Trauma Practice Questions

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.

Q: The diagnosis in a patient who is unable to perform internal and external rotation of the hip is?

Dislocation of hip. ***Dislocation of hip***- Inability to perform **internal and external rotation** (both active and passive) is a hallmark sign of a **dislocated joint**, indicating mechanical blockage due to the displacement of the **femoral head** from the acetabulum.- Hip dislocations (especially posterior) present with severe pain and a **fixed deformity** (usually internal rotation, adduction, and mild flexion), which mechanically prevents any rotary movement.*Femur head fracture*- While a **femur head fracture** causes severe pain and guarded movement, it typically allows some rotation, provided the displacement is not severe enough to cause mechanical locking within the joint.- Differentiating features usually include shortening and **external rotation** of the limb (in displaced fractures), but complete mechanical block of all rotation is less specific than in frank dislocation.*Acetabular fractures*- These fractures cause gross instability and pain, but motion may still be present unless the fracture fragments are severely displaced or impinging on the **femoral head**.- The primary focus of a symptomatic acetabular fracture is significant pain, often exacerbated by axial loading, rather than a total mechanical block of rotation.*Pelvis fracture*- **Pelvis fractures** (especially stable types) cause severe pain and limit weight-bearing, but the hip joint often retains some range of motion, particularly passive rotation, if the acetabulum is intact.- Unstable pelvic ring injuries (e.g., Malgaigne fracture) are defined by instability of the bony ring and potential for hemorrhage, not by complete mechanical inability to rotate the hip joint itself.

Q: A patient is referred to a higher center with the diagnosis of fracture. On examination, the forearm pulses were not palpable. An upper arm X-ray was done, which is given below. Which artery is most likely to be injured in this condition?

Brachial artery. ***Brachial artery*** - The **brachial artery** runs in the anterior compartment of the arm, in close proximity to the humeral shaft. A mid-shaft humeral fracture, as shown in the X-ray, can directly injure or compress this vessel. - The clinical finding of impalpable **radial** and **ulnar pulses** strongly suggests a vascular injury proximal to the elbow, pointing directly to the brachial artery, which is the main arterial supply to the forearm. *Radial artery* - The **radial artery** is a terminal branch of the brachial artery located in the forearm. The fracture is in the humerus (upper arm), making a direct injury to the radial artery unlikely. - An absent radial pulse in this context is a *consequence* of the proximal brachial artery injury, not the primary site of damage. *Ulnar artery* - The **ulnar artery**, like the radial artery, is a major artery of the forearm that arises from the bifurcation of the brachial artery in the cubital fossa. It is not located near the humeral shaft fracture. - Injury to the ulnar artery alone would typically spare the radial pulse; the absence of both pulses points to a more proximal vascular compromise. *Anterior interosseous artery* - The **anterior interosseous artery** is a deep branch of the ulnar artery in the forearm. It is anatomically well-protected and distant from the site of the humeral fracture. - This artery is most commonly injured in association with complex forearm fractures, not humeral shaft fractures.

Question 1

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 2

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 3

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 4

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 5

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 6

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 7

Identify the instrument shown in the image:

Accepted Answer

Bohler braun splint

Answer

Thomas splint

Answer

Volkmann splint

Answer

Cramer wire

Question 8

A 23 year old male epileptic patient presented with pain in right shoulder region. Examination revealed that right upper limb was abducted and externally rotated and the movements could not be performed. Which of the following is the most likely diagnosis?

Accepted Answer

Subglenoid dislocation of shoulder

Answer

Luxation erecta

Answer

Intrathoracic dislocation of shoulder

Answer

Posterior dislocation of shoulder

Question 9

The diagnosis in a patient who is unable to perform internal and external rotation of the hip is?

Accepted Answer

Dislocation of hip

Answer

Pelvis fracture

Answer

Acetabular fractures

Answer

Femur head fracture

Question 10

A patient is referred to a higher center with the diagnosis of fracture. On examination, the forearm pulses were not palpable. An upper arm X-ray was done, which is given below. Which artery is most likely to be injured in this condition?

Accepted Answer

Brachial artery

Answer

Radial artery

Answer

Anterior interosseous artery

Answer

Ulnar artery

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