Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 91: What is the typical union time for a fracture of the femoral shaft in an adult?

A. 3 to 4 weeks
B. 3 to 4 weeks
C. 3 to 4 months (Correct Answer)
D. 4 to 6 months

Explanation: **Explanation:** The femoral shaft is a heavy, weight-bearing cortical bone surrounded by a rich muscle envelope. In adults, the healing process primarily occurs through **callus formation** (secondary bone healing), which typically takes **3 to 4 months (12 to 16 weeks)** to reach clinical and radiological union. This timeline is influenced by the bone's thick cortex and the high-energy nature of the trauma required to cause such a fracture, which often disrupts the endosteal and periosteal blood supply. **Analysis of Options:** * **Options A & B (3 to 4 weeks):** This is the typical union time for fractures in **newborns**. As age increases, the union time increases significantly (e.g., 6 weeks in a 5-year-old, 8 weeks in a teenager). * **Option C (3 to 4 months):** **Correct.** This represents the standard physiological window for a healthy adult femoral shaft to achieve solid bony union. * **Option D (4 to 6 months):** While some fractures may take this long, this range borders on **delayed union**. A fracture of the femoral shaft is generally considered a non-union if there is no evidence of healing by 6 to 9 months. **High-Yield Clinical Pearls for NEET-PG:** * **Rule of Twelves:** A useful mnemonic for adult fractures: Humerus (6 weeks), Forearm (8 weeks), Femur (12 weeks/3 months), and Tibia (16 weeks/4 months). * **Treatment of Choice:** For adult femoral shaft fractures, **Intramedullary (IM) Interlocking Nailing** is the gold standard. * **Blood Loss:** A closed femoral shaft fracture can lead to internal blood loss of **1000–1500 ml**, potentially causing hypovolemic shock. * **Common Complication:** Fat Embolism Syndrome is a high-yield association with long bone fractures like the femur.

Question 92: Inability to touch the opposite shoulder in a dislocated shoulder is known as which test?

A. Bryant Test
B. Callaway Test
C. Dugas Test (Correct Answer)
D. Hamilton Ruler Test

Explanation: **Explanation:** The correct answer is **Dugas Test**. This is a classic clinical sign used to diagnose an anterior dislocation of the shoulder. **1. Why Dugas Test is Correct:** In a normal shoulder, the range of motion allows the hand to be placed on the opposite shoulder while the elbow touches the chest wall. In an **anterior shoulder dislocation**, the humeral head is displaced from the glenoid fossa. Due to this mechanical displacement and associated muscle spasms, the patient is **unable to touch the opposite shoulder** while the elbow is in contact with the chest. If the patient is forced to touch the shoulder, the elbow will lift off the chest. **2. Analysis of Incorrect Options:** * **Bryant Test:** Used to evaluate **developmental dysplasia of the hip (DDH)** or proximal femoral shortening. It involves measuring the distance between the anterior superior iliac spine and the greater trochanter. * **Callaway Test:** Used in shoulder dislocations. It involves measuring the **vertical circumference of the axilla**. In dislocation, the circumference is increased due to the displaced humeral head. * **Hamilton Ruler Test:** A positive test occurs when a straight edge (ruler) can simultaneously touch the acromion process and the lateral epicondyle of the humerus. In a normal shoulder, the convexity of the deltoid (humeral head) prevents this. **Clinical Pearls for NEET-PG:** * **Most common shoulder dislocation:** Anterior (Subcoracoid is the most common subtype). * **Regimental Badge Sign:** Loss of sensation over the lateral deltoid due to **Axillary nerve** injury (most common nerve injured). * **Hill-Sachs Lesion:** A compression fracture of the posterosuperolateral humeral head. * **Bankart Lesion:** Avulsion of the anterior-inferior glenoid labrum.

Question 93: Adson's test is positive in which condition?

