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2. Trauma MCQs

Practice Set 583 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 11641

Topic: Pelvic & Acetabular Trauma

A 25-year-old male is brought to the trauma bay after a crush injury with a mechanically unstable pelvis and hypotension. A decision is made to place a circumferential pelvic sheet or binder. What is the correct anatomical landmark for centering the binder?

. Iliac crests
. Greater trochanters
. Pubic symphysis
. Anterior superior iliac spines
. Subtrochanteric line

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders must be centered over the greater trochanters to effectively reduce the pelvic volume. Placement over the iliac crests can paradoxically open the pelvis further, worsening an unstable open-book injury.

Question 11642

Topic: 2. Trauma

A 45-year-old male presents with a midshaft femur fracture after an axial load injury. What is the approximate rate at which an associated ipsilateral femoral neck fracture is initially missed in this setting?

. 1%
. 10%
. 30%
. 60%
. 80%

Correct Answer & Explanation

. 30%

Explanation

Ipsilateral femoral neck fractures occur in 2-6% of femoral shaft fractures due to high-energy axial loading. Because they are typically non-displaced basicervical or vertical shear fractures, they are missed on initial presentation up to 30% of the time.

Question 11643

Topic: 2. Trauma

A 28-year-old male with a tibial shaft fracture reports severe pain out of proportion to the injury. The clinical diagnosis of compartment syndrome is suspected. How is the delta P (perfusion pressure) accurately calculated?

. Systolic Blood Pressure minus compartment pressure
. Diastolic Blood Pressure minus compartment pressure
. Mean Arterial Pressure minus compartment pressure
. Compartment pressure minus central venous pressure
. Systolic Blood Pressure plus compartment pressure

Correct Answer & Explanation

. Diastolic Blood Pressure minus compartment pressure

Explanation

The Delta P (perfusion pressure) is calculated as the Diastolic Blood Pressure minus the intracompartmental pressure. A Delta P of 30 mmHg or less is an absolute indication for emergent four-compartment fasciotomy.

Question 11644

Topic: 2. Trauma

A 40-year-old male is struck by a bus and presents with a large, fluctuant mass over his greater trochanter. Skin mobility is significantly increased over the mass. What is the most likely diagnosis?

. Trochanteric bursitis
. Necrotizing fasciitis
. Morel-Lavallee lesion
. Myositis ossificans
. Gluteal compartment syndrome

Correct Answer & Explanation

. Morel-Lavallee lesion

Explanation

A Morel-Lavallee lesion is a closed degloving injury where subcutaneous tissue is sheared off the underlying fascia, creating a potential space that fills with blood and lymph. Early identification and management are vital to prevent deep infection and tissue necrosis.

Question 11645

Topic: 2. Trauma

A 35-year-old male sustains a high-energy closed pilon fracture. The ankle exhibits severe soft tissue swelling, ecchymosis, and fracture blisters. What is the most appropriate initial management?

. Immediate ORIF of the tibia and fibula
. Spanning external fixation and delayed ORIF
. Cast immobilization for 6 weeks
. Primary intramedullary nailing of the tibia
. Primary tibiotalar arthrodesis

Correct Answer & Explanation

. Spanning external fixation and delayed ORIF

Explanation

High-energy pilon fractures have tenuous soft tissue envelopes that cannot safely tolerate immediate surgical incisions. A spanning external fixator provides length and alignment while allowing soft tissue recovery over 10 to 14 days prior to definitive ORIF.

Question 11646

Topic: 2. Trauma
A 30-year-old male sustains an open tibia fracture with a 12 cm laceration, extensive periosteal stripping, and exposed bone requiring a rotational gastrocnemius flap for coverage. There is no major arterial injury. What is the Gustilo-Anderson classification?
. Grade II
. Grade IIIA
. Grade IIIB
. Grade IIIC
. Grade IV

Correct Answer & Explanation

. Grade IIIB

Explanation

Gustilo-Anderson IIIB open fractures exhibit extensive soft-tissue stripping and inadequate bone coverage, necessitating a local rotational or free flap. Grade IIIC would imply an arterial injury requiring repair for limb salvage.

Question 11647

Topic: 2. Trauma

A 29-year-old female sustains a closed distal third spiral humeral shaft fracture (Holstein-Lewis pattern). Initial examination in the trauma bay reveals a complete wrist drop. What is the most appropriate next step in management?

. Immediate surgical exploration of the radial nerve
. Closed reduction and coaptation splint with observation
. Immediate electromyography (EMG)
. MRI of the humerus to locate the nerve
. External fixation of the humerus

Correct Answer & Explanation

. Closed reduction and coaptation splint with observation

Explanation

A primary radial nerve palsy in the setting of a closed humeral shaft fracture is overwhelmingly a neuropraxia. The standard of care is closed fracture management and observation of the nerve deficit for 3 to 4 months.

