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2. Trauma MCQs

Practice Set 593 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 11841

Topic: 2. Trauma

When performing open reduction and internal fixation of a posterior malleolus fracture, what anatomical structure is at greatest risk during a posterolateral approach?

. Superficial peroneal nerve
. Saphenous nerve
. Sural nerve
. Deep peroneal nerve
. Posterior tibial artery

Correct Answer & Explanation

. Sural nerve

Explanation

During a posterolateral approach to the ankle for posterior malleolus fractures, the sural nerve is consistently at risk. It lies superficially and courses along the posterolateral aspect of the ankle. Careful dissection and retraction are required to protect it. The superficial peroneal nerve is more anterior-lateral. The saphenous nerve is medial. The deep peroneal nerve and posterior tibial artery are deep structures that are more at risk with anterior-medial or direct posterior approaches, respectively.

Question 11842

Topic: 2. Trauma

A 28-year-old male presents with a 'dashboard injury' resulting in a posterior hip dislocation. Which of the following is the most important immediate radiographic assessment after reduction?

. CT scan of the hip and pelvis
. AP and lateral radiographs of the hip
. MRI of the hip
. Pelvic outlet view
. Judet views of the pelvis

Correct Answer & Explanation

. CT scan of the hip and pelvis

Explanation

After emergent reduction of a posterior hip dislocation, a CT scan of the hip and pelvis is essential. This is critical to assess for associated acetabular fractures (especially posterior wall or column), incarcerated intra-articular fragments, femoral head impression fractures (e.g., Pipkin fracture), and hip joint congruency. Plain radiographs confirm reduction but are insufficient to rule out critical intra-articular pathology. MRI is better for soft tissue but less urgent than CT for bony fragments. Pelvic outlet and Judet views are useful for initial evaluation but not sufficient post-reduction for complex injuries.

Question 11843

Topic: 2. Trauma

Which complication is uniquely associated with intramedullary nailing of tibial fractures, particularly with reaming?

. Nonunion
. Malunion
. Compartment syndrome
. Fat embolism syndrome
. Infection

Correct Answer & Explanation

. Fat embolism syndrome

Explanation

Fat embolism syndrome (FES) is a distinct complication that can be associated with intramedullary nailing of long bone fractures, particularly during the reaming process. Reaming increases intramedullary pressure, potentially forcing fat globules into the venous circulation, leading to pulmonary and systemic symptoms. While nonunion, malunion, compartment syndrome, and infection can occur with tibial nailing, FES is particularly linked to the reaming process. Proper patient selection and technique, including meticulous reaming and appropriate ventilation, are crucial to mitigate this risk.

Question 11844

Topic: 2. Trauma

What is the main advantage of a retrograde intramedullary nail over a conventional antegrade nail for certain distal femoral fractures?

. Better control of proximal fragment rotation
. Avoidance of a piriformis fossa entry point
. Less risk of damage to the extensor mechanism of the knee
. Improved stability for highly comminuted diaphyseal fractures
. Applicable for concomitant ipsilateral hip fractures

Correct Answer & Explanation

. Avoidance of a piriformis fossa entry point

Explanation

The main advantage of a retrograde intramedullary nail for distal femoral fractures is that it avoids the piriformis fossa or greater trochanter entry point, thus eliminating potential complications associated with antegrade nailing such as abductor weakness, gluteal pain, or damage to the piriformis fossa. It does, however, involve an entry point through the knee (e.g., intercondylar notch), which can sometimes lead to patellofemoral pain or irritation. It doesn't necessarily offer better control of proximal rotation or improved stability for diaphyseal fractures over an antegrade nail, and it cannot be used for ipsilateral hip fractures. It reduces the risk of hip complications, but introduces potential knee complications.

Question 11845

Topic: 2. Trauma

What is the optimal window for performing a definitive open reduction and internal fixation (ORIF) of a displaced acetabular fracture with stable soft tissues?

