Trauma — MCQs
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Which of the following diagnostic studies is NOT useful in the evaluation of upper-extremity pain?
What is the best treatment for an old fracture?
A 40-year-old man presents with a fracture of the shaft of the femur following a road traffic accident. Three days after trauma, he becomes tachypnoeic and develops conjunctival petechiae. What is the most likely diagnosis?
In acute knee injuries with swelling and hemarthrosis with muscle spasm, which of the following tests is most sensitive to detect anterior cruciate ligament injury?
What is a Colles fracture?
What does an increase in Pauwel's angle indicate?
What is the initial management for an open fracture?
A patient presents with hip dislocation characterized by limitation of abduction, and a fixed deformity of flexion and internal rotation at the hip, along with limb shortening. What is the most likely diagnosis?
All of the following factors evaluate the chances of amputation in a limb, except?
What is true about intertrochanteric fracture?
Trauma Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following diagnostic studies is NOT useful in the evaluation of upper-extremity pain?
- A. Cervical spine x-ray
- B. Chest X-ray
- C. Neural conduction studies of the median nerve
- D. Adson's test (Correct Answer)
Explanation: **Explanation:** The correct answer is **Adson’s test**. While it is a classic physical examination maneuver used to assess for Thoracic Outlet Syndrome (TOS), it is **not a diagnostic study** (imaging or electrodiagnostic test). Furthermore, in modern clinical practice, Adson’s test is considered unreliable due to a high rate of false positives (up to 25% in healthy individuals), making it "not useful" as a definitive diagnostic tool compared to objective studies. **Analysis of Options:** * **Cervical spine X-ray:** Essential to rule out cervical spondylosis or a herniated disc, which frequently cause referred pain to the upper extremity (cervical radiculopathy). * **Chest X-ray:** Crucial for identifying a **cervical rib** or a **Pancoast tumor** (at the lung apex), both of which can compress the brachial plexus and cause radiating arm pain. * **Neural conduction studies (NCS):** These are objective electrodiagnostic tests used to confirm focal neuropathies, such as Carpal Tunnel Syndrome (median nerve compression), a common cause of upper limb pain. **Clinical Pearls for NEET-PG:** * **Adson’s Test:** Performed by extending the patient's neck and rotating the head toward the affected side while taking a deep breath. A positive result is the disappearance of the radial pulse. * **Thoracic Outlet Syndrome (TOS):** Most commonly caused by a cervical rib (C7) or tight scalene muscles. * **High-Yield Fact:** For upper extremity pain radiating from the neck, the **Spurling test** (foraminal compression) is more specific for cervical radiculopathy than Adson’s is for TOS.
Question 2: What is the best treatment for an old fracture?
- A. Manipulation and POP cast application.
- B. Open reduction and internal fixation and bone grafting. (Correct Answer)
- C. K Wire fixation
- D. External fixation
Explanation: **Explanation:** In orthopaedics, an **"old fracture"** (also known as a neglected fracture) refers to a fracture that has remained untreated for more than 3 weeks. By this stage, the fracture ends are rounded off, the medullary canal may be sclerosed, and the intervening gap is filled with dense fibrous tissue or exuberant callus. **Why Option B is correct:** Treatment of an old fracture requires a three-pronged approach: 1. **Open Reduction:** Since the fracture is no longer fresh, manual manipulation is impossible due to soft tissue contractures and fibrous union. The site must be surgically opened to clear the fibrous tissue. 2. **Internal Fixation:** Rigid stability (usually with plates or nails) is necessary to allow for primary or secondary bone healing. 3. **Bone Grafting:** This is the **most critical step**. In old fractures, the biological healing potential is diminished. Bone grafting provides osteoconductive, osteoinductive, and osteogenic properties to "jump-start" the healing process and bridge any gaps created during the freshening of bone ends. **Why other options are incorrect:** * **Option A:** Manipulation is only effective for fresh fractures (<1-2 weeks). In old fractures, the soft tissue has contracted, and the fracture is "sticky," making closed reduction impossible and dangerous. * **Option C:** K-wires do not provide enough rigid stability to overcome the mechanical challenges of an old fracture and do not address the biological need for grafting. * **Option D:** External fixation is primarily used for open fractures with severe soft tissue injury or infected non-unions; it is not the standard primary treatment for a simple old fracture. **Clinical Pearls for NEET-PG:** * **Definition:** A fracture is generally termed "old" after 3 weeks. * **The "Freshening" Concept:** During surgery for old fractures, the bone ends must be "freshened" until punctate bleeding (the **Papineau sign**) is seen to ensure a good blood supply for the graft. * **Gold Standard Graft:** Autologous Iliac Crest Bone Graft (ICBG) remains the gold standard for treating neglected fractures and non-unions.
