Trauma Practice Questions

Q: 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:

Extra capsular fracture neck of femur. **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.

Q: What is the angle formed by joining a line extended from the fracture line of the fracture neck to an arbitrary line depicting the horizontal plane?

Pauwel's angle. ***Pauwel's angle*** - **Pauwel's angle** measures the angulation of a femoral neck fracture relative to the horizontal plane, indicating the degree of shear force across the fracture site. - A higher Pauwel's angle (Type III) suggests greater instability and higher shear forces, impacting treatment decisions. *Shenton's line* - **Shenton's line** is a curved line seen on an X-ray formed by the inferior border of the superior pubic ramus and the inferomedial border of the femoral neck. - Disruption of Shenton's line indicates hip dislocation or a femoral neck fracture with displacement. *Perkins line* - **Perkins line** is used in the evaluation of developmental dysplasia of the hip (DDH) to assess the lateral displacement of the femoral head. - It is drawn perpendicular to Hilgenreiner's line through the lateral rim of the acetabulum. *Nelaton's line* - **Nelaton's line** is a clinical landmark used to assess the position of the greater trochanter relative to the pelvis. - It extends from the anterior superior iliac spine to the ischial tuberosity; if the greater trochanter lies above this line, it may indicate hip dislocation or fracture.

Q: A patient presents with a compound fracture of the tibia, with a 1-cm opening in the skin. Which grade does it belong to?

Grade II. ***Grade II*** - A **Grade II open fracture** is defined by a skin wound between **1 cm and 10 cm** in length, often accompanied by moderate crush injury and minimal to moderate soft tissue damage. - The presence of a **1-cm skin opening** with a compound fracture places it within this category, distinguishing it from smaller (Grade I) or larger/more complex (Grade III) wounds. *Grade I* - A **Grade I open fracture** involves a clean skin wound of **less than 1 cm** and typically has minimal soft tissue damage. - The stated wound size of **1 cm** exceeds the strict definition for Grade I, which requires the wound to be *under* 1 cm. *Grade IIIA* - **Grade IIIA open fractures** are characterized by extensive soft tissue damage, **adequate bone coverage**, and wound sizes *greater than 10 cm*. - Although the wound is *compound*, its small size (1 cm) does not fit the criteria for *extensive* soft tissue damage or a wound larger than 10 cm, which are hallmarks of Grade IIIA. *Grade IIIB* - **Grade IIIB open fractures** involve severe soft tissue loss with **periosteal stripping** and **bone exposure**, even after debridement. - These fractures require **soft tissue reconstruction** for wound closure, which is a much more severe injury than described by a 1-cm skin opening.

Q: Subtrochanteric fractures of the femur can be treated by all of the following methods, except:

Smith Petersen Nail. ***Smith Petersen Nail*** - The **Smith Petersen nail** is an **intramedullary device** used primarily for **femoral neck fractures** or certain types of **intertrochanteric fractures**, but it is generally **not indicated** for subtrochanteric fractures due to suboptimal stability in this region. - Its design does not provide adequate fixation or rotational control for the unique forces acting on the **subtrochanteric area**, which is under significant bending and shear stress. *Skeletal traction on Thomas' splint* - **Skeletal traction** can be used as a **temporary measure** for subtrochanteric fractures to maintain length and alignment, especially in cases where definitive surgical fixation is delayed. - The **Thomas' splint** helps to support the limb and keep it in traction, reducing pain and preventing further displacement. *Condylar blade plate* - A **condylar blade plate** or **proximal femoral locking plate** is a suitable implant for **complex subtrochanteric fractures**, particularly those with comminution or extending into the trochanteric region. - It provides **angular stability** and strong fixation, which is crucial for successful healing in this high-stress area. *Ender's nail* - **Ender's nails** are flexible **intramedullary nails** that can be used for certain types of subtrochanteric fractures, particularly in situations where a less invasive approach is desired or in elderly patients. - While they offer some stability, their use for subtrochanteric fractures has largely been superseded by more rigid interlocking nails due to **higher rates of malunion** and **rotational instability**.

Q: Which of the following is NOT a primary goal of open reduction and internal fixation (ORIF)?

