Trauma Practice Questions

Q: Most common complication of mid shaft humerus fracture is ?

Radial nerve palsy. ***Radial nerve palsy*** - The **radial nerve** runs in close proximity to the **spiral groove** of the humerus, making it highly vulnerable to injury in mid-shaft fractures. - This results in the characteristic **wrist drop** and loss of sensation over the dorsal aspect of the hand. *Median nerve palsy* - The **median nerve** is not typically affected by mid-shaft humeral fractures as it is located more medially and anteriorly. - Injury to the median nerve is more common with supracondylar fractures of the humerus or carpal tunnel syndrome. *Nonunion* - While **nonunion** (failure of bone healing) occasionally occurs after mid-shaft humerus fractures, **radial nerve palsy** is a more immediate and frequent complication observed at the time of injury. - Risks for nonunion include severe trauma, soft tissue interposition, and inadequate immobilization. *Malunion* - **Malunion** (healing in an unacceptable alignment) can occur, especially with conservative management, but like nonunion, it is a complication of the healing process rather than an acute injury presentation. - Functional outcomes are generally good even with some degree of angulation in humeral shaft fractures.

Q: Thomas splint is used for immobilizing fractures of ?

Femur. ***Femur*** - The **Thomas splint** is primarily designed for the temporary immobilization and traction of **femoral shaft fractures**. - Its design allows for effective stabilization and helps reduce muscle spasms and pain associated with these types of fractures. *Tibia* - While it can be used in some lower limb injuries, the Thomas splint is not the primary or most effective device for isolated **tibial fractures**. - Other splints, such as a **long leg posterior splint** or an air splint, are typically preferred for tibial immobilization. *Radius* - The **radius** is a bone in the forearm, and its fractures are typically managed with a variety of **short arm casts** or splints. - The Thomas splint is specifically designed for the much longer and larger **femur** and would be completely unsuitable for a forearm injury. *Ulna* - Similar to the radius, the **ulna** is a forearm bone, and its fractures require immobilization techniques appropriate for the upper limb. - The **Thomas splint's bulk** and mechanism are inappropriate for the immobilization of forearm bones.

Q: Which of the following factors does NOT indicate an unstable pelvis?

Avulsion fractures of the L5 transverse process. ***Avulsion fractures of the L5 transverse process*** - While significant, avulsion fractures of the **L5 transverse process** are generally considered indicative of a **high-energy trauma** and potential for associated injuries, but they do not directly represent **pelvic instability** in the same way as disruptions to the pelvic ring itself. - These fractures point to powerful shearing forces but don't disrupt the **structural integrity** of the pelvic ring that dictates its stability. *Posterior sacroiliac complex displacement by > 1 cm* - This degree of displacement signifies a substantial injury to the **strong posterior ligamentous structures** of the sacroiliac joint. - Such displacement indicates a highly unstable pelvic ring, often associated with significant hemorrhage and requiring surgical stabilization. *Avulsion fracture of sacral or ischial end of the sacrospinous ligament* - An avulsion fracture at either the sacral or ischial attachment of the **sacrospinous ligament** suggests a severe disruption of the posterior pelvic ring. - The **sacrospinous ligament** is a key stabilizer of the pelvis, and injury to it indicates pelvic instability due to the loss of its anchoring function between the sacrum and ischium. *Isolated disruption of pubic symphysis with pubic diastasis of 2 cm.* - A **pubic diastasis of 2 cm** signifies a significant opening of the pubic symphysis, which is a critical anterior component of the pelvic ring. - This indicates **anterior pelvic instability**, even in the absence of posterior injuries, as the normal interlocking mechanism of the symphysis is compromised.

Q: Patient comes with crush injury to upper limb, doctor is concerned about gangrene and sepsis. What scoring system can help decide between amputation and limb salvage?

MESS. ***MESS*** - The **Mangled Extremity Severity Score (MESS)** is a widely used scoring system to assess the severity of limb injuries and predict the need for **amputation**. - It considers factors like **skeletal/soft tissue injury**, **limb ischemia**, **shock**, and **age** to guide management decisions. *Glasgow Coma Scale* - The **Glasgow Coma Scale (GCS)** is used to assess a patient's level of **consciousness** following a traumatic brain injury or other neurological insults. - It has no relevance in evaluating the severity of a **crush injury** to a limb or guiding decisions between amputation and limb salvage. *Gustilo Anderson classification* - The **Gustilo-Anderson classification** is used to categorize **open fractures** based on the extent of soft tissue damage, wound size, and contamination. - While it helps in assessing the **severity of an open fracture** and guiding initial treatment, it does not provide a comprehensive assessment for limb salvage versus amputation decision-making as MESS does. *ASIA guidelines* - The **ASIA (American Spinal Injury Association) Impairment Scale** is used to classify the severity of **spinal cord injuries**. - It evaluates sensory and motor function to determine the level and completeness of a spinal cord injury, which is unrelated to the assessment of a **crush injury** for limb salvage.