. Within 6 hours of injury
. Within 24 hours of injury
. Between 3-7 days after injury, after initial swelling subsides
. Between 7-14 days after injury, allowing for soft tissue recovery
. After 3 weeks to allow for fracture callus formation

Correct Answer & Explanation

. Between 7-14 days after injury, allowing for soft tissue recovery

Explanation

For displaced acetabular fractures, especially complex ones, definitive ORIF is typically performed between 7-14 days after injury. This allows for initial resuscitation, stabilization of the patient, and, most importantly, for soft tissue swelling to subside and fracture blisters to dry. Operating on an acute, severely swollen soft tissue envelope significantly increases the risk of wound complications and infection. Earlier surgery (<7 days) may be considered for irreducible dislocations or femoral head impaction. Delaying beyond 3 weeks can lead to fracture consolidation and make reduction significantly more difficult.

Question 11846

Topic: 2. Trauma

A 68-year-old male sustains a comminuted ipsilateral femoral neck and shaft fracture. Which fixation strategy is generally preferred?

. Cannulated screws for the neck and a plate for the shaft
. Separate reconstruction plate for the neck and a conventional IMN for the shaft
. Hemiarthroplasty for the neck and a plate for the shaft
. Long cephalomedullary nail
. External fixator spanning both fractures

Correct Answer & Explanation

. Long cephalomedullary nail

Explanation

For ipsilateral femoral neck and shaft fractures, a long cephalomedullary nail is generally the preferred method. This single implant can address both fractures, providing stability to the neck (via proximal locking screws) and the shaft (via the nail and distal locking screws). It simplifies the surgical approach and minimizes soft tissue dissection. Separate implants (plates, cannulated screws) for each fracture are technically more demanding and carry higher complication rates. Hemiarthroplasty might be considered for a highly comminuted neck in an elderly, low-demand patient but is not the primary treatment for the combination. External fixators are typically temporary.

Question 11847

Topic: 2. Trauma

In the management of a high-energy pelvic fracture, what is the 'pelvic volume reduction' aimed at achieving?

. Decreasing intra-abdominal pressure
. Reducing the risk of neurologic injury
. Controlling hemorrhage by tamponading venous bleeding
. Facilitating immediate surgical access
. Preventing fat embolism

Correct Answer & Explanation

. Controlling hemorrhage by tamponading venous bleeding

Explanation

Pelvic volume reduction, achieved with a pelvic binder or external fixator, is a critical initial step in managing hemodynamically unstable pelvic fractures. Its primary aim is to tamponade ongoing venous hemorrhage from torn presacral veins and venous plexuses by closing the disrupted pelvic ring and reducing the pelvic volume. This mechanical stabilization helps to reduce blood loss and improve hemodynamic stability. While it doesn't directly decrease intra-abdominal pressure, prevent neurologic injury (though stability helps), or prevent fat embolism, it's vital for hemorrhage control.

Question 11848

Topic: 2. Trauma

A 75-year-old female presents with a non-displaced osteoporotic patella fracture. She has a intact extensor mechanism and can perform a straight leg raise. What is the most appropriate management?

. Total patellectomy
. Tension band wiring
. Immobilization in a knee immobilizer or hinged knee brace, allowing early range of motion
. Partial patellectomy
. Open reduction and plate fixation

Correct Answer & Explanation

. Immobilization in a knee immobilizer or hinged knee brace, allowing early range of motion

Explanation

For non-displaced patella fractures with an intact extensor mechanism (i.e., the patient can perform a straight leg raise against gravity), non-operative management is appropriate. This typically involves immobilization in a knee immobilizer or hinged knee brace, allowing for early, protected range of motion (usually flexion to 30-60 degrees initially) to prevent stiffness, while restricting weight-bearing and aggressive knee flexion until healing. Surgical options (patellectomy, tension band wiring, plate fixation) are reserved for displaced fractures or those with extensor mechanism disruption.

