Orthopedic Trauma Anesthesia — MCQs
Which of the following is a major risk factor for fat embolism syndrome in a patient with major trauma?
Road traffic accident (RTA) with multiple fractures - initial treatment would be:
Which fracture is most commonly associated with fat embolism?
When do we have to start antibiotics to prevent post-operative infection?
Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve?
A 25 year old male with roadside accident underwent debridement and reduction of fractured both bones right forearm under axillary block. On the second postoperative day the patient complained of persistent numbness and paresthesia in the right forearm and the hand. The commonest cause of this neurological dysfunction could be all of the following except :
Which of the following injuries can be classified as Gustilo-Anderson Grade III injuries?
What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
A 60-year-old man underwent cardiac bypass surgery 2 days ago. He has now started forgetting things and is unable to recall names and phone numbers of his relatives. What is the probable diagnosis?
Which of the following can be used as a pre-anesthetic medication to decrease secretions and reflux bronchospasm during general anesthesia?
Orthopedic Trauma Anesthesia Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is a major risk factor for fat embolism syndrome in a patient with major trauma?
- A. Long bone fractures (femur or tibia) (Correct Answer)
- B. Isolated soft tissue injury
- C. Hypovolemic shock
- D. Increased mobility after trauma
Explanation: ***Long bone fractures (femur or tibia)*** - **Long bone fractures**, particularly of the **femur and tibia**, are the **most common cause** of fat embolism syndrome, accounting for 90% of cases - Fat globules from the bone marrow enter the venous circulation through disrupted medullary vessels - Multiple fractures increase the risk significantly - Early fracture stabilization reduces the risk of fat embolism syndrome *Increased mobility after trauma* - Early mobilization is actually **protective** against complications like DVT and does not cause fat embolism - Fat embolism occurs due to the initial trauma itself, not subsequent mobility *Isolated soft tissue injury* - Soft tissue injuries alone rarely cause clinically significant fat embolism - Fat embolism syndrome requires release of bone marrow fat, which occurs with skeletal trauma *Hypovolemic shock* - While hypovolemic shock can occur concurrently with trauma, it is **not a causative factor** for fat embolism - Both may result from the same traumatic event but represent different pathophysiological processes
Question 2: Road traffic accident (RTA) with multiple fractures - initial treatment would be:
- A. Management of shock
- B. Splinting of limbs
- C. Airway management (Correct Answer)
- D. Cervical spine protection
Explanation: ***Airway management*** - In trauma, **establishing and maintaining a patent airway** is the absolute priority, as compromised breathing can lead to rapid deterioration and death. - The **ABCs (Airway, Breathing, Circulation)** of trauma care dictate that airway intervention precedes other life-saving measures. *Management of shock* - While crucial, **managing shock (C)** follows **airway (A)** and **breathing (B)** in the primary survey of trauma care. - Addressing profound shock without a patent airway can be ineffective and leads to irreversible damage. *Splinting of limbs* - **Splinting fractures** is important for pain control, preventing further injury, and minimizing blood loss in open fractures, but it is not an immediate life-saving intervention. - This falls under the **secondary survey** or definitive management, after life-threatening issues have been addressed. *Cervical spine protection* - **Cervical spine protection** is essential in trauma to prevent further neurological injury and is performed simultaneously with airway management (often with in-line stabilization). - However, a patent airway is the **most immediate life-sustaining intervention** if the airway is compromised.
Question 3: Which fracture is most commonly associated with fat embolism?
- A. Humeral shaft fracture
- B. Distal radius fracture
- C. Femoral shaft fracture (Correct Answer)
- D. Clavicle fracture
Explanation: ***Femoral shaft fracture*** - **Femoral shaft fractures** are highly associated with **fat embolism syndrome (FES)** due to the large amount of **yellow marrow** released from the long bone into the circulation following trauma. - The risk of FES is particularly high with **multiple fractures** or **delayed stabilization** of long bone fractures. *Humeral shaft fracture* - While humeral shaft fractures can potentially lead to fat embolism, they are **less common** sources compared to lower limb long bone fractures due to a smaller bone marrow volume. - The incidence of **fat embolism syndrome** with isolated upper limb fractures is generally lower. *Distal radius fracture* - **Distal radius fractures** are typically **low-energy injuries** involving a smaller bone and less marrow, making them a very rare cause of significant fat embolism. - **Fat embolism syndrome** is exceptionally uncommon following fractures of the small bones of the forearm. *Clavicle fracture* - **Clavicle fractures** involve a flat bone with a limited quantity of marrow, and hence they are **not typically associated** with fat embolism. - The risk of **fat embolism syndrome** is negligible with clavicular injuries.
