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2. Trauma MCQs

Practice Set 553 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 11041

Topic: 2. Trauma

A polytrauma patient develops a massive, tense thigh following a blunt crush injury. Thigh compartment pressures are measured at 45 mmHg with a diastolic blood pressure of 60 mmHg. If surgical fasciotomy of the thigh is indicated, which compartment is most commonly the primary source of the compartment syndrome?

. Posterior compartment
. Medial compartment
. Anterior compartment
. Lateral compartment
. Adductor compartment

Correct Answer & Explanation

. Posterior compartment

Explanation

While compartment syndrome of the thigh is relatively rare compared to the leg, when it occurs, the anterior compartment (containing the quadriceps) is the most frequently affected. A standard lateral incision is typically utilized to decompress the anterior compartment.

Question 11042

Topic: 2. Trauma

A large-for-gestational-age infant is delivered via vaginal birth complicated by severe shoulder dystocia. On physical examination, the neonate has an asymmetric Moro reflex and palpable crepitus over the right clavicle. No other neurological deficits are noted. What is the standard orthopedic management?

. Surgical open reduction and internal fixation
. Rigid figure-of-eight bracing for 4 weeks
. Reassurance and non-operative management with the sleeve pinned to the shirt
. Application of a unilateral shoulder spica cast
. Closed reduction under sedation and casting

Correct Answer & Explanation

. Surgical open reduction and internal fixation

Explanation

Neonatal clavicle fractures secondary to birth trauma possess immense remodeling potential. They heal rapidly without functional deficits. The standard of care is entirely non-operative, consisting of parental reassurance, gentle handling, and minimizing arm movement by pinning the infant's sleeve to their shirt for a week or two.

Question 11043

Topic: 2. Trauma

A patient is evaluated 8 weeks after surgical fixation of a Hawkins Type II talar neck fracture. An AP radiograph of the ankle demonstrates a subchondral radiolucent band extending across the dome of the talus. What is the clinical significance of this radiographic finding?

. It represents early-stage avascular necrosis (AVN) of the talar body
. It confirms the development of a talar neck nonunion
. It is an indicator of preserved or re-established blood supply to the talar body
. It is a pathognomonic sign of intra-articular osteomyelitis
. It suggests rapid chondrolysis of the ankle joint

Correct Answer & Explanation

. It represents early-stage avascular necrosis (AVN) of the talar body

Explanation

The presence of a subchondral radiolucent band in the talar dome at 6-8 weeks post-injury is known as the Hawkins sign. This radiolucency represents subchondral bone atrophy secondary to hyperemic bone resorption. It is an excellent prognostic sign indicating that the talar body is vascularized, thereby ruling out avascular necrosis (AVN).

Question 11044

Topic: 2. Trauma

A 24-year-old athlete sustains a fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (Jones fracture). This specific fracture pattern is notorious for a high risk of delayed union or nonunion. What anatomical factor is the primary reason for this complication?

. Constant avulsion forces from the inserting peroneus brevis tendon
. The fracture occurs in a vascular watershed area
. Overpull from the lateral band of the plantar fascia
. Lack of surrounding soft tissue envelope to provide secondary healing cells
. Excessive localized weight-bearing forces during the heel-strike phase

Correct Answer & Explanation

. Constant avulsion forces from the inserting peroneus brevis tendon

Explanation

A true Jones fracture occurs at the metaphyseal-diaphyseal junction of the 5th metatarsal. The primary reason for the high nonunion rate is that this region is a vascular watershed area. The proximal portion is supplied by a retrograde metaphyseal artery, while the distal diaphysis is supplied by antegrade nutrient arteries, leaving the junction relatively avascular.

Question 11045

Topic: 2. Trauma

A hypotensive polytrauma patient presents in the emergency department following a crush injury. Pelvic radiographs show a significant anteroposterior compression (APC) injury with massive diastasis of the pubic symphysis. To optimally reduce the pelvic volume and help control venous hemorrhage, where should the pelvic binder be centered anatomically?

. Over the anterior superior iliac spines (ASIS)
. Over the iliac crests
. Over the greater trochanters
. Around the mid-thigh level
. Directly over the umbilicus

Correct Answer & Explanation

. Over the anterior superior iliac spines (ASIS)

Explanation

To be biomechanically effective in closing the pelvic ring and reducing internal volume (thereby assisting in tamponade of venous bleeding), a pelvic binder must be applied directly centered over the greater trochanters. Application over the iliac crests can paradoxicially open the pelvic ring further or fail to provide adequate closure.

