External Fixation — MCQs
A 60-year-old man who fell in the bathroom and is unable to stand on his right buttock region due to ecchymosis, with external rotation of the leg and the lateral border of the foot touching the bed. The most probable diagnosis is:
The contraindication to internal fixation -
An RTA patient presented to the emergency department with severe pain in the ankle. An X-ray was performed, given below. What is the best next step in management?
A patient with metastatic breast cancer presents with pathological fracture of femur. What is the best fixation method?
Open reduction (OR) is not required in which fracture?
Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint
Which of the following is false regarding clavicle?
Locking compression plating is indicated in
All of the following are indications for open reduction and internal fixation (ORIF) of fractures EXCEPT:
Treatment of choice of flail chest is
External Fixation Indian Medical PG Practice Questions and MCQs
Question 1: A 60-year-old man who fell in the bathroom and is unable to stand on his right buttock region due to ecchymosis, with external rotation of the leg and the lateral border of the foot touching the bed. The most probable diagnosis is:
- A. Extra capsular fracture neck of femur (Correct Answer)
- B. Anterior dislocation of hip
- C. Intra capsular fracture neck of femur
- D. Posterior dislocation of hip
Explanation: **Extra capsular fracture neck of femur** - The classic presentation of an **extra capsular fracture of the neck of femur** includes a fall, **ecchymosis** in the buttock region, and the affected leg displaying **external rotation** and shortening. - This type of fracture often involves the **intertrochanteric region**, leading to significant soft tissue damage and the observed clinical signs. *Anterior dislocation of hip* - This typically presents with the hip in **flexion, abduction, and external rotation**, but the limb is usually **lengthened**, not shortened. - While there is external rotation, the characteristic **shortening of the leg** and inability to bear weight on the buttock are less typical. *Intra capsular fracture neck of femur* - This fracture often presents with a less pronounced deformity, and the leg may show **mild external rotation** or be in a neutral position. - **Ecchymosis** may be delayed or less significant compared to extracapsular fractures because the fracture is contained within the joint capsule. *Posterior dislocation of hip* - This type of dislocation is characterized by the hip being in **flexion, adduction, and internal rotation**. - The presented symptoms of **external rotation** and the foot touching the bed laterally are inconsistent with a posterior dislocation.
Question 2: The contraindication to internal fixation -
- A. Fracture dislocation
- B. Intraarticular fracture
- C. Physeal injury
- D. Active infection (Correct Answer)
Explanation: ***Active infection*** - **Active infection** is a strong contraindication to internal fixation because introducing foreign material (implants) into an infected area can spread the infection, make it chronic, and lead to implant failure, osteomyelitis, or sepsis. - The presence of bacteria can colonize the implant surface, forming **biofilms** that are highly resistant to antibiotics and host immune responses, severely complicating treatment. *Fracture dislocation* - **Fracture dislocations** are often a strong *indication* for internal fixation to achieve anatomical reduction and stable fixation, allowing for early mobilization and preventing avascular necrosis or persistent instability. - The goal is to restore joint congruity and maintain reduction, which is difficult to achieve and maintain with non-operative methods. *Intraarticular fracture* - **Intraarticular fractures** are frequently *managed with* internal fixation to restore articular surface congruity, minimize post-traumatic arthritis, and allow for early range of motion. - Precise reduction and stable fixation are crucial to prevent long-term complications such as joint stiffness and osteoarthritis. *Physeal injury* - **Physeal injuries** (growth plate fractures) are often *treated with* surgical fixation, particularly unstable or displaced fractures, to ensure anatomical reduction and prevent growth disturbances. - The fixation technique must be chosen carefully to avoid damaging the physis itself, often using smooth pins or screws that do not cross the growth plate.
Question 3: An RTA patient presented to the emergency department with severe pain in the ankle. An X-ray was performed, given below. What is the best next step in management?