Question 4: When do we have to start antibiotics to prevent post-operative infection?
- A. 1 week before surgery
- B. 2 days before surgery
- C. After surgery
- D. 30-60 minutes before incision (up to 24 hours post-op) (Correct Answer)
Explanation: ***30-60 minutes before incision (up to 24 hours post-op)*** - Surgical antibiotic prophylaxis (SAP) should be administered **30-60 minutes before surgical incision** to ensure adequate tissue and serum concentrations at the time of incision. - This timing allows optimal drug distribution to surgical tissues, which is crucial for preventing surgical site infections (SSIs). - For most clean and clean-contaminated surgeries, prophylaxis should be limited to a **single dose** or continued for **maximum 24 hours post-operatively** as per WHO and CDC guidelines. - Prolonged post-operative antibiotics beyond 24 hours do **not** reduce infection rates and increase the risk of **antibiotic resistance** and **adverse effects**. *1 week before surgery* - Administering antibiotics this far in advance is **unnecessary** and **ineffective** for surgical prophylaxis. - It increases the risk of **antibiotic resistance** and does not guarantee adequate drug levels at the time of incision. - Pre-operative antibiotic use should be avoided unless treating an active infection. *2 days before surgery* - This timeframe is too early to achieve prophylactic benefit during the surgical procedure. - Prolonged pre-operative use promotes **bacterial resistance** without providing additional protection. - Drug levels will not be optimal at the time of incision due to metabolism and excretion. *After surgery* - Starting antibiotics **after surgical incision** is **too late** for prophylaxis as contamination has already occurred. - Post-operative initiation is considered **therapeutic treatment** for established infection, not prevention. - The critical window for prophylaxis is the period from skin incision to wound closure.
Question 5: Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve?
- A. Median
- B. Musculocutaneous
- C. Radial
- D. Ulnar (Correct Answer)
Explanation: ***Ulnar*** - The **ulnar nerve** (C8-T1) emerges from the lower trunk of the brachial plexus. During an **interscalene block**, the local anesthetic is typically deposited at the level of the roots and trunks (C5-C7), which is superior to the origin of the lower trunk that gives rise to the ulnar nerve. - Due to the **cephalad spread** of the local anesthetic from an interscalene block, the **C8 and T1** nerve roots (and thus the ulnar nerve) are often not adequately blocked, leading to suboptimal anesthesia in its distribution. *Median* - The **median nerve** (C5-T1) originates from the lateral and medial cords, which are typically well-covered by the spread of local anesthetic in an interscalene block due to its formation from the middle and upper trunks. - Optimal anesthesia in the distribution of the median nerve is generally achieved with an interscalene block, as its nerve roots are within the targeted antegrade spread. *Musculocutaneous* - The **musculocutaneous nerve** (C5-C7) arises from the lateral cord, which is formed by the upper and middle trunks. These structures are reliably blocked during an interscalene approach. - Sensory and motor functions of the musculocutaneous nerve, such as **biceps contraction** and lateral forearm sensation, are usually well anesthetized. *Radial* - The **radial nerve** (C5-T1) is a branch of the posterior cord, which receives fibers from all three trunks. Its upper and middle trunk components are generally well-blocked by an interscalene approach. - While complete anesthesia of the entire brachial plexus can be variable, the radial nerve is more consistently affected by an interscalene block than the ulnar nerve due to its more extensive proximal root contributions which are within the typical spread.
