Trauma Practice Questions

Q: A young male presented with dyspnea, bleeding, and petechial hemorrhage in the chest 2 days after sustaining a fracture of the shaft of the right femur. What is the most likely cause?

Fat embolism. ### Explanation **Correct Answer: B. Fat Embolism** The clinical presentation of **dyspnea**, **petechial rashes** (typically on the chest, axilla, and conjunctiva), and **neurological symptoms** following a long bone fracture (like the femur) is the classic triad of **Fat Embolism Syndrome (FES)**. * **Pathophysiology:** Mechanical trauma to the bone marrow releases fat globules into the venous circulation. These globules cause mechanical obstruction in the pulmonary capillaries and trigger a chemical inflammatory response (free fatty acid toxicity), leading to Acute Respiratory Distress Syndrome (ARDS). * **Timeline:** Symptoms typically appear **24–72 hours** after the injury (the "latent period"). **Why other options are incorrect:** * **A. Air Embolism:** Usually occurs due to iatrogenic causes (central line insertion, surgery) or penetrating chest trauma. It presents acutely, not after a 2-day delay. * **C. Pulmonary Thromboembolism (PTE):** While common in trauma patients, PTE usually occurs **1–2 weeks** post-injury due to deep vein thrombosis (DVT). It does not present with petechial hemorrhages. * **D. Amniotic Fluid Embolism:** This is an obstetric emergency occurring during labor or immediate postpartum; it is irrelevant to a male patient with a femur fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis. Major criteria include axillary/subconjunctival petechiae, hypoxemia ($PaO_2 < 60$ mmHg), and CNS depression. * **Snowstorm Appearance:** Characteristic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Treatment:** Primarily **supportive** (oxygenation and stabilization of the fracture). Early internal fixation of long bone fractures significantly reduces the risk of FES. * **Most common site:** Femur shaft fracture.

Q: Calcaneum is most commonly associated with which fracture?

Vertebral fracture. **Explanation:** The correct answer is **Vertebral fracture**. This association is a classic example of a "Don Juan Syndrome" or "Lover’s Leap" injury. **1. Why Vertebral Fracture is Correct:** The mechanism of injury for a calcaneal fracture typically involves a high-energy axial load, such as falling from a height and landing on the heels. The force is transmitted proximally through the talus to the tibia, femur, and ultimately the axial skeleton. Approximately **10% of patients** with a calcaneal fracture will have a concomitant compression fracture of the lumbar spine (most commonly at the **L1 level**). This is why any patient presenting with a calcaneal fracture must undergo a thorough clinical and radiological evaluation of the spine. **2. Why Other Options are Incorrect:** * **Rib and Skull fractures:** These are typically associated with direct blunt trauma or high-velocity motor vehicle accidents rather than the specific axial loading mechanism seen in heel strikes. * **Fibula fracture:** While a fibular fracture can occur in complex lower limb trauma, it is not the "most commonly associated" systemic fracture linked specifically to the mechanism of calcaneal injury. **Clinical Pearls for NEET-PG:** * **Bilateral Calcaneal Fractures:** If one calcaneum is fractured, there is a high probability (approx. 10%) of the other side being fractured as well. * **Mondor’s Sign:** Ecchymosis extending to the sole of the foot is a pathognomonic clinical sign for calcaneal fracture. * **Bohler’s Angle:** Normal is 20°–40°. An angle <20° indicates a depressed calcaneal fracture. * **Gissane’s Angle:** Normal is 120°–145°. An increase suggests a fracture of the posterior facet.

Q: After falling on the pavement, a 72-year-old woman is found to have a fracture of the radius and ulna (Colles' fracture). What is true of this fracture?

The distal radial metaphysis is displaced dorsally.. **Explanation:** **Colles’ fracture** is a common extra-articular fracture of the distal radius, typically occurring about 2 cm proximal to the radiocarpal joint. 1. **Why Option D is correct:** The hallmark of a Colles’ fracture is the **dorsal (posterior) displacement** and dorsal angulation of the distal radial fragment. This occurs because the force of the fall is transmitted through the carpus to the dorsal aspect of the radius, resulting in the classic **"Dinner Fork Deformity."** 2. **Why other options are incorrect:** * **Option A:** The mechanism of injury is a fall on an **outstretched hand (FOOSH)** with the wrist in **extension**, not on the dorsum. A fall on a flexed wrist (dorsum) leads to a **Smith’s fracture** (Reverse Colles’). * **Option B:** Most Colles’ fractures are managed via **closed reduction** and immobilization in a Colles’ cast (below-elbow cast with slight wrist flexion and ulnar deviation). Open reduction is reserved for unstable or intra-articular fractures. * **Option C:** This fracture typically affects **elderly post-menopausal women** due to underlying osteoporosis. In younger individuals, high-energy trauma is required to cause a similar injury. **NEET-PG High-Yield Pearls:** * **Deformities in Colles’:** Dorsal displacement, dorsal tilt, lateral displacement, lateral tilt, and impaction (shortening). * **Smith’s Fracture:** Distal fragment is displaced **ventrally/palmarly** (Garden Spade deformity). * **Barton’s Fracture:** Intra-articular fracture-dislocation of the radiocarpal joint. * **Complications:** The most common late complication is **malunion**; the most common nerve involved is the **Median nerve** (Carpal Tunnel Syndrome); a specific late complication is rupture of the **Extensor Pollicis Longus (EPL)** tendon.

