Trauma Practice Questions

Q: Which of the following requires emergency treatment?

Vascular compression injury. **Explanation:** In orthopaedic trauma, emergencies are categorized into conditions that are **life-threatening** or **limb-threatening**. **Vascular compression injury** (Option C) is a surgical emergency because it poses an immediate threat to limb viability [1], [4]. Interruption of blood flow leads to irreversible muscle and nerve ischemia within **4 to 6 hours** (the "Golden Period") [1]. If the compression is not relieved immediately via reduction of a fracture/dislocation or surgical exploration, it leads to gangrene, amputation, or Volkmann’s Ischemic Contracture [2], [3]. **Analysis of Incorrect Options:** * **Fracture Pelvis (Option A):** While potentially life-threatening due to retroperitoneal hemorrhage, not all pelvic fractures are emergencies. Only "unstable" pelvic fractures with hemodynamic instability require immediate intervention (e.g., pelvic binder). * **Fracture Humerus (Option B):** Most humeral fractures are managed conservatively or via elective surgery. Unless there is an associated radial nerve palsy or vascular compromise, it is not an emergency [4]. * **Car Accident (Option D):** This is a mechanism of injury, not a diagnosis. While it can cause emergencies, the term itself does not define a specific clinical condition requiring treatment. **NEET-PG High-Yield Pearls:** 1. **Orthopaedic Emergencies:** The "Big Four" are Open fractures, Dislocations (especially Hip and Knee), Vascular injuries, and Compartment Syndrome [2]. 2. **The 6 P’s of Ischemia:** Pain (out of proportion), Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. **Pain** is the earliest sign; **Pulselessness** is a late sign [2]. 3. **Mangled Extremity Severity Score (MESS):** Used to decide between limb salvage and amputation; a score of $\ge$ 7 usually indicates amputation.

Q: Vascular repair is indicated in which Gustilo-Anderson type of fracture?

IIIc. The **Gustilo-Anderson Classification** is the gold standard for grading open fractures based on the mechanism of injury, soft tissue damage, and degree of contamination. ### **Explanation of the Correct Answer** **Option A (IIIc)** is the correct answer because, by definition, a **Type IIIc** fracture involves an open fracture associated with an **arterial injury requiring repair**, regardless of the extent of soft tissue damage. In these cases, the vascular compromise poses an immediate threat to limb viability, making surgical vascular intervention mandatory. ### **Explanation of Incorrect Options** * **Option B (Type I):** Low-energy trauma with a clean wound 1 cm but <10 cm without extensive soft tissue damage, flaps, or avulsions. No vascular repair is required. * **Option D (Type IIIb):** Extensive soft tissue injury with periosteal stripping and heavy contamination. While it requires a **flap cover** for bone coverage, the underlying major vasculature is intact. ### **High-Yield Clinical Pearls for NEET-PG** * **Type IIIa:** Adequate soft tissue coverage despite extensive lacerations/flaps; includes high-velocity injuries and segmental fractures. * **Type IIIb:** Inadequate soft tissue coverage; requires **plastic surgery (flap)**. * **Type IIIc:** Requires **vascular surgery**. * **Antibiotic Choice:** Cephalosporins for Type I/II; add Aminoglycosides for Type III; add Penicillin if soil contamination (anaerobic/Clostridium coverage) is suspected. * **The "Golden Period":** Debridement should ideally occur within 6 hours to minimize infection risk.

Q: Which of the following fractures is not managed by compression screws?

Comminuted fracture of lateral malleolus. ### Explanation The fundamental principle of using **compression screws** (such as lag screws) is to achieve absolute stability by compressing two smooth, matching bone surfaces together. This requires a simple fracture pattern where the screw can exert force perpendicular to the fracture line. **Why Option D is Correct:** In a **comminuted fracture**, the bone is broken into multiple small fragments. Compression screws are contraindicated here because: 1. There is no stable "opposite" surface to compress against. 2. Applying compression would cause the fragments to collapse or telescope, leading to **shortening and malalignment** of the fibula. 3. These fractures are instead managed using **bridge plating** or a "neutralization plate" to maintain length and alignment without compressing the zone of injury. **Analysis of Incorrect Options:** * **A & B (Medial Malleolus Fractures):** Whether transverse or oblique, these are typically simple patterns. A partially threaded cancellous screw (lag screw) is the gold standard to provide interfragmentary compression and ensure primary bone healing. * **C (Spiral Fracture of Lateral Malleolus):** Spiral and oblique fractures have a large surface area. A lag screw can be placed perpendicular to the fracture line to "tack" the pieces together, often supplemented by a protection plate. **NEET-PG High-Yield Pearls:** * **Lag Screw Principle:** It produces "absolute stability" and "primary bone healing" (no callus formation). * **Pitch:** The distance between two adjacent screw threads. * **Lead:** The distance a screw advances with one 360° turn. * **Gold Standard for Malleolar Fixation:** 4.0 mm partially threaded cancellous screws. * **Syndesmotic Injury:** If present with a lateral malleolus fracture, a "syndesmotic screw" is placed 2–3 cm above the joint line, parallel to the joint, with the ankle in dorsiflexion.

