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2. Trauma MCQs

Practice Set 55 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 1081

Topic: 2. Trauma
According to established orthopedic principles, which of the following scenarios is generally considered an absolute contraindication to reamed antegrade intramedullary nailing of a tibial shaft fracture?
. A patient presenting with a Gustilo-Anderson Type IIIA open fracture
. A concurrent ipsilateral fibular shaft fracture
. A fracture extending into the proximal diaphyseal-metaphyseal junction
. Active intramedullary osteomyelitis
. A patient with a documented allergy to non-steroidal anti-inflammatory drugs (NSAIDs)

Correct Answer & Explanation

. Active intramedullary osteomyelitis

Explanation

Active intramedullary infection (osteomyelitis) is an absolute contraindication to intramedullary nailing, as placing a nail will disseminate the infection throughout the entire canal and create a large foreign body nidus.

Question 1082

Topic: 2. Trauma

During the pathophysiologic cascade of acute compartment syndrome in a fractured tibia, the sequence of microvascular compromise is predictable. Which of the following clinical signs or physiological parameters is typically the LAST to be lost or altered?

. Capillary perfusion
. Venous outflow
. Paresthesia
. Arterial pulses
. Pain out of proportion

Correct Answer & Explanation

. Venous outflow

Explanation

In compartment syndrome, increased tissue pressure first obstructs venous outflow, then capillary perfusion, leading to ischemia. The peripheral arterial pulses remain palpable until the very late stages, making their presence a poor rule-out tool.

Question 1083

Topic: 2. Trauma

A 35-year-old male smoker has an 8-month-old aseptic hypertrophic nonunion of a midshaft tibia fracture. He was originally treated with an 8-mm unreamed intramedullary nail. There is no bone loss or deformity. What is the most successful definitive surgical intervention?

. Removal of the nail and application of an Ilizarov external fixator
. Exchange nailing with a larger diameter reamed nail
. Pulsed electromagnetic field (PEMF) bone stimulation
. Augmentation with a medial locking plate leaving the nail in situ
. Fibular osteotomy alone

Correct Answer & Explanation

. Exchange nailing with a larger diameter reamed nail

Explanation

Exchange nailing (removing the small nail, reaming the canal, and placing a larger nail) is the gold standard for aseptic hypertrophic and oligotrophic tibial nonunions. The reaming provides biological stimulation and the larger nail provides mechanical stability.

Question 1084

Topic: 2. Trauma
A 22-year-old agricultural worker sustains a Gustilo-Anderson Type IIIB open tibia fracture highly contaminated with soil and manure. Alongside immediate surgical debridement, what is the most appropriate prophylactic intravenous antibiotic regimen based on standard trauma guidelines?
. Cefazolin monotherapy for 24 hours
. Cefazolin and Gentamicin for 48 hours
. Cefazolin, Gentamicin, and Penicillin G
. Vancomycin and Piperacillin-Tazobactam
. Oral Ciprofloxacin and Clindamycin

Correct Answer & Explanation

. Cefazolin, Gentamicin, and Penicillin G

Explanation

High-energy open fractures with farm or soil contamination require coverage for Gram-positives (Cefazolin), Gram-negatives (Gentamicin), and anaerobes like Clostridium species (Penicillin G).

Question 1085

Topic: 2. Trauma

A 40-year-old male sustains an isolated, closed midshaft tibia fracture. Radiographs confirm that the ipsilateral fibula is entirely intact. If this injury is treated non-operatively in a cast, what is the most significant structural complication associated with this specific injury pattern?

. Profound valgus malunion
. Varus malunion and delayed union
. Accelerated fracture healing leading to leg length discrepancy
. Spontaneous distal tibiofibular syndesmosis rupture
. Anterior dislocation of the proximal tibiofibular joint

Correct Answer & Explanation

. Varus malunion and delayed union

Explanation

An intact fibula acts as a mechanical strut, preventing the tibial fracture ends from compressing evenly. This strut effect frequently pulls the tibia into varus malalignment and significantly increases the risk of delayed union or nonunion.

