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2. Trauma MCQs

Practice Set 56 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 1101

Topic: 2. Trauma

A 25-year-old male is admitted with a closed midshaft tibia fracture. Overnight, he develops severe leg pain that is unresponsive to parenteral opioids. On examination, he has exquisite pain with passive toe extension. His blood pressure is 110/70 mmHg. Intracompartmental pressure monitoring reveals a pressure of 45 mmHg in the anterior compartment and 35 mmHg in the deep posterior compartment. What is the most appropriate next step in management?

. Elevate the leg above the heart and reassess in 2 hours
. Immediate four-compartment fasciotomy
. Remove the splint and administer IV dexamethasone
. Perform a single-incision anterior fasciotomy only
. Emergent intramedullary nailing to decompress the canal

Correct Answer & Explanation

. Immediate four-compartment fasciotomy

Explanation

A Delta P (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is an absolute indication for fasciotomy. In this case, the Delta P is 25 mmHg (70 - 45 = 25), necessitating immediate four-compartment fasciotomy.

Question 1102

Topic: 2. Trauma
Based on the SPRINT (Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures) trial, which of the following is the most significant finding when comparing reamed and unreamed intramedullary nailing for tibial shaft fractures?
. Reamed nailing significantly reduces the nonunion rate in open fractures compared to unreamed nailing.
. Reamed nailing reduces the risk of hardware failure and the need for secondary interventions in closed fractures.
. Unreamed nailing leads to a significantly lower infection rate in closed fractures compared to reamed nailing.
. Reamed nailing has a substantially higher incidence of compartment syndrome in closed fractures.
. Unreamed nailing is recommended for all Gustilo Type IIIA fractures due to better union rates.

Correct Answer & Explanation

. Reamed nailing reduces the risk of hardware failure and the need for secondary interventions in closed fractures.

Explanation

The SPRINT trial demonstrated that in closed tibial shaft fractures, reamed intramedullary nailing resulted in a significantly lower rate of primary events (like nonunion or hardware failure) compared to unreamed nailing. No significant difference in union or infection was found in open fractures.

Question 1103

Topic: 2. Trauma

A 40-year-old male is transferred to a tertiary trauma center 4 days after sustaining a closed tibial shaft fracture following a drug overdose. He has received no prior medical care. The leg is tense and woody, and lacks any sensation or motor function below the knee. Distal pulses are intact. Intracompartmental pressure is measured at 60 mmHg. What is the most appropriate management?

. Immediate four-compartment fasciotomy
. Immediate single-incision perifibular fasciotomy
. Non-operative management of the compartments and supportive care
. Emergent above-knee amputation
. Hyperbaric oxygen therapy followed by delayed fasciotomy

Correct Answer & Explanation

. Non-operative management of the compartments and supportive care

Explanation

In delayed presentations of compartment syndrome (>48 hours) with established irreversible muscle necrosis (absent motor and sensory function), fasciotomy is contraindicated due to a high risk of lethal sepsis. Non-operative management is indicated, though amputation may be required if systemic toxicity develops.

Question 1104

Topic: 2. Trauma

When performing a single-incision perifibular approach for a four-compartment fasciotomy of the leg, which two compartments are accessed by dissecting posterior to the fibula?

. Anterior and lateral compartments
. Lateral and superficial posterior compartments
. Anterior and deep posterior compartments
. Superficial posterior and deep posterior compartments
. Lateral and deep posterior compartments

Correct Answer & Explanation

. Anterior and lateral compartments

Explanation

In the single-incision perifibular approach, a lateral incision is made. The anterior and lateral compartments are accessed anterior to the fibula, whereas the superficial and deep posterior compartments are accessed posterior to the fibula.

Question 1105

Topic: 2. Trauma

A 22-year-old female sustains a closed, isolated, minimally displaced midshaft tibia fracture. She is treated non-operatively in a long leg cast. According to standard criteria for acceptable alignment in the non-operative management of tibial shaft fractures, what is the maximum acceptable varus/valgus angulation?

. 2 degrees
. 5 degrees
. 10 degrees
. 15 degrees
. 20 degrees

Correct Answer & Explanation

. 5 degrees

Explanation

Standard acceptable alignment criteria for non-operative management of tibia fractures include less than 5 degrees of varus/valgus angulation, less than 10 degrees of anteroposterior angulation, greater than 50% cortical apposition, and less than 1 cm of shortening.

