Trauma Practice Questions

Q: An 80-year-old female patient with a history of slip and fall in the bathroom was brought to the casualty. She is having pain in the left hip and is unable to walk. She has no history of osteoarthritis. On examination, the left lower limb is shortened and externally rotated. X-ray findings are shown below. How will you manage this patient?

Hemiarthroplasty. ***Hemiarthroplasty*** - This is the treatment of choice for a **displaced intracapsular femoral neck fracture** in an elderly patient (typically >75 years) due to the high risk of **avascular necrosis (AVN)** and **non-union** if treated with internal fixation. - It involves replacing the femoral head with a prosthesis, which allows for **early mobilization** and weight-bearing, significantly reducing the risk of complications associated with immobility in geriatric patients, such as DVT and pneumonia. *Internal fixation with cancellous screws* - This approach is reserved for **undisplaced femoral neck fractures** or for displaced fractures in younger, more physiologically fit patients (<65 years) where preserving the native femoral head is a priority. - In an 80-year-old with a displaced fracture and likely poor bone quality, the risk of fixation failure, **non-union**, or subsequent **AVN** is unacceptably high, often requiring a second surgery. *Meyer's operation* - This is a **muscle-pedicle bone graft** procedure, typically using the quadratus femoris, designed to improve the blood supply to the femoral head. - It is not a primary treatment for an acute fracture but is sometimes used as an adjunct to internal fixation in younger patients to prevent AVN, or as a treatment for early-stage AVN itself. *McMurray's osteotomy* - This is a type of **intertrochanteric osteotomy** historically used to treat **non-union** of femoral neck fractures by converting shear forces at the fracture site into compressive forces. - It is not indicated for the primary management of an acute femoral neck fracture in an elderly patient and has been largely superseded by modern arthroplasty techniques.

Q: A 60-year-old female patient complains of pain and swelling in the left wrist following a fall on an outstretched hand. On examination, dinner fork deformity can be noticed. What is the most likely displacement seen in this patient?

Distal and dorsal displacement of radius. ***Distal and dorsal displacement of radius*** This patient presents with a **Colles' fracture**, the most common distal radius fracture in elderly patients following a fall on an outstretched hand (FOOSH injury). **Key Features of Colles' Fracture:** - Fracture of the **distal radius** (within 2.5 cm of radiocarpal joint) - **Dorsal (posterior) displacement** of the distal fragment - **Dorsal angulation** of the distal fragment - **Radial displacement and shortening** - Creates the characteristic **"dinner fork deformity"** when viewed from the side - The intact proximal radius fragment remains in normal position **Why the dinner fork deformity occurs:** The dorsal displacement and angulation of the distal radius fragment causes the wrist to have a bayonet-like appearance on lateral view, resembling the curve of a dinner fork. *Incorrect - Proximal displacement options:* In Colles' fracture, it is the **distal fragment** that displaces, not the proximal fragment. The proximal radius remains attached to the elbow and stays in its normal anatomical position. *Incorrect - Ventral (volar/palmar) displacement:* Volar displacement would be seen in **Smith's fracture** (reverse Colles'), which is much less common and occurs from a fall on the back of the hand. This would produce a "garden spade deformity," not a dinner fork deformity. *Incorrect - Ulnar displacement:* The ulna is not the primary bone involved in dinner fork deformity. While ulnar styloid fractures may occur concurrently in 50-60% of cases, the characteristic deformity results from distal radius displacement.

Q: What is the preferred treatment for an inter-trochanteric fracture in a 72-year-old female?

