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2. Trauma MCQs

Practice Set 54 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 1061

Topic: 2. Trauma

A 45-year-old male presents 9 months after unreamed IM nailing of a closed midshaft tibia fracture with persistent pain. Radiographs demonstrate a hypertrophic nonunion. What is the most appropriate definitive surgical management?

. Autologous iliac crest bone grafting
. Exchange intramedullary nailing with reaming
. Plate osteosynthesis with structural allograft
. Pulsed electromagnetic field therapy
. Removal of hardware and application of a circular external fixator

Correct Answer & Explanation

. Exchange intramedullary nailing with reaming

Explanation

Hypertrophic nonunions possess adequate biology (evident by callus formation) but lack sufficient mechanical stability. Exchange nailing (removing the old nail, reaming, and inserting a larger diameter nail) provides the necessary stability to achieve union.

Question 1062

Topic: 2. Trauma

A patient develops clawing of the lesser toes, loss of sensation on the plantar aspect of the foot, and a fixed equinus deformity 6 months after a severe tibia fracture treated with IM nailing. This presentation is most consistent with a missed compartment syndrome of which compartment?

. Anterior
. Lateral
. Superficial posterior
. Deep posterior
. Peroneal

Correct Answer & Explanation

. Deep posterior

Explanation

A missed deep posterior compartment syndrome results in ischemic contracture of the long toe flexors (FDL and FHL) causing claw toes. It also causes ischemic neuropathy of the tibial nerve, resulting in plantar sensory loss.

Question 1063

Topic: 2. Trauma

A 10-year-old boy is admitted after a closed reduction and long leg casting of a displaced tibia shaft fracture. Which of the following is the most sensitive early clinical indicator of developing compartment syndrome in this pediatric patient?

. Loss of palpable dorsalis pedis pulse
. Decreased capillary refill time
. Increasing requirement for opioid analgesia
. Development of paresthesias in the first web space
. Paralysis of the extensor hallucis longus

Correct Answer & Explanation

. Increasing requirement for opioid analgesia

Explanation

In pediatric patients, the classic Ps (pulselessness, pallor, paresthesia) of compartment syndrome are unreliable and present very late. Increasing analgesic requirement (pain out of proportion) is the most sensitive and earliest indicator in children.

Question 1064

Topic: 2. Trauma

A patient with a highly contaminated open tibia fracture is initially managed with an external fixator. The surgeon plans to convert to an intramedullary nail. Which of the following factors is most strongly associated with deep infection following this conversion?

. Conversion performed within 14 days
. Pin site inflammation or infection prior to conversion
. Use of a reamed nail instead of an unreamed nail
. Leaving the external fixator in place for less than 7 days
. Administration of preoperative prophylactic antibiotics

Correct Answer & Explanation

. Pin site inflammation or infection prior to conversion

Explanation

Conversion from an external fixator to an IM nail is generally safe if performed early (within 1-2 weeks). However, the presence of pin tract infections drastically increases the risk of deep medullary infection and is a relative contraindication to immediate conversion.

Question 1065

Topic: 2. Trauma

Six months following a statically locked IM nail for a midshaft tibia fracture, a patient has a delayed union with a visible gap. Dynamization is planned. Which of the following fracture patterns is an absolute contraindication to dynamization?

. Transverse midshaft fracture
. Short oblique midshaft fracture
. Highly comminuted, length-unstable fracture
. Hypertrophic nonunion
. Fractures with an associated intact fibula

Correct Answer & Explanation

. Highly comminuted, length-unstable fracture

Explanation

Dynamization involves removing the interlocking screws on one side of the fracture to allow axial loading. It is contraindicated in length-unstable fractures (severe comminution, long spiral fractures) because it will lead to progressive shortening and deformity.

Question 1066

Topic: 2. Trauma
A 35-year-old sustains a Gustilo-Anderson IIIB open tibia fracture requiring a free tissue transfer for coverage. According to Godina's classic principles, what is the optimal timeframe for this soft tissue coverage to minimize infection and maximize flap survival?
. Within 24 hours
. Within 72 hours
. Between 7 and 10 days
. After 14 days when robust granulation tissue forms
. At the time of secondary bone grafting at 6 weeks

Correct Answer & Explanation

. Within 72 hours

Explanation

Godina's classic study demonstrated that early soft tissue coverage (within 72 hours) of complex open lower extremity wounds significantly reduces infection rates, flap failure, and time to union compared to delayed coverage.

Question 1067

Topic: 2. Trauma

A 28-year-old male sustains a proximal third diaphyseal tibia fracture and undergoes infrapatellar intramedullary nailing. Postoperatively, radiographs reveal the most common malalignment associated with this specific injury pattern. Which of the following describes this typical deformity?

. Apex anterior (procurvatum) and valgus
. Apex posterior (recurvatum) and varus
. Apex anterior (procurvatum) and varus
. Apex posterior (recurvatum) and valgus
. Neutral sagittal alignment with profound external rotation

Correct Answer & Explanation

. Apex anterior (procurvatum) and valgus

Explanation

Proximal third tibia fractures treated with an infrapatellar approach typically deform into apex anterior (procurvatum) and valgus. This is primarily due to the pull of the extensor mechanism and the wide metaphysis allowing the nail to track anteriorly and laterally.

