Trauma Practice Questions

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: Cubitus varus deformity in supracondylar fracture of humerus is usually due to which of the following?

Coronal tilt. **Explanation:** **Cubitus Varus (Gunstock Deformity)** is the most common late complication of a supracondylar fracture of the humerus. While this fracture involves several planes of displacement (posterior, medial, and rotational), the development of the varus deformity is specifically attributed to the **Coronal Tilt** (medial tilt) of the distal fragment. 1. **Why Coronal Tilt is Correct:** In a supracondylar fracture, if the distal fragment tilts medially in the coronal plane, it alters the alignment of the humeral axis relative to the forearm. This tilt leads to a decrease in the carrying angle, resulting in a permanent varus deformity. Unlike rotational or sagittal displacements, which may undergo some remodeling in children, coronal tilt does not remodel and must be corrected during initial reduction. 2. **Why Other Options are Incorrect:** * **Posterior Displacement/Angulation:** These occur in the sagittal plane. They primarily lead to a loss of flexion or extension range of motion but do not influence the lateral/medial (varus/valgus) alignment of the elbow. * **Malunion vs. Growth Arrest:** It is important to note that Cubitus Varus is almost always due to **malunion** (poor reduction of the coronal tilt) rather than an injury to the growth plate (epiphyseal arrest), as the distal humeral epiphysis contributes only 20% to longitudinal growth. **Clinical Pearls for NEET-PG:** * **Most common complication:** Cubitus Varus (Gunstock Deformity). * **Most common nerve injured:** Median nerve (specifically the Anterior Interosseous Nerve/AIN); however, in extension-type fractures with posterolateral displacement, the Radial nerve is at risk. * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to brachial artery injury or compartment syndrome. * **Treatment of choice for Cubitus Varus:** French Osteotomy (Modified Step-cut Osteotomy).

Q: Dinner fork deformity is seen in which of the following conditions?

Colles' fracture. **Explanation:** **Colles' Fracture** is a distal radius fracture occurring within 2.5 cm of the wrist joint, typically resulting from a fall on an outstretched hand (FOUSH). The characteristic **"Dinner Fork Deformity"** (also known as the silver fork deformity) is caused by the **posterior (dorsal) displacement** and dorsal tilt of the distal fragment, which creates a prominent hump on the back of the wrist resembling the curve of a fork. **Analysis of Incorrect Options:** * **Smith’s Fracture:** Often called a "Reverse Colles," this involves **volar (palmar) displacement** of the distal fragment. This results in a **"Garden Spade Deformity,"** not a dinner fork appearance. * **Supracondylar Fracture of Humerus:** This is common in children and involves the distal humerus. While it can cause significant swelling and deformity (like the "S-shaped" deformity), it does not affect the wrist morphology associated with the dinner fork sign. * **Volar Barton Fracture:** This is an intra-articular fracture-dislocation of the radiocarpal joint. Like Smith’s, the displacement is volar, leading to a deformity similar to a garden spade. **Clinical Pearls for NEET-PG:** * **Displacements in Colles' (6):** Dorsal displacement, Dorsal tilt, Lateral displacement, Lateral tilt, Impaction, and Supination. * **Eponym Check:** Colles = Dorsal displacement; Smith = Volar displacement. * **Common Complication:** The most common late complication of Colles' fracture is **Malunion**, while the most common tendon involvement is rupture of the **Extensor Pollicis Longus (EPL)**. * **Treatment:** Most are managed by closed reduction and a "Colles' cast" (below-elbow cast with the wrist in slight flexion and ulnar deviation).

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).

Q: The provided image displays a fracture. Based on the X-ray, identify the type of fracture shown.

Intertrochanteric fracture. ***Intertrochanteric fracture*** - The fracture line is located in the region between the **greater** and **lesser trochanters** of the femur, which is the defining characteristic of this fracture type. - These are **extracapsular** fractures, common in the elderly, and often present with a **shortened** and **externally rotated** limb due to the unopposed pull of the iliopsoas on the lesser trochanter. *Subtrochanteric Fracture* - A subtrochanteric fracture occurs in the proximal femoral shaft, beginning at or up to 5 cm distal to the **lesser trochanter**. The fracture shown is located superior to this region. - These fractures are often associated with high-energy trauma in younger individuals or can be pathological fractures related to long-term **bisphosphonate** use. *Femoral Neck Fracture* - This is an **intracapsular** fracture occurring in the area between the femoral head and the greater trochanter. The fracture in the image is located distal to the femoral neck. - Femoral neck fractures carry a high risk of **avascular necrosis (AVN)** of the femoral head due to disruption of the retinacular arteries, a complication less common in intertrochanteric fractures. *Pubic Rami Fracture* - This fracture involves the **pelvic girdle**, specifically the superior or inferior pubic ramus. The radiograph clearly shows the fracture is located in the proximal **femur**. - Patients with pubic rami fractures typically present with groin pain and inability to bear weight, but the femur itself is not fractured.

Q: An elderly woman involved in a road traffic accident presents with difficulty in breathing and altered mental status. D-Dimer is elevated. X-ray shows a long bone fracture. What is the most likely diagnosis?

