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Here is the complete MCQ and Clinical Case Question bank drawn from all 8 PDFs, with deep general orthopaedic knowledge woven in:
ORTHOPAEDIC TRAUMA & EXAMINATION - COMPLETE MCQ & CLINICAL CASE BANK
SECTION 1: MANAGEMENT OF ORTHOPAEDIC TRAUMA
MCQs
Q1. In the primary survey of a trauma patient, what does the "E" in ABCDE stand for?
- A) Evaluation
- B) Exposure
- C) Extremity exam
- D) Echo (FAST)
Answer: B - Exposure. The full primary survey sequence is Airway, Breathing, Circulation, Disability, Exposure. Exposure means fully undressing the patient to identify all injuries.
Q2. Which principle best describes the priority in orthopaedic trauma management?
- A) Limb before life
- B) Life before limb
- C) Imaging before examination
- D) Surgery before stabilization
Answer: B - Life before limb. Treat life-threatening injuries (airway, hemorrhage, shock) before addressing fractures.
Q3. Which of the following fracture types is an absolute indication for surgical management?
- A) Stable, non-displaced closed fracture
- B) Stable fracture in an elderly patient
- C) Open fracture with neurovascular injury
- D) Minimally displaced radial fracture
Answer: C - Open fracture with neurovascular injury. Open fractures require emergency surgery: antibiotics, debridement, and fracture stabilization. Neurovascular injury adds urgency.
Q4. What is the first-line imaging modality for evaluating a suspected fracture?
- A) MRI
- B) CT
- C) X-ray
- D) Ultrasound
Answer: C - X-ray. X-ray uses ionizing radiation to produce images of bones and is the standard first-line investigation for all suspected fractures.
Q5. Which of the following is NOT part of the classic compartment syndrome (5P) monitoring?
- A) Pain
- B) Pulse
- C) Paralysis
- D) Pyrexia
Answer: D - Pyrexia. The 5Ps of compartment syndrome are: Pain, Pulse (weak), Pallor, Paresthesia, Paralysis. Fever is a sign of infection, not compartment syndrome.
Q6. A patient sustains a fracture. Pain worsens with passive stretch of the affected muscles. What is the most likely diagnosis?
- A) Deep vein thrombosis
- B) Wound infection
- C) Compartment syndrome
- D) Malunion
Answer: C - Compartment syndrome. Pain on passive stretch is the hallmark early sign. It requires emergency fasciotomy.
Q7. RICE stands for which management principle in soft tissue injuries?
- A) Rest, Ice, Compression, Elevation
- B) Reduction, Immobilization, Cast, Exercise
- C) Rest, Imaging, Cast, Elevation
- D) Range-of-motion, Ice, Compression, Exercise
Answer: A - Rest, Ice, Compression, Elevation. This is standard first-line treatment for sprains and strains.
Q8. Which surgical fixation method is most commonly used for femoral shaft fractures?
- A) External fixation
- B) ORIF with plates
- C) Intramedullary nail
- D) Casting alone
Answer: C - Intramedullary nail. IM nailing is the gold standard for femoral shaft fractures - it provides strong axial stability and allows early weight bearing.
Q9. The secondary survey in trauma includes:
- A) ABCDE assessment
- B) Full musculoskeletal examination
- C) Emergency airway management
- D) Hemorrhage control
Answer: B - Full musculoskeletal examination. The secondary survey is performed after life-threatening issues are stabilized and involves a head-to-toe examination including the musculoskeletal system.
Q10. Which complication is characterized by abnormal bone healing in a malpositioned alignment?
- A) Non-union
- B) Malunion
- C) Osteomyelitis
- D) Avascular necrosis
Answer: B - Malunion. Malunion = fracture healed in an incorrect position. Non-union = fracture failed to heal.
SECTION 2: SHOULDER & ARM EXAMINATION
MCQs
Q11. The rotator cuff is composed of which four muscles?
- A) Deltoid, supraspinatus, infraspinatus, subscapularis
- B) Supraspinatus, infraspinatus, teres minor, subscapularis
- C) Supraspinatus, teres major, infraspinatus, subscapularis
- D) Deltoid, teres minor, infraspinatus, subscapularis
Answer: B - Supraspinatus, infraspinatus, teres minor, subscapularis. Remember the mnemonic SITS. Teres major is NOT part of the rotator cuff.
Q12. A painful arc occurs during shoulder abduction between which degrees?
- A) 0-30°
- B) 60-120°
- C) 120-180°
- D) 0-60°
Answer: B - 60-120°. A painful arc during mid-range abduction suggests supraspinatus tendon impingement under the coracoacromial arch.