Question 3: A 40-year-old man presents with a fracture of the shaft of the femur following a road traffic accident. Three days after trauma, he becomes tachypnoeic and develops conjunctival petechiae. What is the most likely diagnosis?
- A. Pulmonary embolism
- B. Sepsis syndrome
- C. Fat embolism (Correct Answer)
- D. Hemothorax
Explanation: ### Explanation The clinical presentation of a **long bone fracture** (femur shaft) followed by a **symptom-free interval of 24–72 hours**, and the subsequent development of the classic triad of **respiratory distress (tachypnea), cerebral dysfunction, and petechial rashes**, is pathognomonic for **Fat Embolism Syndrome (FES)**. #### Why Fat Embolism is Correct: FES occurs when fat globules from the bone marrow enter the systemic circulation following a fracture. These globules cause mechanical obstruction and trigger a biochemical inflammatory response (Free Fatty Acid toxicity). The **conjunctival petechiae** are a hallmark sign, occurring in only 20-50% of cases but highly specific to FES. #### Why Other Options are Incorrect: * **Pulmonary Embolism (PE):** While it causes tachypnea, PE typically occurs later (usually 1–2 weeks post-surgery/trauma) due to DVT. It does not present with petechial rashes. * **Sepsis Syndrome:** While sepsis causes tachypnea, it is usually accompanied by high-grade fever, hypotension, and a clear source of infection. Three days is too early for post-traumatic osteomyelitis to cause systemic sepsis. * **Hemothorax:** This would present immediately after trauma with decreased breath sounds and dullness on percussion, not after a 3-day delay. #### High-Yield Clinical Pearls for NEET-PG: * **Gurd’s Criteria:** Used for diagnosis. Major criteria include axillary/conjunctival petechiae, respiratory insufficiency, and cerebral involvement. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Earliest Sign:** Tachycardia is often the earliest clinical sign. * **Management:** Primarily **supportive** (Oxygenation/Ventilation). Early stabilization of the fracture (Internal fixation) is the best preventive measure. * **Schonfeld’s Criteria:** Another scoring system used for FES diagnosis.
Question 4: In acute knee injuries with swelling and hemarthrosis with muscle spasm, which of the following tests is most sensitive to detect anterior cruciate ligament injury?
- A. Lachman's test (Correct Answer)
- B. Pivot shift test
- C. Apley's grinding test
- D. Anterior drawer test
Explanation: **Explanation:** The **Lachman’s test** is the most sensitive clinical test for diagnosing an acute Anterior Cruciate Ligament (ACL) injury. In the acute phase, knee injuries are often accompanied by significant swelling (hemarthrosis) and protective muscle spasms (hamstring guarding). * **Why Lachman’s is the correct answer:** The test is performed at **20–30° of flexion**. At this angle, the bony geometry of the femoral condyles does not stabilize the tibia, and the hamstrings are relatively relaxed, minimizing the effect of muscle spasms. This allows for the detection of even subtle anterior translation and the assessment of the "endpoint" (firm vs. soft). * **Why other options are incorrect:** * **Anterior Drawer Test:** Performed at 90° of flexion. In acute injuries, the hamstrings go into spasm at this angle, preventing anterior translation and leading to high false-negative rates. Additionally, the posterior horn of the medial meniscus can "wedge" against the femoral condyle, blocking movement. * **Pivot Shift Test:** While it is the most **specific** test for ACL insufficiency (indicating rotatory instability), it is very difficult to perform in an acute setting because it is painful and requires complete muscle relaxation. It is often only reliable under anesthesia. * **Apley’s Grinding Test:** This test is used to evaluate **meniscal injuries**, not ligamentous laxity. **Clinical Pearls for NEET-PG:** * **Most Sensitive Test (Overall & Acute):** Lachman’s Test. * **Most Specific Test:** Pivot Shift Test. * **Gold Standard Investigation:** MRI Knee. * **Segond Fracture:** An avulsion fracture of the lateral tibial condyle; it is pathognomonic for an ACL tear.
