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2. Trauma MCQs

Practice Set 629 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 12561

Topic: 2. Trauma

A 60-year-old patient presents with a painful, erythematous lower leg 6 months following internal fixation of a tibial shaft fracture. Radiographs show a ununited fracture with loose hardware.

What is the most appropriate definitive management?

. Intravenous antibiotics for 6 weeks and retain hardware
. Hardware removal, thorough debridement, and placement of a fine wire external fixator
. Exchange nailing with a larger diameter reamed intramedullary nail
. Hardware removal and immediate internal fixation with a new plate
. Suppressive oral antibiotics until clinical union occurs

Correct Answer & Explanation

. Hardware removal, thorough debridement, and placement of a fine wire external fixator

Explanation

In the setting of an infected nonunion with loose hardware, the implant provides no stability and acts as a nidus for infection. Management requires hardware removal, aggressive debridement, and stabilization with an external fixator.

Question 12562

Topic: 2. Trauma

A 12-year-old boy presents after a mild knee sprain. Radiographs reveal an incidental eccentric, lytic, bubbly lesion with sclerotic margins in the distal femur metaphysis.

What is the most appropriate management for this patient?

. Curettage and bone grafting
. Wide surgical resection
. Reassurance and observation
. Radiation therapy
. Radiofrequency ablation

Correct Answer & Explanation

. Reassurance and observation

Explanation

The clinical and radiographic presentation is classic for a non-ossifying fibroma (NOF), a benign, self-limiting fibro-osseous lesion. NOFs are typically asymptomatic and regress by ossifying as the skeleton matures, requiring only observation unless they are large enough to pose a significant fracture risk.

Question 12563

Topic: 2. Trauma

A patient presents with a chronically infected nonunion 6 months following an open reduction internal fixation of a tibial plateau fracture.

When planning definitive management, what is the most appropriate initial surgical step?

. Immediate hardware removal and internal fixation with a new plate
. Hardware removal, aggressive debridement, and placement of an antibiotic spacer/beads
. Debridement with retention of the original hardware and soft tissue coverage
. Local radiation therapy to eradicate the biofilm
. Bone grafting with autologous iliac crest while leaving hardware intact

Correct Answer & Explanation

. Hardware removal, aggressive debridement, and placement of an antibiotic spacer/beads

Explanation

In the setting of a chronic iatrogenic infection with a nonunion, the hardware is colonized by a bacterial biofilm. Definitive management requires complete hardware removal, aggressive debridement of necrotic bone, and local antibiotic delivery (e.g., PMMA beads or spacer) prior to any later reconstructive efforts.

Question 12564

Topic: 2. Trauma

A chronic alcoholic patient is admitted for surgical management of an open tibia fracture. On post-operative day 3, he develops severe tachycardia, hypertension, diaphoresis, visual hallucinations, and extreme agitation. What is the most appropriate immediate pharmacologic treatment?

. Haloperidol
. Lorazepam
. Propofol
. Dexmedetomidine
. Phenytoin

Correct Answer & Explanation

. Lorazepam

Explanation

The patient is exhibiting signs of delirium tremens, a severe and life-threatening form of alcohol withdrawal that typically peaks 48 to 96 hours after the last drink. Benzodiazepines, such as lorazepam, are the first-line pharmacologic agents to control severe withdrawal symptoms and prevent seizures.

Question 12565

Topic: 2. Trauma

A patient develops a deep wound infection with hardware exposure 10 days following an open reduction and internal fixation of a distal tibia fracture.

The hardware remains rigidly fixed. What is the most appropriate initial management strategy?

. Immediate removal of all hardware and placement of a ring fixator
. Surgical debridement, targeted antibiotics, and soft tissue coverage while retaining hardware
. Application of a cast over the open wound
. Local rotational flap without deep debridement
. Intravenous antibiotics alone for 6 weeks

Correct Answer & Explanation

. Surgical debridement, targeted antibiotics, and soft tissue coverage while retaining hardware

Explanation

In early postoperative infections where the fracture is not healed but hardware remains rigidly stable, the standard of care is aggressive debridement, retaining the hardware, and securing prompt soft-tissue coverage.

Question 12566

Topic: 2. Trauma

A patient develops a necrotizing soft tissue infection 5 days after internal fixation of a pilon fracture, resulting in exposed hardware and necrotic tendons over the anterior ankle.

Following serial debridements resulting in a sterile but large composite defect, what is the best reconstructive option for soft tissue coverage?

