Extremity Trauma — MCQs
A patient with a shoulder dislocation is at risk of damage to which nerve?
Which of the following is NOT a complication of a neck femur fracture?
In an accident case, after the arrival of medical team, all should be done in early management except;
A patient with metastatic breast cancer presents with pathological fracture of femur. What is the best fixation method?
Which of the following are true/false about clinical features of Fat embolism syndrome? 1. Tachypnea 2. Systemic hypoxia may occur 3. Fat globules in urine are diagnostic 4. Manifests after several days of trauma 5. Petechiae in anterior chest wall
What is the best procedure to control external hemorrhage in an event of accidental injury?
Which of the following is NOT a primary goal of open reduction and internal fixation (ORIF)?
True about chest trauma:
Clinical feature of fat embolism includes all except:
A patient with a left hypochondrium contusion presents with systolic blood pressure of 70 mm Hg and pulse rate of 110 bpm. What is the best step in management?
Extremity Trauma Indian Medical PG Practice Questions and MCQs
Question 1: A patient with a shoulder dislocation is at risk of damage to which nerve?
- A. Radial nerve
- B. Musculocutaneous nerve
- C. Median nerve
- D. Axillary nerve (Correct Answer)
Explanation: ***Axillary nerve*** - The **axillary nerve** (C5, C6) is particularly vulnerable to injury during **shoulder dislocation** due to its close anatomical proximity to the surgical neck of the humerus. - Damage can result in weakness of the **deltoid muscle** (leading to impaired abduction) and loss of sensation over the lateral shoulder. *Radial nerve* - The **radial nerve** (C5-T1) primarily supplies extensors of the arm and forearm and is more commonly injured in **mid-shaft humeral fractures** or compression in the axilla. - While shoulder dislocation can cause traction injuries, direct radial nerve damage is less typical compared to the axillary nerve. *Musculocutaneous nerve* - The **musculocutaneous nerve** (C5-C7) innervates the biceps and brachialis muscles, responsible for forearm flexion, and provides sensation to the lateral forearm. - It is typically well-protected and rarely injured in an isolated shoulder dislocation; injuries are more common with direct trauma to the anterior arm or humerus. *Median nerve* - The **median nerve** (C5-T1) is responsible for many wrist and finger flexors and sensation in the thumb, index, middle, and radial half of the ring finger. - Injury to the median nerve is uncommon in shoulder dislocations unless there is significant brachial plexus trauma or a severe, complex fracture involving the anterior aspect of the shoulder joint.
Question 2: Which of the following is NOT a complication of a neck femur fracture?
- A. Nonunion
- B. Osteoarthritis
- C. AVN
- D. Malunion (Correct Answer)
Explanation: ***Malunion*** - **Malunion** is a rare complication of a femoral neck fracture because the fracture is inherently unstable and tends to result in **nonunion** rather than healing in an abnormal position. - The **vascular compromise** and mechanical forces often lead to a failure to heal whatsoever, or to avascular necrosis. *Nonunion* - **Nonunion** is a common and severe complication of femoral neck fractures due to the **precarious blood supply** to the femoral head and the high mechanical stress across the fracture site. - The lack of adequate blood flow and movement at the fracture site hinders the formation of a **bony callus**, leading to failure of the bone to heal. *AVN* - **Avascular necrosis (AVN)** of the femoral head is a major complication resulting from the disruption of the arterial blood supply to the femoral head during the fracture. - The **retinacular arteries**, which supply most of the femoral head, are often damaged, leading to the death of bone cells and subsequent collapse of the femoral head. *Osteoarthritis* - **Post-traumatic osteoarthritis** can develop as a long-term complication, even if the fracture heals. - The initial injury and any subsequent irregularities in the joint surface or alignment can lead to accelerated **cartilage degeneration**.
Question 3: In an accident case, after the arrival of medical team, all should be done in early management except;
- A. Glasgow coma scale
- B. Check BP (Correct Answer)
- C. Stabilization of cervical vertebrae
- D. Check Respiration
Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.
Question 4: A patient with metastatic breast cancer presents with pathological fracture of femur. What is the best fixation method?
- A. Long Intramedullary Nail (Correct Answer)
- B. External Fixator
- C. Dynamic Hip Screw
- D. Plate and Screws
Explanation: ***Long Intramedullary Nail*** - Provides **strong internal fixation** that can bear weight immediately, crucial for patients with a limited life expectancy due to metastatic disease. - Stabilizes the entire bone, preventing further **pathological fractures** in the diaphysis and allowing earlier mobilization and pain relief. *External Fixator* - Primarily used for **temporary stabilization** in severe open fractures or polytrauma, and not for definitive fixation of pathological fractures. - High risk of **pin tract infections** and patient discomfort, making it unsuitable for long-term management in cancer patients. *Dynamic Hip Screw* - Primarily used for **intertrochanteric hip fractures**, which are typically proximal femur fractures. - Less effective for **diaphyseal fractures** or for stabilizing bone weakened by metastatic disease along its entire length. *Plate and Screws* - While effective for some fractures, plates may not provide sufficient **load-bearing capacity** for extensively lytic or weakened bone in metastatic disease without extensive bone grafting. - Risk of **stress shielding** and subsequent re-fracture proximal or distal to the plate, especially when the intramedullary canal is compromised by tumor.
