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2. Trauma MCQs

Practice Set 590 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 11781

Topic: 2. Trauma

A 50-year-old male falls directly onto his patella, sustaining a comminuted patella fracture with 5mm displacement and articular incongruity. He is unable to perform a straight leg raise. What is the most appropriate management?

. Non-operative management with a knee immobilizer.
. Tension band wiring.
. Partial patellectomy.
. Total patellectomy.
. Knee arthrodesis.

Correct Answer & Explanation

. Tension band wiring.

Explanation

Displaced patella fractures with disruption of the extensor mechanism (unable to perform a straight leg raise) require surgical fixation to restore extensor function and achieve articular congruity. For comminuted but salvageable patella fractures, tension band wiring (often combined with circumferential cerclage wiring for comminution) is the most common and effective technique. It converts the distraction forces into compression forces at the articular surface during knee flexion. Partial patellectomy is reserved for highly comminuted fragments that cannot be reconstructed. Total patellectomy leads to significant quadriceps weakness and is a salvage procedure. Non-operative management is only for non-displaced fractures with an intact extensor mechanism. Knee arthrodesis is an extreme salvage option for devastating knee injuries.

Question 11782

Topic: 2. Trauma
According to the Gustilo-Anderson classification, which of the following describes a Type IIIB open fracture?
. An open fracture with a wound less than 1 cm, minimal soft tissue damage, and simple fracture pattern.
. An open fracture with a wound greater than 1 cm but less than 10 cm, moderate soft tissue damage, and minimal periosteal stripping.
. An open fracture with extensive soft tissue damage, periosteal stripping, bone exposure, and massive contamination, requiring soft tissue coverage.
. An open fracture with extensive skin and soft tissue damage, typically with vascular injury requiring repair.
. An open fracture with a gunshot wound entrance and exit wound.

Correct Answer & Explanation

. An open fracture with extensive soft tissue damage, periosteal stripping, bone exposure, and massive contamination, requiring soft tissue coverage.

Explanation

The Gustilo-Anderson classification is crucial for guiding management and predicting outcomes in open fractures. Type IIIB is defined as an open fracture with extensive soft tissue damage, periosteal stripping, bone exposure, and massive contamination, requiring reconstructive soft tissue procedures (e.g., local or free flap) for coverage. Type I is a small wound (<1cm), minimal damage. Type II is a wound >1cm but <10cm, moderate damage. Type IIIA has extensive soft tissue damage, but adequate soft tissue coverage is usually possible. Type IIIC includes an associated arterial injury requiring repair, regardless of the soft tissue damage severity. A gunshot wound is not a standalone Gustilo type, but is classified based on wound size and soft tissue damage.

Question 11783

Topic: 2. Trauma

A 20-year-old male sustains a severe crush injury to his leg. He has an open tibia fracture and a palpable but weak dorsalis pedis pulse. The ankle-brachial index (ABI) is 0.7. Which of the following 'hard signs' of vascular injury would necessitate immediate surgical exploration of the popliteal artery?

. Absent distal pulse.
. Non-pulsatile hematoma.
. Paresthesia.
. Diminished pulse with an ABI of 0.7.
. Pain out of proportion.

Correct Answer & Explanation

. Absent distal pulse.

Explanation

Hard signs of vascular injury are clinical indicators that strongly suggest significant arterial disruption and typically mandate immediate surgical exploration without delay for imaging. These include: absent or rapidly diminishing pulse, expanding or pulsatile hematoma, pulsatile bleeding, thrill, and bruit. While a diminished pulse and ABI of 0.7 are 'soft signs' that warrant further investigation (e.g., CTA), an absent distal pulse is a hard sign indicating complete or near-complete occlusion and necessitates immediate surgical intervention to restore blood flow and prevent limb ischemia. Paresthesia and pain out of proportion are signs of ischemia or compartment syndrome, but not specific hard signs of arterial injury themselves.

Question 11784

Topic: 2. Trauma

A 30-year-old male sustains a closed, displaced femoral shaft fracture in a motor vehicle accident. He is hemodynamically stable. What is the most appropriate definitive management for this injury?

