Trauma Practice Questions

Q: Nonunion is common in which of the following fracture locations?

Neck femur. **Explanation:** **Neck of femur** fractures are notorious for high rates of nonunion and avascular necrosis (AVN). This is primarily due to three factors: 1. **Intracapsular Nature:** The fracture is bathed in synovial fluid, which contains fibrinolysins that dissolve the initial blood clot, hindering the formation of a primary callus. 2. **Blood Supply:** The femoral head relies on the retrograde blood supply (mainly the medial circumflex femoral artery). Fractures often disrupt these vessels, leading to ischemia. 3. **Lack of Periosteum:** The femoral neck lacks a cambium layer of periosteum, meaning healing occurs only through endosteal repair, which is slower and less robust. **Analysis of Other Options:** * **Scapula:** These fractures are surrounded by thick, well-vascularized muscle bulk (rotator cuff, subscapularis). They almost always heal with conservative management; nonunion is extremely rare. * **Talus:** While the talus has a high risk of **AVN** (due to its retrograde blood supply), the rate of nonunion is generally lower than that of the femoral neck. * **Tibial Fracture:** The lower third of the tibia is a common site for delayed union due to poor soft tissue cover and nutrient artery distribution, but the absolute incidence of nonunion is statistically lower than in intracapsular femoral neck fractures. **High-Yield Pearls for NEET-PG:** * **Pauwels’ Classification:** Higher angles (Type III > 50°) indicate high shear forces and a higher risk of nonunion. * **Garden’s Classification:** Used for displacement; Stage III and IV have the highest risk of AVN and nonunion. * **Commonest sites for Nonunion:** Neck of femur, Scaphoid, and Talus (often due to precarious blood supply). * **Commonest site for Malunion:** Colles’ fracture and Supracondylar fracture of the humerus.

Q: Prosthetic replacement of the femoral head is indicated for which of the following fracture sites of the femur?

Subcapital fracture of the neck of femur. **Explanation:** The primary indication for prosthetic replacement (Hemiarthroplasty) in femoral neck fractures is the high risk of **Avascular Necrosis (AVN)** and **Non-union**. **1. Why Subcapital Fracture is the Correct Answer:** The femoral head receives its blood supply mainly through the **retinacular vessels** (branches of the medial circumflex femoral artery) which run along the neck. A **subcapital fracture** occurs just below the femoral head, where the fracture line is intracapsular. This frequently disrupts the blood supply, leading to a high incidence of AVN. In elderly patients with low functional demands, primary prosthetic replacement is preferred over internal fixation to avoid the complications of re-operation. **2. Analysis of Incorrect Options:** * **Inter-trochanteric (A) and Transtrochanteric (C) Fractures:** These are **extracapsular** fractures. This region has a rich blood supply and a large surface area of cancellous bone, leading to excellent healing potential. The treatment of choice is internal fixation (e.g., DHS or Cephalomedullary nail), not replacement. * **Basal Fracture of the Neck (D):** This occurs at the junction of the neck and the trochanter. Being further away from the head, the blood supply is often preserved compared to subcapital fractures. These are usually treated with internal fixation. **Clinical Pearls for NEET-PG:** * **Garden’s Classification:** Used for intracapsular fractures. Stage III and IV (displaced) in elderly patients are the classic indications for Hemiarthroplasty. * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (Type III) indicate greater shear forces and higher risk of non-union. * **Choice of Surgery:** In young patients, always attempt **Internal Fixation** (Head salvage) regardless of displacement. In active elderly patients, **Total Hip Arthroplasty (THA)** is superior to Hemiarthroplasty.

Q: X-ray below shows which of the following fractures?

Proximal humerus. ***Proximal humerus*** - The X-ray demonstrates a fracture through the **surgical neck** of the proximal humerus, which appears as a clear break in the bone continuity below the humeral head. - **Neer classification** is used for proximal humerus fractures, with this being a common site for fractures in elderly patients due to osteoporosis. *Lateral third of clavicle* - Would show fracture through the **lateral end** of the clavicle near the acromioclavicular joint, not involving the humeral head area. - The **coracoclavicular ligaments** would be disrupted in lateral clavicle fractures, causing superior displacement of the proximal fragment. *Acromioclavicular dislocation* - Would demonstrate **widening** of the acromioclavicular joint space and possible elevation of the clavicle relative to the acromion. - No fracture line would be visible; instead, there would be **joint incongruity** and soft tissue swelling over the AC joint. *Sternoclavicular fracture* - This location is not visible on a standard **shoulder AP X-ray** as the sternoclavicular joint is medially located and obscured by overlying structures. - Would require specialized views like **serendipity view** or CT scan for proper visualization of the sternoclavicular region.

Q: Uncomplicated shoulder dislocation most commonly occurs in which direction?

