Trauma Practice Questions

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: 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.

Q: What is the angle formed by joining a line extended from the fracture line of the fracture neck to an arbitrary line depicting the horizontal plane?

Pauwel's angle. ***Pauwel's angle*** - **Pauwel's angle** measures the angulation of a femoral neck fracture relative to the horizontal plane, indicating the degree of shear force across the fracture site. - A higher Pauwel's angle (Type III) suggests greater instability and higher shear forces, impacting treatment decisions. *Shenton's line* - **Shenton's line** is a curved line seen on an X-ray formed by the inferior border of the superior pubic ramus and the inferomedial border of the femoral neck. - Disruption of Shenton's line indicates hip dislocation or a femoral neck fracture with displacement. *Perkins line* - **Perkins line** is used in the evaluation of developmental dysplasia of the hip (DDH) to assess the lateral displacement of the femoral head. - It is drawn perpendicular to Hilgenreiner's line through the lateral rim of the acetabulum. *Nelaton's line* - **Nelaton's line** is a clinical landmark used to assess the position of the greater trochanter relative to the pelvis. - It extends from the anterior superior iliac spine to the ischial tuberosity; if the greater trochanter lies above this line, it may indicate hip dislocation or fracture.

Q: A patient presents with a compound fracture of the tibia, with a 1-cm opening in the skin. Which grade does it belong to?

Grade II. ***Grade II*** - A **Grade II open fracture** is defined by a skin wound between **1 cm and 10 cm** in length, often accompanied by moderate crush injury and minimal to moderate soft tissue damage. - The presence of a **1-cm skin opening** with a compound fracture places it within this category, distinguishing it from smaller (Grade I) or larger/more complex (Grade III) wounds. *Grade I* - A **Grade I open fracture** involves a clean skin wound of **less than 1 cm** and typically has minimal soft tissue damage. - The stated wound size of **1 cm** exceeds the strict definition for Grade I, which requires the wound to be *under* 1 cm. *Grade IIIA* - **Grade IIIA open fractures** are characterized by extensive soft tissue damage, **adequate bone coverage**, and wound sizes *greater than 10 cm*. - Although the wound is *compound*, its small size (1 cm) does not fit the criteria for *extensive* soft tissue damage or a wound larger than 10 cm, which are hallmarks of Grade IIIA. *Grade IIIB* - **Grade IIIB open fractures** involve severe soft tissue loss with **periosteal stripping** and **bone exposure**, even after debridement. - These fractures require **soft tissue reconstruction** for wound closure, which is a much more severe injury than described by a 1-cm skin opening.

Q: Which of the following is NOT a primary goal of open reduction and internal fixation (ORIF)?

Consolidation (final healing phase). ***Consolidation (final healing phase)*** - While ORIF aims to facilitate healing, **consolidation** is the *result* of successful treatment, not a direct primary goal achieved *during* the surgical procedure itself. - The surgical goals focus on creating the optimal environment for consolidation to occur naturally after the operation. *Stability (maintaining bone position)* - Achieving and maintaining **stability** of the fractured bone fragments is a fundamental goal of ORIF. - This prevents micromotion at the fracture site, which is crucial for reducing pain and promoting proper healing. *Better function (restoring mobility)* - Restoring **normal or near-normal function and mobility** to the injured limb or body part is a key objective of ORIF. - By stabilizing the fracture and allowing early mobilization, the procedure helps minimize joint stiffness and muscle atrophy. *Better alignment (correct positioning)* - **Accurate anatomical reduction and alignment** of the fractured bone fragments are paramount in ORIF. - Proper alignment is essential for restoring biomechanical integrity and ensuring optimal long-term functional outcomes.

Q: Subtrochanteric fractures of the femur can be treated by all of the following methods, except:

Smith Petersen Nail. ***Smith Petersen Nail*** - The **Smith Petersen nail** is an **intramedullary device** used primarily for **femoral neck fractures** or certain types of **intertrochanteric fractures**, but it is generally **not indicated** for subtrochanteric fractures due to suboptimal stability in this region. - Its design does not provide adequate fixation or rotational control for the unique forces acting on the **subtrochanteric area**, which is under significant bending and shear stress. *Skeletal traction on Thomas' splint* - **Skeletal traction** can be used as a **temporary measure** for subtrochanteric fractures to maintain length and alignment, especially in cases where definitive surgical fixation is delayed. - The **Thomas' splint** helps to support the limb and keep it in traction, reducing pain and preventing further displacement. *Condylar blade plate* - A **condylar blade plate** or **proximal femoral locking plate** is a suitable implant for **complex subtrochanteric fractures**, particularly those with comminution or extending into the trochanteric region. - It provides **angular stability** and strong fixation, which is crucial for successful healing in this high-stress area. *Ender's nail* - **Ender's nails** are flexible **intramedullary nails** that can be used for certain types of subtrochanteric fractures, particularly in situations where a less invasive approach is desired or in elderly patients. - While they offer some stability, their use for subtrochanteric fractures has largely been superseded by more rigid interlocking nails due to **higher rates of malunion** and **rotational instability**.