Fat embolism. ***Fat embolism*** - The patient's presentation of **respiratory distress** (difficulty breathing) and **altered mental status** following a significant long bone fracture (femur, as seen on X-ray) is classic for **Fat Embolism Syndrome (FES)**. - This syndrome occurs when fat globules from the fractured bone marrow enter the bloodstream, leading to microvascular occlusion and inflammation in the lungs and brain. An elevated **D-Dimer** is also a common, albeit non-specific, finding. *Gas gangrene* - This is a rapidly progressing soft tissue infection caused by **Clostridium perfringens**, characterized by severe pain, swelling, **crepitus** (gas in tissues), and foul-smelling discharge at the wound site, which are not described here. - The primary symptoms in this case are systemic (pulmonary and neurological), not localized to the fracture site with signs of a necrotizing infection. *Infection* - While infection is a risk with fractures, the acute onset of severe respiratory and neurological symptoms is not a typical presentation for a post-traumatic wound infection or **osteomyelitis**. - Sepsis could cause these symptoms, but FES is a more direct and common complication specifically linked to the mechanics of a long bone fracture in the immediate post-trauma period. *Pulmonary embolism* - A pulmonary **thromboembolism** (from a blood clot) is a valid concern after trauma and can cause shortness of breath and an elevated D-Dimer. - However, the prominent **altered mental status** is less characteristic of a typical pulmonary embolism and points more strongly towards the cerebral effects of fat microemboli in FES.

Q: A young adult patient presents with a fracture of the neck of the femur. What is the most appropriate management?

Internal fixation. ***Internal fixation*** - This is the treatment of choice in young adults to **preserve the native femoral head**, which is crucial for long-term function and avoiding prosthetic complications. - It involves stabilizing the fracture with hardware like **cannulated screws** or a **sliding hip screw**, promoting bone healing while maintaining the patient's own joint. *External fixation* - Primarily used for **temporary stabilization** in polytrauma patients or for highly comminuted or open fractures, not as a definitive treatment for a simple femoral neck fracture. - It provides less rigid fixation compared to internal methods and carries a significant risk of **pin-site infections**. *Hemiarthroplasty* - This procedure, which replaces only the femoral head, is typically reserved for **elderly patients** with displaced fractures and lower functional demands. - In a young, active patient, it can lead to **acetabular erosion** and pain, making preservation of the native joint the preferred approach. *Total hip replacement* - Reserved for patients with pre-existing severe **osteoarthritis** or for some active elderly patients, not for an acute fracture in a young individual. - Due to the **limited lifespan of the prosthesis**, performing a total hip replacement in a young patient would likely necessitate multiple complex **revision surgeries** in the future.

Q: Identify the instrument shown in the image:

Bohler braun splint. ***Bohler braun splint*** - The instrument shown is a **Bohler-Braun splint** (or frame), which is used to apply skeletal traction for fractures of the lower limb, particularly the **femur** and **tibia**. - Its design allows the limb to be elevated with the knee in a flexed position, which helps relax the muscles and facilitates the reduction of the fracture through a system of pulleys and weights. *Thomas splint* - A **Thomas splint** is primarily used for first-aid immobilization of **femoral shaft fractures**. It consists of a padded ring that fits into the groin and two long metal rods. - It provides fixed traction but does not have the elaborate pulley and frame system for bed-based skeletal traction seen in the image. *Volkmann splint* - A **Volkmann splint** is a type of gutter splint used for injuries to the **forearm, wrist, and hand**, not the lower leg. - It is specifically designed to prevent **Volkmann's ischemic contracture**, a deformity resulting from compartment syndrome in the forearm. *Cramer wire* - A **Cramer wire splint** is a flexible, ladder-like splint made of wire that can be bent and molded to fit a limb for temporary immobilization. - It is used for emergency splinting and is not strong enough to provide the definitive skeletal traction required for major long bone fractures.

Question 1

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 2

Cubitus varus deformity in supracondylar fracture of humerus is usually due to which of the following?

Accepted Answer

Coronal tilt

Answer

Posterior displacement

Answer

Posterior angulation

Answer

All of the above

Question 3

Dinner fork deformity is seen in which of the following conditions?

Accepted Answer

Colles' fracture

Answer

Supracondylar fracture of humerus

Answer

Smith's fracture

Answer

Volar Barton fracture

Question 4

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 5

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 6

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

Question 7

The provided image displays a fracture. Based on the X-ray, identify the type of fracture shown.

Accepted Answer

Intertrochanteric fracture

Answer

Pubic rami fracture

Answer

Femoral neck fracture

Answer

Subtrochanteric fracture

Question 8

An elderly woman involved in a road traffic accident presents with difficulty in breathing and altered mental status. D-Dimer is elevated. X-ray shows a long bone fracture. What is the most likely diagnosis?

Accepted Answer

Fat embolism

Answer

Pulmonary embolism

Answer

Infection

Answer

Gas gangrene

Question 9

A young adult patient presents with a fracture of the neck of the femur. What is the most appropriate management?

Accepted Answer

Internal fixation

Answer

Total hip replacement

Answer

External fixation

Answer

Hemiarthroplasty

Question 10

Identify the instrument shown in the image:

Accepted Answer

Bohler braun splint

Answer

Thomas splint

Answer

Volkmann splint

Answer

Cramer wire

Trauma — MCQs

Trauma — MCQs

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