Question 11046

Topic: 2. Trauma
A 35-year-old agricultural worker sustains a severely contaminated open tibial shaft fracture (Gustilo-Anderson IIIA) after his leg is caught in a tractor. The wound contains significant amounts of soil and organic matter. Current prophylactic antibiotic guidelines recommend a first-generation cephalosporin, an aminoglycoside, and which additional antibiotic to cover specific soil-borne anaerobic pathogens?
. Oral Ciprofloxacin
. Intravenous Vancomycin
. High-dose Penicillin
. Intravenous Daptomycin
. Oral Azithromycin

Correct Answer & Explanation

. High-dose Penicillin

Explanation

In the setting of farm-related injuries or massive soil contamination, there is a significant risk of Clostridium perfringens infection (gas gangrene). Standard protocols recommend adding high-dose intravenous Penicillin (or Metronidazole for penicillin-allergic patients) for anaerobic coverage, in addition to the standard Gram-positive (cephalosporin) and Gram-negative (aminoglycoside) coverage.

Question 11047

Topic: 2. Trauma

A 25-year-old male presents after an MVC with closed bilateral femur fractures, pulmonary contusions, and a GCS of 9. His admission lactate is 4.5 mmol/L, pH is 7.20, and base excess is -8. What is the most appropriate management for his femur fractures?

. Bilateral reamed antegrade intramedullary nailing
. Bilateral unreamed antegrade intramedullary nailing
. Bilateral external fixation (Damage Control Orthopedics)
. Skeletal traction and observation in ICU
. Unilateral nailing of the more displaced side and external fixation of the other

Correct Answer & Explanation

. Bilateral reamed antegrade intramedullary nailing

Explanation

In a borderline or unstable polytrauma patient (lactate >4.0, pH <7.24, base excess worse than -6), Damage Control Orthopedics (DCO) with external fixation is indicated to minimize the second hit of systemic inflammatory response (SIRS) associated with intramedullary nailing.

Question 11048

Topic: 2. Trauma

A 22-year-old male is admitted with a closed tibia fracture. He complains of pain out of proportion to his injury. His diastolic blood pressure is 70 mmHg. Intracompartmental pressure testing of the anterior compartment yields a pressure of 45 mmHg. What is his Delta pressure, and what is the next best step?

. Delta pressure 25 mmHg; Urgent four-compartment fasciotomy
. Delta pressure 45 mmHg; Urgent four-compartment fasciotomy
. Delta pressure 25 mmHg; Elevation and observation
. Delta pressure 45 mmHg; Elevation and observation
. Delta pressure 70 mmHg; Urgent four-compartment fasciotomy

Correct Answer & Explanation

. Delta pressure 25 mmHg; Urgent four-compartment fasciotomy

Explanation

Delta pressure = Diastolic BP - Intracompartmental pressure. Here, 70 - 45 = 25 mmHg. A Delta pressure of less than 30 mmHg is an objective indication for urgent fasciotomy in the setting of suspected acute compartment syndrome.

Question 11049

Topic: 2. Trauma

A 45-year-old male sustains a high-energy closed pilon fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?

. Immediate open reduction and internal fixation of both tibia and fibula
. Immediate fibula fixation and spanning external fixation of the tibia
. Spanning external fixation and delayed ORIF of the tibia at 10-14 days once soft tissues permit
. Closed reduction and casting for 6 weeks
. Primary arthrodesis of the ankle

Correct Answer & Explanation

. Immediate open reduction and internal fixation of both tibia and fibula

Explanation

For high-energy pilon fractures with significant soft tissue compromise, the standard of care is a staged approach: immediate joint-spanning external fixation followed by delayed definitive ORIF of the tibia once the 'wrinkle sign' appears, typically at 10-14 days, to minimize soft tissue complications.

Question 11050

Topic: Lower Extremity Trauma

A 50-year-old male falls off a ladder and sustains a bicondylar tibial plateau fracture with diaphyseal dissociation. What is the Schatzker classification, and what surgical approach is often required for the posteromedial fragment?

