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OR2.1-6 | Upper Limb Fractures — Practice Quiz
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A 22-year-old motorcyclist falls on an outstretched hand and sustains a mid-shaft clavicle fracture. X-ray shows 2 cm shortening with no skin tenting or neurovascular compromise. Which is the most appropriate initial management?
Correct. Conservative treatment with a broad arm sling is the standard of care for uncomplicated mid-shaft clavicle fractures without shortening >2 cm, skin tenting, or neurovascular injury.
The vast majority of clavicle fractures (>80%) are managed conservatively with a broad arm sling or figure-of-eight bandage for 4–6 weeks. Surgery (plate fixation) is reserved for significant shortening >2 cm, skin tenting, neurovascular compromise, or open fractures.
Incorrect. Conservative management (broad arm sling) is the first-line treatment for most mid-shaft clavicle fractures. Operative intervention is reserved for specific indications such as shortening >2 cm, open fracture, or neurovascular compromise.
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A 68-year-old woman with osteoporosis falls on her right shoulder. X-ray shows a proximal humerus fracture with three fragments: the greater tuberosity, humeral head, and humeral shaft are separated. Using the Neer classification, this is classified as:
Correct. When three fragments (humeral head, greater tuberosity, shaft) are each displaced/separated, this constitutes a three-part fracture by Neer classification.
Neer's classification is based on the number of displaced 'parts' (segments displaced >1 cm or rotated >45°). Two-part = 1 segment displaced; Three-part = 2 segments displaced; Four-part = 3 segments displaced from the surgical neck. Three-part fractures involve significant risk of avascular necrosis.
Incorrect. Neer classification counts the number of displaced parts. With the humeral head, greater tuberosity, and shaft as three separate displaced fragments, this is a three-part fracture.
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A 35-year-old man presents with a 3-day history of right wrist drop following a direct blow to the lateral arm. He cannot extend the wrist or fingers. Sensation is reduced over the dorsum of the thumb and index finger. X-ray confirms a fracture of the middle third of the humeral shaft. Which nerve injury is most likely?
Correct. The radial nerve travels in the spiral groove of the humerus and is the nerve most vulnerable in humeral shaft fractures, particularly the Holstein-Lewis fracture at the distal-third junction. Wrist drop and dorsal hand sensory loss are classic.
The radial nerve winds around the posterior aspect of the humerus in the spiral groove (Holstein-Lewis zone at the distal third junction). Humeral shaft fractures — especially at the middle-to-distal third — classically injure the radial nerve, causing wrist drop, finger drop, and sensory loss over the dorsal web space.
Incorrect. Humeral shaft fractures classically injure the radial nerve as it runs in the spiral groove (Holstein-Lewis fracture). The resulting deficit is wrist drop and sensory loss over the dorsal web space.
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A 28-year-old male presents with a Monteggia fracture. Which of the following best describes this injury pattern?
Correct. Monteggia fracture = proximal ulna fracture + radial head dislocation. This is in contrast to the Galeazzi fracture (distal radius + DRUJ dislocation).
Monteggia fracture = fracture of the proximal ulna with dislocation of the radial head. Galeazzi fracture = fracture of the distal radius with dislocation of the distal radioulnar joint (DRUJ). A useful mnemonic: MUG = Monteggia = Ulna fracture + radial head dislocation; GaR = Galeazzi = Radius fracture + DRUJ.
Incorrect. Monteggia = proximal Ulna fracture + radial head dislocation. The option describing a distal radius fracture with DRUJ dislocation describes the Galeazzi fracture.
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A 55-year-old woman falls on an outstretched hand and sustains a Colles fracture. Which of the following correctly describes the characteristic deformity?
Correct. Colles fracture shows dorsal displacement, dorsal tilt, and radial shortening — the classic 'dinner fork' appearance. Reduction involves palmar flexion, ulnar deviation, and pronation.
Colles fracture = distal radius fracture with dorsal displacement/tilt, radial shortening, and radial tilt ('dinner fork' deformity). Smith fracture = volar (palmar) displacement — 'reverse Colles'. Correct identification is essential before reduction.
Incorrect. Colles fracture is characterised by dorsal displacement and dorsal tilt of the distal fragment. Volar displacement describes a Smith fracture ('reverse Colles').
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A 45-year-old man with acute gouty arthritis of the knee presents for analgesia. He has a history of peptic ulcer disease and hypertension controlled with lisinopril. His eGFR is 48 mL/min/1.73 m². Which analgesic regimen is most appropriate for managing his joint pain?
Correct. Colchicine (with dose reduction for reduced eGFR) plus paracetamol is the appropriate choice when NSAIDs are contraindicated due to peptic ulcer disease and CKD.
NSAIDs should be avoided in peptic ulcer disease and are nephrotoxic in CKD (eGFR <60). Colchicine and corticosteroids are preferred for acute gout when NSAIDs are contraindicated. Colchicine is renally cleared (dose reduction for eGFR 30–60) but remains appropriate at reduced dose. Simple analgesics (paracetamol) for background pain control.
Incorrect. NSAIDs (indomethacin, diclofenac) are contraindicated with peptic ulcer disease and CKD (eGFR 48). Aspirin paradoxically raises urate. Colchicine with paracetamol is the safe choice.
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A 30-year-old man is brought to casualty with a suspected Galeazzi fracture of the right forearm. Which radiological finding confirms this diagnosis?
Correct. Galeazzi fracture = distal radius fracture + DRUJ disruption. It is the counterpart to the Monteggia fracture (proximal ulna + radial head dislocation).
The Galeazzi fracture-dislocation comprises a fracture of the distal third of the radius combined with disruption (dislocation) of the distal radio-ulnar joint (DRUJ). On X-ray: the distal radius fracture is seen; DRUJ disruption is evidenced by widening of the DRUJ space, ulnar head prominence on lateral view, and/or avulsion of the ulnar styloid.
Incorrect. The Galeazzi fracture is specifically a distal radius fracture with disruption of the distal radio-ulnar joint. Option A describes the Monteggia pattern.
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A 72-year-old woman sustains an impacted fracture of the surgical neck of the humerus after a low-energy fall. She has no neurovascular deficit. On X-ray, the fracture shows <1 cm displacement and the tuberosities are intact. What is the most appropriate initial management?
Correct. Minimally displaced (Neer one-part) fractures are treated conservatively: a collar-and-cuff sling allows the weight of the arm to maintain traction while allowing early pendulum exercises to prevent stiffness.
Minimally displaced (Neer one-part) proximal humerus fractures are managed conservatively with a collar-and-cuff or broad arm sling, analgesia, and early pendulum exercises. The arm's own weight provides traction maintaining alignment. Open surgery is reserved for displaced multi-part fractures and vascular injury.
Incorrect. Minimally displaced proximal humerus fractures (Neer one-part) in elderly patients are treated conservatively with a collar-and-cuff sling and early pendulum exercises. Surgery is reserved for displaced multi-part fractures.
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