Q13. The Neer test is used to assess:
- A) AC joint instability
- B) Subacromial impingement
- C) Biceps tendon rupture
- D) Glenohumeral dislocation
Answer: B - Subacromial impingement. The Neer test passively flexes the arm while stabilizing the scapula, compressing the supraspinatus under the acromion.
Q14. A patient with anterior shoulder pain worsened by overhead activities most likely has pathology in which structure?
- A) Infraspinatus
- B) Biceps tendon (long head)
- C) Subscapularis
- D) Teres minor
Answer: B - Biceps tendon. Anterior shoulder pain is typically associated with biceps tendinopathy. Global pain suggests frozen shoulder; lateral pain suggests rotator cuff.
Q15. Scapular winging is caused by weakness of which muscle?
- A) Trapezius
- B) Serratus anterior
- C) Deltoid
- D) Rhomboids
Answer: B - Serratus anterior. Serratus anterior (innervated by the long thoracic nerve) holds the scapula against the chest wall. Its weakness causes medial winging.
Q16. Which X-ray view is essential for diagnosing posterior shoulder dislocation?
- A) AP view only
- B) Axillary lateral view
- C) Scapular Y view
- D) Both B and C
Answer: D - Both B and C. AP views can appear normal in posterior dislocation ("lightbulb sign"). Axillary or scapular Y views confirm the dislocation direction.
Q17. The Hawkins test reproduces pain by:
- A) External rotation with adduction
- B) Internal rotation with forward flexion at 90°
- C) Resisted abduction at 90°
- D) Passive horizontal adduction
Answer: B - Internal rotation with forward flexion at 90°. This impinges the supraspinatus tendon under the coracoacromial ligament.
SECTION 3: ELBOW & FOREARM EXAMINATION
MCQs
Q18. Lateral elbow pain reproduced by resisted wrist extension is most consistent with:
- A) Golfer's elbow
- B) Cubital tunnel syndrome
- C) Tennis elbow (lateral epicondylitis)
- D) Olecranon bursitis
Answer: C - Tennis elbow. Lateral epicondylitis involves the ECRB (extensor carpi radialis brevis) origin. The Cozen test (resisted wrist extension) is positive.
Q19. The Golfer's test (medial epicondyle tenderness) tests for:
- A) Lateral epicondylitis
- B) Medial epicondylitis
- C) UCL tear
- D) Radial head fracture
Answer: B - Medial epicondylitis. Golfer's elbow involves the flexor-pronator origin at the medial epicondyle.
Q20. Normal elbow pronation and supination range is approximately:
- A) 60° each
- B) 80° each
- C) 45° each
- D) 90° each
Answer: B - 80° each. Normal pronation is ~80°, supination ~80°. Loss suggests proximal radioulnar joint pathology.
Q21. A Monteggia fracture involves:
- A) Distal radius fracture + distal radioulnar joint dislocation
- B) Proximal ulna fracture + radial head dislocation
- C) Both-bone forearm fracture
- D) Distal ulna fracture + radial styloid fracture
Answer: B - Proximal ulna fracture + radial head dislocation. Galeazzi = distal radius + distal radioulnar dislocation. Monteggia = proximal ulna + radial head dislocation.
Q22. A Tinel sign at the medial elbow (cubital tunnel) suggests compression of which nerve?
- A) Median nerve
- B) Radial nerve
- C) Ulnar nerve
- D) Musculocutaneous nerve
Answer: C - Ulnar nerve. The ulnar nerve passes through the cubital tunnel posterior to the medial epicondyle. Tinel's here = cubital tunnel syndrome.
Q23. Normal elbow flexion is approximately:
- A) 90°
- B) 120°
- C) 145°
- D) 160°
Answer: C - 145°. Normal elbow flexion is approximately 145°, extension 0° (or slight hyperextension in women/children).
SECTION 4: WRIST & HAND EXAMINATION
MCQs
Q24. A patient falls on an outstretched hand (FOOSH) and presents with anatomical snuffbox tenderness. What is the most concerning fracture to rule out?
- A) Distal radius fracture (Colles')
- B) Scaphoid fracture
- C) Triquetrum fracture
- D) Bennett fracture
Answer: B - Scaphoid fracture. The anatomical snuffbox lies over the scaphoid. Scaphoid fractures risk avascular necrosis due to retrograde blood supply and must not be missed even if initial X-ray is normal.
Q25. Which test is positive in carpal tunnel syndrome?