Anterior. **Explanation:** The shoulder (glenohumeral) joint is the most commonly dislocated joint in the body due to the inherent instability provided by a shallow glenoid cavity and a large humeral head. **1. Why Anterior is Correct:** **Anterior dislocation** accounts for approximately **95-97%** of all shoulder dislocations. It typically occurs when the arm is in a position of **abduction and external rotation**. The anatomical weakness of the anterior capsule, specifically between the superior and middle glenohumeral ligaments (Foramen of Weitbrecht), makes the joint prone to displacement in this direction. **2. Why Other Options are Incorrect:** * **Posterior (B):** Accounts for only 2-5% of cases. It is classically associated with **seizures, electric shocks**, or direct trauma to the front of the shoulder. It is often missed on initial X-rays (look for the "Light bulb sign"). * **Superior (C):** Extremely rare. It usually involves a high-energy upward force and is typically associated with fractures of the acromion, clavicle, or coracoid process. * **Medially (D):** This is not a standard anatomical direction for shoulder dislocation. Displacement occurs relative to the glenoid fossa (Anterior, Posterior, or Inferior/Luxatio Erecta). **Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Axillary nerve (tested via sensation over the "Regimental Badge" area). * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head. * **Bankart Lesion:** Avulsion of the anteroinferior glenoid labrum. * **Kocher’s Method:** A historical reduction technique (though no longer preferred due to high complication rates like humeral fractures). * **Hippocratic Method:** The oldest described reduction technique using foot-in-axilla traction.

Q: A 56-year-old woman visits the emergency department after falling on wet pavement. Radiographic examination reveals osteoporosis and a Colles' fracture. Which of the following carpal bones are often fractured or dislocated with a Colles' fracture?

Scaphoid and lunate. **Explanation:** **1. Why Scaphoid and Lunate are correct:** A Colles' fracture is a distal radius fracture (within 2.5 cm of the wrist joint) occurring due to a fall on an outstretched hand (FOOSH) with the wrist in dorsiflexion. The mechanism of injury involves the transmission of force from the ground through the carpal bones to the distal radius. The **Scaphoid** and **Lunate** are the two primary carpal bones that articulate directly with the distal radius (at the scaphoid and lunate fossae). During the impact, these bones act as a wedge against the radial articular surface, making them the most susceptible to concomitant fractures or ligamentous dislocations (such as scapholunate dissociation) alongside the radial fracture. **2. Analysis of Incorrect Options:** * **A & B (Triquetrum):** The triquetrum articulates with the TFCC (Triangular Fibrocartilage Complex) rather than the radius itself. While it can be injured in wrist trauma, it is not as frequently associated with the direct axial loading mechanism of a Colles' fracture compared to the scaphoid and lunate. * **D (Triquetrum, Lunate, and Scaphoid):** While multiple carpal injuries can occur in high-energy trauma, the standard clinical association for a typical Colles' fracture specifically highlights the two bones forming the primary radiocarpal joint. **3. NEET-PG High-Yield Pearls:** * **Colles' Fracture:** Characterized by **dorsal displacement**, dorsal tilt, and radial deviation ("Dinner Fork Deformity"). * **Smith’s Fracture:** The "Reverse Colles," involving volar displacement (Garden Spade Deformity). * **Associated Injury:** The most common associated fracture in a Colles' case is the **Ulnar Styloid process** (60% of cases). * **Complication:** The most common late complication is **Secondary Osteoarthritis**, while the most common tendon rupture is the **Extensor Pollicis Longus (EPL)**.

Q: A child develops severe forearm pain after a supracondylar fracture reduction and POP cast application. The child describes the pain as worse than the fracture pain and has limited finger movement. Volkmann's ischemic contracture is suspected. Which muscle is most commonly affected in Volkmann's ischemia?

Flexor digitorum profundus. **Explanation:** Volkmann’s Ischemic Contracture (VIC) is the sequela of untreated **Compartment Syndrome**, most commonly occurring after supracondylar fractures of the humerus. When tissue pressure within the deep fascia of the forearm exceeds capillary perfusion pressure, ischemia occurs. **Why Flexor Digitorum Profundus (FDP) is the correct answer:** The muscles located deepest in the compartment and closest to the bone are the most vulnerable to increased pressure and ischemia. The **Flexor Digitorum Profundus (FDP)** and the **Flexor Pollicis Longus (FPL)** are the deepest muscles in the volar compartment of the forearm. Among these, the FDP is considered the "watershed" area of perfusion and is the **most commonly and severely affected muscle** in Volkmann’s ischemia. **Analysis of Incorrect Options:** * **A. Pronator teres:** This is a superficial muscle. While it can be involved in severe cases, it is not the primary or most common site of ischemia. * **B. Flexor carpi radialis:** This is a superficial flexor. Ischemia typically progresses from the deep to the superficial layers. * **D. Flexor digitorum superficialis (FDS):** Although frequently involved as the condition progresses, it lies superficial to the FDP and is generally less affected than the deep layer in the early stages. **Clinical Pearls for NEET-PG:** * **Earliest Sign:** Pain out of proportion to the injury and **pain on passive extension** of fingers. * **Infarct Shape:** The ischemic zone is typically **ellipsoid-shaped**, with the center located at the FDP. * **Nerve Involvement:** The **Median nerve** is the most commonly affected nerve in the forearm compartment. * **Management:** Immediate removal of the cast/dressings. If no improvement within 30–60 minutes, urgent **fasciotomy** is indicated.