Question 1106

Topic: 2. Trauma
Compared to the traditional infrapatellar approach, the suprapatellar approach for intramedullary nailing of tibial shaft fractures provides which of the following mechanical or clinical advantages?
. It significantly decreases the risk of deep infection in Gustilo Type IIIB open fractures.
. It entirely eliminates the risk of anterior knee pain postoperatively.
. It allows the knee to remain in semi-extension, neutralizing extensor forces and facilitating reduction in proximal fractures.
. It requires smaller incisions and avoids traversing the knee capsule entirely.
. It provides a lower rate of nonunion in distal third tibial shaft fractures.

Correct Answer & Explanation

. It allows the knee to remain in semi-extension, neutralizing extensor forces and facilitating reduction in proximal fractures.

Explanation

The suprapatellar approach allows the limb to be positioned in semi-extension (10-15 degrees of flexion). This neutralizes the deforming pull of the extensor mechanism, preventing the procurvatum deformity commonly seen during nailing of proximal-third tibia fractures.

Question 1107

Topic: 2. Trauma
A 30-year-old male sustains a Gustilo-Anderson Type IIIB open tibia fracture treated with immediate debridement, irrigation, and intramedullary nailing. According to current orthopedic principles, when is the optimal timeframe to perform definitive soft-tissue coverage with a flap to minimize infection and maximize flap survival?
. Within 7 days of the injury
. Between 10 and 14 days of the injury
. Between 3 and 4 weeks of the injury
. Between 6 and 8 weeks of the injury
. After radiographic signs of fracture callus are visible

Correct Answer & Explanation

. Within 7 days of the injury

Explanation

Early definitive soft-tissue coverage of Gustilo Type IIIB open tibia fractures, optimally performed within the first 7 days (and ideally within 72 hours), significantly decreases the rates of deep infection and flap failure. Delaying coverage allows bacterial colonization and fibrosis, worsening outcomes.

Question 1108

Topic: 2. Trauma

A 28-year-old active male sustains a displaced transverse patella fracture. He undergoes tension band wiring. Which of the following post-operative instructions is most critical to prevent early failure of the construct?

. Strict non-weight bearing for 6 weeks.
. Immediate full weight bearing as tolerated.
. Limited knee flexion to 30 degrees for the first 2 weeks.
. Avoidance of active knee extension against resistance.
. Continuous passive motion (CPM) with unrestricted range.

Correct Answer & Explanation

. Avoidance of active knee extension against resistance.

Explanation

Correct Answer: DThe tension band wiring technique converts the tensile forces on the patella during knee flexion and active extension into compression forces at the fracture site. Active knee extension against resistance, particularly against gravity (e.g., straight leg raises), places significant tensile stress across the anterior aspect of the patella and can lead to immediate failure of the tension band construct. Early motion, especially passive flexion, is often encouraged to prevent stiffness, but active extension needs to be limited or avoided in the early post-operative period. Weight bearing is usually determined by pain tolerance and often progresses from touch-down to full, but it's less critical for the construct integrity than active extension. Restricting flexion too much can lead to stiffness, and unrestricted CPM may also put undue stress on the repair if active extension is performed.

Question 1109

Topic: 2. Trauma

A 68-year-old female with osteoporosis falls at home, sustaining a displaced intertrochanteric hip fracture. She is otherwise healthy. What is the most appropriate definitive management for this fracture?

. Non-operative management with bed rest and pain control.
. Open reduction and internal fixation with a dynamic hip screw (DHS).
. Total hip arthroplasty (THA).
. Hemiarthroplasty.
. External fixation.

Correct Answer & Explanation

. Open reduction and internal fixation with a dynamic hip screw (DHS).

Explanation

Correct Answer: BDisplaced intertrochanteric hip fractures in elderly patients are typically managed surgically. A dynamic hip screw (DHS) is the gold standard for stable and reducible intertrochanteric fractures, providing controlled collapse at the fracture site which promotes impaction and healing. While intramedullary nailing (IMN) is often preferred for unstable intertrochanteric fractures (e.g., reverse obliquity, comminuted), a DHS remains a very viable option for many stable patterns, especially in the context of osteoporosis where load sharing is beneficial. Non-operative management is associated with high mortality and morbidity in this patient population. THA or hemiarthroplasty are generally reserved for displaced femoral neck fractures or failed previous fixation, not primarily for intertrochanteric fractures. External fixation is rarely used for these fractures due to high rates of complications and poor stability.

