostatectomy or initiating alpha-blockers acutely are generally not practical or safe for immediate preoperative management of a hip fracture. Strict fluid restriction is usually discouraged as it can lead to dehydration.
Question 10088
Topic: 2. Trauma
Which type of pelvic fracture is most commonly associated with urethral injury in males?
Straddle fractures, involving bilateral fractures of the pubic rami (often from direct perineal trauma or falls onto hard objects), are strongly associated with urethral injuries in males, particularly posterior urethral disruption. The significant displacement of the pubic symphysis can shear the urethra. While any high-energy pelvic fracture can be associated with urethral injury, straddle fractures carry a particularly high risk. APC I and LC I are relatively stable and less prone to major urogenital trauma. Vertical shear fractures involve significant displacement but the direct force on the perineum is less pronounced than with a straddle mechanism for urethral injury.
Question 10089
Topic: 2. Trauma
Which of the following is an absolute contraindication for non-operative management of a first rib fracture?
Correct Answer & Explanation
. Evidence of subclavian artery or brachial plexus injury.
Explanation
First rib fractures are often associated with high-energy trauma and can be markers for underlying severe injuries, particularly neurovascular structures. Evidence of subclavian artery or brachial plexus injury is an absolute contraindication for non-operative management, as these injuries require immediate surgical evaluation and often repair to prevent permanent neurological or vascular deficits. While pneumothorax, pulmonary contusion, and significant displacement are serious associated injuries and warrant close monitoring or intervention, they do not universally mandate surgical management of the rib fracture itself in the same way neurovascular injury does. Age over 65 increases morbidity but is not an absolute contraindication to non-operative management of the fracture.
Question 10090
Topic: 2. Trauma
A 40-year-old male develops rhabdomyolysis and acute kidney injury following a crush injury to his thigh, requiring emergent fasciotomy for compartment syndrome. Which of the following laboratory findings is most indicative of rhabdomyolysis?
Correct Answer & Explanation
. Elevated creatine kinase (CK).
Explanation
While all options listed are potential consequences or associated findings in rhabdomyolysis and acute kidney injury, an elevated creatine kinase (CK) is the most direct and sensitive laboratory marker for muscle damage characteristic of rhabdomyolysis. CK levels can rise to tens or even hundreds of thousands. Myoglobinuria, hyperkalemia, elevated BUN/creatinine (indicating kidney injury), and hypocalcemia (due to calcium sequestration in damaged muscle) are all important findings but are either less specific or occur as a result of the muscle breakdown. An extremely high CK level is the hallmark of rhabdomyolysis.
Question 10091
Topic: 2. Trauma
A 25-year-old male presents to the ED after a severe chest trauma. He has multiple left rib fractures (ribs 9-11) and tenderness in the left upper quadrant. Initial X-rays show no pneumothorax or hemothorax. What associated visceral injury should be highly suspected and investigated?
Correct Answer & Explanation
. Splenic injury.
Explanation
Fractures of the lower ribs (9-11) on the left side, particularly with tenderness in the left upper quadrant, should raise a high suspicion for splenic injury. The spleen is located under the left lower ribs and is vulnerable to direct trauma. Cardiac contusion is more associated with sternal or anterior rib fractures. Liver laceration would be suspected with right-sided lower rib fractures. Renal contusion would be a consideration for more posterior lower rib fractures, and diaphragmatic rupture, while possible, is less common than splenic injury with this pattern of trauma. A CT scan of the abdomen and pelvis would be indicated.
Question 10092
Topic: 2. Trauma
During an open reduction and internal fixation of a severe acetabular fracture, a large retroperitoneal hematoma is encountered. What is the most common iatrogenic urological injury associated with complex pelvic and acetabular fracture surgery, especially with extensive retroperitoneal dissection?
Correct Answer & Explanation
. Ureteral injury.