Q: Fracture of the neck of the humerus is common in:

Elderly woman. **Explanation:** **1. Why "Elderly woman" is correct:** Fractures of the surgical neck of the humerus are classic **osteoporotic fragility fractures**. They typically occur due to a low-energy mechanism, such as a fall on an outstretched hand (FOOSH) from a standing height. Elderly women are the most susceptible demographic because of the rapid decline in bone mineral density following **menopause** (Type I Osteoporosis). The surgical neck is a site of transition from the dense cortical bone of the shaft to the more cancellous bone of the head, making it a structural weak point in osteoporotic patients. **2. Why other options are incorrect:** * **Young lady:** In younger populations, the bone density is high. A fracture in this region would require high-energy trauma (e.g., motor vehicle accidents) rather than a simple fall, making it much less common. * **Elderly man:** While elderly men can suffer from osteoporosis (Type II), the incidence is significantly lower and occurs later in life compared to post-menopausal women. * **All of these:** This is incorrect because the epidemiological peak is specifically skewed toward the elderly female population. **3. Clinical Pearls for NEET-PG:** * **Nerve Injury:** The **Axillary nerve** is the most commonly injured nerve in surgical neck fractures (check for "regimental badge" anesthesia over the deltoid). * **Vascular Injury:** The **Posterior circumflex humeral artery** is the most common vascular structure at risk. * **Neer’s Classification:** This is the standard classification system for proximal humerus fractures, based on the number of displaced "parts" (Greater tuberosity, Lesser tuberosity, Shaft, and Head). * **Treatment:** Most (approx. 80%) are minimally displaced and managed conservatively with a **U-slab or shoulder immobilizer**. Displaced fractures may require ORIF or Hemiarthroplasty.

Question 1

Perkin's traction is used in which part of the femur?

Accepted Answer

Shaft of femur in adults

Answer

Shaft of femur in children < 2 years

Answer

Shaft of femur in children 2-10 years

Answer

Shaft of femur in children > 10 years

Question 2

Nonunion is common in which of the following fracture locations?

Accepted Answer

Neck femur

Answer

Scapula

Answer

Talus

Answer

Tibial fracture

Question 3

Prosthetic replacement of the femoral head is indicated for which of the following fracture sites of the femur?

Accepted Answer

Subcapital fracture of the neck of femur

Answer

Inter-trochanteric fracture

Answer

Transtrochanteric fracture

Answer

Basal fracture of the neck of femur

Question 4

X-ray below shows which of the following fractures?

Accepted Answer

Proximal humerus

Answer

Lateral third of clavicle

Answer

Acromioclavicular dislocation

Answer

Sternoclavicular fracture

Question 5

A 40-year-old male with a history of road traffic accident (RTA) and multiple long bone fractures develops tachypnea, periumbilical rashes, and has urinary fat globules. What is the most likely diagnosis?

Accepted Answer

Fat embolism syndrome

Answer

Proximal urethral injury

Answer

Bladder injury

Answer

Bacterial pneumonitis

Question 6

Uncomplicated shoulder dislocation most commonly occurs in which direction?

Accepted Answer

Answer

Posterior

Answer

Superior

Answer

Medially

Question 7

A 56-year-old woman visits the emergency department after falling on wet pavement. Radiographic examination reveals osteoporosis and a Colles' fracture. Which of the following carpal bones are often fractured or dislocated with a Colles' fracture?

Accepted Answer

Scaphoid and lunate

Answer

Triquetrum and scaphoid

Answer

Triquetrum and lunate

Answer

Triquetrum, lunate, and scaphoid

Question 8

A child develops severe forearm pain after a supracondylar fracture reduction and POP cast application. The child describes the pain as worse than the fracture pain and has limited finger movement. Volkmann's ischemic contracture is suspected. Which muscle is most commonly affected in Volkmann's ischemia?

Accepted Answer

Flexor digitorum profundus

Answer

Pronator teres

Answer

Flexor carpi radialis longus

Answer

Flexor digitorum superficialis

Question 9

A 30-year-old biker sustained a compound fracture of the leg following a road traffic accident. The fracture has been classified as Gustilo-Anderson type IIIB. Which of the following best represents this injury classification?

Accepted Answer

Open wound more than 10 cm with extensive soft tissue damage and coverage not possible

Answer

Fracture with an open wound less than 1 cm

Answer

Fracture with an open wound of 1-10 cm with soft tissue coverage possible

Answer

Open wound more than 10 cm with arterial injury

Question 10

Fracture of the neck of the humerus is common in:

Accepted Answer

Elderly woman

Answer

Young lady

Answer

Elderly man

Answer

All of these

Trauma — MCQs

Trauma — MCQs

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