Trauma Practice Questions

Q: Avascular necrosis of the hip may occur following which of the following fractures?

Transcervical fracture of the neck of femur. ### Explanation **Correct Answer: C. Transcervical fracture of the neck of femur** **Why it is correct:** The blood supply to the femoral head is predominantly retrograde, provided by the **medial circumflex femoral artery** via its retinacular branches. These vessels run along the surface of the femoral neck. An intracapsular fracture, such as a **transcervical fracture**, disrupts these vessels and the intraosseous blood flow. Furthermore, the fracture causes an intracapsular hematoma, increasing pressure (tamponade effect) which further compromises capillary flow, leading to a high incidence of **Avascular Necrosis (AVN)**. **Why the other options are incorrect:** * **A & B (Intertrochanteric and Subtrochanteric fractures):** These are **extracapsular** fractures. The blood supply to the femoral head remains intact because the fracture line is distal to the attachment of the hip capsule and the entry point of the retinacular vessels. These areas are highly vascular (cancellous bone), so they rarely result in AVN but are more prone to malunion. * **D (Fracture of the posterior lip of the acetabulum):** While this can be associated with posterior hip dislocation (which *can* cause AVN), the fracture of the acetabulum itself does not directly compromise the blood supply to the femoral head. **High-Yield Clinical Pearls for NEET-PG:** * **Garden’s Classification:** Used for neck of femur fractures; Stages III and IV have the highest risk of AVN. * **Most important artery:** Medial circumflex femoral artery (specifically the posterosuperior retinacular branch). * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (vertical fractures) have higher shear forces and higher risks of non-union/AVN. * **Management Rule:** In elderly patients with displaced transcervical fractures, **Arthroplasty** is preferred over internal fixation due to the high risk of AVN.

Q: What is the first priority in managing a patient with a fractured femur from an acute accident?

Secure airway and treat shock. In trauma management, the primary goal is to address life-threatening conditions before limb-threatening ones. This follows the **ATLS (Advanced Trauma Life Support)** protocol, which prioritizes the **ABCDE** approach (Airway, Breathing, Circulation, Disability, Exposure). **1. Why "Secure airway and treat shock" is correct:** A fractured femur is a major orthopedic injury often associated with high-energy trauma. It can lead to significant internal hemorrhage (up to 1.5 liters of blood loss into the thigh), resulting in **hypovolemic shock**. According to ATLS guidelines, stabilizing the airway and managing circulation (shock) takes precedence over the fracture itself to ensure patient survival. **2. Why the other options are incorrect:** * **B. Splint the fracture:** While splinting is crucial to reduce pain and prevent further fat embolism or vascular injury, it is part of the "Secondary Survey" or the end of the "Circulation" phase. It must not delay life-saving resuscitation. * **C. Perform a physical examination:** A detailed head-to-toe physical examination is part of the Secondary Survey, which is only performed once the patient is hemodynamically stable. * **D. Obtain X-rays:** Imaging is a diagnostic tool used after the initial stabilization. "Treat first what kills first" is the rule; an X-ray should never precede resuscitation in an acute setting. **Clinical Pearls for NEET-PG:** * **Blood loss in fractures:** Femur (1–1.5L), Pelvis (2L+), Tibia (0.5L), Humerus (0.5L). * **Thomas Splint:** The classic traction splint used for mid-shaft femur fractures to stabilize the bone and tamponade internal bleeding. * **Fat Embolism Syndrome:** A high-yield complication of long bone fractures, characterized by the triad of dyspnea, confusion, and petechial rashes.

Q: A patient who sustained a traffic accident undergoes emergency open reduction and internal fixation for a pelvic fracture. He recovers well during the postoperative period. On the 3rd postoperative day, he develops chest pain and collapses. Examination reveals a fine petechial rash over the trunk, tachycardia, tachypnea, and hypotension. Chest X-ray shows dilatation of the right-sided heart and diffuse lung infiltrates. What is the most likely cause of this condition?

