Trauma Practice Questions

Q: What is the preferred treatment for an inter-trochanteric fracture in a 72-year-old female?

Hemiarthroplasty / Dynamic Hip Screw (DHS). ***Hemiarthroplasty / Dynamic Hip Screw (DHS)*** - **DHS** is the standard treatment for stable (Type I and II) inter-trochanteric fractures, providing controlled collapse and compression at the fracture site. - For unstable fractures (Type III and IV), especially in elderly patients with poor bone quality, **Intramedullary (IM) nailing** is often preferred over DHS due to superior biomechanical stability, though the combination option provided suggests the widely applicable stabilization principles for this age group. ***Intramedullary nailing*** - **IM nailing** is generally the preferred choice for unstable inter-trochanteric fractures (e.g., reverse oblique pattern or severe comminution) as it resists varus collapse more effectively than DHS. - While highly effective, it is not the *only* preferred treatment, and DHS remains primary for stable patterns, making the combined option more comprehensive for standard fracture care in the elderly. ***Open Reduction and Internal Fixation (ORIF) with plating*** - ORIF with plate fixation (other than DHS) is rarely used for inter-trochanteric fractures today, as it involves extensive soft tissue stripping and offers inferior biomechanical stability compared to compression screws (DHS) or nails. - This technique is typically reserved for highly unusual fracture patterns or as a salvage procedure, not as the primary 'preferred' method. ***Boot and bar*** - **Traction (boot and bar)** is historical and obsolete for treating hip fractures, including inter-trochanteric fractures. - Modern management mandates operative fixation as soon as the patient is medically optimized to allow early mobilization, reduce pain, and prevent complications like **deep vein thrombosis (DVT)** and pneumonia.

Q: A 25-year-old man presents to the emergency department following a motorbike accident and is found to have a closed midshaft fracture of the left tibia. Six hours later, he develops severe leg pain that is disproportionate to the injury and worsens with passive dorsiflexion of the foot. The pain is not relieved by analgesics. On examination, dorsalis pedis and posterior tibial pulses are present, but there is no sensation over the first dorsal webspace. What is the most appropriate next step in management?

Immediate fasciotomy. ***Immediate fasciotomy*** - The clinical presentation of severe, disproportionate pain, pain on passive stretching, and altered sensation (**paresthesia**) in the setting of a major fracture is highly indicative of **acute compartment syndrome**. - **Fasciotomy** is the definitive, urgent treatment to decompress the muscle compartments and prevent irreversible tissue necrosis and nerve damage. *Elevate the limb and observe* - Elevating the limb may further decrease the **arterial-venous pressure gradient**, potentially worsening an already compromised perfusion. - Observation is inappropriate because **acute compartment syndrome** requires immediate surgical intervention to prevent serious, permanent deficits or loss of function. *Administer opioid analgesics and continue observation* - Analgesics, even strong opioids, will only mask the classic symptom (**disproportionate pain**) but will not address the underlying pathology (increased intracompartmental pressure). - Continued observation will lead to progression of **ischemia**, resulting in irreversible muscle and nerve damage after approximately 6-8 hours. *Apply cast and follow up* - Applying a cast in the setting of suspected **compartment syndrome** is contraindicated, as the rigid cast can contribute to or exacerbate the compartment pressure. - Following up later is dangerous and negligent, as this condition is a surgical emergency requiring intervention within the **golden hour(s)** to salvage limb function.

Q: What does the given image show?

Kessel's plate. ***Kessel's plate*** - The image clearly labels the items on the right side as "b. Kessel's plate," which is a type of **osteosynthesis plate** used for fixing bone fractures. - Kessel's plates are designed to provide **stable fixation** for specific types of fractures, often in the distal femur or tibia. *Dynamic hip screw* - The image labels the items on the left side as "a. Dynamic hip screw," which is a different orthopedic implant than the one in question. - A dynamic hip screw (DHS) is primarily used for the fixation of **intertrochanteric hip fractures** and has a distinct design with a sliding screw. *Amp rasp* - An Amp rasp is a surgical tool used in **hip arthroplasty** to prepare the femoral canal for the stem of a hip prosthesis. - The items shown in the image are **implants** for fixation, not surgical rasps. *Bipolar hip prosthesis* - A bipolar hip prosthesis is a type of **hip replacement implant** used in hemiarthroplasty, consisting of two articulating components. - The image displays **fixation plates and screws**, not a joint replacement prosthesis.

Q: Identify the fracture shown in the image below:

Fracture tibia. ***Fracture tibia*** - The image displays a **long bone fracture** in the lower leg, characterized by a visible fracture line (indicated by the arrow) through the shaft. - The upper part of the image clearly shows the **knee joint**, confirming this as a view of the tibia (shin bone). *Fracture radius* - The radius is a bone in the **forearm**, not the lower leg. - The image clearly depicts the **lower extremity** with a knee joint visible. *Colle's fracture* - A Colles' fracture is a specific type of fracture of the **distal radius** (near the wrist), which is in the forearm. - The fracture shown is in the **tibia**, a bone of the lower leg, and the location is not characteristic of a Colles' fracture. *Supracondylar fracture humerus* - The humerus is the **upper arm bone**, and a supracondylar fracture occurs near the elbow joint. - The image shows a fracture in the **lower leg**, specifically the tibia, not the upper arm.

