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2. Trauma MCQs

Practice Set 584 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 11661

Topic: 2. Trauma

According to Hertel's radiographic criteria, which feature of a proximal humerus fracture is the strongest predictor of subsequent avascular necrosis (AVN) of the humeral head?

. Medial hinge disruption with a calcar length of less than 8 mm
. Greater tuberosity displacement > 5 mm
. Valgus impaction
. Lesser tuberosity comminution
. Bicipital groove involvement

Correct Answer & Explanation

. Medial hinge disruption with a calcar length of less than 8 mm

Explanation

Hertel identified specific predictors for humeral head ischemia following proximal humerus fractures. A short calcar length (< 8 mm attached to the articular segment) and disruption of the medial hinge are the strongest predictors of subsequent avascular necrosis.

Question 11662

Topic: 2. Trauma

A 35-year-old male sustains a closed transverse humeral shaft fracture in the middle third and presents with a complete radial nerve palsy at the time of injury. What is the most appropriate initial management?

. Immediate open exploration of the radial nerve and ORIF
. EMG and nerve conduction studies
. Application of a coaptation splint or functional brace with observation
. Immediate intramedullary nailing without nerve exploration
. External fixation

Correct Answer & Explanation

. Application of a coaptation splint or functional brace with observation

Explanation

Primary radial nerve palsy associated with a closed humeral shaft fracture is typically a neuropraxia. The standard of care is closed management of the fracture (e.g., functional bracing) and observation of the nerve, expecting spontaneous recovery in the vast majority of cases.

Question 11663

Topic: 2. Trauma

A 7-year-old boy falls on his outstretched hand and sustains a Bado Type I Monteggia fracture-dislocation. What defines a Bado Type I injury?

. Posterior angulation of the ulna with posterior radial head dislocation
. Anterior angulation of the ulna with anterior radial head dislocation
. Lateral angulation of the ulna with lateral radial head dislocation
. Proximal third ulnar fracture with radial shaft fracture
. Distal third ulnar fracture with distal radioulnar joint dislocation

Correct Answer & Explanation

. Anterior angulation of the ulna with anterior radial head dislocation

Explanation

A Bado Type I Monteggia injury consists of an anteriorly angulated fracture of the ulnar shaft combined with an anterior dislocation of the radial head. It is the most common type of Monteggia lesion seen in pediatric patients.

Question 11664

Topic: 2. Trauma
A 28-year-old farmer sustains a Gustilo-Anderson Type IIIA open femur fracture highly contaminated with soil. According to current guidelines, what is the most appropriate initial prophylactic antibiotic regimen?
. First-generation cephalosporin alone
. First-generation cephalosporin and an aminoglycoside
. First-generation cephalosporin, an aminoglycoside, and penicillin
. Third-generation cephalosporin alone
. Vancomycin and ciprofloxacin

Correct Answer & Explanation

. First-generation cephalosporin, an aminoglycoside, and penicillin

Explanation

For Type III open fractures heavily contaminated with farm soil or with suspected clostridial risk, the addition of penicillin is required. The standard regimen includes a first-generation cephalosporin, an aminoglycoside (or a Gram-negative covering agent), and high-dose penicillin for anaerobic coverage.

Question 11665

Topic: 2. Trauma

In a polytraumatized patient, which of the following physiological parameters is a strong indication to pursue "Damage Control Orthopedics" (external fixation) rather than Early Total Care for a femur fracture?

. Base deficit of 2 mmol/L
. Serum lactate of 1.5 mmol/L
. Platelet count of 150,000/mm3
. Core temperature of 33 degrees Celsius
. Urine output of 1 ml/kg/hr

Correct Answer & Explanation

. Core temperature of 33 degrees Celsius

Explanation

Damage Control Orthopedics (DCO) is indicated in the "borderline" or "in extremis" patient. A core body temperature below 35 degrees Celsius (hypothermia), along with coagulopathy and acidosis (the lethal triad), strongly warrants DCO to prevent further physiological deterioration.

Question 11666

Topic: Pelvic & Acetabular Trauma
A 35-year-old male presents after a motorcycle collision with a blood pressure of 80/50 mmHg. A pelvic binder is applied, and FAST exam is negative. Pelvic radiograph demonstrates an APC III pelvic ring injury. Despite the binder and fluid resuscitation, his blood pressure remains 75/40 mmHg. What is the most appropriate next step in management?
. Retrograde urethrogram
. Preperitoneal pelvic packing
. Emergent open reduction internal fixation of the pelvis
. Exploratory laparotomy
. Application of bilateral chest tubes

Correct Answer & Explanation

. Preperitoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and a negative FAST exam, bleeding is likely retroperitoneal. Preperitoneal pelvic packing or pelvic angiography is indicated after a pelvic binder has failed to achieve hemodynamic stability.

Question 11667

Topic: 2. Trauma

A 28-year-old male sustains a closed femoral shaft fracture and a severe traumatic brain injury (GCS 7) following a motor vehicle collision. An intracranial pressure (ICP) monitor shows elevated pressures. What is the most appropriate initial management for his femur fracture?