- A) Froment sign
- B) Phalen test
- C) Finkelstein test
- D) Tinel sign at the wrist (Phalen)
Answer: B - Phalen test. Phalen test = sustained wrist flexion reproduces numbness/tingling in the median nerve distribution (thumb, index, middle fingers). Tinel at the wrist also supports CTS.
Q26. Froment sign tests for weakness of which muscle?
- A) Flexor pollicis longus
- B) Adductor pollicis (ulnar nerve)
- C) Opponens pollicis
- D) Abductor pollicis brevis
Answer: B - Adductor pollicis. Froment's sign: patient flexes the IP joint of the thumb to compensate for weak adductor pollicis (ulnar nerve palsy) when holding a piece of paper.
Q27. A claw hand deformity (hyperextension at MCP, flexion at IP joints) affecting the ring and little fingers indicates injury to:
- A) Median nerve
- B) Radial nerve
- C) Ulnar nerve
- D) Anterior interosseous nerve
Answer: C - Ulnar nerve. Ulnar claw affects the ring and little fingers (intrinsic minus position). Median nerve injury causes a more subtle claw in index and middle fingers.
Q28. If a patient cannot extend the wrist or fingers after a humeral shaft fracture, which nerve is injured?
- A) Ulnar nerve
- B) Median nerve
- C) Radial nerve
- D) Musculocutaneous nerve
Answer: C - Radial nerve. The radial nerve spirals around the humerus in the radial groove. A mid-shaft humerus fracture classically injures it, causing wrist drop.
Q29. Which imaging modality is best for detecting an occult scaphoid fracture when X-ray is normal?
- A) CT scan
- B) MRI
- C) Ultrasound
- D) Bone scintigraphy
Answer: B - MRI. MRI is the gold standard for occult scaphoid fractures - it detects bone marrow edema within 24 hours. CT is excellent for fracture geometry but may miss early occult fractures.
SECTION 5: THIGH & KNEE EXAMINATION
MCQs
Q30. The Lachman test is used to assess:
- A) MCL integrity
- B) PCL integrity
- C) ACL integrity
- D) Meniscal tear
Answer: C - ACL integrity. Lachman test = anterior tibial translation with knee at 30° flexion. Most sensitive test for ACL rupture (>90% sensitivity vs 80% for anterior drawer test).
Q31. A positive McMurray test indicates:
- A) ACL tear
- B) Meniscal tear
- C) PCL tear
- D) IT band syndrome
Answer: B - Meniscal tear. McMurray test = rotation and compression of the knee during flexion-extension. A click or pain = positive for meniscal tear.
Q32. Hemarthrosis (blood in the knee joint) after trauma most commonly indicates:
- A) Medial collateral ligament sprain
- B) ACL tear or intra-articular fracture
- C) Patellofemoral syndrome
- D) Iliotibial band syndrome
Answer: B - ACL tear or intra-articular fracture. Hemarthrosis within 2 hours of knee injury has ~70% association with ACL rupture. Fat droplets in the aspirate indicate osteochondral fracture.
Q33. Peroneal nerve injury at the fibular head results in:
- A) Foot drop
- B) Calf weakness
- C) Loss of plantar flexion
- D) Inversion weakness
Answer: A - Foot drop. The common peroneal nerve wraps around the fibular neck and supplies dorsiflexors (tibialis anterior) and evertors. Injury = foot drop + sensory loss over dorsum of foot.
Q34. Normal knee flexion is approximately:
- A) 90°
- B) 110°
- C) 135°
- D) 150°
Answer: C - 135°. Normal active knee flexion is approximately 135°, extension 0°.
Q35. A tibial plateau fracture is best further characterized with:
- A) X-ray alone
- B) MRI
- C) CT scan
- D) Ultrasound
Answer: C - CT scan. CT provides detailed 3D characterization of tibial plateau fractures, essential for surgical planning. MRI adds ligament/meniscal assessment.
SECTION 6: ANKLE & FOOT EXAMINATION
MCQs
Q36. The Thompson test assesses:
- A) Anterior talofibular ligament
- B) Achilles tendon integrity
- C) Plantar fascia
- D) Deltoid ligament
Answer: B - Achilles tendon integrity. Thompson test = squeeze the calf in prone position. Absence of plantarflexion = Achilles tendon rupture.
Q37. The anterior drawer test of the ankle assesses:
- A) Deltoid ligament
- B) Calcaneofibular ligament (CFL)
- C) Anterior talofibular ligament (ATFL)
- D) Posterior talofibular ligament (PTFL)
Answer: C - ATFL. The ATFL is the most commonly injured ankle ligament in inversion sprains. Anterior drawer test = anterior translation of the talus on the tibia.
