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2. Trauma MCQs

Practice Set 594 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 11861

Topic: 2. Trauma

A 10-year-old male falls and sustains a femoral shaft fracture. He is hemodynamically stable. Which of the following is the most appropriate treatment?

. Immediate traction in a Bryant's traction.
. Spica cast immobilization.
. Flexible intramedullary nailing.
. Plate and screw fixation.
. External fixation.

Correct Answer & Explanation

. Flexible intramedullary nailing.

Explanation

The optimal treatment for pediatric femoral shaft fractures varies with age, weight, and fracture pattern. For children aged 6-16, flexible intramedullary nailing (FIN) is often preferred for stable fractures due to its minimally invasive nature and allows earlier mobilization. Spica casting is an option for younger children (typically <6 years or <50 lbs) or those with less complex fractures. Plate and screw fixation is reserved for specific indications (e.g., polytrauma, head injury, open fractures, or failed IMN). External fixation is often used for open fractures, polytrauma, or severe soft tissue injuries. Bryant's traction is for very young children (typically <2 years).

Question 11862

Topic: 2. Trauma

A 22-year-old male sustains a traumatic, open patella fracture. After initial debridement, what is the preferred method of internal fixation for a transverse, displaced patella fracture in a young, active patient?

. Cerclage wiring.
. Excision of the patella.
. Tension band wiring.
. Plate and screw fixation.
. Partial patellectomy.

Correct Answer & Explanation

. Tension band wiring.

Explanation

For most displaced transverse patella fractures, tension band wiring is the gold standard technique. It converts the tensile forces during knee flexion into compressive forces across the fracture site, promoting healing and allowing early range of motion. Cerclage wiring alone is usually insufficient. Excision of the patella (total patellectomy) or partial patellectomy are considered salvage procedures for highly comminuted fractures not amenable to fixation, as they lead to significant quadriceps weakness and extensor lag. Plate and screw fixation is generally reserved for highly comminuted fractures or specific fracture patterns not amenable to tension band.

Question 11863

Topic: 2. Trauma
In an elderly patient with a displaced femoral neck fracture, which type of fracture is generally best treated with a hemiarthroplasty rather than internal fixation?
. Impacted valgus fracture.
. Non-displaced fracture.
. Garden I or II fracture.
. Garden III or IV fracture.
. Pauwel's Type I fracture.

Correct Answer & Explanation

. Garden III or IV fracture.

Explanation

Displaced femoral neck fractures (Garden III or IV) in elderly patients, particularly those with pre-existing arthritis or significant medical comorbidities, have a high rate of complications (nonunion, avascular necrosis) when treated with internal fixation. Hemiarthroplasty (or total hip arthroplasty in more active patients) is generally preferred as it provides immediate stability, allows early weight bearing, and has more predictable outcomes. Impacted valgus (Garden I) and non-displaced (Garden II) fractures, and Pauwel's Type I (low angle of obliquity) can often be successfully treated with internal fixation, especially in younger, healthier patients.

Question 11864

Topic: 2. Trauma

Which of the following is considered a relative contraindication to intramedullary nailing of a femoral shaft fracture?

. Open fracture (Gustilo Type I).
. Polytrauma patient.
. Pre-existing osteomyelitis of the femur.
. Segmental fracture.
. Obese patient.

Correct Answer & Explanation

. Pre-existing osteomyelitis of the femur.

Explanation

Pre-existing osteomyelitis of the femur is a relative contraindication to intramedullary nailing, as placing a foreign implant (the nail) directly through an infected bone can exacerbate the infection and lead to chronic osteomyelitis. In such cases, external fixation or staged procedures might be considered. Open fractures (especially Gustilo Type I and II) are often treated successfully with IMN after appropriate debridement. Polytrauma patients often benefit from IMN for early stabilization. Segmental fractures are well-suited for IMN. Obesity can make surgical access challenging but is not a contraindication.

