Trauma Practice Questions

Q: An 18 year old boy had a closed lower limb injury while riding his motorbike. He was brought to hospital where on examination he had severe pain which increased on passive movement of affected limb with distal sensory disturbances. What is the probable diagnosis?

Compartment syndrome. ***Compartment syndrome*** - This diagnosis is strongly suggested by the presence of **severe pain out of proportion to injury**, pain with **passive stretch** of muscles, **paresthesia** (sensory disturbances), and a history of **closed lower limb injury**. These are classic signs of increased pressure within a confined fascial compartment. - The elevated pressure compromises **perfusion**, leading to muscle and nerve ischemia. Prompt recognition and treatment (fasciotomy) are crucial to prevent permanent damage. *Deep Vein thrombosis* - While DVT can cause lower limb pain and swelling, it is typically associated with **venous stasis**, endothelial injury, and hypercoagulability, not immediate severe pain with passive movement and sensory deficits following acute trauma. - The pain in DVT is usually described as a **dull ache** and not typically out of proportion to what would be expected, nor does it typically present with acute sensory loss without major vascular compromise. *Degloving Injury* - A degloving injury involves the **separation of skin and subcutaneous tissue** from deeper structures, often with significant visible skin avulsion. - While it can cause severe pain, the key diagnostic features in this scenario (closed injury, pain on passive movement, and distal sensory disturbances) are more classic for compartment syndrome rather than a primary external soft tissue avulsion. *High Pressure Injection injury* - This type of injury results from the **introduction of foreign material** under high pressure into tissues, often leading to rapid swelling, pain, and tissue necrosis. - It usually has a distinct history of exposure to high-pressure equipment (e.g., paint gun, grease gun), which is not mentioned here, and while severe, the precise constellation of symptoms points away from this specific mechanism.

Q: An 8 year old girl sustained a fall on the outstretched right hand 6 hours ago and was treated with egg albumen bandages by a village bone setter. She presented with gross swelling of the right elbow and forearm. The first essential intervention in this case would be to

completely remove all encircling bandages.. ***completely remove all encircling bandages.*** - An 8-year-old with a fall on an outstretched hand and gross swelling of the elbow and forearm points to a **supracondylar fracture of the humerus**, which can lead to **compartment syndrome**. - **Tight bandages** (like egg albumen) will exacerbate swelling, impede venous return, and compromise arterial inflow, making their immediate removal essential to prevent **ischemia** and potential **nerve damage**. *elevate the right hand.* - While elevation helps reduce swelling, it is **secondary** to relieving any constricting external pressure caused by the bandages, which are the more immediate threat. - Elevating a limb with compromised circulation due to external compression would be insufficient and could delay proper management. *immerse the hand in warm water to increase the circulation.* - Immersing an injured limb in warm water can **increase swelling** and potentially aggravate bleeding into the tissues, which is counterproductive in a situation with suspected compartment syndrome. - This intervention would **worsen the clinical picture** and is inappropriate for acute trauma with significant swelling. *order urgent radiographs of both elbows.* - While radiographs are crucial for diagnosing the underlying fracture, they are **not the first essential intervention** in a limb with gross swelling and potential vascular compromise from tight bandages. - Addressing the immediate threat of **compartment syndrome** and relieving external compression takes priority over diagnostic imaging.

Q: Indications for fasciotomy in compartment syndrome include all EXCEPT:

Palpable distal pulses. ***Palpable distal pulses*** - The presence of **palpable distal pulses is NOT an indication for fasciotomy** and does not rule out compartment syndrome. - **Vascular compromise is a late sign** in compartment syndrome - pulses often remain palpable even with significant nerve and muscle ischemia. - Fasciotomy decisions should be based on **clinical signs** (pain, sensory changes) and **pressure measurements**, not the presence of pulses. - This is the correct answer because it is NOT an indication for the procedure. *Compartment pressure > 30 mm Hg* - **Absolute indication for fasciotomy** when compartment pressure exceeds 30 mmHg, or when the **delta pressure** (diastolic BP minus compartment pressure) is less than 30 mmHg. - This pressure level impairs capillary perfusion and leads to tissue ischemia. *Distal sensory disturbance* - **Early and reliable indication** for fasciotomy showing nerve ischemia. - Paresthesia or numbness in the distribution of nerves running through the affected compartment indicates neurological compromise from elevated intracompartmental pressure. *Pain on passive movement of affected muscles* - **Most sensitive and earliest clinical sign** of compartment syndrome (part of "the 6 P's"). - Pain on passive stretch is typically **out of proportion to the injury** and indicates underlying muscle ischemia. - This is a clear indication for fasciotomy.

