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2. Trauma MCQs

Practice Set 550 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 10981

Topic: 2. Trauma

A 35-year-old construction worker falls from a scaffolding. Pelvic radiographs are obtained, and the obturator oblique view demonstrates a pathognomonic "spur sign." What acetabular fracture pattern does this sign indicate?

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

Correct Answer & Explanation

. Transverse fracture

Explanation

The "spur sign" on the obturator oblique radiograph represents the intact portion of the ilium that remains attached to the axial skeleton. It is pathognomonic for an associated both-column acetabular fracture.

Question 10982

Topic: 2. Trauma

A 24-year-old male undergoes reamed intramedullary nailing for a closed midshaft tibia fracture. Four hours postoperatively, he complains of escalating leg pain out of proportion to the injury. His blood pressure is 110/65 mmHg. Intracompartmental pressure testing reveals an anterior compartment pressure of 40 mmHg. What is the most appropriate next step in management?

. Elevate the leg above the level of the heart and observe
. Administer intravenous pain medication and reassess in 2 hours
. Immediate four-compartment fasciotomy of the leg
. Obtain an urgent duplex ultrasound to rule out deep vein thrombosis
. Remove the intramedullary nail and place an external fixator

Correct Answer & Explanation

. Elevate the leg above the level of the heart and observe

Explanation

The diagnosis of acute compartment syndrome is largely clinical but is confirmed when the delta pressure (diastolic blood pressure minus compartment pressure) is less than 30 mmHg. Here, the delta pressure is 25 mmHg (65 - 40), mandating immediate four-compartment fasciotomy.

Question 10983

Topic: 2. Trauma

A 45-year-old female sustains a high-energy supracondylar femur fracture. Computed tomography reveals a displaced coronal shear fracture of the lateral femoral condyle (Hoffa fragment).

What is the most biomechanically sound fixation strategy for this specific fragment?

. Lateral locking plate capturing the fragment with distal locking screws
. Independent anterior-to-posterior (AP) or posterior-to-anterior (PA) lag screws
. Retrograde intramedullary nailing with condylar interlocking screws
. Independent medial-to-lateral lag screws prior to plating
. Excision of the fragment with primary ligamentous reconstruction

Correct Answer & Explanation

. Lateral locking plate capturing the fragment with distal locking screws

Explanation

Hoffa fractures are coronal plane intra-articular shear injuries. They must be anatomically reduced and stabilized with independent AP or PA interfragmentary lag screws placed orthogonal to the fracture line prior to neutralization plating.

Question 10984

Topic: 2. Trauma

A 22-year-old motorcyclist is thrown from his bike. He presents with massive swelling over the left shoulder, an absent radial pulse, and complete paralysis of the left upper extremity. Chest radiograph demonstrates a widely displaced clavicle fracture with severe lateral displacement of the scapula. What is the most appropriate next step after stabilizing his airway and breathing?

. Immediate closed reduction of the shoulder under procedural sedation
. CT angiography of the left upper extremity
. Application of a shoulder spica cast
. Electromyography (EMG) of the brachial plexus
. Immediate exploration and internal fixation of the clavicle

Correct Answer & Explanation

. Immediate closed reduction of the shoulder under procedural sedation

Explanation

This clinical picture represents scapulothoracic dissociation, a devastating injury highly associated with subclavian or axillary vascular disruption and brachial plexus avulsion. Urgent vascular assessment with CT angiography (or immediate surgical exploration if actively exsanguinating) is critical.

Question 10985

Topic: 2. Trauma
A 50-year-old male sustains a Gustilo-Anderson IIIB open fracture of the proximal third of the tibia. After aggressive serial debridements, a 6 cm x 4 cm anterior soft tissue defect exposes the bare bone and the proximal tibial plate. What is the most appropriate soft tissue coverage option?
. Split-thickness skin graft directly over the hardware
. Pedicled medial gastrocnemius rotational flap
. Pedicled soleus muscle rotational flap
. Free anterolateral thigh (ALT) flap
. Reverse sural artery flap

Correct Answer & Explanation

. Pedicled medial gastrocnemius rotational flap

Explanation

Soft tissue defects in the proximal third of the tibia are classically best covered with a pedicled medial (or lateral) gastrocnemius muscle rotational flap. The soleus flap is preferred for the middle third, while the distal third typically requires free tissue transfer.

