Trauma Practice Questions

Q: Ruedi and Allgower classification is used for which of the following fractures?

Distal tibial fracture. The **Ruedi-Allgower classification** is the standard system used to categorize **Pilon fractures**, which are intra-articular fractures of the **distal tibia** caused by high-energy axial loading (vertical compression). ### Why the Correct Answer is Right: The classification focuses on the degree of comminution and displacement of the distal tibial articular surface. It is divided into three types: * **Type I:** Non-displaced articular fracture. * **Type II:** Displaced articular fracture but without significant comminution. * **Type III:** Highly comminuted and displaced articular fracture (the most severe). ### Why Other Options are Wrong: * **Radius fracture:** Distal radius fractures are commonly classified using the **Frykman** or **Fernandez** classifications. * **Fibular fracture:** While often associated with Pilon fractures, isolated fibular fractures are typically classified using the **Danis-Weber** system (based on the level of the fracture relative to the syndesmosis). * **Proximal tibial fracture:** These are known as Tibial Plateau fractures and are classified using the **Schatzker** classification. ### High-Yield Clinical Pearls for NEET-PG: * **Mechanism of Injury:** Pilon fractures usually result from a fall from height or motor vehicle accidents where the talus is driven into the tibial plafond like a "pestle" into a "mortar." * **Associated Injuries:** Always look for "Don Juan Syndrome" (calcaneal fractures and lumbar spine compression fractures) in axial loading injuries. * **Management Tip:** Soft tissue management is critical; these are often managed with initial external fixation followed by delayed internal fixation (ORIF) once the "wrinkle sign" appears.

Q: Avascular necrosis is not uncommon. Select the type of fracture or dislocation with which it is most likely to be associated.

Navicular (scaphoid) fracture. **Explanation:** The correct answer is **A. Navicular (scaphoid) fracture**. **Why Scaphoid Fracture?** Avascular Necrosis (AVN) occurs when the blood supply to a bone is disrupted, leading to bone death. The scaphoid bone (historically called the navicular bone of the hand) has a unique **retrograde blood supply**. The nutrient arteries enter the bone through the distal pole and flow proximally. Therefore, a fracture across the waist or proximal pole of the scaphoid often severs this blood supply, leaving the proximal fragment ischemic and prone to AVN (Preiser’s disease). **Analysis of Incorrect Options:** * **B. Monteggia’s deformity:** This involves a fracture of the proximal third of the ulna with dislocation of the radial head. While it can lead to nerve injuries (PIN) or malunion, it is not typically associated with AVN. * **C. Greenstick fracture:** This is an incomplete fracture seen in children where the bone bends and breaks only on one side. Because the periosteum remains largely intact and pediatric bone is highly vascular, AVN is not a risk. * **D. Spiral fracture:** This is a descriptive term for a fracture pattern caused by a twisting force. It does not inherently imply a risk of AVN unless it occurs in a specific "at-risk" anatomical site. **High-Yield Clinical Pearls for NEET-PG:** * **Common sites for AVN post-trauma:** Head of femur (most common), Scaphoid (proximal pole), Talus (neck), and Humeral head. * **Scaphoid Fracture:** Tenderness in the **Anatomical Snuffbox** is the classic clinical sign. * **Radiology:** AVN appears as **increased radiodensity** (sclerosis) on X-ray because the dead bone does not undergo the resorption seen in surrounding vascularized bone. * **Management:** Undisplaced scaphoid fractures are treated with a Scaphoid cast; displaced fractures require ORIF with a Herbert screw.

Q: A patient involved in a road traffic accident is found lying in the right lateral position with bruises on the face, elbow, and lateral side of the knee. Which nerve injury has the maximum chance of occurring in this position of the victim?

