Trauma Practice Questions

Q: A 32-year-old man was involved in a high-speed motorcycle accident, sustaining multiple injuries including a pelvic fracture and an open left femur fracture. He underwent urgent irrigation and debridement. Due to medical instability, his fractures could not be stabilized initially. On the second day, he became confused, tachypneic, dyspneic, and developed petechiae. His electrocardiogram and chest X-ray were normal. Which of the following is the most likely diagnosis?

Fat embolism. **Explanation:** The clinical presentation of a patient with a **long bone fracture** (femur) and **pelvic fracture** who develops the classic triad of **confusion (neurological symptoms), respiratory distress (tachypnea/dyspnea), and petechiae** (typically on the axilla, neck, or conjunctiva) after a 24–72 hour "latent period" is pathognomonic for **Fat Embolism Syndrome (FES)**. 1. **Why Fat Embolism is correct:** FES occurs when fat globules from the bone marrow enter the systemic circulation following trauma. These globules cause mechanical obstruction and a biochemical inflammatory response (free fatty acid release). The diagnosis is clinical (Gurd’s Criteria). The normal initial chest X-ray and ECG help rule out immediate cardiothoracic catastrophes, as FES often shows a "snowstorm appearance" on X-ray only in later stages. 2. **Why other options are incorrect:** * **Pneumonia:** Usually presents later (3–5 days) with fever, productive cough, and localized infiltrates on X-ray. * **Pulmonary Contusion:** Would typically show immediate respiratory distress and opacities on the initial chest X-ray following high-energy trauma. * **Pneumothorax:** Characterized by sudden onset, pleuritic chest pain, and decreased breath sounds; it would be visible on a chest X-ray as a radiolucent area with no lung markings. **High-Yield Pearls for NEET-PG:** * **Classic Triad:** Respiratory distress, Cerebral signs, and Petechial rash (rash is present in only ~20-50% but is highly specific). * **Gurd’s Criteria:** Used for diagnosis. * **Treatment:** Primarily supportive (Oxygenation/Ventilation). Early stabilization of fractures (within 24 hours) is the best preventive measure. * **Most common site of petechiae:** Vestigial (axilla) and subconjunctival.

Q: Which of the following is NOT included in Gurd's criteria?

Deep vein thrombosis. This question tests your knowledge of **Fat Embolism Syndrome (FES)**, a classic complication following long bone fractures (especially the femur). Diagnosis is primarily clinical, using **Gurd’s and Wilson’s Criteria**. ### Why "Deep Vein Thrombosis" is the Correct Answer Deep Vein Thrombosis (DVT) is a separate thromboembolic complication of trauma but is **not** part of Gurd’s criteria for Fat Embolism. While both involve vascular occlusion, FES is caused by fat globules entering the circulation, whereas DVT involves blood clot formation. ### Analysis of Incorrect Options (Included in Gurd’s Criteria) Gurd’s criteria are divided into Major and Minor categories. Diagnosis requires **at least 1 Major + 4 Minor** (or 2 Major) signs. * **Option A (Major Criterion):** CNS depression (confusion, coma, or seizures) that is disproportionate to the degree of systemic hypoxemia is a hallmark major sign. * **Option D (Major Criterion):** A petechial rash, typically found in the axilla, root of the neck, or subconjunctiva, is the most pathognomonic (though late) sign of FES. * **Option B (Minor Criterion):** Tachycardia (usually **> 110 bpm**) is a recognized minor criterion. While the option says "< 110," in the context of "which is NOT included," DVT is the absolute distractor, as tachycardia (the parameter) is part of the list. ### NEET-PG High-Yield Pearls * **Classic Triad:** Dyspnea (Respiratory), Petechiae (Skin), and Confusion (CNS). * **Earliest Sign:** Hypoxemia/Respiratory distress. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Treatment:** Primarily **supportive** (Oxygenation/Ventilation). Early stabilization/fixation of fractures is the best preventive measure. * **Free Fat Globules:** May be found in urine (lipiduria) or sputum, but this is not specific.

Q: Pain around the hip with flexion, adduction, and internal rotation of the lower limb in a young adult after a road traffic accident is suggestive of which of the following conditions?

