Trauma Practice Questions

Q: A 60-year-old female presents after a fall with inability to stand. Examination reveals her right leg to be in external rotation with limited movement, and tenderness in Scarpa's triangle. There is no history of fever, and the X-ray shows no fracture line. What is the next step in management?

MRI. **Explanation:** The clinical presentation of an elderly female with a fall, inability to weight-bear, and a leg in **external rotation** is highly suggestive of a **hip fracture** (specifically a femoral neck or intertrochanteric fracture). Tenderness in **Scarpa’s triangle** (femoral triangle) further localizes the pathology to the hip joint. **1. Why MRI is the Correct Answer:** In elderly patients with clinical signs of a hip fracture but **normal initial X-rays**, an **occult fracture** must be suspected. X-rays can be negative in up to 2–10% of hip fractures. **MRI is the gold standard** (100% sensitivity) for detecting occult fractures as it identifies bone marrow edema within 24 hours. If MRI is contraindicated, a CT scan or Bone Scan (after 48–72 hours) are alternatives. **2. Why Incorrect Options are Wrong:** * **Option B:** Delaying diagnosis with bed rest increases the risk of fracture displacement, avascular necrosis (AVN), and medical complications like DVT or pneumonia. * **Option C:** Joint aspiration is used to rule out septic arthritis. The absence of fever and the history of trauma make this unlikely. * **Option D:** Mobilizing an undiagnosed fracture can lead to displacement of a stable/impacted fracture, necessitating more invasive surgery (e.g., Arthroplasty instead of internal fixation). **Clinical Pearls for NEET-PG:** * **Classic Triad of Hip Fracture:** Shortening, Abduction, and External Rotation. * **Occult Fracture:** A fracture not visible on initial radiographs. * **Garden’s Classification:** Used for femoral neck fractures; Stage I and II are stable, III and IV are displaced. * **Management Rule:** In an elderly patient with hip pain after trauma and negative X-ray, **always** assume it is a fracture until proven otherwise by MRI.

Q: A 17-year-old male presented with complaints of severe shoulder pain along with his left arm hanging by the side with some external rotation. The patient suffered a blow to his left arm while playing football. A radiograph of the injured site was ordered. What is the most likely nerve injured?

Axillary nerve. ### Explanation **Clinical Diagnosis: Anterior Dislocation of the Shoulder** The clinical presentation—a young athlete with a history of direct trauma, the arm held in **external rotation**, and severe pain—is classic for an **Anterior Shoulder Dislocation**. In this injury, the humeral head is displaced anteriorly and inferiorly. **1. Why Axillary Nerve is the Correct Answer:** The **Axillary nerve (C5, C6)** is the most commonly injured nerve in anterior shoulder dislocations due to its close anatomical proximity to the surgical neck of the humerus. As the humeral head displaces, it can stretch or compress the nerve within the quadrangular space. * **Clinical Sign:** Loss of sensation over the "Regimental Badge area" (lateral aspect of the deltoid) and weakness in shoulder abduction. **2. Why Other Options are Incorrect:** * **Musculocutaneous Nerve:** While it can be injured in severe trauma or Coracoid fractures, it is far less common than axillary nerve involvement in simple dislocations. * **Radial Nerve:** Most commonly injured in **fractures of the shaft of the humerus** (Holstein-Lewis fracture) or "Saturday Night Palsy." * **Ulnar Nerve:** Typically injured in fractures of the **medial epicondyle** of the humerus or elbow dislocations. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common type of shoulder dislocation:** Anterior (95%). * **Most common nerve injured:** Axillary nerve (Neuropraxia is the most common type of lesion). * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head (seen in anterior dislocation). * **Bankart Lesion:** Avulsion of the anterior-inferior labrum. * **Kocher’s Method & Milch’s Technique:** Common reduction maneuvers for anterior dislocation. * **Posterior Dislocation:** Associated with seizures or electric shocks; the arm is held in **internal rotation**.

Q: Putti Platt operation is performed for which condition?