Question 1086

Topic: 2. Trauma
A 30-year-old male undergoes intramedullary (IM) nailing for a closed midshaft tibia fracture. Based on the findings of the SPRINT trial, what is the primary clinical advantage of utilizing a reamed IM nail compared to an unreamed IM nail in this specific patient population?
. Decreased incidence of compartment syndrome
. Significant reduction in the need for secondary procedures to promote union
. Lower rate of deep surgical site infection
. Decreased incidence of chronic anterior knee pain
. Elimination of the risk of thermal osteonecrosis

Correct Answer & Explanation

. Significant reduction in the need for secondary procedures to promote union

Explanation

The SPRINT trial demonstrated that reamed intramedullary nailing for closed tibia fractures significantly decreases the need for secondary procedures (like bone grafting or exchange nailing) compared to unreamed nails. There was no significant difference in infection rates or compartment syndrome.

Question 1087

Topic: 2. Trauma

When performing intramedullary nailing of a proximal third extra-articular tibia fracture using a standard infrapatellar approach, the fracture is most susceptible to which of the following classic malalignment patterns?

. Varus and recurvatum
. Valgus and procurvatum
. Valgus and recurvatum
. Varus and procurvatum
. Pure rotational deformity

Correct Answer & Explanation

. Valgus and procurvatum

Explanation

Proximal third tibia fractures treated with standard infrapatellar IM nailing typically fall into apex anterior (procurvatum) and valgus deformities. This is due to the pull of the patellar tendon (causing procurvatum) and the lateral starting point of the nail pushing the proximal segment into valgus.

Question 1088

Topic: 2. Trauma

To prevent the classic valgus and procurvatum deformity during intramedullary nailing of a proximal third tibia fracture, blocking (Poller) screws can be utilized. Relative to the planned path of the nail, where should these screws be placed in the proximal fragment?

. Anterior and medial to the nail
. Posterior and lateral to the nail
. Posterior and medial to the nail
. Anterior and lateral to the nail
. Directly anterior and posterior to the nail

Correct Answer & Explanation

. Posterior and lateral to the nail

Explanation

Blocking screws should be placed in the concavity of the expected deformity to narrow the medullary canal and direct the nail. To prevent valgus and procurvatum, they are placed posterior (to prevent procurvatum) and lateral (to prevent valgus) to the nail.

Question 1089

Topic: 2. Trauma

A 25-year-old male sustains a severe crush injury to his left leg. His blood pressure is 110/70 mmHg. Intracompartmental pressure monitoring is initiated due to a tense calf. Which of the following thresholds is the most reliable and widely accepted indication to perform a four-compartment fasciotomy?

. Absolute intracompartmental pressure > 20 mmHg
. Absolute intracompartmental pressure > 25 mmHg
. Delta pressure (Diastolic BP - Intracompartmental Pressure) < 30 mmHg
. Delta pressure (Systolic BP - Intracompartmental Pressure) < 40 mmHg
. Delta pressure (Mean Arterial Pressure - Intracompartmental Pressure) < 10 mmHg

Correct Answer & Explanation

. Delta pressure (Diastolic BP - Intracompartmental Pressure) < 30 mmHg

Explanation

A delta pressure (Diastolic Blood Pressure minus Intracompartmental Pressure) of less than 30 mmHg is the most reliable threshold for diagnosing acute compartment syndrome. Absolute pressure measurements are less reliable due to systemic blood pressure variations.

Question 1090

Topic: 2. Trauma
A 40-year-old male is found down 36 hours after a drug overdose with his leg crushed beneath his body. He has a tense, firm calf, an absent dorsalis pedis pulse, dense foot drop, and absent sensation in the deep peroneal nerve distribution. Pressures measure >70 mmHg. What is the most appropriate initial management?
. Immediate single-incision four-compartment fasciotomy
. Immediate double-incision four-compartment fasciotomy
. Observation and supportive medical care
. Immediate above-knee amputation
. Administration of hyperbaric oxygen therapy

Correct Answer & Explanation

. Observation and supportive medical care

Explanation

Fasciotomy is contraindicated in missed or late compartment syndrome (>24 hours) where irreversible muscle necrosis has already occurred. Operating on dead muscle dramatically increases the risk of severe, life-threatening infection and does not restore nerve or muscle function; supportive care is the standard initial approach.

