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2. Trauma MCQs

Practice Set 552 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 11021

Topic: 2. Trauma
A 24-year-old cyclist falls directly onto his shoulder and sustains a completely displaced midshaft clavicle fracture. Which of the following is considered an ABSOLUTE indication for acute open reduction and internal fixation?
. 1.5 cm of shortening
. 100% vertical displacement of the fragments
. Z-deformity with a comminuted butterfly fragment
. Skin tenting that threatens skin integrity
. Patient preference for a faster return to competitive sports

Correct Answer & Explanation

. Skin tenting that threatens skin integrity

Explanation

Absolute indications for acute operative fixation of a clavicle fracture include: open fracture, associated neurovascular injury, skin tenting threatening to progress to an open fracture, and 'floating shoulder' (ipsilateral displaced scapular neck fracture). Factors like 100% displacement, shortening > 2 cm, and severe comminution are considered RELATIVE indications, often discussed with the patient regarding the risk of symptomatic nonunion versus surgical risks.

Question 11022

Topic: 2. Trauma

A 35-year-old polytrauma patient undergoes damage control orthopedics (DCO) with external fixation of bilateral femur fractures. Which parameter is the MOST reliable indicator that the patient has been adequately resuscitated and is physiologically optimized for definitive intramedullary nailing?

. Normalization of heart rate and mean arterial pressure
. Urine output consistently > 0.5 mL/kg/hr for 12 hours
. Serum lactate < 2.0 mmol/L and base deficit between -2 and +2
. Systemic vascular resistance > 800 dynes/sec/cm^-5
. Central venous pressure > 8 mmHg

Correct Answer & Explanation

. Normalization of heart rate and mean arterial pressure

Explanation

Clearance of serum lactate (target < 2.0 mmol/L) and normalization of base deficit (between -2 and +2) are the most reliable indicators of adequate tissue perfusion and successful resuscitation in polytrauma patients. While heart rate, blood pressure, and urine output are useful clinical markers, they can normalize before cellular hypoxia has resolved (occult hypoperfusion).

Question 11023

Topic: 2. Trauma

In a patient presenting with severe traumatic brain injury (GCS 6) and an ipsilateral closed comminuted femur fracture, what is the major physiological rationale for performing damage control external fixation rather than early intramedullary nailing within the first 24 hours?

. To prevent the acceleration of severe heterotopic ossification in the thigh
. To avoid the 'second hit' of intraoperative hypoxia and hypotension which exacerbates secondary brain injury
. To definitively prevent systemic fat embolization syndrome
. To wait for clearance of the cervical spine prior to definitive positioning
. To prevent arrest of fracture callus formation due to the systemic inflammatory response

Correct Answer & Explanation

. To prevent the acceleration of severe heterotopic ossification in the thigh

Explanation

In severe TBI, early total care (e.g., reamed intramedullary nailing) can act as a 'second hit' due to intraoperative hypotension, hypoxia, and fat embolization. These physiological insults significantly exacerbate secondary brain injury and increase intracranial pressure. Therefore, Damage Control Orthopedics (DCO) with rapid external fixation is often preferred to stabilize the fracture while minimizing surgical physiological burden.

Question 11024

Topic: Pelvic & Acetabular Trauma
A hemodynamically unstable 42-year-old male is brought in after a motorcycle crash. Pelvic radiographs demonstrate an anteroposterior compression (APC-III) pelvic ring injury. Where is the anatomically correct position to place a pelvic circumferential compression device (binder) for optimal reduction and hemorrhage control?
. Level of the anterior superior iliac spines (ASIS)
. Level of the iliac crests
. Level of the greater trochanters
. Midway between the umbilicus and the pubic symphysis
. Proximal third of the femurs

Correct Answer & Explanation

. Level of the greater trochanters

Explanation

A pelvic binder must be placed at the level of the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement higher (e.g., at the iliac crests or ASIS) is a common error and fails to adequately close the symphysis pubis, and can sometimes paradoxically open the pelvic floor or impede abdominal access.

