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2. Trauma MCQs

Practice Set 527 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 10521

Topic: 2. Trauma

A 42-year-old male sustains a severe intra-articular distal femur fracture (OTA 33-C3). CT imaging reveals a distinct coronal plane fracture of the lateral femoral condyle. What is the optimal surgical approach to directly visualize and reduce this specific fragment?

. Standard lateral approach
. Medial parapatellar approach
. Swashbuckler (modified anterior) approach
. Subvastus approach
. Direct posterior approach

Correct Answer & Explanation

. Standard lateral approach

Explanation

A coronal fracture of the femoral condyle is a Hoffa fragment. The Swashbuckler (modified anterior) approach provides extensive exposure to the distal articular surface, allowing direct visualization and reduction of coronal plane fractures.

Question 10522

Topic: 2. Trauma

A 30-year-old male with a closed tibial shaft fracture complains of pain out of proportion to the injury. Compartment pressure monitoring reveals an absolute anterior compartment pressure of 45 mmHg. His diastolic blood pressure is 65 mmHg. What is the most appropriate next step?

. Immediate four-compartment fasciotomy
. Continuous clinical monitoring
. Elevation of the extremity above the heart
. Administration of IV mannitol
. Application of a compressive dressing

Correct Answer & Explanation

. Immediate four-compartment fasciotomy

Explanation

The delta P (Diastolic BP minus compartment pressure) is 20 mmHg. A delta P of less than 30 mmHg is highly diagnostic of acute compartment syndrome and warrants immediate fasciotomy.

Question 10523

Topic: 2. Trauma

A 45-year-old diabetic male sustains a high-energy closed pilon fracture with severe soft tissue swelling and prominent fracture blisters over the medial ankle. What is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Spanning external fixation and elevation
. Primary ankle arthrodesis
. Application of a tight short leg cast
. Intramedullary nailing of the fibula only

Correct Answer & Explanation

. Immediate open reduction and internal fixation

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with staged treatment. Initial spanning external fixation allows the soft tissue envelope to recover before definitive open reduction and internal fixation.

Question 10524

Topic: 2. Trauma

During surgical approach for a displaced intra-articular calcaneus fracture, care must be taken to avoid a specific tendon that runs directly inferior to the sustentaculum tali. Which tendon is this?

. Tibialis posterior
. Flexor digitorum longus
. Flexor hallucis longus
. Peroneus longus
. Peroneus brevis

Correct Answer & Explanation

. Tibialis posterior

Explanation

The flexor hallucis longus (FHL) tendon passes directly under the sustentaculum tali. It is at risk for injury or entrapment during the reduction and fixation of calcaneus fractures.

Question 10525

Topic: 2. Trauma

A 32-year-old female sustains a talar neck fracture. Six weeks post-operatively, a subchondral radiolucent line is visible in the talar dome on the AP ankle radiograph. What does this radiographic finding indicate?

. Onset of avascular necrosis
. Intact vascularity to the talar body
. Nonunion of the fracture site
. Post-traumatic osteoarthritis
. Deep bone infection

Correct Answer & Explanation

. Onset of avascular necrosis

Explanation

The subchondral radiolucent line is known as Hawkins sign. It represents subchondral osteopenia due to bone resorption, which requires intact vascularity, thereby ruling out avascular necrosis of the talar body.

Question 10526

Topic: 2. Trauma

A 22-year-old male with bilateral femur fractures develops acute confusion, a petechial rash over the axilla and thorax, and hypoxia 36 hours after his injury. What is the most likely diagnosis?

. Pulmonary embolism
. Acute respiratory distress syndrome
. Fat embolism syndrome
. Septic shock
. Hypovolemic shock

Correct Answer & Explanation

. Pulmonary embolism

Explanation

The classic triad of respiratory distress, neurologic changes, and a petechial rash appearing 24 to 72 hours after long bone fractures is hallmark for Fat Embolism Syndrome (FES).