Question 11849

Topic: 2. Trauma

What is the most common cause of nonunion in a surgically treated tibial shaft fracture?

. Inadequate antibiotics
. Improper patient nutrition
. Biological factors (avascularity, poor bone quality)
. Inadequate stability at the fracture site
. Early weight-bearing

Correct Answer & Explanation

. Inadequate stability at the fracture site

Explanation

Inadequate stability at the fracture site (either from initial fixation or subsequent hardware loosening/failure) is the most common mechanical cause of nonunion in surgically treated tibial shaft fractures. While biological factors (like poor vascularity, significant comminution, infection, or poor bone quality) and patient factors (e.g., smoking, malnutrition, comorbidities) also contribute, insufficient mechanical stability often prevents the formation of a rigid callus necessary for union. Inadequate antibiotics primarily leads to infection, not necessarily nonunion directly.

Question 11850

Topic: 2. Trauma

A 20-year-old male sustains a high-energy segmental tibia fracture. He also has bilateral forearm fractures. What is the preferred method for temporary stabilization of the tibia fracture in this polytrauma patient?

. Long leg splint
. Immediate intramedullary nailing (IMN)
. External fixator
. Plating with locking screws
. Skeletal traction

Correct Answer & Explanation

. External fixator

Explanation

In polytrauma patients, particularly with segmental or open tibial fractures, an external fixator is the preferred method for temporary stabilization. It allows for rapid application, control of bleeding, stabilization of the limb for patient transport and resuscitation, and facilitates wound care (if open) without adding significant physiological stress. Once the patient is stabilized, definitive fixation (e.g., IMN) can be performed. Immediate IMN or plating might be too physiologically demanding or technically challenging in the acute setting. Long leg splints provide insufficient stability for high-energy segmental fractures. Skeletal traction is less stable and harder to manage than an external fixator for initial stabilization.

Question 11851

Topic: 2. Trauma

A 35-year-old male with a history of smoking presents with a femoral shaft nonunion 9 months after intramedullary nailing. The nail is intact and centrally placed. What is the most appropriate next step in management?

. Nail exchange with reaming and bone grafting
. Plate augmentation alongside the existing nail
. Removal of the nail and casting
. Continuous passive motion (CPM)
. Electrical stimulation alone

Correct Answer & Explanation

. Nail exchange with reaming and bone grafting

Explanation

For aseptic femoral shaft nonunion after intramedullary nailing with an intact nail, nail exchange with reaming and bone grafting (autogenous or allograft) is the gold standard. Reaming provides a biological stimulus by creating bone dust and releasing growth factors. The larger-diameter nail provides increased mechanical stability, and bone grafting addresses biological deficiencies. Plate augmentation alongside the nail is a less common option. Removal of the nail and casting is inappropriate for nonunion. CPM and electrical stimulation alone are insufficient for established nonunion.

Question 11852

Topic: 2. Trauma

Which type of stress fracture in the lower limb has the highest risk of progression to complete fracture and nonunion, often requiring surgical intervention?

. Tibial shaft (posteromedial)
. Fibula shaft
. Femoral shaft
. Femoral neck (tension side)
. Metatarsal

Correct Answer & Explanation

. Femoral neck (tension side)

Explanation

Stress fractures on the tension side of the femoral neck (superior aspect) are notoriously problematic. Unlike compression-side stress fractures (inferior aspect), they have a high risk of progression to a complete displaced fracture and avascular necrosis or nonunion. These often require surgical fixation (e.g., cannulated screws) to prevent catastrophic failure. Other stress fractures listed are generally managed non-operatively unless symptoms persist or risk factors are high, but the femoral neck tension-side fracture carries the highest inherent risk of severe complications.

Question 11853

Topic: 2. Trauma

A 29-year-old male sustains a fracture of the talar body with impaction of the posterior facet. What is the preferred imaging modality to assess for articular incongruity and guide surgical planning?