Question 5: What is a Colles fracture?
- A. Common in adolescence
- B. A fracture about the ankle joint
- C. Common in elderly women (Correct Answer)
- D. A fracture of the head of the radius
Explanation: **Explanation:** A **Colles fracture** is a classic extra-articular fracture of the distal radius occurring approximately 2.5 cm proximal to the wrist joint, characterized by **dorsal displacement** and angulation (the "Dinner Fork" deformity). **Why Option C is Correct:** This fracture is most frequently seen in **elderly women** (post-menopausal). The underlying medical concept is **osteoporosis**, which weakens the metaphyseal bone of the distal radius. The typical mechanism of injury is a **fall on an outstretched hand (FOOSH)** with the wrist in dorsiflexion. In younger patients, the same mechanism usually results in a scaphoid fracture or requires high-energy trauma. **Why Other Options are Incorrect:** * **Option A:** In adolescents, the distal radial epiphysis is more likely to slide (Slipped Capital Radial Epiphysis) or result in a "Greenstick" fracture rather than a classic Colles. * **Option B:** Fractures about the ankle joint include Pott’s fracture or Cotton’s fracture, not Colles. * **Option C:** A fracture of the head of the radius is a separate clinical entity, often associated with Essex-Lopresti injury, but it is not a Colles fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Deformities:** Remember the mnemonic **"P-DOG"** for Colles: **P**roximal to joint, **D**orsal displacement, **O**utstretched hand, **G**arden spade deformity (Wait—Dinner Fork is Colles; Garden Spade is Smith’s). * **Smith’s Fracture:** Often called a "Reverse Colles," involving **volar** (palmar) displacement. * **Complications:** The most common late complication is **malunion** (leading to Dinner Fork deformity). The most common tendon involved is a rupture of the **Extensor Pollicis Longus (EPL)**. Sudeck’s osteodystrophy (CRPS) is also a known complication.
Question 6: What does an increase in Pauwel's angle indicate?
- A. Good prognosis
- B. Impaction
- C. More chances of displacement (Correct Answer)
- D. Trabecular alignment disrupted
Explanation: **Explanation:** The **Pauwel’s Classification** is based on the angle formed by the fracture line of the femoral neck with the horizontal plane. It is a biomechanical classification used to predict the stability of femoral neck fractures. **1. Why "More chances of displacement" is correct:** As the Pauwel’s angle increases, the fracture line becomes more **vertical**. According to the laws of mechanics, a vertical fracture line converts compressive forces (which aid healing) into **shearing forces**. * **Type I (<30°):** Compressive forces dominate; stable. * **Type II (30°–50°):** Mixed shear and compressive forces. * **Type III (>50°):** High shear forces dominate. Therefore, a higher angle indicates high instability, a higher risk of displacement, and a higher rate of non-union or avascular necrosis (AVN). **2. Why other options are incorrect:** * **A. Good prognosis:** Higher angles have a **poor prognosis** due to instability and shear stress. * **B. Impaction:** Impaction usually occurs in stable, valgus-impacted fractures (Garden Type I), which typically have a lower Pauwel’s angle. * **D. Trabecular alignment disrupted:** While alignment is disrupted in displaced fractures, this is the basis of the **Garden Classification**, not the Pauwel’s angle itself. **Clinical Pearls for NEET-PG:** * **Garden Classification:** Most commonly used; based on the degree of displacement on X-ray. * **Pauwel’s Type III:** Often requires more robust internal fixation (e.g., sliding hip screw or multiple cannulated screws) due to the high shear stress. * **High-yield rule:** Vertical fracture = High Pauwel’s angle = High Shear = High instability.
Question 7: What is the initial management for an open fracture?
