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2. Trauma MCQs

Practice Set 58 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 1141

Topic: 2. Trauma

A 38-year-old male presents to the emergency department after a high-speed motor vehicle collision. He was wearing a lap belt only. On examination, he has significant abdominal bruising and tenderness. Neurological exam reveals mild weakness in bilateral lower extremities (4/5) and a sensory deficit below the umbilicus. Imaging reveals a T12 fracture with disruption of the posterior ligamentous complex, involving the vertebral body, pedicles, and lamina, with a horizontal fracture line through all three columns. There is minimal kyphosis and no significant canal compromise. Which of the following is the most likely fracture pattern and the most appropriate management?

. Burst fracture; conservative management with bracing.
. Compression fracture; immediate posterior fusion.
. Flexion-distraction (Chance-type) fracture; surgical stabilization with posterior instrumentation.
. Fracture-dislocation; anterior decompression and fusion.
. Rotational injury; trial of halo immobilization.

Correct Answer & Explanation

. Flexion-distraction (Chance-type) fracture; surgical stabilization with posterior instrumentation.

Explanation

Correct Answer: CRationale:The patient's history of a lap belt-only injury in a high-speed collision, combined with abdominal bruising, is highly suggestive of a flexion-distraction injury, often referred to as a Chance-type fracture. The description of a horizontal fracture line through all three columns (vertebral body, pedicles, lamina) and disruption of the posterior ligamentous complex confirms this pattern. These injuries are inherently unstable due to the failure of both anterior and posterior tension bands. The presence of even mild neurological deficit further mandates surgical intervention.Why other options are incorrect:A) Burst fracture; conservative management with bracing:A burst fracture typically results from an axial load and involves comminution of the vertebral body with retropulsion into the canal. While it can cause neurological deficits, the described mechanism (lap belt) and horizontal fracture through all columns are not characteristic of a pure burst fracture. Conservative management is generally not appropriate for unstable flexion-distraction injuries, especially with neurological deficits.B) Compression fracture; immediate posterior fusion:A compression fracture involves failure of the anterior column under axial load, typically without significant posterior element involvement or instability. The described injury is far more severe and unstable than a simple compression fracture.D) Fracture-dislocation; anterior decompression and fusion:While fracture-dislocations are highly unstable, the specific description of a horizontal fracture through all three columns is more indicative of a flexion-distraction injury. Anterior decompression is typically reserved for significant anterior canal compromise, which is not emphasized here, and posterior stabilization is usually the primary approach for flexion-distraction injuries.E) Rotational injury; trial of halo immobilization:Rotational injuries involve significant torsional forces and often present with severe instability. While unstable, halo immobilization is generally not effective for thoracolumbar fractures and is primarily used for certain cervical spine injuries.

Question 1142

Topic: 2. Trauma
A 42-year-old male sustains a high-energy pelvic injury after being crushed between two vehicles. He has a Denis Zone III sacral fracture with significant displacement and a concomitant open book pelvic ring injury. On examination, he has absent sensation in the S2-S5 dermatomes and poor rectal tone. What is the most critical aspect of his surgical management for the sacral fracture?
. Immediate closed reduction and external fixation of the pelvic ring.
. Decompression of the cauda equina and nerve roots.
. Sacral laminectomy alone for pain relief.
. Non-operative management with bed rest.
. Anterior plating of the sacrum.

Correct Answer & Explanation

. Decompression of the cauda equina and nerve roots.

Explanation

A Denis Zone III sacral fracture involves the sacral foramen and the central sacral canal, carrying the highest risk of neurological injury, particularly to the cauda equina and sacral nerve roots. The patient's presentation with absent S2-S5 sensation and poor rectal tone indicates significant cauda equina injury. In such cases, the most critical aspect of surgical management is urgent decompression of the cauda equina and nerve roots to prevent permanent neurological deficits. This typically involves a posterior approach to decompress the neural elements, often combined with stabilization of the sacral and pelvic ring fracture.

Question 1143

Topic: 2. Trauma

A 62-year-old female with a history of osteoporosis sustains a displaced intra-articular fracture of the distal radius (AO type C3). She is active and has good functional demands. What is the most appropriate definitive management strategy?