Common peroneal nerve. **Explanation:** The correct answer is **Common Peroneal Nerve (CPN)**. The common peroneal nerve is the most frequently injured nerve in the lower limb due to its superficial and vulnerable anatomical course. It winds around the **neck of the fibula**, where it is covered only by skin and fascia, making it highly susceptible to compression against the underlying bone. In this scenario, the patient is lying in a **right lateral position**. This position causes the lateral aspect of the right knee (specifically the fibular neck) to be compressed against the hard ground. The presence of bruises on the lateral side of the knee further confirms a direct impact or prolonged pressure in this specific anatomical region, leading to a "compression neuropathy" of the CPN. **Analysis of Incorrect Options:** * **Trigeminal Nerve (A):** While facial bruises are present, the trigeminal nerve is deep-seated and protected by the skull and facial bones; it is rarely injured by simple lateral positioning. * **Ulnar Nerve (B):** Although there are bruises on the elbow, the ulnar nerve is most vulnerable at the medial epicondyle (cubital tunnel). In a lateral position, the lateral elbow is usually the point of contact, not the medial side. * **Tibial Nerve (D):** This nerve is deeply embedded in the popliteal fossa and posterior compartment of the leg, protected by thick muscle and fat, making it much less likely to be injured by external compression compared to the CPN. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** CPN injury leads to **Foot Drop** (loss of dorsiflexion) and loss of sensation over the first dorsal web space (deep peroneal) and lateral leg/dorsum of the foot (superficial peroneal). * **Common Causes:** Tight plaster casts, cross-legged sitting, or lateral decubitus positioning during surgery/unconsciousness. * **Mnemonic:** **PED** (Peroneal Everts and Dorsiflexes; if injured, you get **D**rop foot).

Q: All of the following are types of avascular non-union except:

Elephant foot. ### Explanation The classification of non-union is primarily based on the **Weber and Cech classification**, which divides non-unions into two main categories: **Hypervascular (Hypertrophic)** and **Avascular (Atrophic)**. **1. Why "Elephant Foot" is the Correct Answer:** An **Elephant foot** non-union is a classic example of a **Hypervascular (Hypertrophic)** non-union. It occurs when there is adequate blood supply but **inadequate stability** at the fracture site. The body attempts to heal by forming exuberant callus (resembling an elephant's foot on X-ray) to bridge the gap, but fails due to excessive motion. Since it is hypervascular, it is *not* an avascular non-union. **2. Analysis of Incorrect Options (Avascular Types):** Avascular non-unions occur due to poor blood supply and lack of biological activity. * **Comminuted (Necrotic):** Occurs when intermediate fragments lose their blood supply (sequestrum), preventing bridge formation. * **Torsion Wedge:** Results from a butterfly fragment that has a deficient blood supply, leading to healing on only one side. * **Atrophic:** The end-stage of avascular non-union where there is no callus formation; bone ends appear rounded or osteoporotic due to complete biological inactivity. **Clinical Pearls for NEET-PG:** * **Hypertrophic Non-union:** Rich blood supply. Treatment focuses on **Stability** (e.g., rigid internal fixation/nailing). * **Atrophic Non-union:** Poor blood supply. Treatment requires **Biology** (e.g., decortication and bone grafting) plus stability. * **Horse's Foot:** Another type of hypertrophic non-union, but with less callus than the elephant foot type. * **Most common site for non-union:** Scaphoid, Talus, and Neck of Femur (due to retrograde/precarious blood supply).

Q: What is the best treatment for a fracture of the neck of the femur in a 65-year-old female patient?

Hemireplacement arthroplasty. **Explanation:** Fractures of the neck of the femur are **intracapsular**, which disrupts the retrograde blood supply (primarily from the medial circumflex femoral artery). This leads to a high risk of **Avascular Necrosis (AVN)** and non-union. **Why Hemireplacement Arthroplasty (HRA) is correct:** In elderly patients (typically >60-65 years), the primary goal is early mobilization to prevent complications like pneumonia, bedsores, and DVT. Since the regenerative capacity of the bone is low and the risk of AVN is high, internal fixation often fails. HRA (using a Thompson or Austin Moore prosthesis) or Total Hip Arthroplasty (THA) allows the patient to weight-bear immediately after surgery. **Analysis of Incorrect Options:** * **A. Pop cast:** Femur neck fractures are unstable and cannot be managed by immobilization. Prolonged bed rest in the elderly is associated with high mortality. * **B. Gleotomy:** This is likely a distractor or a misspelling of "Osteotomy" (e.g., McMurray’s). Osteotomies are used to realign the fracture to promote healing in younger patients, not as a primary treatment in the elderly. * **C. Bone grafting and compression:** While used for non-union or in younger patients (e.g., using a DHS or Cannulated Cancellous screws), it requires a long period of non-weight bearing, which is poorly tolerated by 65-year-olds. **High-Yield Clinical Pearls for NEET-PG:** 1. **Garden’s Classification:** Used to grade the severity of displacement; Stages III and IV usually require replacement in the elderly. 2. **Young vs. Old:** In patients ** 60 years**, the priority is "Life for the Patient" (Arthroplasty). 3. **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (Type III) are more unstable due to shear forces.