Shoulder instability. **Explanation:** The **Putti-Platt operation** is a classic surgical procedure historically used for the management of **recurrent anterior shoulder instability**. **1. Why Shoulder Instability is Correct:** The underlying concept of the Putti-Platt procedure is "reefing" or **shortening of the subscapularis muscle and the anterior joint capsule**. By overlapping and suturing the cut ends of the subscapularis tendon (vest-over-pants repair), the surgeon creates a tight anterior barrier. This limits external rotation of the humeral head, thereby preventing anterior dislocation. While effective at preventing recurrence, it is less commonly performed today because the resulting loss of external rotation can lead to secondary osteoarthritis. **2. Why Other Options are Incorrect:** * **Elbow instability:** This is typically managed by ligamentous reconstruction (e.g., Tommy John surgery for UCL tears) or the Boyd-Anderson procedure, not Putti-Platt. * **Rotator cuff tear:** Management involves reattachment of the tendons (supraspinatus, infraspinatus, etc.) to the greater tuberosity, often via arthroscopic anchors. * **Biceps Tendinitis:** This is an inflammatory condition managed conservatively or via biceps tenodesis/tenotomy if chronic. **3. High-Yield Clinical Pearls for NEET-PG:** * **Bankart Repair:** The current "gold standard" for anterior instability; involves reattaching the detached anterior labrum to the glenoid rim. * **Bristow-Latarjet Procedure:** A bone-block procedure involving the transfer of the coracoid process to the glenoid for cases with significant bony defects. * **Magnuson-Stack Procedure:** Another historical surgery for shoulder instability involving the lateral advancement of the subscapularis insertion. * **Key Limitation:** The hallmark of a post-Putti-Platt patient is a permanent **loss of external rotation**.

Q: In some old fractures, cartilaginous tissue forms over the fractured bone ends with a cavity in between containing clear fluid. What is this condition called?

Pseudoarthrosis. ### Explanation **Correct Option: D. Pseudoarthrosis** **Pseudoarthrosis** (literally "false joint") is a specific type of non-union where the fracture site fails to heal and instead develops features of a synovial joint. When there is excessive abnormal motion at a fracture site, the body attempts to adapt. The bone ends become smooth, sclerotic, and rounded off. They are covered by **fibrocartilage**, and a fibrous capsule forms around the gap. This "capsule" secretes **synovial-like fluid**, creating a fluid-filled cavity between the bone ends. This mimics the structure of a true joint, though it lacks functional stability. **Why other options are incorrect:** * **A & B. Delayed/Slow Union:** These terms refer to a fracture that is taking longer than the expected time to heal but still shows signs of progressing toward union. The biological process of repair is active, and there is no formation of a fluid-filled cavity or permanent false joint. * **C. Non-union:** This is a broad category where the fracture has failed to heal and shows no radiographic evidence of progression for at least 3 months. While pseudoarthrosis is a *type* of non-union (specifically an atrophic or mobile type), the question describes the specific pathological formation of a fluid-filled cavity and cartilage, which defines **Pseudoarthrosis**. **High-Yield NEET-PG Pearls:** * **Common Sites:** Most common in the scaphoid, femoral neck, and tibia. * **Radiographic Sign:** Look for "sclerosis" of bone ends and "obliteration" of the medullary canal. * **Congenital Pseudoarthrosis:** Most commonly affects the **tibia** and is strongly associated with **Neurofibromatosis Type 1 (NF-1)**. * **Treatment:** Usually requires surgical intervention, including freshening of bone ends, internal fixation, and bone grafting.

Q: Which part of a proximal humerus fracture has the maximum chance of avascular necrosis?

Four parts. **Explanation:** The risk of **Avascular Necrosis (AVN)** in proximal humerus fractures is directly proportional to the degree of disruption of the blood supply to the humeral head. **Why Four-Part Fractures have the maximum chance:** The primary blood supply to the humeral head is provided by the **Anterior Circumflex Humeral Artery (ACHA)** via its ascending branch (the arcuate artery) and the **Posterior Circumflex Humeral Artery (PCHA)**. In a **Neer’s Four-Part Fracture**, all four anatomical segments (greater tuberosity, lesser tuberosity, surgical neck, and anatomical neck) are displaced. This results in the complete isolation of the articular surface from its soft tissue attachments and periosteal blood supply. The incidence of AVN in four-part fractures is reported to be as high as **45% to 90%**. **Analysis of Incorrect Options:** * **One-Part Fracture:** These are non-displaced or minimally displaced fractures. The periosteum remains intact, ensuring a stable blood supply; thus, the risk of AVN is negligible. * **Two-Part Fracture:** Only one segment is displaced (e.g., surgical neck). Most of the vascularity remains intact through the attached tuberosities. * **Three-Part Fracture:** Two segments are displaced (e.g., surgical neck and one tuberosity). While the risk of AVN increases (approx. 15-25%), the humeral head still maintains a vascular connection through the remaining attached tuberosity. **High-Yield Clinical Pearls for NEET-PG:** * **Neer’s Classification:** Based on the displacement of the four segments. A part is considered "displaced" if there is **>1 cm translation** or **>45° angulation**. * **Hertel’s Criteria:** Predictors of ischemia include a short calcar segment (<8mm) and disruption of the medial periosteal hinge. * **Management:** In elderly patients with four-part fractures and a high risk of AVN, **Hemiarthroplasty** or **Reverse Shoulder Arthroplasty** is often preferred over internal fixation.