Question 1110

Topic: 2. Trauma
A 32-year-old male sustains a Gustilo Type IIIB open tibia fracture with significant soft tissue loss and exposed bone. After initial debridement and stabilization, what is the most appropriate timing and method for definitive soft tissue coverage?
. Primary closure within 6 hours to minimize infection risk.
. Delayed primary closure once swelling subsides, typically 5-7 days.
. Local rotational flap or free flap coverage within 72 hours.
. Split-thickness skin graft within 24 hours.
. Leave wound open and manage with wet-to-dry dressings for several weeks.

Correct Answer & Explanation

. Local rotational flap or free flap coverage within 72 hours.

Explanation

Gustilo Type IIIB open tibia fractures involve extensive soft tissue damage and often require specialized soft tissue coverage. The 'golden period' for these injuries extends beyond primary closure, which is typically reserved for clean, smaller wounds without significant contamination or tissue loss. For Type IIIB injuries, early and definitive soft tissue coverage, usually within 72 hours of injury, is critical to reduce infection rates and promote fracture healing. This often involves local rotational flaps or free tissue transfer, depending on the size and location of the defect. Delayed primary closure is not appropriate for large defects with exposed bone. Split-thickness skin grafts require a well-vascularized bed and are usually insufficient to cover exposed bone or deep structures. Leaving the wound open for weeks increases infection risk and prolongs hospitalization.

Question 1111

Topic: 2. Trauma

A 72-year-old male with a history of hypertension and diabetes presents with a displaced comminuted subtrochanteric femur fracture. He is hemodynamically stable. What is the preferred surgical treatment for this fracture pattern?

. Dynamic hip screw (DHS).
. Intramedullary nail (IMN).
. Plate and screws (e.g., Less Invasive Stabilization System - LISS).
. Non-operative management with traction.
. Hemiarthroplasty.

Correct Answer & Explanation

. Intramedullary nail (IMN).

Explanation

Correct Answer: BSubtrochanteric femur fractures are highly load-bearing and are subject to significant deforming forces (pull of gluteus medius/minimus on the proximal fragment, adductors on the distal fragment). Intramedullary nailing (IMN) is considered the gold standard for subtrochanteric femur fractures due to its load-sharing nature, biomechanical advantages, and typically less soft tissue stripping compared to plating. A DHS is primarily designed for intertrochanteric fractures and is less stable for subtrochanteric patterns, particularly comminuted ones. Plating can be an option but often requires more extensive exposure and is more prone to failure in comminuted or osteoporotic bone. Non-operative management is generally associated with poor outcomes. Hemiarthroplasty is not indicated for subtrochanteric fractures unless there's a concomitant femoral neck fracture or pre-existing hip pathology requiring replacement.

Question 1112

Topic: 2. Trauma

Which of the following findings is most concerning for impending compartment syndrome in a patient with a closed tibial shaft fracture?

. Severe pain unresponsive to increasing doses of opioids.
. Paresthesia in the foot.
. Diminished pulses in the dorsalis pedis artery.
. Pallor of the foot.
. Pain with passive stretching of the toes.

Correct Answer & Explanation

. Pain with passive stretching of the toes.

Explanation

Correct Answer: EWhile all listed options are potential signs of compartment syndrome, 'pain with passive stretching of the toes' (for the deep posterior and anterior compartments) and 'severe pain unresponsive to increasing doses of opioids' (pain out of proportion to injury) are considered the most sensitive and earliest signs of evolving compartment syndrome. Paresthesia can be an early sign but may also indicate nerve injury unrelated to compartment syndrome. Diminished pulses and pallor are late signs, often indicating irreversible muscle ischemia and nerve damage, and are less reliable early indicators because compartment pressure often exceeds venous pressure long before arterial flow is compromised.

Question 1113

Topic: 2. Trauma

A 60-year-old male falls from a height and sustains a Pilon fracture (distal tibial plafond fracture). He presents with significant swelling and skin blistering. What is the most appropriate initial management strategy?

. Immediate open reduction internal fixation (ORIF).
. Application of a circular external fixator and delayed definitive fixation.
. Long leg cast application and non-weight bearing.
. Percutaneous screw fixation.
. Amputation due to high complication rates.

