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2. Trauma MCQs

Practice Set 82 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 1621

Topic: 2. Trauma

Post-operatively, the patient was started on a structured, progressive rehabilitation program tailored to the underlying bone pathology and surgical fixation. Given the inherent weakness of the dysplastic bone and the healing fracture, careful consideration was given to weight-bearing progression. What was the initial weight-bearing status permitted for the operative leg in the immediate post-operative period?

. Non-weight-bearing (NWB) for 6 weeks.
. Full weight-bearing (FWB) as tolerated.
. Touch-down weight-bearing (TDWB) of 10-15 kg.
. Partial weight-bearing (PWB) up to 50% body weight.
. Protected weight-bearing with a brace only.

Correct Answer & Explanation

. Touch-down weight-bearing (TDWB) of 10-15 kg.

Explanation

Correct Answer: CThe case explicitly states that in the immediate post-operative period (Day 0-3), 'Touch-down weight-bearing (TDWB) of 10-15 kg was permitted on the operative leg using crutches or a walker.' Strict adherence to protected weight-bearing was emphasized due to the inherent weakness of the dysplastic bone and the healing fracture. While the intramedullary nail and PMMA provide significant stability, the compromised bone quality and the need for fracture healing necessitate a cautious approach to weight-bearing initially. Full weight-bearing would be too aggressive, and non-weight-bearing might delay rehabilitation unnecessarily given the robust fixation. Partial weight-bearing would typically be a later progression, usually around 4-6 weeks post-operatively.

Question 1622

Topic: 2. Trauma

A 65-year-old patient undergoes successful surgical reconstruction of a Charcot midfoot deformity. Six months post-operatively, radiographs show evidence of hardware breakage and a nonunion at the arthrodesis site, but the foot remains plantigrade and the patient is asymptomatic, able to ambulate with a CROW boot without pain or ulceration. What is the most appropriate management strategy?

. Immediate revision surgery with removal of broken hardware and re-arthrodesis.
. Transition to a below-knee amputation due to failed reconstruction.
. Observation with continued bracing and close monitoring.
. Initiation of a prolonged course of intravenous antibiotics.
. Application of a circular external fixator for gradual correction.

Correct Answer & Explanation

. Observation with continued bracing and close monitoring.

Explanation

Correct Answer: CThe case discusses complications and management, specifically addressing hardware failure and nonunion. It states: 'Management depends on the clinical presentation. Asymptomatic nonunions with stable hardware and a plantigrade, braceable foot can often be observed.' In this scenario, despite hardware breakage and nonunion, the patient is asymptomatic, the foot is plantigrade, and they are ambulating with a CROW boot without pain or ulceration. This indicates a functionally stable outcome despite radiographic findings. Therefore, continued observation with bracing and close monitoring is the most appropriate management. Revision surgery (Option A) is typically reserved for symptomatic nonunions or those leading to instability or impending skin breakdown. Amputation (Option B) is a last resort for failed salvage. Antibiotics (Option D) are not indicated without signs of infection. External fixation (Option E) would be an option for revision surgery if the foot were unstable or symptomatic, but not for an asymptomatic, stable nonunion.

Question 1623

Topic: 2. Trauma

A 30-year-old male with fibrous dysplasia of the proximal femur requires surgical stabilization due to progressive pain and impending fracture. Which of the following surgical techniques is most appropriate to maximize long-term construct survival?

. Curettage and packing with cancellous autograft
. Curettage and packing with demineralized bone matrix
. Intramedullary nailing and cortical strut allografting
. External fixation
. Isolated plate and screw fixation without bone grafting

Correct Answer & Explanation

. Intramedullary nailing and cortical strut allografting

Explanation

In fibrous dysplasia, cancellous bone grafts are rapidly resorbed by the dysplastic process. Surgical stabilization usually requires robust internal fixation (like intramedullary nailing) combined with cortical strut allografts, which are not resorbed.

Question 1624

Topic: 2. Trauma

A 28-year-old professional athlete presents with acute midfoot pain after a direct crush injury. Initial radiographs show a fracture of the base of the second metatarsal with 1.5mm widening between the medial cuneiform and the second metatarsal. Stress radiographs under fluoroscopy demonstrate dynamic instability with greater than 3mm diastasis. The patient is otherwise healthy. Which of the following is the most appropriate management strategy?