. Skeletal traction for 6-8 weeks.
. Application of a hip spica cast.
. External fixation.
. Intramedullary nailing (IMN).
. Dynamic compression plating.

Correct Answer & Explanation

. Intramedullary nailing (IMN).

Explanation

For closed, displaced adult femoral shaft fractures, intramedullary nailing (IMN) is considered the gold standard of care. It provides stable fixation, allows for early mobilization and weight-bearing, and has high union rates with low complication rates. Skeletal traction is a temporary measure or used in specific situations (e.g., damage control in polytrauma) but not a definitive treatment for adults. A hip spica cast is typically used for pediatric femoral shaft fractures. External fixation is generally reserved for open fractures, polytrauma patients in damage control, or cases where IMN is contraindicated. Dynamic compression plating is an option but generally has higher complication rates and longer healing times compared to IMN for femoral shaft fractures.

Question 11785

Topic: 2. Trauma
A 40-year-old male falls from a roof, landing on his buttocks. He has severe sacral pain and a palpable step-off over the posterior superior iliac spine (PSIS). Neurological exam reveals decreased sensation in the perineum and diminished rectal tone. Which Denis classification zone of sacral fracture is most likely?
. Denis Zone I
. Denis Zone II
. Denis Zone III
. Isolated sacral ala fracture
. Coccyx fracture

Correct Answer & Explanation

. Denis Zone III

Explanation

The Denis classification categorizes sacral fractures based on their relationship to the sacral foramina and spinal canal, which correlates with neurological injury risk. Denis Zone III fractures involve the sacral spinal canal centrally (medial to the neural foramina). These fractures carry the highest risk of neurological injury, often affecting bowel, bladder, and sexual function, as well as perineal sensation and rectal tone, consistent with the patient's presentation. Denis Zone I fractures are lateral to the neural foramina (ala fractures) and typically have a lower risk of neurological injury. Denis Zone II fractures involve the neural foramina but spare the central canal. Coccyx fractures and isolated ala fractures do not typically cause these significant neurological deficits.

Question 11786

Topic: 2. Trauma

A 20-year-old female elite runner reports insidious onset of increasing pain in her anterior shin that is worse with running and relieved by rest. Physical exam reveals localized tenderness over the anterior tibia. Radiographs are normal. What is the most appropriate next diagnostic step?

. Referral for physical therapy.
. Continue rest and NSAIDs for 2 weeks.
. Order a bone scan or MRI of the tibia.
. Consider a compartment pressure measurement.
. Prescribe a short course of oral corticosteroids.

Correct Answer & Explanation

. Order a bone scan or MRI of the tibia.

Explanation

The patient's symptoms (insidious onset, activity-related pain, localized tenderness, normal radiographs) are highly suggestive of a tibial stress fracture. While rest and NSAIDs are part of the initial management, confirmation of the diagnosis is crucial to prevent progression to a complete fracture, especially in an elite athlete. Plain radiographs are often normal in early stress fractures. A bone scan (showing increased uptake) or MRI (showing marrow edema) are the most sensitive imaging modalities to confirm the diagnosis of a stress fracture. Compartment pressure measurement would be for chronic exertional compartment syndrome, which presents with diffuse pain and cramping, not typically focal tenderness. Physical therapy and NSAIDs are treatment, not the next diagnostic step to confirm a stress fracture.

Question 11787

Topic: 2. Trauma

A 30-year-old female sustains a unimalleolar fracture of the medial malleolus with 3mm of displacement and no syndesmotic widening. What is the most appropriate definitive management for this injury?

. Non-weight-bearing cast immobilization for 6 weeks.
. Open reduction internal fixation (ORIF) with screws.
. Close reduction and short leg cast for 4 weeks.
. Application of an ankle-foot orthosis (AFO) with immediate weight-bearing.
. Below-knee amputation.

Correct Answer & Explanation

. Open reduction internal fixation (ORIF) with screws.

