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2. Trauma MCQs

Practice Set 539 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 10761

Topic: 2. Trauma
A 28-year-old male sustains a severe open tibial shaft fracture with extensive soft tissue stripping and a 12 cm laceration (Gustilo-Anderson Type IIIB). According to current evidence-based guidelines, what is the most critical factor in reducing the risk of deep infection?
. Time to surgical debridement strictly within 6 hours
. Immediate administration of systemic antibiotics
. Use of high-pressure pulsatile lavage
. Primary closure of the wound
. Application of local antibiotic beads at the first surgery

Correct Answer & Explanation

. Immediate administration of systemic antibiotics

Explanation

Immediate administration of systemic antibiotics (ideally within 1 hour of injury) is the most critical and proven factor in reducing infection rates in open fractures. The rigid "6-hour rule" for surgical debridement has not been consistently substantiated by recent literature.

Question 10762

Topic: 2. Trauma

A 40-year-old female presents with a closed proximal third tibial shaft fracture. She complains of out-of-proportion pain. Her diastolic blood pressure is 70 mmHg. Intracompartmental pressure testing of the anterior compartment yields a value of 45 mmHg. What is her delta pressure, and what is the appropriate management?

. Delta P is 25 mmHg; urgent four-compartment fasciotomy is indicated.
. Delta P is 25 mmHg; observe and recheck in 2 hours.
. Delta P is 45 mmHg; urgent four-compartment fasciotomy is indicated.
. Delta P is 45 mmHg; observe and recheck in 2 hours.
. Delta P is 115 mmHg; immediate amputation is indicated.

Correct Answer & Explanation

. Delta P is 25 mmHg; urgent four-compartment fasciotomy is indicated.

Explanation

Delta pressure is calculated as Diastolic BP minus Intracompartmental Pressure (70 - 45 = 25 mmHg). A delta P of less than 30 mmHg is highly suggestive of acute compartment syndrome, necessitating an urgent 4-compartment fasciotomy.

Question 10763

Topic: 2. Trauma

In a polytraumatized patient, which of the following physiological parameters is a definitive indication for Damage Control Orthopedics (DCO) rather than Early Total Care (ETC) for a bilateral femur fracture?

. Serum lactate of 2.0 mmol/L
. Base deficit of 2.0 mEq/L
. Body temperature of 36.5 C
. Arterial pH of 7.20
. Urine output of 1.5 mL/kg/hr

Correct Answer & Explanation

. Serum lactate of 2.0 mmol/L

Explanation

An arterial pH < 7.24, base deficit > 6, core temperature < 35 C, or clinical coagulopathy are physiologic criteria defining a "borderline" or "in extremis" patient. Such parameters mandate Damage Control Orthopedics (e.g., external fixation) to prevent the "second hit" phenomenon.

Question 10764

Topic: 2. Trauma

A 45-year-old male falls from a height. Radiographs and CT reveal a complex acetabular fracture. The presence of a "spur sign" on the obturator oblique radiograph is pathognomonic for which acetabular fracture pattern?

. Transverse with posterior wall
. T-type fracture
. Associated both-column fracture
. Anterior column with posterior hemitransverse
. Isolated posterior column

Correct Answer & Explanation

. Transverse with posterior wall

Explanation

The "spur sign" represents the intact strut of the posterior ilium projecting posterior to the medially displaced articular fragment. It is a pathognomonic finding for an associated both-column acetabular fracture.

Question 10765

Topic: 2. Trauma

During internal fixation of a severe supracondylar distal femur fracture, a coronal plane fracture of the lateral femoral condyle is identified. Which of the following describes this fragment, and what is the optimal fixation strategy?

. Barton's fragment; buttress plate fixation
. Hoffa fragment; anterior-to-posterior interfragmentary screws
. Hoffa fragment; posterior-to-anterior interfragmentary screws
. Cedell fragment; tension band wiring
. Volkmann fragment; lateral locked plating alone

Correct Answer & Explanation

. Barton's fragment; buttress plate fixation

Explanation

A coronal fracture of the femoral condyle is known as a Hoffa fragment (AO/OTA 33-B3). Optimal biomechanical fixation is achieved with anterior-to-posterior (AP) interfragmentary lag screws, often countersunk beneath the articular cartilage.