Question 11025

Topic: 2. Trauma
A 40-year-old male sustains a Gustilo-Anderson Type IIIB open fracture of the distal third of the tibia. After serial debridements resulting in a clean wound bed with exposed bone devoid of periosteum, soft tissue coverage is required. Which of the following is the most appropriate soft tissue flap for this specific zone?
. Medial gastrocnemius rotational flap
. Soleus rotational flap
. Latissimus dorsi or Anterolateral thigh (ALT) free flap
. Sural artery cross-leg flap
. Fasciocutaneous advancement flap

Correct Answer & Explanation

. Latissimus dorsi or Anterolateral thigh (ALT) free flap

Explanation

Coverage for open tibia fractures is classically divided by thirds: the proximal third is covered by the gastrocnemius flap, the middle third by the soleus flap, and the distal third typically requires a free tissue transfer (such as an ALT or latissimus dorsi flap) due to the lack of adequate local muscle bulk.

Question 11026

Topic: 2. Trauma

A 25-year-old male sustains a low-velocity civilian gunshot wound to the right thigh, resulting in a comminuted midshaft femur fracture. The entrance and exit wounds are 1 cm each, with no expanding hematoma or signs of ischemia. What is the most appropriate definitive management strategy?

. Immediate formal open debridement of the fracture site and skeletal traction
. Local wound care, intravenous antibiotics, and intramedullary nailing without formal track debridement
. Formal track debridement, external fixation, and delayed primary closure
. Local wound care, tetanus prophylaxis, and nonoperative management in a spica cast
. Exploratory laparotomy and external fixation

Correct Answer & Explanation

. Immediate formal open debridement of the fracture site and skeletal traction

Explanation

Low-velocity gunshot wounds resulting in femur fractures without intra-articular extension or significant vascular injury are treated similarly to closed fractures. Management involves local wound care (superficial debridement), antibiotics, and definitive fixation, typically with an intramedullary nail. Formal open debridement of the bullet track is not routinely indicated.

Question 11027

Topic: 2. Trauma

A 32-year-old male undergoes reamed intramedullary nailing for a closed tibial shaft fracture. In the recovery room, he complains of worsening, intractable leg pain. His diastolic blood pressure is 65 mmHg. The anterior compartment pressure is measured directly at 40 mmHg. What is the calculated "delta P" and the most appropriate next step?

. Delta P is 25 mmHg; perform urgent four-compartment fasciotomies.
. Delta P is 25 mmHg; elevate the leg above the level of the heart and observe.
. Delta P is 40 mmHg; administer intravenous mannitol and recheck in 1 hour.
. Delta P is 105 mmHg; remove the intramedullary nail and place an external fixator.
. Delta P is 25 mmHg; apply ice and prescribe patient-controlled analgesia.

Correct Answer & Explanation

. Delta P is 25 mmHg; perform urgent four-compartment fasciotomies.

Explanation

Delta P is calculated as the Diastolic Blood Pressure minus the Compartment Pressure. Here, 65 mmHg - 40 mmHg = 25 mmHg. A Delta P of 30 mmHg or less (some sources say < 30 mmHg) is a widely accepted threshold indicating acute compartment syndrome requiring emergent fasciotomy. Elevation above the heart is contraindicated as it decreases arterial perfusion pressure.

Question 11028

Topic: 2. Trauma

In the staged management of severe pilon fractures (OTA/AO 43-C3), spanning external fixation is initially applied. What is the primary clinical indicator used to determine when it is safe to proceed with definitive open reduction and internal fixation (ORIF)?