- A. Neurovascular Assessment and Closed reduction with slab application (Correct Answer)
- B. Neurovascular Assessment and Closed reduction with cast application
- C. Neurovascular Assessment and Immediate surgery
- D. Neurovascular Assessment and Immediate open reduction
Explanation: ***Neurovascular Assessment and Closed reduction with slab application*** - The X-ray shows an **ankle dislocation without an obvious fracture**, making **closed reduction** the appropriate initial treatment. - A **slab (splint)** is preferred over a full cast initially for acute injuries to accommodate for swelling, reducing the risk of compartment syndrome, and allowing for serial neurovascular checks. *Neurovascular Assessment and Closed reduction with cast application* - While closed reduction is correct, applying a **full cast** immediately after an acute injury carries a risk of **compartment syndrome** due to potential swelling that cannot be accommodated by a rigid cast. - A cast would typically be applied after the initial swelling has subsided, usually a few days to a week after initial reduction and splinting. *Neurovascular Assessment and Immediate surgery* - **Immediate surgery** is generally reserved for **open fractures/dislocations**, dislocations that cannot be reduced closed (irreducible dislocations), or those with significant associated fractures that require surgical fixation to stabilize the joint. - In this case, the dislocation appears to be isolated and amenable to closed reduction, making surgery not the immediate next step. *Neurovascular Assessment and Immediate open reduction* - **Open reduction** is performed when closed reduction fails or is contraindicated, for example, due to soft tissue interposition or highly unstable fracture patterns. - Since closed reduction has not yet been attempted, immediate open reduction is premature and unnecessary for an apparently simple dislocation.
Question 4: A patient with metastatic breast cancer presents with pathological fracture of femur. What is the best fixation method?
- A. Long Intramedullary Nail (Correct Answer)
- B. External Fixator
- C. Dynamic Hip Screw
- D. Plate and Screws
Explanation: ***Long Intramedullary Nail*** - Provides **strong internal fixation** that can bear weight immediately, crucial for patients with a limited life expectancy due to metastatic disease. - Stabilizes the entire bone, preventing further **pathological fractures** in the diaphysis and allowing earlier mobilization and pain relief. *External Fixator* - Primarily used for **temporary stabilization** in severe open fractures or polytrauma, and not for definitive fixation of pathological fractures. - High risk of **pin tract infections** and patient discomfort, making it unsuitable for long-term management in cancer patients. *Dynamic Hip Screw* - Primarily used for **intertrochanteric hip fractures**, which are typically proximal femur fractures. - Less effective for **diaphyseal fractures** or for stabilizing bone weakened by metastatic disease along its entire length. *Plate and Screws* - While effective for some fractures, plates may not provide sufficient **load-bearing capacity** for extensively lytic or weakened bone in metastatic disease without extensive bone grafting. - Risk of **stress shielding** and subsequent re-fracture proximal or distal to the plate, especially when the intramedullary canal is compromised by tumor.
Question 5: Open reduction (OR) is not required in which fracture?
- A. Fracture of the patella
- B. Fracture of the outer one-third of the radius (Correct Answer)
- C. Displaced fracture of the olecranon
- D. Fracture of the condyle of the humerus
Explanation: ***Fracture of the outer one-third of the radius*** - Fractures of the **outer one-third of the radius** (distal radius fractures) often can be managed with **closed reduction and casting** if stable and adequately reduced. - While some unstable distal radius fractures require OR, many stable patterns, especially those with minimal displacement or good alignment after closed manipulation, do not. *Fracture of the patella* - Many patellar fractures lead to significant **extensor mechanism disruption**, necessitating OR with **tension band wiring** or screw fixation to restore quadriceps function. - Displaced patellar fractures, especially transverse ones, require surgical fixation to prevent extensor lag and **nonunion**. *Displaced fracture of the olecranon* - Displaced olecranon fractures disrupt the **triceps mechanism** and compromise elbow stability, almost always requiring **open reduction and internal fixation (ORIF)**, typically with tension band wiring. - Without surgical repair, a displaced olecranon fracture can lead to significant loss of extension strength and **nonunion**. *Fracture of the condyle of the humerus* - Fractures of the humeral condyle, particularly in children, often require OR due to the risk of **avascular necrosis** (especially lateral condyle) and the need for **precise anatomical reduction** to prevent joint incongruity and cubitus varus/valgus deformities. - Intra-articular and displaced condylar fractures almost invariably require surgical intervention to ensure harmonious joint function and prevent long-term complications like **stiffness and deformity**.