Posterior dislocation of hip. ### Explanation **Correct Answer: C. Posterior Dislocation of Hip** The clinical presentation of a **shortened, adducted, and internally rotated** limb following high-energy trauma (like a dashboard injury in an RTA) is the classic hallmark of a **Posterior Dislocation of the Hip**. In this condition, the femoral head is pushed out of the acetabulum posteriorly. The tension of the iliofemoral ligament and the position of the displaced head result in the characteristic "FADIR" deformity (Flexion, Adduction, Internal Rotation). **Why the other options are incorrect:** * **A & B (Femoral Neck Fractures):** Both intracapsular and extracapsular fractures typically present with **External Rotation** and shortening. In extracapsular (intertrochanteric) fractures, the external rotation is often more severe (nearly 90 degrees) compared to intracapsular fractures. * **D (Anterior Dislocation of Hip):** This presents with the opposite deformity: **Abduction and External Rotation** (the "FABER" position). The limb may appear lengthened or neutral, but never internally rotated. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Most common cause is a "Dashboard injury" where the knee strikes the dashboard with the hip flexed. * **Most Common Type:** Posterior dislocation accounts for ~90% of all hip dislocations. * **Associated Nerve Injury:** The **Sciatic nerve** (specifically the peroneal division) is the most commonly injured nerve in posterior dislocations. * **Complications:** Avascular Necrosis (AVN) of the femoral head is a dreaded complication; the risk increases if the dislocation is not reduced within 6 hours (**Surgical Emergency**). * **X-ray Sign:** In a posterior dislocation, the femoral head appears smaller than the contralateral side on an AP view (due to being closer to the film/further from the source).

Q: Which of the following injuries is likely to cause severe vascular damage?

Elbow dislocation. **Explanation:** The correct answer is **Elbow dislocation**. This is because of the intimate anatomical relationship between the distal humerus and the **brachial artery**. In a posterior elbow dislocation (the most common type), the brachial artery is frequently compressed or tethered between the sharp edge of the displaced distal humerus and the bicipital aponeurosis. This can lead to arterial spasm, intimal tears, or complete rupture, potentially resulting in **Volkmann’s Ischemic Contracture**. **Analysis of Options:** * **A. Closed posterior dislocation of the knee:** While knee dislocations are notorious for **popliteal artery** injuries, the question asks which is "likely" to cause severe damage in a comparative context. Statistically, in many clinical datasets, elbow injuries (including supracondylar fractures and dislocations) are more frequent precursors to acute limb-threatening ischemia in the upper extremity. *Note: Some textbooks debate the priority between knee and elbow, but for NEET-PG, the elbow-brachial artery link is a classic high-yield association.* * **C. Fracture of the middle third of the clavicle:** These are common and usually benign. While the subclavian vessels lie inferiorly, they are rarely injured unless there is high-energy comminution or penetrating trauma. * **D. Tibial plateau fracture:** These are primarily intra-articular fractures. While they can cause compartment syndrome, direct "severe vascular damage" to major trunks is less common than in knee dislocations. **Clinical Pearls for NEET-PG:** * **Highest Risk:** The most common orthopedic injury causing vascular compromise is the **Supracondylar fracture of the humerus** (Gartland Type III). * **Golden Rule:** Always check the **radial pulse** before and after reduction of any elbow or knee dislocation. * **Management:** If the pulse is absent after reduction, the next step is an **Angiography** (or CT Angio) to localize the lesion.

Q: A patient develops compartment syndrome (swelling, pain, and numbness) following manipulation and plaster for a fracture of both bones of the leg. What is the best treatment?

Operative decompression of fascial compartment. **Explanation:** **1. Why Option D is Correct:** The clinical presentation of swelling, severe pain (especially on passive stretch), and numbness following a fracture and casting is diagnostic of **Acute Compartment Syndrome (ACS)**. This is a surgical emergency where increased pressure within a closed osteofascial space compromises local circulation. Once the diagnosis is clinically established, the definitive and gold-standard treatment is **urgent operative decompression via fasciotomy**. This involves long incisions to open the fascia of all involved compartments to restore tissue perfusion and prevent irreversible muscle and nerve necrosis. **2. Why Other Options are Incorrect:** * **Option A & C:** Splitting the plaster or elevating the limb are initial "first-aid" measures. While splitting the cast can reduce pressure by approximately 30-65%, it is **not a definitive treatment** for established ACS. Furthermore, **elevation is contraindicated** in compartment syndrome because it reduces the arteriovenous pressure gradient, further compromising capillary perfusion. * **Option B:** Low molecular weight dextran is used to improve microcirculation in certain vascular conditions but has no role in relieving the mechanical pressure of compartment syndrome. **3. Clinical Pearls for NEET-PG:** * **Earliest Clinical Sign:** Pain out of proportion to the injury and pain on **passive stretching** of muscles. * **Late Sign:** Pulselessness (The presence of a distal pulse does *not* rule out compartment syndrome). * **Pressure Threshold:** Fasciotomy is generally indicated if the absolute compartment pressure is **>30 mmHg** or if the "Delta pressure" (Diastolic BP minus Compartment Pressure) is **<30 mmHg**. * **Most Common Site:** The **Deep Posterior Compartment** of the leg is most frequently involved in leg fractures.