Correct Answer & Explanation

. Application of a circular external fixator and delayed definitive fixation.

Explanation

Correct Answer: BPilon fractures are high-energy injuries often associated with severe soft tissue damage. Significant swelling and blistering indicate compromised soft tissue envelope, making immediate ORIF risky due to high rates of wound complications and infection. The preferred initial management is to apply a spanning external fixator across the ankle to restore length, alignment, and indirectly reduce the fracture, which allows the soft tissues to recover. Definitive ORIF is then performed in a delayed fashion (often 7-14 days) once the swelling has subsided, and the skin wrinkles ('wrinkle sign'). A cast is insufficient to stabilize such a complex fracture. Percutaneous screws alone are usually inadequate. Amputation is a last resort.

Question 1114

Topic: 2. Trauma

A 45-year-old male sustains a high-energy valgus injury to his knee. Radiographs show a Schatzker Type VI tibial plateau fracture. Clinically, his lower leg is tense, exquisitely painful to passive stretch of the toes, and he reports paresthesia in the foot. Dorsalis pedis pulse is palpable. What is the most critical immediate next step in management?

. Obtain a CT scan for surgical planning.
. Perform an emergent four-compartment fasciotomy.
. Administer IV opioids and splint the limb.
. Order an ankle-brachial index (ABI) and doppler studies.
. Elevate the limb above the heart to reduce swelling.

Correct Answer & Explanation

. Perform an emergent four-compartment fasciotomy.

Explanation

Correct Answer: BThe clinical presentation of a tense leg, exquisite pain to passive stretch, and paresthesia, especially after a high-energy tibial plateau fracture, is highly suspicious for acute compartment syndrome, even with a palpable dorsalis pedis pulse. This is a surgical emergency. An emergent four-compartment fasciotomy is the most critical immediate step to prevent irreversible neuromuscular damage. A CT scan is for definitive surgical planning of the fracture but should not delay fasciotomy if compartment syndrome is suspected. Elevating the limb can actually worsen compartment syndrome by reducing perfusion pressure. ABI and doppler are for vascular injury assessment, which is different from compartment syndrome although both can coexist.

Question 1115

Topic: 2. Trauma
A 30-year-old male presents with a Gustilo-Anderson Type IIIA open tibial shaft fracture after a motorcycle accident. He has intact neurovascular status. What is the most appropriate initial management regarding definitive wound closure?
. Immediate primary wound closure after debridement.
. Delayed primary closure at 24-48 hours.
. Closure with local muscle flap after initial debridement.
. Leave the wound open for serial debridement and delayed soft tissue coverage.
. Application of a vacuum-assisted closure (VAC) device followed by immediate skin grafting.

Correct Answer & Explanation

. Leave the wound open for serial debridement and delayed soft tissue coverage.

Explanation

For Gustilo-Anderson Type IIIA open fractures, there is significant soft tissue damage requiring thorough debridement. The wound should be left open for serial debridement to remove all devitalized tissue and prevent infection. Definitive soft tissue coverage, often requiring local or free flaps for Type IIIA and IIIB injuries, is typically performed in a delayed fashion, usually within 72 hours, once the wound is clean and healthy. Immediate primary closure in Type IIIA carries a high risk of infection. Delayed primary closure might be considered for less severe wounds but not for a Type IIIA. VAC is a dressing option, but immediate skin grafting is usually not feasible or appropriate for an initially contaminated wound of this severity.

Question 1116

Topic: 2. Trauma

A 60-year-old male sustains a high-energy pelvic injury. He is hypotensive (BP 80/50 mmHg) and tachycardic (HR 120 bpm) despite initial fluid resuscitation. Pelvic X-ray shows a displaced open-book pelvic fracture (APC Type II). What is the most appropriate next step in managing his hemodynamic instability?

. Immediate CT angiography of the pelvis.
. Application of a pelvic binder and embolization if bleeding continues.
. Transfer to the operating room for external fixation.
. Placement of a chest tube for potential pneumothorax.
. Administer vasopressors to stabilize blood pressure.

Correct Answer & Explanation

. Application of a pelvic binder and embolization if bleeding continues.

