Trauma Practice Questions

Q: What is the commonest complication of extra capsular fracture of the femur?

Mal union. **Explanation:** **Extra-capsular fractures** of the femur primarily include **intertrochanteric (IT) fractures**. Unlike intra-capsular fractures, the extra-capsular region has a robust blood supply and consists of cancellous bone with a large surface area, which promotes reliable healing. **1. Why Mal-union is the correct answer:** Because the blood supply is preserved, these fractures almost always heal. However, due to the strong pull of the hip musculature (iliopsoas, abductors, and short rotators), the fragments tend to displace. If not anatomically reduced or if the fixation fails, the fracture heals in a deformed position. The most common deformity is a **Coxa Vara** (decreased neck-shaft angle) associated with shortening and external rotation. **2. Why other options are incorrect:** * **Non-union:** Rare in extra-capsular fractures due to the excellent vascularity and cancellous nature of the bone. It is much more common in intra-capsular (neck of femur) fractures. * **Avascular Necrosis (AVN):** The blood supply to the femoral head (mainly the medial circumflex femoral artery) is located intra-capsularly. Extra-capsular fractures do not typically disrupt this supply, making AVN a rare complication. * **Osteoarthritis:** While it can occur as a long-term secondary result of mal-alignment, it is not the most common immediate or direct complication of the fracture itself. **High-Yield Clinical Pearls for NEET-PG:** * **Intra-capsular fracture:** Commonest complication is **Non-union**, followed by **AVN**. * **Extra-capsular (IT) fracture:** Commonest complication is **Mal-union (Coxa Vara)**. * **Standard Treatment:** The Dynamic Hip Screw (DHS) or Proximal Femoral Nail (PFN) are the implants of choice. * **Clinical Sign:** In IT fractures, the limb shows marked external rotation (up to 90 degrees) and shortening.

Q: The provided X-ray shows a fracture of which bone?

Both Radius and Ulna. ***Both Radius and Ulna*** - **Both-bone forearm fractures** typically occur from high-energy trauma such as falls or motor vehicle accidents, causing fractures of both the **radius** and **ulna** shafts. - X-ray shows clear fracture lines through both bones, which is distinct from isolated fractures like **Monteggia** (ulna fracture with radial head dislocation) or **Galeazzi** (radius fracture with distal radioulnar joint disruption). *Radius* - An isolated **radius fracture** would show fracture line only through the radius bone while the **ulna remains intact**. - Should be accompanied by **distal radioulnar joint disruption** (Galeazzi fracture) if truly isolated, which requires careful evaluation of joint alignment. *Ulna* - An isolated **ulna fracture** would demonstrate fracture through the ulna shaft with an **intact radius**. - Often associated with **radial head dislocation** (Monteggia fracture), requiring assessment of the **radiocapitellar line** on lateral views. *None of the above* - The X-ray clearly demonstrates **fracture lines** through both forearm bones, making this option incorrect. - **Both-bone forearm fractures** are common injuries requiring surgical fixation due to the **interosseous membrane** disruption and potential for **compartment syndrome**.

Q: Regarding the displacement of the distal fragment in a Colles fracture, which statement is true?

Posteriorly and laterally. ### Explanation **1. Why the Correct Answer is Right:** A **Colles fracture** is a fracture of the distal radius occurring within 2.5 cm of the wrist joint, typically resulting from a fall on an outstretched hand (FOOSH). The hallmark of this fracture is the specific displacement of the **distal fragment**. Due to the mechanism of injury and the pull of the brachioradialis and extensor tendons, the distal fragment is displaced **posteriorly (dorsally)** and **laterally (radially)**. The classic "Dinner Fork Deformity" is a direct result of this dorsal (posterior) displacement and dorsal tilting. The lateral (radial) displacement, along with radial shortening and tilt, leads to the prominence of the ulnar styloid. **2. Analysis of Incorrect Options:** * **Option A & C (Anteriorly):** Anterior (ventral/volar) displacement is characteristic of a **Smith’s fracture** (also known as a "Reverse Colles"). This occurs from a fall on the back of a flexed wrist. * **Option D (Medially):** Medial (ulnar) displacement does not occur in Colles fractures. Instead, there is radial (lateral) deviation because the distal fragment shifts toward the thumb side, often associated with a fracture of the ulnar styloid process. **3. Clinical Pearls for NEET-PG:** * **The 6 Displacements of Colles:** (1) Dorsal displacement, (2) Dorsal tilt, (3) Lateral displacement, (4) Lateral tilt, (5) Impaction/Shortening, and (6) Supination. * **Dinner Fork Deformity:** Caused by dorsal displacement/tilt. * **Most Common Complication:** Stiffness of the fingers and shoulder (due to neglect during casting). * **Most Common Late Complication:** Malunion (leading to a weak grip). * **Specific Tendon Rupture:** Spontaneous rupture of the **Extensor Pollicis Longus (EPL)** can occur weeks after the injury due to ischemia or attrition at Lister’s tubercle.