Explanation
Ureteral injury, particularly during extensive retroperitoneal dissection for complex pelvic and acetabular fracture surgery, is a recognized although uncommon iatrogenic complication. The ureters can be inadvertently clamped, ligated, or lacerated, especially when dealing with large hematomas or distorted anatomy. Bladder rupture and urethral laceration are more common with the initial trauma itself rather than iatrogenic during surgery, although bladder injury is possible with anterior acetabular approaches. Renal artery avulsion is less likely with acetabular surgery, and testicular torsion is unrelated.
Question 10093
Topic: 2. Trauma
Which of the following is a classic presentation of fat embolism syndrome after a long bone fracture, particularly affecting the respiratory system?
Correct Answer & Explanation
. Sudden onset of dyspnea, hypoxemia, and petechial rash.
Explanation
Fat embolism syndrome (FES) is a serious complication following long bone fractures, particularly femur and tibia. The classic triad of FES includes respiratory distress (dyspnea, hypoxemia, tachypnea), neurological dysfunction (confusion, disorientation), and a petechial rash (over the chest, axillae, conjunctiva). Sudden onset of dyspnea, hypoxemia, and petechial rash is the most classic and specific presentation of FES affecting the respiratory system. The other options are either local fracture symptoms, general inflammatory responses, or other complications of trauma/immobility, not specific to FES.
Question 10094
Topic: 2. Trauma
Which of the following interventions is most crucial for preventing acute kidney injury (AKI) in a patient undergoing massive transfusion for a complex pelvic fracture?
Correct Answer & Explanation
. Maintaining euvolemia and blood pressure.
Explanation
In the setting of massive transfusion for complex pelvic fractures, patients are at high risk for acute kidney injury due to hypoperfusion, shock, and complications from transfusion (e.g., pigment nephropathy from hemolysis). Maintaining euvolemia and systemic blood pressure (mean arterial pressure > 65 mmHg) is paramount to ensure adequate renal perfusion and oxygenation, thereby preventing AKI. Loop diuretics can worsen hypovolemia. Aggressive vasopressors without adequate volume resuscitation can exacerbate renal ischemia. Restricting crystalloids too much can lead to under-resuscitation. Prophylactic hemodialysis is not indicated.
Question 10095
Topic: 2. Trauma
A 30-year-old female presents with severe pain in her right upper extremity after a fall. She has sustained a comminuted fracture of the right humeral shaft. She is also complaining of shortness of breath and pleuritic chest pain. On examination, there is crepitus over the right lateral chest wall. What is the most likely associated thoracic injury?
Correct Answer & Explanation
. Pneumothorax.
Explanation
The patient's symptoms of shortness of breath and pleuritic chest pain, along with crepitus over the lateral chest wall, are highly suggestive of a pneumothorax, likely caused by an associated rib fracture that might have punctured the pleura. While a humeral shaft fracture typically does not directly cause thoracic injury, a severe fall could lead to both injuries independently. Pulmonary contusion can cause shortness of breath, but crepitus points more to air in the subcutaneous tissues from a pneumothorax. Cardiac contusion and aortic dissection are less likely given the presentation. Diaphragmatic rupture is also possible but less directly indicated by crepitus.
Question 10096
Topic: 2. Trauma
A 35-year-old male presents with persistent pain and numbness in the C8-T1 distribution after a clavicle fracture that healed with significant malunion. What is the most likely cause of his new neurological symptoms?
Correct Answer & Explanation
. Brachial plexus compression by the malunited clavicle or exuberant callus.
Explanation
A malunited clavicle, particularly with significant displacement or exuberant callus formation, can compress the brachial plexus (especially the lower trunk, C8-T1) as it passes through the thoracic outlet. This compression leads to pain, numbness, and weakness in the C8-T1 distribution. While a nonunion can also cause symptoms, direct compression from a malunion/callus is a specific orthopedic complication. Long thoracic nerve injury primarily affects serratus anterior function (scapular winging). Cervical radiculopathy is a differential but less likely to be directly caused by a healed clavicle fracture. A Pancoast tumor would be a rare and unrelated occurrence in this context.
