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OR2.1-6 | Upper Limb Fractures — Graded Quiz
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A 45-year-old man sustains a comminuted mid-shaft clavicle fracture with 2.5 cm shortening after a road traffic accident. On examination, the overlying skin shows tenting. There is no brachial plexus injury. Which of the following is the most appropriate definitive management?
Correct. Skin tenting and >2 cm shortening are both absolute indications for operative fixation of clavicle fractures. Plate fixation restores length, relieves skin pressure, and allows early mobilisation.
Surgical fixation (plate osteosynthesis) is indicated for clavicle fractures with shortening >2 cm, open or threatened skin (skin tenting), neurovascular compromise, or polytrauma. Conservative management is not appropriate when skin integrity is at risk.
Incorrect. The combination of skin tenting and >2 cm shortening are indications for operative treatment. Conservative measures risk skin necrosis and non-union.
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A 70-year-old woman is found to have a Neer four-part fracture of the proximal right humerus with associated brachial artery injury. Which structure is most vulnerable in this fracture pattern and what is the primary surgical concern?
Correct. In Neer four-part fractures, disruption of the arcuate artery causes AVN of the humeral head in >90% of cases. In elderly patients, hemiarthroplasty is preferred to avoid late collapse. The brachial artery injury must be addressed urgently.
In Neer four-part fractures, the humeral head blood supply (primarily the anterior circumflex humeral artery via the arcuate artery) is disrupted, leading to a very high risk (>90%) of avascular necrosis (AVN). In elderly patients, hemiarthroplasty or reverse total shoulder arthroplasty is often preferred over ORIF. Concomitant brachial artery injury requires urgent vascular repair.
Incorrect. The defining concern in Neer four-part fractures is avascular necrosis of the humeral head due to disruption of the blood supply. Hemiarthroplasty is the preferred treatment in elderly patients.
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A 40-year-old man develops sudden wrist drop following closed humeral shaft fracture at the junction of the middle and distal thirds (Holstein-Lewis fracture). Nerve conduction studies show axonotmesis. What is the expected prognosis and initial management?
Correct. Axonotmesis of the radial nerve carries a good prognosis for spontaneous recovery. A cock-up wrist splint maintains function while awaiting regeneration. Surgical exploration is indicated only if there is no improvement by 3–4 months.
Radial nerve palsy complicating humeral shaft fractures (especially Holstein-Lewis at the distal third) is usually axonotmesis — the endoneurium is intact, allowing spontaneous recovery. Conservative management with wrist splinting and physiotherapy is appropriate. Recovery typically occurs in 3–6 months (regeneration ~1 mm/day). Exploration is deferred unless no recovery by 3–4 months.
Incorrect. Axonotmesis (intact endoneurium) has a good prognosis for spontaneous recovery. Initial management is a wrist extension splint and observation; exploration is indicated only after 3–4 months without recovery.
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A 25-year-old man is involved in a road traffic accident and sustains a fracture of the proximal ulna with anterior dislocation of the radial head. Which nerve is most likely to be injured, and what deficit would you expect?
Correct. The posterior interosseous nerve (deep branch of radial nerve) is vulnerable at the radial neck in Monteggia fracture-dislocations. It is a purely motor branch, so injury causes finger extension weakness (drop) without wrist drop or sensory deficit.
A Monteggia fracture (proximal ulna + radial head dislocation) can injure the posterior interosseous nerve (PIN, deep branch of radial nerve) as it winds around the radial neck. PIN injury causes weakness of finger extension (extensor digitorum, extensor pollicis) without wrist drop (extensor carpi radialis is spared) and without sensory loss (PIN is purely motor).
Incorrect. The Monteggia fracture threatens the posterior interosseous nerve (deep radial branch) as it winds around the radial neck. Because PIN is motor only, the deficit is finger drop without wrist drop and without sensory loss.
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A 60-year-old woman with known osteoporosis presents with a Smith fracture of the distal radius after a fall from standing height. Which direction is the distal fragment displaced, and how does this differ from a Colles fracture?
Correct. Smith fracture = volar displacement (reverse Colles). The fracture results from a fall on a flexed wrist, and the distal fragment tilts palmarly, in contrast to the dorsal tilt of a Colles fracture.
Smith fracture (reverse Colles) = volar (palmar) displacement/tilt of the distal radius fragment, caused by a fall on a flexed wrist (back of hand hitting ground). Colles fracture = dorsal displacement/tilt caused by a fall on an outstretched hand (extended wrist). Smith fractures often require operative fixation (volar locking plate) because reduction is unstable.
Incorrect. Smith fracture shows volar (palmar) displacement — the opposite of Colles fracture. It is sometimes called 'reverse Colles'.
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A 50-year-old woman with rheumatoid arthritis and chronic kidney disease (eGFR 35 mL/min) presents with severe pain in her left knee. She is already on methotrexate. She needs short-term analgesia for an acute joint flare. Which is the safest analgesic choice?
