Trauma Practice Questions

Q: A 30 year old previously healthy man presented to the emergency department immediately after being involved in a road traffic accident. After clinical examination, scaphoid injury was suspected. A radiograph of the left wrist was obtained and found to be equivocal. What is the best next step?

Presumptive Casting. ***Presumptive Casting*** - When scaphoid fracture is suspected clinically but **radiographs are equivocal**, conservative management with **presumptive casting** is appropriate. - This prevents potential avascular necrosis and allows for healing if a fracture is present but not yet visible. *MRI Scan* - While an **MRI** is highly sensitive for detecting scaphoid fractures, it is not always immediately available or cost-effective as the very first step following equivocal X-rays in a stable patient. - Delaying immobilization to obtain an immediate MRI could lead to further displacement or complications if a fracture is indeed present. *Bone scintigraphy of wrist* - **Bone scintigraphy** (bone scan) can detect subtle fractures, but it is not typically performed immediately after injury due to its lower specificity and relatively longer time frame to show changes compared to other modalities like MRI. - It involves radiation and is usually reserved for cases where MRI is contraindicated or unavailable and earlier imaging was inconclusive. *CT Scan* - A **CT scan** is excellent for visualizing cortical bone and complex fractures but is less sensitive than MRI for detecting occult scaphoid fractures or soft tissue injuries. - It also involves significant radiation exposure, making it a secondary option to MRI or conservative management for initial detection.

Q: Which of the following is true about Colles' Fracture?

It is associated with dorsal angulation. ***It is associated with dorsal angulation*** - A **Colles' fracture** is a **distal radius fracture** with **dorsal displacement** and **dorsal angulation** of the distal fragment. - This classic presentation gives rise to the characteristic **"dinner fork" deformity** seen in Colles' fractures. *It may lead to gunstock deformity due to malunion* - **Gunstock deformity** (cubitus varus) is a common complication of **supracondylar fractures of the humerus**, not Colles' fractures. - It results from **malunion** of the humerus, leading to a decreased carrying angle of the elbow. *It is an intra-articular fracture* - A Colles' fracture is typically an **extra-articular fracture**, meaning the fracture line does not extend into the **radiocarpal joint**. - Fractures that extend into the joint are generally classified as **Barton's fractures** or **Chauffeur's fractures**. *Volar angulation with Radial deviation occurs* - **Volar angulation** of the distal fragment is characteristic of a **Smith's (or reverse Colles') fracture**, which is a different type of distal radius fracture. - Colles' fracture involves **dorsal displacement** and angulation.

Q: Position of wrist in cast of colle's fracture is:

Palmar deviation & pronation. ***Palmar deviation & pronation*** - This position helps to **reduce the fracture** by counteracting the typical **dorsal displacement** and **supination deformity** seen in a Colles' fracture. - **Pronation** is essential to correct the supination malposition of the distal fragment, achieving the **Cotton-Loder position** for optimal healing. *Palmar deviation & supination* - While **palmar deviation** correctly addresses the dorsal displacement, **supination** would worsen the existing supination deformity of the distal fragment. - This position fails to achieve proper **anatomical alignment** and may lead to malunion. *Dorsal deviation & pronation* - **Dorsal deviation** would exacerbate the typical **dorsal displacement** already present in a Colles' fracture. - Although pronation is correct for forearm positioning, dorsal deviation prevents proper **fracture reduction**. *Dorsal deviation & supination* - **Dorsal deviation** worsens the characteristic **dinner fork deformity** by increasing dorsal angulation. - **Supination** compounds the supination malposition of the distal fragment, leading to poor functional outcomes.

Q: Open reduction (OR) is not required in which fracture?

Fracture of the outer one-third of the radius. ***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**.

Q: Nonunion is most common in fracture of the:

Neck femur. ***Neck femur*** - Fractures of the **femoral neck** are highly prone to **nonunion** due to the precarious and often-disrupted blood supply to the femoral head, particularly the **retinacular arteries**. - The high biomechanical stress and difficulty in achieving stable fixation in this region further contribute to the increased risk of nonunion. *Talus* - While talar fractures, especially those of the **talar neck**, can have a high incidence of complications like **avascular necrosis** due to limited blood supply, nonunion is less common than in femoral neck fractures. - The talus has a complex vascular network that, while vulnerable, often allows for healing. *Scapula* - **Scapular fractures** are generally uncommon and, when they occur, typically heal well without surgical intervention. - Due to the surrounding musculature and rich vascular supply, nonunion of the scapula is extremely rare. *None of the options* - This option is incorrect because **nonunion is indeed a significant problem** in specific fractures, particularly those of the femoral neck, making it a viable answer.