Q: Which of the following is/are benefits of immobilization of a fracture?

All of the above. **Explanation:** Immobilization is the cornerstone of initial fracture management. The correct answer is **D (All of the above)** because stabilizing the bone fragments addresses multiple physiological and mechanical complications associated with trauma. 1. **Reduction in Pain (Option A):** Pain in fractures is primarily caused by the grating of jagged bone ends against each other and the irritation of the sensitive periosteum. Immobilization prevents this abnormal movement, significantly reducing pain and muscle spasms. 2. **Reduced chances of Fat Embolism (Option B):** Movement at the fracture site increases intra-medullary pressure and causes mechanical agitation of the bone marrow. This can force fat globules into the ruptured venous sinusoids, leading to Fat Embolism Syndrome (FES). Splinting "quiets" the marrow, reducing this risk. 3. **Reduced chances of Neurovascular Injury (Option C):** Sharp, displaced bone fragments act like internal knives. Immobilization prevents these fragments from shifting and causing secondary injuries to adjacent nerves (e.g., radial nerve in humeral shafts) or vessels (e.g., popliteal artery in supracondylar femur fractures). **Clinical Pearls for NEET-PG:** * **The "Golden Rule":** Always splint a fracture "where they lie" before transporting the patient to prevent further soft tissue damage. * **Fat Embolism:** Most common in long bone fractures (Femur > Tibia). Classic triad: Dyspnea, Confusion, and Petechial rashes (vest distribution). * **Splinting Principle:** A splint must immobilize the joint above and the joint below the fracture site to be effective. * **Emergency Management:** For open fractures, immobilization also helps in tamponading local hemorrhage and preventing the spread of contamination deeper into the tissues.

Q: Seddon grading is used for what purpose?

Classification of nerve injuries. **Explanation:** **Seddon’s Classification** is the fundamental system used to grade **nerve injuries** based on the degree of damage to the nerve fiber and the connective tissue sheaths. It helps clinicians predict the prognosis and the necessity of surgical intervention. The classification consists of three stages: 1. **Neuropraxia:** The mildest form; a temporary physiological conduction block without anatomical disruption. Recovery is complete and rapid (weeks). 2. **Axonotmesis:** Disruption of the axon but the endoneurial sheath remains intact. Wallerian degeneration occurs distally, but recovery is possible through axonal regeneration (approx. 1mm/day). 3. **Neurotmesis:** Complete transection of the nerve and its connective tissue. Spontaneous recovery is impossible; surgical repair is required. **Analysis of Incorrect Options:** * **B. Grading of open fractures:** These are classified using the **Gustilo-Anderson classification**. * **C. Classification of Potts paraplegia:** This is typically described by the **Tuli’s classification** or categorized into Early-onset and Late-onset paraplegia. * **D. Grading of malignant bone tumors:** The most common system used is the **Enneking (MSTS) classification**. **High-Yield Clinical Pearls for NEET-PG:** * **Sunderland’s Classification:** An expansion of Seddon’s system into 5 degrees (1st degree = Neuropraxia; 5th degree = Neurotmesis). * **Wallerian Degeneration:** Begins 24–36 hours after injury in Axonotmesis and Neurotmesis. * **Tinel’s Sign:** A tingling sensation on percussion over a regenerating nerve; its distal progression is a positive prognostic sign in Axonotmesis.

Q: Avascular necrosis is a known complication of which of the following fractures?

Fracture of talus. **Explanation:** **Avascular Necrosis (AVN)** occurs when the blood supply to a bone is disrupted, leading to bone cell death. This is common in bones that are largely covered by articular cartilage and have a "retrograde" or vulnerable blood supply. **Why Talus is the Correct Answer:** The talus is a high-risk site for AVN because approximately 60% of its surface is covered by articular cartilage, leaving limited areas for nutrient vessels to enter. The primary blood supply comes from the **artery of the tarsal canal** (branch of the posterior tibial artery). Fractures of the **talar neck** frequently disrupt this blood supply. The risk of AVN is classified by the **Hawkins Classification**, where Type III and IV fractures have an AVN incidence of nearly 75–100%. **Why Other Options are Incorrect:** * **Medial condyle of femur:** While the femoral *head* is a classic site for AVN, the femoral *condyles* have a robust, multi-directional blood supply from the genicular anastomosis, making post-traumatic AVN rare. * **Olecranon fracture:** The olecranon has a rich periosteal blood supply and is not a "watershed" area; complications are usually related to non-union or hardware irritation. * **Radial head fracture:** Although it is intra-articular, the radial head has a relatively stable blood supply. While AVN can occur rarely, it is not a "classic" or high-yield complication compared to the talus. **NEET-PG High-Yield Pearls:** * **Common sites for AVN:** Femoral head (most common), Scaphoid (proximal pole), Talus (neck), and Humeral head. * **Hawkins Sign:** A subchondral radiolucency seen on X-ray 6–8 weeks post-fracture; its presence indicates intact vascularity (a good prognostic sign). * **Management:** Displaced talar neck fractures are surgical emergencies requiring urgent anatomical reduction to protect the remaining blood supply.

