Trauma Practice Questions

Q: A 28-year-old male is brought to the emergency department following a high -speed motor vehicle collision in which his knee struck the dashboard. On physical examination, the right lower limb is shortened, adducted, and internally rotated. An anteroposte rior X- ray of the pelvis is shown below. Based on the clinical presentation and radiographic findings, what is the most likely diagnosis?

Posterior hip dislocation. ***Posterior hip dislocation*** - The mechanism of injury, known as the **dashboard injury**, where the knee strikes the dashboard, pushes the femoral head posteriorly out of the acetabulum. - The characteristic clinical presentation is a limb that is **shortened, adducted, and internally rotated**. *Anterior hip dislocation* - This presentation is typically associated with **abduction and external rotation** of the affected limb. - It is usually caused by excessive abduction and external rotation forces, rather than the forward force typical of a dashboard injury. *Intertrochanteric fracture* - In hip fractures, the leg is typically **shortened and externally rotated**, distinguishing it from the internal rotation seen here. - There is often history of a fall in an elderly patient, though it can occur in high-energy trauma, it does not classically present with internal rotation. *Fracture of acetabulum* - While this can occur in high-speed crashes and involve injury to the hip joint, it is a broad diagnosis that describes a bony injury rather than the **dislocation** itself. - This diagnosis would require definitive confirmation via imaging for the presence of a fracture line, whereas the specific posture of adduction/internal rotation is pathognomonic for a posterior dislocation.

Q: A patient sustained an elbow dislocation that was treated locally. Due to improper healing, the patient later developed a tingling sensation in the palm. Which nerve is most likely involved?

Ulnar nerve. ***Ulnar nerve*** - The **ulnar nerve** runs posterior to the **medial epicondyle** of the humerus, a site highly susceptible to injury during an **elbow dislocation** or subsequent **valgus deformity** (tardy ulnar nerve palsy). - Compression or entrapment of this nerve leads to sensory loss and a **tingling sensation** in the medial aspect of the palm, the little finger, and the medial half of the ring finger. *Median nerve* - The **median nerve** is located on the anterior aspect of the elbow, making it more prone to injury during **supracondylar fractures** of the humerus rather than posterior dislocations. - Injury here typically presents with a 'hand of benediction' sign and sensory deficits in the lateral aspect of the palm. *Radial nerve* - The **radial nerve** is primarily associated with **mid-shaft fractures** of the humerus, where it travels in the **spiral groove**. - A lesion here classically results in **wrist drop** and sensory loss on the dorsum of the hand, not the palm. *Axillary nerve* - The **axillary nerve** is commonly injured in **shoulder dislocations** or fractures of the **surgical neck of the humerus**. - Clinical presentation involves weakness of the **deltoid muscle** and loss of sensation over the 'regimental badge' area on the lateral shoulder.

Q: Fracture to the medial epicondyle of the humerus can lead to which of the following nerve injury?

Ulnar. ***Ulnar nerve*** - The **ulnar nerve** runs in the **cubital tunnel** posterior to the **medial epicondyle**, making it highly susceptible to injury during fractures of this region. - Clinical signs of injury include **claw hand deformity**, sensory loss in the **medial 1.5 digits**, and weakness of intrinsic muscles in the hand. *Axillary nerve* - This nerve is most commonly injured with **surgical neck fractures** of the humerus or **shoulder dislocations**. - Injury typically results in **deltoid muscle atrophy** and sensory loss over the lateral aspect of the shoulder, often referred to as the **regimental badge area**. *Radial nerve* - The **radial nerve** is closely related to the humerus in the **spiral groove** (radial groove), making it vulnerable during **mid-shaft humeral fractures**. - A characteristic manifestation of radial nerve injury is **wrist drop**, due to paralysis of the **extensor muscles** of the forearm. *Median nerve* - The **median nerve** is typically at risk during **supracondylar fractures** of the humerus, where it lies anteriorly. - Injury at this level often leads to the **hand of benediction** sign, particularly when attempting to flex the digits.

Q: A 28-year-old male with bilateral femoral and tibial fractures and a chest wound presents with unstable blood pressure and tachycardia. After initial stabilization, what is the most appropriate initial management of his long bone fractures?