. Split-thickness skin graft directly over the hardware
. Free vascularized tissue transfer (e.g., Anterolateral thigh flap)
. Healing by secondary intention with negative pressure wound therapy
. Sural nerve graft
. Reverse superficial sural artery flap (assuming compromised peroneal perforators)

Correct Answer & Explanation

. Free vascularized tissue transfer (e.g., Anterolateral thigh flap)

Explanation

Large composite defects in the distal third of the lower extremity with exposed hardware, bone, and tendons lack adequate local flap options. They generally require a free vascularized tissue transfer to provide robust coverage and allow limb salvage.

Question 12567

Topic: 2. Trauma

A 45-year-old male with a history of heavy daily alcohol use is admitted for an open tibia fracture. On postoperative day 3, he becomes tachycardic, hypertensive, diaphoretic, and severely agitated with visual hallucinations. What is the most appropriate immediate pharmacologic management?

. Intravenous haloperidol
. Intravenous lorazepam
. Oral propranolol
. Intravenous phenytoin
. Oral disulfiram

Correct Answer & Explanation

. Intravenous lorazepam

Explanation

The patient is experiencing Delirium Tremens (DTs), a severe form of alcohol withdrawal. Benzodiazepines, such as intravenous lorazepam or diazepam, are the first-line treatment to control agitation, stabilize vitals, and prevent seizures.

Question 12568

Topic: 2. Trauma

A 14-year-old boy presents to the emergency department with severe thigh pain after a minor fall. Radiographs demonstrate a displaced transverse fracture through a large, eccentric, multiloculated lytic lesion in the distal femur metaphysis, as seen in the imaging.

If a biopsy were performed, what would be the expected histopathological findings?

. Spindle cells arranged in a storiform pattern with scattered giant cells and foamy macrophages
. Cartilage cap with underlying organized endochondral ossification
. Chicken-wire calcification surrounding mononuclear chondroblasts
. Uniform round cells with cleared cytoplasm resembling fried eggs
. Atypical plasma cells with kappa or lambda light chain restriction

Correct Answer & Explanation

. Spindle cells arranged in a storiform pattern with scattered giant cells and foamy macrophages

Explanation

The image and history describe a pathologic fracture through a large non-ossifying fibroma (NOF). Histologically, NOFs are characterized by a storiform arrangement of fibroblastic spindle cells intermixed with multinucleated giant cells and lipid-laden (foamy) macrophages.

Question 12569

Topic: 2. Trauma

A 42-year-old male with a known history of severe chronic alcohol abuse is admitted for an intramedullary nailing of a closed tibia fracture. On postoperative day 3, he becomes agitated, profoundly tachycardic (135 bpm), diaphoretic, and begins experiencing visual hallucinations. What is the most appropriate first-line pharmacologic treatment for this patient's acute systemic condition?

. Haloperidol
. Phenytoin
. Lorazepam
. Clonidine
. Dexmedetomidine

Correct Answer & Explanation

. Lorazepam

Explanation

The patient is exhibiting signs of delirium tremens, a severe and potentially life-threatening complication of alcohol withdrawal typically peaking at 48-72 hours. Benzodiazepines, such as lorazepam or chlordiazepoxide, are the first-line treatment to control agitation and prevent withdrawal seizures.

Question 12570

Topic: 2. Trauma

A 50-year-old alcoholic male undergoes emergency open reduction and internal fixation of a severe tibial plateau fracture. On post-operative day 3, he develops severe agitation, tachycardia, diaphoresis, and visual hallucinations. What is the most appropriate first-line pharmacologic treatment for this acute complication?

. Intravenous haloperidol
. Oral gabapentin
. Intravenous lorazepam
. Intravenous phenytoin
. Intravenous propofol

Correct Answer & Explanation

. Intravenous lorazepam

Explanation

The patient is experiencing Delirium Tremens (DTs), a severe form of alcohol withdrawal that typically peaks 48 to 72 hours after the last drink. Benzodiazepines like lorazepam or diazepam are the first-line treatment to control autonomic hyperactivity, agitation, and prevent seizures.

Question 12571

Topic: 2. Trauma

A 10-year-old boy sustains a minor twisting injury while running and presents with leg pain. Radiographs reveal a pathologic fracture through a cortically based, eccentric, bubbly radiolucent lesion in the distal tibial metaphysis.

What is the most appropriate initial management for this specific lesion?