Q: Myositis ossificans is due to:

All of the above. **Explanation:** **Myositis Ossificans (Traumatic)** is a condition characterized by the formation of heterotopic non-neoplastic bone in soft tissues, most commonly following blunt trauma or repeated injury to a muscle (frequently the brachialis or quadriceps). 1. **Why "All of the above" is correct:** The pathophysiology begins with a traumatic injury that causes a **subperiosteal or intramuscular haematoma**. Instead of being resorbed, this haematoma undergoes organization. Osteoblasts (derived from the periosteum or primitive mesenchymal cells) migrate into the area, leading to **ossification** (the process of laying down new bone material). This results in the **new bone formation** within the soft tissue. Therefore, all three descriptors (ossification, new bone formation, and subperiosteal haematoma involvement) are integral stages of the disease process. 2. **Analysis of Options:** * **Ossification of subperiosteal haematoma:** This is the specific initiating event where blood trapped under the periosteum begins to mineralize. * **New bone formation & Ossification:** These are the broader pathological descriptions of the end result—ectopic bone where it should not exist. **High-Yield Clinical Pearls for NEET-PG:** * **Common Site:** Brachialis muscle (following supracondylar fracture or elbow dislocation). * **Clinical Feature:** A painful, firm mass in the muscle with a decreasing range of motion. * **Radiology:** Characterized by the **"Zonal Phenomenon"** (mature lamellar bone at the periphery and immature osteoid in the center). This helps distinguish it from Osteosarcoma, which has central mineralization. * **Management:** **Rest and immobilization** in the acute phase. Massage and passive stretching are strictly **contraindicated** as they aggravate the condition. Surgery is only considered after the bone matures (usually 6–12 months).

Q: Sudeck's atrophy is more common in which of the following conditions?

Malunited Colles' fracture. ### Explanation **Sudeck’s atrophy**, also known as **Complex Regional Pain Syndrome (CRPS) Type 1**, is a post-traumatic condition characterized by autonomic dysfunction leading to pain, swelling, and vasomotor instability, followed by patchy osteoporosis. **Why Option A is correct:** Sudeck’s atrophy most frequently affects the **distal upper limb**, particularly following a **Colles' fracture**. The incidence is significantly higher in cases of **malunion** or when the cast is applied too tightly, leading to chronic irritation of the sensory nerves and prolonged immobilization. The classic presentation includes a "shoulder-hand syndrome" where the patient develops a painful, stiff hand with trophic skin changes (shiny, red skin) and radiographic evidence of "speckled" or patchy osteoporosis. **Why other options are incorrect:** * **B & C (Femur and Pott’s fracture):** While CRPS can occur in the lower limbs, it is statistically much less common than in the upper extremity. Colles' fracture remains the classic textbook association for Sudeck’s atrophy. * **D (Caries Spine):** This is a chronic infectious/granulomatous condition (Tuberculosis). Sudeck’s atrophy is specifically a **post-traumatic** or post-surgical sympathetic phenomenon, not an infectious process. **High-Yield Clinical Pearls for NEET-PG:** * **Radiographic hallmark:** Patchy/speckled osteoporosis (sudden loss of bone density). * **Clinical Stages:** 1. Hyperemic (Acute), 2. Dystrophic (Ischemic), 3. Atrophic. * **Key Treatment:** Active exercises of the joints (fingers and shoulder) are the best preventive and therapeutic measures. * **Diagnosis:** Primarily clinical; Triple-phase bone scan (TPBS) shows increased uptake in the delayed phase.