Q: 12 yr old Child admitted to ICU with blunt trauma and femur fracture- Pao2 60% despite 100%o2 and rebreather mask, CXR shows lung fields clear but the patient remains confused. What is most likely the diagnosis?

Fat embolism syndrome.. ***Fat embolism syndrome*** - A **femur fracture** is a classic risk factor for fat embolism syndrome, which causes hypoxemia, neurological dysfunction (confusion), and a normal chest X-ray in its early stages [1]. - The severe **hypoxemia (PaO2 60% despite 100% O2)** that is unresponsive to oxygen therapy is characteristic, along with the patient's altered mental status [1]. *Hypovolaemic shock* - While blunt trauma and a femur fracture can lead to hypovolemic shock, the primary symptoms would be **hypotension** and **tachycardia**, not profound hypoxemia with clear lung fields. - Hypovolemic shock typically causes **generalized tissue hypoperfusion**, not selective neurological symptoms and respiratory failure in the context of a normal chest X-ray. *Pulmonary embolism* - A pulmonary embolism can cause hypoxemia and confusion, but it is less likely immediately after blunt trauma unless there's a predisposing condition, and a **clear chest X-ray** makes it less probable compared to fat embolism syndrome. - Furthermore, the sudden and severe presentation of hypoxemia and neurological changes following a long bone fracture is more characteristic of fat embolism syndrome. *Pulmonary contusion* - Pulmonary contusion would likely be visible on a **chest X-ray** as infiltrates or consolidation and would typically present with symptoms of direct lung injury, such as cough or hemoptysis, which are not mentioned. - While it can cause hypoxemia, a **clear chest X-ray** makes pulmonary contusion an unlikely diagnosis in this scenario.

Q: As an intern in the emergency department, you encounter four patients with different types of fractures. Which patient should you prioritize for orthopedic consultation based on the severity of their condition?

Patient's finger shows signs of severe vascular compromise.. ***Patient's finger shows signs of severe vascular compromise*** - **Vascular compromise** is an orthopedic emergency as it can lead to **tissue ischemia**, necrosis, and permanent loss of function if not addressed immediately. - Urgent consultation is needed to restore **blood flow** and prevent irreversible damage to the limb. *Patient can't extend his arm* - This symptom suggests a potential **nerve injury** (e.g., radial nerve) or **tendon rupture**, which requires prompt evaluation but is generally less immediately life-threatening than vascular compromise. - While important, **nerve injuries** typically do not require the same emergent intervention as severe vascular compromise unless there's a rapidly deteriorating neurological deficit. *Intra articular fracture of Elbow Joint* - **Intra-articular fractures** involve the joint space and can lead to long-term complications like **arthrosis** and stiffness if not managed properly, often requiring surgical fixation. - Although significant, it is not as urgent as vascular compromise, which can lead to rapid **tissue death**. *Simple closed fracture of the radius with good distal circulation* - A **simple closed fracture** with **good distal circulation** is a stable injury that is typically managed non-surgically or with elective surgical intervention. - This type of fracture does not present an immediate threat to limb viability.

Q: Identify the bone numbered in the X-ray that most commonly fractures when a person falls on outstretched hands.

Distal radius. ***Distal radius*** - The **distal radius** is the bone most frequently fractured when a person falls on an **outstretched hand**. This is commonly known as a **Colles fracture** if the fragment is displaced dorsally. - The force of impact is transmitted directly to the distal end of the radius, making it susceptible to fracture, especially in cases of **osteoporosis**. *Scaphoid* - The **scaphoid** bone is also commonly fractured with a fall on an outstretched hand, but it is less frequent than the distal radius. - A scaphoid fracture is concerning due to its **precarious blood supply**, which can lead to **avascular necrosis** and non-union. *Lunate* - The **lunate** bone is centrally located in the wrist and is less commonly fractured but can be dislocated or injured in high-impact trauma. - Injuries to the lunate are often associated with **perilunate dislocations**, which are severe wrist injuries. *Capitate* - The **capitate** is the largest carpal bone, located in the center of the wrist, and is rarely fractured in isolation from a fall on an outstretched hand. - Fractures of the capitate are often associated with more extensive carpal injuries due to its robust nature and central, protected position.

