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2. Trauma MCQs

Practice Set 592 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 11821

Topic: 2. Trauma

A 22-year-old male sustains a spiral fracture of the mid-shaft tibia and an intact fibula after a twisting injury. The fracture is minimally displaced and stable. What is the MOST appropriate initial management?

. Open reduction and internal fixation with a plate
. Intramedullary nailing
. Long leg cast and non-weight bearing
. External fixation
. Short leg cast and early weight-bearing

Correct Answer & Explanation

. Intramedullary nailing

Explanation

For most adult diaphyseal tibia fractures, intramedullary nailing (IMN) is the gold standard due to its excellent biomechanical stability, high union rates, and early return to function. While a long leg cast might be considered for minimally displaced, stable fractures, IMN provides superior outcomes for adult tibia shaft fractures, even spiral patterns, especially when the fibula is intact, which can cause issues with shortening if not stabilized internally. Plating is an option but generally reserved for more complex, segmental, or very distal fractures, or when IMN is not feasible. External fixation is mainly for open fractures or temporary stabilization. A short leg cast is inadequate for a tibia shaft fracture.

Question 11822

Topic: 2. Trauma

A 55-year-old female presents with a Schatzker Type IV tibial plateau fracture. What is the most common associated neurovascular injury to be aware of with this fracture pattern?

. Peroneal nerve palsy
. Popliteal artery injury
. Femoral nerve injury
. Posterior tibial artery injury
. Saphenous nerve injury

Correct Answer & Explanation

. Peroneal nerve palsy

Explanation

Schatzker Type IV tibial plateau fractures involve the medial plateau with extension to the intercondylar eminence, often resulting from high-energy valgus and axial forces. While popliteal artery injury can occur with any high-energy knee trauma, peroneal nerve palsy is classically associated with lateral knee trauma or significant displacement, especially involving the fibular head or proximal fibula which can be compromised in these injuries due to its close proximity to the nerve. Medial plateau fractures can lead to increased stress on the lateral compartment and potentially the peroneal nerve. Popliteal artery injury is more common with knee dislocations or severe posterior displacement. Femoral and saphenous nerve injuries are less common with tibial plateau fractures.

Question 11823

Topic: 2. Trauma

Which of the following is a recognized complication of posterior screw placement during acetabular fracture fixation, particularly affecting the quadrilateral surface?

. Sciatic nerve injury
. Vascular injury to the superior gluteal artery
. Intra-articular screw penetration
. Injury to the obturator nerve
. Heterotopic ossification

Correct Answer & Explanation

. Intra-articular screw penetration

Explanation

Intra-articular screw penetration is a critical and well-recognized complication of acetabular fracture fixation, particularly with screws placed into the quadrilateral surface or medial wall. This can lead to rapid articular cartilage damage and post-traumatic arthritis. Sciatic nerve injury is a risk with posterior column or posterior wall fixation but typically due to retractors or direct trauma, not specifically screw placement into the quadrilateral surface. Vascular injury to the superior gluteal artery is a risk with iliosacral screw placement. Injury to the obturator nerve is a risk with anterior approaches. Heterotopic ossification is a general complication of pelvic trauma and surgery, not specific to screw placement into the quadrilateral surface.

Question 11824

Topic: 2. Trauma

A 72-year-old male with a history of osteoporosis sustains a displaced intertrochanteric hip fracture (AO/OTA 31-A2). What is the preferred surgical treatment?

. Total hip arthroplasty (THA)
. Hemiarthroplasty
. Cannulated screws
. Intramedullary nail (IMN)
. Dynamic hip screw (DHS)

Correct Answer & Explanation

. Intramedullary nail (IMN)

Explanation

For displaced intertrochanteric fractures, particularly unstable patterns like AO/OTA 31-A2, intramedullary nailing (IMN) is generally preferred over a dynamic hip screw (DHS). IMNs provide better biomechanical stability, particularly in osteoporotic bone, shorter lever arm, and lower rates of cut-out compared to DHS for unstable patterns. THA and hemiarthroplasty are typically reserved for femoral neck fractures or failed fixation. Cannulated screws are inadequate for these fractures.

Question 11825

Topic: 2. Trauma

A 40-year-old male presents with a stable, isolated fracture of the medial malleolus with less than 2mm displacement and no syndesmotic injury. What is the most appropriate management?