Hemiarthroplasty / Dynamic Hip Screw (DHS). ***Hemiarthroplasty / Dynamic Hip Screw (DHS)*** - **DHS** is the standard treatment for stable (Type I and II) inter-trochanteric fractures, providing controlled collapse and compression at the fracture site. - For unstable fractures (Type III and IV), especially in elderly patients with poor bone quality, **Intramedullary (IM) nailing** is often preferred over DHS due to superior biomechanical stability, though the combination option provided suggests the widely applicable stabilization principles for this age group. ***Intramedullary nailing*** - **IM nailing** is generally the preferred choice for unstable inter-trochanteric fractures (e.g., reverse oblique pattern or severe comminution) as it resists varus collapse more effectively than DHS. - While highly effective, it is not the *only* preferred treatment, and DHS remains primary for stable patterns, making the combined option more comprehensive for standard fracture care in the elderly. ***Open Reduction and Internal Fixation (ORIF) with plating*** - ORIF with plate fixation (other than DHS) is rarely used for inter-trochanteric fractures today, as it involves extensive soft tissue stripping and offers inferior biomechanical stability compared to compression screws (DHS) or nails. - This technique is typically reserved for highly unusual fracture patterns or as a salvage procedure, not as the primary 'preferred' method. ***Boot and bar*** - **Traction (boot and bar)** is historical and obsolete for treating hip fractures, including inter-trochanteric fractures. - Modern management mandates operative fixation as soon as the patient is medically optimized to allow early mobilization, reduce pain, and prevent complications like **deep vein thrombosis (DVT)** and pneumonia.

Q: A 25-year-old man presents to the emergency department following a motorbike accident and is found to have a closed midshaft fracture of the left tibia. Six hours later, he develops severe leg pain that is disproportionate to the injury and worsens with passive dorsiflexion of the foot. The pain is not relieved by analgesics. On examination, dorsalis pedis and posterior tibial pulses are present, but there is no sensation over the first dorsal webspace. What is the most appropriate next step in management?

Immediate fasciotomy. ***Immediate fasciotomy*** - The clinical presentation of severe, disproportionate pain, pain on passive stretching, and altered sensation (**paresthesia**) in the setting of a major fracture is highly indicative of **acute compartment syndrome**. - **Fasciotomy** is the definitive, urgent treatment to decompress the muscle compartments and prevent irreversible tissue necrosis and nerve damage. *Elevate the limb and observe* - Elevating the limb may further decrease the **arterial-venous pressure gradient**, potentially worsening an already compromised perfusion. - Observation is inappropriate because **acute compartment syndrome** requires immediate surgical intervention to prevent serious, permanent deficits or loss of function. *Administer opioid analgesics and continue observation* - Analgesics, even strong opioids, will only mask the classic symptom (**disproportionate pain**) but will not address the underlying pathology (increased intracompartmental pressure). - Continued observation will lead to progression of **ischemia**, resulting in irreversible muscle and nerve damage after approximately 6-8 hours. *Apply cast and follow up* - Applying a cast in the setting of suspected **compartment syndrome** is contraindicated, as the rigid cast can contribute to or exacerbate the compartment pressure. - Following up later is dangerous and negligent, as this condition is a surgical emergency requiring intervention within the **golden hour(s)** to salvage limb function.

Q: What does the given image show?

Kessel's plate. ***Kessel's plate*** - The image clearly labels the items on the right side as "b. Kessel's plate," which is a type of **osteosynthesis plate** used for fixing bone fractures. - Kessel's plates are designed to provide **stable fixation** for specific types of fractures, often in the distal femur or tibia. *Dynamic hip screw* - The image labels the items on the left side as "a. Dynamic hip screw," which is a different orthopedic implant than the one in question. - A dynamic hip screw (DHS) is primarily used for the fixation of **intertrochanteric hip fractures** and has a distinct design with a sliding screw. *Amp rasp* - An Amp rasp is a surgical tool used in **hip arthroplasty** to prepare the femoral canal for the stem of a hip prosthesis. - The items shown in the image are **implants** for fixation, not surgical rasps. *Bipolar hip prosthesis* - A bipolar hip prosthesis is a type of **hip replacement implant** used in hemiarthroplasty, consisting of two articulating components. - The image displays **fixation plates and screws**, not a joint replacement prosthesis.