Question 10766

Topic: 2. Trauma

A 55-year-old male presents with a high-energy closed tibial pilon fracture with severe soft tissue swelling and fracture blisters over the medial malleolus. What is the most appropriate initial management strategy?

. Immediate open reduction and internal fixation (ORIF)
. Application of a spanning external fixator and delayed ORIF in 10-14 days
. Immediate intramedullary nailing of the tibia
. Application of a short leg cast
. Primary arthrodesis of the ankle joint

Correct Answer & Explanation

. Immediate open reduction and internal fixation (ORIF)

Explanation

High-energy pilon fractures with severe soft tissue compromise are best managed with staged protocols. Initial application of a joint-spanning external fixator allows the soft tissue envelope to recover (typically 10-14 days) before definitive ORIF.

Question 10767

Topic: 2. Trauma

A 30-year-old male sustains a low-velocity gunshot wound to the thigh. Radiographs show a midshaft femur fracture with the bullet lodged within the medullary canal. There is no neurovascular deficit. What is the most appropriate management regarding the retained bullet?

. Immediate surgical exploration and removal of the bullet followed by external fixation
. Intramedullary nailing of the femur; the bullet can be safely left in the canal or removed if accessible
. Intramedullary nailing of the femur with mandatory open arthrotomy of the knee
. Conservative management with skeletal traction to prevent lead toxicity
. Amputation due to severe contamination

Correct Answer & Explanation

. Immediate surgical exploration and removal of the bullet followed by external fixation

Explanation

In low-velocity gunshot wounds resulting in femur fractures without joint involvement or vascular injury, routine bullet removal is not mandatory unless it causes a mechanical block. Standard intramedullary nailing is the treatment of choice.

Question 10768

Topic: 2. Trauma

A 22-year-old male with bilateral femur fractures develops tachypnea, confusion, and a petechial rash on his chest 36 hours post-injury. Which of the following is considered the primary pathophysiological mechanism of the acute respiratory distress in Fat Embolism Syndrome (FES)?

. Direct mechanical occlusion of the pulmonary capillaries by large fat globules
. Release of free fatty acids causing direct pneumocyte toxicity and endothelial damage
. Bacterial seeding of the pulmonary vasculature from the fracture site
. Hypovolemia leading to decreased pulmonary perfusion
. Microthrombi formation due to disseminated intravascular coagulation

Correct Answer & Explanation

. Direct mechanical occlusion of the pulmonary capillaries by large fat globules

Explanation

While mechanical occlusion occurs, the severe inflammatory acute respiratory distress in FES is primarily driven by a biochemical cascade. The breakdown of embolized fat into free fatty acids causes severe direct endothelial damage and pneumocyte toxicity.

Question 10769

Topic: Pelvic & Acetabular Trauma
A 35-year-old male is brought into the trauma bay following a high-speed motor vehicle collision. He is hemodynamically unstable with a blood pressure of 80/40 mmHg and heart rate of 120 bpm. Pelvic radiographs reveal an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is immediately applied. What is the most appropriate anatomical landmark for the optimal placement of the pelvic binder?
. Iliac crests
. Greater trochanters
. Anterior superior iliac spines
. Pubic symphysis
. Subtrochanteric region

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders should be centered over the greater trochanters to effectively close the pelvic volume and stabilize the symphysis pubis. Placement over the iliac crests is a common error and can paradoxically open the pelvis further.

Question 10770

Topic: 2. Trauma

A 28-year-old male sustains a closed proximal third tibial shaft fracture and undergoes intramedullary nailing via a standard infrapatellar approach. What is the most common postoperative malalignment associated with this surgical technique?