. Open reduction and internal fixation (ORIF) with screws
. Immobilization in a short leg walking cast for 4-6 weeks
. Immobilization in a non-weight-bearing boot for 2 weeks, then progressively weight-bearing
. Arthroscopic evaluation and debridement
. Immediate protected weight-bearing in a brace

Correct Answer & Explanation

. Immobilization in a short leg walking cast for 4-6 weeks

Explanation

Stable, minimally displaced (less than 2mm) isolated medial malleolus fractures can often be managed non-operatively with immobilization in a short leg walking cast or boot for 4-6 weeks. ORIF is indicated for displacement >2mm, rotational instability, or entrapment of soft tissue. Progressive weight-bearing after only 2 weeks in a non-weight-bearing boot may be too early for a bony injury requiring consolidation. Arthroscopy is not indicated for isolated, stable malleolar fractures. Immediate protected weight-bearing is too aggressive for an acute fracture requiring initial healing.

Question 11826

Topic: 2. Trauma

A 25-year-old rugby player sustains a calcaneal fracture with significant articular depression and widening (Essex-Lopresti Type II, joint depression type). Which approach is typically preferred for open reduction and internal fixation (ORIF) of such fractures?

. Anterior approach
. Medial approach
. Lateral extensile approach
. Posterior approach
. Non-operative management

Correct Answer & Explanation

. Lateral extensile approach

Explanation

The lateral extensile approach is the gold standard for open reduction and internal fixation of displaced intra-articular calcaneal fractures (Essex-Lopresti Type II). This approach provides excellent visualization of the posterior facet, sustentaculum tali, and the lateral wall, allowing for direct reduction and stable fixation. Other approaches are used for specific, less common fracture patterns or percutaneous techniques. Non-operative management is typically reserved for non-displaced extra-articular fractures.

Question 11827

Topic: 2. Trauma

A 60-year-old obese patient sustains a transverse patella fracture with 5mm displacement. What is the most appropriate surgical treatment?

. Partial patellectomy
. Total patellectomy
. Tension band wiring
. Screws and neutralization plate
. Non-operative cast immobilization

Correct Answer & Explanation

. Tension band wiring

Explanation

Displaced transverse patella fractures require surgical fixation to restore the extensor mechanism. Tension band wiring is the gold standard technique for these fractures, converting tensile forces into compression at the fracture site, promoting healing. Partial patellectomy is considered for highly comminuted distal pole fractures or when a small, non-reconstructible fragment is present, but should be avoided if possible. Total patellectomy is a salvage procedure. Screws and neutralization plates are less common for simple transverse fractures. Non-operative management is reserved for non-displaced or minimally displaced (typically <2-3mm) fractures with an intact extensor mechanism.

Question 11828

Topic: 2. Trauma

Which of the following is considered an absolute indication for surgical management of a pediatric femoral shaft fracture?

. Ages 6-12 years with >2 cm shortening
. Ages 2-5 years with an angulation of 20 degrees
. Open fracture
. Stable transverse fracture in a 4-year-old
. Femoral shaft fracture in an adolescent with a planned cast for 6 weeks

Correct Answer & Explanation

. Open fracture

Explanation

An open fracture in any age group is an absolute indication for surgical management due to the high risk of infection and the need for debridement and stabilization. While age and displacement/angulation guide treatment choices for closed fractures, an open fracture always requires surgical intervention. For example, a stable transverse fracture in a 4-year-old would typically be managed with a spica cast. Shortening and angulation thresholds vary by age but are relative indications, whereas an open fracture is absolute.

Question 11829

Topic: 2. Trauma

What is the most common serious early complication following a high-energy tibial plateau fracture?

. Deep vein thrombosis (DVT)
. Nonunion
. Post-traumatic arthritis
. Compartment syndrome
. Infection

Correct Answer & Explanation

. Compartment syndrome

Explanation

Compartment syndrome is a critical early complication following high-energy tibial plateau fractures, especially Schatzker Type IV-VI, due to significant soft tissue swelling and potential vascular compromise. Early recognition and fasciotomy are limb-saving. DVT is also an early concern but typically managed prophylactically. Nonunion and post-traumatic arthritis are late complications. Infection is a risk, particularly with open fractures or extensive surgical dissection, but compartment syndrome often presents more acutely and requires immediate attention to preserve limb viability.

Question 11830

Topic: 2. Trauma

A 65-year-old female presents with a displaced distal femur fracture (AO/OTA 33-A3). What is the preferred surgical treatment option?

. Dynamic condylar screw (DCS)
. Intramedullary nail (IMN)
. Periarticular locking plate
. External fixator as definitive treatment
. Non-operative management

Correct Answer & Explanation

. Periarticular locking plate

Explanation

For displaced distal femur fractures, especially those involving the metaphysis (A-type) or articular surface (C-type), periarticular locking plates are generally considered the gold standard. They provide stable fixation in osteoporotic bone, allow for reduction of articular fragments (if present in other types), and permit early range of motion. IMN is typically reserved for diaphyseal or subtrochanteric fractures, though retrograde IMNs can be used for supracondylar fractures if intra-articular extension is minimal or absent and for stable patterns. DCS is an older technique, largely replaced by locking plates. External fixators are typically temporary. Non-operative management is reserved for non-displaced or medically unfit patients.