Correct. Paracetamol is the safest analgesic in CKD (eGFR 35) and is not nephrotoxic. NSAIDs are contraindicated in severe CKD and interact dangerously with methotrexate.
NSAIDs are contraindicated in significant CKD (eGFR <45) and should be used very cautiously with methotrexate (NSAIDs reduce methotrexate clearance → toxicity). Paracetamol is the safest first-line analgesic in this context. Short-course oral corticosteroids are an alternative if paracetamol is insufficient.
Incorrect. All NSAIDs (ibuprofen, naproxen, ketorolac) are contraindicated with eGFR <45 and carry the risk of methotrexate toxicity. Paracetamol is the safest option.
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A 38-year-old construction worker falls from scaffolding and sustains an open fracture of the radius and ulna. The wound is 3 cm with moderate contamination and no neurovascular injury. Using Gustilo-Anderson classification, this is Grade IIA. Antibiotics should be commenced within:
Correct. Prophylactic antibiotics must be given within 1 hour of injury for open fractures to reduce infection risk. This is a hard rule from ATLS / Gustilo protocols.
ATLS and Gustilo guidelines mandate antibiotic prophylaxis within 1 hour of injury for all open fractures. Gustilo-Anderson Grade II: wound >1 cm, moderate contamination, no extensive soft-tissue damage, neurovascular compromise, or periosteal stripping (that defines IIIA/B/C). First-generation cephalosporins are standard; metronidazole/aminoglycosides added for grade III.
Incorrect. The standard recommendation is antibiotics within 1 hour of injury for open fractures. Every hour of delay increases infection risk.
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A 19-year-old male sustains a supracondylar fracture of the humerus (Gartland III) after a fall from a bicycle. On examination, the forearm is tense, and he complains of paraesthesia in the index finger. Pulses are present. The most likely early diagnosis is:
Correct. Tense forearm with paraesthesia in the context of a supracondylar fracture signals early compartment syndrome. Presence of pulse does NOT exclude compartment syndrome — pulses are lost only when pressures exceed arterial pressure (a late sign). Delta P < 30 mmHg is the operative threshold.
Forearm compartment syndrome can present with pain, paraesthesia, and a tense compartment — crucially, pulses may still be PRESENT in early compartment syndrome (the pulse is lost late). A key diagnostic criterion is delta pressure (diastolic BP − compartment pressure) < 30 mmHg, not the absence of pulse. The threshold for fasciotomy is delta P < 30 mmHg or compartment pressure > 30 mmHg, not absent pulses.
Incorrect. Compartment syndrome is the primary concern. Pulses can be present in early or developing compartment syndrome; their presence does not rule it out. The tense forearm and paraesthesia are the key signs.
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A 65-year-old man with severe osteoporosis is found to have a comminuted distal radius fracture with >20° dorsal tilt, >2 mm articular step-off, and radial shortening of 5 mm. After unsuccessful closed reduction, which is the most appropriate definitive treatment?
Correct. Unstable distal radius fractures with >20° dorsal tilt, >2 mm articular step-off, and 5 mm shortening after failed closed reduction require operative fixation. Volar locking plate (VLP) is the current standard, providing rigid angular fixation and allowing early mobilisation.
Criteria for operative fixation of distal radius fractures: radial shortening >3 mm, dorsal tilt >10° after reduction, articular step-off >2 mm. Volar locking plate (VLP) is currently the preferred implant for distal radius fractures requiring fixation, as it provides stable angular fixation with earlier range of motion. External fixation is an alternative when soft tissue quality is poor.
Incorrect. This fracture has multiple absolute indications for surgery (dorsal tilt >10°, articular step-off >2 mm, shortening >3 mm, failed closed reduction). Volar locking plate is the preferred definitive treatment.
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A 55-year-old farmer with type 2 diabetes and gout is prescribed NSAIDs for an acute gout flare in his right wrist. He returns 2 weeks later with oedema, hypertension, and creatinine 2.1 mg/dL (was 1.0 mg/dL). What is the most likely mechanism for this deterioration?
Correct. NSAIDs inhibit renal prostaglandins that maintain GFR in vulnerable patients (diabetics, elderly, diuretic users). This leads to renal vasoconstriction, AKI, sodium retention, oedema, and hypertension — classic NSAID nephrotoxicity.
NSAIDs inhibit prostaglandin synthesis (COX-1/2). Prostaglandins (PGE2, PGI2) maintain renal afferent arteriolar dilation and are critical for glomerular filtration in states of reduced renal perfusion (elderly, diabetic nephropathy, diuretics, heart failure). NSAID use blocks this compensation, causing acute kidney injury (AKI), sodium retention, and oedema.
Incorrect. The acute doubling of creatinine after NSAID initiation points to NSAID-induced AKI via prostaglandin inhibition, not direct urate deposition or independent progression of diabetic nephropathy.
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