Q: What is a major factor contributing to fat embolism in a trauma patient?

Mobility of a joint. **Explanation:** Fat Embolism Syndrome (FES) typically occurs following fractures of long bones (like the femur) or the pelvis. The pathophysiology is primarily explained by the **Mechanical Theory** (Gauss's Theory). **Why "Mobility of a joint" is correct:** The movement of fractured bone ends or the adjacent joint increases intramedullary pressure. This pressure gradient forces globules of fat from the bone marrow into the torn, non-collapsible venous sinusoids near the fracture site. Therefore, **inadequate immobilization** of a fracture is a major contributing factor to the release of fat emboli into the systemic circulation. Early splinting and internal fixation significantly reduce the risk of FES. **Why other options are incorrect:** * **Diabetes Mellitus:** While metabolic factors (Biochemical Theory) play a role in how fat behaves in the blood (chylomicron stability), Diabetes is not a recognized primary trigger or major risk factor for post-traumatic fat embolism. * **Respiratory failure:** This is a **consequence** (clinical manifestation) of fat embolism, not a contributing factor. FES typically presents with the classic triad of respiratory distress, neurological symptoms, and petechial rashes. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis (Major: Petechial rash, Respiratory insufficiency, Cerebral involvement). * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral infiltrates). * **Treatment:** Primarily supportive (Oxygenation/Ventilation). **Early stabilization of fractures** is the most effective preventive measure. * **Free Fatty Acids:** According to the Biochemical Theory, the breakdown of fat into free fatty acids causes direct toxic injury to lung pneumocytes.

Q: The "Apprehension sign" is seen in dislocation of which joint?

Shoulder joint. **Explanation:** The **Apprehension Test** is the hallmark clinical examination for **recurrent anterior instability of the shoulder joint**. 1. **Why Shoulder Joint is Correct:** In patients with a history of anterior shoulder dislocation, placing the arm in a position of **abduction and external rotation** (the most vulnerable position) mimics the mechanism of dislocation. The patient becomes anxious or "apprehensive," fearing the humeral head will slip out of the glenoid cavity. They may resist further movement or contract the pectoralis major to stabilize the joint. This is a positive Apprehension sign, often followed by the **Relocation Test (Jobe’s test)**, where posterior pressure on the humerus relieves the anxiety. 2. **Why Other Options are Incorrect:** * **Hip Joint:** Dislocation is usually traumatic and stable once reduced. Clinical signs focus on limb shortening and rotation (internal for posterior, external for anterior). * **Elbow Joint:** Stability is assessed via varus/valgus stress tests or the Pivot-shift test for posterolateral rotatory instability. * **Patella:** While there is a specific **Fairbank’s Apprehension Test** for recurrent patellar dislocation (lateral displacement of the patella causes apprehension), the standard "Apprehension sign" without qualification traditionally refers to the shoulder in orthopedic nomenclature. **High-Yield Clinical Pearls for NEET-PG:** * **Bankart Lesion:** Avulsion of the anterior-inferior glenoid labrum; the most common cause of recurrent shoulder dislocation. * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head. * **Nerve Injury:** The **Axillary nerve** is the most commonly injured nerve in anterior shoulder dislocations (look for "regimental badge" anesthesia). * **Most Common Dislocation:** Anterior shoulder dislocation is the most common joint dislocation in the body.

Q: A 6-year-old boy has a history of recurrent dislocation of the right shoulder. On examination, the orthopedician puts the patient in the supine position, abducts his arm to 90 degrees with the bed as the fulcrum, and then externally rotates it. However, the boy does not allow the test to be performed. What is the name of the test performed by the orthopedician?