Question 10527

Topic: 2. Trauma

A 72-year-old female on long-term alendronate therapy presents with progressively worsening anterior thigh pain. Radiographs reveal a localized periosteal reaction and a transverse radiolucent line on the lateral cortex of her subtrochanteric femur. What is the recommended management?

. Discontinue alendronate and observe
. Immediate total hip arthroplasty
. Prophylactic intramedullary nailing
. Application of a hip spica cast
. Switch to zoledronic acid

Correct Answer & Explanation

. Discontinue alendronate and observe

Explanation

This patient has an impending atypical femur fracture associated with bisphosphonate use. Because she is symptomatic with radiographic evidence of a stress fracture, prophylactic intramedullary nailing is indicated to prevent catastrophic completion of the fracture.

Question 10528

Topic: 2. Trauma

A 30-year-old male sustains a low-velocity gunshot wound to the thigh resulting in a comminuted midshaft femur fracture. The bullet remains lodged in the vastus lateralis. He has normal distal pulses and a normal neurologic exam. What is the standard of care for the soft tissue injury?

. Immediate formal surgical exploration and tract debridement
. Local wound care, tetanus prophylaxis, and appropriate antibiotics
. Wide excision of the bullet tract
. Immediate bullet extraction to prevent lead toxicity
. Application of a vacuum-assisted closure device

Correct Answer & Explanation

. Immediate formal surgical exploration and tract debridement

Explanation

Low-velocity gunshot wounds to extremities without significant contamination or vascular injury do not require formal surgical debridement of the tract. Management consists of local wound care, tetanus prophylaxis, and antibiotics.

Question 10529

Topic: 2. Trauma

According to the classic principles described by Godina for lower extremity open fractures, within what optimal timeframe should definitive soft tissue coverage be performed to minimize infection and flap failure?

. Within 24 hours
. Within 72 hours
. Between 7 and 10 days
. Between 14 and 21 days
. After 6 weeks

Correct Answer & Explanation

. Within 24 hours

Explanation

Godina demonstrated that performing definitive soft tissue coverage within 72 hours of injury significantly reduces the rates of deep infection and flap failure in high-energy open lower extremity fractures.

Question 10530

Topic: 2. Trauma

A 45-year-old male presents with a painful midshaft tibia 8 months after cast treatment for a closed fracture. Radiographs show a fracture line with abundant, bridging callus that fails to cross the fracture site (elephant shoe appearance). What is the underlying cause and preferred treatment?

. Inadequate biology; requires autologous bone grafting
. Inadequate stability; requires rigid internal fixation
. Infection; requires aggressive debridement and antibiotics
. Malnutrition; requires vitamin D and calcium supplementation
. Smoking; requires smoking cessation and continued observation

Correct Answer & Explanation

. Inadequate biology; requires autologous bone grafting

Explanation

An "elephant shoe" appearance describes a hypertrophic nonunion, which has excellent biology but lacks adequate mechanical stability. The treatment of choice is rigid internal fixation, typically with an intramedullary nail, without the need for bone grafting.

Question 10531

Topic: 2. Trauma

A 35-year-old male sustains a closed transverse fracture of the middle third of the humerus. On physical exam in the emergency department, he is unable to actively extend his wrist or digits. What is the most appropriate initial management?

. Immediate surgical exploration of the radial nerve
. Closed reduction and coaptation splinting with observation of the nerve palsy
. Electromyography (EMG) to assess the level of nerve injury
. Immediate intramedullary nailing of the humerus
. Primary nerve grafting

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve

Explanation

Primary radial nerve palsy in the setting of a closed humeral shaft fracture (even transverse) is treated expectantly. Most are neurapraxias that will recover spontaneously. Closed reduction and functional bracing/splinting is the standard initial care.

Question 10532

Topic: 2. Trauma

A 25-year-old polytrauma patient is intubated in the ICU with a closed tibial shaft fracture. His blood pressure is 90/60 mmHg. His leg is tense and swollen. Which compartment pressure measurement definitively confirms the diagnosis of acute compartment syndrome in this hypotensive patient?

