Pelvic and Acetabular Fractures — MCQs

10 questions

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

Ovarian fossa is formed by all except?

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

Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint

Which of the following statements about intracapsular fractures of the femoral neck is true?

Pelvic fracture is most commonly associated with which type of bladder injury?

Which of the following statements about the anatomy of the Fallopian tubes is true?

In major/unstable pelvic fractures with vascular injury, the amount of blood loss is around?

Which of the following fractures is associated with high mortality and morbidity?

Q10

A man was brought to the emergency department after meeting with an accident and injuring his perineum. He feels an urge to micturate but is unable to pass urine. There is blood at the tip of the meatus with extensive swelling of the penis and scrotum. What is the possible site of the injury?

Pelvic and Acetabular Fractures Indian Medical PG Practice Questions and MCQs

Question 1: In which of the following conditions is the Kocher-Langenbeck approach for emergency acetabular fixation contraindicated?

A. Morel - Lavallee lesion (Correct Answer)
B. Progressive sciatic nerve injury
C. Open fracture
D. Recurrent dislocation despite closed reduction and traction

Explanation: ***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.

Question 2: Ovarian fossa is formed by all except?

A. Internal iliac artery
B. Ureter
C. Obliterated umbilical artery
D. Round ligament of ovary (Correct Answer)

Explanation: ***Round ligament of ovary*** - The **round ligament of ovary** (ovarian ligament) connects the ovary to the lateral wall of the uterus and does NOT form any boundary of the ovarian fossa [1]. - It lies medial to the ovary and is not involved in forming the depression of the ovarian fossa [1]. - This ligament anchors the ovary but is separate from the peritoneal boundaries defining the fossa [1]. *Obliterated umbilical artery* - The **obliterated umbilical artery** (medial umbilical ligament) forms the **anterior boundary** of the ovarian fossa [2]. - This is a key anatomical landmark running along the lateral pelvic wall anterior to the ovary [2]. *Internal iliac artery* - The **internal iliac artery** forms the **posterior boundary** of the ovarian fossa [2]. - It lies on the lateral pelvic wall, deep and posterior to the ovarian fossa [2]. - This is one of the main structures defining the fossa's posterior limit [2]. *Ureter* - The **ureter** runs along the lateral pelvic wall and forms part of the **posterior/floor boundary** of the ovarian fossa [2]. - It passes posteroinferior to the ovary, contributing to the fossa's posterior limits [2].

Question 3: Which of the following is not considered an emergency treatment for acetabular fractures?

A. Open acetabular fracture
B. Recurrent dislocations despite fixation with traction
C. Progressive sciatic nerve involvement
D. Morel-Lavallee lesion (Correct Answer)

Explanation: **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.

Question 4: Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint

A. $1,2,3,4,5,6$
B. $3,5,6$ (Correct Answer)
C. $3,4,5$
D. $1,2,4$

Explanation: ***3,5,6*** - For **tibia traction** in a femoral shaft fracture, you would need a **Steinmann pin** for skeletal traction, a **Bohler's stirrup** to apply the traction force, and a **Bohler-Braun splint** to support the limb. - The **Steinmann pin** is inserted into the proximal tibia, the **Bohler's stirrup** attaches to the pin, and the **Bohler-Braun splint** provides a fixed structure for the traction system. *1,2,3,4,5,6* - This option incorrectly includes items not specifically used for applying **tibia traction** (e.g., K-wire is for internal fixation, Thomas splint is for early femur fracture management but not specifically for tibia traction application). - While some components might be used in general fracture management, not all are directly involved in setting up tibia traction as requested. *3,4,5* - This option correctly includes the **Steinmann pin** and **Bohler's stirrup** but incorrectly replaces the **Bohler-Braun splint** with a **Denham's pin**. - A **Denham's pin** is an alternative to a Steinmann pin for skeletal traction, but a **Bohler-Braun splint** is crucial for supporting the limb in this setup, which is missing here. *1,2,4* - This option includes a **Thomas splint** (used for femur fracture support, not tibia traction application), a **K-wire** (used for internal fixation, not traction), and a **Denham's pin** (an alternative to Steinmann pin, but lacks the necessary support and traction application equipment). - These items are not suitable for setting up comprehensive **tibia traction** for a femoral shaft fracture.

Question 5: Which of the following statements about intracapsular fractures of the femoral neck is true?

