Trauma Practice Questions

Q: A 65-year-old woman with known osteoporosis presents after falling on her outstretched hand. She reports wrist pain and there is visible dorsal displacement of the distal wrist with a 'dinner fork' deformity on examination. Which bone is most likely fractured?

Distal radius. ***Distal radius*** - A fall on an **outstretched hand (FOOSH)** typically transmits force up the arm, often resulting in a fracture of the distal radius, known as a **Colles fracture** if the fragment is displaced dorsally. - This is one of the most common fractures, particularly in older adults with **osteoporosis**. *Ulnar styloid process* - While the ulnar styloid can be fractured in conjunction with a distal radius fracture, it is usually a **secondary injury** and not the primary bone commonly fractured on its own in a FOOSH injury. - Isolated ulnar styloid fractures are less common as the main injury from this mechanism. *Scaphoid bone* - The **scaphoid** is also susceptible to fracture from a **FOOSH injury**, but it is generally less common than a distal radius fracture. - Scaphoid fractures are particularly concerning due to their **poor blood supply** and risk of **avascular necrosis**. - Scaphoid fractures are more typical in younger patients and present with anatomical snuffbox tenderness rather than a dinner fork deformity. *Lunate bone* - The lunate bone is an important carpal bone that can be dislocated or fractured, but isolated fractures from a typical FOOSH injury are **rare**. - **Lunate dislocations** are more common than fractures and often present with significant pain and wrist deformity.

Q: What is the first sign of Volkmann's ischemia?

Pain. ***Pain*** - **Severe pain** disproportionate to the injury is often the **first and most reliable sign** of impending Volkmann's ischemia (compartment syndrome). - This pain is typically **unrelieved by analgesics** and exacerbated by passive stretching of the affected muscles. *Pallor* - **Pallor (pale skin)** indicates **reduced blood flow** but is generally a later sign of severe ischemia, not the initial presentation. - While concerning, it suggests significant vascular compromise and is usually preceded by pain. *Paralysis* - **Paralysis or significant weakness** is a late and ominous sign, indicating **nerve ischemia** and muscle death due to prolonged lack of oxygen. - This symptom suggests irreversible damage if not addressed promptly. *Pulselessness* - **Pulselessness** is a very late and serious sign, indicating **complete arterial occlusion** or severe vascular compromise. - The presence of a palpable pulse does **not rule out compartment syndrome**, as compartment pressures can exceed capillary perfusion pressure long before arterial flow is completely obstructed.

Q: Elephant foot deformity is indicative of:

Non-union of fractured edentulous mandible. ***Non-union of fractured edentulous mandible*** - An **elephant foot deformity** is a characteristic radiographic finding in the non-union of a fracture, particularly in the context of an **edentulous mandible**. - It describes the appearance of **sclerotic, hypertrophic bone ends** at the fracture site, resembling the thick, club-like foot of an elephant, due to persistent movement and attempted callus formation. *Diplopia* - **Diplopia** refers to the perception of two images from a single object, often caused by ophthalmological or neurological issues affecting eye movement. - It is a symptom related to vision and has no association with bone deformities or fracture healing patterns. *Skeletal Class II malocclusion* - **Skeletal Class II malocclusion** describes a condition where the mandible is retrognathic (set back) relative to the maxilla, resulting in an "overbite." - This is a developmental craniofacial anomaly related to jaw position, not a characteristic sign of fracture non-union. *Unilateral Le Fort I fracture of maxilla* - A **unilateral Le Fort I fracture of the maxilla** is a midfacial fracture that separates the maxilla from the pterygoid plates and nasal septum, usually involving a horizontal fracture line above the maxillary teeth. - While it is a type of facial fracture, it does not typically result in an "elephant foot deformity," which is specific to hypertrophic non-unions, especially in the mandible.

Q: What is the most appropriate management option for an intra-articular fracture?

Plating. ***Plating*** - Plating offers **stable fixation** for intra-articular fractures, allowing for early mobilization and preserving joint function. - It provides **anatomic reduction**, which is crucial for restoring the smooth articular surface and preventing post-traumatic arthritis. *Arthrodesis* - Arthrodesis, or joint fusion, is typically reserved for **severe joint destruction** or failed previous treatments, as it sacrifices joint motion. - It is not the primary approach for acute intra-articular fractures where the goal is to **restore joint function**. *Plaster of Paris* - Plaster of Paris casts often provide **insufficient stability** for complex intra-articular fractures, risking malunion or nonunion. - While it offers immobilization, it can lead to **joint stiffness** and does not allow for early range of motion, which is vital for articular cartilage healing. *External Fixation* - External fixation is usually preferred for **open fractures** with significant soft tissue injury or as a temporary measure in polytrauma patients. - It carries a risk of **pin site infections** and can be cumbersome for the patient, generally not being the definitive treatment for closed intra-articular fractures.

Q: A 25-year-old man presents to the emergency department after falling onto an outstretched hand while playing cricket. He has tenderness in the anatomical snuffbox and pain with axial loading of the thumb. Initial X-rays appear normal. What is the most appropriate next step in management?

