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2. Trauma MCQs

Practice Set 533 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 10641

Topic: 2. Trauma

A 20-year-old basketball player presents with chronic lateral foot pain that acutely worsened during a game. Radiographs reveal a transverse fracture of the fifth metatarsal base located strictly at the metaphyseal-diaphyseal junction, extending into the intermetatarsal articulation between the 4th and 5th metatarsals. What is the classification of this fracture and the recommended treatment for an elite athlete?

. Zone 1 (Pseudo-Jones fracture); managed with a walking boot
. Zone 2 (Jones fracture); managed with intramedullary screw fixation
. Zone 3 (Diaphyseal stress fracture); managed with excision of the proximal fragment
. Zone 2 (Jones fracture); managed with conservative casting for 8 weeks
. Zone 3 (Diaphyseal stress fracture); managed with conservative casting

Correct Answer & Explanation

. Zone 1 (Pseudo-Jones fracture); managed with a walking boot

Explanation

This fracture is at the metaphyseal-diaphyseal junction, classifying it as a Zone 2 or 'true' Jones fracture. Due to a vascular watershed area, it has a high risk of delayed union or nonunion. For high-demand or elite athletes, intramedullary screw fixation is the standard of care to maximize healing rates and expedite return to sport compared to conservative management.

Question 10642

Topic: 2. Trauma
A 30-year-old male sustains a traumatic knee dislocation (KD-III) following a motor vehicle collision. After prompt closed reduction in the trauma bay, the foot is warm with palpable dorsalis pedis and posterior tibial pulses. The Ankle-Brachial Index (ABI) is measured at 0.8. What is the most appropriate next step in management?
. Discharge with a knee immobilizer and outpatient follow-up
. Serial clinical examinations and repeat ABI in 24 hours
. Immediate CT angiography (CTA) of the lower extremity
. Immediate prophylactic four-compartment fasciotomy
. Application of a spanning external fixator without further vascular workup

Correct Answer & Explanation

. Immediate CT angiography (CTA) of the lower extremity

Explanation

Traumatic knee dislocations have a high rate of popliteal artery injury. Even if pulses are palpable, an ABI of less than 0.9 is highly predictive of an occult arterial intimal injury or disruption. Immediate advanced vascular imaging, most commonly CT angiography (CTA), is mandatory to definitively rule out a surgical vascular lesion.

Question 10643

Topic: 2. Trauma

A 19-year-old male cyclist falls directly onto his left shoulder, sustaining a midshaft clavicle fracture. Which of the following clinical scenarios is widely considered an absolute indication for acute open reduction and internal fixation (ORIF) of the clavicle?

. 1.5 cm of shortening of the clavicle
. 10 degrees of angulation
. Presence of an open fracture
. Concomitant closed head injury
. Patient desire for rapid return to athletic competition

Correct Answer & Explanation

. 1.5 cm of shortening of the clavicle

Explanation

Absolute indications for open reduction and internal fixation of a clavicle fracture include open fractures, fractures with associated neurovascular compromise, and severe skin tenting that threatens skin viability (impending open fracture). Shortening, displacement, and patient activity level are relative indications.

Question 10644

Topic: 2. Trauma
Six weeks following open reduction and internal fixation of a Hawkins type III talar neck fracture, a patient undergoes a follow-up radiograph. The radiograph demonstrates a subchondral radiolucent band in the talar dome. This radiographic finding:
. Indicates the presence of advanced avascular necrosis
. Is a poor prognostic sign for subtalar arthritis
. Indicates intact vascularity to the talar body
. Represents a nonunion of the talar neck
. Dictates the need for immediate bone grafting

Correct Answer & Explanation

. Indicates intact vascularity to the talar body

Explanation

The subchondral radiolucency in the dome of the talus, seen 6 to 8 weeks post-injury, is known as the Hawkins sign. It represents subchondral atrophy due to hyperemia and disuse. Its presence is a highly reliable indicator of intact vascularity to the talar body and virtually excludes the development of avascular necrosis.