Consolidation (final healing phase). ***Consolidation (final healing phase)*** - While ORIF aims to facilitate healing, **consolidation** is the *result* of successful treatment, not a direct primary goal achieved *during* the surgical procedure itself. - The surgical goals focus on creating the optimal environment for consolidation to occur naturally after the operation. *Stability (maintaining bone position)* - Achieving and maintaining **stability** of the fractured bone fragments is a fundamental goal of ORIF. - This prevents micromotion at the fracture site, which is crucial for reducing pain and promoting proper healing. *Better function (restoring mobility)* - Restoring **normal or near-normal function and mobility** to the injured limb or body part is a key objective of ORIF. - By stabilizing the fracture and allowing early mobilization, the procedure helps minimize joint stiffness and muscle atrophy. *Better alignment (correct positioning)* - **Accurate anatomical reduction and alignment** of the fractured bone fragments are paramount in ORIF. - Proper alignment is essential for restoring biomechanical integrity and ensuring optimal long-term functional outcomes.

Q: Which of the following is a contraindication for open reduction & internal fixation (ORIF)?

All of the options. ***All of the options*** - **Active infection** at the surgical site is a significant contraindication for ORIF due to the high risk of **osteomyelitis** and implant failure. - **Soft bones**, such as those found in patients with **osteoporosis**, may not adequately hold the internal fixation devices (screws, plates), leading to implant loosening or cutout. - **Soft tissue contractures** around the fracture site can make surgical access difficult, compromise soft tissue coverage, and increase the risk of wound complications and poor functional outcomes. *Active infection* - While a direct contraindication, it's not the *only* one for ORIF. - Performing ORIF in the presence of infection significantly increases the risk of **surgical site infection** and implant failure, potentially leading to chronic osteomyelitis. *Soft bones* - This is a significant challenge for ORIF, as the bone quality may not be sufficient to hold the hardware securely. - It increases the risk of **implant failure** and non-union, but again, it's not the sole contraindication listed. *Soft tissue contractures around the fracture site* - Severe contractures can **impede surgical exposure**, make anatomical reduction difficult, and compromise the vascularity of the tissues. - This can lead to increased rates of **wound complications** and poor healing, but it is one of several contraindications.

Q: Avascular necrosis (AVN) is commonly associated with which type of femoral neck fracture?

Subcapital. ***Subcapital*** - Subcapital fractures occur at the anatomical **neck of the femur**, just below the femoral head, and often disrupt the **blood supply** to the femoral head due to injury to the lateral epiphyseal arteries. - The high rate of **vascular disruption** in these fractures significantly increases the risk of avascular necrosis (AVN) a condition where bone tissue dies due to lack of blood supply. *Transcervical* - Transcervical fractures are located through the **middle part of the femoral neck**, between subcapital and basal fractures, and also carry a risk of AVN. - However, the risk of AVN is generally considered **lower than subcapital fractures** but higher than basal fractures, due to less consistent disruption of the retinacular vessels. *Basal* - Basal fractures occur at the **base of the femoral neck**, near the intertrochanteric line, and typically have a **better prognosis** regarding AVN. - The principal blood supply to the femoral head is usually **less compromised** in basal fractures compared to subcapital or transcervical fractures, as the fracture line is more distal to the weight-bearing femoral head. *Intertrochanteric* - Intertrochanteric fractures occur **outside the hip joint capsule**, in the region between the greater and lesser trochanters, and are considered **extracapsular**. - Due to their location being well away from the **femoral head's vascular supply**, these fractures have a very low risk of avascular necrosis and primarily raise concerns about stability and healing.

Q: Which of the following is not considered an emergency treatment for acetabular fractures?

Morel-Lavallee lesion. **Morel-Lavallee lesion** - While a Morel-Lavallee lesion is a serious injury that can occur with acetabular fractures, it is not typically considered an **absolute emergency** requiring immediate surgical intervention in the same way other complications are. - Management often involves drainage and compression, and surgical débridement is usually performed electively if it significantly enlarges or becomes symptomatic. *Recurrent dislocations despite fixation with traction* - This indicates **instability** of the hip joint, which can lead to further damage to the articular cartilage, labrum, and surrounding soft tissues, necessitating **urgent surgical stabilization**. - Persistent dislocation can result in avascular necrosis of the femoral head or damage to the **neurovascular structures**. *Open acetabular fracture* - An open fracture presents a direct communication between the fracture site and the external environment, carrying a **high risk of infection** (osteomyelitis). - This requires **immediate surgical débridement** and antibiotics to prevent severe complications. *Progressive sciatic nerve involvement* - Progressive neurological deficit, such as increasing weakness or sensory loss in the distribution of the sciatic nerve, indicates **ongoing nerve compression or injury**. - This is a neurosurgical emergency that requires **urgent decompression** to prevent permanent neurological damage.

