Week 6 - MSK Regional Adult and Paediatric Trauma Formative

Question 1

What nerve is most at risk secondary to a displaced Colles fracture? Select one: a. Ulnar b. Radial c. Median

Answer 1

Median nerve compression from stretch of the nerve or a bleed into the carpal tunnel can accompany a Colles fractures.

Question 2

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Answer 2

A → Greater trochanter B → Lesser trochanter C → Pubic symphysis D → Superior pubic rami E → Left sacro-iliac joint

Question 3

Which nerve is particularly at risk of injury in humeral shaft fractures? Select one: a. Radial nerve b. Ulnar nerve c. Axillary nerve d. Median nerve

Answer 3

a. Radial nerve

Question 4

The forearm acts as a ring where if one bone is fractured, there is usually a fracture or dislocation involving the other bone. If an isolated displaced fracture of one of the forearm bones is identified, one should have a very high index of suspicion of a fracture or dislocation involving the other bone. Match the pattern of injury to the correct eponymous name associated with that injury type: * Fracture of the radius with dislocation of the distal radio-ulnar joint (DRUJ) * Fracture of the ulna with dislocation of radial head

Answer 4

Fracture of the radius with dislocation of the distal radio-ulnar joint (DRUJ) - Galeazzi injury Fracture of the ulna with dislocation of radial head - Monteggia injury

Question 5

Proximal humeral fractures are common injuries, often secondary to falls onto an outstretched hand in osteoporotic bone. Minimally displaced fractures are common and the position often improves as the muscle spasm settles. What is the most common management of these minimally displaced, 2 part proximal humeral fractures? Select one: * a. Operatively with external fixation * b. Operatively with an intra-medullary nail * c. Non-operatively in collar and cuff

Answer 5

Proximal humeral fractures are common and most of them are minimally displaced fractures and, as the shoulder joint is highly mobile, a small amount of angulation can be tolerated. Therefore, the vast majority of these fractures are managed non-operatively in a collar and cuff for a short period (3-4 weeks) followed by physiotherapy and gradual increasing movement.

Question 6

How are displaced proximal humeral fractures treated? How are head splitting humeral fractures treated? (comminuted)

Answer 6

Displaced proximal humeral tractures are treated with internal fixation (plate, screws, wires or intramedullary nail) Head splitting humeral fractures are generally treated with arthroplasty * Unless the patient is young with very good bone - then use internal fixation

Question 7

A 30 year old patient with diabetes attends the A&E department for urgent review. They report a short history of severe right knee pain. There is no history of trauma but they report feeling nauseated and feverish. O/E, their temperature is 38.2 degrees and their right knee is swollen and warm. Both active & passive range of movement is grossly reduced from 20 degrees of extension to 30 degrees of flexion, limited by severe pain. Select one as your initial working diagnosis? * A flare up of psoriatic arthritis * A flare up of rheumatoid arthritis * Cellulitis * Septic arthritis * Gout

Answer 7

SEPTIC ARTHRITIS This patient is presenting with severe joint pain but is also describing symptoms and showing signs of systemic upset. They also have a history of diabetes which increases their risk of contracting infections. For this reason, the diagnosis is septic arthritis until proven otherwise.

Question 8

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Answer 8

A - lateral femoral condyle B - medial tibial plateau C - head of fibula D - medial femoral condyle E - lateral tibial plateau

Question 9

The most common anatomical site for proximal humeral fractures is: Select one: a. The supracondylar region of the humerus b. The anatomical neck of the humerus c. The surgical neck of the humerus

Answer 9

Proximal humerus fractures are common with the majority being low energy injuries in osteoprotic bone due to a fall onto the outstretched hand or directly onto the shoulder. The most common site of fracture is through the surgical neck of the humerus.

Question 10

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Answer 10

A → Obturator artery, B → Lateral circumflex artery

Question 11

Hip fractures are a common injury in our increasing elderly population. Many patients have significant co-morbidities and unfortunately, despite increasing investment in the timely and complete medical and surgical care of these patients, mortality following a hip fracture remains high. What is the approximate mortality rate post hip fracture at 1 year? Select one: * a. 50% * b. 20% * c. 30% * d. 10%

Answer 11

c - 30% Mortality from hip fracture is around 10% at one month, 20% at four months and 30% at one year

Question 12

Mallet finger is not an uncommon injury sustained whilst played sports. It involves tendon injury and results in a problem with active movement at the DIPJ. Which of the following descriptions is accurate of mallet finger? a. An avulsion of the extensor tendon from the middle phalynx resulting in inability to actively extend the DIPJ. b. An avulsion of the extensor tendon from the distal phalynx resulting in inability to actively extend the DIPJ. c. An avulsion of the flexor tendon from the middle phalynx resulting in inability to actively extend the DIPJ. d. An avulsion of the flexor tendon from the distal phalynx resulting in inability to actively flex the DIPJ.