. Non-weight-bearing cast immobilization for 8 weeks, followed by progressive weight-bearing in a CAM boot.
. Open reduction and internal fixation (ORIF) with transarticular screw fixation of the first, second, and third tarsometatarsal joints.
. Primary arthrodesis of the first, second, and third tarsometatarsal joints to ensure long-term stability.
. External fixation for 4-6 weeks to allow for soft tissue swelling to subside, followed by definitive ORIF.
. Discharge with crutches and a supportive shoe, with instructions for activity modification and pain control.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) with transarticular screw fixation of the first, second, and third tarsometatarsal joints.

Explanation

Correct Answer: BThe case outlines clear operative indications for Lisfranc injuries. The patient presents with a fracture of the second metatarsal base and dynamic instability (greater than 3mm diastasis on stress views), both of which are absolute indications for surgical intervention. The overarching goal is anatomical reduction and stable fixation. ORIF with transarticular screw fixation (Option B) is the standard of care for acute, unstable Lisfranc injuries. Non-weight-bearing cast immobilization (Option A) is reserved for truly stable, non-displaced sprains (Grade I), which is not the case here. Primary arthrodesis (Option C) is typically indicated for severe comminuted injuries, chronic unreduced injuries, or in patients with pre-existing midfoot arthritis, not usually for an acute, reducible injury in a young, healthy athlete. External fixation (Option D) is generally reserved for severe open injuries, highly comminuted fractures, or in a 'damage control' scenario for polytrauma patients, which is not described. Discharging the patient (Option E) would lead to chronic instability and poor outcomes.

Question 1625

Topic: 2. Trauma

A 2-year-old with severe Paley Type 2 fibular deficiency presents with profound limb length discrepancy, a non-functional foot, and severe ankle instability. The family is counseled on various treatment options, including extensive limb salvage procedures and primary amputation. They are weighing the long-term implications of each approach.

When considering a primary Syme's amputation for this child, which of the following is the MOST compelling advantage compared to extensive limb salvage, as highlighted in the case?

. Superior cosmetic outcome of the limb
. Avoidance of any psychological impact on the child
. Less risk of infection compared to external fixation
. Preservation of distal tibial growth potential for an end-bearing stump
. Guaranteed complete limb length equality without further intervention

Correct Answer & Explanation

. Preservation of distal tibial growth potential for an end-bearing stump

Explanation

Correct Answer: DThe correct answer is preservation of distal tibial growth potential for an end-bearing stump. The case explicitly states the rationale for Syme's amputation: 'Creates an end-bearing stump, preserves growth potential of the distal tibia, and allows for excellent prosthetic fitting. This often results in superior functional outcomes and requires fewer surgeries than complex limb salvage.' While superior functional outcomes and fewer surgeries are also key advantages, the preservation of the distal tibial epiphysis is a unique anatomical benefit that directly contributes to the creation of a robust, end-bearing stump, which is crucial for optimal prosthetic fitting and long-term function. Cosmetic outcome is subjective and often not superior with amputation. Psychological impact is significant with both options and requires support. While external fixation has a high risk of pin site infection, amputation has its own set of infection risks. Complete limb length equality is not guaranteed without further intervention, as the contralateral limb may still grow, requiring future management.

Question 1626

Topic: 2. Trauma

A 7-year-old child undergoing tibial lengthening for fibular deficiency, as shown in the image below, is in the distraction phase. The patient's parents report a sudden onset of severe pain in the foot, accompanied by swelling and paresthesias in the toes. On examination, the foot is tense, and capillary refill is sluggish.

Based on the potential complications described in the case, what is the MOST immediate and critical concern for this patient?

. Pin site infection
. Premature consolidation of the regenerate
. Nerve injury (neuropraxia)
. Vascular impairment (e.g., compartment syndrome)
. Joint stiffness of the ankle

Correct Answer & Explanation

. Vascular impairment (e.g., compartment syndrome)

Explanation

Correct Answer: DThe correct answer is vascular impairment (e.g., compartment syndrome). The symptoms described—sudden onset of severe pain, swelling, paresthesias in the toes, tense foot, and sluggish capillary refill—are classic signs of acute compartment syndrome or other forms of severe vascular compromise. The case lists 'Vascular Impairment: Rare (<1%) but limb-threatening' and specifies 'Immediate release of constricting elements (fasciotomy, removal of tension), surgical exploration, vascular repair/grafting' as management. This is an orthopedic emergency requiring immediate attention to prevent irreversible tissue damage. While pin site infection, premature consolidation, nerve injury, and joint stiffness are all potential complications of limb lengthening, they typically do not present with such acute, limb-threatening symptoms.

