Trauma Practice Questions

Q: A 74-year-old woman, in otherwise good health, sustained a leg injury 2 days ago and has been bedridden since the accident. Two hours ago, she became delirious. On physical examination, her temperature is 99 F, blood pressure is 120/70 mmHg, heart rate is 110, and respiratory rate is 32. Pulse oximetry shows an oxygen saturation of 80%, and a chest x-ray film is normal. Which of the following is the most likely diagnosis?

Pulmonary thromboembolism. ### Explanation The correct diagnosis is **Pulmonary Thromboembolism (PTE)**. **1. Why Pulmonary Thromboembolism is Correct:** The patient presents with the classic triad of **Virchow’s Triad** components: stasis (bedridden for 2 days) and advanced age. In elderly patients with lower limb injuries, the risk of Deep Vein Thrombosis (DVT) leading to PTE is high. * **Clinical Presentation:** Sudden onset of tachycardia, tachypnea, and significant hypoxia (SpO2 80%) with a **normal chest X-ray** is a hallmark of PTE. * **Delirium:** In the elderly, acute hypoxia often manifests as delirium or altered mental status rather than classic dyspnea. **2. Why Other Options are Incorrect:** * **Acute Cerebral Hemorrhage/Infarction:** While these cause delirium, they do not typically cause profound hypoxia (80%) or a respiratory rate of 32 in the absence of primary lung pathology. * **Myocardial Infarction:** While it can cause tachycardia and distress, the primary presentation would likely involve chest pain or signs of heart failure (pulmonary edema), which would show on a chest X-ray. * **Fat Embolism (Differential):** Though common in trauma, it usually presents with a petechial rash and "snowstorm" appearance on X-ray, typically occurring 24–72 hours after long bone fractures. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). * **ECG Finding:** Most common is Sinus Tachycardia; most specific is **S1Q3T3** pattern. * **Chest X-ray:** Usually normal, but look for **Westermark sign** (focal oligemia) or **Hampton’s Hump** (wedge-shaped opacity). * **Initial Management:** Hemodynamic stabilization and anticoagulation (LMWH/Unfractionated Heparin).

Q: Spur sign is/are seen in which of the following conditions?

Acetabulum fracture of pelvis. ### Explanation The **Spur Sign** is a pathognomonic radiological feature of **Both Column Acetabular Fractures**. **1. Why Acetabulum fracture is correct:** In a "both column" fracture, the articular surface is completely detached from the stable posterior ilium (the axial skeleton). On an Obturator Oblique view (Judet view), the **Spur Sign** represents the lowermost part of the intact posterior ilium that remains attached to the sacroiliac joint. Because the acetabular roof has displaced medially and posteriorly, this intact piece of bone "juts out" like a spur. Its presence confirms that no part of the articular surface remains attached to the sciatic buttress. **2. Why other options are incorrect:** * **Supracondylar fracture of humerus:** This is associated with the "Fat Pad sign" (Sail sign) or "Gartland classification," but not a spur sign. * **Radial head fracture:** Common signs include the "Fat Pad sign" due to joint effusion and the "Mason classification." * **Talus fracture:** These are associated with "Hawkins’ Sign" (subchondral lucency indicating intact vascularity), which is a crucial prognostic factor for avascular necrosis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Judet Views:** Essential for acetabular fractures. *Iliac Oblique* shows the posterior column and anterior wall; *Obturator Oblique* shows the anterior column and posterior wall (and the Spur Sign). * **Letournel Classification:** The gold standard for acetabular fractures (divided into 5 simple and 5 associated patterns). * **Both Column Fracture:** The only acetabular fracture where the "Spur Sign" is visualized. * **Floating Acetabulum:** Another term used for both column fractures because the joint is completely disconnected from the ilium.

Q: What is the most serious complication of a fracture of a long bone?

Fat embolism. ### Explanation **Correct Option: A. Fat Embolism** Fat Embolism Syndrome (FES) is considered the most serious and life-threatening systemic complication specifically associated with long bone fractures (especially the femur and tibia). When a long bone breaks, fat globules from the bone marrow are released into the systemic circulation. These globules can cause mechanical obstruction and trigger a biochemical inflammatory response (via free fatty acids), leading to acute respiratory distress, neurological dysfunction, and petechial rashes. Its rapid onset (24–72 hours) and high mortality rate make it the most dreaded acute complication. **Why other options are incorrect:** * **B. Pulmonary Embolism (PE):** While life-threatening, PE is usually a secondary complication of DVT and occurs later in the recovery phase (often after a week of immobilization). In the context of the *fracture event itself*, fat embolism is the more direct and classic "serious" complication. * **C. Deep Vein Thrombosis (DVT):** DVT is a common complication due to stasis and immobilization, but it is not as acutely fatal as a massive fat embolism. * **D. Associated Joint Injuries:** These are common and can lead to long-term morbidity (like stiffness or arthritis), but they are rarely life-threatening. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosing FES. Major criteria include **respiratory insufficiency**, **cerebral involvement** (confusion/coma), and **petechial rash** (typically over the chest, axilla, and conjunctiva). * **Snowstorm Appearance:** The classic finding on a chest X-ray in a patient with FES. * **Prevention:** Early internal fixation and stabilization of the fracture is the most effective way to prevent FES. * **Treatment:** Primarily supportive (Oxygenation/Ventilation). Corticosteroids are controversial but sometimes mentioned.