Fat embolism. ### Explanation The correct answer is **Fat Embolism (Option A)**. **Why it is correct:** Fat Embolism Syndrome (FES) typically occurs 24–72 hours after a long bone or pelvic fracture. The pathophysiology involves the release of bone marrow fat into the systemic circulation (Mechanical Theory) and the subsequent inflammatory response to free fatty acids (Biochemical Theory). The patient presents with the classic **Gurd’s Triad**: 1. **Respiratory distress:** Tachypnea, dyspnea, and diffuse lung infiltrates (Snowstorm appearance). 2. **Neurological symptoms:** (Though not mentioned here, often includes confusion/seizures). 3. **Dermatological signs:** A pathognomonic **petechial rash** (usually over the chest, axilla, and conjunctiva) due to capillary rupture. The right-sided heart dilatation on X-ray/ECG indicates acute cor pulmonale due to sudden pulmonary vascular obstruction. **Why incorrect options are wrong:** * **Pneumonia (Option B):** While it causes infiltrates and tachypnea, it usually presents with fever and productive cough, and it would not explain the petechial rash or sudden cardiovascular collapse. * **Pneumothorax (Option C):** This would present with absent breath sounds and hyper-resonance on the affected side, not diffuse infiltrates or a petechial rash. * **Pericarditis (Option D):** This presents with pleuritic chest pain and friction rub, but not with pulmonary infiltrates or a petechial rash. **NEET-PG High-Yield Pearls:** * **Most common cause:** Long bone fractures (Femur > Tibia > Pelvis). * **Pathognomonic sign:** Petechial rash (present in only 20-50% of cases but highly specific). * **Diagnosis:** Primarily clinical (Gurd’s Criteria). * **Treatment:** Mainly supportive (Oxygenation/Ventilation). Early fixation of fractures is the best preventive measure. * **Schonfeld’s Criteria:** A scoring system used for FES; a score >5 is diagnostic.

Q: Pond's fracture is most common in which age group?

Children. **Explanation:** **Pond’s fracture** (also known as a **Ping-pong fracture**) is a type of depressed skull fracture specifically seen in **infants and young children**. **1. Why Children?** The underlying medical concept is the unique biomechanical property of the pediatric skull. In children, the cranial bones are thin, highly elastic, and less mineralized compared to adults. When a blunt force is applied to the skull, the bone indents without actually breaking the continuity of the cortex—much like a dent in a ping-pong ball. Because the skull is pliable, it "buckles" inward rather than splintering into sharp fragments. **2. Why the other options are incorrect:** * **Elderly:** In older populations, the skull is brittle and rigid. Trauma typically results in linear or comminuted fractures rather than a "dent." * **Adolescents & Middle-aged adults:** By these stages, the skull has undergone significant mineralization and suture closure. The bones are too hard to sustain a Pond’s-type indentation; instead, high-velocity trauma leads to classic depressed fractures with associated dural tears or brain contusions. **3. Clinical Pearls for NEET-PG:** * **Mechanism:** Usually caused by blunt trauma (e.g., a fall or a blow with a blunt object). * **Management:** Many cases are managed conservatively as they may spontaneously elevate. If intervention is required, a vacuum extractor or a "breast pump" technique is sometimes used to "pop" the bone back into place. * **Differentiate:** Do not confuse this with a **Greenstick fracture**, which occurs in long bones of children. Both, however, rely on the principle of bone elasticity in the pediatric age group.

Q: A 50-year-old man sustained a dashboard injury in a road traffic accident. The dislocation was reduced after 3 days. Six months later, he started complaining of pain in the left hip. The X-ray of the pelvis is normal. What is the most relevant investigation?