. Absolute compartment pressure > 30 mmHg
. Absolute compartment pressure > 45 mmHg
. Delta pressure (diastolic blood pressure minus compartment pressure) < 30 mmHg
. Delta pressure (mean arterial pressure minus compartment pressure) < 30 mmHg
. Delta pressure (systolic blood pressure minus compartment pressure) < 30 mmHg

Correct Answer & Explanation

. Absolute compartment pressure > 30 mmHg

Explanation

In hypotensive patients, delta pressure (diastolic blood pressure minus compartment pressure) < 30 mmHg is the most accurate diagnostic threshold for acute compartment syndrome, preventing over-diagnosis.

Question 10533

Topic: 2. Trauma

A 28-year-old male with a severe traumatic brain injury (GCS 6) and an isolated closed femoral shaft fracture is brought to the emergency department. His intracranial pressure (ICP) is being continuously monitored and is consistently measuring 28 mmHg despite maximal medical therapy. What is the most appropriate initial orthopedic management of his femoral shaft fracture?

. Reamed intramedullary nailing
. Unreamed intramedullary nailing
. Open reduction and internal fixation with a plate
. External fixation
. Skeletal traction

Correct Answer & Explanation

. Reamed intramedullary nailing

Explanation

In a patient with a severe traumatic brain injury and elevated intracranial pressure (greater than 20 mmHg), early definitive fixation such as intramedullary nailing can cause a "second hit" via hypotension or hypoxia, worsening the brain injury. Damage control orthopedics with temporary external fixation is the safest and most appropriate initial management.

Question 10534

Topic: 2. Trauma

A 35-year-old obtunded polytrauma patient is admitted to the intensive care unit after sustaining a closed tibial shaft fracture. Due to the patient's altered mental status, continuous intracompartmental pressure monitoring is initiated. Which of the following pressure thresholds is the most reliable indicator for performing a four-compartment leg fasciotomy?

. Absolute intracompartmental pressure greater than 30 mmHg
. Absolute intracompartmental pressure greater than 40 mmHg
. Systolic blood pressure minus intracompartmental pressure less than 30 mmHg
. Mean arterial pressure minus intracompartmental pressure less than 30 mmHg
. Diastolic blood pressure minus intracompartmental pressure less than 30 mmHg

Correct Answer & Explanation

. Absolute intracompartmental pressure greater than 30 mmHg

Explanation

The delta pressure (diastolic blood pressure minus intracompartmental pressure) is the most accurate prognostic indicator for acute compartment syndrome. A delta pressure of less than 30 mmHg is an absolute indication for emergency fasciotomy, as it accounts for the patient's systemic perfusion pressure.

Question 10535

Topic: 2. Trauma

Which of the following physiologic parameters is the most reliable indicator of adequate systemic resuscitation, allowing safe progression from temporary damage control external fixation to definitive intramedullary nailing in a polytrauma patient?

. Urine output consistently greater than 0.5 mL/kg/hr for 6 hours
. Systolic blood pressure strictly greater than 100 mmHg for 24 hours
. Normalization of serum lactate to less than 2.0 mmol/L
. Serum hemoglobin concentration greater than 8 g/dL
. Sustained resting heart rate less than 90 beats per minute

Correct Answer & Explanation

. Urine output consistently greater than 0.5 mL/kg/hr for 6 hours

Explanation

Normalization of serum lactate (less than 2.0 mmol/L) and resolution of base deficit are the most reliable indicators of adequate end-organ tissue perfusion. These biochemical markers confirm that the patient has cleared the "first hit" systemic inflammatory response and can safely tolerate the physiological burden of definitive fracture fixation.

Question 10536

Topic: 2. Trauma

A 9-year-old boy presents with a proximal humerus fracture after a minor fall. Radiographs show a centrally located, completely lytic metaphyseal lesion with a 'fallen leaf' sign. Aspiration of the fluid from this lesion would most likely reveal pathologically high levels of which of the following?