Explanation

Medial malleolus fractures with greater than 2mm of displacement or any degree of rotation are generally considered unstable and typically require open reduction and internal fixation (ORIF) with screws (e.g., lag screws or tension band wiring). This ensures anatomical reduction of the articular surface and restores the integrity of the deltoid ligament attachment, preventing chronic instability and post-traumatic arthritis. Non-operative management with a cast is reserved for truly non-displaced, stable medial malleolus fractures. Immediate weight-bearing in an AFO is too aggressive for a displaced fracture. Below-knee amputation is not indicated.

Question 11788

Topic: 2. Trauma

A 55-year-old male sustains a severe pilon fracture of the distal tibia with extensive articular comminution and significant soft tissue swelling. Which of the following is a common long-term complication of this specific type of fracture?

. Nonunion.
. Malunion.
. Post-traumatic ankle arthritis.
. Compartment syndrome.
. Popliteal artery injury.

Correct Answer & Explanation

. Post-traumatic ankle arthritis.

Explanation

Pilon fractures (distal tibial plafond fractures) are intra-articular fractures resulting from high-energy axial loading. Due to the significant articular cartilage damage and comminution, and the difficulty in achieving and maintaining anatomical reduction, post-traumatic ankle arthritis is a very common and often debilitating long-term complication, even with optimal surgical management. While nonunion and malunion can occur, and compartment syndrome is an acute risk, post-traumatic arthritis is the most prevalent and significant long-term sequela due to the direct damage to the joint surface. Popliteal artery injury is uncommon in pilon fractures but more common in knee dislocations or supracondylar femur fractures.

Question 11789

Topic: 2. Trauma

A 35-year-old male sustains a closed, non-displaced spiral fracture of the middle third of the tibia shaft. The fibula is intact. What is the most appropriate initial treatment?

. Immediate intramedullary nailing (IMN).
. Surgical plating of the tibia.
. Short leg cast, non-weight bearing.
. Long leg cast, non-weight bearing, followed by functional brace.
. External fixation.

Correct Answer & Explanation

. Long leg cast, non-weight bearing, followed by functional brace.

Explanation

For a closed, non-displaced spiral tibial shaft fracture with an intact fibula, non-operative management is often appropriate. A long leg cast is typically applied initially to control rotation and provide stability, followed by conversion to a patellar tendon-bearing (PTB) brace (functional brace) once acute pain and swelling subside, allowing for early weight-bearing and knee range of motion. The intact fibula provides some inherent stability, aiding non-operative treatment. IMN or plating would be overtreatment for a non-displaced fracture, typically reserved for displaced or unstable fractures. A short leg cast does not adequately control rotation for a tibial shaft fracture. External fixation is reserved for more complex open or unstable fractures.

Question 11790

Topic: 2. Trauma

A 58-year-old male sustains a displaced femoral neck fracture. He has a history of chronic alcoholism and smoking. What is the most significant long-term complication associated with femoral neck fractures, especially in patients with predisposing factors?

. Nonunion.
. Malunion.
. Deep vein thrombosis (DVT).
. Avascular necrosis (AVN) of the femoral head.
. Infection.

Correct Answer & Explanation

. Avascular necrosis (AVN) of the femoral head.

Explanation

Displaced femoral neck fractures disrupt the blood supply to the femoral head, which predominantly comes from the medial and lateral circumflex arteries. This makes avascular necrosis (AVN) of the femoral head a particularly high-risk complication, occurring in 15-40% of displaced fractures, and is significantly higher in patients with compromised vascularity due to factors like smoking and alcoholism. Nonunion is also a common complication, but AVN is often more devastating, potentially leading to femoral head collapse and the need for arthroplasty. While DVT and infection are risks with any major orthopedic trauma, AVN is uniquely prevalent and devastating for femoral neck fractures due to the specific anatomy of blood supply.

Question 11791

Topic: 2. Trauma

A 7-year-old child sustains a closed, displaced transverse fracture of the midshaft femur. He is otherwise healthy. What is the most appropriate definitive treatment?