Question 5: Which of the following are true/false about clinical features of Fat embolism syndrome? 1. Tachypnea 2. Systemic hypoxia may occur 3. Fat globules in urine are diagnostic 4. Manifests after several days of trauma 5. Petechiae in anterior chest wall
- A. 1, 3, 4, 5 true & 2 false
- B. 1, 2, 3, 5 true & 4 false
- C. All are true (Correct Answer)
- D. 2, 4 false & 1, 3, 5 true
Explanation: ***All are true*** - **Tachypnea** (1), **systemic hypoxia** (2) [2], **fat globules in urine** (3) [2], **petechiae in the anterior chest wall** (5) [1], and manifestation **after several days of trauma** (4) [1] are all recognized clinical features or associated findings of **Fat Embolism Syndrome (FES)**. - The classic triad of FES includes **respiratory insufficiency**, **neurological symptoms**, and **petechial rash**, which frequently emerge 24-72 hours post-injury [1]. *1, 3, 4, 5 true & 2 false* - This option incorrectly states that systemic hypoxia is false. **Systemic hypoxia** is a common and serious manifestation of **Fat Embolism Syndrome**, often resulting from pulmonary microvascular obstruction [2]. - While other points are correct, the misidentification of hypoxia as false makes this option incorrect. *1, 2, 3, 5 true & 4 false* - This option incorrectly states that FES does not manifest after several days of trauma. **Fat Embolism Syndrome** typically has a delayed onset, occurring **12-72 hours (several days)** after the initial injury [1], [2]. - The delayed presentation is a key diagnostic characteristic distinguishing it from immediate post-traumatic complications. *2, 4 false & 1, 3, 5 true* - This option is extensively incorrect as it falsely identifies both **systemic hypoxia** and the **delayed manifestation** as false. - **Systemic hypoxia** is a hallmark of pulmonary involvement in FES [2], and **delayed onset** is a crucial diagnostic criterion.
Question 6: What is the best procedure to control external hemorrhage in an event of accidental injury?
- A. Proximal tourniquet
- B. Artery forceps
- C. Elevation
- D. Direct pressure (Correct Answer)
Explanation: ***Direct pressure*** - **Direct pressure** is the most immediate and effective first-aid measure for controlling external bleeding by compressing the injured vessel. - Applying firm, direct pressure with a clean cloth or hand helps to promote **hemostasis** and allow for clot formation at the site of injury. *Proximal tourniquet* - A **tourniquet** is a last resort for severe, life-threatening hemorrhage that cannot be controlled by direct pressure, as it can cause **tissue damage** and ischemia. - It should be applied proximal to the injury, but its prolonged use carries risks of **nerve damage** and limb loss. *Artery forceps* - **Artery forceps** are surgical instruments used to clamp individual blood vessels during a surgical procedure, not for initial control of external hemorrhage in an emergency. - Their use requires expertise and carries risks of further injury if not applied correctly by trained medical personnel. *Elevation* - **Elevation** of the injured limb above the level of the heart can help reduce blood flow and venous pressure, which may aid in controlling minor bleeding. - However, elevation alone is usually insufficient for significant hemorrhage and should be used in conjunction with **direct pressure**.
Question 7: Which of the following is NOT a primary goal of open reduction and internal fixation (ORIF)?
- A. Consolidation (final healing phase) (Correct Answer)
- B. Stability (maintaining bone position)
- C. Better function (restoring mobility)
- D. Better alignment (correct positioning)
Explanation: ***Consolidation (final healing phase)*** - While ORIF aims to facilitate healing, **consolidation** is the *result* of successful treatment, not a direct primary goal achieved *during* the surgical procedure itself. - The surgical goals focus on creating the optimal environment for consolidation to occur naturally after the operation. *Stability (maintaining bone position)* - Achieving and maintaining **stability** of the fractured bone fragments is a fundamental goal of ORIF. - This prevents micromotion at the fracture site, which is crucial for reducing pain and promoting proper healing. *Better function (restoring mobility)* - Restoring **normal or near-normal function and mobility** to the injured limb or body part is a key objective of ORIF. - By stabilizing the fracture and allowing early mobilization, the procedure helps minimize joint stiffness and muscle atrophy. *Better alignment (correct positioning)* - **Accurate anatomical reduction and alignment** of the fractured bone fragments are paramount in ORIF. - Proper alignment is essential for restoring biomechanical integrity and ensuring optimal long-term functional outcomes.