Q: When the gap between fracture segments is between 0.3-1mm, what type of healing occurs?

Woven bone formation later replaced by lamellar bone.. This question tests your understanding of **Primary (Direct) Bone Healing**, which occurs only under conditions of absolute stability (e.g., compression plating). Primary healing is further divided into two types based on the microscopic gap between fracture fragments: **1. Why Option B is Correct (Gap Healing):** When the fracture gap is between **0.1 mm and 1 mm**, it is too wide for direct lamellar growth but stable enough to avoid callus. This is called **Gap Healing**. * Initially, the gap is filled by **woven bone** (formed by osteoblasts depositing bone perpendicular to the long axis). * Subsequently, longitudinal **Haversian remodeling** occurs, where "cutting cones" (osteoclasts followed by osteoblasts) replace the woven bone with permanent **lamellar bone**. **2. Why other options are incorrect:** * **Option A:** Direct lamellar bone formation (Contact Healing) occurs only when the gap is **less than 0.01 mm** and fragments are in direct contact. Here, lamellar bone is formed immediately across the fracture line without a woven bone precursor. * **Option C:** Secondary healing occurs when there is **relative instability** (e.g., intramedullary nailing or casts). It is characterized by **callus formation** and involves a cartilaginous intermediate stage, which is absent in primary gap healing. **High-Yield NEET-PG Pearls:** * **Absolute Stability:** Leads to Primary Healing (No Callus). * **Relative Stability:** Leads to Secondary Healing (Callus present). * **Cutting Cones:** The functional unit of bone remodeling during primary healing. * **Strain Theory (Perren):** Bone formation requires low strain. If the gap is too wide or motion is too high, fibrous tissue or non-union occurs instead of bone.

Q: Aseptic necrosis is common in which of the following bones?

Scaphoid. **Explanation:** The correct answer is **Scaphoid**. The primary reason for the high incidence of aseptic necrosis (Avascular Necrosis - AVN) in the scaphoid is its **retrograde blood supply**. Approximately 70-80% of the scaphoid's blood supply enters through the dorsal ridge and distal pole via the radial artery. Consequently, a fracture through the waist or proximal pole interrupts the blood flow to the proximal fragment, leaving it ischemic. Since the scaphoid is largely covered by articular cartilage, it has limited areas for vascular entry, further predisposing it to AVN and non-union. **Analysis of Incorrect Options:** * **B. Calcaneum:** This is a large, cancellous bone with a robust, multi-directional blood supply. Fractures here typically heal well, though they may lead to subtalar arthritis. * **C. Cuboid:** Like most tarsal bones, it has a rich vascular network and is rarely subject to isolated ischemic necrosis. * **D. Trapezium:** While located in the carpus, it does not share the precarious retrograde vascular anatomy of the scaphoid and thus has a low risk of AVN. **High-Yield Clinical Pearls for NEET-PG:** * **Common Sites for AVN:** Remember the mnemonic **"S-F-A-T"** (Scaphoid, Femur head, Astragalus/Talus, Tally/Capitate). * **Talus:** Similar to the scaphoid, the talus has a retrograde blood supply (entering through the neck), making the body prone to AVN after neck fractures (**Hawkins’ Sign** on X-ray indicates a good prognosis/revascularization). * **Preiser’s Disease:** This refers to idiopathic AVN of the scaphoid (without a preceding fracture). * **Kienbock’s Disease:** AVN of the **Lunate** bone. * **Kohler’s Disease:** AVN of the **Navicular** bone in children.

Q: What is the most common site of vertebral compression fracture?