. Immediate wide resection with a fibular strut allograft.
. Urgent intralesional curettage and bone grafting within 24 hours.
. Immobilization in a cast to allow the fracture to heal, followed by observation.
. Neoadjuvant bisphosphonates followed by curettage.
. Below-knee amputation.

Correct Answer & Explanation

. Immobilization in a cast to allow the fracture to heal, followed by observation.

Explanation

The image and clinical presentation are classic for a pathologic fracture through a non-ossifying fibroma (NOF). These are benign, self-limiting lesions; pathologic fractures are typically managed non-operatively with casting, and the NOF often heals and ossifies concurrently with the fracture.

Question 12572

Topic: 2. Trauma

A 52-year-old male with a known history of chronic, severe alcohol use disorder is admitted for surgical fixation of a closed highly comminuted tibial plateau fracture. On postoperative day 3, he develops tachycardia, hypertension, diaphoresis, and severe agitation with visual hallucinations. What is the primary mechanism of the first-line pharmacologic treatment for this patient's acute postoperative complication?

. Blockade of postsynaptic dopamine D2 receptors in the limbic system
. Allosteric modulation of the GABA-A receptor, increasing the frequency of chloride channel opening
. Inhibition of voltage-gated sodium channels in the central nervous system
. Reversible inhibition of acetylcholinesterase in the synaptic cleft
. Direct agonism of alpha-2 adrenergic receptors in the brainstem

Correct Answer & Explanation

. Allosteric modulation of the GABA-A receptor, increasing the frequency of chloride channel opening

Explanation

The patient is experiencing delirium tremens, a severe manifestation of alcohol withdrawal common in traumatized alcoholic patients postoperatively. The first-line treatment relies on benzodiazepines, which act by allosterically modulating the GABA-A receptor to increase the frequency of chloride channel opening.

Question 12573

Topic: 2. Trauma

A 20-year-old man undergoes reamed intramedullary nailing for a closed tibial shaft fracture. Which of the following is the most frequently reported complication following this procedure?

. Delayed union or nonunion
. Malunion
. Anterior knee pain
. Deep infection
. Compartment syndrome

Correct Answer & Explanation

. Anterior knee pain

Explanation

Correct Answer: C. Anterior knee painAnterior knee pain is the most common complication following intramedullary nailing of the tibia, occurring in up to 57% of patients. It is often activity-related and exacerbated by kneeling. The incidence of nonunion, malunion, infection, and compartment syndrome is significantly lower.

Question 12574

Topic: Pelvic & Acetabular Trauma
A 35-year-old man presents with a hemodynamically unstable anteroposterior compression (APC) type III pelvic ring injury following a motorcycle accident. A pelvic binder is applied. What is the most common anatomic source of hemorrhage in this type of injury?
. Internal pudendal artery
. Superior gluteal artery
. Presacral venous plexus and cancellous bone
. Corona mortis
. External iliac artery

Correct Answer & Explanation

. Presacral venous plexus and cancellous bone

Explanation

The vast majority (80-90%) of bleeding in pelvic ring injuries is venous, originating from the presacral venous plexus and bleeding cancellous bone ends. Arterial bleeding accounts for a smaller percentage of life-threatening hemorrhage.

Question 12575

Topic: 2. Trauma

A 28-year-old man suffers a closed comminuted tibia fracture. He is being monitored for acute compartment syndrome. According to current guidelines, what intracompartmental pressure parameter is most diagnostic for compartment syndrome?

. Absolute compartment pressure > 20 mmHg
. Compartment pressure within 30 mmHg of the patient's diastolic blood pressure
. Compartment pressure within 10 mmHg of the patient's systolic blood pressure
. Absolute compartment pressure > 15 mmHg
. Difference between mean arterial pressure and compartment pressure < 50 mmHg

Correct Answer & Explanation

. Compartment pressure within 30 mmHg of the patient's diastolic blood pressure

Explanation

The differential pressure (delta p) is the most reliable diagnostic metric for acute compartment syndrome. A delta p (diastolic blood pressure minus compartment pressure) of less than 30 mmHg is the accepted threshold for performing a fasciotomy.

Question 12576

Topic: 2. Trauma

A 30-year-old man undergoes percutaneous fixation for a displaced talar neck fracture. At the 8-week follow-up, an AP radiograph of the ankle reveals a subchondral radiolucent band extending across the dome of the talus (Hawkins sign). What does this finding indicate?

