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2. Trauma MCQs

Practice Set 528 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 10541

Topic: 2. Trauma

A 3-year-old boy sustains a closed, isolated, midshaft femur fracture after a fall from a playground structure.

Radiographs show 1.5 cm of overriding. What is the most widely accepted definitive management for this patient?

. Pavlik harness application
. Early single-leg spica casting
. Flexible intramedullary nailing
. Submuscular bridge plating
. External fixation

Correct Answer & Explanation

. Pavlik harness application

Explanation

The standard of care for isolated, closed femur fractures in children aged 6 months to 5 years (with <2 cm of shortening) is early spica casting. The Pavlik harness is indicated for infants under 6 months. Flexible intramedullary nailing is typically indicated for school-aged children (5 to 11 years).

Question 10542

Topic: 2. Trauma

A 7-year-old boy undergoes closed reduction and percutaneous pinning of a displaced supracondylar humerus fracture.

Six hours postoperatively, he is crying uncontrollably on the ward and requires escalating doses of IV opioids. Which of the following is the most reliable early clinical indicator of compartment syndrome in this pediatric patient?

. Absence of a radial pulse
. Pallor and poikilothermia of the digits
. Increasing analgesic requirement / Agitation
. Paresis of the intrinsic hand muscles
. Tense, woody swelling of the forearm

Correct Answer & Explanation

. Absence of a radial pulse

Explanation

In pediatric patients, classic signs like paresthesia and pain out of proportion are difficult to assess. The '3 As' (Anxiety, Agitation, and Increasing Analgesic requirement) are considered the earliest, most sensitive, and most reliable indicators of developing compartment syndrome in children. Pulselessness, pallor, and paresis are very late, often irreversible signs.

Question 10543

Topic: 2. Trauma

An 8-year-old, 35 kg boy sustains a transverse midshaft fracture of the right femur. He is treated with titanium elastic nails (TENs). What is the most common complication associated with this surgical treatment?

. Nonunion
. Deep surgical site infection
. Leg length discrepancy > 2 cm
. Symptomatic hardware irritation at the insertion site
. Avascular necrosis of the femoral head

Correct Answer & Explanation

. Nonunion

Explanation

The most common complication of flexible intramedullary nailing (TENs) for pediatric femur fractures is soft tissue irritation and pain at the distal entry sites. This often necessitates hardware removal once the fracture has healed.

Question 10544

Topic: 2. Trauma

A 9-year-old male presents with acute shoulder pain after throwing a baseball. Radiographs reveal a pathologic fracture through a centrally located, lytic, expansile bone lesion in the proximal humeral metaphysis. A "fallen leaf" sign is noted. What is the most appropriate initial management?

. Immediate curettage and bone grafting
. Immobilization in a sling to allow the fracture to heal
. Aspiration and injection of methylprednisolone in the emergency department
. En bloc resection of the lesion
. Preoperative radiation therapy followed by intramedullary nailing

Correct Answer & Explanation

. Immediate curettage and bone grafting

Explanation

The clinical presentation and "fallen leaf" sign are pathognomonic for a Unicameral Bone Cyst (UBC). When a pathologic fracture occurs through a UBC, initial treatment is immobilization to allow the fracture to heal, which occasionally leads to spontaneous cyst resolution.

Question 10545

Topic: 2. Trauma

A 3-year-old boy sustains an isolated midshaft femur fracture. Radiographs demonstrate 1.5 cm of shortening and 10 degrees of varus angulation. What is the most appropriate definitive management?

. Pavlik harness
. Closed reduction and spica casting
. Flexible intramedullary nailing
. Rigid antegrade intramedullary nailing
. External fixation

Correct Answer & Explanation

. Pavlik harness

Explanation

For children aged 6 months to 5 years with a diaphyseal femur fracture and acceptable shortening (<2 cm), closed reduction and spica casting is the standard of care. Flexible nails are generally reserved for children aged 5 to 11 years or heavier children (>50 lbs).