. Immediate intramedullary nailing (IMN).
. Flexible intramedullary nailing.
. Open reduction and internal fixation with a plate.
. Hip spica cast.
. Skeletal traction.

Correct Answer & Explanation

. Flexible intramedullary nailing.

Explanation

For pediatric femoral shaft fractures in the 6-12 year age group, flexible intramedullary nailing (TENs or Ender nails) is often the preferred treatment. It provides stable fixation, allows for early weight-bearing and mobilization, minimizes the risk of physeal injury, and preserves growth potential. While IMN is common in adults, reamed solid nails are generally avoided in younger children due to potential damage to the trochanteric apophysis and growth disturbance. A hip spica cast is suitable for younger children (typically <6 years) or minimally displaced fractures. Skeletal traction is usually a temporary measure or for very young children. Plate fixation is an option but associated with larger incisions and potential for refracture or growth disturbance.

Question 11792

Topic: 2. Trauma

A 40-year-old male sustains a fall directly onto his knee, resulting in a significantly displaced, transverse patella fracture with 1 cm of diastasis. He cannot extend his knee against gravity. Which of the following is the most appropriate surgical technique to address this injury?

. Partial patellectomy.
. Total patellectomy.
. Tension band wiring with cerclage.
. Screw fixation without wiring.
. Non-operative management with a cast.

Correct Answer & Explanation

. Tension band wiring with cerclage.

Explanation

For displaced patella fractures that compromise the extensor mechanism (inability to extend the knee), surgical fixation is required. The goal is to restore articular congruity and the extensor mechanism. Tension band wiring, often augmented with cerclage wiring for comminution, is the most common and effective technique for reconstructible patella fractures. It converts the distracting forces of the quadriceps and patellar tendons into compressive forces at the fracture site during knee flexion, promoting healing. Partial patellectomy or total patellectomy are salvage procedures for extensively comminuted or irredeemable fragments. Screw fixation alone may not withstand the strong tensile forces. Non-operative management is only for non-displaced fractures with an intact extensor mechanism.

Question 11793

Topic: 2. Trauma

A 50-year-old male suffers a high-energy Schatzker Type VI tibial plateau fracture with significant soft tissue swelling and blistering. What is the primary indication for initial temporary spanning external fixation rather than immediate definitive internal fixation?

. To allow for early rehabilitation and range of motion.
. To facilitate definitive hardware removal at a later date.
. To improve patient comfort and reduce pain.
. To allow the compromised soft tissue envelope to recover and swell to subside.
. To prevent compartment syndrome.

Correct Answer & Explanation

. To allow the compromised soft tissue envelope to recover and swell to subside.

Explanation

High-energy tibial plateau fractures (like Schatzker Type VI) are frequently associated with severe soft tissue injury, swelling, and blistering. Attempting immediate definitive internal fixation (ORIF) in such a compromised soft tissue environment carries an unacceptably high risk of wound dehiscence, infection, and skin necrosis. Therefore, the primary indication for initial temporary spanning external fixation (damage control orthopedics) is to provide stability while allowing the soft tissues to recover and for swelling to subside. Definitive ORIF is then performed in a delayed fashion (typically 7-14 days) once the soft tissue 'wrinkle sign' is present and the skin is healthy enough for surgery. While it can improve comfort, that's not the primary reason for delaying definitive fixation.

Question 11794

Topic: 2. Trauma
A 30-year-old male sustains an open Gustilo Type IIIB tibial shaft fracture with a large soft tissue defect requiring a free flap for coverage. In addition to prompt debridement and stabilization, what is a crucial component of his long-term rehabilitation plan?
. Early full weight-bearing on the affected limb.
. Strict immobilization of the ankle and knee for 3 months.
. Serial radiographs every week until union.
. Aggressive range of motion exercises for the knee and ankle.
. Antibiotic prophylaxis for 6 months.

Correct Answer & Explanation

. Aggressive range of motion exercises for the knee and ankle.