Question 11865

Topic: 2. Trauma

What is the primary concern for a missed or delayed diagnosis of a pediatric femoral neck fracture?

. Nonunion.
. Malunion.
. Avascular necrosis (AVN) of the femoral head.
. Early osteoarthritis.
. Leg length discrepancy.

Correct Answer & Explanation

. Avascular necrosis (AVN) of the femoral head.

Explanation

Pediatric femoral neck fractures have a high complication rate, and avascular necrosis (AVN) of the femoral head is the most devastating. The risk of AVN is directly related to the initial displacement and the time to reduction, making prompt diagnosis and anatomical reduction crucial. Missed or delayed diagnosis significantly increases the risk of AVN, which can lead to premature degenerative arthritis, nonunion, and malunion. While nonunion and malunion can occur, AVN is the most unique and severe complication directly linked to the blood supply disruption.

Question 11866

Topic: 2. Trauma

What is the primary biomechanical advantage of reamed intramedullary nailing over unreamed nailing for tibia fractures?

. Decreased risk of fat embolism.
. Reduced operative time.
. Increased implant-bone contact and construct stiffness.
. Lower incidence of compartment syndrome.
. Ability to use smaller diameter nails.

Correct Answer & Explanation

. Increased implant-bone contact and construct stiffness.

Explanation

Reamed intramedullary nailing involves reaming the medullary canal to a larger diameter, allowing for a larger diameter nail. This results in increased implant-bone contact, providing greater construct stiffness and biomechanical stability, which can improve healing rates. However, reaming generates heat and can increase intramedullary pressure, potentially increasing the risk of fat embolism and, in compromised soft tissue, compartment syndrome. Unreamed nails are often smaller in diameter and may be preferred in cases with tenuous soft tissues or open fractures to minimize further compromise.

Question 11867

Topic: 2. Trauma
Which of the following characteristics of a tibial shaft fracture indicates increased risk for nonunion?
. Transverse fracture pattern.
. Spiral fracture pattern.
. Open fracture, Gustilo Type IIIB.
. Fracture at the junction of the middle and distal thirds.
. Fracture with minimal soft tissue injury.

Correct Answer & Explanation

. Open fracture, Gustilo Type IIIB.

Explanation

Open fractures, particularly Gustilo Type IIIB with extensive soft tissue damage and periosteal stripping, have a significantly higher risk of nonunion due to compromised blood supply to the fracture site and increased risk of infection. Transverse fractures generally heal slower than spiral fractures but are not as high a risk as Type IIIB open fractures. The junction of the middle and distal thirds of the tibia is considered a 'watershed' area with poorer blood supply, increasing risk. Minimal soft tissue injury implies a better prognosis.

Question 11868

Topic: 2. Trauma

What is the appropriate management for an undisplaced, stable avulsion fracture of the base of the fifth metatarsal (Jones fracture zone 1)?

. Open reduction internal fixation.
. Percutaneous screw fixation.
. Non-weight bearing in a short leg walking boot for 4-6 weeks.
. Full weight bearing in a regular shoe.
. Excision of the fragment.

Correct Answer & Explanation

. Non-weight bearing in a short leg walking boot for 4-6 weeks.

Explanation

Avulsion fractures of the base of the fifth metatarsal (often referred to as 'pseudo-Jones' fractures or in Zone 1) are typically caused by inversion injuries and traction from the peroneus brevis tendon. These fractures generally have an excellent blood supply and heal well with conservative management. Non-weight bearing in a short leg walking boot for 4-6 weeks is appropriate. Surgical fixation is rarely needed unless displacement is significant or nonunion occurs. Full weight bearing in a regular shoe is too early and carries a risk of nonunion or displacement. Excision is not a primary treatment.

Question 11869

Topic: 2. Trauma

What is the primary objective of a two-stage approach (external fixation followed by ORIF) for open tibial plateau fractures with significant soft tissue injury?