External fixation of both femur and tibia. ***External fixation of both femur and tibia*** - In a patient with **polytrauma** and physiological instability (unstable blood pressure and tachycardia), **Damage Control Orthopedics (DCO)** is the priority to minimize the systemic inflammatory response. - **External fixation** is the fastest and least invasive method to stabilize fractures, allowing for rapid patient transport and physiological stabilization before definitive internal fixation is performed later. *Internal fixation of femur with screws and external fixation of tibia* - Definitive internal fixation, such as intramedullary nailing of the femur, is a prolonged procedure (

Q: A proximal humerus fracture is classified using Neer's classification. Which surgical option is most appropriate for a 4-part fracture in a young patient?

Humerus plating. ***Humerus plating*** - In **young patients** with a **4-part proximal humerus fracture**, the goal is **joint preservation** and anatomical restoration of the humeral head. - **Open Reduction Internal Fixation (ORIF)** using a **locking plate** provides stable fixation, allowing for early rehabilitation while avoiding the long-term complications of arthroplasty. *Humerus nailing* - **Intramedullary nailing** is generally reserved for **2-part surgical neck fractures** or certain proximal shaft fractures. - It is often unsuitable for **4-part fractures** because it provides poor purchase in the fragmented humeral head and complicates reduction of the tuberosities. *Hanging cast/K-wires* - A **hanging cast** is a conservative management technique typically used for **diaphyseal humeral shaft fractures**, not intra-articular proximal fractures. - **K-wire fixation** generally lacks the **mechanical stability** required to maintain a complex 4-part fracture pattern during the healing process. *Shoulder hemiarthroplasty* - This is typically reserved for **elderly patients** with low functional demand or where the **vascularity of the humeral head** is severely compromised resulting in a high risk of avascular necrosis. - In a **young patient**, hemiarthroplasty is considered a salvage procedure due to limited longevity and the potential for **glenoid erosion** over time.

Q: In femoral neck fracture management using Garden classification, which treatment is indicated for an elderly patient?

Hemiarthroplasty. ***Hemiarthroplasty*** - In elderly patients with displaced femoral neck fractures, Hemiarthroplasty is the preferred treatment as it lowers the risk of non-union and avascular necrosis compared to internal fixation. - This procedure provides immediate stability and early mobilization, reducing the complications associated with prolonged bed rest in geriatric populations. *Cannulated screws* - These are typically reserved for **nondisplaced** femoral neck fractures (Garden I and II) or in younger patient populations where preserving the femoral head is a priority. - Using screws in elderly patients with displaced fractures carries a high risk of **fixation failure** and the need for reoperation. *Total hip replacement (THR)* - While THR can be used for displaced femoral neck fractures, it is generally reserved for active, physiologically younger, or high-functioning elderly individuals with intact acetabular cartilage. - It is a more extensive surgery than hemiarthroplasty and carries a slightly higher risk of **dislocation**, though it offers better long-term functional outcomes. *Conservative management* - This approach is almost exclusively reserved for patients who are medically unfit for surgery due to severe comorbidities or extremely limited baseline mobility. - It generally leads to poor outcomes, including significant pain, loss of independence, and high rates of **complications related to immobility** like pneumonia and deep vein thrombosis.

Q: A 30-year-old female post-RTA has persistent pain uncontrolled by analgesics. Compartment pressure is 90 mmHg with absent pulse. What is the treatment?

Emergency fasciotomy. ***Emergency fasciotomy*** - This patient presents with hallmark signs of **acute compartment syndrome**, specifically a pressure of 90 mmHg (normal is <10-15 mmHg) and absent pulses indicating **vascular compromise**. - **Emergency fasciotomy** is the definitive and limb-saving treatment to release the internal pressure and restore **tissue perfusion**. *Observation* - Observation is dangerous and inappropriate given the clinical evidence of **ischemia** and elevated compartment pressures. - Delaying surgical intervention significantly increases the risk of permanent **neuromuscular damage** and **rhabdomyolysis**. *Increase IV analgesics* - Increasing analgesia masks the symptoms without addressing the underlying **pathophysiology** of the increased **intra-compartmental pressure**. - Pain out of proportion to the injury is a classic sign of compartment syndrome that mandates surgical decompression, not sedation. *External fixation* - While external fixation is used to stabilize fractures, it does not relieve the **intramuscular pressure** causing the compartment syndrome. - Relying on stabilization rather than decompression leads to irreversible ischemic contractures such as **Volkmann's contracture**.