A. Malunion is rare, with avascular necrosis and nonunion being more common complications. (Correct Answer)
B. The contour of the greater trochanter remains unaffected in most cases.
C. Displacement occurs less frequently compared to extracapsular fractures.
D. Tenderness is mainly present over the anterior joint line

Explanation: ***Malunion is rare, with avascular necrosis and nonunion being more common complications.*** - Intracapsular fractures disrupt the **blood supply** to the femoral head, making **avascular necrosis** and **nonunion** much more likely than malunion. - The inherent instability and poor healing potential due to limited blood flow predispose to these specific complications. *Displacement occurs less frequently compared to extracapsular fractures.* - **Intracapsular fractures** are often highly unstable and prone to significant displacement due to the forces acting on the proximal femur. - In contrast to some stable **extracapsular fractures**, intracapsular fractures frequently present with notable displacement. *The contour of the greater trochanter remains unaffected in most cases.* - The **greater trochanter** is a part of the proximal femur, and **intracapsular fractures** involve the femoral neck, which is distal to the trochanter. - While a fracture of the femoral neck doesn't directly involve the trochanter, the **displacement** of the femoral head can indirectly affect the relationship and perceived contour of the greater trochanter. *Tenderness is mainly present over the anterior joint line* - Tenderness in **femoral neck fractures** is typically found in the **groin region** and over the greater trochanter, reflecting the location of the injury. - Anterior joint line tenderness is more commonly associated with **hip joint pathologies** or conditions like **hip flexor strains**, not isolated femoral neck fractures.

Question 6: Pelvic fracture is most commonly associated with which type of bladder injury?

A. Extraperitoneal bladder rupture (Correct Answer)
B. Intraperitoneal bladder rupture
C. Anterior urethral injury
D. Posterior urethral injury

Explanation: ***Extraperitoneal bladder rupture*** - **Pelvic fractures** are most commonly associated with **extraperitoneal bladder ruptures** (85-90% of bladder injuries from pelvic fractures). The tear in the bladder often occurs at the neck or anterior wall. These ruptures result from bone fragments from the pelvic fracture directly puncturing the bladder or from shearing forces. - Urine extravasates into the **retropubic space** and other extraperitoneal pelvic tissues, causing symptoms like suprapubic pain, hematuria, and difficulty voiding. - **Posterior urethral injuries** are also commonly associated with pelvic fractures (particularly pubic rami fractures), but among bladder injuries specifically, extraperitoneal rupture is most characteristic. *Intraperitoneal bladder rupture* - **Intraperitoneal bladder ruptures** are less common with pelvic fractures (10-15% of pelvic fracture-related bladder injuries) and typically occur from a direct blow to a **distended bladder**, causing rupture of the bladder dome. - Urine extravasates into the **peritoneal cavity**, leading to generalized abdominal pain, peritonitis, and potentially a larger volume of fluid accumulation. *Anterior urethral injury* - **Anterior urethral injuries** (e.g., bulbous or pendulous urethra) are usually caused by a **straddle injury** or direct trauma to the perineum. - They are generally **not associated with pelvic fractures**, which typically affect the **posterior urethra** (membranous portion) in males, particularly with pubic rami fractures.

Question 7: Which of the following statements about the anatomy of the Fallopian tubes is true?

A. Length is 20 cm
B. All of the options
C. Medial to lateral structures are isthmus, interstitial part, ampulla & fimbriae
D. Lateral to medial structures are fimbriae, ampulla, isthmus, interstitial part (Correct Answer)

Explanation: ***Lateral to medial structures are fimbriae, ampulla, isthmus, interstitial part*** - The Fallopian tube segments, from the **ovary** towards the **uterus**, logically follow this order to facilitate **egg transport**. - The **fimbriae** capture the egg, the **ampulla** is the site of fertilization, the **isthmus** is a narrow segment, and the **interstitial part** traverses the uterine wall [1]. *Length is 20 cm* - The typical length of the **Fallopian tube** is approximately **10-12 cm**, not 20 cm [1]. - A length of 20 cm would be significantly longer than the average human Fallopian tube. *Medial to lateral structures are isthmus, interstitial part, ampulla & fimbriae* - This order is incorrect as it describes the segments from the **uterus** towards the **ovary** but places the **isthmus** before the **interstitial part**. - The correct order from medial to lateral (uterus to ovary) would be **interstitial part**, **isthmus**, **ampulla**, and **infundibulum/fimbriae** [1]. *All of the options* - Since two of the other options contain factual inaccuracies regarding the length and the medial-to-lateral structural arrangement, this option cannot be correct. - Only one statement can be entirely true when specifically asked for the "true" statement among given choices.