Thumb-spica immobilization and early MRI of the wrist. ***Thumb-spica immobilization and early MRI of the wrist*** - The clinical findings of **anatomical snuffbox tenderness** and **pain with axial loading of the thumb** are highly suggestive of a scaphoid fracture, even when initial X-rays appear normal (occult scaphoid fracture). - This type of fracture often results from a **fall onto an outstretched hand** and can be challenging to detect on initial plain films. - The most appropriate next step is **immediate thumb-spica immobilization** to protect the scaphoid, combined with **early MRI**, which is the most sensitive modality for detecting occult scaphoid fractures and allows prompt definitive diagnosis and management. *Thumb-spica immobilization and repeat X-rays in 10–14 days* - This is an acceptable alternative approach; repeat plain films after 10–14 days may reveal a fracture line as bone resorption occurs. However, **early MRI is preferred** as it provides a definitive diagnosis sooner, avoiding prolonged unnecessary immobilization or missing the fracture. *Discharge with analgesia and outpatient follow-up* - This is incorrect because a clinically suspected scaphoid fracture must be **treated as a fracture until proven otherwise**. Failure to immobilize risks avascular necrosis of the proximal pole and non-union, which are serious complications. *Immediate open reduction and internal fixation* - Surgical intervention is **not indicated at this stage** without imaging confirmation of a fracture. Initial management is conservative immobilization with appropriate imaging to confirm the diagnosis before any operative decision.

Q: Holstein-Lewis fracture is associated with injury to which nerve?

Radial. ***Radial*** - Holstein's Lewis fracture is a specific fracture of the **distal humeral shaft** that characteristically entraps the **radial nerve**. - Injury to the radial nerve in this region typically results in **wrist drop** and sensory loss over the dorsal hand. *Median* - The median nerve is most commonly entrapped in the **carpal tunnel**, leading to carpal tunnel syndrome. - Injury to the median nerve affects the **flexors of the forearm** and sensation in the first 3.5 digits. *Ulnar* - The ulnar nerve is often injured at the **cubital tunnel** (elbow) or Guyon's canal (wrist). - Its injury leads to a characteristic **claw hand deformity** and sensory loss in the little finger and ulnar half of the ring finger. *Axillary* - The axillary nerve is most susceptible to injury during **shoulder dislocations** or fractures of the surgical neck of the humerus. - Damage to this nerve causes weakness in **shoulder abduction** (due to deltoid paralysis) and sensory loss over the lateral shoulder.

Q: In the case of an inferior shoulder dislocation, which nerve is most commonly injured?

Axillary nerve. ***Axillary nerve*** - The **axillary nerve** wraps around the surgical neck of the humerus, making it highly vulnerable to injury during shoulder dislocations, especially **inferior dislocations**. - Injury to this nerve leads to **deltoid muscle weakness** (impaired abduction) and sensory loss over the **regimental badge area** (lateral shoulder). *Median nerve* - The **median nerve** is located more medially and deeper within the axilla and arm, making it less susceptible to injury from a simple shoulder dislocation. - Injury typically results in impaired pronation, wrist flexion, thumb opposition, and sensory deficits in the **first three and a half digits**. *Ulnar nerve* - The **ulnar nerve** runs medially in the arm and is well-protected in the axilla, making it an uncommon site of injury from a shoulder dislocation. - Damage leads to weakness in intrinsic hand muscles (e.g., **interossei, hypothenar muscles**) and sensory loss over the medial 1.5 digits. *Radial nerve* - The **radial nerve** courses posteriorly around the humerus in the spiral groove, making it prone to fracture of the humeral shaft, not typically shoulder dislocations. - Injury results in **wrist drop** due to paralysis of wrist and finger extensors, and sensory loss over the posterior arm, forearm, and dorsal hand.

Q: A 36-year-old man presents with an ankle injury sustained during a soccer match. What urgent intervention is required?

Applying a splint to stabilize the injury. ***Applying a splint to stabilize the injury*** - **Splinting** is a crucial urgent intervention for an ankle injury to **immobilize** the affected joint, reducing pain and preventing further damage to soft tissues or bone fragments. - It provides temporary stability until a definitive diagnosis and treatment plan can be established. *Performing a CT scan to assess the injury* - A **CT scan** is a diagnostic tool used to visualize complex fractures or soft tissue injuries in detail, but it is not an urgent intervention for initial management. - While important for diagnosis, it should typically follow initial stabilization and clinical assessment. *Immediate reduction of the dislocation* - **Reduction** is an urgent intervention for **dislocations**, but the question describes an "ankle injury," which could be a sprain, fracture, or dislocation. **Reduction** is only appropriate if a **dislocation** is confirmed. - Attempting to reduce a potential fracture without imaging can cause further trauma or pain. *Manipulation to restore alignment* - **Manipulation to restore alignment** is typically reserved for **dislocations** or certain types of **fractures** after proper imaging has been performed to understand the extent and type of injury. - Similar to reduction, it is not the universal first urgent intervention for an undiagnosed ankle injury.