Q: What is the typical position of the leg in a fracture of the neck of the femur?

External rotation with the patella facing outwards.. ### Explanation In a **fracture of the neck of the femur**, the characteristic clinical presentation is a shortened limb held in **external rotation**. **Why the correct answer is right:** When the femoral neck fractures, the distal fragment is no longer mechanically connected to the acetabulum. The powerful **iliopsoas muscle**, which inserts into the lesser trochanter, acts as a potent external rotator. Additionally, the weight of the foot naturally pulls the limb into external rotation due to gravity. Because the entire distal segment rotates outward, the **patella faces outwards** (laterally). **Analysis of Incorrect Options:** * **A & D (Patella facing inwards):** This describes internal rotation. Internal rotation is characteristic of **posterior hip dislocations**, not neck of femur fractures. * **C (Internal rotation with patella facing outwards):** This is anatomically contradictory; if the limb is internally rotated, the patella must face medially (inwards). **Clinical Pearls for NEET-PG:** 1. **Degree of Rotation:** In **intracapsular** fractures (Neck of Femur), external rotation is typically moderate (45°–60°) because the capsule limits movement. In **extracapsular** fractures (Intertrochanteric), the rotation is more severe (nearly 90°), often with the lateral border of the foot touching the bed. 2. **Shortening:** True shortening occurs due to the upward pull of the hamstrings and rectus femoris. 3. **Vascularity:** The main blood supply to the femoral head is the **medial circumflex femoral artery** (via retinacular vessels). Fractures here carry a high risk of **Avascular Necrosis (AVN)** and non-union. 4. **Shenton’s Line:** This radiological arc is broken in femoral neck fractures.

Q: Management of calcaneal fractures depends upon which of the following?

All of the above. The management of calcaneal fractures is complex and multifactorial, requiring a tailored approach based on the specific clinical scenario. **1. Why "All of the Above" is Correct:** * **Type of Fracture (Option A):** This is the most critical factor. Fractures are classified into **Extra-articular** (usually managed conservatively) and **Intra-articular** (often requiring surgery). The **Sanders Classification** (based on CT scans) determines the surgical approach; Type I is non-operative, while Types II and III often require Open Reduction and Internal Fixation (ORIF). * **Subtalar Joint Dislocation (Option B):** The involvement and displacement of the subtalar joint significantly impact the prognosis. If the joint is dislocated or severely comminuted, the goal of management shifts toward restoring articular congruity to prevent debilitating post-traumatic arthritis. * **Duration of Presentation (Option C):** Timing is vital due to the high risk of soft tissue complications. In acute settings with massive swelling or fracture-blisters, surgery is delayed (7–14 days) until the **"wrinkle sign"** appears. Conversely, late presentations (neglected fractures) may require primary arthrodesis rather than ORIF. **Clinical Pearls for NEET-PG:** * **Mechanism of Injury:** Usually a fall from height (Don Juan Syndrome); always screen for associated **compression fractures of the lumbar spine (L1)**. * **Bohler’s Angle:** Normal is **25°–40°**. A decrease in this angle indicates a depressed calcaneal fracture. * **Angle of Gissane:** Normal is **120°–145°**; it increases in intra-articular fractures. * **Gold Standard Investigation:** CT scan (Coronary and Axial planes). * **Most Common Complication:** Post-traumatic subtalar arthritis (leading to pain on uneven ground).

Q: Which nerve is most at risk in the injury shown in the accompanying radiograph?

