USMLE STEP 2 CK: SURGERY QUESTIONS AND
ANSWERS
penetrating trauma to the neck - zone 3 - Answers-zone 3 is angle of mandible and
above -> triple endoscopy - direct laryngoscopy, bronchoscopy, and esophascopy at the
time of initial evaluation.
penetrating trauma to the neck- zone 1 - Answers-zone 1 is at the cricoid cartilage and
below. aortography is necessary.
penetrating trauma to the neck - zone 2 - Answers-zone 2 is between the angle of the
mandible and the cricoid cartilage. 2D doppler +/- exploratory surgery
anterior cord vs central cord syndrome - Answers-anterior cord syndrome (burst fracture
of vertebral bodies -> spinothalamic and motor tracts) Loss of motor function and loss of
pain and temperature sensation on both sides distal to injury. DCML intact (vibration and
pressure) .
traumatic rupture of the aorta - Answers-the worst hidden injury. occurs at the section of
the aorta where the ligamentum arteriosum attaches and occurs due to high
decelleration injury. Death occurs by adventitial rupture of extravasated hematoma.
air embolism - Answers-presentation is a chest trauma patient who is intubated and on
respirator or subclavian vein is opened to the air i.e. central line, supraclavicular lymph
node biopsy. managment is cardiac massage in Left lateral decubitus. Trendelenburg
position while performing procedures is a good preventitive measure.
fat embolism - Answers-patient with multiple trauma - several long bone fractures
developing petechial rashes in axillae and neck ; fever, tachycardia, low platelet count
who shows a full-blown pic of respiratory distress, hypoxemia, and b/L patchy infiltrates
on chest X-ray . Respiratory therapy support.
gunshot wounds to the abdomen - Answers-exploratory lap- below the nipple line is
grounds for ex lap
blunt trauma to the abdomen - Answers-symptoms of internal hemorrhage i.e. low CVP,
hypotension warrants exploratory laparotomy
signs of internal bleeding in a patient with blunt trauma - Answers-drop in blood
pressure, fast thready pulse, low CVP, and low urinary output.
Urethral injury - 1st step management - Answers-retrograde urethrogram ( for any
suspect urethral injury)
Tx of pelvic hematomas - Answers-Leave alone if not expanding
, Routine procedure for pelvic fractures - Answers-Rectal exam, proctoscopy, bladder -
retrograde cystourethrogram pelvic exam in women and urethrogram in males.
Bladder injury management - Answers-Retrograde cystourethrogram, followed by post
void films. Surgical repair done and protected with suprapubic cystostomy.
Pelvic fractures with uncontrolled bleeding - Answers-Pelvic fixation to tamponade the
source of the bleed, then have IR angiographic embolization of both internal iliac
arteries.
central cord syndrome (rear end collision -> forced hyperextension of neck) - paralysis
and burning pain in the upper extremities with preservation of most function in lower
exgtremities
pulmonary contusion - Dx and Tx - Answers-deteriorating blood gases, white out of the
lung - Tx fluid restriction and diuretics , b/L chest tubes if ribs fractured.
myocardial contusion - Answers-EKG will detect it; troponins study ; management is
prevention of arrythmias.
traumatic rupture of the diaphragm - Answers-bowel in the chest always on the left (liver
is protective). Any suspicion calls for laparoscopy. surgery is via the abdominal cavity.
traumatic rupture of the trachea or major bronchus - Answers-subcutaneous
emphysema in upper chest and lower neck or large air leak from a chest tube. Chest X-
ray confirms the presence of air in the tissues, and fiberoptic bronchoscopy identifies
the lesion and allows for intubation to secure an airway. surgical repair follows.
Potential complications of renal laceration from blunt trauma (ribs) - Answers-
Development of an AV fistula causing systolic congestive heart failure
or
Renal artery stenosis leading to renovascular hypertension
High voltage electrical burns - Answers-Myoglobinuria- renal failure -> fluids and
osmotic diuretics
other complications: posterior shoulder dislocations, compression fx to vertebral bodies,
late development of cataracts, and demyelination.
Respiratory burns- inhalational injuries - Answers-Burns and/or soot in or around the
mouth indicate inhalational injury
Dx made with fiberoptic bronchoscopy. Monitor blood gases with ABG (to determine if
respirator needed) and monitor carbon monoxide levels.