Q: Which of the following classifications is used to assess the fracture shown below?

Pipkins classification. ***Pipkins classification*** - The image shows a **femoral head fracture**, indicated by the arrow, with internal fixation. The Pipkins classification system specifically categorizes fractures of the **femoral head**. - This system helps guide treatment and prognostication for these particular hip injuries, differentiating based on location and associated injuries. *Gustilo classification* - The Gustilo classification is used for **open fractures**, assessing the extent of soft tissue damage and contamination. - The image displays a post-operative X-ray of a surgically fixed fracture, and the classification is not applicable here as it pertains to the initial presentation of an open fracture. *Salter and Harris classification* - The Salter-Harris classification system is used for **growth plate (physeal) fractures** in children. - The image shows a fracture in an adult bone (as evidenced by the fused growth plates and the morphology of the bone), making this classification irrelevant. *Weber classification* - The Weber classification is used for **ankle fractures**, specifically those involving the distal fibula. - The fracture shown in the image is of the **femoral head**, not the ankle, hence the Weber classification is not appropriate.

Q: The X-ray was taken 8 weeks after sustaining fracture. What is the diagnosis?

Nonunion. ***Nonunion*** - The X-ray image shows a clear **gap** between the two bone fragments, and the bone ends appear **sclerotic** and rounded, indicating that the bone has failed to heal after 8 weeks. - Nonunion is the failure for a fracture to heal after a reasonable period, often defined by the absence of signs of healing for 3-6 months depending on the bone and site, but after 8 weeks with clearly visible sclerotic fragment ends suggests this condition. *Malunion* - **Malunion** occurs when a fracture heals, but in a **deformed** or anatomically incorrect position, which is not evident in the provided image as the fragments are still separate. - The primary problem here is the *absence* of healing, not the healing in a misaligned fashion. *Myositis ossificans* - **Myositis ossificans** is the formation of **heterotopic bone** within muscle or soft tissue, typically following trauma, and would appear as calcification *outside* the bone shaft. - The image clearly depicts unhealed bone fragments, not new bone formation within surrounding soft tissues. *Avascular necrosis* - **Avascular necrosis** (AVN) is the death of bone tissue due to interruption of blood supply, often leading to **collapse of the bone**, which is usually seen in particular bones like the femoral head or scaphoid. - While AVN can complicate fractures, the image primarily shows a lack of bony bridging rather than changes indicative of bone death and collapse.

Q: Which of the following is most commonly seen after the accident shown?

Posterior hip dislocation. ***Posterior hip dislocation*** - The image depicts a classic mechanism of injury in a dashboard injury, where the **knee strikes the dashboard**, driving the femur posteriorly. - This force, especially when the hip is flexed and adducted, can eject the femoral head **posteriorly out of the acetabulum**. *Anterior hip dislocation* - This type of dislocation typically occurs with the hip in **flexion, abduction, and external rotation**, a mechanism not suggested by the diagram. - It is much **less common** than posterior hip dislocation in dashboard injuries. *Posterior tibial dislocation* - While a dashboard injury can affect the knee, a direct posterior force on the tibia itself is more likely to cause a **tibial plateau fracture** or **ligamentous injury** (e.g., PCL tear) than a complete tibiofemoral dislocation in this context. - A posterior tibial dislocation results from severe hyperextension or a direct blow to the anterior tibia when the knee is flexed, which is a different vector of force than the one illustrated. *Anterior tibial dislocation* - This injury typically results from a **hyperextension injury** of the knee or a force applied to the posterior aspect of the proximal tibia. - The image shows a force specifically directed towards the *anterior* aspect of the knee (dashboard impact), making posterior displacement of the femur relative to the pelvis more likely.

Q: What is the name of the splint shown here?

Bohler Braun splint. ***Bohler Braun splint*** - The image displays a **Bohler Braun splint**, characterized by its **trapezoidal shape** and often used for lower extremity fractures. - It features a frame designed to provide **traction and support**, with a U-shaped or ring component at one end and a tapering support surface. *Aeroplane splint* - An aeroplane splint positions the arm in **abduction** (away from the body) and often **external rotation**, resembling an airplane wing. - It is typically used for shoulder and upper arm injuries, which is distinct from the lower limb support seen in the image. *Von Rosen splint* - The Von Rosen splint is a **hip abduction brace** used in infants for congenital hip dislocation. - It positions the hips in **flexion and abduction**, which is entirely different from the long, tapering splint shown. *Thomas splint* - A Thomas splint is a **traction splint** used for femoral shaft fractures, characterized by a large ring that fits around the groin and long sidebars. - While it provides traction like the Bohler Braun splint, its design, particularly the **prominent thigh ring**, is distinctly different from the broad, tapering shape in the image.

