Trauma Practice Questions

Q: A 33-year-old male presents with complaints of pain in the left hip. On examination, there is flexion and external rotation of the left lower limb, with a 7 cm shortening of the left lower limb. A gluteal mass is palpable, which moves with the movement of the femoral shaft. What is the most probable diagnosis?

Pipkin's type 4 fracture. ***Pipkin's type 4 fracture*** - This fracture involves a **femoral head fracture** combined with a **hip dislocation**. The described findings of flexion, external rotation, shortening, and a palpable gluteal mass, which moves with the femoral shaft, are classic signs of a **femoral head fracture-dislocation**, often categorized as a Pipkin type. - The gluteal mass moving with the femoral shaft indicates that the **femoral head** is displaced and can be palpated, which is consistent with a **femoral head fracture** that has dislocated. *Anterior dislocation of hip* - An **anterior hip dislocation** typically presents with the limb in **flexion, abduction, and external rotation**, but it usually involves lengthening rather than shortening due to the head being displaced anteriorly. - There would typically not be a palpable gluteal mass, and the degree of shortening described (7 cm) is more consistent with a complex injury like a fracture-dislocation. *Central fracture dislocation* - A **central fracture dislocation** involves the femoral head pushing through the **acetabulum into the pelvis**. This usually presents with a **shortened and internally rotated limb**, and pain, but not typically a palpable gluteal mass or the specific flexion and external rotation described. - While there is shortening, the mechanism of injury and the palpable mass are not consistent with the femoral head being displaced into the pelvic cavity. *Posterior dislocation* - A **posterior hip dislocation** presents with the limb in **flexion, adduction, and internal rotation**, often with significant shortening. - Although it causes shortening, the patient presents with **external rotation**, not internal rotation, differentiating it from a posterior dislocation. The palpable gluteal mass is also not a typical finding in a pure posterior dislocation without an associated fracture.

Q: In which of the following conditions is the Kocher-Langenbeck approach for emergency acetabular fixation contraindicated?

Morel - Lavallee lesion. ***Morel - Lavallee lesion*** - A Morel-Lavallee lesion is a **closed degloving injury** where the skin and subcutaneous tissue are avulsed from the underlying fascia, creating a potential space that fills with hematoma, fat, and lymphatic fluid. - The **Kocher-Langenbeck approach** involves significant soft tissue dissection, which increases the risk of **wound complications**, infection, and flap necrosis in an already compromised and devascularized soft tissue envelope found in a Morel-Lavallee lesion. *Open fracture* - An **open fracture** involves a break in the skin, exposing the fracture site, which significantly increases the risk of infection. - While it presents a challenge, an open fracture is generally a **stronger indication for urgent surgical stabilization** to prevent further contamination and promote healing, rather than a contraindication to a specific surgical approach if it's the most appropriate for the fracture pattern. *Progressive sciatic nerve injury* - **Progressive neurologic deficits**, including sciatic nerve injury, often necessitate urgent surgical intervention to decompress the nerve and prevent irreversible damage. - This symptom emphasizes the **urgency of surgical stabilization** and internal fixation for the acetabular fracture, making it an indication for rather than a contraindication to the Kocher-Langenbeck approach if it provides optimal access. *Recurrent dislocation despite closed reduction and traction* - **Instability** of the hip joint despite conservative measures indicates a need for surgical intervention to achieve stable reduction and fixation of the acetabular fracture. - This situation generally **supports the need for open reduction and internal fixation**, often via approaches like Kocher-Langenbeck, to restore joint congruity and stability, making it an indication, not a contraindication.

Q: Sciatic nerve palsy may occur in which injury?

Posterior dislocation of hip joint. ***Posterior dislocation of hip joint*** - This injury commonly results from **high-energy trauma**, such as a dashboard injury, forcing the femoral head posteriorly out of the acetabulum. - The **sciatic nerve** runs in close proximity to the posterior aspect of the hip joint and can be stretched or compressed during such a dislocation, leading to palsy. *Fracture neck of femur* - This fracture typically involves the **femoral neck** and is more associated with complications like avascular necrosis due to disruption of blood supply. - While it can involve nerve injury, **sciatic nerve palsy** is not a common or direct complication of this specific fracture type. *Trochanteric fracture* - This fracture involves the **greater or lesser trochanter** of the femur, often due to a fall in elderly individuals. - Nerve injury is rare with this type of fracture, and the sciatic nerve is generally not vulnerable in this location. *Anterior dislocation of hip* - This is a less common type of hip dislocation where the femoral head displaces **anteriorly**. - While other neurovascular structures might be at risk, the **femoral nerve** or vessels are more likely to be involved, not the sciatic nerve, which is located posteriorly.

