Trauma Practice Questions

Q: Which of the following statements is false regarding Colles' fracture?

Not associated with dorsal angulation of the wrist. ***Not associated with dorsal angulation of the wrist*** - This statement is **false** because a Colles' fracture is classically defined by **dorsal displacement** and **dorsal angulation** of the distal radial fragment, often leading to a "dinner fork" deformity. - The fracture typically occurs with the hand in **forced dorsiflexion**, causing the distal fragment to tip dorsally. *In old age* - Colles' fractures are common in **older individuals**, particularly postmenopausal women, due to **osteoporosis** which weakens bone density. - The reduced bone strength makes the distal radius susceptible to fracture during falls onto an outstretched hand. *Dorsal shift* - A key characteristic of a Colles' fracture is the **dorsal displacement** of the distal radial fragment. - This posterior shift contributes to the classic "dinner fork" deformity seen clinically. *At cortico-cancellous junction* - The fracture usually occurs approximately **2.5 cm proximal to the radiocarpal joint** in the distal radius. - This region is where the denser cortical bone transitions to the more porous cancellous bone, making it a common site for fracture.

Q: A 42-year-old man is brought to the trauma center after a fall from a ladder. Physical examination reveals a slightly deformed left lower extremity with a 0.5 cm soft tissue defect over the anterolateral aspect of his leg. The wound appears relatively clean with no gross contaminants present. Radiographs depict a short oblique proximal one-third diaphyseal tibia fracture. What is his Gustilo open fracture classification grade?

I. ***I*** - A **Gustilo Grade I** open fracture is characterized by a wound size of less than 1 cm, with minimal soft tissue damage and a relatively clean wound. - The description of a **0.5 cm soft tissue defect**, a "relatively clean" wound, and a "short oblique" fracture fits these criteria. *II* - A **Gustilo Grade II** open fracture involves a wound greater than 1 cm but less than 10 cm, with moderate soft tissue damage and contamination. - This patient's wound is only **0.5 cm**, indicating less extensive soft tissue involvement than a Grade II injury. *IIIa* - **Gustilo Grade IIIa** fractures involve extensive soft tissue damage, a wound greater than 10 cm, and significant contamination, but with adequate soft tissue coverage of the bone. - The patient's **small, clean wound** and lack of extensive damage rule out Grade IIIa. *IIIb* - **Gustilo Grade IIIb** fractures are characterized by massive soft tissue damage, significant contamination, and periosteal stripping, typically requiring reconstructive procedures. - This definition clearly deviates from the presented case, which describes a **minimal wound** and no significant soft tissue loss.

Q: Velpeau bandage and Sling and Swathe splint are used in?

Shoulder dislocation. ***Shoulder dislocation*** - Both the **Velpeau bandage** and the **Sling and Swathe splint** immobilize the shoulder in adduction and internal rotation, which is the preferred position for **anterior glenohumeral dislocations**. - These devices help prevent **re-dislocation** and promote healing of the soft tissues damaged during the dislocation event. *Fracture scapula* - While sometimes requiring immobilization, a **scapular fracture** typically requires different stabilization methods depending on the fracture pattern, given its close proximity to the chest wall. - Immobilization for scapular fractures may involve a simple sling to support the arm, but the specific **Velpeau or Sling and Swathe** is not the primary or universal choice. *Acromioclavicular dislocation* - **AC joint dislocations** involve injury to the ligaments connecting the acromion and clavicle. - Treatment often involves a simple sling for comfort and support, allowing gravity to reduce the displacement, and not the specific restrictive immobilization of a **Velpeau or Sling and Swathe**, which maintains internal rotation. *Fracture clavicle* - A **clavicle fracture** typically requires immobilizing the arm and shoulder for pain relief and alignment. - A **figure-of-eight bandage** or a simple arm sling is more commonly used to support the arm and retract the shoulders, rather than the specific immobilization provided by a Velpeau or Sling and Swathe.

Q: Which bone is commonly fractured when a person falls on outstretched hands?

Distal radius. ***Distal radius*** - A fall on an **outstretched hand (FOOSH)** typically transmits force up the arm, often resulting in a fracture of the distal radius, known as a **Colles fracture** if the fragment is displaced dorsally. - This is one of the most common fractures, particularly in older adults with **osteoporosis**. *Ulnar styloid process* - While the ulnar styloid can be fractured in conjunction with a distal radius fracture, it is usually a **secondary injury** and not the primary bone commonly fractured on its own in a FOOSH injury. - Isolated ulnar styloid fractures are less common as the main injury from this mechanism. *Scaphoid bone* - The **scaphoid** is also susceptible to fracture from a **FOOSH injury**, but it is generally less common than a distal radius fracture. - Scaphoid fractures are particularly concerning due to their **poor blood supply** and risk of **avascular necrosis**. *Lunate bone* - The lunate bone is an important carpal bone that can be dislocated or fractured, but isolated fractures from a typical FOOSH injury are **rare**. - **Lunate dislocations** are more common than fractures and often present with significant pain and wrist deformity.