Question 6: Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint
- A. $1,2,3,4,5,6$
- B. $3,5,6$ (Correct Answer)
- C. $3,4,5$
- D. $1,2,4$
Explanation: ***3,5,6*** - For **tibia traction** in a femoral shaft fracture, you would need a **Steinmann pin** for skeletal traction, a **Bohler's stirrup** to apply the traction force, and a **Bohler-Braun splint** to support the limb. - The **Steinmann pin** is inserted into the proximal tibia, the **Bohler's stirrup** attaches to the pin, and the **Bohler-Braun splint** provides a fixed structure for the traction system. *1,2,3,4,5,6* - This option incorrectly includes items not specifically used for applying **tibia traction** (e.g., K-wire is for internal fixation, Thomas splint is for early femur fracture management but not specifically for tibia traction application). - While some components might be used in general fracture management, not all are directly involved in setting up tibia traction as requested. *3,4,5* - This option correctly includes the **Steinmann pin** and **Bohler's stirrup** but incorrectly replaces the **Bohler-Braun splint** with a **Denham's pin**. - A **Denham's pin** is an alternative to a Steinmann pin for skeletal traction, but a **Bohler-Braun splint** is crucial for supporting the limb in this setup, which is missing here. *1,2,4* - This option includes a **Thomas splint** (used for femur fracture support, not tibia traction application), a **K-wire** (used for internal fixation, not traction), and a **Denham's pin** (an alternative to Steinmann pin, but lacks the necessary support and traction application equipment). - These items are not suitable for setting up comprehensive **tibia traction** for a femoral shaft fracture.
Question 7: Which of the following is false regarding clavicle?
- A. First bone to ossify
- B. Membranous ossification
- C. Fracture can be treated with figure of 8 bandage
- D. Non-union is the commonest complication of clavicle fractures (Correct Answer)
Explanation: ***Non-union is the commonest complication of clavicle fractures*** - While clavicle fractures are relatively common, **malunion** (healing in an imperfect position) is more frequent than non-union. - **Non-union** typically occurs in less than 5% of all clavicle fractures, making it a rare complication rather than the commonest. *First bone to ossify* - The clavicle is indeed the **first bone to ossify** in the human embryo, beginning around the 5th to 6th week of gestation. - This characteristic highlights its unique developmental pathway compared to most other bones. *Membranous ossification* - The clavicle develops primarily through **intramembranous ossification**, which involves direct ossification of mesenchymal tissue without a cartilaginous precursor. - It's one of the few bones in the body, along with some bones of the skull, that ossifies this way. *Fracture can be treated with figure of 8 bandage* - A **figure-of-eight bandage** was historically used for clavicle fractures to provide reduction and immobilization. - However, current evidence suggests that a **simple sling** is equally effective and often more comfortable, with less risk of complications like neurovascular compression.
Question 8: Locking compression plating is indicated in
- A. Fracture shaft of femur
- B. Fracture shaft of humerus
- C. Periarticular fractures (Correct Answer)
- D. Intertrochanteric fracture
Explanation: ***Periarticular fractures*** - **Locking compression plates (LCPs)** are designed with threaded screw holes that lock the screws into the plate, providing **angular stability**. - This construct is particularly beneficial in **periarticular fractures** where the bone quality is often poor and comminution is common, as it prevents screw pull-out and maintains reduction. *Fracture shaft of femur* - For diaphyseal fractures of the femur, **intramedullary nailing** is generally the preferred treatment due to its load-sharing capabilities and minimally invasive nature. - While plates can be used in certain situations, LCPs are not the primary indication for routine femoral shaft fractures. *Fracture shaft of humerus* - Many humerus shaft fractures can be treated non-operatively with a brace or functional casting, especially if they are closed and stable. - Surgical intervention often involves **intramedullary nailing** or conventional plating, but LCPs are not selectively indicated over other plating systems for straightforward diaphyseal humerus fractures. *Intertrochanteric fracture* - **Intertrochanteric fractures** of the hip are typically treated with **intramedullary nails** (e.g., Gamma nail, Trochanteric Fixation Nail) or dynamic hip screws. - These devices allow for controlled collapse and impaction, which is crucial for stability in these osteoporotic fractures; LCPs are not the standard treatment.