- A. Tourniquet
- B. Internal fixation
- C. Debridement (Correct Answer)
- D. External fixation
Explanation: **Explanation:** The management of open fractures is a surgical emergency aimed primarily at preventing infection (osteomyelitis) and promoting bone healing. **Why Debridement is Correct:** The most critical initial step in the management of an open fracture is **thorough surgical debridement and irrigation**. Open fractures are considered contaminated by definition. Debridement involves the removal of devitalized tissue, foreign bodies, and debris, which significantly reduces the bacterial load and the risk of infection. According to the Gustilo-Anderson classification management, early debridement (ideally within 6–24 hours) is the gold standard for limb salvage. **Analysis of Incorrect Options:** * **A. Tourniquet:** A tourniquet is only indicated in cases of life-threatening exsanguination that cannot be controlled by direct pressure. Routine use is avoided as it causes limb ischemia and can worsen tissue necrosis. * **B. Internal Fixation:** This is generally contraindicated as an *initial* step in contaminated wounds (especially Gustilo Type II and III) due to the high risk of hardware infection. It is usually reserved for definitive management once the wound is clean. * **C. External Fixation:** While often used for stabilization in open fractures (Damage Control Orthopaedics), it follows debridement. Stabilization is secondary to wound cleaning. **High-Yield Clinical Pearls for NEET-PG:** * **Antibiotic Timing:** Prophylactic antibiotics should be administered as soon as possible (ideally within 3 hours of injury). * **The "Rule of 6s":** Debridement should ideally occur within 6 hours, using 6 liters of saline (for Type II/III), performed by a senior surgeon. * **Gustilo-Anderson Classification:** Remember that Type IIIA, B, and C are distinguished by the adequacy of soft tissue coverage and vascular status, not just wound size. * **Tetanus Prophylaxis:** Always check the immunization status; it is a mandatory component of initial management.
Question 8: A patient presents with hip dislocation characterized by limitation of abduction, and a fixed deformity of flexion and internal rotation at the hip, along with limb shortening. What is the most likely diagnosis?
- A. Central dislocation
- B. Anterior dislocation
- C. Posterior dislocation (Correct Answer)
- D. Fracture dislocation
Explanation: ### Explanation **1. Why Posterior Dislocation is Correct:** Posterior dislocation is the most common type of hip dislocation (approx. 90%). The characteristic clinical presentation is a result of the femoral head being displaced behind the acetabulum. The tension of the surrounding ligaments and muscles forces the limb into a classic **"FADIR"** position: **F**lexion, **A**dduction, and **I**nternal **R**otation. Because the femoral head is no longer in the socket and is displaced superiorly/posteriorly, there is significant **limb shortening**. The limitation of abduction occurs because the limb is locked in an adducted position. **2. Why Other Options are Incorrect:** * **Anterior Dislocation:** This presents with the opposite deformity. The limb is typically held in **Abduction and External Rotation** (the "FABER" position). * **Central Dislocation:** This occurs when the femoral head is driven through the floor of the acetabulum (intrapelvic displacement). It is technically a fracture-dislocation of the acetabulum and does not present with the classic rotational deformities of pure dislocations. * **Fracture Dislocation:** While a posterior dislocation can be associated with a posterior wall acetabular fracture, the specific clinical triad of flexion, internal rotation, and adduction is the hallmark of the dislocation itself. **3. NEET-PG High-Yield Pearls:** * **Mechanism of Injury:** Usually a "Dashboard injury" (force applied to the flexed knee in a motor vehicle accident). * **Nerve Injury:** The **Sciatic nerve** (specifically the peroneal division) is the most commonly injured nerve in posterior dislocations. * **Radiology:** On an AP X-ray, the femoral head appears smaller than the contralateral side in posterior dislocation (due to being closer to the film) and larger in anterior dislocation. * **Emergency:** Hip dislocation is an orthopedic emergency. Reduction must be performed within 6 hours to minimize the risk of **Avascular Necrosis (AVN)** of the femoral head.
Question 9: All of the following factors evaluate the chances of amputation in a limb, except?