Q: What is the first sign of Volkmann's ischemia?

Pain. ***Pain*** - **Severe pain** disproportionate to the injury is often the **first and most reliable sign** of impending Volkmann's ischemia (compartment syndrome). - This pain is typically **unrelieved by analgesics** and exacerbated by passive stretching of the affected muscles. *Pallor* - **Pallor (pale skin)** indicates **reduced blood flow** but is generally a later sign of severe ischemia, not the initial presentation. - While concerning, it suggests significant vascular compromise and is usually preceded by pain. *Paralysis* - **Paralysis or significant weakness** is a late and ominous sign, indicating **nerve ischemia** and muscle death due to prolonged lack of oxygen. - This symptom suggests irreversible damage if not addressed promptly. *Pulselessness* - **Pulselessness** is a very late and serious sign, indicating **complete arterial occlusion** or severe vascular compromise. - The presence of a palpable pulse does **not rule out compartment syndrome**, as compartment pressures can exceed capillary perfusion pressure long before arterial flow is completely obstructed.

Q: Elephant foot deformity is indicative of:

Non-union of fractured edentulous mandible. ***Non-union of fractured edentulous mandible*** - An **elephant foot deformity** is a characteristic radiographic finding in the non-union of a fracture, particularly in the context of an **edentulous mandible**. - It describes the appearance of **sclerotic, hypertrophic bone ends** at the fracture site, resembling the thick, club-like foot of an elephant, due to persistent movement and attempted callus formation. *Diplopia* - **Diplopia** refers to the perception of two images from a single object, often caused by ophthalmological or neurological issues affecting eye movement. - It is a symptom related to vision and has no association with bone deformities or fracture healing patterns. *Skeletal Class II malocclusion* - **Skeletal Class II malocclusion** describes a condition where the mandible is retrognathic (set back) relative to the maxilla, resulting in an "overbite." - This is a developmental craniofacial anomaly related to jaw position, not a characteristic sign of fracture non-union. *Unilateral Le Fort I fracture of maxilla* - A **unilateral Le Fort I fracture of the maxilla** is a midfacial fracture that separates the maxilla from the pterygoid plates and nasal septum, usually involving a horizontal fracture line above the maxillary teeth. - While it is a type of facial fracture, it does not typically result in an "elephant foot deformity," which is specific to hypertrophic non-unions, especially in the mandible.

Q: What is the most appropriate management option for an intra-articular fracture?

Plating. ***Plating*** - Plating offers **stable fixation** for intra-articular fractures, allowing for early mobilization and preserving joint function. - It provides **anatomic reduction**, which is crucial for restoring the smooth articular surface and preventing post-traumatic arthritis. *Arthrodesis* - Arthrodesis, or joint fusion, is typically reserved for **severe joint destruction** or failed previous treatments, as it sacrifices joint motion. - It is not the primary approach for acute intra-articular fractures where the goal is to **restore joint function**. *Plaster of Paris* - Plaster of Paris casts often provide **insufficient stability** for complex intra-articular fractures, risking malunion or nonunion. - While it offers immobilization, it can lead to **joint stiffness** and does not allow for early range of motion, which is vital for articular cartilage healing. *External Fixation* - External fixation is usually preferred for **open fractures** with significant soft tissue injury or as a temporary measure in polytrauma patients. - It carries a risk of **pin site infections** and can be cumbersome for the patient, generally not being the definitive treatment for closed intra-articular fractures.

Q: In the case of an inferior shoulder dislocation, which nerve is most commonly injured?

Axillary nerve. ***Axillary nerve*** - The **axillary nerve** wraps around the surgical neck of the humerus, making it highly vulnerable to injury during shoulder dislocations, especially **inferior dislocations**. - Injury to this nerve leads to **deltoid muscle weakness** (impaired abduction) and sensory loss over the **regimental badge area** (lateral shoulder). *Median nerve* - The **median nerve** is located more medially and deeper within the axilla and arm, making it less susceptible to injury from a simple shoulder dislocation. - Injury typically results in impaired pronation, wrist flexion, thumb opposition, and sensory deficits in the **first three and a half digits**. *Ulnar nerve* - The **ulnar nerve** runs medially in the arm and is well-protected in the axilla, making it an uncommon site of injury from a shoulder dislocation. - Damage leads to weakness in intrinsic hand muscles (e.g., **interossei, hypothenar muscles**) and sensory loss over the medial 1.5 digits. *Radial nerve* - The **radial nerve** courses posteriorly around the humerus in the spiral groove, making it prone to fracture of the humeral shaft, not typically shoulder dislocations. - Injury results in **wrist drop** due to paralysis of wrist and finger extensors, and sensory loss over the posterior arm, forearm, and dorsal hand.