Q: An emergency room physician examines a patient who has fallen from a motorcycle and injured his shoulder. The clinician notices a loss of the normal contour of the shoulder and an abnormal-appearing depression below the acromion. Which of the following injuries did the patient most likely sustain?

Dislocated shoulder joint. **Explanation:** The clinical presentation of a **loss of normal shoulder contour** and a **hollow/depression below the acromion** is the classic "squared-off shoulder" appearance, pathognomonic for an **anterior shoulder dislocation**. **1. Why the Correct Answer is Right:** The deltoid muscle normally creates the rounded contour of the shoulder by draping over the greater tubercle of the humerus. In a dislocation (most commonly anterior), the humeral head is displaced from the glenoid fossa. This leaves a void under the acromion (the "hollow" sign) and causes the acromion to become the most lateral bony point, resulting in a flattened, squared-off appearance. **2. Why the Incorrect Options are Wrong:** * **Avulsion of the coronoid process:** This involves the ulna at the elbow joint and would not affect the contour of the shoulder. * **Fracture of the midshaft of the humerus:** This typically presents with localized pain, swelling, and potential radial nerve palsy (wrist drop), but the shoulder contour remains intact as the humeral head is still in the glenoid. * **Fracture of the surgical neck of the humerus:** While this occurs near the shoulder, the humeral head remains in the glenoid cavity, preserving the rounded contour. However, it is a high-yield differential for axillary nerve injury. **3. NEET-PG High-Yield Pearls:** * **Most Common Type:** Anterior dislocation (95%), often caused by forceful abduction and external rotation. * **Associated Nerve Injury:** The **Axillary Nerve** is most commonly injured (test for sensation over the "Regimental Badge" area). * **Associated Lesions:** Look for **Bankart lesion** (detachment of anterior labrum) and **Hill-Sachs lesion** (compression fracture of posterolateral humeral head). * **Posterior Dislocation:** Often associated with seizures or electric shocks; shows a "Light bulb sign" on X-ray.

Q: What is the most troubling aspect of a Thomas splint?

Ring. The **Thomas splint** is a classic orthopedic device used primarily for the immobilization of femur fractures. The correct answer is the **Ring**, as it represents the most problematic component of the splint’s design. ### Why the Ring is the most troubling: The Thomas splint is a form of **skin traction** where the counter-traction is provided by the ring pressing against the **ischial tuberosity**. Because the ring must be snug to provide effective counter-traction, it frequently causes: * **Pressure Sores:** Constant pressure on the groin and ischial area leads to skin breakdown. * **Hygiene Issues:** The area is prone to soiling from urine and feces, increasing the risk of infection. * **Size Mismatch:** If the ring is too small, it causes excessive pressure; if too large, it slides up, losing effective counter-traction and potentially injuring the perineum. ### Why other options are incorrect: * **Side bars:** These provide the structural framework and are generally well-tolerated. They rarely cause direct complications unless they are bent or improperly sized. * **Gauze support:** These "slings" support the limb within the frame. While they must be adjusted to prevent sagging, they do not pose a significant clinical "trouble" compared to the ring. * **Traction attachment:** This is the mechanism (e.g., a W-shaped distal end) where the cord is tied. It is a functional component that rarely causes patient morbidity. ### NEET-PG High-Yield Pearls: * **Measurement:** To select the correct size, measure the **oblique circumference of the thigh** at the groin and **add 2 inches**. * **Indications:** Primarily used for fractures of the shaft of the femur and to transport patients with lower limb injuries. * **Modification:** The **Keller-Blake splint** is a modification with a "half-ring" to reduce the pressure complications associated with the full ring.