Question 10986

Topic: 2. Trauma

An 82-year-old female presents with a displaced intertrochanteric femur fracture. She has a history of coronary stents placed 2 years ago and takes clopidogrel (Plavix) daily. According to current AAOS guidelines, what is the safest and most effective approach regarding the timing of her surgery?

. Delay surgery for 5-7 days to allow clopidogrel washout
. Transfuse platelets immediately and operate within 6 hours
. Proceed with operative fixation within 48 hours without delaying for washout
. Place the patient in skeletal traction until clopidogrel is reversed
. Administer prothrombin complex concentrate (PCC) and operate immediately

Correct Answer & Explanation

. Delay surgery for 5-7 days to allow clopidogrel washout

Explanation

Current AAOS guidelines strongly recommend operative fixation of geriatric hip fractures within 48 hours to decrease mortality and complications. Delaying surgery for clopidogrel washout is not indicated and increases overall morbidity.

Question 10987

Topic: Pelvic & Acetabular Trauma
A 40-year-old male arrives in the trauma bay hypotensive and tachycardic. Radiographs confirm an anteroposterior compression type III (APC-III) pelvic ring injury. After application of a circumferential pelvic binder and transfusion of 2 units of packed red blood cells, his blood pressure remains 75/40 mmHg. A FAST examination is negative. What is the most appropriate next step in management?
. Exploratory laparotomy
. Application of a supracondylar femoral traction pin
. Preperitoneal pelvic packing and/or pelvic angioembolization
. Removal of the pelvic binder to re-examine the pelvis
. Immediate open reduction and internal fixation of the symphysis pubis

Correct Answer & Explanation

. Preperitoneal pelvic packing and/or pelvic angioembolization

Explanation

In a hemodynamically unstable patient with an unstable pelvic ring injury and a negative FAST scan, the source of bleeding is primarily presumed to be retroperitoneal/pelvic (venous plexus or arterial). The gold standard interventions are preperitoneal pelvic packing and/or angiography for embolization.

Question 10988

Topic: 2. Trauma

A 35-year-old female falls onto a fully extended knee. Radiographs reveal a depressed, split fracture of the medial tibial plateau.

What is the classic mechanism of injury for this Schatzker IV fracture, and what surgical approach is typically required?

. Valgus force; Anterolateral approach
. Varus force; Posteromedial approach
. Axial load; Direct posterior approach
. Hyperextension; Anteromedial approach
. Hyperflexion; Lateral parapatellar approach

Correct Answer & Explanation

. Valgus force; Anterolateral approach

Explanation

A Schatzker IV fracture involves the medial tibial plateau and is typically caused by a high-energy varus force combined with axial loading. It requires a medial or posteromedial approach to apply an anti-glide buttress plate to prevent varus collapse.

Question 10989

Topic: 2. Trauma

A 26-year-old male presents with a closed, transverse fracture of the middle third of the humeral shaft following an arm wrestling match. Physical examination reveals an inability to extend the wrist and fingers, with numbness in the first dorsal web space, which was present immediately after the injury. What is the most appropriate initial management of this neurologic deficit?

. Immediate surgical exploration of the radial nerve and rigid plate fixation
. Application of a functional fracture brace and clinical observation for 3-4 months
. Urgent EMG and nerve conduction studies
. Corticosteroid injection into the spiral groove
. External fixation to restore humeral length

Correct Answer & Explanation

. Immediate surgical exploration of the radial nerve and rigid plate fixation

Explanation

Immediate complete radial nerve palsy in the setting of a closed humeral shaft fracture is mostly a neuropraxia or axonotmesis. Standard of care is functional bracing and observation, as over 70% will spontaneously recover within 3 to 4 months.

Question 10990

Topic: 2. Trauma

A 38-year-old male presents with a severely displaced, comminuted distal tibia fracture (pilon fracture) extending into the tibiotalar joint. The ankle is massively swollen with multiple hemorrhagic fracture blisters. What is the most appropriate initial surgical management?