Q: The K nail can be used for all of the following types of fractures except -

Intertrochanteric fractures. ***Intertrochanteric fractures*** - The K nail (specifically, the Kuntscher nail) is a **straight intramedullary nail** primarily designed for diaphyseal fractures. - It is **not suitable for intertrochanteric fractures** as these are metaphyseal and involve the proximal femur, requiring implants that offer greater stability in this region, such as cephalomedullary nails or plates. *Isthmic femur shaft fractures* - The **Kuntscher nail** was originally developed for and is well-suited for **isthmic femur shaft fractures** due to the narrow canal providing good cortical fixation. - Its design as a straight, broad nail fits snugly in the isthmus, providing excellent stability. *Low subtrochanteric fractures* - While more challenging, **K nails can be used for low subtrochanteric fractures**, especially if the fracture extends into the diaphyseal region. - However, newer implants like **cephalomedullary nails** are often preferred due to better biomechanical stability in this region. *Distal femur shaft fractures* - **K nails can be employed for distal femoral shaft fractures** if the fracture pattern allows for adequate fixation distal to the isthmus without compromising knee joint function. - The nail must be long enough to achieve stability, and the lack of proper locking mechanisms in traditional K nails may be a limiting factor compared to locked intramedullary nails.

Question 1

Most common complication of mid shaft humerus fracture is ?

Accepted Answer

Radial nerve palsy

Answer

Median nerve palsy

Answer

Nonunion

Answer

Malunion

Question 2

Thomas splint is used for immobilizing fractures of ?

Accepted Answer

Femur

Answer

Tibia

Answer

Radius

Answer

Ulna

Question 3

Which of the following factors does NOT indicate an unstable pelvis?

Accepted Answer

Avulsion fractures of the L5 transverse process

Answer

Posterior sacroiliac complex displacement by > 1 cm

Answer

Avulsion fracture of sacral or ischial end of the sacrospinous ligament

Answer

Isolated disruption of pubic symphysis with pubic diastasis of 2 cm.

Question 4

Patient comes with crush injury to upper limb, doctor is concerned about gangrene and sepsis. What scoring system can help decide between amputation and limb salvage?

Accepted Answer

MESS

Answer

Glasgow Coma Scale

Answer

Gustilo Anderson classification

Answer

ASIA guidelines

Question 5

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?

Accepted Answer

Neurovascular Assessment and Closed reduction with slab application

Answer

Neurovascular Assessment and Closed reduction with cast application

Answer

Neurovascular Assessment and Immediate surgery

Answer

Neurovascular Assessment and Immediate open reduction

Question 6

12 yr old Child admitted to ICU with blunt trauma and femur fracture- Pao2 60% despite 100%o2 and rebreather mask, CXR shows lung fields clear but the patient remains confused. What is most likely the diagnosis?

Accepted Answer

Fat embolism syndrome.

Answer

Hypovolaemic shock.

Answer

Pulmonary embolism.

Answer

Pulmonary contusion.

Question 7

As an intern in the emergency department, you encounter four patients with different types of fractures. Which patient should you prioritize for orthopedic consultation based on the severity of their condition?

Accepted Answer

Patient's finger shows signs of severe vascular compromise.

Answer

Patient can't extend his arm

Answer

Intra articular fracture of Elbow Joint

Answer

Simple closed fracture of the radius with good distal circulation

Question 8

Identify the bone numbered in the X-ray that most commonly fractures when a person falls on outstretched hands.

Accepted Answer

Distal radius

Answer

Scaphoid

Answer

Lunate

Answer

Capitate

Question 9

What is meant by perilunate dislocations?

Accepted Answer

Lower radius, scaphoid, and lunate in alignment; capitate alone is out of plane.

Answer

Lower radius, scaphoid, and capitate in alignment; lunate alone out of plane.

Answer

Both lunate and capitate are out of plane.

Answer

Lower radius, scaphoid, lunate, and capitate all in the same plane.

Question 10

The K nail can be used for all of the following types of fractures except -

Accepted Answer

Intertrochanteric fractures

Answer

Isthmic femur shaft fractures

Answer

Low subtrochanteric fractures

Answer

Distal femur shaft fractures

Trauma — MCQs

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