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2. Trauma MCQs

Practice Set 526 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 10501

Topic: 2. Trauma

A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago.

Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure

A. What is the next most appropriate step in treatment?

. Exchange nailing
. Manipulation under anesthesia
. Nail removal and plate fixation
. Percutaneous locked plating
. Nail dynamization

Correct Answer & Explanation

. Exchange nailing

Explanation

Plate fixation (with bone graft as needed) is the procedure of choice for humeral shaft nonunions.Rubel et al in a combined cadaveric and clinical study comparing one versus two plate constructs for humeral nonunions found that the two plate construct was significantly stiffer, but had no difference in healing rate compared with a single plate construct; 92% of the humeral shaft nonunion patients went onto union with rigid plate fixation.Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. Theyreport 100% union rate with locking plate fixation of these humeral shaft nonunions, with use of autograft in >50% of their cases. Subjective shoulder scores were excellent or good in 22 of 24 patients.Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.

Question 10502

Topic: 2. Trauma
A 25-year-old male sustains a humeral shaft fracture and is treated with the implant seen in Figure A. Compared with open reduction and internal fixation with a plate and screw construct, the treatment shown in Figure A is associated with all of the following EXCEPT?
. Increased shoulder impingement
. No difference in rate of union
. Increased shoulder range of motion
. No difference in rate of radial nerve injury
. Increased risk of revision surgery

Correct Answer & Explanation

. Increased shoulder range of motion

Explanation

The radiograph shows a humeral shaft fracture treated with an intramedullary nail (IMN). It is important to note that the answer to this question continues to evolve as more data and studies are performed. McCormack prospectively randomized 44 humeral shaft fractures to treatment by intramedullary nailing vs. dynamic compression (DCP) plating and found the risk of shoulder impingement, iatrogenic comminution, and nonunion were higher in the nail treatment group resulting in a higher revision rate. They found no significant differences in shoulder/elbow function, VAS pain scores, ROM, or time to return to normal activity. Chapman et al in their prospective randomized trial between IMN and plate fixation found that the IMN group had higher rates of postoperative shoulder pain and a slower time to fracture union. The ORIF had faster time to union, but reduced elbow range of motion. Both studies show the effectiveness of IMN and ORIF in the treatment of humeral shaft fractures. More recent meta-analysis such as by Ma et al show that both IMN and DCP can achieve similar fracture union with a similar incidence of radial nerve injury and infection. IMN was associated with an increased risk of shoulder impingement, more restriction of shoulder movement, an increased risk of intraoperative fracture comminution, a higher incidence of implant failure, and an increased risk of re-operation.

Question 10503

Topic: 2. Trauma
A 69-year-old female sustains the injuries seen in Figures A and B. This injury is best classified as which of the following?
. Schatzker type I tibial plateau fracture
. Schatzker type III tibial plateau fracture
. Schatzker type IV tibial plateau fracture
. Schatzker type V tibial plateau fracture
. Schatzker type VI tibial plateau fracture

Correct Answer & Explanation

. Schatzker type III tibial plateau fracture

Explanation

The radiographs and CT scan images show a depressed lateral tibial plateau fracture, which is correctly classified as a Schatzker III tibial plateau fracture. This fracture typically occurs as the result of the femoral condyle directly impacting the articular surface in older patients with osteopenia. The referenced article by Bennett et al reviews the associated soft tissue injury with tibial plateau fractures. They found a 56% frequency of associated soft tissue injuries overall, with MCL injured in 20%, the LCL in 3%, the menisci in 20%, the peroneal nerve in 3%, and the anterior cruciate ligaments in 10%. Schatzker type IV and type II fracture patterns were associated with the highest frequency of soft tissue injuries.

Question 10504

Topic: 2. Trauma

A 25-year-old polytraumatized male is intubated and sedated. He has a closed tibial shaft fracture. Which of the following pressure measurements is an absolute indication for a four-compartment fasciotomy?

. Absolute compartment pressure > 20 mmHg
. Diastolic blood pressure minus compartment pressure < 30 mmHg
. Mean arterial pressure minus compartment pressure < 40 mmHg
. Absolute compartment pressure > 25 mmHg
. Systolic blood pressure minus compartment pressure < 50 mmHg

Correct Answer & Explanation

. Absolute compartment pressure > 20 mmHg

Explanation

In an obtunded patient, a delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is the most reliable threshold indicating the need for emergent fasciotomy.

Question 10505

Topic: 2. Trauma

A 30-year-old farmer sustains an open tibial shaft fracture heavily contaminated with soil and manure. Which of the following intravenous antibiotic regimens is most appropriate for initial management?

. Cefazolin alone
. Cefazolin and clindamycin
. Cefazolin and an aminoglycoside
. Ceftriaxone, an aminoglycoside, and high-dose penicillin
. Vancomycin and piperacillin-tazobactam

Correct Answer & Explanation

. Cefazolin alone

Explanation

Open fractures with severe agricultural contamination require broad-spectrum coverage, including high-dose penicillin, to protect against Clostridium species, in addition to Gram-positive and Gram-negative coverage.