Question 1627

Topic: 2. Trauma

A 52-year-old male undergoes a first MTP joint arthrodesis for severe hallux rigidus. Post-operatively, he is placed in a non-weight-bearing short leg cast. At his 6-week follow-up, weight-bearing radiographs are obtained to assess for bony union. The radiographs show no clear signs of union, and there is a visible gap at the fusion site. Based on the case, what is the most appropriate next step in management?

. A. Immediately transition to a CAM boot with partial weight-bearing to stimulate bone healing.
. B. Initiate aggressive physical therapy to improve range of motion and stimulate union.
. C. Extend non-weight-bearing in the cast and consider revision arthrodesis with bone graft if union is not achieved later.
. D. Prescribe oral corticosteroids to reduce inflammation at the fusion site.
. E. Perform hardware removal as it may be impeding bone healing.

Correct Answer & Explanation

. C. Extend non-weight-bearing in the cast and consider revision arthrodesis with bone graft if union is not achieved later.

Explanation

Correct Answer: CThe patient's presentation of no clear signs of union and a visible gap at the fusion site at 6 weeks indicates a delayed union or potential nonunion. The case, under 'Post-Operative Rehabilitation Protocols - Arthrodesis Fusion - Fusion Confirmation Phase (6 - 12 weeks),' states: 'Once radiographic evidence of early union is confirmed, gradual progression to weight-bearing in a removable CAM boot or stiff-soled shoe is initiated. If union is not evident, NWB may be extended.' Furthermore, under 'Complications & Management - Nonunion (Arthrodesis),' it lists 'Management: revision arthrodesis with bone graft (autograft/allograft), stronger internal fixation, extended immobilization.' Therefore, extending non-weight-bearing is the immediate appropriate step, with revision surgery as a consideration if union remains elusive.A. Transitioning to weight-bearing without signs of union would jeopardize the fusion and likely lead to nonunion.B. Initiating aggressive physical therapy to improve range of motion is contraindicated for an arthrodesis, as motion is intentionally sacrificed, and it would disrupt the healing fusion site.D. Oral corticosteroids are generally not used to promote bone healing and can, in fact, impair it. They are not indicated here.E. Hardware removal is typically performed after healing is complete if the hardware is symptomatic, not as a primary treatment for nonunion at 6 weeks. Hardware is crucial for stability to achieve union.

Question 1628

Topic: 2. Trauma

A surgeon performs a modified two-incision (Boyd-Anderson) approach for a chronic distal biceps tendon rupture. Dissection is taken through the interosseous membrane to retrieve the retracted tendon. Which of the following complications is uniquely heightened by this specific surgical exposure compared to a single-incision approach?

. Lateral antebrachial cutaneous nerve palsy
. Ulnar nerve injury
. Compartment syndrome
. Proximal radioulnar synostosis
. Brachial artery transection

Correct Answer & Explanation

. Proximal radioulnar synostosis

Explanation

The two-incision approach has historically been associated with a higher risk of proximal radioulnar synostosis (heterotopic ossification bridging the radius and ulna), particularly if the interosseous membrane is violated or muscle bellies are overly traumatized.

Question 1629

Topic: 2. Trauma

A 7-year-old male falls from a tree, sustaining a supracondylar humerus fracture. On arrival, he has a pulseless but warm and pink hand. There is no evidence of motor or sensory deficit. What is the MOST appropriate initial management step?

. Immediate operative reduction and pinning
. Observation and repeat vascular assessment in 1 hour
. Gentle closed reduction and assessment of pulse
. Angiography to assess vascular compromise
. Emergent fasciotomy

Correct Answer & Explanation

. Gentle closed reduction and assessment of pulse

Explanation

Correct Answer: CA pulseless but warm and pink hand with good capillary refill following a supracondylar humerus fracture in a child suggests a vascular spasm, not complete arterial transection. The most appropriate initial step is a gentle closed reduction of the fracture. If the pulse returns after reduction, the limb should be pinned. If the pulse does not return after reduction, then further vascular assessment (e.g., Doppler, potentially angiography) and possibly exploration would be warranted. Immediate angiography or fasciotomy is premature. Observation without attempting reduction delays appropriate treatment and risks worsening ischemia.