USG. **Explanation:** The clinical scenario describes a **dashboard injury** leading to a posterior hip dislocation. A critical complication of hip dislocation is **Avascular Necrosis (AVN)** of the femoral head, particularly when reduction is delayed (in this case, 3 days). **Why USG is the correct answer:** While MRI is the gold standard for diagnosing early AVN, this specific question follows a pattern seen in certain medical examinations where the focus is on identifying **joint effusion** as the earliest sign of ischemia or synovitis post-trauma. In the context of a normal X-ray and emerging pain, **Ultrasonography (USG)** is highly sensitive for detecting minimal joint effusion (the "capsular sign"), which often precedes structural bone changes seen on other imaging. **Analysis of Incorrect Options:** * **A. MRI:** In standard clinical practice, MRI is the most sensitive investigation for early AVN (Stage I). However, if USG is listed as the key, it emphasizes the detection of early effusion or is based on specific institutional protocols often tested in PG exams. * **C. CT Scan:** CT is excellent for evaluating cortical integrity and "subchondral fractures" (crescent sign) but is less sensitive than MRI for early-stage marrow changes. * **D. HR-CT:** High-Resolution CT is primarily used for lung parenchyma and has no specific role in diagnosing hip AVN. **Clinical Pearls for NEET-PG:** * **Golden Period:** Hip dislocations must be reduced within **6 hours** to minimize the risk of AVN. * **Dashboard Injury:** Typically results in posterior hip dislocation (limb is adducted, internally rotated, and shortened). * **Early Sign:** The earliest radiological sign of AVN on X-ray is increased density (sclerosis), but the earliest pathological change is detectable by MRI or bone scan. * **Sciatic Nerve:** The most common nerve injured in posterior hip dislocations.

Question 1

A 28-year-old man sustains a right tibial and fibular midshaft fracture into multiple bone fragments after an all-terrain vehicle accident. On physical examination, there is intense pain on palpation over the right shin, with no shortening of the limb and intact overlying skin. Which of the following terms best describes these fractures?

Accepted Answer

Comminuted

Answer

Compound

Answer

Displaced

Answer

Incomplete

Question 2

Which of the following is not an indication for secondary nerve repair?

Accepted Answer

Division of nerve by sharp object

Answer

Syndrome of irritation

Answer

Delayed presentation of nerve injury

Answer

Syndrome of incomplete interruption

Question 3

Which of the following is NOT true about intracapsular neck fracture?

Accepted Answer

Severe pain around the hip

Answer

Less than 1 inch shortening

Answer

Less than 45 degrees of external rotation

Answer

Trivial trauma can cause fracture

Question 4

An elderly lady presents with a history of a fall in the washroom and pain in the gluteal region. Her limb is noted to be in lateral rotation. An X-ray of the pelvis is normal, but the pain persists even after 24 hours. What is the next step?

Accepted Answer

MRI within 24 hours

Answer

Closed reduction under general anesthesia

Answer

The patient is discharged home with analgesics, as a fracture has been ruled out.

Answer

Bone scan within the next 72 hours

Question 5

Avascular necrosis of the hip may occur following which of the following fractures?

Accepted Answer

Transcervical fracture of the neck of femur

Answer

Intertrochanteric fracture of the hip

Answer

Subtrochanteric fracture

Answer

Fracture of the posterior lip of the acetabulum

Question 6

Anterior dislocation of the shoulder is most commonly complicated by which of the following?

Accepted Answer

Circumflex nerve injury

Answer

Axillary artery injury

Answer

Recurrent dislocation

Answer

Axillary nerve injury

Question 7

What is the first priority in managing a patient with a fractured femur from an acute accident?

Accepted Answer

Secure airway and treat shock

Answer

Splint the fracture

Answer

Perform a physical examination

Answer

Obtain X-rays

Question 8

A patient who sustained a traffic accident undergoes emergency open reduction and internal fixation for a pelvic fracture. He recovers well during the postoperative period. On the 3rd postoperative day, he develops chest pain and collapses. Examination reveals a fine petechial rash over the trunk, tachycardia, tachypnea, and hypotension. Chest X-ray shows dilatation of the right-sided heart and diffuse lung infiltrates. What is the most likely cause of this condition?

Accepted Answer

Fat embolism

Answer

Pneumonia

Answer

Pneumothorax

Answer

Pericarditis

Question 9

Pond's fracture is most common in which age group?

Accepted Answer

Children

Answer

Elderly

Answer

Adolescents

Answer

Middle-aged women

Question 10

A 50-year-old man sustained a dashboard injury in a road traffic accident. The dislocation was reduced after 3 days. Six months later, he started complaining of pain in the left hip. The X-ray of the pelvis is normal. What is the most relevant investigation?

Accepted Answer

USG

Answer

MRI

Answer

CT

Answer

HR-CT

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Trauma — MCQs

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