. Normalization of serum inflammatory markers (CRP and ESR)
. Appearance of the "wrinkle sign" on the skin overlying the fracture
. Radiographic evidence of soft fracture callus
. Achievement of exactly 14 days post-injury
. Negative wound cultures from the external fixator pin sites

Correct Answer & Explanation

. Normalization of serum inflammatory markers (CRP and ESR)

Explanation

Staged management of high-energy pilon fractures involves early spanning external fixation to allow for soft tissue recovery. The primary clinical indicator that soft tissue swelling has subsided enough to safely permit definitive ORIF (minimizing wound dehiscence risk) is the appearance of the "wrinkle sign" in the skin.

Question 11029

Topic: 2. Trauma
A 35-year-old male sustains a severe blunt force trauma to the lateral hip. Two weeks later, examination reveals a fluctuant, ballotable mass over the greater trochanter with overlying skin hypesthesia. Aspiration yields serosanguinous fluid. What is the specific pathophysiology of this lesion?
. Herniation of the tensor fasciae latae muscle through a fascial defect
. Subperiosteal hematoma secondary to an occult intertrochanteric fracture
. Traumatic shearing separation of the subcutaneous tissue from the underlying deep fascia
. Laceration of the superior gluteal artery leading to a pseudoaneurysm
. Infection of the trochanteric bursa

Correct Answer & Explanation

. Traumatic shearing separation of the subcutaneous tissue from the underlying deep fascia

Explanation

The patient has a Morel-Lavallée lesion, which is a closed degloving injury. The pathophysiology involves a severe shearing force that separates the subcutaneous fat from the underlying deep fascia, creating a potential space that fills with blood, lymph, and necrotic fat.

Question 11030

Topic: 2. Trauma

A 50-year-old smoker presents 8 months after nonoperative management of a midshaft humerus fracture. Radiographs demonstrate an atrophic nonunion with no bridging callus and pencil-point sclerosis of the fracture ends. Which of the following is the most critical component of surgical management for this specific type of nonunion?

. Rigid internal fixation to enhance mechanical stability alone
. Provision of biological stimulation (e.g., autologous bone grafting) coupled with rigid internal fixation
. Dynamization of the fracture site to stimulate micromotion and callus formation
. Noninvasive pulsed electromagnetic field (PEMF) bone stimulation
. Extracorporeal shock wave therapy (ESWT)

Correct Answer & Explanation

. Rigid internal fixation to enhance mechanical stability alone

Explanation

An atrophic nonunion lacks the biological capacity to heal. Therefore, management requires BOTH biological stimulation (e.g., autologous iliac crest bone graft or RIA) and rigid mechanical stability. In contrast, a hypertrophic nonunion (elephant shoe appearance) has adequate biology but lacks mechanical stability, and can be treated with rigid fixation alone.

Question 11031

Topic: 2. Trauma

A 24-year-old motorcyclist presents after a high-speed collision. Clinical exam reveals massive swelling over the shoulder girdle, a pulseless ipsilateral upper extremity, and complete flaccid paralysis of the arm. Radiographs show significant lateral displacement of the scapula. What is the most immediate life-threatening complication associated with this injury pattern?

. Tension pneumothorax
. Exsanguinating hemorrhage from subclavian or axillary vessel disruption
. Irreversible brachial plexus avulsion leading to a flail limb
. Systemic fat embolism syndrome
. Cervical spine fracture-dislocation

Correct Answer & Explanation

. Tension pneumothorax

Explanation

The diagnosis is scapulothoracic dissociation, characterized by lateral displacement of the scapula, complete brachial plexus avulsion, and severe vascular injury. The most immediate life-threatening complication is massive hemorrhage from avulsion/disruption of the subclavian or axillary vessels. Immediate operative control of hemorrhage or endovascular intervention is critical.

Question 11032

Topic: 2. Trauma

A 22-year-old male is recovering in the ICU 36 hours after sustaining bilateral closed femur fractures. He develops acute hypoxemia, confusion, and a non-blanching rash over his axilla and chest. According to Gurd and Wilson's criteria for Fat Embolism Syndrome (FES), which of his symptoms is considered a MAJOR criterion?