Radial nerve. ***Radial nerve*** - The **radial nerve** travels in the **spiral groove** (radial groove) on the posterior aspect of the mid-shaft humerus, making it highly vulnerable in **humeral shaft fractures**. - **Radial nerve palsy** presents with **wrist drop**, inability to extend the wrist and fingers at the metacarpophalangeal joints, and loss of sensation in the **first web space**. *Median nerve* - The **median nerve** runs medially in the arm and is protected from humeral shaft injuries by the **brachial artery** and surrounding soft tissues. - It is more commonly injured in **supracondylar fractures** or **carpal tunnel syndrome**, not mid-shaft humeral fractures. *Posterior interosseous nerve* - This is a **branch of the radial nerve** that passes around the **neck of the radius** and is at risk in **proximal radial fractures**. - It would not be directly affected by a **humeral shaft fracture** as it branches distally from the main radial nerve. *Ulnar nerve* - The **ulnar nerve** travels medially and posteriorly in the **cubital tunnel** at the elbow, making it susceptible to **medial epicondylar** or **olecranon fractures**. - It is anatomically distant from the **humeral shaft** and would not be injured in this fracture pattern.

Q: Which of the following elbow injuries involves the three-point relationship?

Supracondylar fracture of the humerus. ### Explanation The **three-point relationship** of the elbow refers to the clinical landmarking of the **olecranon process**, the **medial epicondyle**, and the **lateral epicondyle**. In a normal flexed elbow (90°), these three points form an isosceles triangle; in full extension, they lie in a straight horizontal line. #### Why Supracondylar Fracture is Correct In a **Supracondylar fracture of the humerus**, the fracture line is proximal to the epicondyles. Since the anatomy of the distal humerus and its relationship with the proximal ulna remains intact, the **three-point relationship is maintained**. This is the most critical clinical feature used to differentiate it from an elbow dislocation. #### Why Other Options are Incorrect * **Posterior Dislocation of the Elbow:** The olecranon is displaced posteriorly relative to the epicondyles. This **disturbs** the three-point relationship, making it the primary clinical differentiator from a supracondylar fracture. * **Fracture of the Medial/Lateral Epicondyle:** These are intra-articular or peri-articular fractures involving the landmarks themselves. Displacement of either epicondyle will **distort** the equilateral/isosceles triangle symmetry. #### NEET-PG High-Yield Pearls * **The "Rule of Three":** In Supracondylar fractures, the relationship is **Normal**. In Elbow Dislocation, the relationship is **Abnormal**. * **Most Common Complication:** The most common immediate complication of supracondylar fractures is **Neuropraxia** (Median nerve, specifically the Anterior Interosseous Nerve/AIN). * **Late Sequel:** The most characteristic late deformity is **Cubitus Varus** (Gunstock deformity). * **Emergency:** Always check the radial pulse to rule out **Volkmann’s Ischemic Contracture (VIC)** due to brachial artery involvement.

Q: What are the complications of fracture of the radius?

All of the above. Fractures of the radius (including distal radius, shaft, or radial head) are common orthopedic injuries associated with several significant complications. The correct answer is **All of the above** because radial fractures can lead to vascular, soft tissue, and surgical complications. ### **Explanation of Options:** * **Volkmann Ischemic Contracture (VIC):** This is a devastating sequela of **Compartment Syndrome**. Fractures of the forearm (radius and ulna) are high-risk areas for increased intracompartmental pressure. If left untreated, ischemia leads to muscle infarction and eventual fibrosis/contracture of the forearm flexors. * **Myositis Ossificans:** This refers to heterotopic ossification within the soft tissues/muscles. It is particularly common in fractures around the elbow (radial head/neck) or when there is significant soft tissue trauma and hematoma formation. * **Infection:** This is a potential complication in any **open fracture** of the radius or following **Open Reduction and Internal Fixation (ORIF)** using plates and screws. ### **Clinical Pearls for NEET-PG:** * **Colles’ Fracture:** The most common complication is **Stiffness** (shoulder-hand syndrome), followed by **Malunion** (Dinner fork deformity). The most common late tendon complication is rupture of the **Extensor Pollicis Longus (EPL)**. * **Galeazzi Fracture:** (Distal radius fracture + DRUJ dislocation) often requires ORIF because it is inherently unstable. * **Monteggia Fracture:** (Proximal ulna fracture + Radial head dislocation) carries a risk of **Posterior Interosseous Nerve (PIN)** injury. * **VIC Sign:** The "Volkmann’s sign" is present when passive extension of the fingers is painful and limited unless the wrist is flexed.