Q: In a road traffic accident, a patient sustained soft tissue and brachial plexus injuries. Nerve involvement causing weakness in extensors of the entire arm, forearm, and hand, along with weakness in shoulder flexion and extension, is suggestive of:

C5 to T1 nerve root involvement. **Explanation:** The clinical presentation describes a **total brachial plexus palsy**. To identify the level of injury, we must analyze the specific muscle groups involved: 1. **Extensors of the entire arm, forearm, and hand:** These are primarily supplied by the **Radial Nerve** (C5-T1). Weakness here indicates involvement of the posterior cord and its contributing roots. 2. **Shoulder Flexion and Extension:** Shoulder flexion is primarily mediated by the Musculocutaneous nerve (C5-C6) and Deltoid (C5), while extension involves the Latissimus dorsi (C6-C8) and Posterior Deltoid (C5-C6). Since the weakness spans the shoulder (C5-C6), the arm/forearm extensors (C5-T1), and the hand (C8-T1), the entire plexus from **C5 to T1** must be involved. **Analysis of Incorrect Options:** * **Option A (Middle and lower cord):** This would spare the upper cord (C5-C6) functions, such as shoulder abduction and elbow flexion, which are affected in this patient. * **Option B (C5, C6, C7):** This would spare the intrinsic muscles of the hand and long flexors/extensors of the fingers (supplied by C8-T1), leading to an incomplete clinical picture. * **Option D (Posterior trunk):** There is no "posterior trunk" in the brachial plexus anatomy (only superior, middle, and inferior trunks). Even if referring to the posterior cord, it would not explain the weakness in shoulder flexion (Musculocutaneous nerve/Lateral cord). **NEET-PG High-Yield Pearls:** * **Erb’s Palsy (C5-C6):** "Waiter's tip" deformity; loss of abduction, external rotation, and supination. * **Klumpke’s Palsy (C8-T1):** "Claw hand" deformity; involves intrinsic hand muscles and may present with Horner’s syndrome (if T1 pre-ganglionic). * **Total Plexus Injury:** Usually results from high-energy traction (RTA); presents with a flail, anesthetic limb. * **Winged Scapula:** Injury to the Long Thoracic Nerve (C5, C6, C7).

Q: What is the recommended treatment for non-union of a fractured femoral shaft?

Bone grafting with internal fixation using a K-Nail. **Explanation:** The management of non-union in long bone fractures, such as the femoral shaft, is governed by the principle of addressing both **mechanical stability** and **biological activity**. 1. **Why Option C is correct:** Non-union occurs when the fracture healing process has ceased. To restart this process, two things are required: **Internal Fixation** (to provide rigid stability and eliminate shear forces) and **Bone Grafting** (to provide osteoconductive, osteoinductive, and osteogenic factors). The **Kuntscher Nail (K-Nail)** is a classic intramedullary device used for mid-shaft femoral fractures. It provides stable internal fixation, while the addition of bone grafts (usually autologous iliac crest) stimulates new bone formation across the non-union site. 2. **Why other options are incorrect:** * **Option A:** External fixation is generally reserved for open fractures with severe soft tissue injury or infected non-unions. It does not provide the same level of stable compression required for a standard aseptic non-union of the femur. * **Option B:** Excision of the bone would lead to a massive segmental defect and permanent limb shortening/disability; it is not a treatment for non-union. **Clinical Pearls for NEET-PG:** * **Definition of Non-union:** A fracture that shows no clinical or radiological signs of healing for at least 3 consecutive months, usually after 6–9 months of injury. * **Hypertrophic Non-union:** Characterized by "Elephant foot" callus; it requires stability (fixation) but usually does not need grafting. * **Atrophic Non-union:** Characterized by "pencil-like" bone ends; it requires both stability and bone grafting (as seen in this question). * **Gold Standard:** Autologous bone graft (from the iliac crest) remains the gold standard for treating atrophic non-unions.

Q: What does an increase in Pauwel's angle indicate?

Increased chances of displacement. **Explanation:** The **Pauwel’s Classification** is based on the angle formed by the fracture line of the femoral neck relative to the horizontal plane. This classification is a biomechanical assessment of the stability of neck of femur fractures. **1. Why the correct answer is right:** As the Pauwel’s angle increases, the fracture line becomes more **vertical**. According to the principles of biomechanics: * **Shearing forces** increase as the angle becomes more vertical. * **Compressive forces** (which aid healing) decrease. Because vertical fractures are subject to high shear stress and gravity, they are inherently unstable, leading to **increased chances of displacement** and a higher risk of non-union or fixation failure. **2. Why the incorrect options are wrong:** * **A. Good prognosis:** A high Pauwel’s angle (Type III >70°) indicates a *poor* prognosis due to instability. * **B. Impaction:** Impaction is typically seen in stable, more horizontal fractures (Pauwel Type I) or Garden Type I fractures. * **D. Displacement of trabecular alignment:** While trabecular alignment is used in the **Garden Classification**, Pauwel’s classification specifically measures the angle of the fracture line itself. **Clinical Pearls for NEET-PG:** * **Pauwel Type I:** 70° (Highly unstable, shear forces dominate). * **High-Yield Fact:** For young patients with Pauwel Type III fractures, a **sliding hip screw (SHS)** or a **fixed-angle device** is often preferred over multiple cannulated screws to better resist the high shearing forces.