Question 11831

Topic: 2. Trauma

A 20-year-old male sustains a high-energy subtrochanteric femur fracture (AO/OTA 32-C1). What is the preferred definitive fixation method?

. Dynamic hip screw (DHS)
. Long cephalomedullary nail
. Reconstruction plate
. Cannulated screws
. Short intramedullary nail

Correct Answer & Explanation

. Long cephalomedullary nail

Explanation

For subtrochanteric femur fractures, particularly high-energy and comminuted patterns (32-C1), a long cephalomedullary nail is the implant of choice. It provides superior biomechanical stability compared to plates and short nails, controls both proximal and distal fragments effectively, and has lower rates of fixation failure and nonunion. A DHS is generally used for intertrochanteric fractures and is biomechanically inferior for subtrochanteric patterns. Reconstruction plates are an alternative but have higher rates of failure and refracture compared to nails. Cannulated screws are not appropriate for these fractures. A short intramedullary nail may not adequately stabilize the distal fragment in a subtrochanteric fracture.

Question 11832

Topic: 2. Trauma

Which of the following is the most sensitive imaging modality for evaluating occult or non-displaced scaphoid fractures in the foot (navicular)?

. Plain radiographs (standard views)
. CT scan
. MRI
. Bone scan
. Ultrasound

Correct Answer & Explanation

. MRI

Explanation

For evaluating occult or non-displaced navicular fractures (scaphoid bone of the foot), MRI is the most sensitive imaging modality. It can detect bone edema and subtle fracture lines not visible on plain radiographs or even CT scans. While bone scans are sensitive, they are less specific than MRI. CT scans are excellent for evaluating bony architecture and complex fractures, but MRI's ability to detect bone marrow edema makes it superior for occult fractures. Ultrasound is not typically used for bony fractures.

Question 11833

Topic: 2. Trauma

A 50-year-old male undergoes open reduction and internal fixation of a pilon fracture (AO/OTA 43-C3). Which of the following is the most critical factor influencing the long-term outcome?

. Type of implant used
. Age of the patient
. Anatomic reduction of the articular surface
. Duration of non-weight-bearing
. Early physiotherapy commencement

Correct Answer & Explanation

. Anatomic reduction of the articular surface

Explanation

For pilon fractures, particularly highly comminuted articular fractures (AO/OTA 43-C3), anatomic reduction of the articular surface and stable fixation are paramount for good long-term outcomes. Restoration of joint congruity significantly reduces the risk of post-traumatic arthritis, which is a common and debilitating complication. While age, implant type, weight-bearing duration, and physiotherapy are important, they are secondary to achieving an accurate reduction of the load-bearing joint surface.

Question 11834

Topic: 2. Trauma
In the setting of a high-energy trauma leading to a Gustilo-Anderson Type IIIB open tibial fracture, what is the role of a free flap?
. To provide early weight-bearing capability
. To prevent compartment syndrome
. To achieve stable soft tissue coverage over exposed bone or hardware
. To allow for immediate definitive internal fixation
. To reduce the risk of deep vein thrombosis

Correct Answer & Explanation

. To achieve stable soft tissue coverage over exposed bone or hardware

Explanation

For Gustilo-Anderson Type IIIB open tibial fractures, there is significant soft tissue loss requiring advanced coverage. A free flap (microvascular transfer of tissue) is often necessary to achieve stable, vascularized soft tissue coverage over exposed bone, joints, or hardware. This is critical for preventing infection, promoting bone healing, and ultimately limb salvage. It does not directly provide early weight-bearing, prevent compartment syndrome, allow immediate definitive fixation, or reduce DVT risk, though these are all aspects of overall management.

Question 11835

Topic: 2. Trauma

A 38-year-old male sustains a femoral shaft fracture (AO/OTA 32-B2). He is hemodynamically stable. What is the generally accepted timing for definitive surgical fixation of isolated femoral shaft fractures in otherwise healthy patients?

. Within 6 hours (Emergent)
. Within 24 hours (Urgent)
. Within 3-7 days (Early definitive)
. After 7 days (Delayed)
. Non-operative management

Correct Answer & Explanation

. Within 3-7 days (Early definitive)

Explanation

For isolated femoral shaft fractures in hemodynamically stable patients, early definitive fixation, typically within 24-72 hours or 3-7 days, is generally recommended. This approach is associated with reduced rates of pulmonary complications, shorter hospital stays, and earlier rehabilitation. While immediate fixation is ideal in some trauma settings, it's not always feasible or necessary if the patient's overall condition requires stabilization. Delayed fixation beyond 7-10 days can increase surgical difficulty and complications.