Q: The treatment of choice for fracture of radius and ulna in an adult is:

Only plates. ***Only plates*** - **Open reduction and internal fixation (ORIF)** with plates and screws is the preferred treatment for diaphyseal fractures of both the radius and ulna in adults, as it provides **stable fixation** and allows for early mobilization. - This method helps restore normal forearm anatomy and function, crucial for maintaining **pronation and supination**. *Plaster for 4 weeks* - **Conservative management** with plaster casting for fractures of both radius and ulna in adults often leads to **malunion**, nonunion, or loss of forearm rotation. - It is generally reserved for **undisplaced fractures** or in situations where surgery is contraindicated. *Closed reduction and calipers* - **Closed reduction** can be attempted for some forearm fractures, but maintaining reduction with external devices like calipers is challenging due to the dynamic forces of the forearm muscles. - This method has a higher risk of **redisplacement** and suboptimal anatomical alignment, leading to functional limitations. *Kuntscher nails* - **Kuntscher nails** (intramedullary nails) are more commonly used for long bone fractures like the femur or tibia. - While intramedullary nailing can be used for forearm fractures, **plating** is generally favored for diaphyseal radius and ulna fractures due to better control of **rotational alignment** and restoration of the interosseous space.

Q: Which of the following is NOT a complication of a neck femur fracture?

Malunion. ***Malunion*** - **Malunion** is a rare complication of a femoral neck fracture because the fracture is inherently unstable and tends to result in **nonunion** rather than healing in an abnormal position. - The **vascular compromise** and mechanical forces often lead to a failure to heal whatsoever, or to avascular necrosis. *Nonunion* - **Nonunion** is a common and severe complication of femoral neck fractures due to the **precarious blood supply** to the femoral head and the high mechanical stress across the fracture site. - The lack of adequate blood flow and movement at the fracture site hinders the formation of a **bony callus**, leading to failure of the bone to heal. *AVN* - **Avascular necrosis (AVN)** of the femoral head is a major complication resulting from the disruption of the arterial blood supply to the femoral head during the fracture. - The **retinacular arteries**, which supply most of the femoral head, are often damaged, leading to the death of bone cells and subsequent collapse of the femoral head. *Osteoarthritis* - **Post-traumatic osteoarthritis** can develop as a long-term complication, even if the fracture heals. - The initial injury and any subsequent irregularities in the joint surface or alignment can lead to accelerated **cartilage degeneration**.

Q: A 34-year-old female was operated for a fracture of the radial neck. Post-operatively, she was unable to extend her fingers at the metacarpophalangeal joints. There was no sensory loss in her hand. Which nerve is most commonly injured?

Posterior interosseous nerve. **Posterior interosseous nerve** - The inability to extend the fingers at the **metacarpophalangeal joints (MCP joints)**, without significant sensory loss in the hand, is characteristic of an injury to the **posterior interosseous nerve (PIN)**. - The PIN is a purely motor nerve that innervates the muscles responsible for MCP joint extension in the fingers, such as the digital extensors, and is vulnerable to injury during radial neck fractures or their surgical repair. *Radial Nerve* - A **radial nerve injury** would typically present with a **wrist drop** (inability to extend the wrist and fingers) and significant sensory loss in the **dorsal aspect of the hand**, which is not described. - While the PIN is a branch of the radial nerve, an injury limited to the PIN selectively affects motor function distal to its branching point, often sparing more proximal radial nerve functions and sensation. *Median Nerve* - A **median nerve injury** would primarily affect sensations in the **palmar aspect of the thumb, index, middle, and radial half of the ring finger**, and result in weakness or paralysis of the **thenar muscles** (e.g., opposition of the thumb). - It does not cause an inability to extend fingers at the MCP joints. *Anterior Interosseous nerve* - An **anterior interosseous nerve (AIN) injury** is also a purely motor deficit but affects the deep muscles of the forearm, leading to specific weaknesses in **flexion of the thumb IP joint** and the **index and middle finger DIP joints** (e.g., inability to make an "OK" sign). - It does not cause an inability to extend fingers at the MCP joints.