. Apex posterior and varus
. Apex anterior and varus
. Apex anterior and valgus
. Apex posterior and valgus
. Internal rotation

Correct Answer & Explanation

. Apex posterior and varus

Explanation

Proximal third tibia fractures treated with standard infrapatellar nailing frequently displace into an apex anterior (procurvatum) and valgus deformity. This is due to the pull of the patellar tendon and the path of the nail.

Question 10771

Topic: 2. Trauma
A 30-year-old female sustains a vertically oriented (Pauwels type III) basicervical femoral neck fracture following a fall. To maximize biomechanical stability and reduce the risk of shear failure, which construct is most appropriate?
. Three parallel cannulated screws
. Sliding hip screw with a derotation screw
. Proximal femoral nail with dual lag screws
. Cephalomedullary nail with a single helical blade
. Cemented unipolar hemiarthroplasty

Correct Answer & Explanation

. Sliding hip screw with a derotation screw

Explanation

Vertical fracture patterns (Pauwels III) experience high shear forces. A sliding hip screw provides superior biomechanical stability compared to parallel screws, and the addition of a derotation screw prevents rotation of the femoral head.

Question 10772

Topic: 2. Trauma

A 25-year-old male presents with a Hawkins Type II talar neck fracture and undergoes emergent open reduction and internal fixation. At 8 weeks postoperatively, an anteroposterior radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this finding indicate?

. Avascular necrosis of the talar body
. Impending nonunion of the talar neck
. Viability of the talar body
. Deep infection of the tibiotalar joint
. Early post-traumatic arthritis

Correct Answer & Explanation

. Avascular necrosis of the talar body

Explanation

A subchondral radiolucent band at 6 to 8 weeks (Hawkins sign) represents subchondral atrophy from disuse, indicating intact vascular supply to the talar body. Its presence makes the development of avascular necrosis highly unlikely.

Question 10773

Topic: 2. Trauma

A 40-year-old male presents with a closed tibial shaft fracture and complains of pain out of proportion to his injury. His blood pressure is 130/80 mmHg, and continuous intracompartmental pressure monitoring reveals a peak pressure of 45 mmHg. What is the calculated delta pressure, and is emergent fasciotomy indicated?

. 85 mmHg; not indicated
. 50 mmHg; indicated
. 35 mmHg; not indicated
. 35 mmHg; indicated
. 50 mmHg; not indicated

Correct Answer & Explanation

. 85 mmHg; not indicated

Explanation

Delta pressure is calculated as diastolic blood pressure minus compartment pressure (80 - 45 = 35 mmHg). A delta pressure of less than 30 mmHg is the generally accepted threshold for emergent fasciotomy, so it is not currently indicated.

Question 10774

Topic: 2. Trauma

In the setting of a subtrochanteric femur fracture, the proximal fragment is typically displaced into flexion, abduction, and external rotation. Which muscle is primarily responsible for the flexion deformity?

. Gluteus medius
. Gluteus minimus
. Iliopsoas
. Adductor longus
. Tensor fasciae latae

Correct Answer & Explanation

. Gluteus medius

Explanation

The iliopsoas inserts onto the lesser trochanter and pulls the proximal fragment into flexion. The abductors (gluteus medius/minimus) pull it into abduction, and the short external rotators pull it into external rotation.

Question 10775

Topic: 2. Trauma

A 72-year-old female, who has been on alendronate for 8 years, presents with a 3-month history of right thigh pain. Radiographs reveal focal lateral cortical thickening and a transverse radiolucent line in the subtrochanteric region of the right femur, but no complete fracture. What is the most appropriate management?

. Discontinue alendronate and observe clinically
. Switch to teriparatide and prescribe strict non-weight-bearing
. Prophylactic intramedullary nailing
. Core decompression of the subtrochanteric lesion
. Plate fixation of the lateral cortex

Correct Answer & Explanation

. Discontinue alendronate and observe clinically

Explanation

The patient has a symptomatic, incomplete atypical femur fracture with radiographic signs (beaking and a radiolucent line). Prophylactic intramedullary nailing is indicated to prevent completion of the fracture and alleviate pain.