Question 1068

Topic: 2. Trauma

To prevent the typical procurvatum and valgus deformity during intramedullary nailing of a proximal third tibia fracture, a surgeon decides to place blocking (Poller) screws. Where should the blocking screws be placed in the proximal segment relative to the intended path of the nail?

. Anterior and medial
. Posterior and medial
. Anterior and lateral
. Posterior and lateral
. Directly central in the medullary canal

Correct Answer & Explanation

. Posterior and lateral

Explanation

Blocking screws should be placed on the concave side of the deformity to narrow the medullary canal and direct the nail. For a procurvatum and valgus deformity, the nail tracks anteriorly and laterally; therefore, blocking screws should be placed posterior and lateral to the nail path.

Question 1069

Topic: 2. Trauma

A 32-year-old intubated multi-trauma patient has a closed, highly comminuted midshaft tibia fracture. His blood pressure is 115/65 mmHg. Intracompartmental pressures of the leg are measured. Which of the following anterior compartment pressures is the threshold to mandate an immediate four-compartment fasciotomy based on the Delta P concept?

. 25 mmHg
. 30 mmHg
. 35 mmHg
. 40 mmHg
. 15 mmHg

Correct Answer & Explanation

. 25 mmHg

Explanation

The Delta P is calculated as diastolic blood pressure minus compartment pressure. A Delta P of less than 30 mmHg (in this case, 65 - 40 = 25 mmHg) strongly correlates with muscle ischemia and mandates emergent fasciotomy.

Question 1070

Topic: 2. Trauma

A 45-year-old male is found down and unresponsive in his apartment for an estimated 72 hours with his leg pinned under heavy furniture. He presents with a rigid, swollen calf, absent sensation, and complete motor loss. Arterial doppler signals are present. What is the most appropriate management of his leg?

. Emergent two-incision, four-compartment fasciotomy
. Emergent single-incision perifibular fasciotomy
. Hyperbaric oxygen therapy and observation
. Observation and supportive care, with potential delayed amputation
. Administration of intravenous tissue plasminogen activator (tPA)

Correct Answer & Explanation

. Observation and supportive care, with potential delayed amputation

Explanation

Fasciotomy in missed, late compartment syndrome (>48 hours) with dead muscle is contraindicated due to a high risk of life-threatening infection. Treatment typically involves supportive care for crush syndrome, with delayed reconstruction or amputation.

Question 1071

Topic: 2. Trauma

A surgeon opts to use a suprapatellar nailing technique in the semi-extended position for a proximal third tibia fracture rather than a standard infrapatellar approach. What is the primary biomechanical advantage of this positioning?

. It completely avoids the risk of anterior knee pain.
. It eliminates the risk of iatrogenic intra-articular cartilage damage.
. It relaxes the extensor mechanism, reducing the deforming forces that cause procurvatum.
. It allows for the use of a significantly larger diameter nail.
. It negates the need for distal locking screws.

Correct Answer & Explanation

. It relaxes the extensor mechanism, reducing the deforming forces that cause procurvatum.

Explanation

Nailing in the semi-extended position (suprapatellar) relieves the tension on the quadriceps and patellar tendon. This significantly mitigates the apex anterior (procurvatum) deforming force seen in conventional hyper-flexed infrapatellar positioning.

Question 1072

Topic: 2. Trauma

During a two-incision fasciotomy for acute compartment syndrome of the leg, a surgeon successfully releases the anterior, lateral, and superficial posterior compartments, but struggles to identify and release the deep posterior compartment. Which specific neurologic deficit would most likely persist if this compartment remains untreated?

. Loss of sensation in the first dorsal webspace
. Loss of sensation over the lateral aspect of the foot
. Plantar numbness and weakness in great toe flexion
. Inability to dorsiflex the ankle
. Weakness in eversion of the foot

Correct Answer & Explanation

. Plantar numbness and weakness in great toe flexion

Explanation

The deep posterior compartment contains the tibial nerve, flexor hallucis longus, flexor digitorum longus, and tibialis posterior. Failure to release it results in persistent plantar numbness and flexor weakness.

Question 1073

Topic: 2. Trauma
A 35-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture requiring surgical debridement and intramedullary nailing. A 12-cm soft tissue defect with exposed bone devoid of periosteum remains. To optimize outcomes and minimize infection risk, when is the ideal timeframe for definitive flap coverage?
. Immediately during the index procedure, regardless of wound contamination
. Within 5 to 7 days post-injury
. Between 2 to 3 weeks post-injury
. Between 4 to 6 weeks post-injury
. Only after radiographic evidence of fracture union is observed

Correct Answer & Explanation

. Within 5 to 7 days post-injury

Explanation

Current guidelines recommend definitive soft tissue coverage of Type IIIB open tibia fractures within 5 to 7 days. Coverage beyond this window significantly increases the risk of deep infection and flap failure.