. Reamed intramedullary nailing
. Unreamed intramedullary nailing
. External fixation
. Open reduction and plate fixation
. Skeletal traction until neurologic recovery

Correct Answer & Explanation

. External fixation

Explanation

Patients with severe head injuries and elevated intracranial pressure should undergo Damage Control Orthopedics (DCO) with temporary external fixation. Early total care with reamed nailing can exacerbate secondary brain injury through fat embolization and intraoperative hypotension.

Question 11668

Topic: 2. Trauma
A 40-year-old male sustains a Gustilo-Anderson Type IIIB open tibial shaft fracture. What is the single most critical factor in preventing the development of a deep infection in this patient?
. Early administration of systemic antibiotics
. Use of antibiotic-impregnated cement beads
. Time to definitive soft tissue coverage
. Type of fracture fixation utilized
. Application of negative pressure wound therapy

Correct Answer & Explanation

. Early administration of systemic antibiotics

Explanation

The single most important factor in reducing infection rates in open fractures is the early administration of appropriate systemic antibiotics, ideally within 1 hour of injury. Thorough surgical debridement is the second most critical step.

Question 11669

Topic: 2. Trauma

A 25-year-old male undergoes reamed intramedullary nailing for a closed tibial shaft fracture. Twelve hours postoperatively, he complains of increasing leg pain out of proportion to the injury, especially with passive toe extension. His diastolic blood pressure is 60 mmHg, and his anterior compartment pressure is measured at 45 mmHg. What is the next best step?

. Elevate the leg above the level of the heart
. Administer a bolus of IV analgesics and re-evaluate in 1 hour
. Immediate four-compartment fasciotomy
. Remove the intramedullary nail
. Apply a continuous ice pack to the leg

Correct Answer & Explanation

. Immediate four-compartment fasciotomy

Explanation

A delta pressure (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is diagnostic for acute compartment syndrome. Immediate four-compartment fasciotomy is required to prevent irreversible muscle necrosis and nerve ischemia.

Question 11670

Topic: 2. Trauma

A 35-year-old female sustains a high-energy varus knee injury, resulting in a Schatzker IV tibial plateau fracture (medial plateau involvement). Due to the mechanism and fracture pattern, which associated injury must be most carefully excluded?

. Anterior tibial artery injury
. Popliteal artery injury
. Superficial femoral artery injury
. Patellar tendon rupture
. Femoral nerve palsy

Correct Answer & Explanation

. Popliteal artery injury

Explanation

Schatzker IV fractures involve the medial tibial plateau, typically resulting from high-energy varus forces, and often represent a knee fracture-dislocation. They carry a significant risk of associated popliteal artery injury and peroneal nerve traction injuries.

Question 11671

Topic: 2. Trauma

A 28-year-old male presents with an isolated coronal plane fracture of the lateral femoral condyle (Hoffa fracture). If open reduction and internal fixation is planned, which screw trajectory offers the most biomechanically stable fixation?

. Anterior-to-posterior (AP) lag screws
. Posterior-to-anterior (PA) lag screws
. Lateral-to-medial lag screws
. Medial-to-lateral lag screws
. Inferior-to-superior lag screws

Correct Answer & Explanation

. Posterior-to-anterior (PA) lag screws

Explanation

Hoffa fractures are coronal plane fractures of the femoral condyle. Posterior-to-anterior (PA) lag screws are biomechanically superior because they compress the fracture perpendicular to the primary plane of the fracture line.

Question 11672

Topic: 2. Trauma

A 22-year-old male sustains a transverse fracture through the proximal pole of the scaphoid after a fall onto an outstretched hand. What is the most appropriate management to minimize the risk of nonunion?

. Short arm thumb spica cast for 6 weeks
. Long arm thumb spica cast for 12 weeks
. Open reduction and internal fixation
. Closed reduction with percutaneous pinning
. Primary excision of the proximal pole

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

Proximal pole scaphoid fractures have a high rate of nonunion and avascular necrosis due to the retrograde intraosseous blood supply. Surgical fixation is generally recommended over casting to provide rigid stability and optimize healing.

Question 11673

Topic: 2. Trauma

A 60-year-old female presents with a severely displaced 4-part proximal humerus fracture. Which radiographic finding is the most reliable predictor for the development of avascular necrosis of the humeral head?

. Displacement of the greater tuberosity greater than 1 cm
. A medial calcar hinge length of less than 8 mm
. Angulation of the surgical neck greater than 45 degrees
. Impaction of the articular surface
. Presence of a concomitant glenoid fracture

Correct Answer & Explanation

. A medial calcar hinge length of less than 8 mm

Explanation

A short or absent medial calcar hinge (less than 8 mm) and disruption of the medial periosteum are highly predictive of ischemia. These findings indicate a significant loss of blood supply to the humeral head, increasing the risk of avascular necrosis.

Question 11674

Topic: 2. Trauma

A 34-year-old male presents with a closed distal third humeral shaft fracture. On initial examination, he is unable to actively extend his wrist or fingers. He undergoes a closed reduction and splinting. Post-reduction examination shows the fracture is acceptably aligned, but the nerve deficit is completely unchanged. What is the next best step in management?