Q: Displaced transverse patella; what is the treatment?

Tension band wiring. ***Tension band wiring*** - This is the standard treatment for **displaced patellar fractures**, especially transverse ones, as it converts distractive forces into compressive ones, promoting healing. - It involves using K-wires and a cerclage wire to achieve **stable fixation** and allow for early range of motion. *POP cast* - A **Plaster of Paris (POP) cast** is typically used for non-displaced or minimally displaced fractures that do not require surgical stabilization. - It would not provide adequate stability for a **displaced transverse patella fracture**, which is prone to further displacement due to quadriceps pull. *Non-operative* - **Non-operative treatment** is reserved for **non-displaced** or minimally displaced patellar fractures where the extensor mechanism remains intact. - A **displaced transverse patella fracture** disrupts the extensor mechanism, making non-operative treatment unsuitable as it would lead to poor functional outcomes and a high risk of nonunion. *Patellectomy* - **Patellectomy** (partial or total removal of the patella) is considered for severely comminuted fractures where reconstruction is not possible or for chronic symptomatic nonunion. - It is generally avoided as a primary treatment for displaced transverse fractures due to the importance of the patella in **knee extension mechanics** and the risk of quadriceps weakness.

Q: In fracture of the olecranon, excision of the proximal fragment is indicated in all of the following situations, EXCEPT:

Fracture extending to coronoid process. ***Fracture extending to coronoid process*** - Excision of the proximal fragment of the olecranon is generally contraindicated when the fracture extends to the **coronoid process** because it can compromise the stability and articulation of the elbow joint. - This type of fracture often requires more extensive reconstructive procedures to restore joint integrity. *Old ununited fractures* - For **old ununited olecranon fractures**, excision of the proximal fragment can be a viable option, especially if the fragment is small and does not contribute significantly to joint stability after non-union. - This approach aims to reduce pain and improve function by removing the source of irritation. *Elderly patient* - In **elderly patients**, excision of the fractured olecranon fragment is often favored, particularly if the fragment is small or the patient has low functional demands. - This approach offers a simpler solution compared to complex internal fixation, reducing surgical time and risks of prolonged immobility and complications. *Comminuted fracture* - For **comminuted olecranon fractures**, especially if the fragments are too small or numerous to be effectively fixed, excision of the proximal fragment is a reasonable option. - This can help restore functional range of motion and reduce pain when reconstruction is not feasible.

Question 1

A 65-year-old woman with known osteoporosis presents after falling on her outstretched hand. She reports wrist pain and there is visible dorsal displacement of the distal wrist with a 'dinner fork' deformity on examination. Which bone is most likely fractured?

Accepted Answer

Distal radius

Answer

Ulnar styloid process

Answer

Lunate bone

Answer

Scaphoid bone

Question 2

What is the first sign of Volkmann's ischemia?

Accepted Answer

Pain

Answer

Paralysis

Answer

Pallor

Answer

Pulselessness

Question 3

Elephant foot deformity is indicative of:

Accepted Answer

Non-union of fractured edentulous mandible

Answer

Unilateral Le Fort I fracture of maxilla

Answer

Diplopia

Answer

Skeletal Class II malocclusion

Question 4

What is the most appropriate management option for an intra-articular fracture?

Accepted Answer

Plating

Answer

External Fixation

Answer

Arthrodesis

Answer

Plaster of Paris

Question 5

A 25-year-old man presents to the emergency department after falling onto an outstretched hand while playing cricket. He has tenderness in the anatomical snuffbox and pain with axial loading of the thumb. Initial X-rays appear normal. What is the most appropriate next step in management?

Accepted Answer

Thumb-spica immobilization and early MRI of the wrist

Answer

Thumb-spica immobilization and repeat X-rays in 10–14 days

Answer

Discharge with analgesia and outpatient follow-up

Answer

Immediate open reduction and internal fixation

Question 6

Holstein-Lewis fracture is associated with injury to which nerve?

Accepted Answer

Radial

Answer

Median

Answer

Ulnar

Answer

Axillary

Question 7

In the case of an inferior shoulder dislocation, which nerve is most commonly injured?

Accepted Answer

Axillary nerve

Answer

Median nerve

Answer

Ulnar nerve

Answer

Radial nerve

Question 8

A 36-year-old man presents with an ankle injury sustained during a soccer match. What urgent intervention is required?

Accepted Answer

Applying a splint to stabilize the injury

Answer

Performing a CT scan to assess the injury

Answer

Manipulation to restore alignment

Answer

Immediate reduction of the dislocation

Question 9

Displaced transverse patella; what is the treatment?

Accepted Answer

Tension band wiring

Answer

POP cast

Answer

Non operative

Answer

Patellectomy

Question 10

In fracture of the olecranon, excision of the proximal fragment is indicated in all of the following situations, EXCEPT:

Accepted Answer

Fracture extending to coronoid process

Answer

Elderly patient

Answer

Old ununited fractures

Answer

Comminuted fracture

Trauma — MCQs

Trauma — MCQs

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