Question 10645

Topic: 2. Trauma



A 28-year-old male sustains a closed, spiral fracture of the distal third of the humerus. On initial examination, he has an intact radial nerve pulse but is unable to extend his wrist or fingers. Closed reduction and splinting are performed. Post-reduction examination reveals persistent complete radial nerve palsy. What is the most appropriate management regarding the radial nerve?

. Immediate surgical exploration and nerve repair
. Observation with clinical and EMG follow-up at 6 weeks
. Urgent MRI of the humerus
. Immediate ORIF of the humerus with concurrent nerve exploration
. Ultrasound-guided nerve block

Correct Answer & Explanation

. Immediate surgical exploration and nerve repair

Explanation

In closed humeral shaft fractures with radial nerve palsy (whether primary or secondary to closed reduction), the initial management is observation. Over 85% of radial nerve palsies in this setting will recover spontaneously. Holstein-Lewis fractures (distal third spiral fractures) have a higher incidence of radial nerve palsy, but even in these cases, observation is the standard of care for closed injuries unless there is a loss of nerve function AFTER a previously successful reduction where the nerve may have been entrapped, although many still observe post-reduction palsies if the reduction is acceptable. The AAOS guidelines recommend observation. Surgery is indicated for open fractures, vascular injury, or failure to recover clinically/EMG at 3-4 months.

Question 10646

Topic: 2. Trauma
A 32-year-old male presents after a high-speed ATV accident with an APC-II pelvic ring injury. Examination reveals a large, fluctuant area over the greater trochanter with overlying skin hypermobility and decreased sensation. Which of the following describes the pathophysiology of this clinical finding?
. Fasciocutaneous arterial avulsion
. Closed degloving injury separating the subcutaneous tissue from the underlying fascia
. Rupture of the gluteus medius muscle belly
. Subfascial hematoma due to superior gluteal artery injury
. Lymphatic disruption leading to a deep seroma

Correct Answer & Explanation

. Closed degloving injury separating the subcutaneous tissue from the underlying fascia

Explanation

The clinical presentation describes a Morel-Lavallée lesion, which is a closed degloving injury resulting from a shearing force that separates the subcutaneous fat and skin from the underlying deep fascia. This creates a potential space that fills with blood, lymph, and necrotic fat. It is highly associated with pelvic and acetabular fractures. If unrecognized or untreated, it can lead to skin necrosis and a high rate of deep infection following surgical fixation of underlying fractures.

Question 10647

Topic: 2. Trauma
A 40-year-old farmer sustains an open fracture of the tibia and fibula (Gustilo-Anderson Grade IIIA) from a tractor accident in a muddy field. According to current guidelines for severe open fractures in a highly contaminated agricultural environment, the most appropriate initial intravenous antibiotic regimen is:
. Cefazolin alone
. Cefazolin and Gentamicin
. Ceftriaxone alone
. Cefazolin, Gentamicin, and Penicillin G
. Vancomycin and Piperacillin/Tazobactam

Correct Answer & Explanation

. Cefazolin, Gentamicin, and Penicillin G

Explanation

For a Grade III open fracture, current guidelines typically recommend a first-generation cephalosporin (e.g., Cefazolin) plus an aminoglycoside (e.g., Gentamicin). In the setting of agricultural injuries or gross fecal contamination, the addition of Penicillin G (or Ampicillin) is recommended to provide coverage against Clostridium species. High-dose penicillin is the drug of choice to prevent gas gangrene in farm-related severe open wounds.

Question 10648

Topic: 2. Trauma
A 55-year-old female sustains a high-energy varus stress injury to her knee. Radiographs and CT scan reveal a displaced fracture of the medial tibial plateau with a coronal plane fracture line exiting posteromedially. The lateral plateau is intact. According to the Schatzker classification, what type of fracture is this, and what is the optimal surgical approach?
. Schatzker II, Anterolateral approach
. Schatzker IV, Posteromedial approach
. Schatzker V, Dual incisions (Anterolateral and Posteromedial)
. Schatzker VI, Anterior midline approach
. Schatzker III, Arthroscopic-assisted percutaneous fixation

Correct Answer & Explanation

. Schatzker IV, Posteromedial approach

Explanation

An isolated medial tibial plateau fracture is a Schatzker type IV injury. It is typically a high-energy injury with significant soft tissue trauma and varus instability. The posteromedial fragment is best addressed via a posteromedial approach with anti-glide plating, as standard anteromedial or medial plates often fail to adequately capture and buttress the posteromedial shear fragment.