Question 10546

Topic: 2. Trauma

A 6-year-old girl presents with a painless "clunking" in her right knee. She has no history of trauma. MRI confirms the presence of a Wrisberg variant discoid lateral meniscus. This specific variant is characterized by the absence of which of the following structures?

. Anterior horn meniscal attachment
. Posterior meniscotibial (coronary) ligament
. Transverse intermeniscal ligament
. Meniscofemoral ligament of Humphrey
. Meniscofemoral ligament of Wrisberg

Correct Answer & Explanation

. Anterior horn meniscal attachment

Explanation

The Wrisberg variant of a discoid meniscus lacks the normal posterior meniscotibial (coronary) ligament attachments. Its only posterior tether is the meniscofemoral ligament of Wrisberg, making it highly hypermobile and prone to snapping.

Question 10547

Topic: 2. Trauma
In the evaluation of an intra-articular calcaneus fracture, the Sanders classification is utilized. What specific anatomical finding defines a Sanders Type III fracture?
. One primary fracture line through the posterior facet
. Two primary fracture lines through the posterior facet creating 3 articular fragments
. Three or more primary fracture lines through the posterior facet
. Involvement of the calcaneocuboid joint without posterior facet extension
. Extra-articular fracture involving the calcaneal tuberosity only

Correct Answer & Explanation

. Two primary fracture lines through the posterior facet creating 3 articular fragments

Explanation

The Sanders classification is based on coronal CT images of the posterior facet. Type I: non-displaced. Type II: 1 fracture line (2 articular fragments). Type III: 2 fracture lines (3 articular fragments). Type IV: highly comminuted (4 or more fragments).

Question 10548

Topic: Lower Extremity Trauma

During the radiographic evaluation of a suspected midfoot injury, what finding is considered pathognomonic for a Lisfranc injury?

. Widening of the 1st and 2nd intermetatarsal space > 2mm
. A small bony avulsion fragment in the 1st intermetatarsal space (fleck sign)
. Dorsal displacement of the 1st metatarsal base on the medial cuneiform
. Plantar gapping of the 1st TMT joint
. Compression fracture of the cuboid

Correct Answer & Explanation

. Widening of the 1st and 2nd intermetatarsal space > 2mm

Explanation

The "fleck sign" represents a bony avulsion of the Lisfranc ligament from the base of the second metatarsal. When present on an AP or oblique radiograph, it is considered pathognomonic for a Lisfranc ligament injury.

Question 10549

Topic: 2. Trauma

A 24-year-old elite collegiate basketball player suffers a Zone 2 proximal fifth metatarsal fracture. To minimize the risk of nonunion and expedite his return to play, what is the recommended treatment?

. Short leg cast, strictly non-weight bearing for 6 weeks
. Hard-soled shoe, weight-bearing as tolerated
. Intramedullary screw fixation
. Lateral plate and screw fixation
. Excision of the proximal fragment with peroneus brevis advancement

Correct Answer & Explanation

. Short leg cast, strictly non-weight bearing for 6 weeks

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction, a watershed vascular area prone to nonunion. In elite athletes, early intramedullary screw fixation is highly recommended to reduce the nonunion rate and allow a faster return to competitive play.

Question 10550

Topic: 2. Trauma

When managing a highly comminuted distal tibia pilon fracture (AO/OTA 43-C3) with significant soft tissue injury, standard protocol involves a staged approach (spanning external fixation followed by delayed ORIF). What is the primary rationale for this delay?

. To allow the fracture blisters to re-epithelialize completely
. To allow resolution of the soft tissue swelling and minimize wound complications
. To allow for early callus formation to aid in reduction
. To ascertain patient compliance with non-weight bearing instructions
. To allow for elective scheduling of a 3D CT scan

Correct Answer & Explanation

. To allow the fracture blisters to re-epithelialize completely

Explanation

The primary reason for employing a staged protocol in pilon fractures is to allow the massive soft tissue swelling to resolve (often taking 10-21 days). Attempting early definitive ORIF through a compromised soft tissue envelope carries an unacceptably high risk of wound dehiscence and deep infection.