Question 9: All of the following are indications for open reduction and internal fixation (ORIF) of fractures EXCEPT:
- A. Multiple trauma
- B. Stable closed fracture (Correct Answer)
- C. Compound fracture
- D. Intra-articular fracture
Explanation: ***Stable closed fracture*** - A **stable closed fracture** typically does not require surgical intervention with ORIF as it can usually be managed non-surgically with casting or bracing. - The goal of ORIF is to achieve **anatomic reduction and rigid fixation**, which is not necessary for stable fractures that maintain alignment. *Multiple trauma* - In patients with **multiple trauma**, early stabilization of long bone fractures using ORIF can help reduce pain, prevent further injury, and facilitate patient mobilization. - This approach aims to reduce the risk of complications such as **ARDS (acute respiratory distress syndrome)** and fat embolism for critically ill patients. *Compound fracture* - **Compound (open) fractures** involve a break in the skin, exposing the bone to the external environment, and are a classic indication for surgical management. - ORIF in these cases helps to achieve **stabilization** after debridement, crucial for preventing infection and promoting bone healing. *Intra-articular fracture* - **Intra-articular fractures** involve the joint surface, and accurate anatomical reduction is critical to prevent post-traumatic arthritis and preserve joint function. - ORIF provides the precise reduction and stable fixation needed to restore the **joint congruity**.
Question 10: Treatment of choice of flail chest is
- A. Strapping
- B. Intrapleural local analgesia
- C. Ext. fixation of flail segment & mech ventilation (Correct Answer)
- D. O2 administration
Explanation: ***Ext. fixation of flail segment & mech ventilation*** - **Modern context**: External fixation is now **rarely used** and has been largely replaced by internal pneumatic stabilization. - **Mechanical ventilation** with positive end-expiratory pressure (PEEP) provides **internal pneumatic stabilization** of the flail segment and is indicated for **severe respiratory failure**, refractory hypoxemia, or when conservative measures fail. - This represents the **definitive intervention** for severe flail chest with respiratory compromise, though modern management emphasizes a **stepwise approach** starting with aggressive pain control. - **Surgical fixation** (rib plating) is now reserved for specific indications: severe chest wall instability, failed conservative management, or during thoracotomy for other injuries. *Strapping* - **Contraindicated** in flail chest as it restricts chest wall movement, impairs ventilation, and worsens respiratory mechanics. - Increases risk of **atelectasis**, **pneumonia**, and **respiratory failure** by preventing adequate chest expansion. - This outdated approach has been abandoned in modern trauma care. *Intrapleural local analgesia* - **Pain control is crucial** in modern flail chest management and is considered the **cornerstone of conservative treatment**. - **Epidural analgesia**, **intercostal nerve blocks**, and **intrapleural analgesia** allow effective breathing, coughing, and pulmonary toilet, preventing respiratory complications. - Modern guidelines emphasize that **adequate analgesia** may avoid the need for mechanical ventilation in many cases by enabling effective spontaneous breathing. - However, analgesia alone does not provide respiratory support in cases with **severe pulmonary contusion** or **respiratory failure**. *O2 administration* - Supportive measure that addresses **hypoxemia** but does not stabilize the chest wall or provide ventilatory support. - Insufficient as monotherapy for significant flail chest, especially with associated pulmonary contusion. - Should be part of comprehensive management but is not definitive treatment.
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