T12-L1. **Explanation:** The most common site for vertebral compression fractures is the **thoracolumbar junction (T12-L1)**. **1. Why T12-L1 is the Correct Answer:** The thoracolumbar junction represents a critical **transition zone** in the spinal column. The thoracic spine is relatively rigid due to its attachment to the rib cage, whereas the lumbar spine is highly mobile. When a vertical load or hyperflexion force is applied (common in falls from height or osteoporosis), the stress concentrates at the point where the rigid segment meets the mobile segment. T12 and L1 bear the brunt of this mechanical transition, making them the most vulnerable to wedge compression fractures. **2. Analysis of Incorrect Options:** * **C5-C6:** This is the most common site for **cervical spondylosis** and degenerative disc disease due to high mobility, but not for compression fractures. * **C7-T1 (Cervicothoracic junction):** While a transition zone, it is less frequently fractured than the thoracolumbar junction. It is, however, a common site for "Clay Shoveler’s fracture" (spinous process of C7). * **L5-S1:** This is the most common site for **spondylolisthesis** and **lumbar disc herniation** (sciatica), but it is protected from compression fractures by the heavy iliolumbar ligaments and the pelvic girdle. **Clinical Pearls for NEET-PG:** * **Mechanism:** Most compression fractures are "wedge fractures," where the anterior column fails while the posterior column remains intact. * **Osteoporosis:** In elderly patients, T12-L1 compression fractures can occur with minimal trauma (e.g., sneezing or bending). * **Neurology:** Most T12-L1 fractures do not cause complete paraplegia but may result in **Conus Medullaris syndrome**. * **Imaging:** The lateral X-ray is the initial investigation of choice to visualize the loss of anterior vertebral height.

Q: Carpal tunnel syndrome is due to involvement of which nerve?

Median nerve. **Explanation:** **Carpal Tunnel Syndrome (CTS)** is the most common entrapment neuropathy, caused by the compression of the **Median nerve** as it passes through the carpal tunnel—a narrow osteofibrous passage at the wrist. The tunnel is bounded by the carpal bones (floor) and the flexor retinaculum (roof). The median nerve is the most superficial structure in this tunnel, making it highly susceptible to pressure from inflammation, fluid retention, or space-occupying lesions. **Analysis of Options:** * **Median Nerve (Correct):** It provides sensory innervation to the lateral 3.5 fingers and motor supply to the thenar muscles. Compression leads to classic symptoms: nocturnal paresthesia, thenar atrophy, and a positive **Phalen’s test** or **Tinel’s sign**. * **Radial Nerve:** This nerve passes through the radial tunnel and the anatomical snuffbox. Compression usually occurs at the spiral groove (Saturday Night Palsy) or the arcade of Frohse (PIN palsy), leading to wrist drop. * **Ulnar Nerve:** It passes through the **Guyon’s canal** (not the carpal tunnel). Compression here causes "Ulnar Tunnel Syndrome," affecting the medial 1.5 fingers. * **Axillary Nerve:** This nerve winds around the surgical neck of the humerus. Injury typically follows shoulder dislocation or proximal humerus fractures, resulting in deltoid paralysis. **High-Yield Clinical Pearls for NEET-PG:** * **Contents of Carpal Tunnel:** 10 structures (1 Median nerve, 4 tendons of FDS, 4 tendons of FDP, and 1 tendon of FPL). * **Most Common Cause:** Idiopathic; however, secondary causes include Hypothyroidism, Diabetes, Pregnancy, and Rheumatoid Arthritis. * **Clinical Sign:** **Ape Thumb Deformity** (due to thenar muscle wasting). * **Treatment:** First-line is wrist splinting in neutral; definitive treatment is surgical release of the **Flexor Retinaculum**.

Q: Which is the earliest reliable sign suggestive of compartment syndrome?

Stretch pain. **Explanation:** Compartment syndrome occurs when increased interstitial pressure within a closed osteofascial space compromises local circulation and neuromuscular function. **1. Why "Stretch Pain" is correct:** The earliest and most reliable clinical indicator of compartment syndrome is **pain out of proportion** to the injury and **pain on passive stretching** of the muscles within the affected compartment (Stretch Pain). This occurs because passive stretching increases the pressure within the already tense compartment, stimulating ischemic sensory nerves before permanent damage occurs. **2. Analysis of Incorrect Options:** * **Paraesthesia (C):** This is often the second sign to appear, indicating early nerve ischemia. While early, it is subjective and usually follows the onset of severe pain. * **Pallor (D) and Pulselessness (B):** These are **late signs** (the "6 Ps"). Pulselessness is particularly unreliable because the systolic pressure often remains higher than the intracompartmental pressure; therefore, a palpable pulse does not rule out compartment syndrome. If these signs are present, the limb is likely already suffering from irreversible ischemic necrosis. **High-Yield Clinical Pearls for NEET-PG:** * **The 6 Ps:** Pain (earliest), Pressure, Pain on passive stretch, Paraesthesia, Pallor, and Pulselessness (latest). * **Diagnosis:** Primarily clinical. However, the gold standard for objective measurement is **Intracompartmental Pressure (ICP)** monitoring. * **Critical Threshold:** A **Delta pressure** (Diastolic BP minus ICP) of **≤ 30 mmHg** is highly suggestive of the need for surgical intervention. * **Treatment:** Immediate **emergency fasciotomy** to release all involved compartments. * **Most common sites:** Deep posterior compartment of the leg (tibia fractures) and the volar compartment of the forearm (Supracondylar fractures).