Q: Management of Smith's fracture is

Above-elbow cast with forearm in pronation. ***Above-elbow cast with forearm in pronation*** - A Smith's fracture, also known as a **reverse Colles' fracture**, involves dorsal displacement of the distal radial fragment. - Applying an **above-elbow cast with the forearm in pronation** helps to stabilize the fracture by counteracting the deforming forces and maintaining reduction. *Above-elbow cast with forearm in supination* - **Supination** is typically used for a **Colles' fracture**, which involves volar (palmar) displacement. - In a Smith's fracture, supination would exacerbate the dorsal displacement and destabilize the reduction. *Open reduction and fixation* - This is considered for **unstable, highly comminuted, or irreducible fractures**, or when closed reduction fails. - For most Smith's fractures, especially if stable after reduction, conservative management with casting is the first line of treatment. *Closed reduction with below-elbow cast* - A **below-elbow cast** may not provide sufficient immobilization of the forearm, particularly in cases involving pronation/supination instability. - An **above-elbow cast** is generally preferred to control the rotation of the forearm and prevent redisplacement of the fracture fragments.

Q: Treatment of choice in a 65-year-old female with impacted fracture of the neck of the humerus is:

Triangular sling. ***Triangular sling*** - For **impacted fractures** of the humeral neck in elderly patients, non-operative management with a sling is often preferred due to the **stability of the fracture** and the patient's age. - This approach aims for pain control and early mobilization, reducing risks associated with surgery in the elderly. *Observation* - While close monitoring is part of management, simply "observation" without any immobilization like a sling is generally insufficient for a fracture. - It does not provide the initial support needed for fracture healing and pain management. *Arthroplasty* - **Arthroplasty** (joint replacement) is typically reserved for highly **displaced or comminuted fractures** where surgical fixation is not feasible, or in cases of **avascular necrosis**. - It is an **invasive procedure** with higher risks in an elderly patient and is not the first choice for a stable, impacted fracture. *Arm chest strapping* - **Arm chest strapping** is typically used for specific injuries like **rib fractures** or sternal contusions to immobilize the chest wall. - It is **not appropriate** for a humeral neck fracture, as it does not adequately immobilize the shoulder joint and could lead to complications like **shoulder stiffness**.

Q: A moving vehicle hits a pedestrian on his lateral aspect of the knee and causes a fracture. The fracture line is passing through the intercondylar eminence. Which of the following structures will most likely be injured

Anterior cruciate ligament. ***Anterior cruciate ligament*** - A fracture of the **intercondylar eminence** typically involves the avulsion of the **tibial attachment** of the anterior cruciate ligament (ACL). - The ACL's fibers attach to the **tibial intercondylar area**, making it highly susceptible to injury with a fracture in this region. *Medial collateral ligament* - The **medial collateral ligament** (MCL) originates from the medial femoral epicondyle and attaches to the medial tibia, primarily resisting valgus forces. - While knee trauma can affect the MCL, a fracture of the intercondylar eminence specifically points to an injury involving a structure attached to that area. *Medial meniscus* - The **medial meniscus** is a C-shaped cartilage in the knee joint and can be injured by rotational forces or compression. - Its injury is not directly linked to an intercondylar eminence fracture, although severe trauma can injure multiple structures. *Lateral collateral ligament* - The **lateral collateral ligament** (LCL) originates from the lateral femoral epicondyle and attaches to the fibular head, resisting varus forces. - An injury to the LCL is less likely with an intercondylar eminence fracture, as the LCL does not attach to this specific tibial region.

Q: A patient on colles cast presents after two weeks with the inability to extend his thumb, the most likely reason is:

Rupture of extensor pollicis longus tendon. ***Rupture of extensor pollicis longus tendon*** - The **extensor pollicis longus (EPL)** tendon is vulnerable to rupture in a Colles' cast due to **ischemia** from pressure or **attritional rupture** over bony prominences following fracture healing. - This typically presents weeks after casting with an inability to **actively extend the thumb**. *Sudek's osteodystrophy* - Characterized by **pain, swelling, stiffness, and skin changes** (e.g., shiny, atrophic skin, excessive sweating) distal to the injury, often associated with a painful joint. - While it causes significant disability, it does not specifically present as an isolated inability to extend the thumb. *Carpal tunnel syndrome* - Involves compression of the **median nerve**, leading to **numbness, tingling, and weakness** in the thumb, index, middle, and radial half of the ring fingers. - It would typically cause weakness in **thumb abduction and opposition**, not primarily an inability to extend the thumb, and is often painful. *Compartment syndrome* - Presents with severe pain, paresthesias, pallor, pulselessness, and paralysis, indicating **compromised blood flow** and pressure buildup within a fascial compartment. - It is an **acute emergency** usually occurring soon after injury and does not manifest primarily as isolated thumb extensor weakness two weeks later.