Question 8: True about chest trauma:
- A. All of the options
- B. ECG done in all cases associated with sternal fracture (Correct Answer)
- C. Urgent surgery needed in all cases
- D. Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice
Explanation: ***ECG done in all cases associated with sternal fracture*** - A **sternal fracture** is a significant injury often caused by high-impact trauma, which can lead to **myocardial contusion** or other cardiac injuries. - An **ECG** is **mandatory** in all cases of sternal fracture for detecting potential cardiac involvement, such as **arrhythmias** or **ischemic changes**, indicating underlying myocardial damage. - This is a clear, unequivocal true statement about chest trauma management and the **best answer**. *All of the options* - This option is incorrect because not all statements provided are true or represent best practices in chest trauma management. - Specifically, "urgent surgery needed in all cases" is clearly false, making this option incorrect. *Urgent surgery needed in all cases* - This statement is **false**. Approximately **80-85% of chest trauma** cases are managed **non-operatively** with supportive care. - Urgent surgery is required only in specific situations: **massive hemothorax**, **cardiac tamponade**, **major airway injury**, **esophageal perforation**, or ongoing bleeding. - Simple rib fractures, minor pneumothorax, and pulmonary contusions rarely require surgery. *Under water seal drainage if associated with pneumothorax. X-ray chest investigation of choice* - While both components of this statement are individually true, the option combines two separate management concepts without clear connection. - **Underwater seal drainage (chest tube)** is indeed appropriate for significant pneumothorax, and **chest X-ray** is the initial investigation of choice for chest trauma. - However, this option is less precise than Option B, which states an absolute management protocol, making Option B the superior choice.
Question 9: Clinical feature of fat embolism includes all except:
- A. Tachypnoea and systemic hypoxia are common
- B. All of the options
- C. Petechiae are seen in the anterior chest wall
- D. Fat globules in urine are diagnostic, and it manifests after several days of trauma (Correct Answer)
Explanation: ***Fat globules in urine are diagnostic, and it manifests after several days of trauma*** - While fat globules can be found in urine in **fat embolism syndrome (FES)**, it is **not diagnostic** on its own and can be seen in other conditions. - The onset of FES symptoms, including urinary findings, typically occurs within **1-3 days** (24-72 hours) of trauma, not "several days." *Tachypnoea and systemic hypoxia are common* - **Respiratory distress**, marked by **tachypnoea** (rapid breathing), is a cardinal symptom of FES due to fat emboli lodging in pulmonary capillaries. - This leads to impaired gas exchange and **systemic hypoxia**, which is a life-threatening complication. *Petechiae are seen in the anterior chest wall* - **Petechial rash**, particularly over the anterior chest, neck, axillae, and conjunctiva, is a classic and highly characteristic dermatological sign of FES. - These petechiae are caused by the **occlusion of capillaries by fat emboli** and subsequent extravasation of red blood cells. *All of the options* - This option is incorrect because the statement regarding **fat globules in urine** being diagnostic and the timeline of manifestation is incorrect. - A core task in FES diagnosis is recognizing the typical signs while understanding the limitations of certain diagnostic markers.
Question 10: A patient with a left hypochondrium contusion presents with systolic blood pressure of 70 mm Hg and pulse rate of 110 bpm. What is the best step in management?
- A. Conservative management with observation
- B. Chest tube insertion
- C. Antibiotic therapy
- D. Emergency surgical exploration (Correct Answer)
Explanation: ***Emergency surgical exploration*** - The patient's **hypotension** (BP 70 mmHg) and **tachycardia** (HR 110 bpm) indicate **hemodynamic instability**, suggesting active bleeding, likely from a splenic or liver injury in the context of a left hypochondrium contusion. - While initial resuscitation with IV fluids is started simultaneously, this degree of shock (class III-IV hemorrhage) with a high-risk mechanism typically requires **emergency surgical exploration** to identify and control the source of bleeding. - According to **ATLS protocols**, patients who are non-responders or transient responders to initial resuscitation with ongoing hemodynamic instability are candidates for immediate operative intervention. *Conservative management with observation* - This approach is appropriate only for **hemodynamically stable** patients with solid organ injuries, often with minor extravasation or hematomas that are not actively bleeding. - The patient's severe hypotension and tachycardia preclude conservative management, as it would risk further decompensation and mortality due to ongoing blood loss. *Chest tube insertion* - This procedure is indicated for managing conditions like **pneumothorax** or **hemothorax**, which might present with respiratory distress, decreased breath sounds, and potentially hemodynamic compromise if severe. - While a chest injury could coexist, the primary concern here is profound shock following an abdominal contusion, suggesting intra-abdominal hemorrhage rather than a thoracic injury as the initial priority. *Antibiotic therapy* - **Antibiotic therapy** is important for preventing or treating infections, particularly in cases of bowel perforation or open wounds, but it does not address acute hemodynamic instability from hemorrhage. - Administering antibiotics before surgically addressing the source of bleeding in a hypotensive patient would be a misprioritization and would not stabilize their condition.
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