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?
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.
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
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Fracture Complications
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Nonunion and Malunion
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Polytrauma Management
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Joint Dislocations
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Soft Tissue Injuries
Practice Questions
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