Q: Which of the following complications occurs commonly in the fracture shown in the X-ray, EXCEPT?

Delayed union. ***Delayed union*** - **Colles' fracture** involves the **metaphyseal region** of the distal radius, which has excellent **blood supply** and typically heals readily without delayed union. - The **cancellous bone** in this region promotes rapid healing, making delayed union an uncommon complication. *Malunion* - **Loss of reduction** is common due to **dorsal angulation** and **radial shortening** if immobilization is inadequate. - Results in **dinner fork deformity** and can cause functional impairment and cosmetic issues. *Shoulder stiffness* - Prolonged **immobilization** in a cast or sling commonly leads to **frozen shoulder** (adhesive capsulitis). - **Disuse** of the shoulder joint during healing period causes **capsular contracture** and reduced range of motion. *Carpal tunnel syndrome* - **Hematoma** and **swelling** at the fracture site can compress the **median nerve** in the carpal tunnel. - **Mal-reduction** with **volar angulation** can also narrow the carpal tunnel space, leading to nerve compression symptoms.

Q: What is a comminuted depressed fracture of the lateral tibial condyle classified as?

Bumper fracture. ### Explanation **Correct Answer: C. Bumper fracture** A **Bumper fracture** (also known as a Fender fracture) refers to a fracture of the **lateral tibial plateau/condyle**. * **Mechanism:** It typically occurs when a pedestrian is struck by the bumper of a moving vehicle. The impact hits the lateral side of the knee, creating a forceful **valgus (abduction) stress**. This causes the hard lateral femoral condyle to be driven into the softer articular surface of the lateral tibial plateau, resulting in a depressed and/or comminuted fracture. * **Classification:** These fractures are categorized using the **Schatzker Classification** (Types I–VI). --- ### Why the other options are incorrect: * **A & B. Pilon / Plafond fracture:** These terms are often used interchangeably. They refer to a comminuted intra-articular fracture of the **distal tibia** (the "ceiling" of the ankle joint), usually caused by high-energy axial loading (e.g., a fall from height). * **D. Malgaigne's fracture:** This is a vertical shear injury of the **pelvis**. It involves a double vertical fracture through the anterior pelvic ring (pubic rami) and the posterior pelvic ring (sacrum, SI joint, or ilium) on the same side. --- ### High-Yield Clinical Pearls for NEET-PG: 1. **Nerve Injury:** The most commonly injured nerve in a Bumper fracture is the **Common Peroneal Nerve** (due to its proximity to the fibular neck). 2. **Ligamentous Injury:** Because of the valgus stress mechanism, the **Medial Collateral Ligament (MCL)** is frequently torn. 3. **Schatzker Type II** is the most common pattern (cleavage with depression of the lateral plateau). 4. **Management Goal:** The priority is restoring the articular congruity of the knee joint to prevent early-onset osteoarthritis.

Q: Garden I fractures are also known as?

Valgus impaction fractures. The **Garden Classification** is the most widely used system for femoral neck fractures, based on the degree of displacement and the alignment of medial trabeculae on an AP radiograph. ### **Explanation of the Correct Answer** **Option D (Valgus impaction fractures)** is correct. Garden Stage I is defined as an **incomplete or abducted (valgus) impacted fracture**. In this type, the femoral head tilts into a valgus position, causing the medial trabeculae of the neck to be "jammed" or impacted. Because the fragments are wedged together, these are considered inherently stable fractures with a lower risk of avascular necrosis (AVN) compared to higher stages. ### **Analysis of Incorrect Options** * **Option A:** This describes **Garden Stage II**. In Stage II, the fracture is complete (extending across the entire neck), but there is no displacement. The alignment remains normal. * **Option B:** This describes **Garden Stage III**. There is complete disruption with partial displacement. The femoral head usually tilts into a varus position, but some contact between the fragments remains. * **Option C:** This describes **Garden Stage IV**. There is complete displacement with no contact between the fracture fragments. The femoral head often realigns with the acetabulum, appearing "normal" while the shaft is displaced. ### **NEET-PG High-Yield Pearls** * **Stability:** Garden I and II are "Undisplaced/Stable"; Garden III and IV are "Displaced/Unstable." * **Management:** In elderly patients, Stage I and II are often treated with **Internal Fixation (Cannulated Cancellous Screws)**, whereas Stage III and IV usually require **Arthroplasty** (Hemi or Total) due to the high risk of non-union and AVN. * **Pauwels Classification:** Another high-yield system based on the **angle of the fracture line** (verticality); higher angles (Type III) indicate greater shear force and instability.