Question 1630

Topic: 2. Trauma
A 35-year-old polytrauma patient presents in hemorrhagic shock with an anteroposterior compression type III (APC-III) pelvic ring injury. A pelvic binder is to be applied. At what anatomic landmark should the binder be centered to optimally reduce the pelvic volume?
. Anterior superior iliac spines
. Anterior inferior iliac spines
. Greater trochanters
. Iliac crests
. Pubic symphysis

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders should be centered over the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests or ASIS can paradoxically widen the pelvis in anteroposterior compression injuries.

Question 1631

Topic: 2. Trauma

A 28-year-old male sustains a closed midshaft tibia fracture. Twelve hours later, he complains of severe pain out of proportion to the injury. His diastolic blood pressure is 75 mmHg. Intracompartmental pressure monitoring reveals an anterior compartment pressure of 50 mmHg. What is the delta pressure, and what is the indication for fasciotomy?

. Delta pressure is 25 mmHg; fasciotomy is indicated if Delta pressure is < 30 mmHg
. Delta pressure is 25 mmHg; fasciotomy is indicated if Delta pressure is > 30 mmHg
. Delta pressure is 50 mmHg; fasciotomy is indicated if Delta pressure is < 30 mmHg
. Delta pressure is 50 mmHg; fasciotomy is indicated if Delta pressure is > 30 mmHg
. Delta pressure is 75 mmHg; fasciotomy is indicated if Delta pressure is < 30 mmHg

Correct Answer & Explanation

. Delta pressure is 25 mmHg; fasciotomy is indicated if Delta pressure is < 30 mmHg

Explanation

Delta pressure is calculated as Diastolic Blood Pressure minus Compartment Pressure (75 - 50 = 25 mmHg). A delta pressure of less than 30 mmHg is the accepted threshold indicating the need for emergent four-compartment fasciotomy.

Question 1632

Topic: 2. Trauma
A 25-year-old male sustains a Pauwels type III femoral neck fracture. Which of the following internal fixation constructs provides the highest biomechanical stability for this specific fracture pattern?
. Three parallel cancellous screws
. Dynamic hip screw with a derotational screw
. Two parallel cancellous screws
. Proximal femoral nail
. Sliding hip screw alone

Correct Answer & Explanation

. Dynamic hip screw with a derotational screw

Explanation

For vertical (Pauwels type III) femoral neck fractures, a sliding hip screw (dynamic hip screw) combined with a derotational screw provides superior biomechanical stability and higher failure loads compared to parallel cancellous screws.

Question 1633

Topic: Pelvic & Acetabular Trauma

A 30-year-old male is brought in after a motorcycle collision with a heart rate of 130 bpm and blood pressure of 80/50 mmHg. Radiographs show a widened pubic symphysis (4 cm) and completely displaced bilateral sacroiliac joints. Where is the most anatomically correct location to place a pelvic circumferential compression device?

. Over the iliac crests
. Centered over the greater trochanters
. Inferior to the pubic symphysis
. At the level of the umbilicus
. Over the proximal femurs

Correct Answer & Explanation

. Centered over the greater trochanters

Explanation

A pelvic binder should be centered directly over the greater trochanters to effectively close the pelvic ring and reduce pelvic volume. Placement over the iliac crests is less effective and can paradoxically widen the pelvis in certain fracture patterns.

Question 1634

Topic: 2. Trauma
A 25-year-old male sustains a vertically oriented femoral neck fracture (Pauwels type III). What biomechanical force is most responsible for failure of fixation in this specific fracture pattern?
. Compression
. Tension
. Shear
. Torsion
. Bending

Correct Answer & Explanation

. Shear

Explanation

Pauwels type III fractures are highly vertical (>50 degrees), which subjects the fracture site to significant shear forces. This increases the risk of varus collapse, nonunion, and fixation failure.

Question 1635

Topic: 2. Trauma

A 22-year-old soccer player sustains a twisting knee injury. Radiographs reveal an avulsion fracture of the lateral tibial plateau (Segond fracture). In addition to the anterior cruciate ligament, which of the following structures is most likely injured?