Question 10649

Topic: 2. Trauma

A 22-year-old professional football player sustains an acute, closed injury to his foot during a game. Radiographs show a transverse fracture through the diaphyseal-metaphyseal junction of the fifth metatarsal base, involving the 4th-5th intermetatarsal articulation. What is the most appropriate management for this elite athlete to ensure the fastest return to play with the lowest risk of nonunion?

. Non-weight bearing cast for 6-8 weeks
. Weight-bearing as tolerated in a stiff-soled shoe
. Intramedullary screw fixation
. Open reduction and internal fixation with a mini-fragment plate
. Primary bone grafting and immobilization

Correct Answer & Explanation

. Non-weight bearing cast for 6-8 weeks

Explanation

This is a Zone 2 fracture of the proximal fifth metatarsal, also known as a Jones fracture. It involves the metaphyseal-diaphyseal junction and extends into the 4th-5th intermetatarsal facet. Due to a vascular watershed area, it has a high risk of delayed union or nonunion. In elite athletes, early intramedullary screw fixation is recommended to decrease the time to union, minimize the risk of nonunion, and allow for a faster return to sport compared to conservative management.

Question 10650

Topic: 2. Trauma
A 30-year-old male sustains a femoral neck fracture following a fall from height. Radiographs demonstrate a vertically oriented fracture line with an angle of 75 degrees relative to the horizontal. According to Pauwels' classification, this fracture is characterized by:
. High compressive forces and low shear forces, favoring primary bone healing
. High shear forces, leading to a high rate of nonunion and varus collapse
. Extracapsular involvement, requiring dynamic hip screw fixation
. Low risk of avascular necrosis due to intact retinacular vessels
. Stability in flexion and extension, allowing early weight-bearing

Correct Answer & Explanation

. High shear forces, leading to a high rate of nonunion and varus collapse

Explanation

Pauwels' classification is based on the angle of the fracture line relative to the horizontal. Type I is <30 degrees, Type II is 30-50 degrees, and Type III is >50 degrees. A 75-degree angle is a Pauwels type III fracture. These vertically oriented fractures are subjected to high shear forces rather than compressive forces across the fracture site, leading to a high rate of nonunion, varus collapse, and hardware failure. Fixation often requires a sliding hip screw with a derotation screw or specialized fixed-angle constructs to counteract these shear forces in young patients.

Question 10651

Topic: 2. Trauma

A 25-year-old male sustains a closed comminuted tibial shaft fracture. He complains of severe pain out of proportion to the injury. Which of the following clinical or objective findings is the most reliable indicator for emergent fasciotomy?

. Loss of dorsalis pedis and posterior tibial pulses
. Intracompartmental pressure of 25 mmHg
. Delta pressure (Diastolic blood pressure minus intracompartmental pressure) of 20 mmHg
. Capillary refill time greater than 3 seconds
. Mild swelling and pain with active toe flexion

Correct Answer & Explanation

. Loss of dorsalis pedis and posterior tibial pulses

Explanation

Acute compartment syndrome is a clinical diagnosis, but when objective measurement is used, the delta pressure is the most reliable parameter. Delta pressure = Diastolic BP - Intracompartmental pressure. A delta pressure of 30 mmHg or less (e.g., 20 mmHg) is a strong indication for emergent fasciotomy. Loss of pulses and capillary refill changes are late and unreliable signs (pulses usually remain intact). An absolute pressure of 25 mmHg alone is not necessarily an indication for surgery without considering the patient's blood pressure.