- A. Age
- B. Blood Pressure
- C. Velocity of trauma
- D. Presence of infection (Correct Answer)
Explanation: The decision to salvage or amputate a severely injured limb is guided by standardized scoring systems, the most common being the **Mangled Extremity Severity Score (MESS)**. ### **Explanation of the Correct Answer** **D. Presence of Infection:** The MESS score is designed to be used at the **time of presentation** (acute trauma) to predict the necessity of primary amputation. Infection is a delayed complication or a late sequela of trauma; it is not a factor used in the initial assessment to decide whether a limb is salvageable or requires immediate amputation. ### **Explanation of Incorrect Options** The MESS score is based on four primary criteria, which include the other options: * **A. Age:** Increasing age is a critical factor because older patients have poorer regenerative capacity and often have pre-existing peripheral vascular disease. (Score: <30 yrs = 0; 30–50 yrs = 1; >50 yrs = 2). * **B. Blood Pressure (Shock):** Persistent hypotension indicates severe systemic trauma and poor limb perfusion. (Score: Normotensive = 0; Transient hypotension = 1; Prolonged hypotension = 2). * **C. Velocity of Trauma (Skeletal/Soft Tissue Injury):** High-energy mechanisms (e.g., high-velocity gunshots or crush injuries) cause more extensive tissue damage than low-energy falls. (Score: Low energy = 1; Medium = 2; High = 3; Massive = 4). * **Ischemia (The 4th Factor):** The degree and duration of limb ischemia (pulselessness, coldness) are also scored. ### **Clinical Pearls for NEET-PG** * **MESS Threshold:** A score of **≥ 7** is highly predictive of the need for amputation, while a score of ≤ 6 suggests a high likelihood of successful salvage. * **The "Golden Period":** Ischemia for >6 hours doubles the score for the ischemia component, significantly increasing the likelihood of amputation. * **Other Scores:** While MESS is the most popular, others include the NISSSA and LEAP study findings, though MESS remains the high-yield focus for exams.
Question 10: What is true about intertrochanteric fracture?
- A. More than 1 inch shortening (Correct Answer)
- B. More than 1 inch lengthening
- C. Tenderness in Scarpa's triangle
- D. Less than 45 degrees external rotation of the limb
Explanation: **Explanation:** Intertrochanteric (IT) fractures are extracapsular fractures occurring between the greater and lesser trochanters. Understanding the clinical presentation is crucial for differentiating them from intracapsular neck of femur fractures. **1. Why "More than 1 inch shortening" is correct:** In IT fractures, the fracture line is distal to the hip capsule. This allows the powerful proximal migration of the distal fragment due to the pull of the gluteal and hamstring muscles. Because the fracture is extracapsular, there is no capsular restriction to this displacement, leading to **marked shortening**, typically exceeding 1 inch (2.5 cm). **2. Analysis of Incorrect Options:** * **B. More than 1 inch lengthening:** Fractures of the femur never result in lengthening; muscle pull always causes proximal migration/shortening. * **C. Tenderness in Scarpa's triangle:** This is a classic sign of **intracapsular neck of femur fractures**. In IT fractures, the maximum tenderness is usually located over the **greater trochanter** (lateral aspect), as the fracture is further away from the femoral artery/Scarpa's triangle. * **D. Less than 45 degrees external rotation:** IT fractures present with **marked external rotation (nearly 90 degrees)**, often with the lateral border of the foot touching the bed. This is because the fracture is extracapsular, removing the check-rein effect of the iliofemoral ligament. In contrast, intracapsular fractures usually show moderate external rotation (45–60 degrees). **High-Yield Clinical Pearls for NEET-PG:** * **Ecchymosis:** Often present in IT fractures (extracapsular) but absent in neck of femur fractures (intracapsular). * **Blood Loss:** IT fractures are associated with higher occult blood loss (up to 1500ml) compared to neck fractures. * **Treatment of Choice:** Stable IT fractures are typically treated with a **Dynamic Hip Screw (DHS)**, while unstable/comminuted patterns often require a **Cephalomedullary nail (PFN)**.
Practice by Chapter
Principles of Fracture Management
Practice Questions
Upper Limb Fractures
Practice Questions
Lower Limb Fractures
Practice Questions
Spinal Trauma
Practice Questions
Pelvic and Acetabular Fractures
Practice Questions
Open Fractures
Practice Questions
Fractures in Children
Practice Questions
Fracture Complications
Practice Questions
Nonunion and Malunion
Practice Questions
Polytrauma Management
Practice Questions
Joint Dislocations
Practice Questions
Soft Tissue Injuries
Practice Questions
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