Q: A 72-year-old osteoporotic woman is brought to the emergency department after a low-energy fall from standing height. Prior to the fall, she was independently mobile in the community without any walking aids, lived alone, and was cognitively intact with no history of dementia or significant cognitive impairment. She has severe right hip pain and is unable to bear weight. On examination, the right lower limb is shortened and externally rotated. Her AP pelvis radiograph confirms a displaced intracapsular (subcapital) femoral neck fracture (Garden Grade IV) as shown in Image 1. She is medically fit for surgery with no significant comorbidities. What is the most appropriate definitive surgical management?

A. Cemented total hip replacement. ***A. Cemented total hip replacement*** - Per **NICE guidelines**, patients with displaced intracapsular fractures who were **independently mobile**, cognitively intact, and medically fit should receive a **Total Hip Replacement (THR)** rather than hemiarthroplasty. - **Cementing** is preferred in elderly, **osteoporotic** patients to provide immediate stability, allow for early mobilization, and reduce the risk of periprosthetic fractures. *B. Cannulated cancellous screw fixation* - This method is typically reserved for **undisplaced intracapsular fractures** (Garden I and II) or for young patients where **head preservation** is the primary goal. - In an elderly patient with a **Garden IV (displaced)** fracture, internal fixation is associated with unacceptably high rates of **non-union** and **avascular necrosis**. *C. Dynamic hip screw with side plate* - A **Dynamic Hip Screw (DHS)** is the gold standard for **extracapsular intertrochanteric** hip fractures, not subcapital intracapsular fractures. - Using a DHS for a subcapital fracture does not address the high risk of **blood supply disruption** to the femoral head seen in displaced intracapsular patterns. *D. Skeletal traction followed by delayed internal fixation* - **Skeletal traction** is only a temporary stabilizing measure and is not considered a **definitive surgical treatment** for femoral neck fractures. - Prolonged immobility in elderly patients leads to severe complications such as **pressure sores**, **DVT/PE**, and **hypostatic pneumonia**, greatly increasing mortality.

Q: A 40-year-old man presents with a fracture of the shaft of the femur following a road traffic accident. Three days after trauma, he becomes tachypnoeic and develops conjunctival petechiae. What is the most likely diagnosis?

Fat embolism. ### Explanation The clinical presentation of a **long bone fracture** (femur shaft) followed by a **symptom-free interval of 24–72 hours**, and the subsequent development of the classic triad of **respiratory distress (tachypnea), cerebral dysfunction, and petechial rashes**, is pathognomonic for **Fat Embolism Syndrome (FES)**. #### Why Fat Embolism is Correct: FES occurs when fat globules from the bone marrow enter the systemic circulation following a fracture. These globules cause mechanical obstruction and trigger a biochemical inflammatory response (Free Fatty Acid toxicity). The **conjunctival petechiae** are a hallmark sign, occurring in only 20-50% of cases but highly specific to FES. #### Why Other Options are Incorrect: * **Pulmonary Embolism (PE):** While it causes tachypnea, PE typically occurs later (usually 1–2 weeks post-surgery/trauma) due to DVT. It does not present with petechial rashes. * **Sepsis Syndrome:** While sepsis causes tachypnea, it is usually accompanied by high-grade fever, hypotension, and a clear source of infection. Three days is too early for post-traumatic osteomyelitis to cause systemic sepsis. * **Hemothorax:** This would present immediately after trauma with decreased breath sounds and dullness on percussion, not after a 3-day delay. #### High-Yield Clinical Pearls for NEET-PG: * **Gurd’s Criteria:** Used for diagnosis. Major criteria include axillary/conjunctival petechiae, respiratory insufficiency, and cerebral involvement. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Earliest Sign:** Tachycardia is often the earliest clinical sign. * **Management:** Primarily **supportive** (Oxygenation/Ventilation). Early stabilization of the fracture (Internal fixation) is the best preventive measure. * **Schonfeld’s Criteria:** Another scoring system used for FES diagnosis.