. Immediate open reduction and internal fixation through an anterolateral approach
. Fasciotomies and immediate open reduction of the fibula only
. Application of a spanning joint external fixator and delayed definitive internal fixation
. Closed reduction and application of a long leg cast
. Primary arthrodesis of the tibiotalar joint

Correct Answer & Explanation

. Immediate open reduction and internal fixation through an anterolateral approach

Explanation

High-energy pilon fractures with severe soft tissue injury (fracture blisters, massive swelling) mandate a staged protocol. A spanning external fixator restores length and alignment while allowing the soft tissue envelope to heal (usually 1-3 weeks) prior to definitive ORIF.

Question 10991

Topic: 2. Trauma

A 25-year-old hemodynamically stable male sustains an ipsilateral midshaft femur and midshaft tibia fracture ("floating knee") in a motorcycle collision. Assuming both fractures are amenable to intramedullary nailing, what is the most widely accepted sequence of operative fixation?

. Tibia first, followed by the femur
. Femur first, followed by the tibia
. Simultaneous nailing using a single incision
. External fixation of the femur, followed by nailing of the tibia
. Plating of the femur, followed by nailing of the tibia

Correct Answer & Explanation

. Tibia first, followed by the femur

Explanation

In a hemodynamically stable patient with a floating knee, it is standard practice to fix the femur first. Stabilizing the femur eliminates the larger lever arm, prevents further soft tissue injury, and facilitates positioning of the leg for the subsequent tibial nailing.

Question 10992

Topic: 2. Trauma

A 45-year-old male is struck by a vehicle and sustains the injury shown in the reference radiograph.

The imaging confirms a highly depressed, isolated medial tibial plateau fracture (Schatzker IV) with a varus deformity. Which of the following surgical approaches and fixation strategies is most appropriate?

. Anterolateral approach with a pre-contoured locking plate
. Direct medial approach with a tension band construct
. Posteromedial approach with an anti-glide buttress plate
. Posterior approach with dual plating
. Spanning external fixation alone as definitive treatment

Correct Answer & Explanation

. Anterolateral approach with a pre-contoured locking plate

Explanation

Schatzker IV fractures involving the medial plateau typically feature a posteromedial shear fragment. A posteromedial approach allows for the application of an anti-glide buttress plate to directly counteract the deforming varus shear forces.

Question 10993

Topic: 2. Trauma

A 68-year-old female sustains a 4-part proximal humerus fracture. Recent quantitative anatomic studies regarding the arterial supply to the humeral head indicate that which vessel is responsible for providing the majority of the blood supply to the articular segment?

. Anterior humeral circumflex artery
. Thoracoacromial artery
. Profunda brachii artery
. Posterior humeral circumflex artery
. Suprascapular artery

Correct Answer & Explanation

. Anterior humeral circumflex artery

Explanation

Historically, the anterior humeral circumflex artery was thought to be the main blood supply. However, recent studies (e.g., Hettrich et al.) demonstrate that the posterior humeral circumflex artery supplies 64% of the humeral head, providing the most significant portion of its perfusion.

Question 10994

Topic: 2. Trauma

A 22-year-old male undergoes open reduction and intramedullary nailing for a closed tibial shaft fracture. In the recovery room, he complains of unremitting leg pain out of proportion to the injury. Which of the following defines the critical 'Delta P' threshold used to diagnose acute compartment syndrome?

. Diastolic blood pressure minus compartment pressure < 30 mmHg
. Mean arterial pressure minus compartment pressure < 40 mmHg
. Systolic blood pressure minus compartment pressure < 30 mmHg
. Absolute compartment pressure > 20 mmHg
. Absolute compartment pressure > 25 mmHg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure < 30 mmHg

Explanation

The Delta P is calculated as the patient's diastolic blood pressure minus the intracompartmental pressure. A Delta P of less than 30 mmHg is the accepted threshold indicating inadequate perfusion and the need for emergent fasciotomies.

Question 10995

Topic: 2. Trauma

A 40-year-old male sustains a severe subtrochanteric femur fracture. Preoperative radiographs demonstrate the classic deformity of the proximal fracture fragment, which is flexed, abducted, and externally rotated. Which muscle is primarily responsible for the flexion deformity of the proximal segment?

