Trauma Practice Questions

Q: Posterior interosseous nerve is injured in

Monteggia fracture dislocation. ***Monteggia fracture dislocation*** - A Monteggia fracture dislocation involves a fracture of the **proximal ulna** with **dislocation of the radial head**. - The **posterior interosseous nerve (PIN)**, a deep branch of the radial nerve, is particularly vulnerable to injury due to its close proximity to the radial head and the forces involved in this type of injury, leading to **wrist drop** and **finger extensor weakness**. *Reversed monteggia fracture dislocation* - This is an older term sometimes used to describe a **Galeazzi fracture**, which is a fracture of the **distal radius** with dislocation of the **distal radioulnar joint**. - While other nerves might be at risk, the PIN is less commonly injured in a typical Galeazzi fracture compared to a Monteggia injury. *Supracondylar fracture of humerus* - Supracondylar fractures are common in children and involve the **distal humerus**. - The most commonly injured nerves are the **median nerve** and **anterior interosseous nerve**, and sometimes the ulnar nerve, but not typically the posterior interosseous nerve. *Posterior dislocation of elbow* - A posterior dislocation of the elbow involves displacement of the ulna and radius posteriorly in relation to the humerus. - While nerve injuries can occur, the **ulnar nerve** is most frequently affected due to its superficial position behind the medial epicondyle, with the PIN being less commonly affected in an isolated posterior dislocation.

Q: Which type of fracture is most likely to cause exsanguinating blood loss?

Femur fracture with soft tissue injury. ***Femur fracture with soft tissue injury*** - A **femur fracture** can lead to significant internal bleeding due to the large size of the bone and the surrounding highly vascular muscle tissue, potentially causing **1-2 liters of blood loss**. - When combined with **soft tissue injury**, the risk of **exsanguinating hemorrhage** is greatly increased as vessels are directly damaged and hemorrhage is less contained. *Humerus fracture without soft tissue injury* - While a **humerus fracture** can cause bleeding, the blood loss is generally contained within the muscle and fascia, and is typically not as severe, usually around **0.5-1 liter**. - Without significant **soft tissue injury**, major vascular disruption leading to exsanguination is less likely. *Humerus fracture with soft tissue injury* - A **humerus fracture** with **soft tissue injury** does increase the potential for blood loss compared to a simple fracture, but the total volume of potential hemorrhage in the upper arm is still significantly less than in the thigh. - The risk of **exsanguination** is lower due to the smaller size of the limb and less extensive surrounding musculature. *Tibia fracture without soft tissue injury* - A **tibia fracture** can result in moderate blood loss, typically **0.5-1.5 liters**, especially if the bone is comminuted. - However, without **soft tissue injury**, the blood often extravasates into the relatively confined fascial compartments of the lower leg, limiting immediate massive external or uncontrolled internal bleeding.

Q: All of the following are indications for open reduction and internal fixation (ORIF) of fractures EXCEPT:

Stable closed fracture. ***Stable closed fracture*** - A **stable closed fracture** typically does not require surgical intervention with ORIF as it can usually be managed non-surgically with casting or bracing. - The goal of ORIF is to achieve **anatomic reduction and rigid fixation**, which is not necessary for stable fractures that maintain alignment. *Multiple trauma* - In patients with **multiple trauma**, early stabilization of long bone fractures using ORIF can help reduce pain, prevent further injury, and facilitate patient mobilization. - This approach aims to reduce the risk of complications such as **ARDS (acute respiratory distress syndrome)** and fat embolism for critically ill patients. *Compound fracture* - **Compound (open) fractures** involve a break in the skin, exposing the bone to the external environment, and are a classic indication for surgical management. - ORIF in these cases helps to achieve **stabilization** after debridement, crucial for preventing infection and promoting bone healing. *Intra-articular fracture* - **Intra-articular fractures** involve the joint surface, and accurate anatomical reduction is critical to prevent post-traumatic arthritis and preserve joint function. - ORIF provides the precise reduction and stable fixation needed to restore the **joint congruity**.

Q: Most common muscle involved in Volkmann's ischemic contracture is

Flexor-digitorum profundus. ***Flexor-digitorum profundus*** - The **flexor digitorum profundus (FDP)** is the most commonly involved muscle in Volkmann's ischemic contracture due to its deep location and long course, making it highly susceptible to **ischemia** in the forearm compartment. - Its involvement leads to the characteristic **flexion deformities** of the digits at the interphalangeal joints. *Flexor-indicis* - The **flexor indicis** is not a formally recognized muscle, and while finger flexors are involved, the FDP is explicitly the most common. - This option likely refers to muscles that flex the index finger, but the primary pathology affects the entire FDP muscle group. *Flexor pollicis longus* - While the **flexor pollicis longus (FPL)** can be affected in Volkmann's contracture, it is not the *most common* muscle involved compared to the FDP. - The FPL is responsible for **thumb flexion**, and its involvement would manifest primarily in thumb deformities. *Abductor pollicis* - The **abductor pollicis** muscles (e.g., abductor pollicis longus, abductor pollicis brevis) are involved in **thumb abduction**, not flexion, and are typically less affected by the ischemia that causes Volkmann's contracture. - These muscles are generally located in different compartments or are more superficial, offering them some protection.