Q: Which of the following is NOT a complication of Colles fracture?

Nonunion. **Explanation:** The correct answer is **Nonunion** because Colles fracture occurs through the **cancellous bone** of the distal radius. Cancellous bone is highly vascular and has a large surface area, which facilitates rapid healing. Consequently, nonunion is extremely rare in Colles fractures; if the fragments don't align, they typically result in malunion rather than failing to unite. **Analysis of Options:** * **Malunion (A):** This is the **most common complication**. It often results in the classic "Dinner Fork Deformity" due to residual dorsal tilt and radial shortening. * **Sudeck’s Osteodystrophy (C):** Also known as Complex Regional Pain Syndrome (CRPS) Type 1. It is a frequent complication characterized by post-traumatic pain, swelling, and vasomotor instability leading to trophic skin changes and osteoporosis. * **Rupture of EPL tendon (D):** This is a classic late complication. It occurs due to ischemia or attrition of the Extensor Pollicis Longus tendon as it turns around **Lister’s tubercle**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Malunion. * **Most common late complication:** Secondary Osteoarthritis (especially of the distal radio-ulnar joint). * **Median Nerve Palsy:** Can occur acutely (Carpal Tunnel Syndrome) due to pressure from the displaced fragments or hematoma. * **Stiffness:** "Frozen shoulder" is a common associated complication because elderly patients often keep the shoulder immobilized while the wrist is in a cast. Always advise shoulder exercises!

Q: A boy fell from a height onto his outstretched hand. The X-ray of his forearm is shown below. What is the most likely diagnosis?

Galeazzi fracture. ***Galeazzi fracture*** - Fracture of the **distal third of the radius** with **distal radioulnar joint (DRUJ) dislocation**, commonly caused by **fall on outstretched hand (FOOSH)**. - The **ulnar head appears prominent** on X-ray due to DRUJ disruption, and there's shortening of the radius relative to the ulna. *Colles' fracture* - Involves a **distal radius fracture** with **dorsal angulation** and **dorsal displacement**, creating a "dinner fork" deformity. - Does **not involve dislocation** of the DRUJ, unlike the Galeazzi fracture pattern. *Rolando fracture* - A **comminuted intra-articular fracture** of the **base of the first metacarpal** (thumb). - Affects the **carpometacarpal joint** of the thumb, not the radius or DRUJ as seen in this case. *Monteggia fracture* - Fracture of the **proximal or mid-shaft ulna** with **radial head dislocation** at the radiocapitellar joint. - The **radiocapitellar line** fails to pass through the capitellum, which is not the pattern described here.

Q: A 20-year-old male patient presented with acute pain in the left hip region and inability to bear weight on the left hip. On examination, deformity of the left lower limb was noticed. The lower limb was in slight flexion, adduction, and internal rotation. The patient gave a history of a road accident with sudden braking. Neurovascular examination was normal. Which of the following x-rays will most likely correspond to the above condition?

X-ray showing left hip posterior dislocation. ***X-ray showing left hip posterior dislocation*** - The classic **triad** of slight flexion, adduction, and internal rotation is pathognomonic for **posterior hip dislocation**. - **Dashboard injury** mechanism (sudden braking in road accident) with axial loading of the flexed hip causes the femoral head to be driven posteriorly out of the acetabulum. *X-ray showing left hip anterior dislocation* - Anterior hip dislocation presents with the limb in **extension**, **abduction**, and **external rotation** - opposite to this case. - Much less common (10-15% of hip dislocations) and typically occurs with **forced abduction** and external rotation. *X-ray showing left femoral neck fracture* - Femoral neck fractures typically present with **external rotation** and **shortening** of the affected limb, not internal rotation. - More common in **elderly patients** with osteoporosis following low-energy trauma, not young adults in high-energy accidents. *All of the above* - Only **posterior hip dislocation** matches the clinical presentation and mechanism described. - The specific **deformity pattern** and **dashboard injury** mechanism are diagnostic for posterior dislocation only.

Q: What is the most common complication of a talar neck fracture?