Question 10506

Topic: 2. Trauma

A 40-year-old male presents with bilateral femoral shaft fractures and a severe head injury (GCS 6) following a motor vehicle collision. His serum lactate is 4.5 mmol/L. What is the most appropriate initial management of his femoral fractures?

. Immediate bilateral reamed antegrade intramedullary nailing
. Immediate bilateral unreamed intramedullary nailing
. Bilateral damage control external fixation
. Open reduction and internal fixation with plates
. Skeletal traction and delayed internal fixation

Correct Answer & Explanation

. Immediate bilateral reamed antegrade intramedullary nailing

Explanation

In a hemodynamically unstable polytrauma patient with an elevated lactate (>2.5 mmol/L) and severe traumatic brain injury, damage control orthopedics with external fixation is indicated to minimize the second hit phenomenon.

Question 10507

Topic: 2. Trauma

What is the maximum acceptable coronal plane deformity (varus/valgus) when treating a closed tibial shaft fracture non-operatively in a long leg cast?

. 2 degrees
. 5 degrees
. 10 degrees
. 15 degrees
. 20 degrees

Correct Answer & Explanation

. 2 degrees

Explanation

Acceptable alignment for non-operative management of a tibial shaft fracture includes <5 degrees of varus/valgus angulation, <10 degrees of AP angulation, <10 degrees of rotation, and <1 cm of shortening.

Question 10508

Topic: 2. Trauma
A 45-year-old male is struck by a vehicle, sustaining a closed pelvic ring injury. Examination reveals a large, fluctuant swelling over the greater trochanter with overlying skin bruising and necrosis. What is the most likely diagnosis?
. Ischial bursitis
. Gluteal compartment syndrome
. Morel-Lavallée lesion
. Trochanteric bursitis
. Necrotizing fasciitis

Correct Answer & Explanation

. Morel-Lavallée lesion

Explanation

A Morel-Lavallée lesion is a closed degloving injury where the skin and subcutaneous tissue are separated from the underlying fascia, leading to a hemolymphatic fluid collection that is at high risk for infection.

Question 10509

Topic: 2. Trauma

A 28-year-old motorcyclist sustains a distal femur fracture. Radiographs and CT scan show a coronal plane fracture of the lateral femoral condyle. What is the standard classification and recommended fixation for this specific fragment?

. Jones fracture; tension band wiring
. Hoffa fracture; anterior-to-posterior or posterior-to-anterior lag screws
. Barton fracture; volar plating
. Segond fracture; conservative management
. Pilon fracture; external fixation

Correct Answer & Explanation

. Jones fracture; tension band wiring

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle (most commonly lateral). It requires anatomic reduction and interfragmentary compression with AP or PA lag screws.

Question 10510

Topic: 2. Trauma

A 22-year-old male sustains a low-velocity gunshot wound to the thigh. Radiographs show a minimally displaced midshaft femur fracture. The bullet passed through the thigh and exited. There are no hard signs of vascular injury. What is the most appropriate management?

. Local wound care, IV antibiotics, and emergent intramedullary nailing
. Formal surgical debridement of the bullet track and external fixation
. Angiography followed by open reduction and internal fixation
. Excisional debridement of all skin margins and skeletal traction
. Local wound care, oral antibiotics, and cast bracing

Correct Answer & Explanation

. Local wound care, IV antibiotics, and emergent intramedullary nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures without neurovascular compromise are treated similar to closed fractures with local wound care, antibiotics, and early intramedullary nailing.

Question 10511

Topic: 2. Trauma

Which of the following is a classic triad associated with Fat Embolism Syndrome (FES)?

. Hypoxemia, neurologic compromise, and petechial rash
. Hypotension, tachycardia, and muffled heart sounds
. Fever, right upper quadrant pain, and jaundice
. Hypertension, bradycardia, and irregular respirations
. Hematuria, flank pain, and palpable abdominal mass

Correct Answer & Explanation

. Hypoxemia, neurologic compromise, and petechial rash

Explanation

Fat Embolism Syndrome (FES) classically presents with hypoxemia, neurological abnormalities, and a petechial rash, typically 24-72 hours after major long bone trauma. Early fracture fixation reduces its incidence.

Question 10512

Topic: 2. Trauma
A 32-year-old male presents with a displaced, vertically oriented Pauwels type III femoral neck fracture. Which of the following fixation constructs provides the most biomechanically stable construct for this fracture pattern?
. Three parallel cancellous screws in an inverted triangle
. Sliding hip screw with a derotation cancellous screw
. Cephalomedullary nail
. Hemiarthroplasty
. Two parallel cancellous screws

Correct Answer & Explanation

. Sliding hip screw with a derotation cancellous screw

Explanation

For highly vertical, shear-type femoral neck fractures (Pauwels type III) in young adults, a sliding hip screw with a supplemental derotation screw offers superior biomechanical stability compared to multiple cancellous screws.

Question 10513

Topic: 2. Trauma

A 35-year-old male undergoes intramedullary nailing for a proximal third tibial shaft fracture. Post-operatively, a significant apex-anterior (procurvatum) deformity is noted. Which technique could have been used to prevent this deformity during the procedure?