Q: Pathognomonic sign of traumatic fracture is

Crepitus. - ***Crepitus*** - Crepitus, the **grating or crunching sound** or sensation produced by the friction of bone fragments, is the most specific and **pathognomonic sign** of a fracture. - It occurs when the rough surfaces of bone ends rub against each other due to movement. - *Tenderness* - While **tenderness** is a common sign of a fracture, it is not pathognomonic, as it can occur with many other injuries, such as sprains or contusions. - **Localized pain** upon palpation is a general indicator of injury but lacks specificity for bone fracture. - *Redness* - **Redness (erythema)** is a sign of inflammation and can be present in various injuries or infections but is not typically a direct indicator of a traumatic fracture unless accompanied by significant soft tissue damage or infection. - It is a non-specific sign and doesn't confirm bone disruption. - *Swelling* - **Swelling (edema)** commonly accompanies fractures due to hematoma formation and inflammation but is also a general response to many types of injury and is not unique to fractures. - It indicates tissue damage but does not specifically differentiate a fracture from a sprain or severe contusion.

Q: Most common complication of Colles' fracture is:

Malunion. ***Malunion*** - **Malunion** is the most common complication of Colles' fracture, occurring when the fracture heals in a **deformed position**. - This typically results in residual **dorsal tilt**, **radial shortening**, and a **"dinner fork" deformity** of the wrist. *Gunstock deformity* - **Gunstock deformity** is an angular deformity of the elbow, usually associated with **supracondylar humeral fractures**, not Colles' fracture. - It results in the forearm deviating away from the body when the elbow is extended. *Non-union* - **Non-union** refers to the failure of a fracture to heal after a sufficient period, which is **rare** in distal radial fractures like Colles' fracture due to their excellent blood supply. - It typically requires surgical intervention and is not the most common complication. *Sudek's osteodystrophy* - **Sudek's osteodystrophy**, also known as **Complex Regional Pain Syndrome (CRPS) Type I**, is a less common but severe complication characterized by chronic pain, swelling, and changes in skin temperature/color. - While it can occur after Colles' fracture, its incidence is lower than malunion.

Q: Internal splints (fixation devices) are used in all except:

Compound fractures. ***Compound fractures*** - **Internal splints** are generally avoided in **compound (open)** fractures due to the increased risk of **infection** and the difficulties in maintaining sterility around the exposed hardware. - The primary management of compound fractures involves thorough **debridement**, irrigation, and often **external fixation** or plaster immobilization followed by delayed internal fixation once soft tissue conditions allow. *Fractures in elderly patients* - **Internal fixation** is often the preferred method for fractures in elderly patients, especially hip fractures, as it allows for **early mobilization**, reducing complications like pneumonia, bed sores, and DVT. - It stabilizes the fracture site, promoting comfort and facilitating a faster return to function. *Multiple fractures* - In cases of **multiple fractures (polytrauma)**, internal fixation is crucial for stabilizing different fracture sites, reducing pain, and allowing for comprehensive patient care and rehabilitation. - It helps manage systemic effects of trauma like **fat embolism** and allows earlier mobilization compared to external methods for multiple sites. *Fracture of neck of femur* - **Internal fixation** (e.g., cannulated screws, dynamic hip screw) or **arthroplasty** (hemiarthroplasty or total hip replacement) are the standard treatments for **femoral neck fractures**. - This approach aims to restore stability, allow for **early weight-bearing**, and prevent complications such as **avascular necrosis** and non-union.

Q: Hill-Sachs lesion is seen in?

Anterior dislocation of shoulder joint. ***Anterior dislocation of shoulder joint*** - A **Hill-Sachs lesion** is a **cortical depression** in the posterolateral head of the humerus. - It occurs when the humeral head impacts the **anterior glenoid rim** during an anterior shoulder dislocation. *Glenoid labrum tear* - A **glenoid labrum tear** refers to damage to the cartilage rim around the glenoid socket. - While it can coexist with dislocations and contribute to instability, it is not the direct site of a Hill-Sachs lesion. *Posterolateral humerus* - The **posterolateral humerus** is the specific location where the Hill-Sachs lesion occurs on the humeral head. - However, the lesion itself is *caused by* the anterior dislocation, not an independent finding listed this way. *Posterior dislocation of shoulder joint* - A **posterior shoulder dislocation** is typically associated with a **reverse Hill-Sachs lesion** (also known as a trough line fracture or medial humeral head compression fracture), which occurs on the anteromedial aspect of the humeral head. - The classic Hill-Sachs lesion is specific to anterior dislocations.