Question 6: A 25 year old male with roadside accident underwent debridement and reduction of fractured both bones right forearm under axillary block. On the second postoperative day the patient complained of persistent numbness and paresthesia in the right forearm and the hand. The commonest cause of this neurological dysfunction could be all of the following except :
- A. Tourniquet pressure
- B. Crush injury to the hand and lacerated nerves
- C. A tight cast or dressing
- D. Systemic toxicity of local anaesthetics (Correct Answer)
Explanation: ***Systemic toxicity of local anaesthetics*** - This typically presents with **acute neurological symptoms** (e.g., seizures, metallic taste, tinnitus) or **cardiovascular collapse** during or immediately after local anesthetic administration. - Persistent numbness and paresthesia on the second postoperative day are **not characteristic** of systemic local anesthetic toxicity, which is a transient effect. *Tourniquet pressure* - **Prolonged or excessively high tourniquet pressure** can lead to nerve ischemia and damage, causing paresthesia and numbness in the limb distal to the tourniquet. - These symptoms often persist for some time post-operatively, consistent with the patient's presentation. *Crush injury to the hand and lacerated nerves* - The initial **roadside accident** involving a severely injured limb could directly cause **nerve lacerations or crush injuries**, leading to immediate and persistent neurological deficits like numbness and paresthesia. - Such direct nerve trauma would manifest immediately and continue post-operatively, aligning with the patient's complaints. *A tight cast or dressing* - A **tight cast or dressing** applied to the forearm can compress nerves, leading to **ischemia and neuropathy**. - This mechanical compression can cause persistent numbness and paresthesia, which might become more noticeable as swelling increases post-surgery.
Question 7: Which of the following injuries can be classified as Gustilo-Anderson Grade III injuries?
- A. Open fracture with clean wounds less than 1 cm long
- B. Open fractures with a laceration more than 1 cm long usually up to 10 cms, without extensive soft tissue damage, flaps or avulsions
- C. Compartment syndrome with an open fracture
- D. Open segmental fractures, open fractures with extensive soft tissue damage, or traumatic amputation. (Correct Answer)
Explanation: ***Open segmental fractures, open fractures with extensive soft tissue damage, or traumatic amputation.*** - Gustilo-Anderson **Grade III** injuries are characterized by **extensive soft tissue damage**, often with significant contamination and compromised vascularity. - This grade includes **segmental fractures**, traumatic amputations, or open fractures with **soil contamination** or a high-energy mechanism. *Open fracture with clean wounds less than 1 cm long* - This description corresponds to a **Gustilo-Anderson Grade I** injury, which involves a clean wound with minimal soft tissue damage. - The wound is typically less than 1 cm, and there is no significant muscle contusion or crushing. *Open fractures with a laceration more than 1 cm long usually up to 10 cms, without extensive soft tissue damage, flaps or avulsions* - This would be classified as a **Gustilo-Anderson Grade II** injury, characterized by a skin laceration greater than 1 cm but without significant soft tissue loss or extensive periosteal stripping. - The soft tissue damage is moderate, and the fracture pattern is usually simple. *Compartment syndrome with an open fracture* - While **compartment syndrome** is a serious complication often associated with high-energy open fractures, its presence alone does not define the Gustilo-Anderson classification grade. - The grading focuses on the extent of soft tissue injury, fracture pattern, and contamination at the time of injury, not secondary complications.