. Tachycardia > 120 bpm
. Pyrexia > 39.5°C
. Petechial rash
. Sudden drop in hemoglobin
. Oliguria

Correct Answer & Explanation

. Tachycardia > 120 bpm

Explanation

Gurd and Wilson's criteria for Fat Embolism Syndrome classify symptoms into major and minor criteria. The major criteria are: 1) Respiratory insufficiency (hypoxemia), 2) Cerebral involvement (confusion/coma), and 3) Petechial rash (typically over the thorax, axilla, and conjunctiva). Tachycardia, fever, and drop in hemoglobin are minor criteria.

Question 11033

Topic: 2. Trauma

In a hemodynamically borderline polytrauma patient, Damage Control Orthopedics (DCO) principles are being applied. Which of the following inflammatory markers has been most extensively validated as a strong predictor of the systemic inflammatory response magnitude and multiorgan failure, often used to guide the timing of definitive fracture fixation?

. Interleukin-1 (IL-1)
. Interleukin-6 (IL-6)
. Tumor Necrosis Factor-alpha (TNF-a)
. C-Reactive Protein (CRP)
. Erythrocyte Sedimentation Rate (ESR)

Correct Answer & Explanation

. Interleukin-1 (IL-1)

Explanation

Interleukin-6 (IL-6) is the most heavily studied cytokine in trauma and orthopedics for measuring the systemic inflammatory response syndrome (SIRS). Its levels peak early and correlate tightly with the risk of multiorgan failure, making it a valuable marker when deciding if a "borderline" patient is ready to transition from DCO to early total care.

Question 11034

Topic: 2. Trauma
A 30-year-old farmer sustains an open midshaft femur fracture (Gustilo-Anderson Type IIIA) from a tractor accident. The wound is heavily contaminated with soil and organic matter. In addition to a first-generation cephalosporin and an aminoglycoside, what specific antibiotic coverage must be added?
. High-dose Penicillin
. Clindamycin
. Vancomycin
. Metronidazole
. Doxycycline

Correct Answer & Explanation

. High-dose Penicillin

Explanation

In the setting of a farm injury or heavy soil contamination, there is a high risk of Clostridium perfringens infection, which can lead to gas gangrene. The standard of care mandates the addition of high-dose Penicillin to the regimen of a cephalosporin and aminoglycoside.

Question 11035

Topic: 2. Trauma

A 28-year-old male suffers a severe crush injury to the foot. He presents with excruciating midfoot pain out of proportion to examination, tense swelling, and pain with passive toe extension. If a fasciotomy is deemed necessary for impending compartment syndrome, how many discrete fascial compartments are anatomically recognized in the foot?

. 4
. 5
. 7
. 9
. 11

Correct Answer & Explanation

. 4

Explanation

The foot contains 9 recognized anatomical compartments: Medial, Lateral, Superficial Central, Deep Central (Calcaneal), and 4 Interosseous compartments. Standard releases are often performed via a dual dorsal incision approach or a combination of medial and dorsal incisions.

Question 11036

Topic: 2. Trauma

A 25-year-old male is brought in after a high-speed motor vehicle collision. He is intubated, with a blood pressure of 85/50 mmHg, a serum lactate of 5.0 mmol/L, and a core temperature of 34°C. Secondary survey reveals a closed midshaft femur fracture. According to the principles of Damage Control Orthopedics (DCO), what is the most appropriate initial management for his femur fracture?

. Early total care with intramedullary nailing
. Immediate plate osteosynthesis
. Temporary external fixation
. Skeletal traction pin and bed rest only
. Primary amputation

Correct Answer & Explanation

. Early total care with intramedullary nailing

Explanation

This patient is in extremis and exhibiting signs of the 'lethal triad' of trauma (hypothermia, acidosis, and coagulopathy, although coagulopathy is unstated, it is presumed). In an unstable polytrauma patient, Early Total Care (ETC) such as IM nailing provides a 'second hit' that can be fatal. Damage Control Orthopedics (DCO) principles dictate rapid, temporary stabilization with external fixation to control hemorrhage and stabilize soft tissues, allowing for physiologic resuscitation in the ICU before definitive fracture care.