. Plain radiographs (ankle and foot)
. CT scan with 3D reconstructions
. MRI of the ankle
. Bone scan
. Ultrasound

Correct Answer & Explanation

. CT scan with 3D reconstructions

Explanation

For complex talar body fractures, especially those with articular involvement and impaction, a CT scan with 3D reconstructions is the gold standard imaging modality. It provides detailed visualization of the fracture pattern, articular displacement, comminution, and any intra-articular fragments, which is crucial for precise surgical planning and reduction. Plain radiographs are initial screening tools but lack detail. MRI is excellent for soft tissue and avascular necrosis but less superior to CT for bony anatomy. Bone scans are not for acute fracture detail.

Question 11854

Topic: 2. Trauma
Which type of distal tibia fracture (Pilon fracture) is most amenable to minimally invasive plate osteosynthesis (MIPO) techniques?
. AO/OTA 43-C3 (highly comminuted intra-articular)
. AO/OTA 43-C1 (simple articular, simple metaphyseal)
. Gustilo-Anderson Type IIIB open fracture
. Fracture with significant soft tissue compromise and fracture blisters
. Fracture with a large posterior fragment requiring direct visualization

Correct Answer & Explanation

. AO/OTA 43-C1 (simple articular, simple metaphyseal)

Explanation

Minimally invasive plate osteosynthesis (MIPO) techniques are best suited for simpler articular pilon fractures, such as AO/OTA 43-C1 (simple articular, simple metaphyseal), where the articular fragments can be reduced percutaneously or indirectly, and the soft tissue envelope is favorable. MIPO helps preserve the soft tissue, which is critical in pilon fractures. Highly comminuted C3 fractures, open fractures, or those with significant soft tissue compromise often require more extensive open approaches or staged management. Fractures with large posterior fragments may require a direct posterolateral approach.

Question 11855

Topic: 2. Trauma

A 13-year-old male with an asymptomatic 3 cm NOF in the proximal humerus is being observed. His parents are concerned about future problems. What is the most reassuring information you can provide regarding its long-term prognosis?

. He will likely need amputation in adulthood.
. It will definitely require surgery at some point.
. The lesion will likely spontaneously regress and resolve completely.
. It will recur aggressively after childhood.
. It significantly increases his risk of developing other bone cancers.

Correct Answer & Explanation

. The lesion will likely spontaneously regress and resolve completely.

Explanation

The most reassuring information is that NOFs typically regress spontaneously and resolve completely by skeletal maturity, with minimal or no residual deformity. Surgery is only indicated in a minority of cases (e.g., fracture risk). Amputation, aggressive recurrence, or increased cancer risk are incorrect and misleading statements for a NOF.

Question 11856

Topic: 2. Trauma

A 14-year-old boy presents with sudden onset of severe pain and inability to bear weight after a minor fall. Radiographs show a transverse fracture through a previously asymptomatic, large (6 cm) lytic lesion in the distal femur with significant cortical thinning. What is the most likely initial treatment for the fracture component?

. Immediate open reduction and internal fixation of the fracture, followed by definitive tumor surgery after healing.
. Cast immobilization followed by surgical curettage and bone grafting of the lesion upon union.
. Immediate curettage and bone grafting of the NOF, combined with internal fixation of the fracture.
. Close observation and pain management.
. Biopsy of the lesion, then chemotherapy.

Correct Answer & Explanation

. Immediate curettage and bone grafting of the NOF, combined with internal fixation of the fracture.

Explanation

For a pathological fracture through a large NOF, the most appropriate immediate treatment involves addressing both the fracture and the underlying lesion. This typically means initial reduction and stabilization (often with internal fixation) and simultaneous curettage of the NOF with bone grafting. Delaying tumor surgery until fracture union is generally not ideal as the underlying lesion remains and contributes to delayed healing or nonunion. Conservative management alone is insufficient for a large lesion with a pathological fracture. Chemotherapy is not indicated for a benign NOF.