Q: An 18-year-old male presents with a history of trauma. An X-ray is shown below. What is the diagnosis?

Monteggia fracture. ***Monteggia fracture*** - Characterized by a **proximal ulna fracture** with **radial head dislocation**, which fits the typical pattern seen in trauma cases involving the forearm. - The **radiocapitellar line** on X-ray fails to pass through the center of the capitellum, confirming radial head dislocation - a pathognomonic sign. *Supra-Condylar Fracture* - Occurs in the **distal humerus** above the condyles, most commonly in children aged 5-8 years. - Would show **posterior angulation** of the distal fragment and potential **anterior humeral line** disruption on lateral X-ray. *Colles' Fracture* - Involves the **distal radius** with **dorsal displacement** and angulation, creating a "dinner fork" deformity. - Typically occurs in **elderly patients** following a fall on an outstretched hand, not involving ulna or radial head. *Galeazzi fracture* - Features a **distal radius fracture** with **distal radioulnar joint (DRUJ) dislocation**, opposite to Monteggia pattern. - Mnemonic: **"GRU"** - Galeazzi = Radius fracture + Ulnar dislocation; **"MoRU"** - Monteggia = Radius dislocation + Ulnar fracture.

Question 1

Ruedi and Allgower classification is used for which of the following fractures?

Accepted Answer

Distal tibial fracture

Answer

Radius fracture

Answer

Fibular fracture

Answer

Proximal tibial fracture

Question 2

Avascular necrosis is not uncommon. Select the type of fracture or dislocation with which it is most likely to be associated.

Accepted Answer

Navicular (scaphoid) fracture

Answer

Monteggia's deformity

Answer

Greenstick fracture

Answer

Spiral fracture

Question 3

A patient involved in a road traffic accident is found lying in the right lateral position with bruises on the face, elbow, and lateral side of the knee. Which nerve injury has the maximum chance of occurring in this position of the victim?

Accepted Answer

Common peroneal nerve

Answer

Trigeminal nerve

Answer

Ulnar nerve

Answer

Tibial nerve

Question 4

All of the following are types of avascular non-union except:

Accepted Answer

Elephant foot

Answer

Comminuted

Answer

Torsion wedge

Answer

Atrophic

Question 5

What is the best treatment for a fracture of the neck of the femur in a 65-year-old female patient?

Accepted Answer

Hemireplacement arthroplasty

Answer

Pop cast

Answer

Gleotomy

Answer

Bone grafting and compression

Question 6

Which of the following is/are benefits of immobilization of a fracture?

Accepted Answer

All of the above

Answer

Reduction in pain

Answer

Reduced chances of fat embolism

Answer

Reduced chances of further injury to neurovascular structures

Question 7

Which of the following is typically NOT seen in a Colles fracture?

Accepted Answer

Medial rotation

Answer

Proximal impaction

Answer

Lateral rotation

Answer

Dorsal angulation

Question 8

Seddon grading is used for what purpose?

Accepted Answer

Classification of nerve injuries

Answer

Grading of open fractures

Answer

Classification of Potts paraplegia

Answer

Grading of severity of malignant bone tumors

Question 9

Avascular necrosis is a known complication of which of the following fractures?

Accepted Answer

Fracture of talus

Answer

Fracture of medial condyle of femur

Answer

Olecranon fracture

Answer

Radial head fracture

Question 10

An 18-year-old male presents with a history of trauma. An X-ray is shown below. What is the diagnosis?

Accepted Answer

Monteggia fracture

Answer

Supra-Condylar Fracture

Answer

Colles' Fracture

Answer

Galeazzi fracture

Trauma — MCQs

Trauma — MCQs

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