Q: Spot the diagnosis:

Malgaigne fracture. ***Malgaigne fracture*** - This image demonstrates a **Malgaigne fracture**, characterized by **vertical sheer unstable pelvic fractures** involving the posterior pelvic arch (sacroiliac joint dislocation or sacral fracture) and two fractures of the ipsilateral anterior pelvic arch (pubic rami fractures). - The arrows in the image point to the fractures of the pubic rami and the displacement at the sacroiliac joint, consistent with the definition. *Straddle fracture* - A **straddle fracture** involves bilateral fractures of both the superior and inferior pubic rami, typically as a result of a direct blow to the perineum. - This image shows unilateral pubic rami fractures combined with a posterior injury (sacroiliac dislocation), which is characteristic of a Malgaigne fracture rather than a straddle fracture. *Pubic rami with penile fracture* - While there are pubic rami fractures visible, there is **no radiological evidence of a penile fracture** on an X-ray. Penile fractures are soft tissue injuries involving the tunica albuginea and are typically diagnosed clinically or with ultrasound/MRI. - The combination of anterior and posterior pelvic ring injuries observed in the image points to a Malgaigne fracture, which has a specific definition beyond just pubic rami fractures. *Sacroiliac joint dislocation only* - The image clearly shows disruption of the **sacroiliac joint** on one side, but it also demonstrates **associated fractures of the ipsilateral pubic rami**. - A diagnosis of "sacroiliac joint dislocation only" would be incomplete as it misses the critical anterior pelvic ring injuries, which together with the posterior injury define a Malgaigne fracture.

Q: What is the grade of fracture according to Garden's classification?

Grade III. ***Grade III*** - This image shows a **complete displaced fracture** of the femoral neck, but with the **distal fragment in valgus** position, which corresponds to Garden Grade III. - In Garden Grade III, the fracture is **complete and displaced**, but there is still some **engagement** of the fracture surfaces, leading to the valgus alignment of the head on the shaft. *Grade I* - Garden Grade I refers to an **incomplete impacted valgus fracture** of the femoral neck. - The fracture line is visible, but there is no displacement, and the head is tilted into a valgus position relative to the neck. *Grade II* - Garden Grade II describes a **complete but non-displaced fracture** of the femoral neck. - The fracture line extends across the entire neck, but the fragments remain in anatomical alignment without angulation or displacement. *Grade IV* - Garden Grade IV is characterized by a **complete and fully displaced fracture** of the femoral neck, with the **femoral head completely separated** from the shaft and in a neutral or varus position. - There is a complete loss of contact and alignment between the femoral head and the shaft, indicating significant instability.

Question 1

What is the preferred treatment for an inter-trochanteric fracture in a 72-year-old female?

Accepted Answer

Hemiarthroplasty / Dynamic Hip Screw (DHS)

Answer

Intramedullary nailing

Answer

Open Reduction and Internal Fixation (ORIF) with plating

Answer

Boot and bar

Question 2

A 25-year-old man presents to the emergency department following a motorbike accident and is found to have a closed midshaft fracture of the left tibia. Six hours later, he develops severe leg pain that is disproportionate to the injury and worsens with passive dorsiflexion of the foot. The pain is not relieved by analgesics. On examination, dorsalis pedis and posterior tibial pulses are present, but there is no sensation over the first dorsal webspace. What is the most appropriate next step in management?

Accepted Answer

Immediate fasciotomy

Answer

Administer opioid analgesics and continue observation

Answer

Apply cast and follow up

Answer

Elevate the limb and observe

Question 3

What does the given image show?

Accepted Answer

Kessel's plate

Answer

Dynamic hip screw

Answer

Amp rasp

Answer

Bipolar hip prosthesis

Question 4

Identify the fracture shown in the image below:

Accepted Answer

Fracture tibia

Answer

Fracture radius

Answer

Colle's fracture

Answer

Supracondylar fracture humerus

Question 5

Which of the following classifications is used to assess the fracture shown below?

Accepted Answer

Pipkins classification

Answer

Gustilo classification

Answer

Salter and Harris classification

Answer

Weber classification

Question 6

The X-ray was taken 8 weeks after sustaining fracture. What is the diagnosis?

Accepted Answer

Nonunion

Answer

Malunion

Answer

Myositis ossificans

Answer

Avascular necrosis

Question 7

Which of the following is most commonly seen after the accident shown?

Accepted Answer

Posterior hip dislocation

Answer

Anterior hip dislocation

Answer

Posterior tibial dislocation

Answer

Anterior tibial dislocation

Question 8

What is the name of the splint shown here?

Accepted Answer

Bohler Braun splint

Answer

Aeroplane splint

Answer

Von Rosen splint

Answer

Thomas splint

Question 9

Spot the diagnosis:

Accepted Answer

Malgaigne fracture

Answer

Straddle fracture

Answer

Pubic rami with penile fracture

Answer

Sacroiliac joint dislocation only

Question 10

What is the grade of fracture according to Garden's classification?

Accepted Answer

Grade III

Answer

Grade I

Answer

Grade II

Answer

Grade IV

Trauma — MCQs

Trauma — MCQs

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