Q38. Which Ottawa Ankle Rule finding requires X-ray after ankle injury?
- A) Soft tissue swelling only
- B) Inability to bear weight for 4 steps
- C) Lateral ankle bruising
- D) Pain on movement
Answer: B - Inability to bear weight for 4 steps. Ottawa Ankle Rules: inability to bear weight OR bony tenderness at the posterior 6 cm of fibula or tibia or base of 5th metatarsal or navicular.
Q39. A calcaneal fracture after a fall from height is best imaged with:
- A) X-ray only
- B) MRI
- C) CT scan
- D) Ultrasound
Answer: C - CT scan. Calcaneal fractures from axial loading are complex and require CT for accurate classification (Sanders classification) and surgical planning.
Q40. Lateral ankle pain after an inversion injury most likely involves:
- A) Deltoid ligament
- B) Achilles tendon
- C) Anterior talofibular ligament
- D) Plantar fascia
Answer: C - ATFL. The ATFL is the weakest and most commonly torn ligament in lateral ankle sprains from inversion.
Q41. The three ankle mortise X-ray views are:
- A) AP, lateral, oblique
- B) AP, lateral, mortise
- C) AP, lateral, axial
- D) Oblique, mortise, axial
Answer: B - AP, lateral, mortise. The mortise view (15-20° internal rotation) shows the full talar dome and all three mortise surfaces clearly.
SECTION 7: PELVIS & HIP EXAMINATION
MCQs
Q42. A positive Trendelenburg test indicates weakness of:
- A) Iliopsoas
- B) Adductor longus
- C) Gluteus medius
- D) Gluteus maximus
Answer: C - Gluteus medius. Trendelenburg test: when standing on one leg, contralateral pelvis drops = positive = ipsilateral gluteus medius weakness (or superior gluteal nerve injury/hip pathology).
Q43. The Thomas test detects:
- A) Hip abductor weakness
- B) Hip flexor contracture
- C) Sacroiliac joint pathology
- D) Femoral neck fracture
Answer: B - Hip flexor contracture. Thomas test: supine patient flexes uninvolved hip to flatten lumbar lordosis; if the test leg rises off the table = fixed flexion deformity of the hip (iliopsoas contracture).
Q44. Which imaging modality is the gold standard for pelvic fracture assessment?
- A) X-ray
- B) MRI
- C) Ultrasound
- D) CT scan
Answer: D - CT scan. CT is the gold standard for pelvic fractures, providing detailed bony anatomy and vascular injury assessment. FAST ultrasound detects free fluid (hemorrhage).
Q45. A patient involved in a high-energy motor vehicle accident presents with hypotension, pelvic instability, and hematuria. What is the priority concern?
- A) Femoral neck fracture
- B) Acetabular fracture alone
- C) Pelvic ring disruption with hemorrhage and bladder injury
- D) Hip dislocation
Answer: C - Pelvic ring disruption with hemorrhage and bladder injury. Pelvic fractures are life-threatening due to massive retroperitoneal hemorrhage. Hematuria suggests associated bladder/urethral injury.
Q46. FAST ultrasound in trauma detects:
- A) Fracture lines
- B) Free intraperitoneal fluid/blood
- C) Nerve injuries
- D) Joint effusions
Answer: B - Free intraperitoneal fluid/blood. FAST (Focused Assessment with Sonography in Trauma) detects free fluid in the pericardium, hepatorenal space, splenorenal space, and pelvis.
Q47. Hip ROM assessment includes all of the following EXCEPT:
- A) Flexion
- B) Extension
- C) Internal/external rotation
- D) Pronation
Answer: D - Pronation. Pronation/supination is a forearm movement. Hip ROM includes flexion, extension, abduction, adduction, and internal/external rotation.
SECTION 8: CAST, INTERNAL & EXTERNAL FIXATION
MCQs
Q48. After applying a cast, which immediate check is most important?
- A) Request X-ray
- B) Perform neurovascular assessment
- C) Administer antibiotics
- D) Check blood pressure
Answer: B - Neurovascular assessment. Immediately post-cast, assess circulation (color, temperature, pulses), sensation (paresthesia), and movement (paralysis) - the 5Ps.
Q49. Which complication is most feared after tight cast application?
- A) Cast cracking
- B) Compartment syndrome
- C) Superficial skin irritation
- D) Joint stiffness
Answer: B - Compartment syndrome. A tight cast increases compartment pressure, reducing perfusion and risking muscle and nerve necrosis. Early recognition is life/limb-saving.
