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2. Trauma MCQs

Practice Set 530 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 10581

Topic: 2. Trauma

A 28-year-old male sustains severe bilateral femur fractures, multiple rib fractures, and bilateral pulmonary contusions in an MVC. Upon arrival, his serum lactate is 5.5 mmol/L, base deficit is -9, and pH is 7.21. After initial resuscitation, his lactate remains at 4.2 mmol/L. What is the most appropriate management for his femur fractures?

. Immediate bilateral intramedullary nailing
. Bilateral external fixation (Damage Control Orthopedics)
. Intramedullary nailing of one femur, external fixation of the other
. Non-operative management with skeletal traction for 6 weeks
. Open reduction and internal fixation with plates

Correct Answer & Explanation

. Immediate bilateral intramedullary nailing

Explanation

This patient presents with polytrauma and remains physiologically 'borderline' to 'in extremis' based on his persistent lactic acidosis, base deficit, and pulmonary contusions. Early Total Care (ETC) with reamed intramedullary nailing can exacerbate the systemic inflammatory response syndrome (SIRS), leading to acute respiratory distress syndrome (ARDS), the 'second hit' phenomenon. Damage Control Orthopedics (DCO) using temporary external fixation is indicated to provide skeletal stability while minimizing the physiological burden.

Question 10582

Topic: 2. Trauma
A 30-year-old male sustains a Pauwels type III femoral neck fracture. To maximize biomechanical stability and reduce the risk of non-union, which of the following internal fixation constructs is most appropriate?
. Three parallel cancellous screws
. Two parallel cancellous screws
. A sliding hip screw (SHS) with an anti-rotation screw
. A dynamic condylar screw (DCS)
. Hemiarthroplasty

Correct Answer & Explanation

. A sliding hip screw (SHS) with an anti-rotation screw

Explanation

Pauwels type III fractures have a vertical fracture line (angle > 50 degrees), which creates high shear forces across the fracture site, predisposing them to non-union and varus collapse. While parallel cancellous screws are commonly used for more horizontal (Pauwels I or II) fractures, a sliding hip screw (with or without an anti-rotation screw) or a proximal femoral locking plate provides better biomechanical stability against vertical shear forces. The addition of an anti-rotation screw to an SHS construct is highly recommended in young patients.

Question 10583

Topic: 2. Trauma
A 45-year-old male suffers a Gustilo-Anderson IIIB open tibia fracture with a 10 cm soft tissue defect over the distal third of the tibia, exposing the bone without periosteal coverage. After serial debridements and skeletal stabilization, what is the most appropriate soft tissue coverage option?
. Split-thickness skin graft
. Medial gastrocnemius rotational flap
. Soleus rotational flap
. Free tissue transfer (e.g., anterolateral thigh or latissimus dorsi flap)
. Reverse sural artery flap

Correct Answer & Explanation

. Free tissue transfer (e.g., anterolateral thigh or latissimus dorsi flap)

Explanation

Soft tissue defects over the distal third of the tibia that expose bone lacking periosteum require robust coverage. Rotational muscle flaps are geographically limited: the medial gastrocnemius covers the proximal third, and the soleus covers the middle third of the tibia. For the distal third, a free tissue transfer (such as an ALT, gracilis, or latissimus dorsi flap) is the gold standard for reliable coverage. A reverse sural flap is an option for smaller defects, but a 10 cm defect typically necessitates a free flap.

Question 10584

Topic: 2. Trauma

A 65-year-old female sustains a subtrochanteric femur fracture. During closed reduction prior to intramedullary nailing, the proximal fragment is noted to be flexed, abducted, and externally rotated. Which muscle groups are primarily responsible for this classic deformity?