Q: Identify the implant shown in the image:

Dynamic hip screw. ***Dynamic hip screw*** - The image shows a **lag screw** inserted into the femoral neck and head, which slides within a **side plate** attached to the femoral shaft with cortical screws. - This construct allows for controlled **dynamic collapse** and impaction at the fracture site, promoting healing and providing stable fixation for **extracapsular hip fractures**. *Cannulated hip screw* - Cannulated screws are typically used in a **parallel configuration** or as a single large screw for hip fractures, particularly **femoral neck fractures**. - They do not feature a **side plate** that extends down the femoral shaft for additional fixation. *Condylar hip screw* - A condylar hip screw (DCS) is used for **distal femur fractures**, often extending into the **condyles**. - It involves a different angulation and design compared to the proximal femoral implant seen, which is fixed to the femoral shaft. *Intramedullary nail* - An intramedullary nail is inserted into the **medullary canal** of the bone, running through its center. - While some hip nails (e.g., trochanteric nails) have a cephalic screw component, they primarily stabilize the shaft from within, unlike the **extracortical side plate** seen here.

Q: A patient fell off a bicycle and now complains of pain around the hip, with shortening of the affected limb. The hip is held in a position of flexion, adduction, and internal rotation. What is the most likely diagnosis?

Posterior dislocation. **Posterior dislocation** - **Posterior hip dislocations** typically occur after high-energy trauma (e.g., falls from height, motor vehicle accidents) and present with the affected limb in a classic position of **flexion, adduction, and internal rotation**. - **Shortening of the limb** is also a hallmark sign, often due to the femoral head displacing posteriorly and superiorly. *Intertrochanteric fracture (IT fracture)* - **Intertrochanteric fractures** usually present with the affected limb in **external rotation** and shortening, which is contrary to the internal rotation described in the case. - While pain is present, the specific rotational deformity helps differentiate it from a hip dislocation. *Transcervical fracture* - **Transcervical fractures** (femoral neck fractures) also typically present with the leg in **external rotation** and shortening. - These fractures are common in older adults and often associated with less severe trauma or falls. *Anterior dislocation* - **Anterior hip dislocations** are less common and typically present with the affected limb in a position of **flexion, abduction, and external rotation**. - This presentation is directly opposite to the adduction and internal rotation described in the question.

Q: What should be done as an immediate measure for ongoing bleeding in a patient with pelvic bone fracture?

Use Pelvic Binders. **Use Pelvic Binders** - **Pelvic binders** apply circumferential compression, which helps to stabilize the fracture and reduce the pelvic volume. - This mechanical stabilization significantly reduces ongoing hemorrhage from venous and bone surface bleeding in unstable pelvic fractures. *Rapid blood transfusion* - While critically important for managing **hemorrhagic shock**, blood transfusion alone does not address the source of ongoing bleeding. - It is a supportive measure, not an immediate means to stop the bleeding from an unstable pelvic fracture. *Internal definitive fixation* - **Internal definitive fixation** is a surgical procedure aimed at permanently stabilizing the fracture and would typically be performed after initial resuscitation and bleeding control. - It is not an immediate measure for **ongoing life-threatening hemorrhage** and carries procedural risks. *External fixation* - **External fixation** can stabilize an unstable pelvic fracture and helps in controlling bleeding, but applying a **pelvic binder** is a quicker and less invasive initial step. - External fixation is usually performed by a surgeon in a controlled environment, not as the very first immediate bedside measure to stop bleeding.

Q: A 40 year male patient presented to the ER with a history of fall and C/O pain and swelling in right shoulder region. The x-ray of the patients suggests tear in which of the following ligament?

Acromioclavicular ligament. ***Acromioclavicular ligament*** - A fall on an outstretched arm or direct trauma to the shoulder can cause an **acromioclavicular joint separation**, leading to a tear in the acromioclavicular ligament. - Pain and swelling in the right shoulder region are classic symptoms, and an X-ray can confirm the **widening of the AC joint space**. *Coracoacromial ligament* - This ligament forms the roof of the **subacromial space** and is rarely torn in isolation from trauma. - Tears are more commonly associated with **impingement syndrome** or **rotator cuff pathology**, not primarily with a traumatic fall leading to joint pain and swelling. *Coracoclavicular ligament* - While it helps stabilize the acromioclavicular joint, a tear of the **coracoclavicular ligament** is usually present in more severe acromioclavicular joint dislocations (Type III and above). - Its rupture would result in a more pronounced **superior displacement of the clavicle** compared to an isolated AC ligament tear. *Glenohumeral ligament* - These ligaments reinforce the **glenohumeral joint capsule** and are primarily involved in stabilizing the shoulder against dislocation. - A tear would typically present with symptoms of **shoulder instability** or a **dislocation**, rather than just pain and swelling from a fall focused on the AC joint.