. To allow for early weight bearing.
. To minimize blood loss during the initial surgery.
. To optimize the soft tissue envelope prior to definitive fixation.
. To reduce the risk of deep vein thrombosis.
. To prevent compartment syndrome.

Correct Answer & Explanation

. To optimize the soft tissue envelope prior to definitive fixation.

Explanation

For complex periarticular fractures like tibial plateau fractures, especially with significant soft tissue injury (open fractures, severe swelling, blistering), a two-stage approach is often employed. The first stage involves temporary stabilization with an external fixator to restore alignment, debride open wounds, and allow the acute soft tissue swelling to resolve. The primary objective is to 'optimize the soft tissue envelope' so that definitive internal fixation can be performed safely at a later date (typically 7-14 days) when the tissues are less inflamed, reducing the risk of wound complications and infection. Early weight-bearing is not the goal, and it doesn't primarily minimize blood loss or reduce DVT risk, nor does it prevent compartment syndrome (which may still require fasciotomy).

Question 11870

Topic: 2. Trauma

Which of the following is a recognized complication of prolonged skeletal traction for a femoral shaft fracture?

. Fat embolism syndrome.
. Nonunion.
. Pressure sores.
. Compartment syndrome.
. Osteomyelitis.

Correct Answer & Explanation

. Pressure sores.

Explanation

Prolonged skeletal traction, historically used for femoral shaft fractures, requires the patient to remain in bed for extended periods. This immobility significantly increases the risk of pressure sores (decubitus ulcers) at points of contact or pressure, as well as pneumonia, DVT, and joint stiffness. While nonunion can occur with any fracture, it's not a specific complication of traction itself. Compartment syndrome is an acute post-injury complication, and osteomyelitis is typically related to open fractures or surgical procedures. Fat embolism can occur with the initial trauma or reaming for IMN but is not a complication of prolonged traction specifically.

Question 11871

Topic: 2. Trauma

A 68-year-old female presents with a displaced femoral neck fracture. Her past medical history includes severe dementia, rendering her non-ambulatory prior to the fall. What is the most appropriate treatment option?

. Open reduction and internal fixation (ORIF) with cannulated screws.
. Hemiarthroplasty.
. Total hip arthroplasty (THA).
. Non-operative management with bed rest and pain control.
. External fixation.

Correct Answer & Explanation

. Non-operative management with bed rest and pain control.

Explanation

For frail, non-ambulatory elderly patients with severe dementia and a displaced femoral neck fracture, surgical intervention may not improve their functional status and carries significant risks of complications (delirium, infection, cardiac events). In such cases, non-operative management focusing on comfort, pain control, and early mobilization out of bed (e.g., to a wheelchair) is often the most humane and appropriate approach. While this results in nonunion, the goal is palliation rather than functional recovery. Hemiarthroplasty or THA would be too extensive given her pre-morbid state. ORIF has high failure rates in this group. External fixation is not used for femoral neck fractures.

Question 11872

Topic: 2. Trauma

Which classification system is used to assess the severity of soft tissue damage in open fractures?

. Danis-Weber.
. AO Classification.
. Salter-Harris.
. Gustilo-Anderson.
. Schatzker.

Correct Answer & Explanation

. Gustilo-Anderson.

Explanation

The Gustilo-Anderson classification system is specifically designed to classify open fractures based on the extent of soft tissue damage, wound size, contamination, and associated comminution. This classification guides management, particularly regarding debridement, antibiotic use, and definitive soft tissue coverage. Danis-Weber classifies ankle fractures. AO classifies all fractures. Salter-Harris classifies physeal injuries. Schatzker classifies tibial plateau fractures.

Question 11873

Topic: 2. Trauma

Which of the following is a strong indication for surgical fixation of a tibia shaft fracture in an adult?

. Undisplaced hairline fracture.
. Closed fracture with <5 degrees angulation and 1 cm shortening.
. Segmental fracture.
. Fibula fracture at the same level as the tibia fracture.
. Patient with well-controlled diabetes.