. Alkaline phosphatase
. Prostaglandins
. Matrix metalloproteinases
. Vascular endothelial growth factor
. Interleukin-6

Correct Answer & Explanation

. Alkaline phosphatase

Explanation

The 'fallen leaf' sign indicates a pathologic fracture through a unicameral bone cyst (UBC). The cyst fluid typically contains high levels of prostaglandins, oxygen free radicals, and interleukins, which stimulate osteoclastic bone resorption.

Question 10537

Topic: 2. Trauma

A 2-year-old boy sustains a closed, isolated midshaft femur fracture. The decision is made to treat him with early spica casting. To appropriately control the proximal fragment and align the fracture, in what position should the hip be casted?

. Extension and adduction
. Flexion and adduction
. Flexion, abduction, and external rotation
. Extension, abduction, and internal rotation
. Neutral flexion/extension and internal rotation

Correct Answer & Explanation

. Extension and adduction

Explanation

In a proximal or midshaft pediatric femur fracture, the proximal fragment assumes a predictable position due to muscle pull: flexion (iliopsoas), abduction (gluteus medius and minimus), and external rotation (short external rotators). To achieve alignment, the distal fragment (controlled by the spica cast) must be matched to the position of the proximal fragment. Thus, the cast is applied with the hip flexed, abducted, and externally rotated.

Question 10538

Topic: 2. Trauma
A 10-year-old girl sustains a knee injury while skiing. Radiographs reveal a completely displaced (Meyers and McKeever Type III) avulsion fracture of the tibial eminence. During a closed reduction attempt, the fragment fails to reduce into its anatomical bed. Which anatomical structure is most commonly responsible for blocking the reduction?
. Anterior horn of the medial meniscus
. Transverse intermeniscal ligament
. Anterior horn of the lateral meniscus
. Ligament of Wrisberg
. Infrapatellar fat pad

Correct Answer & Explanation

. Anterior horn of the medial meniscus

Explanation

In Meyers and McKeever Type II and III tibial eminence (tibial spine) avulsion fractures, the most common structure to interpose and block an anatomic reduction is the anterior horn of the medial meniscus, and occasionally the intermeniscal ligament. Because of this entrapment, anatomic reduction often requires arthroscopic or open intervention to extricate the meniscus and anatomically secure the bony fragment.

Question 10539

Topic: Lower Extremity Trauma
An 8-year-old boy presents with a painful clunking sensation in his left knee when walking. MRI confirms a discoid lateral meniscus. During arthroscopic evaluation, the meniscus is found to be hypermobile due to an absent posterior meniscotibial attachment, tethered only by the meniscofemoral ligament. Which Watanabe type does this represent?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

The Watanabe classification of discoid meniscus describes three types: Type I (Complete) covers the entire tibial plateau and has normal attachments; Type II (Incomplete) partially covers the plateau and has normal attachments; Type III (Wrisberg variant) lacks the normal posterior meniscotibial attachment (coronary ligament), relying solely on the meniscofemoral ligament of Wrisberg. This leads to a hypermobile meniscus and the classic 'snapping knee' syndrome.

Question 10540

Topic: 2. Trauma

A 6-year-old boy sustains a severe extension-type supracondylar fracture of the humerus. On examination in the emergency department, his hand is pink and warm, with brisk capillary refill, but the radial pulse is not palpable. What is the most appropriate initial management step?

. Immediate vascular surgery consultation for brachial artery exploration
. CT angiogram of the upper extremity
. Closed reduction and percutaneous pinning, followed by reassessment of the pulse
. Open reduction through an anterior approach to explore the brachial artery
. Application of a long arm cast in 120 degrees of flexion and admit for observation

Correct Answer & Explanation

. Immediate vascular surgery consultation for brachial artery exploration

Explanation

A 'pink, pulseless hand' following a supracondylar humerus fracture indicates that, while the brachial artery may be kinked or in spasm, collateral circulation is adequately maintaining distal perfusion. The gold standard initial management is prompt closed reduction and percutaneous pinning (CRPP) to restore anatomy and relieve kinking. Reassessment of the pulse and perfusion follows fixation. Routine vascular exploration is not indicated initially if the hand remains well-perfused. Casting in severe flexion is contraindicated due to the risk of compartment syndrome.

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