Q: 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

$3,5,6$. ***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.

Q: Which of the following findings appear late in compartment syndrome?

Pulselessness. ***Pulselessness*** - **Pulselessness** is a very late and ominous sign in compartment syndrome, indicating severe arterial compromise that has progressed beyond simple venous and lymphatic outflow obstruction. - Its presence suggests **irreversible tissue damage** has likely already occurred due to prolonged ischemia. *Paralysis* - **Paralysis** is a late sign, indicating significant nerve ischemia and damage due to sustained pressure within the compartment. - While it's a serious finding, it typically appears before pulselessness, as nerves are sensitive to ischemia but arteries are more resistant to complete occlusion until very high pressures are reached. *Pain on passive stretch* - **Pain on passive stretch** is considered one of the earliest and most reliable clinical signs of early compartment syndrome. - It results from the stretching of ischemic muscle fibers within the confined compartment. *Pallor* - **Pallor** (skin paleness) is also a relatively late sign, occurring when capillary perfusion is significantly reduced due to rising intracompartmental pressure. - It usually manifests when the pressure is high enough to restrict blood flow but often precedes the complete absence of pulses.

Question 1

An 18 year old boy had a closed lower limb injury while riding his motorbike. He was brought to hospital where on examination he had severe pain which increased on passive movement of affected limb with distal sensory disturbances. What is the probable diagnosis?

Accepted Answer

Compartment syndrome

Answer

Deep Vein thrombosis

Answer

Degloving Injury

Answer

High Pressure Injection injury

Question 2

An 8 year old girl sustained a fall on the outstretched right hand 6 hours ago and was treated with egg albumen bandages by a village bone setter. She presented with gross swelling of the right elbow and forearm. The first essential intervention in this case would be to

Accepted Answer

completely remove all encircling bandages.

Answer

elevate the right hand.

Answer

immerse the hand in warm water to increase the circulation.

Answer

order urgent radiographs of both elbows.

Question 3

Which one of the following statements about Compartment Syndrome is NOT correct?

Accepted Answer

Pain is on active movement but not on passive movement of muscles

Answer

Fasciotomy is the treatment of choice

Answer

It is commonest in a closed fracture

Answer

Volkmann's Ischaemic contracture is a late complication

Question 4

Indications for fasciotomy in compartment syndrome include all EXCEPT:

Accepted Answer

Palpable distal pulses

Answer

Compartment pressure > 30 mm Hg

Answer

Distal sensory disturbance

Answer

Pain on passive movement of affected muscles

Question 5

Identify the implant shown in the image:

Accepted Answer

Dynamic hip screw

Answer

Cannulated hip screw

Answer

Condylar hip screw

Answer

Intramedullary nail

Question 6

A patient fell off a bicycle and now complains of pain around the hip, with shortening of the affected limb. The hip is held in a position of flexion, adduction, and internal rotation. What is the most likely diagnosis?

Accepted Answer

Posterior dislocation

Answer

Intertrochanteric fracture (IT fracture)

Answer

Transcervical fracture

Answer

Anterior dislocation

Question 7

What should be done as an immediate measure for ongoing bleeding in a patient with pelvic bone fracture?

Accepted Answer

Use Pelvic Binders

Answer

Rapid blood transfusion

Answer

External fixation

Answer

Internal definitive fixation

Question 8

A 40 year male patient presented to the ER with a history of fall and C/O pain and swelling in right shoulder region. The x-ray of the patients suggests tear in which of the following ligament?

Accepted Answer

Acromioclavicular ligament

Answer

Coracoacromial ligament

Answer

Coracoclavicular ligament

Answer

Glenohumeral ligament

Question 9

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

Accepted Answer

$3,5,6$

Answer

$1,2,3,4,5,6$

Answer

$3,4,5$

Answer

$1,2,4$

Question 10

Which of the following findings appear late in compartment syndrome?

Accepted Answer

Pulselessness

Answer

Paralysis

Answer

Pain on passive stretch

Answer

Pallor

Trauma — MCQs

Trauma — MCQs

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