Answer 12

b - Mallet finger is an avulsion of the extensor tendon from its insertion into the terminal phalanx and is caused by forced flexion of the extended DIPJ, often from a ball at sport. * The patient presents with pain, a drooped DIPJ of the affected finger and inability to extend at the DIPJ. * Treatment is with a mallet splint holding the DIPJ extended which should be worn continuously for a minimum of 4 weeks.

Question 13

What is the most common type of shoulder dislocation? Select one: a. Inferior b. Posterior c. Anterior d. Lateral

Answer 13

Anterior shoulder dislocation is much more common than posterior dislocation (only 2‐5% of all shoulder dislocations). * Traumatic anterior shoulder dislocation occurs due to an excessive external rotation force or a fall onto the back of the shoulder.

Question 14

The incidence of brachial plexis injury during vaginal delivery is approximately: Select one: 0.02% 2% 20% 0.2%

Answer 14

The incidence of brachial plexus injury during vaginal delivery is around 2 in 1000 and most commonly arises in large babies (macrosomia in diabetes), twin deliveries and shoulder dystocia (difficult delivery of the shoulder after the head with compression of the shoulder on the pubic symphysis). The correct answer is: 0.2%

Question 15

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Answer 15

A - medial malleolus B - talus C - calcaneus D - talus E - tibia F - navicular G - lateral malleolus

Question 16

What type of splint may be used for the temporary splintage of femoral shaft fractures? Select one: a. Pelvic binder b. Howard splint c. Thomas splint d. Extension splint e. Futura splint

Answer 16

c- Thomas splint Initial management after initial resuscitation includes optimizing analgesia with a femoral nerve block and application of a Thomas splint which stabilizes the fracture minimizing further blood loss and fat embolism. Definitive management is usually closed reduction and stabilization with an intramedullary nail

Question 17

Scaphoid fractures usually occur after a fall onto an outstretched hand. In relation to scaphoid fractures Select the three true statements from the options below: * a. Undisplaced scaphoid fractures are usually treated in a cast for 6-12 weeks * b. Scaphoid fractures may cause avascular necrosis of the distal pole * c. Scaphoid fractures may not be visible on x-rays immediately post injury * d. Patients with symptoms/signs of a scaphoid fracture but no fracture visible on x-ray are reviewed again at 6 weeks to ensure symptoms have settled * e. Scaphoid x-rays involve obtaining 4 different views of the bone

Answer 17

CORRECT a - Undisplaced fractures are usually treated with plaster cast for 6‐12 weeks. * c - Around 5% of scaphoid fractures are not visible on initial x‐rays * e - 4 views are taken if scaphoid fracture is suspected (AP, lateral and 2 oblique views). Avascular necrosis can occur at the prooximal pole Fractures not immediately visible on xray can show up on radiographs 2 weeks later after resorption of the fracture ends as the first stage of fracture healing.

Question 18

Fractures of the 5th metacarpal neck often occur with a punching injury, these are known as Boxer’s fractures. Usually, these injuries can be managed conservatively as some deformity can be tolerated without function being affected. However, deformity in which plane is not well tolerated and requires manipulation and possibly fixation? Select one: * a. Rotational deformity * b. Ulnar deviation * c. Flexion deformity

Answer 18

Rotational alignment should be checked as rotational mal-alignment is not well tolerated and can lead to problems with grip. This should be corrected by manipulation with neighbor strapping or k‐wire stabilization.

Question 19

True or false: Finger flexor tendon injuries may occur secondary to a penetrating wound to the volar aspect of the forearm. Select one: True False

Answer 19

TRUE

Question 20

A Colles fracture describes a dorsally angulated or displaced fracture at what site? Select one: a. Distal humerus b. Distal radius c. Proximal radius d. Distal tibia

Answer 20

b - A Colles fracture is an extra‐articular fracture of the distal radius within an inch of the articular surface and with dorsal displacement or angulation. A Smith’s fracture is a volarly displaced or angulated extra‐articular fracture of the distal radius which usually occurs after falling onto the back of a flexed wrist.

Question 21

Hip fractures: Hip fractures can be classified as intra-capsular and extra-capsular. How are extra-capsular hip fractures often treated? Select one: * a. Open reduction, internal fixation * b. Dynamic hip screw * c. Hemiarthroplasty or Total Hip Replacement

Answer 21

Extracapsular hip fractures should not cause avascular necrosis and have a high union rate. These farctures can therefore be fixed with a Dynamic Hip Screw (DHS) keeping the patient’s own natural hip joint