. Flexion by iliopsoas, abduction by gluteus medius/minimus, external rotation by short external rotators
. Flexion by rectus femoris, abduction by tensor fasciae latae, external rotation by piriformis
. Flexion by sartorius, abduction by gluteus maximus, external rotation by obturator internus
. Extension by hamstrings, adduction by adductor longus, internal rotation by gluteus minimus
. Flexion by iliopsoas, adduction by adductor magnus, external rotation by quadratus femoris

Correct Answer & Explanation

. Flexion by iliopsoas, abduction by gluteus medius/minimus, external rotation by short external rotators

Explanation

In a subtrochanteric fracture, the proximal fragment is subjected to distinct deforming muscle forces: the iliopsoas (inserting on the lesser trochanter) causes flexion; the gluteus medius and minimus (inserting on the greater trochanter) cause abduction; and the short external rotators (inserting in the trochanteric fossa/crest) cause external rotation. The distal fragment is typically adducted (by the adductor muscles) and shortened.

Question 10585

Topic: 2. Trauma

Which of the following describes the threshold value of 'delta pressure' typically considered an indication for emergency fasciotomy in a suspected acute compartment syndrome of the lower leg?

. Delta pressure < 40 mmHg
. Delta pressure < 30 mmHg
. Delta pressure < 20 mmHg
. Delta pressure < 45 mmHg
. Delta pressure < 10 mmHg

Correct Answer & Explanation

. Delta pressure < 40 mmHg

Explanation

The diagnosis of acute compartment syndrome is primarily clinical, but in obtunded or polytrauma patients, compartment pressure monitoring is essential. While an absolute intracompartmental pressure > 30 mmHg is considered a warning sign, the delta pressure (diastolic blood pressure minus intracompartmental pressure) is a more accurate threshold. A delta pressure of < 30 mmHg indicates inadequate tissue perfusion and is a strong indication for emergency four-compartment fasciotomy.

Question 10586

Topic: 2. Trauma
A 28-year-old male presents with a posterior hip dislocation following a dashboard injury. Post-reduction CT scan reveals a Pipkin Type II fracture. What defines a Pipkin Type II fracture?
. Fracture of the femoral head caudad to the fovea capitis
. Fracture of the femoral head cephalad to the fovea capitis
. Femoral head fracture associated with a femoral neck fracture
. Femoral head fracture associated with an acetabular fracture
. Isolated fracture of the posterior wall of the acetabulum

Correct Answer & Explanation

. Fracture of the femoral head cephalad to the fovea capitis

Explanation

The Pipkin classification describes fractures of the femoral head associated with posterior hip dislocations. Type I is a fracture caudad (inferior) to the fovea capitis (non-weight-bearing portion). Type II is a fracture cephalad (superior) to the fovea capitis (weight-bearing portion). Type III is any femoral head fracture (Type I or II) with an associated femoral neck fracture. Type IV is a femoral head fracture with an associated acetabular fracture.

Question 10587

Topic: 2. Trauma

A 40-year-old male falls from a height and sustains an acetabular fracture. Radiographs and CT demonstrate a transverse fracture line through the acetabulum and an oblique fracture extending down through the obturator ring, separating the anterior and posterior columns. The ischiopubic ramus and iliopubic ramus are fractured, but a portion of the articular surface remains attached to the intact ilium. What is the correct classification?

. Both-column fracture
. T-type fracture
. Transverse fracture
. Anterior column posterior hemi-transverse
. Posterior column with posterior wall

Correct Answer & Explanation

. Both-column fracture

Explanation

The Letournel classification divides acetabular fractures into 5 elementary and 5 associated types. A T-type fracture is an associated fracture pattern characterized by a transverse fracture component combined with a vertical split that extends into the obturator foramen, effectively separating the anterior and posterior columns inferiorly. Unlike a both-column fracture (where NO articular segment remains attached to the intact ilium, denoted by the 'spur sign'), in a T-type fracture, the superior articular surface (the roof) remains attached to the intact ilium.