Question 10652

Topic: 2. Trauma



A 45-year-old male presents with a high-energy closed pilon fracture (OTA/AO 43-C3) with severe soft tissue swelling and fracture blisters. The standard of care for the initial management of this injury involves:

. Immediate open reduction and internal fixation of the tibia and fibula
. Closed reduction and placement in a long leg cast
. Spanning external fixation and delayed definitive fixation in 10-14 days
. Immediate intramedullary nailing of the tibia
. Primary tibiotalar arthrodesis

Correct Answer & Explanation

. Immediate open reduction and internal fixation of the tibia and fibula

Explanation

High-energy pilon fractures are associated with severe soft tissue injury. Immediate open reduction and internal fixation (ORIF) carries an unacceptably high risk of wound complications, necrosis, and deep infection. The standard of care is a staged protocol: initial closed reduction and application of a spanning external fixator (with or without initial fibular fixation) to restore length and alignment, followed by delayed definitive ORIF of the tibial articular surface 10-21 days later, once the soft tissue envelope has recovered (evidenced by resolving edema and the appearance of skin wrinkles).

Question 10653

Topic: 2. Trauma

During open reduction and internal fixation of a severe supracondylar/intercondylar distal femur fracture (OTA/AO 33-C3) via a lateral approach, the surgeon identifies a separate, coronal plane fracture of the lateral femoral condyle. This fragment is often missed on plain AP and lateral radiographs. Which of the following represents the optimal fixation strategy for this specific fragment?

. Posterior-to-anterior directed lag screws
. Anterior-to-posterior directed lag screws, countersunk beneath the articular cartilage
. A separate medial buttress plate
. Intramedullary nailing
. Resection of the fragment and osteochondral allograft

Correct Answer & Explanation

. Posterior-to-anterior directed lag screws

Explanation

A coronal plane fracture of the femoral condyle is known as a Hoffa fracture (OTA/AO 33-B3). It is typically located posterior to the mid-axial line. Optimal biomechanical fixation for a Hoffa fracture is achieved with anterior-to-posterior (AP) directed lag screws. To avoid joint irritation, the screws must be countersunk beneath the articular cartilage. PA screws are biomechanically less stable and technically more challenging to insert via standard approaches.

Question 10654

Topic: 2. Trauma



An 8-month follow-up radiograph of a tibial shaft fracture treated with a cast shows a 'horse-shoe' or 'elephant foot' appearance at the fracture site, with abundant callus formation but a persistent radiolucent fracture line. The patient reports pain with walking. The underlying cause and the most appropriate treatment principle for this condition are:

. Biologic failure; requires decortication and bone grafting
. Infection; requires thorough debridement and culture-specific antibiotics
. Mechanical instability; requires rigid internal fixation
. Avascular necrosis; requires free vascularized fibular graft
. Malnutrition; requires Vitamin D and calcium supplementation

Correct Answer & Explanation

. Biologic failure; requires decortication and bone grafting

Explanation

The 'elephant foot' or 'horse-shoe' appearance describes a hypertrophic nonunion. Hypertrophic nonunions are characterized by abundant, well-vascularized callus that fails to bridge the fracture site. The biological potential for healing is excellent, but the biological process is thwarted by inadequate mechanical stability (excessive motion at the fracture site). The primary treatment principle is to provide rigid mechanical stability (e.g., via intramedullary nailing or compression plating); bone grafting is generally not required.

Question 10655

Topic: 2. Trauma
A 30-year-old cyclist falls directly onto his shoulder. Radiographs demonstrate a fracture of the distal third of the clavicle. The fracture is displaced, with the medial fragment elevated superiorly. According to the Neer classification, what type of distal clavicle fracture is associated with rupture of the coracoclavicular ligaments and has a high rate of nonunion if treated conservatively?
. Neer Type I
. Neer Type II
. Neer Type III
. Neer Type IV
. Neer Type V

Correct Answer & Explanation

. Neer Type II

Explanation

Neer Type II distal clavicle fractures involve the region of the coracoclavicular (CC) ligaments. In Type II fractures, the CC ligaments are detached from the medial fragment, which is consequently displaced superiorly by the pull of the trapezius. The lateral fragment remains attached to the acromion. Because of the significant displacement and deforming forces, Neer Type II fractures have a nonunion rate of up to 30% when treated non-operatively, and surgical fixation is frequently recommended for active patients.