Q: Which of the following statement(s) is/are true?

Dinner fork deformity is characteristic of Colles' fracture. **Dinner fork deformity is characteristic of Colles' fracture** - **Colles' fracture** involves a **dorsal displacement** and angulation of the distal radius, creating a characteristic **"dinner fork" or "bayonet" deformity** of the wrist. - This specific deformity is a classic clinical sign that aids in the diagnosis of a Colles' fracture, which is an **extra-articular fracture** of the distal radius with dorsal angulation. *Normally the radial styloid is 1/2 lower than the ulnar* - The **radial styloid** normally extends approximately **1-1.5 cm (or about 1/2 inch)** *distal* to the ulnar styloid, not lower than. - This difference in length is crucial for normal wrist kinematics, and its reversal can indicate conditions like **ulnar positive variance**. *All of the options* - This option is incorrect because the statement regarding the radial styloid being lower than the ulnar is **false**. - Since one of the options provided is factually incorrect, this choice cannot be true. *Oedema & tenderness over the anatomical snuffbox is the characteristic features of Fracture of the scaphoid* - While **oedema and tenderness in the anatomical snuffbox** are hallmark signs of a **scaphoid fracture**, this statement alone does not encompass all the truth presented in the options. - This specific physical finding is highly indicative of a scaphoid fracture, necessitating further imaging to confirm the diagnosis due to **poor vascular supply** to the scaphoid and risk of **avascular necrosis**.

Question 1

A 30 year old previously healthy man presented to the emergency department immediately after being involved in a road traffic accident. After clinical examination, scaphoid injury was suspected. A radiograph of the left wrist was obtained and found to be equivocal. What is the best next step?

Accepted Answer

Presumptive Casting

Answer

MRI Scan

Answer

Bone scintigraphy of wrist

Answer

CT Scan

Question 2

Which of the following is true about Colles' Fracture?

Accepted Answer

It is associated with dorsal angulation

Answer

It may lead to gunstock deformity due to malunion

Answer

It is an intra-articular fracture

Answer

Volar angulation with Radial deviation occurs

Question 3

Position of wrist in cast of colle's fracture is:

Accepted Answer

Palmar deviation & pronation

Answer

Dorsal deviation & supination

Answer

Palmar deviation & supination

Answer

Dorsal deviation & pronation

Question 4

Open reduction (OR) is not required in which fracture?

Accepted Answer

Fracture of the outer one-third of the radius

Answer

Fracture of the patella

Answer

Displaced fracture of the olecranon

Answer

Fracture of the condyle of the humerus

Question 5

Nonunion is most common in fracture of the:

Accepted Answer

Neck femur

Answer

Talus

Answer

Scapula

Answer

None of the options

Question 6

Management of Smith's fracture is

Accepted Answer

Above-elbow cast with forearm in pronation

Answer

Above-elbow cast with forearm in supination

Answer

Open reduction and fixation

Answer

Closed reduction with below-elbow cast

Question 7

Treatment of choice in a 65-year-old female with impacted fracture of the neck of the humerus is:

Accepted Answer

Triangular sling

Answer

Observation

Answer

Arthroplasty

Answer

Arm chest strapping

Question 8

A moving vehicle hits a pedestrian on his lateral aspect of the knee and causes a fracture. The fracture line is passing through the intercondylar eminence. Which of the following structures will most likely be injured

Accepted Answer

Anterior cruciate ligament

Answer

Medial collateral ligament

Answer

Medial meniscus

Answer

Lateral collateral ligament

Question 9

A patient on colles cast presents after two weeks with the inability to extend his thumb, the most likely reason is:

Accepted Answer

Rupture of extensor pollicis longus tendon

Answer

Sudek's osteodystrophy

Answer

Carpal tunnel syndrome

Answer

Compartment syndrome

Question 10

Which of the following statement(s) is/are true?

Accepted Answer

Dinner fork deformity is characteristic of Colles' fracture

Answer

Normally the radial styloid is 1/2 lower than the ulnar

Answer

All of the options

Answer

Oedema & tenderness over the anatomical snuffbox is the characteristic features of Fracture of the scaphoid

Trauma — MCQs

Trauma — MCQs

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