Q: A 25-year-old man presents to the emergency department after falling onto an outstretched hand while playing cricket. He has tenderness in the anatomical snuffbox and pain with axial loading of the thumb. What is the most likely diagnosis based on the X-ray findings?

Scaphoid fracture. ***Scaphoid fracture*** - The provided image clearly shows a **fracture line through the waist of the scaphoid bone**, which is the most common site for scaphoid fractures. - This type of fracture often results from a **fall onto an outstretched hand** and can be challenging to detect initially. *Scaphoid fracture with perilunate dislocation* - While a scaphoid fracture is present, there is **no clear evidence of perillunate dislocation**, which would show as a misalignment of the carpal bones relative to the lunate. - Perilunate dislocation is characterized by the **lunate maintaining its articulation with the radius** while the other carpal bones are dislocated dorsally. *Perilunate dislocation only* - This option is incorrect because the X-ray clearly demonstrates a **scaphoid fracture**, and there is **no isolated perilunate dislocation** without associated carpal injury here. - A pure perilunate dislocation would show the lunate in proper alignment with the radius, but **all other carpal bones displaced dorsally** or volarly. *Colles' fracture* - A Colles' fracture involves a **fracture of the distal radius with dorsal displacement** of the distal fragment, which is not seen in the image. - The fracture in the image is clearly within the **scaphoid bone**, not the distal radius.

Q: Holstein-Lewis fracture is associated with injury to which nerve?

Radial. ***Radial*** - Holstein's Lewis fracture is a specific fracture of the **distal humeral shaft** that characteristically entraps the **radial nerve**. - Injury to the radial nerve in this region typically results in **wrist drop** and sensory loss over the dorsal hand. *Median* - The median nerve is most commonly entrapped in the **carpal tunnel**, leading to carpal tunnel syndrome. - Injury to the median nerve affects the **flexors of the forearm** and sensation in the first 3.5 digits. *Ulnar* - The ulnar nerve is often injured at the **cubital tunnel** (elbow) or Guyon's canal (wrist). - Its injury leads to a characteristic **claw hand deformity** and sensory loss in the little finger and ulnar half of the ring finger. *Axillary* - The axillary nerve is most susceptible to injury during **shoulder dislocations** or fractures of the surgical neck of the humerus. - Damage to this nerve causes weakness in **shoulder abduction** (due to deltoid paralysis) and sensory loss over the lateral shoulder.

Question 1

Which of the following statements is false regarding Colles' fracture?

Accepted Answer

Not associated with dorsal angulation of the wrist

Answer

Dorsal shift

Answer

At cortico-cancellous junction

Answer

In old age

Question 2

A 42-year-old man is brought to the trauma center after a fall from a ladder. Physical examination reveals a slightly deformed left lower extremity with a 0.5 cm soft tissue defect over the anterolateral aspect of his leg. The wound appears relatively clean with no gross contaminants present. Radiographs depict a short oblique proximal one-third diaphyseal tibia fracture. What is his Gustilo open fracture classification grade?

Accepted Answer

I

Answer

II

Answer

IIIa

Answer

IIIb

Question 3

Velpeau bandage and Sling and Swathe splint are used in?

Accepted Answer

Shoulder dislocation

Answer

Fracture scapula

Answer

Acromioclavicular dislocation

Answer

Fracture clavicle

Question 4

Which bone is commonly fractured when a person falls on outstretched hands?

Accepted Answer

Distal radius

Answer

Ulnar styloid process

Answer

Scaphoid bone

Answer

Lunate bone

Question 5

What is the first sign of Volkmann's ischemia?

Accepted Answer

Pain

Answer

Paralysis

Answer

Pallor

Answer

Pulselessness

Question 6

Elephant foot deformity is indicative of:

Accepted Answer

Non-union of fractured edentulous mandible

Answer

Unilateral Le Fort I fracture of maxilla

Answer

Diplopia

Answer

Skeletal Class II malocclusion

Question 7

What is the most appropriate management option for an intra-articular fracture?

Accepted Answer

Plating

Answer

External Fixation

Answer

Arthrodesis

Answer

Plaster of Paris

Question 8

In the case of an inferior shoulder dislocation, which nerve is most commonly injured?

Accepted Answer

Axillary nerve

Answer

Median nerve

Answer

Ulnar nerve

Answer

Radial nerve

Question 9

A 25-year-old man presents to the emergency department after falling onto an outstretched hand while playing cricket. He has tenderness in the anatomical snuffbox and pain with axial loading of the thumb. What is the most likely diagnosis based on the X-ray findings?

Accepted Answer

Scaphoid fracture

Answer

Scaphoid fracture with perilunate dislocation

Answer

Perilunate dislocation only

Answer

Colles' fracture

Question 10

Holstein-Lewis fracture is associated with injury to which nerve?

Accepted Answer

Radial

Answer

Median

Answer

Ulnar

Answer

Axillary

Trauma — MCQs

Trauma — MCQs

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