. Immediate surgical exploration of the radial nerve
. Observation and symptomatic treatment with an extension splint
. MRI of the humerus to evaluate the nerve
. Ultrasound of the brachial plexus
. Immediate nerve grafting

Correct Answer & Explanation

. Observation and symptomatic treatment with an extension splint

Explanation

Primary radial nerve palsy associated with a closed humeral shaft fracture is typically a neuropraxia and is managed non-operatively with observation. Surgical exploration is indicated if the palsy occurs or worsens strictly after closed reduction, or in the setting of an open fracture.

Question 11675

Topic: 2. Trauma

A 40-year-old male sustains a severely comminuted intra-articular distal tibia fracture (Pilon fracture) with massive soft tissue swelling and extensive fracture blisters. What is the most appropriate initial management?

. Immediate ORIF with dual plates
. External fixation with delayed definitive fixation
. Intramedullary nailing of the tibia
. Long leg cast immobilization
. Primary tibiotalar arthrodesis

Correct Answer & Explanation

. External fixation with delayed definitive fixation

Explanation

For high-energy Pilon fractures with severely compromised soft tissues, a staged protocol is the standard of care. Initial management consists of spanning external fixation until soft tissues recover (typically 10-14 days), followed by definitive ORIF.

Question 11676

Topic: Pelvic & Acetabular Trauma
A 40-year-old male presents in hemorrhagic shock after a motorcycle crash. Pelvic radiographs show an anteroposterior compression type III (APC-III) pelvic ring injury. A FAST scan is negative. Despite application of a pelvic binder and massive transfusion protocol, his blood pressure remains 75/40 mm Hg. What is the most appropriate next step in management?
. CT scan of the abdomen and pelvis
. Application of a pelvic C-clamp
. Retrograde urethrogram
. Preperitoneal pelvic packing or angiography
. Exploratory laparotomy

Correct Answer & Explanation

. Preperitoneal pelvic packing or angiography

Explanation

In a hemodynamically unstable patient with a pelvic ring injury and negative FAST, the source of bleeding is likely pelvic venous plexus or arterial injury. Preperitoneal pelvic packing or pelvic angiography are the appropriate interventions.

Question 11677

Topic: 2. Trauma

A 25-year-old male sustains a closed tibial shaft fracture. Two hours post-injury, he complains of progressive pain out of proportion to the injury, unrelieved by narcotics. Which of the following pressure measurements is an absolute indication for a four-compartment fasciotomy?

. Absolute compartment pressure > 20 mm Hg
. Diastolic blood pressure minus compartment pressure < 30 mm Hg
. Mean arterial pressure minus compartment pressure < 40 mm Hg
. Systolic blood pressure minus compartment pressure < 30 mm Hg
. Absolute compartment pressure > 25 mm Hg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure < 30 mm Hg

Explanation

The delta P (diastolic blood pressure minus compartment pressure) is the most reliable indicator for compartment syndrome. A delta P of less than 30 mm Hg is an absolute indication for emergency fasciotomy.

Question 11678

Topic: 2. Trauma

A 22-year-old male sustains a severe closed head injury and a closed femoral shaft fracture in an MVC. His intracranial pressure (ICP) is 25 mm Hg and cannot be reliably controlled. According to damage control orthopedics (DCO) principles, what is the best initial management of the femur fracture?

. Immediate reamed intramedullary nailing
. Immediate unreamed intramedullary nailing
. Open reduction and internal fixation with a plate
. Spanning external fixation
. Skeletal traction for 6 weeks

Correct Answer & Explanation

. Spanning external fixation

Explanation

In a polytraumatized patient with an unstable head injury (high ICP) or hemodynamic instability, DCO is indicated. External fixation provides rapid skeletal stability while minimizing the physiological hit of definitive intramedullary nailing.

Question 11679

Topic: 2. Trauma

In a proximal third subtrochanteric femur fracture, the proximal fragment is typically held in flexion, abduction, and external rotation. Which muscle is primarily responsible for the flexion deformity?

. Gluteus medius
. Gluteus minimus
. Iliopsoas
. Piriformis
. Adductor longus

Correct Answer & Explanation

. Iliopsoas

Explanation

The iliopsoas inserts on the lesser trochanter and is responsible for the flexion of the proximal fragment. The gluteus medius and minimus cause abduction, while the short external rotators cause external rotation.

Question 11680

Topic: 2. Trauma

A 45-year-old male presents with a high-energy Schatzker VI tibial plateau fracture with severe soft tissue swelling and hemorrhagic fracture blisters. What is the most appropriate initial management?

. Immediate dual plating
. Spanning external fixation across the knee joint
. Intramedullary nailing
. Arthroscopically assisted percutaneous fixation
. Cast immobilization

Correct Answer & Explanation

. Spanning external fixation across the knee joint

Explanation

High-energy tibial plateau fractures (Schatzker VI) with severe soft tissue compromise require a staged approach. Initial management involves a knee-spanning external fixator to restore length and alignment while allowing the soft tissue envelope to recover.

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