Q: Identify the fracture shown in the image below:

Fracture tibia. ***Fracture tibia*** - The image displays a **long bone fracture** in the lower leg, characterized by a visible fracture line (indicated by the arrow) through the shaft. - The upper part of the image clearly shows the **knee joint**, confirming this as a view of the tibia (shin bone). *Fracture radius* - The radius is a bone in the **forearm**, not the lower leg. - The image clearly depicts the **lower extremity** with a knee joint visible. *Colle's fracture* - A Colles' fracture is a specific type of fracture of the **distal radius** (near the wrist), which is in the forearm. - The fracture shown is in the **tibia**, a bone of the lower leg, and the location is not characteristic of a Colles' fracture. *Supracondylar fracture humerus* - The humerus is the **upper arm bone**, and a supracondylar fracture occurs near the elbow joint. - The image shows a fracture in the **lower leg**, specifically the tibia, not the upper arm.

Q: Which of the following classifications is used to assess the fracture shown below?

Pipkins classification. ***Pipkins classification*** - The image shows a **femoral head fracture**, indicated by the arrow, with internal fixation. The Pipkins classification system specifically categorizes fractures of the **femoral head**. - This system helps guide treatment and prognostication for these particular hip injuries, differentiating based on location and associated injuries. *Gustilo classification* - The Gustilo classification is used for **open fractures**, assessing the extent of soft tissue damage and contamination. - The image displays a post-operative X-ray of a surgically fixed fracture, and the classification is not applicable here as it pertains to the initial presentation of an open fracture. *Salter and Harris classification* - The Salter-Harris classification system is used for **growth plate (physeal) fractures** in children. - The image shows a fracture in an adult bone (as evidenced by the fused growth plates and the morphology of the bone), making this classification irrelevant. *Weber classification* - The Weber classification is used for **ankle fractures**, specifically those involving the distal fibula. - The fracture shown in the image is of the **femoral head**, not the ankle, hence the Weber classification is not appropriate.

Q: The X-ray was taken 8 weeks after sustaining fracture. What is the diagnosis?

Nonunion. ***Nonunion*** - The X-ray image shows a clear **gap** between the two bone fragments, and the bone ends appear **sclerotic** and rounded, indicating that the bone has failed to heal after 8 weeks. - Nonunion is the failure for a fracture to heal after a reasonable period, often defined by the absence of signs of healing for 3-6 months depending on the bone and site, but after 8 weeks with clearly visible sclerotic fragment ends suggests this condition. *Malunion* - **Malunion** occurs when a fracture heals, but in a **deformed** or anatomically incorrect position, which is not evident in the provided image as the fragments are still separate. - The primary problem here is the *absence* of healing, not the healing in a misaligned fashion. *Myositis ossificans* - **Myositis ossificans** is the formation of **heterotopic bone** within muscle or soft tissue, typically following trauma, and would appear as calcification *outside* the bone shaft. - The image clearly depicts unhealed bone fragments, not new bone formation within surrounding soft tissues. *Avascular necrosis* - **Avascular necrosis** (AVN) is the death of bone tissue due to interruption of blood supply, often leading to **collapse of the bone**, which is usually seen in particular bones like the femoral head or scaphoid. - While AVN can complicate fractures, the image primarily shows a lack of bony bridging rather than changes indicative of bone death and collapse.

Q: Which of the following is most commonly seen after the accident shown?

Posterior hip dislocation. ***Posterior hip dislocation*** - The image depicts a classic mechanism of injury in a dashboard injury, where the **knee strikes the dashboard**, driving the femur posteriorly. - This force, especially when the hip is flexed and adducted, can eject the femoral head **posteriorly out of the acetabulum**. *Anterior hip dislocation* - This type of dislocation typically occurs with the hip in **flexion, abduction, and external rotation**, a mechanism not suggested by the diagram. - It is much **less common** than posterior hip dislocation in dashboard injuries. *Posterior tibial dislocation* - While a dashboard injury can affect the knee, a direct posterior force on the tibia itself is more likely to cause a **tibial plateau fracture** or **ligamentous injury** (e.g., PCL tear) than a complete tibiofemoral dislocation in this context. - A posterior tibial dislocation results from severe hyperextension or a direct blow to the anterior tibia when the knee is flexed, which is a different vector of force than the one illustrated. *Anterior tibial dislocation* - This injury typically results from a **hyperextension injury** of the knee or a force applied to the posterior aspect of the proximal tibia. - The image shows a force specifically directed towards the *anterior* aspect of the knee (dashboard impact), making posterior displacement of the femur relative to the pelvis more likely.