Q50. What is the correct limb position after cast application to reduce swelling?
- A) Dependent (below heart)
- B) Horizontal
- C) Elevated above heart level
- D) Position does not matter
Answer: C - Elevated above heart level. Elevation reduces venous pooling, edema, and compartment pressure after cast application.
Q51. External fixators are used in which scenario?
- A) Stable closed fractures
- B) Simple wrist fractures
- C) Severe open fractures and complex pelvic trauma
- D) Undisplaced metacarpal fractures
Answer: C - Severe open fractures and complex pelvic trauma. External fixators provide rapid stabilization in severe open injuries, polytrauma, and when soft tissue conditions preclude internal fixation.
Q52. Pin site care for external fixators involves:
- A) Weekly soaking in water
- B) Daily cleaning and monitoring for infection
- C) Tight dressing with no air exposure
- D) Antibiotic ointment every 6 hours
Answer: B - Daily cleaning and monitoring for infection. Pin site infections are the most common complication of external fixation. Daily cleaning with antiseptic solution and close monitoring are standard.
Q53. Which type of internal fixation provides rotational stability and allows early weight bearing for long bone fractures?
- A) K-wire
- B) External fixator
- C) Intramedullary nail
- D) Half-pin fixator
Answer: C - Intramedullary nail. IM nailing provides axial and rotational stability through the medullary canal, enabling early weight bearing and reducing non-union risk.
CLINICAL CASE QUESTIONS
CASE 1 - Orthopaedic Trauma (Management)
A 28-year-old male motorcyclist is brought to the ED after a high-speed collision. He is agitated, BP 85/50 mmHg, HR 128/min. He has obvious right thigh deformity, an open wound with bone visible on the left forearm, and is moving all four limbs.
Q1. What is the immediate priority in management?
Answer: Primary survey (ABCDE). The patient is in hemorrhagic shock (BP 85/50, HR 128). Airway, breathing, and circulation take priority - IV access, fluid resuscitation, hemorrhage control. Life before limb.
Q2. The open forearm fracture is classified as an emergency. What are the three immediate steps?
Answer: (1) IV antibiotics (cephalosporin ± aminoglycoside based on contamination), (2) wound debridement and irrigation in theatre, (3) fracture stabilization (external fixation or IM nail depending on soft tissue). Early tetanus prophylaxis.
Q3. 6 hours post-surgery, the forearm cast feels tight and the patient reports severe pain unrelieved by morphine, with tingling in the fingers. What must be done immediately?
Answer: This is compartment syndrome (severe pain + paresthesia post-cast). Immediately split/bivalve the cast. If pressure remains elevated (>30 mmHg or within 30 mmHg of diastolic), emergency fasciotomy is required.
Q4. On day 3, the patient develops fever, wound discharge, and redness around the surgical site. What is the diagnosis and management?
Answer: Surgical site infection. Wound swab for culture, IV antibiotics, wound inspection/washout if needed. Maintain strict sterile technique on dressing changes.
CASE 2 - Shoulder Examination
A 45-year-old right-handed painter presents with 3 months of right shoulder pain, worse with overhead work. He has no history of trauma. On examination: painful arc 60-120°, positive Neer sign, positive Hawkins test. Full passive ROM.
Q1. What is the most likely diagnosis?
Answer: Subacromial impingement syndrome (rotator cuff tendinopathy). Painful arc, positive Neer and Hawkins tests, and normal passive ROM are characteristic.
Q2. Which specific rotator cuff muscle is most likely affected?
Answer: Supraspinatus - it passes directly under the coracoacromial arch and is the most commonly impinged tendon.
Q3. What is the most appropriate initial imaging?
Answer: Shoulder X-ray (AP + axillary) to exclude bony pathology. If symptoms persist after conservative treatment, MRI or ultrasound to assess rotator cuff integrity directly.
Q4. Conservative management fails after 3 months. What are the next steps?
Answer: Subacromial corticosteroid injection for symptom relief, continued physiotherapy (scapular stabilization, rotator cuff strengthening). If symptoms persist >6 months, arthroscopic subacromial decompression.
CASE 3 - Elbow Examination
A 35-year-old tennis player presents with 6 weeks of lateral elbow pain that worsens when lifting objects with the elbow extended. Cozen test is positive.
Q1. What is the diagnosis?
Answer: Lateral epicondylitis (tennis elbow). Involves the extensor carpi radialis brevis (ECRB) origin at the lateral epicondyle.
Q2. The patient also reports tingling on the medial side of his hand (ring and little fingers). What additional diagnosis must be considered?