. Gluteus maximus
. Adductor longus
. Iliopsoas
. Gluteus medius
. Short external rotators

Correct Answer & Explanation

. Gluteus maximus

Explanation

In a subtrochanteric fracture, the proximal fragment is acted upon by the iliopsoas (causing flexion), the gluteus medius and minimus (causing abduction), and the short external rotators (causing external rotation).

Question 10996

Topic: 2. Trauma
A 35-year-old female is diagnosed with a displaced transverse acetabular fracture after a rollover motor vehicle collision. On physical examination, a large, fluctuant, ecchymotic mass is palpated over the ipsilateral greater trochanter. What is the most appropriate management of this soft tissue lesion in the context of planned surgical fixation?
. Immediate ORIF directly through the center of the lesion
. Observation as it will spontaneously resorb prior to surgery
. Application of a hip spica cast to compress the lesion
. Percutaneous drainage and debridement prior to or concurrent with definitive fixation
. Avoidance of open surgery and exclusive use of percutaneous screws

Correct Answer & Explanation

. Percutaneous drainage and debridement prior to or concurrent with definitive fixation

Explanation

A Morel-Lavallรฉe lesion is a closed degloving injury that harbors a high risk of bacterial colonization and deep infection. It requires thorough drainage, debridement, and dead space management (often via percutaneous methods or limited incisions) prior to or simultaneously with underlying fracture fixation.

Question 10997

Topic: 2. Trauma

A patient with a talar neck fracture demonstrates a subchondral radiolucent band in the talar dome on a radiograph at 6 weeks (Hawkins sign). What does this finding indicate?

. Avascular necrosis is imminent
. Intact vascularity of the talar body
. Nonunion of the fracture
. Infection of the talar dome
. Subchondral collapse

Correct Answer & Explanation

. Avascular necrosis is imminent

Explanation

The Hawkins sign represents subchondral osteopenia due to hyperemia from intact vascularity. Its presence is highly predictive that avascular necrosis of the talar body will not occur.

Question 10998

Topic: 2. Trauma

A 28-year-old male with multiple injuries has a severely comminuted femur fracture, bilateral pulmonary contusions, and a lactate of 4.5 mmol/L. What is the most appropriate initial management of the femur fracture?

. Reamed intramedullary nailing
. Unreamed intramedullary nailing
. External fixation
. Plate osteosynthesis
. Skeletal traction

Correct Answer & Explanation

. Reamed intramedullary nailing

Explanation

This patient is physiologically unstable with a high lactate and pulmonary contusions. Damage control orthopedics (DCO) with external fixation is indicated to minimize the second-hit phenomenon associated with intramedullary nailing.

Question 10999

Topic: 2. Trauma

A 35-year-old male sustains a closed tibial plateau fracture. Six hours later, he develops severe pain out of proportion to the injury. Which of the following is the most sensitive early clinical finding of acute compartment syndrome?

. Loss of distal pulses
. Capillary refill greater than 3 seconds
. Pain with passive stretch of the involved muscles
. Pallor of the extremity
. Motor paralysis

Correct Answer & Explanation

. Loss of distal pulses

Explanation

Pain with passive stretch of the muscles within the affected compartment is the most sensitive and earliest clinical sign of acute compartment syndrome. Pulselessness and paralysis are late, often irreversible signs.

Question 11000

Topic: 2. Trauma

A 40-year-old male sustains a high-energy trauma resulting in a coronal plane fracture of the lateral femoral condyle (Hoffa fracture). According to biomechanical studies, what is the optimal trajectory for screw fixation to achieve maximum stability?

. Anterior-to-posterior
. Posterior-to-anterior
. Medial-to-lateral
. Lateral-to-medial
. Distal-to-proximal

Correct Answer & Explanation

. Anterior-to-posterior

Explanation

Biomechanical studies demonstrate that posterior-to-anterior screw trajectory provides superior fixation strength for Hoffa fractures. This orientation is more perpendicular to the fracture plane compared to the traditional anterior-to-posterior technique.

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