Q: Tardy ulnar nerve palsy is most commonly associated with which of the following fractures of the humerus?

Medial condyle of the humerus. ***Medial condyle of the humerus*** - Fractures involving the **medial condyle** or **epicondyle** can directly injure the **ulnar nerve** as it passes through the cubital tunnel. - Malunion or delayed healing of these fractures can lead to chronic irritation or compression, resulting in **tardy ulnar nerve palsy**. *Lateral condyle of the humerus* - Fractures of the **lateral condyle** are less directly associated with ulnar nerve injury because the nerve is located on the medial side of the elbow. - While all elbow fractures carry some risk of nerve injury, the proximity of the ulnar nerve to the medial structures makes medial condyle fractures more relevant. *Supracondylar condyle of the humerus* - **Supracondylar fractures** are more commonly associated with injury to the **brachial artery** and the **median nerve** (Volkmann's contracture). - Although any severe elbow trauma can cause nerve damage, primary ulnar nerve involvement is less typical with supracondylar fractures compared to medial condyle fractures. *Fracture shaft of the humerus* - Fractures of the **humeral shaft** are most commonly associated with injury to the **radial nerve** due to its close proximity to the mid-shaft of the humerus. - The ulnar nerve courses more distally and medially, making shaft fractures an infrequent cause of direct ulnar nerve palsy.

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.

Question 1

A 33-year-old male presents with complaints of pain in the left hip. On examination, there is flexion and external rotation of the left lower limb, with a 7 cm shortening of the left lower limb. A gluteal mass is palpable, which moves with the movement of the femoral shaft. What is the most probable diagnosis?

Accepted Answer

Pipkin's type 4 fracture

Answer

Anterior dislocation of hip

Answer

Central fracture dislocation

Answer

Posterior dislocation

Question 2

In which of the following conditions is the Kocher-Langenbeck approach for emergency acetabular fixation contraindicated?

Accepted Answer

Morel - Lavallee lesion

Answer

Progressive sciatic nerve injury

Answer

Open fracture

Answer

Recurrent dislocation despite closed reduction and traction

Question 3

Which of the following best describes a Monteggia fracture?

Accepted Answer

Fracture of the proximal third of the ulna with dislocation of the radial head.

Answer

Fracture of distal radius with dislocation of the distal ulna

Answer

Fracture of distal third of ulna with dislocation of the radial head.

Answer

Fracture of proximal one third of radius with dislocation of the distal ulna.

Question 4

Sciatic nerve palsy may occur in which injury?

Accepted Answer

Posterior dislocation of hip joint

Answer

Fracture neck of femur

Answer

Trochanteric fracture

Answer

Anterior dislocation of hip

Question 5

Which fracture is characterized by a 'dinner fork' deformity?

Accepted Answer

Colle's fracture (distal radius fracture with dorsal angulation).

Answer

Lateral condyle fracture (elbow injury)

Answer

Supracondylar fracture (humerus injury)

Answer

March fracture (metatarsal stress fracture)

Question 6

The treatment of choice for fracture of radius and ulna in an adult is:

Accepted Answer

Only plates

Answer

Plaster for 4 weeks

Answer

Closed reduction and calipers

Answer

Kuntscher nails

Question 7

Which of the following is NOT a complication of a neck femur fracture?

Accepted Answer

Malunion

Answer

Nonunion

Answer

Osteoarthritis

Answer

AVN

Question 8

A 34-year-old female was operated for a fracture of the radial neck. Post-operatively, she was unable to extend her fingers at the metacarpophalangeal joints. There was no sensory loss in her hand. Which nerve is most commonly injured?

Accepted Answer

Posterior interosseous nerve

Answer

Radial Nerve

Answer

Median Nerve

Answer

Anterior Interosseous nerve

Question 9

Tardy ulnar nerve palsy is most commonly associated with which of the following fractures of the humerus?

Accepted Answer

Medial condyle of the humerus

Answer

Supracondylar condyle of the humerus

Answer

Fracture shaft of the humerus

Answer

Lateral condyle of the humerus

Question 10

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

Trauma — MCQs

Trauma — MCQs

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