Answer: Cubital tunnel syndrome (ulnar nerve compression at the elbow). A positive Tinel sign at the medial elbow and Froment's sign would support this.
Q3. What is the first-line imaging for suspected radial head fracture in a different patient who falls on an outstretched hand with posterior elbow pain and limited pronation/supination?
Answer: AP and lateral X-ray of the elbow (include both joints). CT if fracture is not visible but clinically suspected, or for surgical planning.
Q4. Name the fracture combination: proximal ulna fracture with radial head dislocation.
Answer: Monteggia fracture. Remember: Monteggia = ulna + radial head dislocates anteriorly. Galeazzi = distal radius + distal radioulnar joint dislocation.
CASE 4 - Wrist & Hand Examination
A 22-year-old falls onto an outstretched hand playing football. He has anatomical snuffbox tenderness, pain on axial compression of the thumb, and a normal X-ray.
Q1. What fracture must be assumed until proven otherwise?
Answer: Scaphoid fracture. Snuffbox tenderness + normal X-ray = treat as scaphoid fracture. Initial X-rays miss up to 20% of scaphoid fractures.
Q2. What is the risk of missed/untreated scaphoid fracture?
Answer: Avascular necrosis (AVN) of the proximal scaphoid due to its retrograde blood supply. This leads to collapse and wrist osteoarthritis (scapholunar advanced collapse, SLAC wrist).
Q3. What imaging should be ordered to confirm the diagnosis when X-ray is negative?
Answer: MRI (gold standard, detects marrow edema within 24 hours) or CT (better for fracture geometry). Bone scintigraphy if MRI unavailable.
Q4. Another patient has weakness of thumb adduction and a positive Froment sign. Which nerve is injured and where is the most common site of compression?
Answer: Ulnar nerve. Most common compression site: Guyon's canal at the wrist (ulnar tunnel syndrome). Also affected at the elbow (cubital tunnel).
CASE 5 - Thigh & Knee Examination
A 19-year-old footballer hears a "pop" during a cutting maneuver. His knee immediately swells (hemarthrosis within 1 hour). Lachman test is positive.
Q1. What structure is most likely injured?
Answer: Anterior cruciate ligament (ACL). Acute hemarthrosis + positive Lachman test after a non-contact twisting injury is the classic ACL presentation.
Q2. Which other structures should be assessed in the same examination?
Answer: MCL (valgus stress test), LCL (varus stress test), PCL (posterior drawer/sag sign), and menisci (McMurray + Thessaly tests). A combined ACL + MCL + medial meniscus tear = O'Donoghue's unhappy triad.
Q3. What is the recommended imaging sequence?
Answer: X-ray first (rule out fracture, Segond fracture = lateral capsular avulsion pathognomonic of ACL rupture), then MRI for ligament, meniscal, and cartilage assessment.
Q4. A 70-year-old woman with the same mechanism has a tibial plateau fracture on X-ray. Why is CT essential here?
Answer: CT provides 3D characterization of the fracture pattern (lateral vs medial, depression vs split, Schatzker classification), which directly determines surgical approach and need for bone grafting.
CASE 6 - Ankle & Foot Examination
A 24-year-old basketball player twists his ankle in inversion. He has lateral ankle swelling and tenderness anterior to the fibula. He can walk 4 steps but with pain.
Q1. Which ligament is most likely injured?
Answer: Anterior talofibular ligament (ATFL) - the weakest lateral ankle ligament, first to rupture in inversion injury.
Q2. Is an X-ray indicated according to Ottawa Ankle Rules?
Answer: Ottawa rules require X-ray if: bony tenderness over posterior 6 cm of fibula or tibia OR inability to bear weight for 4 steps. He can walk 4 steps. X-ray is not strictly required if there is no bony tenderness - it is a clinical decision.
Q3. How would you assess for Achilles tendon rupture in a different patient?
Answer: Thompson test: prone patient, squeeze the calf - absence of plantarflexion = complete Achilles tendon rupture. Also check for a palpable gap, loss of plantarflexion power.
Q4. A 50-year-old falls from a height and cannot walk. Severe calcaneal bruising (Mondor sign). What is the investigation of choice and what associated injury must be excluded?
Answer: CT scan of the calcaneus (Sanders classification). Axial loading from height = always exclude thoracolumbar spine fracture (T12-L1) in the same mechanism.
CASE 7 - Pelvis & Hip Examination
A 75-year-old woman falls and cannot bear weight on her left leg. The leg is shortened and externally rotated. BP is stable.