. Schatzker V; Anterolateral approach alone
. Schatzker VI; Dual approaches (Anterolateral and Posteromedial)
. Schatzker IV; Medial approach alone
. Schatzker VI; Single midline anterior approach
. Schatzker V; Dual approaches (Anterolateral and Posteromedial)

Correct Answer & Explanation

. Schatzker V; Anterolateral approach alone

Explanation

A bicondylar tibial plateau fracture with complete dissociation of the metaphysis from the diaphysis is a Schatzker VI fracture. Because of the common posteromedial shear fragment, dual incisions (anterolateral and posteromedial) are frequently required to achieve stable fixation and avoid extensive soft tissue stripping.

Question 11051

Topic: 2. Trauma
A 40-year-old roof worker falls and sustains an intra-articular calcaneus fracture. The coronal CT scan shows a single primary fracture line through the posterior facet, dividing it into two pieces (one lateral, one medial). According to the Sanders classification, what type is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The Sanders classification is based on coronal CT cuts of the posterior facet. Type I is non-displaced. Type II has one fracture line (two articular fragments). Type III has two fracture lines (three fragments). Type IV is highly comminuted (four or more fragments).

Question 11052

Topic: 2. Trauma

A 28-year-old restrained driver presents after an MVC with a posterior hip dislocation. A post-reduction CT scan reveals a posterior wall acetabular fracture involving 45% of the articular surface. The hip is stable on dynamic stress fluoroscopy. What is the most appropriate management?

. Skeletal traction for 6 weeks
. Open reduction and internal fixation (ORIF) via a Kocher-Langenbeck approach
. ORIF via an ilioinguinal approach
. Touch-down weight-bearing for 6 weeks
. Total hip arthroplasty

Correct Answer & Explanation

. Skeletal traction for 6 weeks

Explanation

Posterior wall fractures involving >40-50% of the posterior articular surface are typically unstable and require surgical fixation. The Kocher-Langenbeck approach is standard. Even if the hip appears stable on initial examination, the large defect size is an indication for ORIF to prevent late subluxation.

Question 11053

Topic: 2. Trauma
A 35-year-old male sustains an open tibia fracture with a 12 cm laceration. After thorough surgical debridement, the bone can be adequately covered by local soft tissue without the need for a rotational or free flap. There is no arterial injury. What is the Gustilo-Anderson classification?
. Type II
. Type IIIA
. Type IIIB
. Type IIIC
. Type I

Correct Answer & Explanation

. Type IIIA

Explanation

A Gustilo-Anderson Type IIIA fracture is a high-energy open fracture with extensive soft tissue laceration or stripping, but adequate soft tissue coverage of the fractured bone. Type IIIB requires a flap for coverage, and Type IIIC involves an arterial injury requiring repair.

Question 11054

Topic: 2. Trauma

A 34-year-old male sustains a distal femur fracture. CT imaging reveals a coronal plane fracture of the lateral femoral condyle. What is the eponym for this fracture, and what is the optimal fixation strategy?

. Barton fracture; Anteroposterior lag screws
. Hoffa fracture; Posteroanterior lag screws
. Chopart fracture; Medial-to-lateral lag screws
. Segond fracture; Suture anchors
. Tillaux fracture; K-wires

Correct Answer & Explanation

. Barton fracture; Anteroposterior lag screws

Explanation

A coronal plane fracture of the femoral condyle is a Hoffa fracture. It must be fixed with screws placed perpendicular to the fracture line. Posterior-to-anterior (PA) screws have been shown biomechanically to provide stronger fixation than AP screws.

Question 11055

Topic: 2. Trauma

A 45-year-old smoker presents 9 months after an intramedullary nailing of a tibial shaft fracture with persistent pain. Radiographs show no bridging callus, rounding of the fracture ends, and a persistent fracture gap. What is the primary cause of this nonunion, and what is the required surgical strategy?

. Inadequate stability; requires exchange nailing only
. Inadequate biology; requires debridement, bone grafting, and potentially exchange nailing
. Infection; requires 6 weeks of IV antibiotics only
. Hypertrophic nonunion; requires dynamization
. Excessive strain; requires application of a circular frame without grafting

Correct Answer & Explanation

. Inadequate stability; requires exchange nailing only

Explanation

The radiographic appearance (no callus, rounded fracture ends) is classic for an atrophic nonunion, representing a failure of biology. Treatment requires improving the biological environment through debridement, adding bone graft, and ensuring stable fixation.