Q: Pat's fracture is a fracture of which of the following?

Lower end of tibia and fibula. **Explanation:** **Pott’s fracture** (also known as Pott’s syndrome or Dupuytren’s fracture) is a classic eponym used to describe a fracture-dislocation of the ankle joint. Specifically, it involves a fracture of the **lower end of the tibia (medial malleolus) and the fibula (lateral malleolus)**. The injury is typically caused by a forceful eversion or abduction of the foot, which puts excessive strain on the deltoid ligament and the malleoli. In a classic Pott’s fracture, the lateral malleolus fractures first, followed by the medial malleolus (or a tear of the deltoid ligament), leading to instability of the talus within the ankle mortise. **Analysis of Options:** * **Option B (Correct):** It accurately identifies the involvement of both the tibia and fibula at the ankle joint level. * **Option A:** A fracture of the lower end of the tibia alone (e.g., isolated medial malleolus fracture) does not constitute a Pott’s fracture. * **Option C & D:** These involve the tarsal bones (calcaneum and talus). While these bones form the ankle and subtalar joints, they are not part of the definition of a Pott’s fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Cotton’s Fracture:** A "Trimalleolar fracture" involving the medial malleolus, lateral malleolus, and the posterior lip of the tibia (posterior malleolus). * **Maisonneuve Fracture:** A proximal fibular fracture associated with an ankle injury (medial malleolar fracture or deltoid ligament tear); always palpate the proximal fibula in ankle traumas. * **Pilon Fracture:** A comminuted intra-articular fracture of the distal tibia caused by vertical compression (axial loading). * **Lauge-Hansen Classification:** The most widely used system to categorize ankle fractures based on the foot's position and the direction of the injuring force.

Question 1

A 74-year-old woman, in otherwise good health, sustained a leg injury 2 days ago and has been bedridden since the accident. Two hours ago, she became delirious. On physical examination, her temperature is 99 F, blood pressure is 120/70 mmHg, heart rate is 110, and respiratory rate is 32. Pulse oximetry shows an oxygen saturation of 80%, and a chest x-ray film is normal. Which of the following is the most likely diagnosis?

Accepted Answer

Pulmonary thromboembolism

Answer

Acute cerebral hemorrhage

Answer

Acute cerebral infarction

Answer

Myocardial infarction

Question 2

Spur sign is/are seen in which of the following conditions?

Accepted Answer

Acetabulum fracture of pelvis

Answer

Supracondylar fracture of humerus

Answer

Radial head fracture

Answer

Talus fracture

Question 3

What is the most serious complication of a fracture of a long bone?

Accepted Answer

Fat embolism

Answer

Pulmonary embolism

Answer

Deep vein thrombosis

Answer

Associated joint injuries

Question 4

When the gap between fracture segments is between 0.3-1mm, what type of healing occurs?

Accepted Answer

Woven bone formation later replaced by lamellar bone.

Answer

Direct lamellar bone formation.

Answer

Secondary healing.

Answer

Any of the above.

Question 5

Aseptic necrosis is common in which of the following bones?

Accepted Answer

Scaphoid

Answer

Calcaneum

Answer

Cuboid

Answer

Trapezium

Question 6

What is the most common site of vertebral compression fracture?

Accepted Answer

T12-L1

Answer

C5-C6

Answer

C7-T1

Answer

L5-S1

Question 7

Carpal tunnel syndrome is due to involvement of which nerve?

Accepted Answer

Median nerve

Answer

Radial nerve

Answer

Ulnar nerve

Answer

Axillary nerve

Question 8

Which is the earliest reliable sign suggestive of compartment syndrome?

Accepted Answer

Stretch pain

Answer

Pulselessness

Answer

Paraesthesia

Answer

Pallor

Question 9

Pat's fracture is a fracture of which of the following?

Accepted Answer

Lower end of tibia and fibula

Answer

Lower end of tibia

Answer

Lower end of tibia and calcaneum

Answer

Calcaneum and talus

Question 10

A 45-year-old driver involved in a motor vehicle collision sustains a posterior dislocation of the left hip. What is the most likely concomitant injury?

Accepted Answer

Left knee anterior cruciate ligament tear

Answer

Right knee meniscus tear

Answer

Subdural hematoma

Answer

Lumbar burst fracture

Trauma — MCQs

Trauma — MCQs

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