Q1. What is the most likely diagnosis?
Answer: Left femoral neck (intracapsular) or intertrochanteric (extracapsular) fracture. Shortened, externally rotated leg in an elderly woman after a low-energy fall = classic hip fracture presentation.
Q2. What is the initial imaging?
Answer: AP pelvis and lateral hip X-ray. If X-ray is negative but clinical suspicion remains high (e.g., unable to weight bear), MRI is the gold standard for occult hip fracture.
Q3. The patient develops hypotension and tachycardia after a high-energy pelvic fracture in a different scenario. What is the immediate investigation?
Answer: FAST ultrasound (detects free fluid/hemorrhage) followed by CT if stable. Pelvic ring disruption causes massive retroperitoneal hemorrhage - pelvic binder + resuscitation as bridge to angioembolization or surgery.
Q4. A positive Trendelenburg test during a hip examination indicates:
Answer: Weakness of the ipsilateral gluteus medius or superior gluteal nerve palsy, or hip pathology (osteoarthritis, hip dysplasia). The contralateral pelvis drops when standing on the affected leg.
CASE 8 - Cast & Fixation Care
A 10-year-old child has a below-knee cast for a distal tibia fracture. 4 hours later he is crying with severe pain, and his toes are pale, cold, with reduced sensation.
Q1. What is the diagnosis and immediate action?
Answer: Acute compartment syndrome in a tight cast. Immediate action: bivalve (split) the cast fully, including padding. Reassess neurovascular status. If no improvement, urgent fasciotomy.
Q2. Name all 5 Ps of compartment syndrome monitoring.
Answer: Pain (especially on passive stretch), Pallor, Pulselessness, Paresthesia, Paralysis.
Q3. Two weeks later, a different patient with an external fixator has pin site redness, warmth, and purulent discharge. What is the management?
Answer: Pin site infection. Wound swab for culture and sensitivities. Start oral antibiotics (usually flucloxacillin or co-amoxiclav). Daily pin site cleaning. In severe cases, pin removal and replacement may be needed.
Q4. What is the rehabilitation principle that has replaced prolonged immobilization in modern fracture management?
Answer: Early mobilization (and physiotherapy). Evidence shows early movement reduces stiffness, muscle wasting, DVT risk, and speeds functional recovery. Full immobilization is reserved for cases with specific indications.
DEEP GENERAL KNOWLEDGE MCQs (Beyond the Slides)
Q53. The blood supply to the femoral head runs primarily via:
- A) Obturator artery
- B) Lateral femoral circumflex artery
- C) Medial femoral circumflex artery
- D) Superior gluteal artery
Answer: C - Medial femoral circumflex artery. It supplies the retinacular vessels that course along the femoral neck. Fractures disrupt this supply, causing AVN of the femoral head.
Q54. Garden classification is used for:
- A) Tibial plateau fractures
- B) Femoral neck fractures
- C) Distal radius fractures
- D) Calcaneal fractures
Answer: B - Femoral neck fractures. Garden I-IV: I = incomplete/valgus impacted, II = complete undisplaced, III = complete partially displaced, IV = complete fully displaced.
Q55. The Segond fracture on X-ray is a strong indicator of:
- A) MCL tear
- B) PCL tear
- C) ACL tear
- D) Meniscal root tear
Answer: C - ACL tear. A Segond fracture is a small avulsion from the lateral tibial plateau - it is nearly pathognomonic for ACL rupture.
Q56. Scapholunar advanced collapse (SLAC wrist) is the end result of:
- A) Untreated distal radius fracture
- B) Untreated scaphoid AVN
- C) TFCC tear
- D) Extensor tendon injury
Answer: B - Untreated scaphoid AVN. Proximal scaphoid AVN leads to scaphoid collapse, rotatory subluxation of the scaphoid, and a predictable pattern of radiocarpal then midcarpal arthritis.
Q57. Which fracture pattern involves a radial head fracture combined with elbow dislocation?
- A) Monteggia fracture
- B) Galeazzi fracture
- C) Terrible triad of the elbow
- D) Essex-Lopresti fracture
Answer: C - Terrible triad. Terrible triad = elbow dislocation + coronoid fracture + radial head fracture. Very unstable, requires surgical fixation.
Q58. The scaphoid tubercle (Palmer aspect) is a landmark for which nerve?
- A) Radial nerve
- B) Ulnar nerve
- C) Median nerve (in Guyon's canal)
- D) Anterior interosseous nerve
Answer: C - Median nerve. The median nerve passes through the carpal tunnel medial to the scaphoid tubercle, which is the radial border of the tunnel.