Q: In myositis ossificans, where is mature bone typically seen?

At the periphery. **Explanation:** **Myositis Ossificans (MO)** is a benign, heterotopic ossification where bone forms within soft tissues, usually following trauma (e.g., a muscle hematoma). 1. **Why Option A is Correct:** The hallmark of Myositis Ossificans is the **"Zonal Phenomenon."** As the lesion matures, it organizes from the outside in. The most mature, lamellar bone forms at the **periphery** (forming a shell), while the center remains composed of immature fibroblastic tissue and osteoid. This centrifugal maturation is a crucial diagnostic feature on imaging and histology. 2. **Why Other Options are Incorrect:** * **Option B:** The center contains the most immature, cellular components. If a biopsy is taken only from the center, it may be misdiagnosed as osteosarcoma due to high mitotic activity. * **Option C:** Bone is not distributed uniformly; the distinct "zonal" maturation pattern differentiates it from malignant tumors. * **Option D:** MO occurs within the muscle belly (extra-articular), not the joint capsule. **High-Yield Clinical Pearls for NEET-PG:** * **Radiology:** Shows a characteristic "eggshell calcification" or "circumferential calcification" on X-ray. There is often a **radiolucent zone** (string sign) between the lesion and the underlying bone, distinguishing it from a parosteal osteosarcoma. * **Common Site:** Brachialis (following elbow dislocation) and Quadriceps femoris. * **Management:** Conservative initially (Rest, NSAIDs). Surgery is only indicated for mature lesions (usually after 6–12 months) if they cause significant pain or limit joint motion. Excision of an immature lesion leads to high recurrence rates.

Question 1

A 32-year-old man was involved in a high-speed motorcycle accident, sustaining multiple injuries including a pelvic fracture and an open left femur fracture. He underwent urgent irrigation and debridement. Due to medical instability, his fractures could not be stabilized initially. On the second day, he became confused, tachypneic, dyspneic, and developed petechiae. His electrocardiogram and chest X-ray were normal. Which of the following is the most likely diagnosis?

Accepted Answer

Fat embolism

Answer

Pneumonia

Answer

Pulmonary contusion

Answer

Pneumothorax

Question 2

From the following neck of femur fractures, which one has the worst prognosis?

Accepted Answer

Garden's type 4

Answer

Basicervical

Answer

Transcervical

Answer

Prognosis same in all types

Question 3

Which of the following is NOT included in Gurd's criteria?

Accepted Answer

Deep vein thrombosis

Answer

Central nervous system depression disproportionate to hypoxemia

Answer

Tachycardia < 110 bpm

Answer

Axillary or subconjunctival petechiae

Question 4

Pain around the hip with flexion, adduction, and internal rotation of the lower limb in a young adult after a road traffic accident is suggestive of which of the following conditions?

Accepted Answer

Posterior dislocation of hip

Answer

Intracapsular fracture of the femoral neck

Answer

Extracapsular fracture of the femoral neck

Answer

Anterior dislocation of hip

Question 5

Which of the following injuries is likely to cause severe vascular damage?

Accepted Answer

Elbow dislocation

Answer

Closed posterior dislocation of the knee

Answer

Fracture of the middle third of the clavicle

Answer

Tibial plateau fracture

Question 6

A patient develops compartment syndrome (swelling, pain, and numbness) following manipulation and plaster for a fracture of both bones of the leg. What is the best treatment?

Accepted Answer

Operative decompression of fascial compartment

Answer

Split the plaster

Answer

Infusion of low molecular weight dextran

Answer

Elevate the leg after splitting the plaster

Question 7

Which of the following complications occurs commonly in the fracture shown in the X-ray, EXCEPT?

Accepted Answer

Delayed union

Answer

Malunion

Answer

Shoulder stiffness

Answer

Carpal tunnel syndrome

Question 8

What is a comminuted depressed fracture of the lateral tibial condyle classified as?

Accepted Answer

Bumper fracture

Answer

Pilon fracture

Answer

Plafond fracture

Answer

Malgaigne's fracture

Question 9

Garden I fractures are also known as?

Accepted Answer

Valgus impaction fractures

Answer

Complete fracture without displacement

Answer

Complete fracture with minimal (partial) displacement

Answer

Complete fracture with full displacement

Question 10

In myositis ossificans, where is mature bone typically seen?

Accepted Answer

At the periphery

Answer

In the center

Answer

Throughout the entire muscle mass

Answer

Within the joint capsule

Trauma — MCQs

Trauma — MCQs

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