Question 1

A 28-year-old male is brought to the emergency department following a high -speed motor vehicle collision in which his knee struck the dashboard. On physical examination, the right lower limb is shortened, adducted, and internally rotated. An anteroposte rior X- ray of the pelvis is shown below. Based on the clinical presentation and radiographic findings, what is the most likely diagnosis?

Accepted Answer

Posterior hip dislocation

Answer

Anterior hip dislocation

Answer

Intertrochanteric fracture

Answer

Fracture of acetabulum

Question 2

A patient sustained an elbow dislocation that was treated locally. Due to improper healing, the patient later developed a tingling sensation in the palm. Which nerve is most likely involved?

Accepted Answer

Ulnar nerve

Answer

Median nerve

Answer

Radial nerve

Answer

Axillary nerve

Question 3

Fracture to the medial epicondyle of the humerus can lead to which of the following nerve injury?

Accepted Answer

Ulnar

Answer

Axillary

Answer

Radial

Answer

Median

Question 4

A 28-year-old male with bilateral femoral and tibial fractures and a chest wound presents with
unstable blood pressure and tachycardia. After initial stabilization, what is the most appropriate
initial management of his long bone fractures?

Accepted Answer

External fixation of both femur and tibia

Answer

Internal fixation of femur with screws and external fixation of tibia

Answer

External fixation of femur and internal fixation of tibia with nailing

Answer

External fixation, or screw/plating/nailing depending on surgical skill of the surgeon which saves time

Question 5

A proximal humerus fracture is classified using Neer's classification. Which surgical option is
most appropriate for a 4-part fracture in a young patient?

Accepted Answer

Humerus plating

Answer

Humerus nailing

Answer

Hanging cast/K-wires

Answer

Shoulder hemiarthroplasty

Question 6

In femoral neck fracture management using Garden classification, which treatment is indicated
for an elderly patient?

Accepted Answer

Hemiarthroplasty

Answer

Cannulated screws

Answer

Total hip replacement (THR)

Answer

Conservative management

Question 7

A 30-year-old female post-RTA has persistent pain uncontrolled by analgesics. Compartment
pressure is 90 mmHg with absent pulse. What is the treatment?

Accepted Answer

Emergency fasciotomy

Answer

Observation

Answer

Increase IV analgesics

Answer

External fixation

Question 8

A 72-year-old osteoporotic woman is brought to the emergency department after a low-energy fall from standing height. Prior to the fall, she was independently mobile in the community without any walking aids, lived alone, and was cognitively intact with no history of dementia or significant cognitive impairment. She has severe right hip pain and is unable to bear weight. On examination, the right lower limb is shortened and externally rotated. Her AP pelvis radiograph confirms a displaced intracapsular (subcapital) femoral neck fracture (Garden Grade IV) as shown in Image 1. She is medically fit for surgery with no significant comorbidities. What is the most appropriate definitive surgical management?

Accepted Answer

A. Cemented total hip replacement

Answer

B. Cannulated cancellous screw fixation

Answer

C. Dynamic hip screw with side plate

Answer

D. Skeletal traction followed by delayed internal fixation

Question 9

What is the best treatment for an old fracture?

Accepted Answer

Open reduction and internal fixation and bone grafting.

Answer

Manipulation and POP cast application.

Answer

K Wire fixation

Answer

External fixation

Question 10

A 40-year-old man presents with a fracture of the shaft of the femur following a road traffic accident. Three days after trauma, he becomes tachypnoeic and develops conjunctival petechiae. What is the most likely diagnosis?

Accepted Answer

Fat embolism

Answer

Pulmonary embolism

Answer

Sepsis syndrome

Answer

Hemothorax

Trauma — MCQs

Trauma — MCQs

On this page

Practice by Chapter

Want unlimited practice?