Question 10776

Topic: 2. Trauma

A 25-year-old male sustains a closed, spiral fracture of the distal third of the humeral shaft (Holstein-Lewis fracture). Upon presentation in the emergency department, he is noted to be unable to extend his wrist or fingers. What is the most appropriate initial management?

. Immediate surgical exploration and plate fixation
. Closed reduction and application of a coaptation splint
. Intramedullary nailing of the humerus
. Application of an external fixator
. Emergent MRI of the arm to evaluate the radial nerve

Correct Answer & Explanation

. Immediate surgical exploration and plate fixation

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture is generally treated non-operatively with a coaptation splint and observation. Surgical exploration is indicated if the palsy occurs after a closed reduction.

Question 10777

Topic: 2. Trauma

A 35-year-old male sustains a posterior wall acetabulum fracture. Under which of the following conditions is non-operative management considered the most appropriate definitive treatment?

. The fracture fragment involves 40% of the posterior wall
. There is a 3 mm intra-articular step-off on CT scan
. The hip remains concentrically reduced and stable under fluoroscopic dynamic stress examination
. There is marginal impaction of the articular cartilage noted on imaging
. The patient presents with an ipsilateral sciatic nerve palsy

Correct Answer & Explanation

. The fracture fragment involves 40% of the posterior wall

Explanation

Dynamic fluoroscopic stress examination under anesthesia is the gold standard for determining stability in posterior wall fractures. If the hip remains concentrically reduced and stable, non-operative management is appropriate.

Question 10778

Topic: 2. Trauma
A 45-year-old farmer sustains a Gustilo-Anderson Type IIIA open tibial shaft fracture that is heavily contaminated with soil and organic debris. According to current guidelines, what is the most appropriate initial prophylactic antibiotic regimen?
. First-generation cephalosporin only
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin and clindamycin
. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin
. Vancomycin and piperacillin-tazobactam

Correct Answer & Explanation

. First-generation cephalosporin, an aminoglycoside, and high-dose penicillin

Explanation

Type III open fractures generally require a first-generation cephalosporin and an aminoglycoside for gram-negative coverage. The addition of high-dose penicillin is necessary for farm-related or highly contaminated injuries to cover Clostridium species.

Question 10779

Topic: 2. Trauma

A 50-year-old male presents with a severely displaced intra-articular distal tibia (Pilon) fracture. Clinical examination reveals massive soft tissue swelling, marked ecchymosis, and extensive clear fluid-filled fracture blisters. What is the most appropriate initial management?

. Immediate open reduction and internal fixation with dual plating
. Joint-spanning external fixation and delayed definitive fixation in 10-14 days
. Primary intramedullary nailing of the tibia
. Closed reduction and application of a snug short leg cast
. Primary arthrodesis of the tibiotalar joint

Correct Answer & Explanation

. Immediate open reduction and internal fixation with dual plating

Explanation

Pilon fractures with severe soft tissue compromise (swelling, blisters) are at high risk for wound complications. The standard of care is a staged protocol: initial joint-spanning external fixation followed by delayed definitive ORIF when the soft tissues allow (wrinkle sign).

Question 10780

Topic: Pelvic & Acetabular Trauma

A 25-year-old male presents after a motorcycle collision with a pelvic ring injury. AP radiograph shows 3 cm of pubic symphysis diastasis and widening of the anterior sacroiliac joints. The posterior SI joints are intact. What is the most appropriate definitive management?

. Spanning external fixation
. Symphyseal plating
. Symphyseal plating and percutaneous SI screws
. Pelvic binder and skeletal traction
. Conservative management with restricted weight-bearing

Correct Answer & Explanation

. Spanning external fixation

Explanation

This is an APC-II injury characterized by diastasis >2.5 cm, torn anterior SI ligaments, and intact posterior SI ligaments. Definitive management is anterior stabilization, typically achieved with symphyseal plating.

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