Explanation

Open tibial shaft fractures, especially Gustilo Type IIIB, are complex injuries involving bone, muscle, and skin. While bone healing and flap integration are paramount, aggressive and early range of motion exercises for adjacent joints (knee and ankle) are crucial to prevent stiffness and optimize functional outcome. Prolonged immobilization can lead to severe joint contractures, which are difficult to treat. Weight-bearing is typically initiated gradually after appropriate bone and soft tissue healing. Serial radiographs are important, but not a 'crucial component' of rehabilitation. Antibiotic prophylaxis duration is much shorter than 6 months. Preventing joint stiffness and restoring motion is key for functional recovery.

Question 11795

Topic: 2. Trauma

A 40-year-old male develops acute compartment syndrome in his lower leg after a high-energy trauma. Which muscle compartment is most commonly affected in the lower leg and necessitates fasciotomy?

. Superficial posterior compartment.
. Deep posterior compartment.
. Lateral compartment.
. Anterior compartment.
. Peroneal compartment.

Correct Answer & Explanation

. Anterior compartment.

Explanation

The anterior compartment of the lower leg is the most commonly affected compartment in acute compartment syndrome. This is due to several factors: it is a relatively tight osteofascial compartment, it contains the tibialis anterior, extensor hallucis longus, and extensor digitorum longus muscles (which swell significantly with trauma), and it houses the deep peroneal nerve and anterior tibial artery. While all four compartments (anterior, lateral, superficial posterior, deep posterior) can be affected, the anterior compartment is most frequently involved, followed by the deep posterior compartment. Therefore, a release of at least the anterior and lateral compartments, and often also the superficial and deep posterior compartments, is performed during a fasciotomy.

Question 11796

Topic: Pelvic & Acetabular Trauma
A 25-year-old male sustains a pelvic ring injury after being crushed between two vehicles. Radiographs show widening of the pubic symphysis (>2.5 cm) and disruption of the anterior sacroiliac ligaments with partial tearing of the posterior sacroiliac ligaments. His posterior structures remain intact. This injury pattern is classified as which Young-Burgess type?
. Lateral Compression Type I (LC-I).
. Lateral Compression Type II (LC-II).
. Anteroposterior Compression Type I (APC-I).
. Anteroposterior Compression Type II (APC-II).
. Vertical Shear (VS).

Correct Answer & Explanation

. Anteroposterior Compression Type II (APC-II).

Explanation

The Young-Burgess classification categorizes pelvic ring injuries by mechanism and pattern of instability. An Anteroposterior Compression (APC) mechanism results from forces applied from anterior to posterior. APC-II injuries are characterized by widening of the pubic symphysis (>2.5 cm) and disruption of the anterior sacroiliac ligaments, but with intact posterior sacroiliac ligaments, making them rotationally unstable but vertically stable. APC-I has only symphysis widening or pubic rami fractures without significant posterior disruption. APC-III involves complete disruption of both anterior and posterior sacroiliac ligaments, leading to both rotational and vertical instability. Lateral compression injuries involve forces from the side, and vertical shear involves superior/inferior forces.

Question 11797

Topic: 2. Trauma

A 68-year-old male falls down stairs and sustains a subtrochanteric femur fracture. He has significant comminution and extension into the greater trochanter. What is the preferred surgical treatment for this fracture pattern?

. Dynamic hip screw (DHS) with an antirotation screw.
. Open reduction internal fixation (ORIF) with a locking plate.
. Long cephalomedullary nail.
. Hemiarthroplasty.
. Short intramedullary nail.

Correct Answer & Explanation

. Long cephalomedullary nail.

Explanation

Subtrochanteric femur fractures are highly unstable and subject to significant deforming forces (pull of gluteus medius, iliopsoas, adductors). A long cephalomedullary nail is the implant of choice for most subtrochanteric fractures, particularly those with comminution or extension into the greater trochanter. It provides superior biomechanical stability compared to plates, controls rotation, and allows for earlier weight-bearing. Short intramedullary nails are generally only suitable for intertrochanteric fractures that do not extend into the subtrochanteric region. DHS is primarily for intertrochanteric fractures. Plating is an option but has a higher failure rate and longer healing for subtrochanteric fractures. Hemiarthroplasty is not indicated for subtrochanteric fractures unless there's severe pre-existing arthritis or non-reconstructible femoral head. The length of the nail is crucial to bypass the comminution adequately.