Apprehension test. The clinical scenario describes the **Apprehension Test**, which is the gold standard for diagnosing **Anterior Shoulder Instability**. ### Why the Correct Answer is Right The test is performed by placing the patient in a supine position, abducting the arm to 90°, and then applying external rotation. This maneuver mimics the position of most frequent dislocations (anteroinferior). In a patient with recurrent instability, this movement causes the humeral head to glide anteriorly, creating a sensation of impending dislocation. The "positive" sign is not pain, but rather the patient’s **apprehension** (anxiety or resistance) and refusal to allow further movement. ### Explanation of Incorrect Options * **B. Sulcus test:** Used to assess **inferior or multidirectional instability**. It is performed by pulling the arm downward (inferior traction); a positive result is a visible "gap" or sulcus between the acromion and the humeral head. * **C. Dugas test:** Used to diagnose **acute shoulder dislocation**. A patient with a dislocated shoulder cannot touch the opposite shoulder with their hand while the elbow is touching the chest. * **D. McMurray's test:** A physical exam maneuver used to identify **meniscal tears in the knee**, involving rotation of the tibia on the femur. It is irrelevant to shoulder trauma. ### NEET-PG High-Yield Pearls * **Relocation Test (Jobe’s Test):** If the apprehension test is positive, applying a posterior pressure on the humeral head relieves the apprehension, confirming anterior instability. * **Bankart Lesion:** The most common cause of recurrent anterior dislocation, involving an avulsion of the anteroinferior labrum. * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head, often seen on X-ray (Stryker notch view) in these patients.

Question 1

A 60-year-old female presents after a fall with inability to stand. Examination reveals her right leg to be in external rotation with limited movement, and tenderness in Scarpa's triangle. There is no history of fever, and the X-ray shows no fracture line. What is the next step in management?

Accepted Answer

MRI

Answer

Strict bed rest for 10 days and repeat X-ray

Answer

Joint aspiration

Answer

Provide analgesia and mobilization to prevent stiffness

Question 2

A 17-year-old male presented with complaints of severe shoulder pain along with his left arm hanging by the side with some external rotation. The patient suffered a blow to his left arm while playing football. A radiograph of the injured site was ordered. What is the most likely nerve injured?

Accepted Answer

Axillary nerve

Answer

Musculocutaneous nerve

Answer

Radial nerve

Answer

Ulnar nerve

Question 3

Which of the following statements is true regarding fat embolism?

Accepted Answer

Most patients with major trauma involving long bones have urinary fat globules

Answer

All patients with urinary fat globules develop fat embolism

Answer

Peak incidence of respiratory insufficiency for pulmonary fat embolism is around day 7 after injury

Answer

Heparin as an anticoagulant decreases mortality and morbidity in fat embolism syndrome

Question 4

Putti Platt operation is performed for which condition?

Accepted Answer

Shoulder instability

Answer

Elbow instability

Answer

Rotator cuff tear

Answer

Biceps Tendinitis

Question 5

A compound fracture is initially treated by antibiotics and wound toilet. Which of the following are appropriate subsequent management steps?

Accepted Answer

Skin cover, prosthesis, and internal fixation

Answer

Skin cover, external splintage, and internal fixation

Answer

External splintage, prosthesis, and internal fixation

Answer

Skin cover, external splintage, and prosthesis

Question 6

In some old fractures, cartilaginous tissue forms over the fractured bone ends with a cavity in between containing clear fluid. What is this condition called?

Accepted Answer

Pseudoarthrosis

Answer

Delayed union

Answer

Slow union

Answer

Non union

Question 7

Which part of a proximal humerus fracture has the maximum chance of avascular necrosis?

Accepted Answer

Four parts

Answer

One part

Answer

Two parts

Answer

Three parts

Question 8

What is a major factor contributing to fat embolism in a trauma patient?

Accepted Answer

Mobility of a joint

Answer

Diabetes Mellitus

Answer

Respiratory failure

Answer

All of the above

Question 9

The "Apprehension sign" is seen in dislocation of which joint?

Accepted Answer

Shoulder joint

Answer

Hip joint

Answer

Elbow joint

Answer

Patella

Question 10

A 6-year-old boy has a history of recurrent dislocation of the right shoulder. On examination, the orthopedician puts the patient in the supine position, abducts his arm to 90 degrees with the bed as the fulcrum, and then externally rotates it. However, the boy does not allow the test to be performed. What is the name of the test performed by the orthopedician?

Accepted Answer

Apprehension test

Answer

Sulcus test

Answer

Dugas test

Answer

McMurray's test

Trauma — MCQs

Trauma — MCQs

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