Question 1074

Topic: 2. Trauma

A 28-year-old male presents 5 months after static intramedullary nailing of a closed midshaft tibia fracture. He reports moderate pain with weight-bearing. Radiographs show minimal callus formation and no hardware failure. The fracture is axially stable. What is the most appropriate next step in management?

. Exchange nailing with a larger reamed nail
. Removal of the nail and application of a circular external fixator
. Dynamization by removing the static locking screws furthest from the fracture
. Addition of a medial locking compression plate
. Autologous iliac crest bone grafting only

Correct Answer & Explanation

. Dynamization by removing the static locking screws furthest from the fracture

Explanation

For axially stable delayed unions of the tibia without hardware failure, dynamization (removing locking screws furthest from the fracture) allows axial micromotion. This mechanical stimulation promotes callus formation and progression to union.

Question 1075

Topic: 2. Trauma

A patient is admitted following a high-energy tibial shaft fracture. Two hours later, they complain of disproportionate leg pain. Physical examination reveals decreased sensation in the first dorsal webspace and profound pain with passive stretching of the extensor hallucis longus. Which compartment is experiencing the highest tissue pressure?

. Anterior compartment
. Lateral compartment
. Superficial posterior compartment
. Deep posterior compartment
. Tibiofibular syndesmotic space

Correct Answer & Explanation

. Anterior compartment

Explanation

The anterior compartment contains the deep peroneal nerve, which supplies sensation to the first dorsal webspace. It also contains the extensor hallucis longus, which causes severe pain when passively stretched if ischemic.

Question 1076

Topic: 2. Trauma

During the reaming process for an intramedullary tibial nail, the surgeon is concerned about the risk of thermal necrosis to the diaphyseal bone. Which of the following technical strategies is most effective in minimizing this complication?

. Using a high-speed, continuous advancement technique without pausing
. Reaming through a tight pneumatic tourniquet to reduce blood-pooling
. Using sharp reamers and frequently withdrawing them to clear flutes
. Using unreamed nails for all diaphyseal fractures
. Applying warm saline irrigation during the reaming process

Correct Answer & Explanation

. Using sharp reamers and frequently withdrawing them to clear flutes

Explanation

Thermal necrosis is caused by excessive friction during reaming. Using sharp reamers, passing them slowly, and frequently withdrawing them to clear the flutes minimizes intramedullary pressure and heat generation.

Question 1077

Topic: 2. Trauma

A resident is planning an infrapatellar intramedullary nail for a midshaft tibia fracture. To achieve ideal fracture alignment and prevent iatrogenic deformity, what is the optimal anatomic starting point on the anteroposterior (AP) radiograph?

. Medial to the medial tibial eminence
. Directly centered over the intercondylar eminence
. Just medial to the lateral tibial eminence
. Just lateral to the lateral tibial eminence
. At the direct center of the tibial plateau articular surface

Correct Answer & Explanation

. Just medial to the lateral tibial eminence

Explanation

The optimal starting point for an antegrade tibial nail on the AP view is slightly medial to the lateral tibial eminence. This aligns perfectly with the anatomical axis of the medullary canal.

Question 1078

Topic: 2. Trauma

A 33-year-old female presents for her 1-year follow-up after an uncomplicated, fully healed infrapatellar intramedullary nailing of a closed tibia fracture. Radiographs show a well-consolidated fracture. What is the most frequently reported chronic complication she is likely to experience?

. Sural nerve neuralgia
. Anterior knee pain
. Chronic osteomyelitis
. Ankle stiffness limiting plantarflexion
. Patellar tendon rupture

Correct Answer & Explanation

. Anterior knee pain

Explanation

Anterior knee pain is the most common complication following intramedullary nailing of the tibia, occurring in up to 40-50% of patients. It occurs regardless of whether an infrapatellar or suprapatellar approach is used, though suprapatellar may slightly reduce the incidence.

Question 1079

Topic: 2. Trauma

A 40-year-old female undergoes intramedullary nailing for a distal metaphyseal-diaphyseal junction tibia fracture. Because the distal metaphysis is wide and offers poor cortical contact for the nail, what is the most common postoperative malalignment encountered in this region?

. Varus
. Valgus
. Apex posterior (recurvatum)
. Apex anterior (procurvatum)
. Internal rotation deformity

Correct Answer & Explanation

. Valgus

Explanation

Distal third tibia fractures are notoriously prone to valgus malalignment when treated with IM nailing. This occurs because the nail typically rests against the lateral cortex of the wider distal segment, pushing the distal fragment into valgus.

Question 1080

Topic: 2. Trauma

A surgeon attempts a single-incision lateral (perifibular) fasciotomy to release all four compartments of the leg. Compared to the gold-standard double-incision technique, this single-incision approach carries a significantly higher risk of iatrogenic injury to which nerve?

. Deep peroneal nerve
. Superficial peroneal nerve
. Saphenous nerve
. Sural nerve
. Tibial nerve

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The single-incision lateral (perifibular) approach requires extensive subcutaneous dissection to access the anterior and posterior compartments. This places the superficial peroneal nerve, which runs in the lateral compartment and exits anteriorly, at high risk of iatrogenic injury.

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