Question 11798

Topic: 2. Trauma
A 25-year-old male falls from a height and sustains a displaced fracture of the talar neck. What is the most critical complication to counsel the patient about regarding this injury?
. Nonunion.
. Malunion.
. Infection.
. Avascular necrosis (AVN) of the talar body.
. Post-traumatic subtalar arthritis.

Correct Answer & Explanation

. Avascular necrosis (AVN) of the talar body.

Explanation

Talus fractures, especially displaced talar neck fractures (Hawkins Type II, III, IV), carry a very high risk of avascular necrosis (AVN) of the talar body. The talus has a precarious blood supply, with arterial branches entering through the talar neck and sinus tarsi. Displaced fractures significantly disrupt this blood supply. The more displaced the fracture, the higher the risk of AVN. While nonunion, malunion, and post-traumatic subtalar arthritis are also common and significant complications, AVN is often the most feared due to its potential for talar collapse and devastating long-term consequences. Infection is a risk for open fractures but not inherent to the blood supply issue.

Question 11799

Topic: 2. Trauma
A 22-year-old male is involved in a high-speed motorcycle accident, sustaining an open book pelvic fracture (APC III) with complete disruption of the pubic symphysis and both sacroiliac joints. He is hemodynamically unstable despite initial resuscitation and external pelvic binding. What is the most appropriate next step for urgent management of the posterior pelvic ring instability?
. Immediate CT scan of the pelvis with contrast.
. Percutaneous iliosacral screw fixation.
. Skeletal traction through the distal femur.
. Open reduction and internal fixation of the pubic symphysis.
. Angiography and embolization of identified arterial bleeding.

Correct Answer & Explanation

. Percutaneous iliosacral screw fixation.

Explanation

In a patient with an APC III pelvic fracture, who is hemodynamically unstable despite initial resuscitation and pelvic binding, the primary bleeding is often venous from the sacral plexus, or arterial from sacral branches. While angiography for arterial bleeding is critical if instability persists, achieving mechanical stability of the posterior pelvic ring is paramount to tamponade venous bleeding and prevent ongoing hemorrhage. Percutaneous iliosacral screw fixation provides definitive stabilization of the posterior pelvic ring, significantly reducing pelvic volume and allowing for a more stable environment for clotting. This often precedes or is performed in conjunction with angiography if arterial bleed is suspected. A CT scan is useful but should not delay life-saving hemorrhage control. Skeletal traction is generally not used for pelvic fractures. ORIF of the symphysis only addresses the anterior ring, not the posterior instability.

Question 11800

Topic: 2. Trauma

A 70-year-old female with severe osteoporosis sustains a displaced fracture of the greater trochanter after a fall. She is able to bear weight with pain, and the fracture is isolated with minimal comminution. What is the most appropriate management approach?

. Open reduction internal fixation (ORIF) with a plate.
. Intramedullary nailing (IMN).
. Non-operative management with protected weight-bearing.
. Hemiarthroplasty.
. Total hip arthroplasty (THA).

Correct Answer & Explanation

. Non-operative management with protected weight-bearing.

Explanation

Isolated, displaced fractures of the greater trochanter are typically avulsion fractures due to the pull of the gluteus medius and minimus. If the patient is able to bear weight and the fracture is isolated without extension into the intertrochanteric region, and the fragment is not significantly retracted causing abductor insufficiency, non-operative management with protected weight-bearing (e.g., crutches or walker) and progressive rehabilitation is often successful. Surgical fixation is usually reserved for very large, displaced fragments (typically >2 cm displacement) leading to significant abductor weakness. Intramedullary nailing or arthroplasty would be overtreatment for an isolated greater trochanteric fracture.

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