Q: What is the acceptable angle of reduction for a tibial fracture?

5. ***5*** - A **5-degree angulation** for a tibial shaft fracture is generally considered an acceptable radiographic reduction in most planes. - This degree of **angulation** typically allows for satisfactory healing and good functional outcomes without significant long-term complications. *1* - While **1 degree of angulation** would represent an excellent reduction, it is not the standard "acceptable" maximum. - Achieving such a minimal **angulation** can be challenging and is often unnecessary for a good functional outcome. *20* - **Twenty degrees of angulation** in a tibial shaft fracture is generally considered an unacceptable degree of displacement. - Such significant **angulation** can lead to malunion, functional impairment, and aesthetic deformities. *15* - **Fifteen degrees of angulation** is typically considered excessive for an acceptable reduction of a tibial shaft fracture. - This much angulation can interfere with proper gait, cause abnormal joint loading, and increase the risk of delayed union or nonunion.

Q: In which type of fracture is closed pinning not typically performed?

Shaft humerus fracture. ***Shaft humerus fracture*** - Closed pinning (intramedullary nailing) for **humeral shaft fractures** is technically challenging due to the curved anatomy and the risk of neurovascular injury, especially with *retrograde nailing*. - **Open reduction and internal fixation (ORIF)** with plates and screws is generally preferred for **humeral shaft fractures** to achieve stable fixation and union. *Neck humerus fracture* - **Minimally invasive pinning** is a common technique for stabilizing **displaced humeral neck fractures**, particularly in older patients, to achieve good functional outcomes. - The anatomical location allows for safe percutaneous pin insertion under fluoroscopic guidance, minimizing soft tissue disruption. *Distal radius fracture* - **Percutaneous pinning** is a well-established and effective treatment for many types of **distal radius fractures**, especially those that are unstable or reduced but difficult to hold in place with casting alone. - It provides internal support while allowing for early motion of unaffected joints. *Supracondylar fracture humerus* - **Closed reduction and percutaneous pinning** (CRPP) is the gold standard for displaced **supracondylar humerus fractures** in children. - This technique achieves stable fixation with minimal surgical exposure and has excellent outcomes when performed correctly.

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:

Accepted Answer

Extra capsular fracture neck of femur

Answer

Anterior dislocation of hip

Answer

Intra capsular fracture neck of femur

Answer

Posterior dislocation of hip

Question 2

What is the angle formed by joining a line extended from the fracture line of the fracture neck to an arbitrary line depicting the horizontal plane?

Accepted Answer

Pauwel's angle

Answer

Shenton's line

Answer

Perkins line

Answer

Nelton's line

Question 3

A patient presents with a compound fracture of the tibia, with a 1-cm opening in the skin. Which grade does it belong to?

Accepted Answer

Grade II

Answer

Grade IIIA

Answer

Grade IIIB

Answer

Grade I

Question 4

Subtrochanteric fractures of the femur can be treated by all of the following methods, except:

Accepted Answer

Smith Petersen Nail

Answer

Ender's nail

Answer

Skeletal traction on Thomas' splint

Answer

Condylar blade plate

Question 5

Which of the following is NOT a primary goal of open reduction and internal fixation (ORIF)?

Accepted Answer

Consolidation (final healing phase)

Answer

Stability (maintaining bone position)

Answer

Better function (restoring mobility)

Answer

Better alignment (correct positioning)

Question 6

Which of the following is a contraindication for open reduction & internal fixation (ORIF)?

Accepted Answer

All of the options

Answer

Active infection

Answer

Soft bones

Answer

Soft tissue contractures around the fracture site

Question 7

Avascular necrosis (AVN) is commonly associated with which type of femoral neck fracture?

Accepted Answer

Subcapital

Answer

Transcervical

Answer

Basal

Answer

Intertrochanteric

Question 8

Which of the following is not considered an emergency treatment for acetabular fractures?

Accepted Answer

Morel-Lavallee lesion

Answer

Open acetabular fracture

Answer

Recurrent dislocations despite fixation with traction

Answer

Progressive sciatic nerve involvement

Question 9

What is the acceptable angle of reduction for a tibial fracture?

Accepted Answer

5

Answer

1

Answer

20

Answer

15

Question 10

In which type of fracture is closed pinning not typically performed?

Accepted Answer

Shaft humerus fracture

Answer

Neck humerus fracture

Answer

Distal radius fracture

Answer

Supracondylar fracture humerus

Trauma — MCQs

Trauma — MCQs

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