. Onset of severe avascular necrosis (AVN) of the talar body
. Nonunion of the talar neck fracture
. Intact vascularity and revascularization of the talar body
. Early post-traumatic osteoarthritis of the tibiotalar joint
. Infection of the talar dome

Correct Answer & Explanation

. Intact vascularity and revascularization of the talar body

Explanation

The Hawkins sign is a subchondral radiolucent band representing subchondral osteopenia secondary to disuse. Its presence requires an intact blood supply to the talus, thereby serving as an excellent positive prognostic indicator against the development of complete avascular necrosis.

Question 12577

Topic: 2. Trauma

A 45-year-old man is brought to the emergency department after a high-speed motor vehicle collision. Radiographs and a CT scan of the pelvis demonstrate an acetabular fracture with a continuous fracture line extending from the iliac crest to the ischiopubic ramus. The articular surface of the acetabulum is completely dissociated from the intact axial skeleton, and a 'spur sign' is visible on the obturator oblique radiograph. Which of the following is the most accurate classification of this fracture pattern?

. Transverse with posterior wall
. T-type
. Anterior column with posterior hemitransverse
. Both column
. Isolated anterior column

Correct Answer & Explanation

. Both column

Explanation

The presence of a spur sign on the obturator oblique view is pathognomonic for a both column acetabular fracture. This sign represents the intact portion of the ilium that remains attached to the axial skeleton, projecting posteriorly to the displaced articular fragments. It indicates complete dissociation of the acetabular articular surface from the sciatic buttress.

Question 12578

Topic: Pelvic & Acetabular Trauma
A 35-year-old male presents following a high-speed motor vehicle collision. He is hypotensive and tachycardic. Radiographs reveal an APC III pelvic ring injury. After initial fluid resuscitation, a pelvic binder is placed, but he remains hemodynamically unstable. A FAST examination is negative. What is the most appropriate next step in management?
. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) or preperitoneal pelvic packing
. Placement of an anterior pelvic external fixator
. Emergent exploratory laparotomy
. Immediate CT angiography of the abdomen and pelvis
. Definitive open reduction and internal fixation of the pelvis

Correct Answer & Explanation

. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) or preperitoneal pelvic packing

Explanation

In a hemodynamically unstable patient with a mechanically unstable pelvic ring injury and a negative FAST, bleeding is typically from the retroperitoneal venous plexus or pelvic vessels. Preperitoneal pelvic packing, REBOA, or angiography with embolization is the appropriate next step to control hemorrhage after mechanical stabilization.

Question 12579

Topic: 2. Trauma

A 28-year-old carpenter presents with chronic radial-sided wrist pain. Radiographs reveal a scaphoid waist fracture nonunion with a dorsal intercalated segment instability (DISI) deformity, but no evidence of radiocarpal arthritis. MRI confirms the proximal pole is well-vascularized. Which of the following is the most appropriate definitive management?

. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Non-vascularized structural bone graft and screw fixation
. Vascularized medial femoral condyle bone graft
. Radial styloidectomy alone

Correct Answer & Explanation

. Non-vascularized structural bone graft and screw fixation

Explanation

For a scaphoid nonunion with a humpback deformity (DISI) but no avascular necrosis and no osteoarthritis, the deformity must be corrected to restore carpal kinematics. A non-vascularized structural volar wedge graft (e.g., from the iliac crest) with internal fixation is the gold standard.

Question 12580

Topic: 2. Trauma

A 24-year-old male undergoes intramedullary nailing for a closed tibial shaft fracture. Six hours postoperatively, he has increasing pain out of proportion to his injury that is exacerbated by passive stretch of his toes. His diastolic blood pressure is 65 mmHg, and his anterior compartment pressure is measured at 40 mmHg. What is the most appropriate management?

. Elevate the leg above the level of the heart and administer analgesics
. Administer intravenous mannitol and hypertonic saline
. Perform emergent four-compartment fasciotomy
. Remove the intramedullary nail and place a spanning external fixator
. Bivalve the surgical dressing and apply ice to the leg

Correct Answer & Explanation

. Perform emergent four-compartment fasciotomy

Explanation

The patient has an absolute compartment pressure of 40 mmHg and a delta pressure (diastolic BP minus compartment pressure) of 25 mmHg, which is less than the critical threshold of 30 mmHg. This confirms acute compartment syndrome, requiring an emergent four-compartment fasciotomy.

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