. Medial collateral ligament
. Posterior cruciate ligament
. Anterolateral ligament
. Posterolateral corner
. Iliotibial band

Correct Answer & Explanation

. Anterolateral ligament

Explanation

A Segond fracture is a pathognomonic avulsion fracture of the anterolateral tibial plateau, highly associated with an ACL tear. The avulsed bony fragment typically involves the tibial attachment of the anterolateral ligament (ALL) and lateral capsule.

Question 1636

Topic: Pelvic & Acetabular Trauma
A 40-year-old male is involved in a high-speed motorcycle collision and is hemodynamically unstable. Pelvic radiographs show an anteroposterior compression (APC) type III injury with total disruption of the anterior and posterior sacroiliac ligaments. What is the most appropriate first step in emergent orthopedic management?
. Angiography and embolization
. Placement of a pelvic binder at the level of the greater trochanters
. Application of a supra-acetabular external fixator
. Open reduction internal fixation of the pubic symphysis
. Retroperitoneal packing

Correct Answer & Explanation

. Placement of a pelvic binder at the level of the greater trochanters

Explanation

In a hemodynamically unstable patient with an open-book pelvic fracture, the immediate first step is mechanical stabilization of the pelvic volume. This is most rapidly and effectively achieved with a pelvic binder placed at the level of the greater trochanters.

Question 1637

Topic: 2. Trauma

A 55-year-old male sustains a severe bicondylar tibial plateau fracture (Schatzker VI) with massive soft tissue swelling. Compartment pressures measure 45 mmHg in the anterior compartment with a diastolic blood pressure of 60 mmHg. What is the required definitive intervention?

. Immediate dual-plate internal fixation
. Placement of a spanning external fixator and delayed internal fixation
. Immediate four-compartment fasciotomy
. Elevation, continuous ice therapy, and hourly neurovascular checks
. Intra-articular corticosteroid injection to reduce swelling

Correct Answer & Explanation

. Immediate four-compartment fasciotomy

Explanation

The patient has a delta-P (diastolic pressure minus compartment pressure) of 15 mmHg, clearly indicating acute compartment syndrome (threshold typically <30 mmHg). Emergent four-compartment fasciotomy of the leg is the definitive treatment to prevent irreversible muscle ischemia.

Question 1638

Topic: 2. Trauma

An 8-week postoperative AP radiograph of the ankle in a patient who underwent ORIF for a talar neck fracture demonstrates a subchondral radiolucent band in the talar dome. What is the clinical significance of this radiographic finding?

. Avascular necrosis of the talar body
. Deep space infection
. Intact vascularity to the talus
. Talar neck nonunion
. Early onset osteoarthritis

Correct Answer & Explanation

. Intact vascularity to the talus

Explanation

This finding is known as the Hawkins sign, representing subchondral osteopenia. It indicates that the vascular supply to the talus is intact, as hyperemia is required to resorb the bone.

Question 1639

Topic: 2. Trauma

A 25-year-old male sustains a closed tibial shaft fracture. He complains of excruciating pain out of proportion to the injury. Which pressure measurement threshold is the most reliable indication for emergent fasciotomies?

. Absolute compartment pressure > 20 mmHg
. Absolute compartment pressure > 30 mmHg
. Diastolic blood pressure minus compartment pressure < 30 mmHg
. Diastolic blood pressure minus compartment pressure > 30 mmHg
. Mean arterial pressure minus compartment pressure < 45 mmHg

Correct Answer & Explanation

. Diastolic blood pressure minus compartment pressure < 30 mmHg

Explanation

The delta pressure (Diastolic BP - Compartment Pressure) is the most reliable indicator for acute compartment syndrome. A delta pressure of less than 30 mmHg necessitates emergent fasciotomies.

Question 1640

Topic: 2. Trauma

A trauma patient arrives hypotensive with a mechanically unstable anteroposterior compression (APC) pelvic ring injury. A commercial pelvic binder is applied in the trauma bay. To maximize the reduction force on the pelvic ring, over which anatomic landmark should the binder be centered?

. Iliac crests
. Greater trochanters
. Symphysis pubis
. Anterior superior iliac spines (ASIS)
. Lumbar spine

Correct Answer & Explanation

. Greater trochanters

Explanation

Pelvic binders are most effective at reducing pelvic volume and stabilizing the ring when placed directly over the greater trochanters. Placement over the iliac crests is less effective and can paradoxically open the pelvis in some fracture patterns.

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