Q: Identify the type of fracture in a patient who sustained a road traffic accident resulting in fractures of both the tibia and fibula.

Bumper Fracture. ***Bumper Fracture*** - A **bumper fracture** refers to fractures of the **tibia and fibula** sustained when a pedestrian is struck by a vehicle bumper during a **road traffic accident**. - The term typically describes **mid-shaft or proximal shaft fractures** of both bones caused by direct lateral impact from a car bumper. - This matches the clinical scenario of **both tibia and fibula fractures** following RTA, making it the correct answer. - Note: The term can also refer specifically to lateral tibial plateau fractures, but in the context of "both bones" being fractured, it refers to the shaft fracture pattern. *Patella sleeve fracture* - This is a rare **avulsion fracture** seen almost exclusively in **children and adolescents**, involving the superior or inferior pole of the patella. - It results from forceful contraction of the **quadriceps** or sudden loading, causing avulsion of the cartilaginous sleeve. - This does not involve both tibia and fibula, making it incorrect for this scenario. *Depressed skull fracture* - This fracture involves the **calvarium (skull)** where bone fragments are pushed inward toward the brain. - While RTAs can cause head injuries, the question specifically describes fractures of the **tibia and fibula** (lower limb bones), not skull injury. *Cervical fracture* - Refers to fractures involving the **cervical vertebrae** in the neck region. - Although cervical spine injuries occur in RTAs, this does not match the clinical scenario of **lower limb long bone fractures** (tibia and fibula).

Question 1

A young male presented with dyspnea, bleeding, and petechial hemorrhage in the chest 2 days after sustaining a fracture of the shaft of the right femur. What is the most likely cause?

Accepted Answer

Fat embolism

Answer

Air embolism

Answer

Pulmonary thromboembolism

Answer

Amniotic fluid embolism

Question 2

Calcaneum is most commonly associated with which fracture?

Accepted Answer

Vertebral fracture

Answer

Rib fracture

Answer

Skull fracture

Answer

Fibula fracture

Question 3

After falling on the pavement, a 72-year-old woman is found to have a fracture of the radius and ulna (Colles' fracture). What is true of this fracture?

Accepted Answer

The distal radial metaphysis is displaced dorsally.

Answer

The fall occurs on the dorsum of the wrist.

Answer

Open reduction is most commonly indicated.

Answer

Younger men are generally affected.

Question 4

A child has dye injected into an extremity. Subsequently, the child develops pain and swelling of the upper limb, paresthesias of the fingers, stretch pain, and normal peripheral pulses. What is the appropriate management?

Accepted Answer

Fasciotomy

Answer

Aspiration

Answer

Anti-inflammatory agents

Answer

Observation

Question 5

An emergency room physician examines a patient who has fallen from a motorcycle and injured his shoulder. The clinician notices a loss of the normal contour of the shoulder and an abnormal-appearing depression below the acromion. Which of the following injuries did the patient most likely sustain?

Accepted Answer

Dislocated shoulder joint

Answer

Avulsion of the coronoid process

Answer

Fracture of the midshaft of the humerus

Answer

Fracture of the surgical neck of the humerus

Question 6

What is the most troubling aspect of a Thomas splint?

Accepted Answer

Ring

Answer

Side bars

Answer

Gauze support

Answer

Traction attachment

Question 7

In a road traffic accident, a patient sustained soft tissue and brachial plexus injuries. Nerve involvement causing weakness in extensors of the entire arm, forearm, and hand, along with weakness in shoulder flexion and extension, is suggestive of:

Accepted Answer

C5 to T1 nerve root involvement

Answer

Middle and lower cord involvement

Answer

C5, C6, C7 nerve root involvement

Answer

Posterior trunk involvement

Question 8

What is the recommended treatment for non-union of a fractured femoral shaft?

Accepted Answer

Bone grafting with internal fixation using a K-Nail

Answer

Open reduction with external fixation

Answer

Excision of the bone

Answer

All of the above

Question 9

What does an increase in Pauwel's angle indicate?

Accepted Answer

Increased chances of displacement

Answer

Good prognosis

Answer

Impaction

Answer

Displacement of trabecular alignment

Question 10

Identify the type of fracture in a patient who sustained a road traffic accident resulting in fractures of both the tibia and fibula.

Accepted Answer

Bumper Fracture

Answer

Depressed skull fracture

Answer

Patella sleeve fracture

Answer

Cervical fracture

Trauma — MCQs

Trauma — MCQs

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