Question 11056

Topic: 2. Trauma
A 60-year-old female is struck by a vehicle from the side. Pelvic radiographs demonstrate a transverse fracture of the pubic rami and an impaction fracture of the anterior sacrum on the same side. What type of injury is this, and what is the typical initial management if she is hemodynamically stable?
. APC-II; Application of a pelvic binder
. LC-I; Mobilization with weight-bearing as tolerated
. VS; Immediate application of an external fixator
. LC-III; Skeletal traction
. APC-III; Angioembolization

Correct Answer & Explanation

. LC-I; Mobilization with weight-bearing as tolerated

Explanation

This is a Lateral Compression Type I (LC-I) injury, characterized by transverse pubic rami fractures and a sacral impaction fracture on the side of impact. In a stable patient, these are generally rotationally and vertically stable and treated with mobilization and weight-bearing as tolerated.

Question 11057

Topic: 2. Trauma

A 30-year-old female sustains a transverse patella fracture with 4 mm of displacement. She undergoes ORIF with tension band wiring. What biomechanical principle allows this construct to promote fracture healing?

. It converts tensile forces on the anterior surface into compressive forces at the articular surface during knee flexion
. It acts as a static neutralization plate
. It applies rigid compression via lag screw technique only
. It distracts the fracture to allow secondary bone healing
. It acts as a buttress against shear forces

Correct Answer & Explanation

. It converts tensile forces on the anterior surface into compressive forces at the articular surface during knee flexion

Explanation

The principle of the tension band is to convert tensile forces into compressive forces. Placing the tension band on the anterior (tension) surface ensures that when the knee flexes, it resists distraction and converts the force into compression at the posterior articular surface.

Question 11058

Topic: 2. Trauma

A 22-year-old basketball player presents with lateral foot pain after a pivot injury. Radiographs reveal a transverse fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal, extending into the 4th-5th intermetatarsal articulation. What is the diagnosis, and why is surgical fixation often recommended in elite athletes?

. Avulsion fracture; high risk of nonunion
. Jones fracture; high risk of delayed union/nonunion due to the watershed blood supply
. Pseudo-Jones fracture; early return to play
. Stress fracture of the diaphysis; high risk of infection
. Lisfranc injury; high risk of arch collapse

Correct Answer & Explanation

. Avulsion fracture; high risk of nonunion

Explanation

A fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal is a Jones fracture. This area represents a vascular watershed zone, making these fractures prone to nonunion. In elite athletes, early intramedullary screw fixation is recommended to decrease time to union.

Question 11059

Topic: 2. Trauma
A 24-year-old cyclist falls onto his shoulder. Radiographs show a completely displaced, shortened (>2 cm) midshaft clavicle fracture with skin tenting that does not blanch. What is the most definitive indication for immediate surgical intervention in this scenario?
. Midshaft location
. Patient age
. >2 cm shortening
. Impending open fracture (skin tenting with ischemia)
. Sports participation

Correct Answer & Explanation

. Impending open fracture (skin tenting with ischemia)

Explanation

While >2 cm of shortening is a relative indication for surgery to improve outcomes, an 'impending open fracture' characterized by severe skin tenting with blanching/ischemia is an absolute indication for urgent ORIF to prevent skin necrosis and conversion to an open fracture.

Question 11060

Topic: 2. Trauma

In the context of Damage Control Orthopedics (DCO) for a polytrauma patient, the 'two-hit hypothesis' is a widely accepted pathophysiological model. Which of the following best describes the 'first hit' and 'second hit' respectively?

. First hit: Initial traumatic insult; Second hit: Extensive definitive surgery (e.g., intramedullary nailing)
. First hit: Hemorrhage; Second hit: Hypoxia
. First hit: Initial surgical intervention; Second hit: Post-operative sepsis
. First hit: Systemic Inflammatory Response Syndrome (SIRS); Second hit: Nosocomial infection
. First hit: Fat embolism; Second hit: Acute Respiratory Distress Syndrome (ARDS)

Correct Answer & Explanation

. First hit: Initial traumatic insult; Second hit: Extensive definitive surgery (e.g., intramedullary nailing)

Explanation

The 'two-hit hypothesis' in polytrauma proposes that the initial trauma ('first hit') primes the patient's immune system, leading to a systemic inflammatory response. A subsequent major physiological stressor, such as lengthy, definitive orthopedic surgery like reamed intramedullary nailing ('second hit'), can exacerbate this inflammatory cascade, precipitating Acute Respiratory Distress Syndrome (ARDS), Multiple Organ Dysfunction Syndrome (MODS), and potentially death. This is the core rationale for Damage Control Orthopedics (DCO) over Early Total Care (ETC) in borderline or unstable patients.

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