Question 10097
Topic: 2. Trauma
In evaluating a stable patient with multiple rib fractures and a sternal fracture following blunt chest trauma, what is the most important radiographic finding to monitor for in the initial 24-48 hours to assess for pulmonary contusion progression?
Correct Answer & Explanation
. Increasing opacification and consolidation on chest X-ray.
Explanation
Pulmonary contusion is a common consequence of blunt chest trauma and involves bruising of lung tissue. It often progresses in the first 24-48 hours, leading to increasing inflammation, edema, and hemorrhage within the lung parenchyma. This progression is typically seen on chest X-ray as increasing opacification and consolidation, which correlates with worsening respiratory function (hypoxia, decreased lung compliance). Widening of the mediastinum suggests aortic injury. Hemothorax is blood in the pleural space. Fracture displacement is related to the bony injury. Resolution of subcutaneous emphysema is a good sign, but increasing opacification directly monitors the contusion.
Question 10098
Topic: 2. Trauma
A 65-year-old male undergoes a major spinal fusion for severe kyphoscoliosis. Postoperatively, he develops acute respiratory distress, hypoxemia, and bilateral pulmonary infiltrates, but no fever. Cardiac evaluation is unremarkable. Which of the following is the most likely pulmonary complication?
Correct Answer & Explanation
. Acute respiratory distress syndrome (ARDS).
Explanation
Acute respiratory distress syndrome (ARDS) is a severe form of acute lung injury characterized by acute onset of hypoxemia, bilateral pulmonary infiltrates on chest imaging, and absence of cardiogenic pulmonary edema. Major orthopedic surgeries, especially spinal fusions in patients with pre-existing lung conditions, can trigger a systemic inflammatory response leading to ARDS. While aspiration pneumonia and atelectasis are possible, the severity (acute respiratory distress, bilateral infiltrates) without fever makes ARDS a more likely diagnosis. Pulmonary embolism typically presents with sudden dyspnea and hypoxemia but often without bilateral infiltrates initially. Congestive heart failure would usually show signs of cardiogenic edema.
Question 10099
Topic: 2. Trauma
A 35-year-old male presents with severe pelvic pain after a high-energy motor vehicle collision. He is hypotensive (BP 80/50 mmHg) and tachycardic (HR 120 bpm). Physical examination reveals a distended abdomen, perineal ecchymosis, and an open book pelvic injury evident on AP pelvis X-ray. Initial management should prioritize which of the following?
Correct Answer & Explanation
. Resuscitation with crystalloids and blood products, followed by pelvic binder application
Explanation
In a hemodynamically unstable patient with an open book pelvic fracture, immediate resuscitation with fluids and blood products is paramount. Application of a pelvic binder or sheet is crucial to reduce the pelvic volume and tamponade hemorrhage, thereby stabilizing the patient. While external fixation, angiography, laparotomy, and urethral evaluation are often necessary in subsequent steps, they follow initial hemodynamic stabilization.
Question 10100
Topic: 2. Trauma
A 72-year-old female undergoes a cemented total hip arthroplasty for osteoarthritis. Post-operatively, she develops sudden onset dyspnea, hypoxemia, and a petechial rash. Which of the following is the most likely diagnosis?
Correct Answer & Explanation
. Fat embolism syndrome
Explanation
The classic triad of symptoms (respiratory distress, neurological deficits, and petechial rash) following a long bone fracture or arthroplasty (especially cemented, which can increase intramedullary pressure, pushing marrow contents into the circulation) strongly suggests fat embolism syndrome. Pulmonary embolism often presents with dyspnea and hypoxemia but typically lacks the petechial rash and prominent neurological symptoms. Other options are less likely given the specific symptom constellation and acute post-operative timing.
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