Question 11037

Topic: 2. Trauma

A 40-year-old construction worker falls from a height, sustaining a severe, closed OTA/AO 43-C3 pilon fracture with massive soft tissue swelling, fracture blisters, and extreme tension over the anterior ankle. What is the most appropriate initial, evidence-based management strategy?

. Immediate definitive open reduction and internal fixation (ORIF) with dual plating
. Joint-spanning external fixation across the ankle with leg elevation
. Placement of a calcaneal traction pin and delayed primary closure
. Primary below-knee amputation
. Fasciotomies of the lower leg followed by immediate ORIF

Correct Answer & Explanation

. Immediate definitive open reduction and internal fixation (ORIF) with dual plating

Explanation

For high-energy, complex pilon fractures with severe soft tissue compromise, standard of care dictates a staged protocol. The first stage involves temporary joint-spanning external fixation (often with concurrent fibular fixation if anatomically feasible) to restore length and alignment while allowing soft tissue swelling to subside over 10-14 days. Definitive ORIF is performed once the soft tissue envelope recovers (evidenced by the 'wrinkle test').

Question 11038

Topic: 2. Trauma

A 30-year-old male sustains a high-energy trauma to the knee. A CT scan reveals a supracondylar distal femur fracture with an associated coronal plane shear fracture of the lateral femoral condyle (Hoffa fragment). Biomechanically, what is the most stable screw trajectory for independent lag screw fixation of this specific coronal fragment?

. Anterior-to-posterior placement
. Posterior-to-anterior placement
. Medial-to-lateral placement
. Lateral-to-medial placement
. Inferior-to-superior placement

Correct Answer & Explanation

. Anterior-to-posterior placement

Explanation

A Hoffa fracture is a coronal shear fracture of the femoral condyle. When placing lag screws to fix this fragment, an anterior-to-posterior (AP) trajectory is biomechanically superior to a posterior-to-anterior (PA) trajectory. This is because AP screws engage the denser cortical bone of the posterior condyle, yielding significantly higher pull-out strength and compression across the fracture site.

Question 11039

Topic: 2. Trauma

A patient presents with a knee dislocation and an associated posteromedial tibial plateau fracture. Following closed reduction, the foot remains pulseless, and a CT angiogram confirms a complete occlusion of the popliteal artery. Irreversible skeletal muscle necrosis in the lower extremity typically begins after what duration of warm ischemia time?

. 2 hours
. 4 hours
. 6 hours
. 10 hours
. 12 hours

Correct Answer & Explanation

. 2 hours

Explanation

In the setting of vascular occlusion (e.g., popliteal artery injury with knee dislocation), warm ischemia time is critical. Irreversible muscle necrosis begins at approximately 6 hours. Immediate vascular intervention is necessary to reestablish perfusion and limb salvage.

Question 11040

Topic: 2. Trauma
A Gustilo-Anderson Type IIIB open tibia fracture results in a 6x6 cm soft tissue defect overlying the middle third of the tibia, leaving cortical bone exposed. Following aggressive debridement, which of the following is the most reliable local rotational muscle flap for coverage of this specific defect?
. Medial gastrocnemius rotational flap
. Soleus rotational flap
. Reverse superficial sural artery flap
. Sural nerve fasciocutaneous flap
. Anterolateral thigh free flap

Correct Answer & Explanation

. Soleus rotational flap

Explanation

For soft tissue coverage of the lower extremity, local options are categorized by thirds of the tibia. Proximal third defects are typically covered by the medial (or lateral) gastrocnemius flap. Middle third defects are optimally covered by a soleus muscle rotational flap. Distal third defects usually require a free tissue transfer or specialized reverse-flow local flaps.

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