. Nailing in 90 degrees of knee flexion
. Using a medial entry point
. Placing blocking (Poller) screws posterior to the nail in the proximal fragment
. Using a smaller diameter nail without reaming
. Placing blocking screws anterior to the nail in the distal fragment

Correct Answer & Explanation

. Nailing in 90 degrees of knee flexion

Explanation

Proximal third tibia fractures tend to displace into procurvatum and valgus during IM nailing. This can be prevented by a semi-extended nailing technique or the use of blocking (Poller) screws posterior to the nail in the proximal fragment.

Question 10514

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable patient with an anterior-posterior compression (APC-III) pelvic ring injury requires emergent pelvic binder application. What is the correct anatomical landmark for positioning the binder?
. Over the iliac crests
. Over the greater trochanters
. At the level of the umbilicus
. Mid-thigh
. Over the lower lumbar spine

Correct Answer & Explanation

. Over the greater trochanters

Explanation

Pelvic binders must be centered directly over the greater trochanters to effectively close the pelvic volume and provide tamponade. Placing it over the iliac crests is less effective and may worsen the deformity.

Question 10515

Topic: 2. Trauma
According to Godina's classic principles, what is the optimal timeframe for performing free tissue transfer to cover a severe open tibial fracture (Gustilo IIIB) to minimize infection and maximize flap survival?
. Within 72 hours
. Between 7 to 10 days
. Between 2 to 3 weeks
. After 4 weeks of negative pressure wound therapy
. Immediately during the index debridement

Correct Answer & Explanation

. Within 72 hours

Explanation

Godina's classic studies demonstrated that early free flap coverage within 72 hours for severe open lower extremity fractures significantly reduced the rates of infection and flap failure.

Question 10516

Topic: 2. Trauma
An 18-year-old male presents with a severely mangled lower extremity following a motorcycle accident. Which of the following is considered an absolute indication for primary amputation?
. Gustilo IIIC open fracture
. Loss of plantar sensation
. Warm ischemia time greater than 6 hours
. Complete transaction of the peroneal nerve
. Significant segmental bone loss (>5 cm)

Correct Answer & Explanation

. Warm ischemia time greater than 6 hours

Explanation

Prolonged warm ischemia (> 6 hours) leading to irreversible muscle necrosis and severe crush injuries are absolute indications for primary amputation. Loss of plantar sensation is no longer considered an absolute indication.

Question 10517

Topic: 2. Trauma

A 28-year-old polytrauma patient with a severe bilateral femur fracture presents to the emergency department. Which of the following laboratory values is the best indicator to proceed with Damage Control Orthopedics (DCO) rather than Early Total Care (ETC)?

. Serum lactate of 1.5 mmol/L
. Platelet count of 150,000/mm3
. Base excess of -8.0 mmol/L
. pH of 7.35
. INR of 1.1

Correct Answer & Explanation

. Serum lactate of 1.5 mmol/L

Explanation

A base excess worse than -5.0 mmol/L indicates significant hypoperfusion and acidosis, making the patient a borderline or unstable candidate. In such cases, Damage Control Orthopedics (DCO) is preferred over Early Total Care (ETC) to avoid a second hit phenomenon.

Question 10518

Topic: 2. Trauma
A 35-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture following a motorcycle collision. What is the most critical factor in reducing the patient's risk of deep infection?
. Time to definitive soft tissue coverage
. Time to initial administration of systemic antibiotics
. Time to initial surgical debridement
. Use of local antibiotic-impregnated beads
. Choice of internal versus external fixation

Correct Answer & Explanation

. Time to initial administration of systemic antibiotics

Explanation

The most critical factor in preventing deep infection in open fractures is the early administration of systemic antibiotics. Studies have consistently shown that delaying antibiotics beyond 1-3 hours significantly increases infection rates.

Question 10519

Topic: 2. Trauma
A 25-year-old male presents with a vertically oriented, displaced femoral neck fracture (Pauwels Type III). What fixation construct provides the most biomechanical stability for this high-shear fracture pattern?
. Three parallel cancellous screws
. Sliding hip screw with a derotational screw
. Cephalomedullary nail
. Proximal femoral locking plate
. Two crossed cancellous screws

Correct Answer & Explanation

. Sliding hip screw with a derotational screw

Explanation

Pauwels Type III fractures experience high shear forces leading to varus collapse. A fixed-angle device, such as a sliding hip screw (often with a derotational screw), provides superior biomechanical stability compared to multiple cancellous screws.

Question 10520

Topic: Pelvic & Acetabular Trauma

In a hemodynamically unstable patient with a suspected anteroposterior compression (APC) pelvic ring injury, what is the correct anatomic landmark for the optimal placement of a circumferential pelvic binder?

. Iliac crests
. Greater trochanters
. Anterior superior iliac spines
. Pubic symphysis
. Subtrochanteric femur

Correct Answer & Explanation

. Iliac crests

Explanation

A pelvic binder should be centered precisely over the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests is incorrect and can paradoxically widen the pelvic outlet.

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