Question 10588

Topic: 2. Trauma
A 35-year-old male presents with an ipsilateral femur and tibia fracture (floating knee). Radiographs reveal a diaphyseal femur fracture and an intra-articular tibial plateau fracture. According to the Fraser classification, what type of floating knee injury is this?
. Type I
. Type IIA
. Type IIB
. Type IIC
. Type III

Correct Answer & Explanation

. Type IIB

Explanation

The Fraser classification categorizes 'floating knee' injuries (ipsilateral femur and tibia fractures) based on articular involvement. Type I: both fractures are diaphyseal. Type II: involves the joint. Type IIA: diaphyseal tibia fracture + intra-articular distal femur fracture. Type IIB: diaphyseal femur fracture + intra-articular proximal tibia fracture. Type IIC: both fractures are intra-articular. This case is a Type IIB.

Question 10589

Topic: 2. Trauma
A 42-year-old male sustains a high-energy Reudi-Allgower Type III pilon fracture. The soft tissues are severely swollen with fracture blisters. What is the gold-standard initial management protocol for this injury?
. Immediate definitive open reduction and internal fixation (ORIF)
. Primary arthrodesis of the tibiotalar joint
. Spanning external fixation with delayed definitive ORIF
. Non-operative management in a long leg cast
. Immediate intramedullary nailing of the tibia

Correct Answer & Explanation

. Spanning external fixation with delayed definitive ORIF

Explanation

High-energy Pilon fractures are associated with severe soft tissue compromise. Immediate open reduction and internal fixation (ORIF) carries an unacceptably high risk of wound breakdown, deep infection, and osteomyelitis. The current gold-standard protocol is a staged approach: immediate application of a spanning external fixator across the ankle joint to restore length and alignment, followed by a delay of 1-3 weeks for soft tissue swelling to resolve (positive 'wrinkle sign'), after which definitive ORIF is performed.

Question 10590

Topic: 2. Trauma
A 50-year-old male sustains a severe valgus force to the knee, resulting in a split-depression fracture of the lateral tibial plateau. According to the Schatzker classification, what type of fracture is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The Schatzker classification for tibial plateau fractures is: Type I: split fracture of the lateral plateau (typically younger patients). Type II: split-depression fracture of the lateral plateau (most common, older patients). Type III: pure central depression of the lateral plateau. Type IV: medial plateau fracture. Type V: bicondylar fracture. Type VI: metaphyseal-diaphyseal dissociation. A split-depression lateral plateau fracture is a Type II.

Question 10591

Topic: 2. Trauma

An 82-year-old female with a history of severe rheumatoid arthritis and osteoporosis sustains a comminuted, intra-articular distal humerus fracture (AO/OTA 13-C3). What is the most appropriate surgical treatment that allows for immediate post-operative mobilization and predictable functional outcomes?

. Open reduction and internal fixation with dual orthogonal locking plates
. Total elbow arthroplasty (TEA)
. Hemiarthroplasty of the elbow
. Closed reduction and percutaneous pinning
. Olecranon osteotomy with tension band wiring

Correct Answer & Explanation

. Open reduction and internal fixation with dual orthogonal locking plates

Explanation

In elderly patients with osteoporotic bone, severe comminution, and pre-existing joint disease (like rheumatoid arthritis), obtaining stable internal fixation to permit early range of motion is notoriously difficult. Total elbow arthroplasty (TEA) has emerged as the treatment of choice for non-reconstructible distal humerus fractures in low-demand elderly patients, providing reliable pain relief, immediate stability, and early mobilization.

Question 10592

Topic: 2. Trauma

A 22-year-old active male sustains a closed, completely displaced midshaft clavicle fracture with 2.5 cm of shortening. There is no neurovascular deficit. Based on current orthopedic evidence, what is the primary advantage of open reduction and internal fixation (ORIF) over non-operative management for this specific injury pattern?