Question 11648

Topic: 2. Trauma

A 31-year-old male falls from a height and sustains a displaced intra-articular calcaneus fracture. If an extensile lateral approach is utilized for fixation, which nerve is at the highest risk of iatrogenic injury?

. Posterior tibial nerve
. Sural nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Medial plantar nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach is the workhorse for displaced intra-articular calcaneus fractures. The sural nerve is at high risk of injury, particularly at the proximal vertical limb and the distal horizontal limb of the surgical incision.

Question 11649

Topic: 2. Trauma

A 22-year-old male hyperextends his knee while playing rugby. The knee was reduced on the field. On presentation, distal pulses are palpable but the Ankle-Brachial Index (ABI) is 0.85. What is the next best step in management?

. Discharge with a knee immobilizer and crutches
. Immediate operative exploration of the popliteal artery
. CT angiography of the lower extremity
. Duplex ultrasound in 1 week
. Prophylactic four-compartment fasciotomy

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI less than 0.90 after a suspected knee dislocation is highly suspicious for a popliteal artery intimal tear. CT angiography is immediately indicated to definitively map and rule out a surgical vascular injury.

Question 11650

Topic: 2. Trauma
A 38-year-old female presents hypotensive with an APC-III pelvic ring injury. Following placement of a pelvic binder and massive transfusion protocol, she remains hemodynamically unstable. A FAST exam is negative. What is the most appropriate next step?
. Exploratory laparotomy
. Preperitoneal pelvic packing or angioembolization
. Retrograde urethrogram
. Immediate open reduction and internal fixation
. Application of bilateral distal femur traction pins

Correct Answer & Explanation

. Preperitoneal pelvic packing or angioembolization

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic fracture and a negative FAST, the source of bleeding is the pelvic retroperitoneum. Emergent preperitoneal pelvic packing or pelvic angiography with embolization is indicated to stop the hemorrhage.

Question 11651

Topic: 2. Trauma

A 21-year-old collegiate basketball player sustains a zone 2 proximal fifth metatarsal fracture (Jones fracture). What is the best treatment option to minimize time away from sport and prevent nonunion?

. Non-weight bearing short leg cast for 6 weeks
. Hard-soled shoe for 4 weeks
. Intramedullary screw fixation
. Cross-pinning with K-wires
. Excision of the proximal fragment with peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction, a watershed vascular area highly prone to nonunion. Intramedullary screw fixation is recommended for high-level athletes to significantly accelerate return to play and reduce the risk of nonunion.

Question 11652

Topic: 2. Trauma

A 45-year-old female complains of painful clicking 8 months after a non-operative midshaft clavicle fracture. Radiographs confirm a nonunion. Which factor present at the time of injury most likely increased her risk of developing a nonunion?

. Female sex
. 100% displacement without cortical contact
. Fracture location in the medial third
. High body mass index
. Concomitant non-displaced rib fractures

Correct Answer & Explanation

. 100% displacement without cortical contact

Explanation

The greatest risk factors for nonunion in midshaft clavicle fractures are 100% displacement (no cortical contact), significant shortening greater than 2 cm, and severe comminution. Operative fixation is often recommended for these specific patterns to prevent nonunion.

Question 11653

Topic: 2. Trauma
A 45-year-old male presents with a pelvic ring injury and hemodynamic instability despite massive transfusion. An AP pelvis radiograph shows an APC III fracture pattern. Following placement of a pelvic binder, he remains hypotensive. What is the most appropriate next step in acute management?
. Preperitoneal pelvic packing
. Symphyseal plating
. Immediate sacroiliac screw fixation
. Zone III REBOA
. Bilateral internal iliac artery stenting

Correct Answer & Explanation

. Preperitoneal pelvic packing

Explanation

Hemodynamically unstable pelvic fractures with an open ring after binder placement require preperitoneal packing or angiography. Preperitoneal packing is highly effective and increasingly favored as the immediate surgical step for suspected venous bleeding, which represents the majority of pelvic hemorrhage.

Question 11654

Topic: 2. Trauma
A 28-year-old male sustains a vertically oriented Pauwels type III femoral neck fracture. Biomechanically, which fixation construct provides the greatest stability against shear forces?
. Three parallel cannulated screws
. Dynamic hip screw (DHS) with a derotation screw
. Cephalomedullary nail
. Two parallel cannulated screws
. Multiple fully threaded screws

Correct Answer & Explanation

. Dynamic hip screw (DHS) with a derotation screw

Explanation

Pauwels type III fractures are highly unstable due to significant vertical shear forces. A dynamic hip screw (sliding hip screw) supplemented with a derotation screw provides superior biomechanical stability against shear compared to standard multiple cancellous screws.