Question 8: In major/unstable pelvic fractures with vascular injury, the amount of blood loss is around?

A. 2-4 units
B. 4-8 units (Correct Answer)
C. 1-4 units
D. 2-6 units

Explanation: ***4-8 units*** - Unstable pelvic fractures with associated vascular injury are recognized sources of significant hemorrhage due to the rich vascular supply of the pelvis and the potential for **venous plexus disruption** and **arterial damage**. - This range represents a substantial blood loss that commonly requires **transfusion** and often aggressive hemostatic interventions. *2-4 units* - This amount of blood loss, while significant, is more typical of **isolated unstable pelvic fractures** without major vascular involvement. - While bleeding can be substantial, it often does not reach the higher threshold seen with direct vascular injuries. *1-4 units* - This range of blood loss is relatively less severe and might be seen in **stable or minimally displaced pelvic fractures**. - It does not accurately reflect the major hemorrhage expected in an **unstable pelvic fracture** complicated by vascular injury. *2-6 units* - This option presents an overlap with the more accurate range but still underestimates the potential severity of blood loss in a **major/unstable pelvic fracture** with established vascular injury. - The upper limit often falls short of the true extent of hemorrhage observed in such critical injuries.

Question 9: Which of the following fractures is associated with high mortality and morbidity?

A. Femur Shaft fractures
B. Shaft tibia fractures
C. Subtrochanteric fractures
D. Pelvic fractures (Correct Answer)

Explanation: ***Pelvic fractures*** - Pelvic fractures, especially **unstable** ones, are associated with significant **hemorrhage** due to the rich vascular supply of the pelvis. This can lead to **hypovolemic shock** and high mortality. - They often result from **high-energy trauma** and can cause damage to internal organs, nerves, and blood vessels, leading to high morbidity including long-term pain and disability. *Femur Shaft fractures* - While femur shaft fractures can cause significant **blood loss** (up to 1500 ml), they are generally less critical than pelvic fractures in terms of immediate mortality risks, provided adequate resuscitation. - These fractures typically result from **high-energy trauma** but are usually managed surgically with low long-term morbidity when treated appropriately. *Shaft tibia fractures* - Tibia shaft fractures, while painful and requiring long recovery, are generally not associated with high mortality due to low risk of major hemorrhage or damage to critical organs. - The main complications are **non-union**, **malunion**, and **compartment syndrome**, which contribute to morbidity but not typically mortality. *Subtrochanteric fractures* - Subtrochanteric fractures are located in the **proximal femur** and are often seen in elderly individuals or those with osteoporosis. They can cause considerable pain and disability. - While they can lead to complications such as **non-union** or implant failure, their mortality and immediate life-threatening risks are typically lower compared to severe pelvic fractures.

Question 10: A man was brought to the emergency department after meeting with an accident and injuring his perineum. He feels an urge to micturate but is unable to pass urine. There is blood at the tip of the meatus with extensive swelling of the penis and scrotum. What is the possible site of the injury?

A. Membranous urethra
B. Bulbar urethra (Correct Answer)
C. Penile urethra rupture
D. Urinary bladder

Explanation: ***Bulbar urethra*** - The combination of **perineal injury**, inability to pass urine, **blood at the meatus**, and **swelling of the penis and scrotum** is classic for a bulbar urethral injury. - Trauma to the perineum can crush the urethra against the pubic bone, leading to rupture and extravasation of urine and blood into the **superficial perineal pouch**, causing scrotal and penile swelling. *Membranous urethra* - Injury to the membranous urethra is usually associated with **pelvic fractures**, which are not mentioned in this scenario. - While blood at the meatus can occur, urine extravasation would typically be contained within the **deep perineal space** or spread to the retropubic space, not causing prominent penile and scrotal swelling. *Urinary bladder* - A bladder injury would typically present with **suprapubic pain**, **hematuria**, and possibly inability to void, but not extensive perineal or scrotal swelling as a primary symptom unless it's a massive extravasation. - Bladder rupture is also often associated with **pelvic trauma**, and extravasated urine would usually track into the **peritoneal cavity** (intraperitoneal rupture) or **retropubic space** (extraperitoneal rupture). *Penile urethra rupture* - While penile urethral injury can cause blood at the meatus and difficulty urinating, the extensive swelling of both the penis and scrotum, especially after a **perineal injury**, is more indicative of a bulbar urethral tear where extravasation occurs into the superficial perineal pouch. - Localized swelling limited to the penis would be more characteristic of a penile urethra rupture.

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