. Decreased risk of infection
. Lower rate of symptomatic non-union
. Elimination of the need for future hardware removal
. Reduced risk of pneumothorax
. Improved cosmetic appearance without a scar

Correct Answer & Explanation

. Decreased risk of infection

Explanation

While historically most midshaft clavicle fractures were treated non-operatively, recent randomized controlled trials (such as the Canadian Orthopaedic Trauma Society - COTS study) have shown that completely displaced midshaft clavicle fractures with > 2 cm of shortening have a high non-union rate (up to 15-20%) when treated non-operatively. ORIF with plate and screws significantly reduces the rate of symptomatic non-union and malunion, providing a faster return to function.

Question 10593

Topic: Pelvic & Acetabular Trauma

A 35-year-old male is brought to the ED after a high-speed motorcycle collision. He is hypotensive with a blood pressure of 80/40 mmHg and a heart rate of 125 bpm. Secondary survey reveals an unstable pelvis. A pelvic binder is to be applied. What is the correct anatomical landmark for optimal placement of the pelvic binder to effectively reduce pelvic volume?

. Greater trochanters
. Anterior superior iliac spines
. Iliac crests
. Pubic symphysis
. Umbilicus

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders are most effective at reducing pelvic volume and stabilizing the fracture when placed directly over the greater trochanters. Placing the binder too high (e.g., over the ASIS or iliac crests) is mechanically less effective and may paradoxically exacerbate the deformity.

Question 10594

Topic: 2. Trauma

A 40-year-old male presents with a posterior hip dislocation and an associated posterior wall acetabular fracture following a dashboard injury. After closed reduction of the hip, a CT scan reveals a posterior wall fragment constituting 45% of the articular surface with marginal impaction. What is the most appropriate definitive management?

. Non-weight-bearing for 6 weeks
. Skeletal traction for 6 weeks
. Open reduction and internal fixation through a Kocher-Langenbeck approach
. Open reduction and internal fixation through an ilioinguinal approach
. Total hip arthroplasty

Correct Answer & Explanation

. Non-weight-bearing for 6 weeks

Explanation

Posterior wall fractures involving >20-40% of the articular surface, or those with marginal impaction or hip instability, require surgical fixation. The Kocher-Langenbeck approach provides excellent exposure to the posterior column and posterior wall, making it the standard approach for this injury.

Question 10595

Topic: 2. Trauma
A 25-year-old male polytrauma patient sustains a severe closed femoral shaft fracture, bilateral rib fractures, and a grade III liver laceration. On arrival, his pH is 7.15, lactate is 6.5, core temperature is 34°C, and he has required 6 units of PRBCs. According to Damage Control Orthopedics (DCO) principles, what is the best management of his femur fracture at this time?
. Reamed antegrade intramedullary nailing
. Unreamed retrograde intramedullary nailing
. Temporary spanning external fixation
. Open reduction and internal fixation with a compression plate
. Skeletal traction

Correct Answer & Explanation

. Temporary spanning external fixation

Explanation

This patient is in extremis and exhibiting the 'lethal triad' of trauma (acidosis, hypothermia, coagulopathy). According to DCO principles, Early Total Care (ETC) with prolonged procedures like IM nailing is contraindicated as it acts as a 'second hit'. Rapid temporary stabilization with external fixation limits further physiological insult and allows for ongoing resuscitation.

Question 10596

Topic: 2. Trauma

A 32-year-old female sustains a distal femur fracture following a fall. Radiographs and CT show a coronal shear fracture of the lateral femoral condyle. What is the eponym for this fracture pattern, and what is the preferred method of fixation?

. Segond fracture; conservative management
. Hoffa fracture; anterior-to-posterior (AP) or PA lag screws
. Barton fracture; volar plating
. Stieda fracture; excision
. Tillaux fracture; percutaneous pinning

Correct Answer & Explanation

. Segond fracture; conservative management

Explanation

A coronal shear fracture of the femoral condyle is known as a Hoffa fracture. It most commonly affects the lateral condyle. Definitive fixation is typically achieved using lag screws placed from anterior to posterior (or PA), often countersunk beneath the cartilage to prevent articular damage.

