Intramedullary Nailing — MCQs
The contraindication to internal fixation -
A 26-year-old male presented with proximal 1/3rd fracture shaft of the femur. What is the treatment of choice in this patient?
What is the biomechanical principle involved in symphyseal fracture with lag screw fixation?
Locking compression plating is indicated in
In a patient with multiple fractures, what is the most important initial management step?
All of the following are indications for open reduction and internal fixation (ORIF) of fractures EXCEPT:
All the following are the features of the Kuntscher (K) nail devised by a German surgeon for internal fixation of femoral fractures except
79 yrs old lady had fall, the following X-ray was taken. Which of the following is treatment?
Identify the implant shown in the image:
The commonest complication of fracture of clavicle is :
Intramedullary Nailing Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: A 26-year-old male presented with proximal 1/3rd fracture shaft of the femur. What is the treatment of choice in this patient?
- A. Hip Spica
- B. Above knee Cast
- C. Above knee Slab
- D. Interlocking Nail (Correct Answer)
Explanation: ***Interlocking Nail*** - **Interlocking nailing** is the treatment of choice for **femur shaft fractures** in adults, providing stable fixation and allowing early mobilization. - It involves inserting a **metal rod** into the medullary canal of the bone across the fracture site, with screws locking it in place at both ends. *Hip Spica* - A **hip spica cast** is typically used for **femur fractures in young children** (under 6 years old) as non-operative management. - It is **not suitable for adults** due to weight, discomfort, and the inability to maintain adequate reduction and stability for an adult-sized femur. *Above knee Cast* - An **above-knee cast** is generally insufficient for **femur shaft fractures** as it does not provide adequate immobilization of the hip joint. - It is more commonly used for **tibial fractures** or injuries to the knee/lower leg, not for a fracture as high as the proximal femoral shaft. *Above knee Slab* - An **above-knee slab** offers even less stability than a full cast and is usually a temporary measure for initial immobilization before definitive treatment or for less severe injuries. - It would be **inadequate to stabilize a femoral shaft fracture** and prevent displacement.
Question 3: What is the biomechanical principle involved in symphyseal fracture with lag screw fixation?
- A. Load bearing
- B. Load sharing (Correct Answer)
- C. Compression osteosynthesis
- D. Adaptation osteosynthesis
Explanation: **Load sharing** - Lag screw fixation allows for **interfragmentary compression** while still permitting some load to be borne by the surrounding bone and soft tissues, promoting a more physiological healing response. - This method provides a **stable environment** for bone healing by distributing forces across both the implant and the bone fragments. *Load bearing* - This principle implies that the **implant alone carries the majority of the load**, effectively shielding the fracture site from stress. - While a lag screw provides stability, it is not designed to be the sole load bearer; rather, it facilitates the bone's ability to bear load as it heals. *Compression osteosynthesis* - Although lag screws achieve compression, the term **compression osteosynthesis** is a broader concept that can include techniques like tension banding or plates, with the primary goal of creating stability through direct compression. - While **interfragmentary compression** is a part of lag screw fixation, "load sharing" more accurately describes the overall biomechanical outcome in symphyseal fractures where some physiological stress is beneficial for healing. *Adaptation osteosynthesis* - This refers to fixation designed primarily to **adapt or hold fragments in place** without providing significant compressive forces or the ability to share physiological loads directly with the bone during healing. - It’s typically used for non-weight-bearing fractures or where minimal stress is anticipated, which is not the case for symphyseal fractures.
Question 4: 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 5: In a patient with multiple fractures, what is the most important initial management step?
- A. Intravenous fluids
- B. Open reduction of fractures
- C. Blood transfusion
- D. Airway maintenance (Correct Answer)
Explanation: ***Airway maintenance*** - In any trauma patient, ensuring a **patent airway** is the absolute priority to prevent hypoxia and brain damage. - This is part of the primary survey (**ABCDE**) in trauma management, where life-threatening issues are addressed first. *Intravenous fluids* - While essential for managing **hypovolemia** due to blood loss in polytrauma, fluid resuscitation comes after securing the airway and ensuring adequate breathing. - Administering fluids to a patient who cannot breathe effectively will not resolve the primary issue. *Blood transfusion* - **Blood transfusion** is necessary for significant hemorrhage and can be life-saving, but it is not the *initial* management step. - Airway, breathing, and circulation (which includes addressing significant hemorrhage) collectively precede the decision and initiation of blood transfusions. *Open reduction of fractures* - **Open reduction of fractures** is a definitive treatment for musculoskeletal injuries that is performed much later, after the patient has been stabilized. - It is an elective procedure in the context of initial trauma management and is not a life-saving measure in the acute phase.