. Closed reduction and sugar tong splint immobilization
. Percutaneous pinning
. External fixation with adjunctive K-wires
. Open reduction and internal fixation with a volar locking plate
. Arthroscopic-assisted reduction and fixation

Correct Answer & Explanation

. Open reduction and internal fixation with a volar locking plate

Explanation

Correct Answer: DFor a displaced intra-articular distal radius fracture (AO type C3) in an active patient with good functional demands, open reduction and internal fixation with a volar locking plate is considered the gold standard. This approach allows for stable anatomical reduction, early range of motion, and addresses the challenge of comminution and osteopenia often seen in C3 fractures. Closed reduction and splinting is inadequate for displaced intra-articular fractures. Percutaneous pinning or external fixation alone may not provide sufficient stability or allow for direct visualization and reduction of articular fragments, especially in complex, comminuted patterns.

Question 1144

Topic: 2. Trauma

A 28-year-old male sustains an open Schatzker type VI tibial plateau fracture with significant soft tissue compromise. After initial debridement and external fixation, what is the optimal timing for definitive internal fixation?

. Immediately, within 6 hours of injury
. Within 24-48 hours, following soft tissue resuscitation
. Between 5-10 days, once the 'wrinkle sign' returns
. At 3 weeks, after complete soft tissue healing
. Only after initial external fixator removal and full weight-bearing

Correct Answer & Explanation

. Between 5-10 days, once the 'wrinkle sign' returns

Explanation

Correct Answer: CFor complex open tibial plateau fractures with significant soft tissue injury, the 'staged protocol' is generally preferred. This involves initial debridement, provisional stabilization with an external fixator, and then delayed definitive internal fixation once the soft tissues have adequately recovered and the 'wrinkle sign' is present (indicating decreased edema). This typically occurs between 5-10 days (Option C). Operating immediately in compromised soft tissues increases the risk of wound complications and infection. Waiting too long (3 weeks) might lead to fracture stiffness and more difficult reduction. The question specifically asks fordefinitiveinternal fixation, not initial debridement or external fixation, which should happen urgently. The 'wrinkle sign' is key to timing definitive fixation in such injuries. Although the explanation previously stated 5-10 days, the given options for a delayed approach make 'between 5-10 days, once the 'wrinkle sign' returns' the most appropriate.

Question 1145

Topic: 2. Trauma

In the management of a displaced femoral shaft fracture in a 3-year-old child, which of the following is the most appropriate initial treatment?

. Immediate intramedullary nailing
. Spica cast immobilization
. External fixation
. Open reduction and plate fixation
. Skeletal traction followed by cast

Correct Answer & Explanation

. Spica cast immobilization

Explanation

Correct Answer: BFor a displaced femoral shaft fracture in a 3-year-old child, spica cast immobilization is the preferred initial treatment. Children in this age group have excellent remodeling potential and tolerate cast immobilization well. Intramedullary nailing is typically reserved for older children (usually >5-6 years) or specific fracture patterns. External fixation is generally reserved for open fractures, polytrauma, or significant soft tissue compromise. Open reduction and plating is used in specific circumstances but not as first-line for this age group. Skeletal traction followed by cast is an older method, largely supplanted by immediate spica casting for this age group.

Question 1146

Topic: 2. Trauma

A 30-year-old male is treated with an intramedullary nail for a closed tibial shaft fracture. Postoperatively, he develops severe pain out of proportion to the injury. Which finding is the most sensitive early clinical indicator of acute compartment syndrome?

. Loss of distal pulses
. Pallor of the extremity
. Pain with passive stretch of the toes
. Paresthesias in the deep peroneal nerve distribution
. Tense compartments on palpation

Correct Answer & Explanation

. Pain with passive stretch of the toes

Explanation

Pain with passive stretch of the muscles in the involved compartment is generally considered the most sensitive early clinical sign of compartment syndrome. Pulselessness and pallor are late, unreliable signs indicating irreversible ischemia.

Question 1147

Topic: Pelvic & Acetabular Trauma
In the Young-Burgess classification of pelvic ring injuries, which type is most frequently associated with the highest volume of retroperitoneal hemorrhage and requires urgent pelvic binder placement?
. Lateral Compression Type I (LC-I)
. Lateral Compression Type II (LC-II)
. Anteroposterior Compression Type I (APC-I)
. Anteroposterior Compression Type III (APC-III)
. Vertical Shear (VS)

Correct Answer & Explanation

. Anteroposterior Compression Type III (APC-III)

Explanation

APC-III (open book) pelvic injuries involve complete disruption of the anterior and posterior sacroiliac ligaments, leading to dramatic pelvic volume expansion. This severely compromises the presacral venous plexus, making it prone to exsanguinating hemorrhage.