Question 11655

Topic: 2. Trauma

A 40-year-old patient presents with a coronal plane fracture of the lateral femoral condyle (Hoffa fracture) following a motor vehicle collision. Which of the following surgical approaches is most appropriate for direct visualization and open reduction internal fixation?

. Medial parapatellar approach
. Standard lateral approach with IT band elevation
. Lateral parapatellar approach or swashbuckler approach
. Posterior approach to the popliteal fossa
. Subvastus approach

Correct Answer & Explanation

. Lateral parapatellar approach or swashbuckler approach

Explanation

Lateral Hoffa fractures require direct visualization of the articular surface for anatomic reduction. A lateral parapatellar or a modified anterior (swashbuckler) approach allows adequate exposure of the lateral condyle to place anterior-to-posterior or posterior-to-anterior screws.

Question 11656

Topic: 2. Trauma

A 25-year-old male with a closed tibial shaft fracture complains of severe pain out of proportion to his injury. His diastolic blood pressure is 80 mmHg. What is the threshold of absolute or differential pressure that necessitates an immediate four-compartment fasciotomy?

. Absolute compartment pressure of 25 mmHg
. Absolute compartment pressure of 20 mmHg
. Differential pressure (Delta P) of 30 mmHg or less
. Differential pressure (Delta P) of 45 mmHg or less
. Mean arterial pressure minus compartment pressure < 40 mmHg

Correct Answer & Explanation

. Differential pressure (Delta P) of 30 mmHg or less

Explanation

The delta P (diastolic blood pressure minus compartment pressure) is the most reliable objective indicator for acute compartment syndrome. A delta P of 30 mmHg or less is the widely accepted threshold to perform an immediate fasciotomy.

Question 11657

Topic: 2. Trauma

A 55-year-old male sustains a medial tibial plateau fracture (Schatzker IV) from a high-energy dashboard injury. What associated soft tissue injury is most critical to aggressively rule out due to this specific mechanism and fracture pattern?

. Popliteal artery injury
. Common peroneal nerve palsy
. Anterior tibial artery transaction
. Superficial peroneal nerve entrapment
. Medial meniscus root tear

Correct Answer & Explanation

. Popliteal artery injury

Explanation

High-energy medial tibial plateau fractures (Schatzker IV) often represent a high-velocity knee fracture-dislocation variant. The popliteal artery is tightly tethered at the adductor hiatus and soleal arch, making it highly susceptible to catastrophic intimal disruption or transaction.

Question 11658

Topic: 2. Trauma
A 30-year-old male sustains a Gustilo-Anderson IIIB open tibial shaft fracture. After thorough debridement and skeletal stabilization, a soft tissue defect remains over the middle third of the tibia with exposed bone. Which of the following flap options is most appropriate for coverage?
. Gastrocnemius rotational flap
. Soleus rotational flap
. Reverse sural artery flap
. Free anterolateral thigh (ALT) flap
. Fasciocutaneous local advancement flap

Correct Answer & Explanation

. Soleus rotational flap

Explanation

Rotational muscle flaps are reliable for tibial coverage based on the defect's location. The gastrocnemius flap is utilized for the proximal third, and the soleus flap is the workhorse for the middle third of the tibia.

Question 11659

Topic: 2. Trauma

A 45-year-old construction worker falls from a height, sustaining a displaced intra-articular calcaneus fracture. The presence of which clinical sign strongly suggests that surgical intervention should be delayed?

. Fracture blisters filled with clear fluid
. Hemorrhagic fracture blisters over the lateral incision site
. Positive wrinkle test
. Dependent rubor
. Ecchymosis extending into the plantar arch

Correct Answer & Explanation

. Hemorrhagic fracture blisters over the lateral incision site

Explanation

Surgery for calcaneus fractures is typically delayed until soft tissue swelling subsides to minimize catastrophic wound complications. Hemorrhagic fracture blisters indicate deeper dermal injury and mandate delaying surgery until the "wrinkle sign" appears.

Question 11660

Topic: 2. Trauma

Which of the following is considered an absolute indication for operative fixation of a midshaft clavicle fracture?

. Displacement greater than 2 cm
. Z-type comminution
. Skin tenting without compromise
. Associated progressive brachial plexopathy
. Shortening of 1.5 cm

Correct Answer & Explanation

. Associated progressive brachial plexopathy

Explanation

Absolute indications for operative treatment of clavicle fractures include open fractures, actual skin compromise (impending open), and associated progressive neurologic deficits (e.g., brachial plexopathy) or vascular injury. Displacement and shortening are considered relative indications.

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