ANSWERS
penetrating trauma to the neck - zone 3 - Answers-zone 3 is angle of mandible and
above -> triple endoscopy - direct laryngoscopy, bronchoscopy, and esophascopy at the
time of initial evaluation.
penetrating trauma to the neck- zone 1 - Answers-zone 1 is at the cricoid cartilage and
below. aortography is necessary.
penetrating trauma to the neck - zone 2 - Answers-zone 2 is between the angle of the
mandible and the cricoid cartilage. 2D doppler +/- exploratory surgery
anterior cord vs central cord syndrome - Answers-anterior cord syndrome (burst fracture
of vertebral bodies -> spinothalamic and motor tracts) Loss of motor function and loss of
pain and temperature sensation on both sides distal to injury. DCML intact (vibration and
pressure) .
traumatic rupture of the aorta - Answers-the worst hidden injury. occurs at the section of
the aorta where the ligamentum arteriosum attaches and occurs due to high
decelleration injury. Death occurs by adventitial rupture of extravasated hematoma.
air embolism - Answers-presentation is a chest trauma patient who is intubated and on
respirator or subclavian vein is opened to the air i.e. central line, supraclavicular lymph
node biopsy. managment is cardiac massage in Left lateral decubitus. Trendelenburg
position while performing procedures is a good preventitive measure.
fat embolism - Answers-patient with multiple trauma - several long bone fractures
developing petechial rashes in axillae and neck ; fever, tachycardia, low platelet count
who shows a full-blown pic of respiratory distress, hypoxemia, and b/L patchy infiltrates
on chest X-ray . Respiratory therapy support.
gunshot wounds to the abdomen - Answers-exploratory lap- below the nipple line is
grounds for ex lap
blunt trauma to the abdomen - Answers-symptoms of internal hemorrhage i.e. low CVP,
hypotension warrants exploratory laparotomy
signs of internal bleeding in a patient with blunt trauma - Answers-drop in blood
pressure, fast thready pulse, low CVP, and low urinary output.
Urethral injury - 1st step management - Answers-retrograde urethrogram ( for any
suspect urethral injury)
Tx of pelvic hematomas - Answers-Leave alone if not expanding
, Routine procedure for pelvic fractures - Answers-Rectal exam, proctoscopy, bladder -
retrograde cystourethrogram pelvic exam in women and urethrogram in males.
Bladder injury management - Answers-Retrograde cystourethrogram, followed by post
void films. Surgical repair done and protected with suprapubic cystostomy.
Pelvic fractures with uncontrolled bleeding - Answers-Pelvic fixation to tamponade the
source of the bleed, then have IR angiographic embolization of both internal iliac
arteries.
central cord syndrome (rear end collision -> forced hyperextension of neck) - paralysis
and burning pain in the upper extremities with preservation of most function in lower
exgtremities
pulmonary contusion - Dx and Tx - Answers-deteriorating blood gases, white out of the
lung - Tx fluid restriction and diuretics , b/L chest tubes if ribs fractured.
myocardial contusion - Answers-EKG will detect it; troponins study ; management is
prevention of arrythmias.
traumatic rupture of the diaphragm - Answers-bowel in the chest always on the left (liver
is protective). Any suspicion calls for laparoscopy. surgery is via the abdominal cavity.
traumatic rupture of the trachea or major bronchus - Answers-subcutaneous
emphysema in upper chest and lower neck or large air leak from a chest tube. Chest X-
ray confirms the presence of air in the tissues, and fiberoptic bronchoscopy identifies
the lesion and allows for intubation to secure an airway. surgical repair follows.
Potential complications of renal laceration from blunt trauma (ribs) - Answers-
Development of an AV fistula causing systolic congestive heart failure
or
Renal artery stenosis leading to renovascular hypertension
High voltage electrical burns - Answers-Myoglobinuria- renal failure -> fluids and
osmotic diuretics
other complications: posterior shoulder dislocations, compression fx to vertebral bodies,
late development of cataracts, and demyelination.
Respiratory burns- inhalational injuries - Answers-Burns and/or soot in or around the
mouth indicate inhalational injury
Dx made with fiberoptic bronchoscopy. Monitor blood gases with ABG (to determine if
respirator needed) and monitor carbon monoxide levels.