Question 8: What is the correct sequence of management in a patient who presents to the casualty with an RTA? 1. Cervical spine stabilization 2. Intubation 3. IV cannulation 4. CECT
- A. 2,1,4,3
- B. 1,3,2,4
- C. 2,1,3,4
- D. 1,2,3,4 (Correct Answer)
Explanation: ***1,2,3,4*** - This sequence follows the **ATLS (Advanced Trauma Life Support)** protocol, prioritizing immediate life threats in order. - **Cervical spine stabilization** is the **first action upon patient contact** to prevent secondary neurological injury in any trauma patient. - **Airway management (intubation)** is then performed **with maintained in-line c-spine stabilization** - these occur nearly simultaneously but c-spine protection is instituted first. - **IV cannulation (circulation)** follows to establish vascular access for resuscitation and medications. - **CECT (imaging)** is performed last, once the patient is stabilized after addressing immediate life threats. - This follows the **ATLS Primary Survey: Airway (with c-spine protection) → Breathing → Circulation → Disability → Exposure**. *2,1,4,3* - This incorrectly places intubation **before** cervical spine stabilization is initiated. - In ATLS, **c-spine protection must be applied immediately upon patient contact** before any airway manipulation. - Delaying IV cannulation until after CECT is inappropriate as circulatory access is critical for early resuscitation. *1,3,2,4* - While this correctly starts with cervical spine stabilization, it incorrectly places **IV cannulation before intubation**. - In the ATLS primary survey, **Airway comes before Circulation** - securing the airway takes priority over establishing IV access. - This sequence could delay critical airway management in a patient with respiratory compromise. *2,1,3,4* - This sequence places **intubation before cervical spine stabilization**, which violates ATLS principles. - **C-spine stabilization must be the first action** upon approaching any trauma patient to prevent secondary spinal cord injury. - While intubation with in-line stabilization is possible, the c-spine protection must be instituted first, not after beginning airway manipulation.
Question 9: A 60-year-old man underwent cardiac bypass surgery 2 days ago. He has now started forgetting things and is unable to recall names and phone numbers of his relatives. What is the probable diagnosis?
- A. Cognitive dysfunction (Correct Answer)
- B. Alzheimer's disease
- C. Post traumatic psychosis
- D. Depression
Explanation: ***Cognitive dysfunction*** - **Postoperative cognitive dysfunction (POCD)** is a common complication after cardiac surgery, especially in older patients, marked by memory impairment and difficulty with concentration. - The onset of **forgetfulness** and inability to recall names and phone numbers within days of cardiac bypass surgery is highly suggestive of POCD. *Alzheimer's disease* - Alzheimer's is a **neurodegenerative disease** with a gradual onset, characterized by progressive cognitive decline over months to years [1], not sudden changes post-surgery. - While age is a risk factor, the acute presentation immediately following an operation makes Alzheimer's less likely as the primary cause [2]. *Post traumatic psychosis* - Post-traumatic psychosis typically occurs after a severe traumatic event and involves symptoms like **hallucinations, delusions, and disorganized thinking**, which are not described in this patient. - The patient's symptoms are focused on **memory and recall deficits**, not florid psychotic symptoms. *Depression* - Depression can cause cognitive symptoms like **poor concentration and memory problems**, often referred to as "pseudodementia." - However, the abrupt onset specifically linked to surgery, without other prominent depressive symptoms like low mood, anhedonia, or sleep disturbances, makes depression less likely as the sole immediate cause.
Question 10: Which of the following can be used as a pre-anesthetic medication to decrease secretions and reflux bronchospasm during general anesthesia?
- A. Ipratropium.
- B. Tiotropium.
- C. Glycopyrrolate. (Correct Answer)
- D. Atropine.
Explanation: ***Glycopyrrolate*** - It is a **quaternary ammonium anticholinergic** that reduces salivary, tracheobronchial, and pharyngeal secretions effectively. - Due to its **limited ability to cross the blood-brain barrier**, it has fewer central nervous system side effects compared to atropine. *Ipratropium* - This medication is a **short-acting muscarinic antagonist** primarily used as a bronchodilator for conditions like asthma and COPD. - While it can reduce secretions, it's typically administered via inhalation for its local bronchodilatory effects and is not a common systemic pre-anesthetic antisialagogue. *Tiotropium* - **Tiotropium** is a **long-acting muscarinic antagonist** used for maintenance treatment of COPD, administered via inhalation. - Its primary role is sustained bronchodilation, and it is not employed as a systemic pre-anesthetic antisialagogue. *Atropine* - While atropine is an antipsychotic that can reduce secretions and counteract **bradycardia**, it readily **crosses the blood-brain barrier**, leading to more central nervous system side effects such as confusion and delirium. - Its use has decreased in favor of agents like glycopyrrolate that have a better side effect profile for reducing secretions in the perioperative setting.
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