Question 11836

Topic: 2. Trauma

A 4-year-old child sustains a midshaft femoral fracture. What is the most appropriate management for a stable, closed fracture in this age group?

. Surgical plate fixation
. Flexible intramedullary nailing
. External fixation
. Spica cast
. Skeletal traction

Correct Answer & Explanation

. Spica cast

Explanation

For children aged 6 months to 5-6 years with stable, closed midshaft femoral fractures, a spica cast is the standard and often preferred non-operative treatment. This age group has excellent remodeling potential. Flexible intramedullary nailing or external fixation may be considered for older children (6-12 years) or specific circumstances. Surgical plate fixation is typically for adolescents or complex fractures. Skeletal traction is generally for very young children (under 6 months) or as a temporary measure before casting.

Question 11837

Topic: Pelvic & Acetabular Trauma
Which of the following types of pelvic ring fractures, according to the Young-Burgess classification, is most commonly associated with significant arterial hemorrhage requiring angiography and embolization?
. Lateral Compression (LC) Type I
. Anterior-Posterior Compression (APC) Type I
. Vertical Shear (VS)
. Lateral Compression (LC) Type II
. Anterior-Posterior Compression (APC) Type II

Correct Answer & Explanation

. Vertical Shear (VS)

Explanation

Vertical Shear (VS) injuries and APC Type III injuries are most commonly associated with severe hemorrhage, particularly arterial bleeding. Vertical shear injuries result from high-energy trauma causing vertical displacement of one hemipelvis, often leading to rupture of posterior sacroiliac ligaments, pelvic floor muscles, and tears of posterior vessels (e.g., internal pudendal, superior gluteal arteries). These injuries are inherently unstable and have a high propensity for severe bleeding. APC Type II and III can also have significant bleeding, but VS injuries represent the highest risk for arterial involvement.

Question 11838

Topic: 2. Trauma

What is the most common indication for revision surgery following intramedullary nailing of a femoral shaft fracture?

. Infection
. Malunion
. Hardware failure (broken nail)
. Nonunion
. Fat embolism

Correct Answer & Explanation

. Nonunion

Explanation

Nonunion is the most common indication for revision surgery following intramedullary nailing of a femoral shaft fracture. While malunion can occur, the reaming process and stability provided by IMN typically lead to high union rates. When union fails, nonunion often necessitates revision. Infection and hardware failure are less common but significant complications. Fat embolism is an acute, not a late, complication.

Question 11839

Topic: 2. Trauma

A 58-year-old female sustains a comminuted distal tibia fracture with articular involvement (Pilon fracture). The soft tissue envelope is significantly swollen with fracture blisters. What is the most appropriate initial management strategy?

. Immediate open reduction and internal fixation (ORIF)
. Application of an external fixator and delayed definitive ORIF
. Casting and non-weight bearing for 6 weeks
. Continuous passive motion (CPM) to reduce swelling
. Percutaneous screw fixation

Correct Answer & Explanation

. Application of an external fixator and delayed definitive ORIF

Explanation

For comminuted pilon fractures with significant soft tissue swelling and fracture blisters, the principle of 'staged' or 'damage control' orthopedic management is crucial. Initial management involves applying a temporary external fixator (typically spanning the ankle joint) to restore length, alignment, and stability, which helps to indirectly reduce swelling and improve the soft tissue condition. Definitive ORIF is then delayed until the soft tissue swelling has subsided (typically 7-14 days). Immediate ORIF in a severely swollen limb significantly increases the risk of wound complications and infection. Casting alone is insufficient for unstable, comminuted pilon fractures.

Question 11840

Topic: 2. Trauma

A 22-year-old male presents with a talar neck fracture (Hawkins Type II). What is the primary concern and potential devastating complication associated with this fracture type?

. Post-traumatic arthritis
. Deep vein thrombosis
. Avascular necrosis (AVN) of the talar body
. Nonunion of the fracture
. Peroneal nerve palsy

Correct Answer & Explanation

. Avascular necrosis (AVN) of the talar body

Explanation

Hawkins Type II talar neck fractures involve displacement of the subtalar joint, which disrupts a significant portion of the blood supply to the talar body (especially the artery of the tarsal canal). This places the talar body at a very high risk of avascular necrosis (AVN), a devastating complication that can lead to collapse and severe arthritis. While post-traumatic arthritis and nonunion are also concerns, AVN is the most specific and severe complication related to the vascular compromise of the talar body. DVT and peroneal nerve palsy are not primary concerns directly related to talar neck fracture vascularity.

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