Question 1

An 80-year-old female patient with a history of slip and fall in the bathroom was brought to the casualty. She is having pain in the left hip and is unable to walk. She has no history of osteoarthritis. On examination, the left lower limb is shortened and externally rotated. X-ray findings are shown below. How will you manage this patient?

Accepted Answer

Hemiarthroplasty

Answer

Meyer's operation

Answer

McMurray's osteotomy

Answer

Internal fixation with cancellous screws

Question 2

A 60-year-old female patient complains of pain and swelling in the left wrist following a fall on an outstretched hand. On examination, dinner fork deformity can be noticed. What is the most likely displacement seen in this patient?

Accepted Answer

Distal and dorsal displacement of radius

Answer

Proximal and dorsal displacement of ulna

Answer

Proximal and ventral displacement of ulna

Answer

Proximal and ventral displacement of radius

Question 3

A 65-year-old osteoporotic female falls on her outstretched hand and presents with severe wrist pain and deformity. X-ray shows a distal radius fracture with dorsal angulation of 25°, radial shortening of 8mm, and intra-articular extension with 3mm step-off at the radiocarpal joint. Ulnar styloid is also fractured. Which of the following treatment options provides the best functional outcome and lowest complication rate in this patient?

Accepted Answer

Open reduction and internal fixation with volar locking plate

Answer

External fixation with ligamentotaxis

Answer

Percutaneous K-wire fixation

Answer

Closed reduction and below-elbow cast immobilization

Question 4

What is the preferred treatment for an inter-trochanteric fracture in a 72-year-old female?

Accepted Answer

Hemiarthroplasty / Dynamic Hip Screw (DHS)

Answer

Intramedullary nailing

Answer

Open Reduction and Internal Fixation (ORIF) with plating

Answer

Boot and bar

Question 5

A 25-year-old man presents to the emergency department following a motorbike accident and is found to have a closed midshaft fracture of the left tibia. Six hours later, he develops severe leg pain that is disproportionate to the injury and worsens with passive dorsiflexion of the foot. The pain is not relieved by analgesics. On examination, dorsalis pedis and posterior tibial pulses are present, but there is no sensation over the first dorsal webspace. What is the most appropriate next step in management?

Accepted Answer

Immediate fasciotomy

Answer

Administer opioid analgesics and continue observation

Answer

Apply cast and follow up

Answer

Elevate the limb and observe

Question 6

What does the given image show?

Accepted Answer

Kessel's plate

Answer

Dynamic hip screw

Answer

Amp rasp

Answer

Bipolar hip prosthesis

Question 7

Identify the fracture shown in the image below:

Accepted Answer

Fracture tibia

Answer

Fracture radius

Answer

Colle's fracture

Answer

Supracondylar fracture humerus

Question 8

Which of the following classifications is used to assess the fracture shown below?

Accepted Answer

Pipkins classification

Answer

Gustilo classification

Answer

Salter and Harris classification

Answer

Weber classification

Question 9

The X-ray was taken 8 weeks after sustaining fracture. What is the diagnosis?

Accepted Answer

Nonunion

Answer

Malunion

Answer

Myositis ossificans

Answer

Avascular necrosis

Question 10

Which of the following is most commonly seen after the accident shown?

Accepted Answer

Posterior hip dislocation

Answer

Anterior hip dislocation

Answer

Posterior tibial dislocation

Answer

Anterior tibial dislocation

Trauma — MCQs

Trauma — MCQs

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