Explanation

Correct Answer: BIn a hemodynamically unstable patient with a pelvic fracture, control of hemorrhage is paramount. Application of a pelvic binder (or sheet) provides immediate temporary stabilization of the fracture and reduces pelvic volume, which can help tamponade venous bleeding. If instability persists despite initial binder application and fluid resuscitation, angioembolization is the next step to control arterial bleeding, which accounts for 10-20% of pelvic hemorrhage but is often more challenging to control. External fixation provides definitive mechanical stability but might not be fast enough to control active arterial hemorrhage. CT angiography is useful for identifying the source but treatment takes precedence. Chest tube for pneumothorax addresses a different injury. Vasopressors address the symptom, not the underlying cause of hypovolemic shock.

Question 1117

Topic: 2. Trauma

A 28-year-old male falls from a height and lands on his feet. X-rays reveal a comminuted, intra-articular calcaneus fracture. Which associated injury should you specifically screen for?

. Achilles tendon rupture
. Femoral neck fracture
. Lumbar spine compression fracture
. Patellar fracture
. Talus fracture

Correct Answer & Explanation

. Lumbar spine compression fracture

Explanation

Correct Answer: CFalls from a height that result in calcaneus fractures (known as 'lover's fractures' or 'don Juan' fractures) often transmit axial load up the kinetic chain. Therefore, it is crucial to screen for associated injuries, especially lumbar spine compression fractures (up to 10% of cases) and, less commonly, hip or tibial plateau fractures. While an Achilles rupture can occur with trauma, it's not a direct 'axial load' associated injury. Talus and patellar fractures are less common systemic associations with this mechanism.

Question 1118

Topic: 2. Trauma

A 70-year-old female sustains a distal femoral fracture (supracondylar) after a low-energy fall. She has significant osteopenia. Which fixation method is generally considered superior for achieving stable fixation and early mobilization in this patient population?

. Open reduction and plate fixation with bicortical screws.
. Retrograde intramedullary nailing.
. External fixation.
. Dual plating (medial and lateral).
. Closed reduction and long-leg casting.

Correct Answer & Explanation

. Retrograde intramedullary nailing.

Explanation

Correct Answer: BFor most displaced distal femoral fractures, particularly in osteopenic elderly patients, retrograde intramedullary nailing is often preferred. It offers a load-sharing construct, minimally invasive approach, and allows for earlier weight-bearing and mobilization compared to plate fixation. While plate fixation (especially locking plates) can be effective, nailing often has advantages in osteoporotic bone due to its load-sharing nature. External fixation is generally reserved for open fractures with significant soft tissue compromise or as a temporizing measure. Dual plating can be an option for highly comminuted fractures but is more invasive. Long-leg casting is typically not sufficient for displaced fractures in the elderly due to nonunion risk and difficulty with mobilization.

Question 1119

Topic: Pelvic & Acetabular Trauma
A 35-year-old male is brought to the trauma bay after a motorcycle crash. His pelvis radiograph reveals an anteroposterior compression type III (APC-III) pelvic ring injury. Despite the application of a pelvic binder and infusion of 2 liters of crystalloid and 2 units of packed red blood cells, he remains hemodynamically unstable. A FAST exam is negative. What is the most appropriate next step in management?
. Immediate open reduction and internal fixation of the anterior ring
. Removal of the pelvic binder to assess the skin
. Pelvic angiography and/or preperitoneal pelvic packing
. Retrograde urethrogram
. Exploratory laparotomy

Correct Answer & Explanation

. Pelvic angiography and/or preperitoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST exam, the source of bleeding is presumed to be the pelvis. The standard of care after mechanical stabilization (pelvic binder) is preperitoneal pelvic packing and/or angiography to control venous and arterial hemorrhage.

Question 1120

Topic: 2. Trauma

A 42-year-old female sustains a Schatzker IV tibial plateau fracture after a high-energy fall. Radiographs and CT imaging confirm a displaced posteromedial articular fragment. Which surgical approach is most appropriate for direct visualization and buttressing of this fragment?

. Anterolateral approach
. Posteromedial approach
. Direct medial approach
. Posterior (popliteal) approach
. Direct anterior approach

Correct Answer & Explanation

. Posteromedial approach

Explanation

A posteromedial approach is required to properly reduce and apply a buttress plate to the displaced posteromedial fragment in a Schatzker IV (medial plateau) fracture. An anterolateral approach cannot adequately address the posteromedial shear component.

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