Question 1148

Topic: 2. Trauma
A 28-year-old male sustains a high-energy basicervical femoral neck fracture (Pauwels III). Biomechanical studies indicate that the optimal fixation construct to maximize stiffness and resist shear forces in this vertically oriented fracture is:
. Three parallel cannulated screws
. Intramedullary nail
. Sliding hip screw with a derotational screw
. Proximal femoral locking plate
. Dynamic condylar screw

Correct Answer & Explanation

. Sliding hip screw with a derotational screw

Explanation

For vertically oriented (Pauwels III) and basicervical femoral neck fractures, shear forces are high. A sliding hip screw (fixed-angle device) with an anti-rotation screw provides superior biomechanical stability compared to parallel cannulated screws alone.

Question 1149

Topic: Upper Extremity Trauma
A 30-year-old male sustains an isolated grade III acromioclavicular (AC) joint separation. Which of the following ligaments are primarily responsible for preventing superior translation of the distal clavicle?
. Acromioclavicular ligaments
. Coracoacromial ligament
. Conoid and trapezoid ligaments
. Coracohumeral ligament
. Superior glenohumeral ligament

Correct Answer & Explanation

. Conoid and trapezoid ligaments

Explanation

The coracoclavicular (CC) ligaments, composed of the conoid and trapezoid, provide vertical stability to the AC joint. The AC ligaments primarily provide anteroposterior stability.

Question 1150

Topic: Pelvic & Acetabular Trauma

A 35-year-old male presents in hypotensive shock following a motorcycle crash. Pelvic radiographs show symphyseal diastasis of 4 cm and disruption of the anterior sacroiliac ligaments, but intact posterior sacroiliac ligaments. A pelvic binder is applied, and his hemodynamics stabilize. What is the most appropriate definitive management for his pelvic injury?

. Anterior external fixator only
. Open reduction and internal fixation of the pubic symphysis
. Percutaneous iliosacral screws only
. ORIF of the pubic symphysis and percutaneous iliosacral screws
. Nonoperative management with protected weight-bearing

Correct Answer & Explanation

. Open reduction and internal fixation of the pubic symphysis

Explanation

This is an APC-II pelvic ring injury. Because the posterior SI ligaments are intact, the posterior ring is vertically stable, so anterior ring fixation (ORIF of the symphysis) is sufficient for definitive stabilization.

Question 1151

Topic: 2. Trauma

A 28-year-old male sustains a pathological fracture through an enchondroma in his proximal humerus. What is the recommended management after initial stabilization?

. Immobilization only with subsequent observation
. Curettage and bone grafting once the fracture has healed
. Immediate excision of the lesion
. Radiation therapy
. Systemic bisphosphonates

Correct Answer & Explanation

. Curettage and bone grafting once the fracture has healed

Explanation

Correct Answer: BWhen a pathological fracture occurs through an enchondroma, the fracture should be allowed to heal initially. Once there is radiographic evidence of healing (typically 3-6 months), the patient can then undergo intralesional curettage of the enchondroma and bone grafting to prevent recurrence and address the underlying lesion. Immediate excision is usually not necessary or practical in the acute fracture setting. Radiation therapy and bisphosphonates are not standard treatments for enchondromas.

Question 1152

Topic: 2. Trauma

A 45-year-old male presents to the emergency department after a high-speed motor vehicle collision. He is hypotensive (BP 80/50 mmHg) and tachycardic (HR 125 bpm). Physical examination reveals obvious instability of the pelvic ring with ecchymosis over the perineum and pubic symphysis. Initial resuscitation with 2 liters of crystalloid has failed to improve his hemodynamic status. Which of the following is the most appropriate next step in his immediate management?

. Pelvic X-ray followed by angiography if still unstable.
. Immediate application of a pelvic binder and transfer to the operating room for external fixation.
. CT scan of the abdomen and pelvis to identify retroperitoneal hemorrhage.
. Insertion of a Foley catheter to assess for bladder injury.
. Administration of tranexamic acid and initiation of massive transfusion protocol.

Correct Answer & Explanation

. Immediate application of a pelvic binder and transfer to the operating room for external fixation.

Explanation

Correct Answer: BIn a hemodynamically unstable patient with a suspected pelvic ring injury, the priority is hemorrhage control. A pelvic binder (or sheet) provides immediate temporary stabilization and reduction of the pelvic volume, which can tamponade bleeding. If the patient remains unstable after initial resuscitation and binder application, the next step is typically emergent surgical stabilization (e.g., external fixation) in the operating room or angiography for embolization, often dictated by local protocol and surgeon preference. While CT scan, Foley catheter insertion, and angiography are important diagnostic and therapeutic steps, immediate mechanical reduction via a binder and early surgical intervention for ongoing instability take precedence for life-threatening hemorrhage. Tranexamic acid and massive transfusion protocol are adjuncts but don't address the primary mechanical cause of bleeding.