Q: Which of the following is a contraindication for open reduction & internal fixation (ORIF)?

All of the options. ***All of the options*** - **Active infection** at the surgical site is a significant contraindication for ORIF due to the high risk of **osteomyelitis** and implant failure. - **Soft bones**, such as those found in patients with **osteoporosis**, may not adequately hold the internal fixation devices (screws, plates), leading to implant loosening or cutout. - **Soft tissue contractures** around the fracture site can make surgical access difficult, compromise soft tissue coverage, and increase the risk of wound complications and poor functional outcomes. *Active infection* - While a direct contraindication, it's not the *only* one for ORIF. - Performing ORIF in the presence of infection significantly increases the risk of **surgical site infection** and implant failure, potentially leading to chronic osteomyelitis. *Soft bones* - This is a significant challenge for ORIF, as the bone quality may not be sufficient to hold the hardware securely. - It increases the risk of **implant failure** and non-union, but again, it's not the sole contraindication listed. *Soft tissue contractures around the fracture site* - Severe contractures can **impede surgical exposure**, make anatomical reduction difficult, and compromise the vascularity of the tissues. - This can lead to increased rates of **wound complications** and poor healing, but it is one of several contraindications.

Q: Avascular necrosis (AVN) is commonly associated with which type of femoral neck fracture?

Subcapital. ***Subcapital*** - Subcapital fractures occur at the anatomical **neck of the femur**, just below the femoral head, and often disrupt the **blood supply** to the femoral head due to injury to the lateral epiphyseal arteries. - The high rate of **vascular disruption** in these fractures significantly increases the risk of avascular necrosis (AVN) a condition where bone tissue dies due to lack of blood supply. *Transcervical* - Transcervical fractures are located through the **middle part of the femoral neck**, between subcapital and basal fractures, and also carry a risk of AVN. - However, the risk of AVN is generally considered **lower than subcapital fractures** but higher than basal fractures, due to less consistent disruption of the retinacular vessels. *Basal* - Basal fractures occur at the **base of the femoral neck**, near the intertrochanteric line, and typically have a **better prognosis** regarding AVN. - The principal blood supply to the femoral head is usually **less compromised** in basal fractures compared to subcapital or transcervical fractures, as the fracture line is more distal to the weight-bearing femoral head. *Intertrochanteric* - Intertrochanteric fractures occur **outside the hip joint capsule**, in the region between the greater and lesser trochanters, and are considered **extracapsular**. - Due to their location being well away from the **femoral head's vascular supply**, these fractures have a very low risk of avascular necrosis and primarily raise concerns about stability and healing.

Question 1

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 2

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 3

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 4

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

Question 5

What is the angle formed by joining a line extended from the fracture line of the fracture neck to an arbitrary line depicting the horizontal plane?

Accepted Answer

Pauwel's angle

Answer

Shenton's line

Answer

Perkins line

Answer

Nelton's line

Question 6

A patient presents with a compound fracture of the tibia, with a 1-cm opening in the skin. Which grade does it belong to?

Accepted Answer

Grade II

Answer

Grade IIIA

Answer

Grade IIIB

Answer

Grade I

Question 7

Which of the following is NOT a primary goal of open reduction and internal fixation (ORIF)?

Accepted Answer

Consolidation (final healing phase)

Answer

Stability (maintaining bone position)

Answer

Better function (restoring mobility)

Answer

Better alignment (correct positioning)

Question 8

Subtrochanteric fractures of the femur can be treated by all of the following methods, except:

Accepted Answer

Smith Petersen Nail

Answer

Ender's nail

Answer

Skeletal traction on Thomas' splint

Answer

Condylar blade plate

Question 9

Which of the following is a contraindication for open reduction & internal fixation (ORIF)?

Accepted Answer

All of the options

Answer

Active infection

Answer

Soft bones

Answer

Soft tissue contractures around the fracture site

Question 10

Avascular necrosis (AVN) is commonly associated with which type of femoral neck fracture?

Accepted Answer

Subcapital

Answer

Transcervical

Answer

Basal

Answer

Intertrochanteric

Trauma — MCQs

Trauma — MCQs

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