Correct Answer & Explanation

. Segmental fracture.

Explanation

Segmental tibia fractures involve fracture lines at two or more levels, leading to an unstable segment. These fractures are inherently unstable and have a high risk of nonunion or malunion with non-operative management, making surgical fixation (typically intramedullary nailing) strongly indicated. Undisplaced hairline fractures, closed fractures with minimal displacement and angulation (within acceptable limits), and concomitant fibula fractures (unless part of a complex ankle injury like Maisonneuve) are often amenable to non-operative treatment or are not specific indications for surgery. Diabetes affects healing but is not an indication itself.

Question 11874

Topic: 2. Trauma

In a patient with a suspected femoral shaft fracture, what is the most important initial management step in the emergency department setting after primary survey?

. Administration of broad-spectrum antibiotics.
. Application of a traction splint.
. Immediate referral for CT angiography.
. Preparation for operating room for definitive fixation.
. Long leg cast application.

Correct Answer & Explanation

. Application of a traction splint.

Explanation

After the primary survey (ABCDEs) and resuscitation, the immediate management of a suspected femoral shaft fracture (closed or open) involves the application of a traction splint (e.g., Sager or Hare traction splint). This helps to reduce pain, control bleeding (a femur can bleed significantly), prevent further soft tissue damage, and temporarily stabilize the limb, especially during transport or while awaiting definitive fixation. Antibiotics are for open fractures. CT angiography and operating room preparation are later steps. A long leg cast is insufficient for a femoral shaft fracture.

Question 11875

Topic: 2. Trauma

A 2-year-old child presents with a 'toddler's fracture' (spiral fracture of the distal tibia) with no displacement. What is the most appropriate management?

. Open reduction internal fixation.
. Skeletal traction.
. Long leg cast immobilization for 3-4 weeks.
. Short leg walking boot with immediate full weight bearing.
. Observation only.

Correct Answer & Explanation

. Long leg cast immobilization for 3-4 weeks.

Explanation

A toddler's fracture is a common, non-displaced spiral or oblique fracture of the distal tibia in young children (typically 9 months to 3 years old) due to low-energy rotational forces. These fractures are stable and heal reliably with conservative management. A long leg cast (or sometimes a short leg cast) for 3-4 weeks is the standard treatment, followed by gradual return to activity. Surgical intervention is rarely needed. Observation only is insufficient, and immediate full weight bearing is not advisable initially.

Question 11876

Topic: 2. Trauma

Which of the following is true regarding a Pilon fracture (distal tibial plafond fracture)?

. It typically results from low-energy rotational forces.
. Associated soft tissue injury is usually minimal.
. CT scan is essential for surgical planning.
. Non-operative management with casting is the preferred treatment.
. Ankle arthrodesis is the primary surgical treatment.

Correct Answer & Explanation

. CT scan is essential for surgical planning.

Explanation

Pilon fractures are high-energy intra-articular fractures of the distal tibia, typically resulting from axial loading with associated rotation. They are characterized by significant soft tissue injury and comminution. A CT scan is absolutely essential for comprehensive assessment of the fracture pattern, articular surface involvement, and comminution, which is critical for surgical planning. Non-operative management is reserved for truly non-displaced or low-demand patients, but most require surgery. Ankle arthrodesis is a salvage procedure for post-traumatic arthritis, not the primary treatment for the acute fracture.

Question 11877

Topic: 2. Trauma
A 35-year-old male sustains an open tibia fracture, Gustilo Type II. After debridement and IMN, what is the recommended duration of intravenous antibiotic therapy?
. 24 hours of Cefazolin only.
. 72 hours of Cefazolin only.
. 72 hours of Cefazolin and Gentamicin.
. 5 days of Cefazolin and Metronidazole.
. 6 weeks of oral Doxycycline.

Correct Answer & Explanation

. 72 hours of Cefazolin only.