Question 10597

Topic: Lower Extremity Trauma

A 55-year-old male sustains a high-energy varus impact to his knee. Radiographs reveal a medial tibial plateau fracture with significant depression and widening. What is the Schatzker classification for this injury, and what is the associated soft tissue injury most commonly seen?

. Schatzker I; medial meniscus tear
. Schatzker II; lateral collateral ligament tear
. Schatzker IV; lateral collateral ligament / posterolateral corner injury
. Schatzker V; patellar tendon rupture
. Schatzker VI; isolated medial meniscus tear

Correct Answer & Explanation

. Schatzker I; medial meniscus tear

Explanation

A medial tibial plateau fracture represents a Schatzker IV. This is typically a high-energy pattern resulting from severe varus stress, often leading to distraction or avulsion injuries to the lateral-sided structures, including the lateral collateral ligament (LCL) and the posterolateral corner (PLC).

Question 10598

Topic: 2. Trauma

A 28-year-old male presents with a closed, severely displaced tibial shaft fracture. He complains of excruciating pain out of proportion to the injury. On examination, there is tense swelling and pain with passive stretch of the hallux, but he has palpable dorsalis pedis and posterior tibial pulses.

His diastolic blood pressure is 80 mmHg, and his anterior compartment pressure is measured at 60 mmHg. What is the most appropriate next step in management?

. Elevate the leg above the level of the heart
. Application of a tight compression dressing
. Immediate four-compartment fasciotomy
. Observation and repeat pressure measurements in 4 hours
. Intravenous dexamethasone

Correct Answer & Explanation

. Elevate the leg above the level of the heart

Explanation

The clinical presentation (pain out of proportion, pain with passive stretch) and compartment pressures confirm acute compartment syndrome. A delta pressure (diastolic BP - compartment pressure) of < 30 mmHg (here it is 80 - 60 = 20 mmHg) is an absolute indication for immediate surgical decompression via a four-compartment fasciotomy. Palpable pulses are typically maintained until very late in the disease process.

Question 10599

Topic: 2. Trauma

A 45-year-old male sustains a high-energy tibial pilon fracture. The initial presentation includes severe soft tissue swelling, massive fracture blisters, and skin tenting. What is the most widely accepted initial management strategy for this patient?

. Immediate open reduction and internal fixation with dual plating
. Immediate unreamed intramedullary nailing
. Spanning external fixation across the ankle joint with delayed definitive fixation
. Application of a short leg cast and immediate weight-bearing
. Primary arthrodesis of the tibiotalar joint

Correct Answer & Explanation

. Immediate open reduction and internal fixation with dual plating

Explanation

High-energy pilon fractures with severely compromised soft tissues (swelling, blisters) are at extremely high risk for wound necrosis and deep infection. They are best managed with a staged protocol: initial spanning external fixation to restore length and alignment, followed by definitive ORIF once the soft tissues have recovered (typically 10-21 days later), evidenced by the return of skin wrinkles.

Question 10600

Topic: 2. Trauma

A 30-year-old pilot sustains a hyperdorsiflexion injury to his foot resulting in a displaced talar neck fracture. He undergoes ORIF. At 8 weeks postoperatively, an AP radiograph of the ankle shows a subchondral radiolucent band in the talar dome. What does this radiographic finding indicate?

. Immediate need for subtalar fusion
. Onset of avascular necrosis (AVN) of the talar body
. Septic arthritis of the ankle joint
. Revascularization and intact blood supply to the talar body
. Nonunion of the talar neck

Correct Answer & Explanation

. Immediate need for subtalar fusion

Explanation

This radiographic finding is the 'Hawkins sign', which is a subchondral radiolucent band seen in the talar dome 6 to 8 weeks following a talar neck fracture. It indicates subchondral osteopenia secondary to bone resorption, confirming an intact vascular supply to the talar body and indicating that avascular necrosis (AVN) is unlikely.

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