Question 1153

Topic: 2. Trauma
A 35-year-old construction worker sustains an open tibial shaft fracture (Gustilo-Anderson Type IIIA) after being struck by heavy machinery. He arrives in the ED 1 hour after injury. What is the immediate priority in his management after ATLS resuscitation and basic wound coverage?
. Administer IV vancomycin and gentamicin.
. Perform emergent irrigation and debridement in the operating room.
. Obtain computed tomography angiography (CTA) of the leg.
. Apply a definitive internal fixation device.
. Perform serial compartment pressure measurements.

Correct Answer & Explanation

. Perform emergent irrigation and debridement in the operating room.

Explanation

For open fractures, particularly Gustilo-Anderson Type IIIA, emergent irrigation and debridement in the operating room is the most critical step to prevent infection and facilitate healing. While antibiotics are crucial, they are adjuncts to surgical debridement. The 'golden period' for debridement is traditionally considered within 6-8 hours, but earlier is better, especially for higher grades. CTA might be indicated if there's concern for vascular injury, but controlling contamination is paramount. Definitive fixation is performed after initial debridement, often at a later stage once the soft tissue envelope has been optimized. Compartment pressures would be measured if compartment syndrome is suspected, but initial management focuses on the open wound.

Question 1154

Topic: 2. Trauma

A 22-year-old football player presents with severe pain in his right lower leg after a direct blow. He complains of paresthesia in his foot and pain on passive dorsiflexion of his toes. The calf is tense to palpation. What is the most reliable diagnostic finding for acute compartment syndrome?

. Presence of a palpable distal pulse.
. Pain out of proportion to injury.
. Elevated creatine kinase (CK) levels.
. Absolute intracompartmental pressure reading of 30 mmHg.
. Delta pressure (diastolic blood pressure minus intracompartmental pressure) less than 30 mmHg.

Correct Answer & Explanation

. Delta pressure (diastolic blood pressure minus intracompartmental pressure) less than 30 mmHg.

Explanation

Correct Answer: EThe most reliable diagnostic criterion for acute compartment syndrome is a 'delta pressure' (diastolic blood pressure minus intracompartmental pressure) less than 30 mmHg. While an absolute pressure of 30 mmHg or greater is often used as a threshold, it must be considered in relation to the patient's blood pressure, as a lower absolute pressure can still be significant in hypotensive patients. Pain out of proportion to injury, paresthesia, and a tense compartment are classic clinical signs, but they are subjective and can be unreliable in altered mental status or pediatric patients. A palpable distal pulse does not rule out compartment syndrome, as arterial inflow is typically preserved until very late stages. Elevated CK levels indicate muscle damage but are not diagnostic of acute compartment syndrome.

Question 1155

Topic: 2. Trauma

A 30-year-old male sustains a high-energy knee injury with gross instability in all planes. Radiographs confirm a knee dislocation without associated fractures. Pulses are diminished in the dorsalis pedis and posterior tibial arteries. What is the most appropriate next step in management?

. Immediate closed reduction followed by careful neurovascular reassessment.
. Order an emergent CT angiogram (CTA) prior to any manipulation.
. Perform an open reduction and repair of injured ligaments.
. Apply an external fixator across the knee joint.
. Begin a protocol for deep vein thrombosis (DVT) prophylaxis.

Correct Answer & Explanation

. Immediate closed reduction followed by careful neurovascular reassessment.

Explanation

Correct Answer: AKnee dislocation, especially with vascular compromise, is an orthopedic emergency. The immediate priority is reduction of the knee to restore blood flow and reduce tension on the popliteal artery. Closed reduction should be attempted immediately. After reduction, pulses must be meticulously reassessed. If pulses remain diminished or absent, or if there is any concern for popliteal artery injury (even with palpable pulses if the mechanism suggests high energy), an emergent CT angiogram (or arteriogram) is warranted. Delaying reduction for imaging significantly increases the risk of limb ischemia and potential amputation. Ligament repair and external fixation are important later steps, but re-establishing circulation is paramount.

Question 1156

Topic: 2. Trauma

A 78-year-old female presents after a ground-level fall, complaining of right hip pain. Radiographs show a displaced, comminuted subtrochanteric femur fracture. She has multiple comorbidities including hypertension, diabetes, and atrial fibrillation. Which of the following is the most appropriate definitive management for this fracture?

. Open reduction internal fixation (ORIF) with a dynamic hip screw (DHS).
. Hemiarthroplasty of the hip.
. Intramedullary nailing (IMN) with a long cephalomedullary nail.
. Non-operative management with traction.
. Arthroplasty with a total hip replacement (THR).