Question 1091

Topic: 2. Trauma

During a standard two-incision, four-compartment fasciotomy for acute compartment syndrome of the leg, the medial incision is utilized to decompress the superficial and deep posterior compartments. Which of the following structures must be explicitly detached or mobilized to adequately decompress the deep posterior compartment?

. Tibialis anterior muscle
. Soleus bridge from the posterior tibia
. Gastrocnemius aponeurosis
. Peroneus brevis muscle belly
. Flexor retinaculum

Correct Answer & Explanation

. Soleus bridge from the posterior tibia

Explanation

To adequately access and decompress the deep posterior compartment via the medial incision, the soleus bridge must be detached from its origin on the posteromedial border of the tibia. This exposes the underlying tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles.

Question 1092

Topic: 2. Trauma
A 45-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture with a 10 cm exposed soft tissue and bone defect over the distal third of the anterior tibia. After skeletal stabilization and serial debridements, which of the following 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 flap)
. Reverse sural artery flap

Correct Answer & Explanation

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

Explanation

Soft tissue defects in the distal third of the tibia typically require free tissue transfer because local rotational muscle flaps (like the soleus or gastrocnemius) cannot reach this distal zone reliably. The gastrocnemius is used for the proximal third, and the soleus for the middle third.

Question 1093

Topic: 2. Trauma

A 35-year-old smoker presents 8 months following statically locked intramedullary nailing of a closed midshaft tibia fracture. He reports pain with weight-bearing. Radiographs demonstrate a hypertrophic nonunion with broken distal locking screws. What is the most successful surgical intervention?

. Bone morphogenetic protein (BMP) injection at the nonunion site
. Removal of proximal locking screws (dynamization)
. Exchange nailing with a larger diameter reamed nail
. Plate osteosynthesis with iliac crest bone graft
. Fibular osteotomy alone

Correct Answer & Explanation

. Exchange nailing with a larger diameter reamed nail

Explanation

Hypertrophic nonunions are biologically active (elephant foot appearance) but lack adequate mechanical stability. Exchange nailing with a larger diameter reamed nail provides improved biomechanical stability and stimulates healing, making it the treatment of choice.

Question 1094

Topic: 2. Trauma

Irreversible necrosis of muscle tissue in acute compartment syndrome of the lower extremity typically begins after what duration of continuous ischemia?

. 1 to 2 hours
. 3 to 4 hours
. 6 to 8 hours
. 12 to 14 hours
. 18 to 24 hours

Correct Answer & Explanation

. 6 to 8 hours

Explanation

Irreversible muscle and nerve damage begins after approximately 6 to 8 hours of total ischemia. Prompt clinical recognition and emergent fasciotomy before this critical window closes are essential for preserving functional limb viability.

Question 1095

Topic: 2. Trauma

A surgeon elects to perform a single-incision (perifibular) four-compartment fasciotomy rather than the traditional dual-incision technique. Which of the following is a recognized risk specifically increased with this single-incision approach?

. Higher rate of deep bone infection
. Inability to decompress the anterior compartment
. Increased risk of iatrogenic injury to the superficial peroneal nerve
. Higher incidence of subsequent tibial nonunion
. Inability to perform delayed primary closure

Correct Answer & Explanation

. Increased risk of iatrogenic injury to the superficial peroneal nerve

Explanation

The single-incision (perifibular) approach requires extensive subcutaneous dissection to access both the anterior/lateral and posterior compartments from one lateral incision. This puts the superficial peroneal nerve at a significantly higher risk of iatrogenic traction or transection injury.