Q: Maximum shortening of lower limb is seen in:

intertrochanteric. ***intertrochanteric*** - **Intertrochanteric fractures** often lead to significant leg shortening due to the pull of strong hip muscles on the distal fragment, causing displacement and overriding. - The fracture location between the greater and lesser trochanters allows for considerable muscle-driven impaction and proximal migration of the shaft relative to the pelvis. *shaft femur* - **Femoral shaft fractures** can cause shortening, but the degree is often less severe than with intertrochanteric fractures because muscle spasm may be somewhat contained by the surrounding musculature. - While significant displacement can occur, the extensive muscle attachments around the shaft tend to stabilize it more in comparison to the rotational and upward pull seen in intertrochanteric fractures. *Neck femur* - **Femoral neck fractures** primarily cause pain and inability to bear weight, but they typically result in less significant leg shortening compared to intertrochanteric fractures. - Shortening in femoral neck fractures is often due to impaction or slight collapse, not the extensive overriding seen with intertrochanteric breaks. *Transcervical* - **Transcervical fractures** are a type of femoral neck fracture, and thus, they share similar characteristics where shortening is usually less pronounced and primarily due to impaction at the fracture site. - The shortening is often more subtle and related to the degree of collapse at the fracture margin rather than gross displacement of the entire shaft.

Q: The contraindication to internal fixation -

Active infection. ***Active infection*** - **Active infection** is a strong contraindication to internal fixation because introducing foreign material (implants) into an infected area can spread the infection, make it chronic, and lead to implant failure, osteomyelitis, or sepsis. - The presence of bacteria can colonize the implant surface, forming **biofilms** that are highly resistant to antibiotics and host immune responses, severely complicating treatment. *Fracture dislocation* - **Fracture dislocations** are often a strong *indication* for internal fixation to achieve anatomical reduction and stable fixation, allowing for early mobilization and preventing avascular necrosis or persistent instability. - The goal is to restore joint congruity and maintain reduction, which is difficult to achieve and maintain with non-operative methods. *Intraarticular fracture* - **Intraarticular fractures** are frequently *managed with* internal fixation to restore articular surface congruity, minimize post-traumatic arthritis, and allow for early range of motion. - Precise reduction and stable fixation are crucial to prevent long-term complications such as joint stiffness and osteoarthritis. *Physeal injury* - **Physeal injuries** (growth plate fractures) are often *treated with* surgical fixation, particularly unstable or displaced fractures, to ensure anatomical reduction and prevent growth disturbances. - The fixation technique must be chosen carefully to avoid damaging the physis itself, often using smooth pins or screws that do not cross the growth plate.

Question 1

Posterior interosseous nerve is injured in

Accepted Answer

Monteggia fracture dislocation

Answer

Reversed monteggia fracture dislocation

Answer

Supracondylar fracture of humerus

Answer

Posterior dislocation of elbow

Question 2

Which type of fracture is most likely to cause exsanguinating blood loss?

Accepted Answer

Femur fracture with soft tissue injury

Answer

Humerus fracture without soft tissue injury

Answer

Humerus fracture with soft tissue injury

Answer

Tibia fracture without soft tissue injury

Question 3

All of the following are indications for open reduction and internal fixation (ORIF) of fractures EXCEPT:

Accepted Answer

Stable closed fracture

Answer

Multiple trauma

Answer

Compound fracture

Answer

Intra-articular fracture

Question 4

Most common muscle involved in Volkmann's ischemic contracture is

Accepted Answer

Flexor-digitorum profundus

Answer

Flexor-indicis

Answer

Flexor pollicis longus

Answer

Abductor pollicis

Question 5

Pathognomonic sign of traumatic fracture is

Accepted Answer

Crepitus

Answer

Tenderness

Answer

Redness

Answer

Swelling

Question 6

Most common complication of Colles' fracture is:

Accepted Answer

Malunion

Answer

Gunstock deformity

Answer

Non-union

Answer

Sudek's osteodystrophy

Question 7

Internal splints (fixation devices) are used in all except:

Accepted Answer

Compound fractures

Answer

Fractures in elderly patients

Answer

Multiple fractures

Answer

Fracture of neck of femur

Question 8

Hill-Sachs lesion is seen in?

Accepted Answer

Anterior dislocation of shoulder joint

Answer

Glenoid labrum tear

Answer

Posterolateral humerus

Answer

Posterior dislocation of shoulder joint

Question 9

Maximum shortening of lower limb is seen in:

Accepted Answer

intertrochanteric

Answer

shaft femur

Answer

Neck femur

Answer

Transcervical

Question 10

The contraindication to internal fixation -

Accepted Answer

Active infection

Answer

Fracture dislocation

Answer

Intraarticular fracture

Answer

Physeal injury

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