Question 10656

Topic: Pelvic & Acetabular Trauma
A 45-year-old male is brought to the ED after a high-speed MVC. He is hypotensive (BP 80/50). Pelvic radiograph shows an APC-III injury. Where is the most appropriate anatomical landmark to center a pelvic binder?
. Greater trochanters
. Iliac crests
. Symphysis pubis and ASIS
. Umbilicus
. Proximal thirds of the femurs

Correct Answer & Explanation

. Greater trochanters

Explanation

A pelvic binder should be centered over the greater trochanters to effectively close the pelvic ring, particularly in anteroposterior compression (APC) injuries. Placing it over the iliac crests is a common error and is less effective mechanically, as it does not adequately reduce the symphysis.

Question 10657

Topic: 2. Trauma

A 25-year-old male sustained severe polytrauma. According to current guidelines for Damage Control Orthopedics (DCO), which of the following laboratory values indicates that the patient is in extremis and should undergo temporizing external fixation for his bilateral femur fractures rather than definitive intramedullary nailing?

. Lactate 2.0 mmol/L
. Base excess -2 mEq/L
. Platelet count 150,000/microL
. Arterial pH 7.20
. Core temperature 36.5°C

Correct Answer & Explanation

. Lactate 2.0 mmol/L

Explanation

Markers of a patient in extremis or borderline who would benefit from DCO include arterial pH < 7.24, core temperature < 35°C, massive transfusion requirement (>10 units), and clinical coagulopathy. A pH of 7.20 reflects severe acidosis, making definitive long-bone nailing unacceptably risky due to the 'second hit' phenomenon.

Question 10658

Topic: 2. Trauma

A 30-year-old male sustains a low-velocity gunshot wound to the thigh, resulting in a minimally displaced diaphyseal femur fracture. The bullet passed cleanly through the thigh without injuring major vessels or nerves. What is the most appropriate initial management of the fracture and wounds?

. Immediate surgical debridement of the entire bullet track and IM nailing
. Local wound care with superficial debridement and IM nailing
. Intravenous antibiotics for 7 days and skeletal traction
. Immediate external fixation and delayed definitive fixation
. Formal debridement of the entry and exit wounds with primary closure

Correct Answer & Explanation

. Immediate surgical debridement of the entire bullet track and IM nailing

Explanation

Low-velocity gunshot wounds resulting in femur fractures generally behave like closed fractures or low-grade open fractures. They do not require formal operative debridement of the entire bullet tract. Standard local wound care, superficial debridement of the skin edges, and standard intramedullary nailing are appropriate.

Question 10659

Topic: 2. Trauma
A 40-year-old patient has a Gustilo-Anderson IIIB open tibia fracture from a motorcycle crash on a highway. What is the currently recommended antibiotic prophylaxis upon initial presentation?
. First-generation cephalosporin alone
. First-generation cephalosporin and an aminoglycoside (or a third-generation cephalosporin)
. First-generation cephalosporin and penicillin
. Fluoroquinolone alone
. Macrolide and an aminoglycoside

Correct Answer & Explanation

. First-generation cephalosporin and an aminoglycoside (or a third-generation cephalosporin)

Explanation

For type III open fractures, current guidelines recommend the addition of Gram-negative coverage. This is typically achieved by adding an aminoglycoside to a first-generation cephalosporin, or by using a third-generation cephalosporin (such as ceftriaxone) alone or in combination. Penicillin is added specifically if there is concern for clostridial infection (e.g., heavy soil contamination).

Question 10660

Topic: 2. Trauma

A 28-year-old male presents with a posterior hip dislocation and an associated posterior wall acetabulum fracture.

The hip is reduced in the ED. On post-reduction CT scan, there is a 2 mm intra-articular fragment. The posterior wall fracture involves 25% of the articular surface. Examination under anesthesia shows no instability. What is the best management?

. Skeletal traction for 6 weeks
. Non-operative management with touch-down weight bearing
. Open reduction and internal fixation via a Kocher-Langenbeck approach
. Surgical hip dislocation and primary fragment excision without fixation
. Total hip arthroplasty

Correct Answer & Explanation

. Skeletal traction for 6 weeks

Explanation

An absolute indication for operative intervention in acetabular fractures is an incarcerated intra-articular fragment, regardless of the size of the posterior wall defect or the dynamic stability of the joint. The Kocher-Langenbeck approach is the standard approach for a posterior wall fracture.

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