Q59. Boutonniere deformity (PIP flexion, DIP hyperextension) results from:
- A) FDP tendon rupture
- B) Central slip (extensor mechanism) rupture at PIP joint
- C) Volar plate injury
- D) FDS tendon rupture
Answer: B - Central slip rupture. Central slip disruption allows the lateral bands to slide volar to the PIP joint axis, causing PIP flexion and DIP hyperextension.
Q60. A fracture at the base of the 5th metatarsal from acute inversion is called:
- A) Jones fracture
- B) Dancer's fracture
- C) Lisfranc fracture
- D) Stress fracture
Answer: B - Dancer's (avulsion) fracture. Avulsion of the peroneus brevis at the tuberosity (styloid) of the 5th metatarsal base. Jones fracture is at the metadiaphyseal junction (zone 2) and has higher non-union risk.
ANSWERS SUMMARY TABLE
| Q# | Topic | Answer |
|---|---|---|
| 1 | ABCDE | B - Exposure |
| 2 | Trauma priority | B - Life before limb |
| 3 | Surgery indication | C - Open # + NV injury |
| 4 | First-line imaging | C - X-ray |
| 5 | 5P monitoring | D - Pyrexia (NOT a P) |
| 6 | Compartment syndrome | C |
| 7 | RICE | A |
| 8 | Femoral shaft fixation | C - IM nail |
| 9 | Secondary survey | B - Full MSK exam |
| 10 | Malunion | B |
| 11 | Rotator cuff | B - SITS |
| 12 | Painful arc | B - 60-120° |
| 13 | Neer test | B - Impingement |
| 14 | Anterior shoulder pain | B - Biceps |
| 15 | Scapular winging | B - Serratus anterior |
| 16 | Posterior dislocation X-ray | D - Axillary + Y |
| 17 | Hawkins test | B |
| 18 | Tennis elbow | C |
| 19 | Golfer's test | B - Medial epicondylitis |
| 20 | Forearm ROM | B - 80° |
| 21 | Monteggia | B - Ulna + radial head |
| 22 | Tinel at cubital tunnel | C - Ulnar nerve |
| 23 | Elbow flexion | C - 145° |
| 24 | FOOSH snuffbox | B - Scaphoid |
| 25 | CTS test | B - Phalen |
| 26 | Froment sign | B - Adductor pollicis |
| 27 | Ulnar claw | C - Ulnar nerve |
| 28 | Wrist drop | C - Radial nerve |
| 29 | Occult scaphoid | B - MRI |
| 30 | Lachman test | C - ACL |
| 31 | McMurray test | B - Meniscus |
| 32 | Hemarthrosis | B - ACL or fracture |
| 33 | Foot drop | A - Peroneal nerve |
| 34 | Knee flexion | C - 135° |
| 35 | Tibial plateau imaging | C - CT |
| 36 | Thompson test | B - Achilles |
| 37 | Anterior drawer ankle | C - ATFL |
| 38 | Ottawa rules | B - Cannot bear weight |
| 39 | Calcaneal fracture | C - CT |
| 40 | Lateral ankle injury | C - ATFL |
| 41 | Ankle X-ray views | B - AP/lateral/mortise |
| 42 | Trendelenburg | C - Gluteus medius |
| 43 | Thomas test | B - Hip flexor contracture |
| 44 | Pelvic fracture imaging | D - CT |
| 45 | Pelvic ring disruption | C |
| 46 | FAST ultrasound | B - Free fluid |
| 47 | Hip ROM exception | D - Pronation |
| 48 | Post-cast priority | B - Neurovascular check |
| 49 | Tight cast complication | B - Compartment syndrome |
| 50 | Post-cast positioning | C - Elevated |
| 51 | External fixator indication | C |
| 52 | Pin site care | B - Daily cleaning |
| 53 | Femoral head blood supply | C - MFCA |
| 54 | Garden classification | B - Femoral neck |
| 55 | Segond fracture | C - ACL |
| 56 | SLAC wrist | B - Scaphoid AVN |
| 57 | Terrible triad | C |
| 58 | Scaphoid tubercle nerve | C - Median |
| 59 | Boutonniere | B - Central slip |
| 60 | 5th metatarsal base | B - Dancer's fracture |
That is a total of 60 MCQs with detailed answers and 8 clinical case scenarios with 4 sub-questions each (32 case questions total) - covering all 8 of your PDFs plus deep general orthopaedic knowledge on anatomy, biomechanics, fracture classification, nerve injuries, special tests, and emergency management.
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