Explanation

For Gustilo Type II open fractures, the recommended intravenous antibiotic regimen is a first-generation cephalosporin (e.g., Cefazolin) for 72 hours. For Type III fractures, an aminoglycoside (e.g., Gentamicin) is added to cover gram-negative organisms. Penicillin is added for farmyard injuries (Clostridial coverage). Prophylactic antibiotics for open fractures are typically given for no more than 72 hours, not 24 hours, and not for prolonged periods like 5 days or 6 weeks unless there is a confirmed infection. Metronidazole is for anaerobic coverage and not typically first-line for Type II. The question refers to prophylactic antibiotic duration, not treatment for established infection.

Question 11878

Topic: Pelvic & Acetabular Trauma

What is the most appropriate initial management for an unstable pelvic ring injury in a hemodynamically unstable patient?

. Immediate open reduction internal fixation (ORIF).
. Application of an external fixator as definitive fixation.
. Application of a pelvic binder or sheet wrap.
. Skeletal traction to the lower extremities.
. Immediate angioembolization.

Correct Answer & Explanation

. Application of a pelvic binder or sheet wrap.

Explanation

For hemodynamically unstable patients with unstable pelvic ring injuries, the most critical immediate intervention after primary survey and resuscitation is to stabilize the pelvic ring to reduce the pelvic volume and tamponade venous bleeding. This is achieved quickly and effectively with a pelvic binder, sheet wrap, or C-clamp. While angioembolization may be needed for arterial bleeding, and external fixation or ORIF for definitive stabilization, these are subsequent steps after initial hemorrhage control. Traction is not for pelvic ring stabilization.

Question 11879

Topic: 2. Trauma

A 38-year-old male sustains a comminuted fracture of the distal femur extending into the knee joint (supracondylar-intercondylar fracture). What is the primary concern regarding long-term outcome after surgical fixation?

. Nonunion of the fracture.
. Avascular necrosis of the femoral condyles.
. Post-traumatic osteoarthritis of the knee.
. Leg length discrepancy.
. Deep vein thrombosis.

Correct Answer & Explanation

. Post-traumatic osteoarthritis of the knee.

Explanation

Supracondylar-intercondylar femoral fractures (AO/OTA 33-C type) involve the articular surface of the knee. Despite achieving stable fixation, the primary long-term concern is the development of post-traumatic osteoarthritis due to residual articular incongruity, cartilage damage at the time of injury, and altered joint mechanics. While nonunion, AVN (less common here), and DVT can occur, osteoarthritis is the most common and often debilitating long-term sequela for complex intra-articular fractures. Leg length discrepancy is a concern for shaft fractures but less so for distal femur unless malunion is significant.

Question 11880

Topic: 2. Trauma

In the management of a displaced subtrochanteric femur fracture, why is intramedullary nailing generally preferred over plate and screw fixation?

. IMN provides greater torsional stability.
. IMN reduces the risk of avascular necrosis of the femoral head.
. IMN is a load-sharing device, whereas plates are load-bearing.
. IMN allows for earlier full weight bearing in all patients.
. IMN has a lower infection rate in open fractures.

Correct Answer & Explanation

. IMN is a load-sharing device, whereas plates are load-bearing.

Explanation

Intramedullary nails are load-sharing devices, meaning they share the axial load with the bone, which helps to reduce stress shielding and promote physiological healing. Plates, conversely, are load-bearing, taking most of the load themselves, which can lead to stress risers at the plate ends and increase the risk of implant fatigue or refracture after removal. For subtrochanteric fractures, which are subject to high bending and rotational forces, load-sharing IMN offers superior biomechanical advantages and generally better healing rates compared to plates. While IMN can provide good stability, torsional stability depends on locking screws. AVN is not a primary concern for subtrochanteric fractures. Early weight bearing depends on fracture stability and patient factors. Infection rates are generally comparable when performed appropriately.

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