Question 6: 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 7: All the following are the features of the Kuntscher (K) nail devised by a German surgeon for internal fixation of femoral fractures except
- A. It is clover leaf in cross section
- B. The nail is a hollow with a slot on one side
- C. The nail has eye at one end (Correct Answer)
- D. The fixation by k nailing is based on the three point fixation
Explanation: ***The nail has eye at one end*** - The Kuntscher (K) nail is designed with a specific *cloverleaf cross-section* and is *hollow with a slot* along one side, facilitating its insertion and providing flexibility. - While it has a specific shape and structure, a distinct "eye" at one end is not a characteristic feature of the nail itself; its proximal and distal ends are designed for insertion and stability within the medullary canal. *It is clover leaf in cross section* - This is a characteristic feature of the K-nail, providing **rotational stability** and allowing for efficient load transfer within the medullary canal. - The **cloverleaf design** allows the nail to be driven into the canal while still permitting some blood flow around it. *The nail is a hollow with a slot on one side* - The K-nail has a **hollow design** to allow for instruments to pass through and to reduce its overall weight. - The **longitudinal slot** allows for elasticity and compression when driven into the bone, increasing fixation stability. *The fixation by K nailing is based on the three-point fixation* - **Three-point fixation** is a fundamental mechanical principle used by the K-nail to stabilize femoral fractures. - The nail bends slightly within the medullary canal, creating **three points of contact** with the inner cortical bone, thereby preventing movement at the fracture site.
Question 8: 79 yrs old lady had fall, the following X-ray was taken. Which of the following is treatment?
- A. Hip spica
- B. Nailing
- C. Hemiahroplasty (Correct Answer)
- D. Total Hip Replacement
Explanation: ***Hemiarthroplasty*** - The X-ray shows a **displaced femoral neck fracture** in an elderly patient, which typically has a high risk of **avascular necrosis** of the femoral head due to disruption of blood supply. - Hemiarthroplasty involves replacing only the **femoral head and neck** with a prosthetic component, leaving the acetabulum intact, which is suitable for elderly patients with good acetabular cartilage and less active lifestyles. *Hip spica* - A hip spica cast is primarily used for **pediatric femur fractures** or certain types of hip dislocations in children, not for displaced femoral neck fractures in elderly adults. - This method would not provide stable fixation or address the high risk of **avascular necrosis** associated with these fractures in older patients. *Nailing* - Nailing (intramedullary nailing) is typically used for **intertrochanteric fractures** or subtrochanteric fractures, where the fracture line is distal to the femoral neck. - For displaced femoral neck fractures, nailing alone may not provide adequate stability and carries a higher risk of **non-union** or **avascular necrosis** compared to arthroplasty in elderly patients. *Total Hip Replacement* - Total hip replacement involves replacing both the **femoral head and the acetabulum** with prosthetic components. - While an option for femoral neck fractures, it is generally reserved for younger, more active patients or those with pre-existing **acetabular pathology** like arthritis, as it is a more extensive and complex procedure than hemiarthroplasty.
Question 9: Identify the implant shown in the image:
- A. Dynamic hip screw (Correct Answer)
- B. Cannulated hip screw
- C. Condylar hip screw
- D. Intramedullary nail
Explanation: ***Dynamic hip screw*** - The image shows a **lag screw** inserted into the femoral neck and head, which slides within a **side plate** attached to the femoral shaft with cortical screws. - This construct allows for controlled **dynamic collapse** and impaction at the fracture site, promoting healing and providing stable fixation for **extracapsular hip fractures**. *Cannulated hip screw* - Cannulated screws are typically used in a **parallel configuration** or as a single large screw for hip fractures, particularly **femoral neck fractures**. - They do not feature a **side plate** that extends down the femoral shaft for additional fixation. *Condylar hip screw* - A condylar hip screw (DCS) is used for **distal femur fractures**, often extending into the **condyles**. - It involves a different angulation and design compared to the proximal femoral implant seen, which is fixed to the femoral shaft. *Intramedullary nail* - An intramedullary nail is inserted into the **medullary canal** of the bone, running through its center. - While some hip nails (e.g., trochanteric nails) have a cephalic screw component, they primarily stabilize the shaft from within, unlike the **extracortical side plate** seen here.
Question 10: The commonest complication of fracture of clavicle is :
- A. non union
- B. avascular necrosis
- C. Neurovascular injury
- D. malunion (Correct Answer)
Explanation: ***malunion*** - **Malunion** is the most frequent complication following a clavicle fracture, meaning the bone heals in an anatomically incorrect or deformed position. - This often results in a palpable bump or cosmetic deformity, and can occasionally cause functional impairment. *non union* - **Non-union** occurs when the fracture fails to heal completely, leaving a persistent gap between the bone fragments. - While possible, it is less common than malunion in clavicle fractures, especially with appropriate management. *avascular necrosis* - **Avascular necrosis** is rare in clavicle fractures because the clavicle has a rich blood supply. - It typically affects bones with precarious blood supply, such as the femoral head or scaphoid. *Neurovascular injury* - **Neurovascular injury** involving the subclavian vessels or brachial plexus is a serious but relatively rare complication of clavicle fractures. - While possible, especially with displaced fractures, it is not the most common adverse outcome.
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