Q: Which of the following positions is classically seen in posterior dislocation of the hip?

Posterior dislocation of the hip. In Orthopaedics, the clinical presentation of hip injuries is a high-yield topic for NEET-PG. The correct answer is **Posterior dislocation of the hip**, which is the most common type of hip dislocation (approx. 90%). ### **1. Why Posterior Dislocation is Correct** The classic clinical deformity in posterior dislocation is **Flexion, Adduction, and Internal Rotation (FADIR)**. This occurs because the femoral head is forced out of the acetabulum posteriorly, causing the limb to shorten and the femur to rotate medially. * **Mechanism:** Usually a "dashboard injury" where a force is applied to the flexed knee (e.g., RTA). ### **2. Why Other Options are Incorrect** * **Fracture of the Neck of Femur:** Presents with **Flexion, Abduction, and External Rotation**. The limb appears shortened, but unlike dislocation, it is rotated laterally. * **Anterior Dislocation of the Hip:** Presents with **Flexion, Abduction, and External Rotation (FABER)**. The femoral head is displaced anteriorly, often making it palpable in the inguinal region. * **Congenital Dislocation of the Hip (DDH):** Typically presents in neonates/infants with limited abduction, limb length discrepancy (Galeazzi sign), and positive Ortolani/Barlow maneuvers, rather than an acute traumatic deformity. ### **3. Clinical Pearls for NEET-PG** * **Mnemonic for Posterior Dislocation:** **"P-I"** (Posterior = Internal Rotation). * **Mnemonic for Anterior Dislocation/Neck Fracture:** **"A-E"** (Anterior/Neck = External Rotation). * **Nerve Injury:** The **Sciatic nerve** (specifically the peroneal component) is most commonly injured in posterior dislocations. * **Emergency:** Hip dislocation is a surgical emergency due to the high risk of **Avascular Necrosis (AVN)** of the femoral head. Reduction should ideally occur within 6 hours.

Question 1

Which of the following requires emergency treatment?

Accepted Answer

Vascular compression injury

Answer

Fracture pelvis

Answer

Fracture humerus

Answer

Car accident

Question 2

Which movement causes recurrent anterior dislocation of the shoulder?

Accepted Answer

Abduction and external rotation

Answer

Flexion and internal rotation

Answer

Abduction and internal rotation

Answer

Extension

Question 3

Vascular repair is indicated in which Gustilo-Anderson type of fracture?

Accepted Answer

IIIc

Answer

I

Answer

II

Answer

IIIb

Question 4

Which of the following fractures is not managed by compression screws?

Accepted Answer

Comminuted fracture of lateral malleolus

Answer

Transverse fracture of medial malleolus

Answer

Oblique fracture of medial malleolus

Answer

Spiral fracture of lateral malleolus

Question 5

What is the typical position of the leg in a fracture of the neck of the femur?

Accepted Answer

External rotation with the patella facing outwards.

Answer

External rotation with the patella facing inwards.

Answer

Internal rotation with the patella facing outwards.

Answer

Internal rotation with the patella facing inwards.

Question 6

Management of calcaneal fractures depends upon which of the following?

Accepted Answer

All of the above

Answer

Type of fracture

Answer

Subtalar joint dislocation

Answer

Duration of presentation

Question 7

Which nerve is most at risk in the injury shown in the accompanying radiograph?

Accepted Answer

Radial nerve

Answer

Median nerve

Answer

Posterior interosseous nerve

Answer

Ulnar nerve

Question 8

Which of the following elbow injuries involves the three-point relationship?

Accepted Answer

Supracondylar fracture of the humerus

Answer

Fracture of the lateral epicondyle

Answer

Fracture of the medial epicondyle

Answer

Posterior dislocation of the elbow

Question 9

What are the complications of fracture of the radius?

Accepted Answer

All of the above

Answer

Volkmann ischemic contracture

Answer

Myositis ossificans

Answer

Infection

Question 10

Which of the following positions is classically seen in posterior dislocation of the hip?

Accepted Answer

Posterior dislocation of the hip

Answer

Fracture of the neck of femur

Answer

Anterior dislocation of the hip

Answer

Congenital dislocation of the hip

Trauma — MCQs

Trauma — MCQs

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