Question 1096

Topic: 2. Trauma

A 28-year-old female with a high-energy diaphyseal tibia fracture is undergoing intramedullary nailing. The anesthesia team offers a continuous popliteal nerve block for postoperative pain control. Why is continuous regional anesthesia generally discouraged in this specific scenario?

. It significantly increases the risk of deep vein thrombosis
. It impairs the local inflammatory cascade needed for bone healing
. It masks the breakthrough ischemic pain characteristic of developing compartment syndrome
. It increases the risk of deep surgical site infection
. It causes profound vasodilation leading to massive hematoma formation

Correct Answer & Explanation

. It masks the breakthrough ischemic pain characteristic of developing compartment syndrome

Explanation

Continuous regional anesthesia or epidurals can mask severe ischemic pain (pain out of proportion to the injury) and increase analgesic requirements. This delays the clinical diagnosis of acute compartment syndrome, potentially leading to irreversible limb damage.

Question 1097

Topic: 2. Trauma

Following successful union of a tibia fracture treated with an antegrade intramedullary nail via an infrapatellar approach, what is the most frequently reported long-term complication by patients?

. Symptomatic malunion
. Chronic osteomyelitis
. Anterior knee pain
. Deep peroneal nerve palsy
. Hardware failure

Correct Answer & Explanation

. Anterior knee pain

Explanation

Anterior knee pain is the most frequently reported complication after tibial intramedullary nailing, occurring in up to 40-70% of patients. Its etiology is multifactorial, relating to the surgical incision, fat pad injury, and nail prominence.

Question 1098

Topic: 2. Trauma

Which of the following describes a primary biomechanical advantage of utilizing a suprapatellar approach (with the knee in a semi-extended position) over a traditional infrapatellar approach for tibial intramedullary nailing?

. It eliminates the risk of postoperative anterior knee pain entirely
. It nullifies the deforming forces of the gastrocnemius muscle on the distal fragment
. It relaxes the extensor mechanism, facilitating the reduction of proximal third fractures
. It avoids entirely violating the knee joint capsule
. It eliminates the need for fluoroscopy during guide wire passage

Correct Answer & Explanation

. It relaxes the extensor mechanism, facilitating the reduction of proximal third fractures

Explanation

The suprapatellar approach allows the knee to remain semi-extended (15-20 degrees of flexion). This neutralizes the pull of the extensor mechanism (patellar tendon), which is the primary deforming force causing apex anterior angulation in proximal third tibia fractures.

Question 1099

Topic: 2. Trauma

A 50-year-old male presents with a high-energy closed tibia fracture and massive soft tissue swelling with fracture blisters (Tscherne Grade 3). A temporizing spanning external fixator is placed. When is the most appropriate time to safely convert to an intramedullary nail?

. Within 48 hours to prevent pin tract infections
. Once the soft tissue envelope improves, edema resolves, and the wrinkle sign is present
. After 21 days, regardless of the soft tissue status
. Only if the external fixator loses mechanical stability
. Simultaneously with a prophylactic soleus flap

Correct Answer & Explanation

. Once the soft tissue envelope improves, edema resolves, and the wrinkle sign is present

Explanation

Conversion from a temporizing spanning external fixator to an IM nail should occur once the soft tissue envelope has adequately recovered. This is clinically indicated by resolving edema, epithelialized blisters, and a positive wrinkle sign, ideally performed within 14 days to minimize deep infection risk.

Question 1100

Topic: 2. Trauma

A 42-year-old male is undergoing intramedullary nailing of a proximal-third tibia shaft fracture. To prevent the typical apex anterior and apex medial (valgus) deformities commonly seen with this injury, where should blocking (Poller) screws be placed relative to the path of the intramedullary nail in the proximal fragment?

. Anterior and medial
. Anterior and lateral
. Posterior and medial
. Posterior and lateral
. Directly midline

Correct Answer & Explanation

. Posterior and lateral

Explanation

Proximal tibia fractures commonly displace into apex anterior (procurvatum) and apex medial (valgus) deformities during nailing. Blocking screws should be placed in the concavity of the expected deformity (posterior and lateral) to appropriately direct the nail and maintain reduction.

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