Question 10551

Topic: 2. Trauma
A 40-year-old construction worker falls from a ladder, sustaining a closed, displaced intra-articular calcaneus fracture. The primary fracture line on the coronal CT scan divides the posterior facet into two pieces. Which of the following describes a Sanders Type II fracture?
. A non-displaced articular fracture
. Two fracture lines dividing the posterior facet into three pieces
. A single primary fracture line dividing the posterior facet into two pieces
. A highly comminuted posterior facet with more than three fracture lines
. An extra-articular fracture involving the calcaneal tuberosity

Correct Answer & Explanation

. A single primary fracture line dividing the posterior facet into two pieces

Explanation

The Sanders classification for intra-articular calcaneus fractures is based on the number of fracture lines through the posterior facet on coronal CT slices. Type I is non-displaced. Type II has one fracture line (creating two articular fragments). Type III has two fracture lines (three fragments). Type IV is highly comminuted (four or more fragments).

Question 10552

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains a fracture of the fifth metatarsal base. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction extending into the intermetatarsal (4-5) articulation. This is a Zone 2 injury. To minimize the risk of nonunion and allow early return to play, what is the best treatment?

. Stiff-soled shoe and weight-bearing as tolerated
. Short-leg walking cast for 6 weeks
. Intramedullary screw fixation
. Excision of the proximal fragment and reattachment of the peroneus brevis
. Tension band wiring

Correct Answer & Explanation

. Stiff-soled shoe and weight-bearing as tolerated

Explanation

The scenario describes a Jones fracture (Zone 2 fracture of the 5th metatarsal base). Because of the watershed blood supply in this area, these fractures have a high risk of delayed union or nonunion. In a high-level athlete, early intramedullary screw fixation is recommended to decrease nonunion rates and expedite return to play compared to non-operative treatment.

Question 10553

Topic: 2. Trauma

A 20-year-old male track athlete complains of vague, aching pain in the dorsal midfoot that is worse with sprinting. Radiographs are negative. An MRI reveals a linear signal abnormality in the central third of the navicular. CT scan confirms an incomplete sagittal fracture. What is the most appropriate initial treatment?

. Rigid short-leg walking boot and return to light jogging
. Immediate open reduction and internal fixation
. Extracorporeal shockwave therapy
. Non-weight-bearing in a short-leg cast for 6 weeks
. Custom orthotics and physical therapy

Correct Answer & Explanation

. Rigid short-leg walking boot and return to light jogging

Explanation

Navicular stress fractures typically occur in the relatively avascular central third of the bone. For incomplete or non-displaced fractures, the gold standard initial treatment is strict non-weight-bearing in a cast for 6 weeks. Weight-bearing in a boot leads to unacceptably high rates of delayed union and nonunion. If conservative treatment fails, or if the fracture is displaced, ORIF (usually with screws) is indicated.

Question 10554

Topic: 2. Trauma

In a high-energy tibial pilon fracture, CT imaging is routinely obtained for preoperative planning. The classic three-fragment pattern involves a medial fragment, a posterior fragment, and an anterolateral fragment. The anterolateral fragment is typically attached to which of the following ligaments?

. Deltoid ligament
. Posterior inferior tibiofibular ligament (PITFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Spring ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Deltoid ligament

Explanation

In a classic pilon fracture, the distal tibia breaks into three main fragments based on their ligamentous attachments. The anterolateral (Chaput) fragment remains attached to the fibula via the anterior inferior tibiofibular ligament (AITFL). The posterior (Volkmann) fragment is attached to the PITFL. The medial malleolar fragment is attached to the deltoid ligament.

Question 10555

Topic: 2. Trauma

A 19-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. He wishes to return to play as soon as possible. What is the recommended treatment?

. Short leg walking boot for 4 weeks
. Non-weight-bearing cast for 6 weeks
. Intramedullary screw fixation
. Tension band wiring
. Primary bone grafting

Correct Answer & Explanation

. Short leg walking boot for 4 weeks

Explanation

Zone II (Jones) fractures have a high rate of nonunion due to watershed blood supply. In elite or competitive athletes, early intramedullary screw fixation is recommended to reduce nonunion risk and expedite safe return to play.