Correct Answer & Explanation

. Intramedullary nailing (IMN) with a long cephalomedullary nail.

Explanation

Correct Answer: CSubtrochanteric femur fractures are typically high-energy injuries in younger patients and low-energy in osteoporotic elderly patients. The standard of care for displaced subtrochanteric fractures, particularly comminuted ones, is intramedullary nailing (IMN) with a long cephalomedullary nail. This implant provides biomechanical stability, allows for early weight-bearing, and has better outcomes compared to plate fixation in this region, which is subject to high bending forces. DHS is primarily used for intertrochanteric fractures and is biomechanically less suitable for subtrochanteric fractures. Hemiarthroplasty or THR are used for femoral neck fractures or certain highly comminuted intertrochanteric fractures not amenable to IMN, but not typically for subtrochanteric fractures. Non-operative management with traction is associated with high mortality and morbidity in the elderly and is generally avoided.

Question 1157

Topic: 2. Trauma

A 40-year-old male falls from a height, landing on his heels. He presents with bilateral heel pain. Radiographs show a displaced calcaneus fracture. Which associated injury should be specifically investigated?

. Ankle sprain.
. Lumbar spine compression fracture.
. Lisfranc injury.
. Patella fracture.
. Talonavicular dislocation.

Correct Answer & Explanation

. Lumbar spine compression fracture.

Explanation

Correct Answer: BCalcaneus fractures, especially those resulting from a fall from a height, are associated with a significant incidence of lumbar spine compression fractures (10-15%). The axial loading mechanism transmits force up the kinetic chain. Therefore, it is critical to obtain imaging of the lumbar spine (lateral X-ray or CT) in all patients with calcaneus fractures from a fall from height. While other injuries can occur, a lumbar spine fracture is the most common and critical associated injury to specifically rule out due to potential neurological sequelae.

Question 1158

Topic: 2. Trauma

A 60-year-old obese male sustains a high-energy fall onto his knee, resulting in a Schatzker Type VI tibial plateau fracture. He has multiple open wounds and significant soft tissue swelling. What is the most appropriate initial surgical approach for this injury?

. Immediate open reduction internal fixation (ORIF) with dual plating.
. External fixation with provisional joint spanning, followed by delayed definitive fixation.
. Closed reduction and casting.
. Hemiarthroplasty of the knee.
. Arthroscopic-assisted reduction and screw fixation.

Correct Answer & Explanation

. External fixation with provisional joint spanning, followed by delayed definitive fixation.

Explanation

Correct Answer: BSchatzker Type VI tibial plateau fractures are complex, high-energy injuries often associated with severe soft tissue damage, swelling, and open wounds. Immediate definitive ORIF carries a high risk of wound complications, infection, and flap necrosis due to the compromised soft tissue envelope. The preferred initial management is often damage control orthopedics: emergent external fixation with provisional joint spanning (spanning ex-fix) to stabilize the fracture, protect the soft tissues, and allow swelling to subside. Definitive ORIF is then performed in a delayed fashion (typically 7-14 days) once the 'wrinkle sign' appears and the soft tissues are amenable to surgery. Closed reduction and casting are inadequate for displaced, unstable, or articular fractures. Arthroplasty is not an acute treatment for fractures. Arthroscopic assistance is primarily for less severe fractures.

Question 1159

Topic: Pelvic & Acetabular Trauma

A 45-year-old male is brought to the trauma bay after a motorcycle crash. His blood pressure is 80/50 mmHg. Radiographs show a widened pubic symphysis (4 cm) and disruption of the right sacroiliac joint. What is the most appropriate anatomic landmark for positioning a pelvic binder?

. Iliac crests
. Greater trochanters
. Anterior superior iliac spines
. Umbilicus
. Ischial tuberosities

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders must be centered over the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests can paradoxically open the pelvic ring in certain fracture patterns.

Question 1160

Topic: 2. Trauma
A 25-year-old female sustains a displaced, completely vertical (Pauwels Type III) femoral neck fracture. Which fixation construct provides the greatest biomechanical stability against shear forces for this specific fracture pattern?
. Three parallel cancellous lag screws
. Sliding hip screw with a derotational screw
. Two crossed cancellous screws
. Hemiarthroplasty
. Cephalomedullary nail

Correct Answer & Explanation

. Sliding hip screw with a derotational screw

Explanation

Pauwels Type III (vertical) femoral neck fractures experience extremely high shear forces. A fixed-angle device, such as a sliding hip screw supplemented with a derotational screw, provides superior biomechanical stability compared to parallel screws.

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