Osteoarthritis of subtalar joint. **Explanation:** The talus is a unique bone with no muscle attachments and approximately 60% of its surface covered by articular cartilage. Talar neck fractures are high-energy injuries typically classified by the **Hawkins Classification**. **1. Why Option D is Correct:** While Avascular Necrosis (AVN) is the most "famous" complication, **Post-traumatic Osteoarthritis (OA)** is statistically the **most common** complication overall. Specifically, OA of the **subtalar joint** occurs in nearly 50–90% of cases. This is due to the initial cartilage damage at the time of injury and the difficulty in achieving perfect anatomical reduction of the complex subtalar articular surface. **2. Analysis of Incorrect Options:** * **A. Avascular Necrosis:** This is the most *characteristic* and feared complication due to the retrograde blood supply (via the artery of the tarsal canal). However, its incidence varies by Hawkins type (Type I: 0-15%, Type IV: 100%). Across all types, subtalar OA remains more frequent than AVN. * **B. Nonunion:** This is relatively rare in talar neck fractures (approx. 5%) because the bone is mostly cancellous, which generally heals well if stabilized. * **C. Osteoarthritis of the ankle joint:** While common (especially in Hawkins Type III and IV), it occurs less frequently than subtalar joint arthritis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Hawkins Sign:** A subchondral radiolucency seen on AP/Mortise X-rays at 6–8 weeks post-injury. It indicates intact vascularity (active resorption of bone) and rules out AVN. * **Blood Supply:** The main supply is the **Posterior Tibial Artery** (via the artery of the tarsal canal). * **Mechanism:** Usually forced dorsiflexion (e.g., "Aviator’s Astragalus"). * **Management:** Displaced fractures are surgical emergencies requiring ORIF to minimize the risk of AVN.

Question 1

What is the commonest complication of extra capsular fracture of the femur?

Accepted Answer

Mal union

Answer

Non union

Answer

Avascular necrosis

Answer

Osteoarthritis

Question 2

The provided X-ray shows a fracture of which bone?

Accepted Answer

Both Radius and Ulna

Answer

Radius

Answer

Ulna

Answer

None of the above

Question 3

A 19-year-old man sustains severe lower-extremity trauma, including a femur fracture and a crush injury to his foot. He requires vascular reconstruction of the popliteal artery. On the day after surgery, he becomes dyspneic and hypoxemic and requires intubation and mechanical ventilation. Which of the following is the most likely etiology of his decompensation?

Accepted Answer

Fat embolism syndrome

Answer

Aspiration

Answer

Atelectasis

Answer

Fluid overload

Question 4

Regarding the displacement of the distal fragment in a Colles fracture, which statement is true?

Accepted Answer

Posteriorly and laterally

Answer

Anteriorly and medially

Answer

Anteriorly and laterally

Answer

Posteriorly and medially

Question 5

Myositis ossificans is due to:

Accepted Answer

All of the above

Answer

Ossification

Answer

New bone formation

Answer

Ossification of subperiosteal haematoma

Question 6

Sudeck's atrophy is more common in which of the following conditions?

Accepted Answer

Malunited Colles' fracture

Answer

Malunited fracture of the femur

Answer

Pott's fracture

Answer

Carries spine

Question 7

Which of the following is NOT a complication of Colles fracture?

Accepted Answer

Nonunion

Answer

Malunion

Answer

Sudeck's osteodystrophy

Answer

Rupture of EPL tendon

Question 8

A boy fell from a height onto his outstretched hand. The X-ray of his forearm is shown below. What is the most likely diagnosis?

Accepted Answer

Galeazzi fracture

Answer

Colles' fracture

Answer

Rolando fracture

Answer

Monteggia fracture

Question 9

A 20-year-old male patient presented with acute pain in the left hip region and inability to bear weight on the left hip. On examination, deformity of the left lower limb was noticed. The lower limb was in slight flexion, adduction, and internal rotation. The patient gave a history of a road accident with sudden braking. Neurovascular examination was normal. Which of the following x-rays will most likely correspond to the above condition?

Accepted Answer

X-ray showing left hip posterior dislocation

Answer

X-ray showing left hip anterior dislocation

Answer

X-ray showing left femoral neck fracture

Answer

All of the above

Question 10

What is the most common complication of a talar neck fracture?

Accepted Answer

Osteoarthritis of subtalar joint

Answer

Avascular necrosis

Answer

Nonunion

Answer

Osteoarthritis of ankle joint

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