Question 10556

Topic: 2. Trauma

A 22-year-old elite collegiate basketball player sustains a Zone 2 fracture of the proximal fifth metatarsal. To minimize nonunion risk and expedite return to play, what is the treatment of choice?

. Non-weight bearing in a short leg cast for 6 weeks
. Weight-bearing as tolerated in a hard-soled shoe
. Intramedullary screw fixation
. Hook plate fixation
. Tension band wiring

Correct Answer & Explanation

. Non-weight bearing in a short leg cast for 6 weeks

Explanation

Zone 2 fractures (Jones fractures) have high rates of nonunion due to a watershed blood supply area. In high-level athletes, early intramedullary screw fixation is recommended to significantly reduce nonunion risk and allow for a faster return to sport.

Question 10557

Topic: Lower Extremity Trauma

A competitive skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after a sudden dorsiflexion and inversion injury. Radiographs show a small "fleck sign" avulsed from the posterolateral fibula. What is the primary stabilizing structure injured in this condition?

. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Calcaneofibular ligament
. Anterior talofibular ligament
. Spring ligament

Correct Answer & Explanation

. Inferior extensor retinaculum

Explanation

The scenario describes peroneal tendon subluxation or dislocation. The mechanism typically causes attenuation or avulsion (fleck sign) of the superior peroneal retinaculum, which is the primary restraint to peroneal tendon displacement from the fibular groove.

Question 10558

Topic: 2. Trauma

A 20-year-old female track athlete complains of vague, aching midfoot pain that worsens with running. CT imaging demonstrates a partial, non-displaced dorsal cortical stress fracture in the central third of the navicular. What is the most appropriate initial management?

. Running through the pain with NSAID support
. Strict non-weight bearing in a short leg cast for 6 to 8 weeks
. Immediate open reduction and internal fixation
. Weight-bearing as tolerated in a CAM boot with a bone stimulator
. Corticosteroid injection into the talonavicular joint

Correct Answer & Explanation

. Running through the pain with NSAID support

Explanation

Navicular stress fractures occur in the relatively avascular central third of the bone, making them prone to nonunion. The standard of care for partial, non-displaced fractures is strict non-weight bearing in a cast for 6 to 8 weeks.

Question 10559

Topic: 2. Trauma

A 78-year-old male sustains a Type II odontoid fracture after a low-energy mechanical fall. Which of the following factors represents the greatest risk for nonunion if this injury is treated conservatively with a hard cervical collar?

. Age greater than 65 years
. Posterior displacement of 2 mm
. Initial fracture displacement greater than 5 mm
. Angulation of 5 degrees
. Presence of an associated C1 arch fracture

Correct Answer & Explanation

. Age greater than 65 years

Explanation

Type II odontoid fractures involve the waist of the dens and have the highest rate of nonunion among odontoid fractures. Risk factors for nonunion include initial displacement > 5 mm, angulation > 10 degrees, age > 50 years, and delayed presentation. While advanced age is a risk factor, initial fracture displacement > 5 mm is the strongest independent radiographic predictor of nonunion, often prompting early consideration for surgical intervention (e.g., posterior C1-C2 fusion) in candidates who can tolerate surgery.

Question 10560

Topic: Lower Extremity Trauma
The bending rigidity of an intramedullary nail is mathematically dependent on its material properties and its cross-sectional geometry, specifically the area moment of inertia. For a solid circular intramedullary nail, if the radius is increased by a factor of 2, the bending rigidity increases by a factor of:
. 2
. 4
. 8
. 16
. 32

Correct Answer & Explanation

. 16

Explanation

For a solid cylinder, the area moment of inertia (I) is proportional to the radius raised to the fourth power (I = π * r^4 / 4). Therefore, doubling the radius (2r) increases the area moment of inertia, and thus the bending rigidity, by a factor of 2^4 = 16.

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