Question 11857

Topic: 2. Trauma

A 15-year-old boy presents with a 7 cm Non-Ossifying Fibroma in the distal femur. He is asymptomatic, but the lesion involves approximately 70% of the cortical circumference. What is the most appropriate management?

. Conservative management with serial radiographs every 2 years.
. Curettage and bone grafting with prophylactic internal fixation.
. Immediate amputation to prevent fracture.
. Radiation therapy to shrink the lesion.
. Close observation with no activity restrictions.

Correct Answer & Explanation

. Curettage and bone grafting with prophylactic internal fixation.

Explanation

A 7 cm NOF involving 70% of the cortical circumference, even if asymptomatic, presents a very high risk of pathological fracture. Therefore, prophylactic surgical intervention (curettage, bone grafting, and often internal fixation) is indicated to prevent this complication. Conservative management with activity restrictions might be considered temporarily, but surgical stabilization is usually recommended. Amputation and radiation are inappropriate. 'No activity restrictions' is contraindicated for such a high-risk lesion.

Question 11858

Topic: 2. Trauma

What is a potential mechanical complication of a very large Non-Ossifying Fibroma in a weight-bearing bone, even without an overt fracture?

. Rapid destruction of the adjacent joint.
. Vascular compromise leading to ischemia.
. Progressive bowing or angular deformity of the bone.
. Neurovascular entrapment.
. Pathological new bone formation leading to osteosclerosis.

Correct Answer & Explanation

. Progressive bowing or angular deformity of the bone.

Explanation

A very large Non-Ossifying Fibroma can significantly weaken the bone cortex, making it susceptible to plastic deformation or progressive bowing, especially in weight-bearing long bones like the femur or tibia, even without an acute fracture. Joint destruction, vascular compromise, neurovascular entrapment, or pathological osteosclerosis are not typical complications of NOF.

Question 11859

Topic: 2. Trauma

A 55-year-old male with a history of alcohol abuse presents with a displaced calcaneal fracture after falling from a ladder. He has significant hindfoot swelling and ecchymosis. What is the most important initial assessment prior to definitive management?

. Routine blood work including liver function tests.
. Evaluation for associated lumbar spine and other lower extremity injuries.
. Immediate surgical consultation for ORIF.
. Application of a short leg cast.
. MRI to assess for soft tissue damage.

Correct Answer & Explanation

. Evaluation for associated lumbar spine and other lower extremity injuries.

Explanation

Calcaneal fractures, especially those resulting from falls from height, are often associated with other injuries, particularly spine (lumbar compression fractures) and contralateral lower extremity fractures. Therefore, a thorough secondary survey to rule out these associated injuries is paramount. While liver function tests and imaging (CT is usually preferred over MRI for bony detail) are part of a comprehensive workup, and surgical consultation will be necessary, the immediate priority is to ensure there are no other life- or limb-threatening injuries or associated fractures that might be missed.

Question 11860

Topic: 2. Trauma

What is the primary goal of surgical fixation for a displaced Schatzker Type VI tibial plateau fracture?

. Restoration of overall limb alignment.
. Anatomical reduction of the articular surface and stable fixation.
. Early weight bearing to promote callus formation.
. Prevention of avascular necrosis of the tibial condyle.
. Minimizing surgical incision size.

Correct Answer & Explanation

. Anatomical reduction of the articular surface and stable fixation.

Explanation

Schatzker Type VI tibial plateau fractures are complex bicondylar fractures with disassociation of the metaphysis from the diaphysis. The primary goals of surgical management are anatomical reduction of the articular surface to prevent post-traumatic arthritis and stable fixation to allow early range of motion. Restoration of overall limb alignment is also critical, but articulating surfaces take precedence for long-term joint health. Early weight bearing is generally not recommended for complex plateau fractures. Avascular necrosis is less common in the tibial condyle. While minimizing incision size is desirable, it should not compromise adequate visualization and reduction.

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