A. Thoracic Outlet Syndrome (Correct Answer)
B. Horner's Syndrome
C. Carpal Tunnel Syndrome
D. Axillary artery thrombosis

Explanation: **Explanation:** **Adson’s Test** is a clinical provocative maneuver used to diagnose **Thoracic Outlet Syndrome (TOS)**, specifically the compression of the subclavian artery by a cervical rib or tight scalene muscles. **Why Option A is Correct:** In Thoracic Outlet Syndrome, the neurovascular bundle (brachial plexus and subclavian vessels) is compressed as it passes through the cervico-axillary canal. During Adson's test, the patient’s arm is abducted, the neck is extended, and the head is rotated toward the affected side while taking a deep breath. A **positive test** is indicated by a **marked decrease or disappearance of the radial pulse**, suggesting arterial compression in the interscalene triangle. **Why Other Options are Incorrect:** * **B. Horner’s Syndrome:** This is caused by a lesion in the sympathetic trunk (ptosis, miosis, anhidrosis) and is not assessed by vascular provocative tests. * **C. Carpal Tunnel Syndrome:** This involves compression of the median nerve at the wrist. It is diagnosed using **Phalen’s test** or **Tinel’s sign** at the flexor retinaculum. * **D. Axillary artery thrombosis:** While this affects the pulse, it is a fixed vascular occlusion. Adson's test specifically identifies *positional* compression at the thoracic outlet. **High-Yield Clinical Pearls for NEET-PG:** * **Other TOS Tests:** **Roos Test** (Elevated Arm Stress Test/“East Test”) is considered the most reliable clinical screening test for TOS. * **Cervical Rib:** The most common anatomical cause of neurovascular TOS. * **Halsted’s Maneuver:** Similar to Adson’s but involves downward traction of the arm and neck rotation to the *opposite* side. * **Wright’s Hyperabduction Test:** Used to identify compression in the subcoracoid (pectoralis minor) space.

Question 94: What is the recommended dose of methylprednisolone for acute spinal cord injury?

A. 15 mg/kg body weight
B. 25 mg/kg body weight
C. 30 mg/kg body weight (Correct Answer)
D. 50 mg/kg body weight

Explanation: **Explanation:** The use of high-dose methylprednisolone in acute spinal cord injury (SCI) is based on the **NASCIS (National Acute Spinal Cord Injury Studies)** protocols. The underlying medical concept is that high-dose steroids act as neuroprotective agents by reducing lipid peroxidation, decreasing secondary inflammatory damage, and improving blood flow to the injured spinal cord. **Why Option C is Correct:** According to the **NASCIS-II** trial, the recommended regimen for patients presenting within 8 hours of injury is: * **Bolus Dose:** **30 mg/kg body weight** administered intravenously over 15 minutes. * **Maintenance Dose:** After a 45-minute pause, a continuous infusion of **5.4 mg/kg/hour** is maintained for 23 hours (if started within 3 hours) or 47 hours (if started between 3–8 hours). **Why Other Options are Incorrect:** * **Options A and B (15 and 25 mg/kg):** These doses are sub-therapeutic for the specific purpose of inhibiting lipid peroxidation in acute trauma. * **Option D (50 mg/kg):** This dose exceeds the established protocol and significantly increases the risk of complications like gastrointestinal bleeding, sepsis, and pneumonia without providing additional neurological benefit. **High-Yield Clinical Pearls for NEET-PG:** * **Time Window:** Steroids must be initiated within **8 hours** of injury to be effective. * **Contraindication:** Steroids are generally avoided in penetrating spinal injuries (e.g., gunshot wounds) as they increase infection risk without benefit. * **Current Status:** While historically the "gold standard," recent guidelines (AANS/CNS) now consider it an **optional treatment** rather than a mandatory standard of care due to the high risk of systemic side effects.

Question 95: A bumper fracture is defined as which of the following?

A. Lateral tibial condyle fracture (Correct Answer)
B. Medial tibial condyle fracture
C. Calcaneum fracture
D. Sacrum fracture

Explanation: **Explanation:** **Bumper fracture** (also known as a Fender fracture) refers to a fracture of the **lateral tibial condyle**. 1. **Mechanism of Injury:** The name originates from a pedestrian being struck by the bumper of a motor vehicle. The impact occurs on the lateral side of the knee while the foot is fixed on the ground. This creates a forceful **valgus (abduction) strain**, causing the hard lateral femoral condyle to be driven into the relatively soft articular surface of the lateral tibial plateau, resulting in a depressed or split fracture. 2. **Why other options are incorrect:** * **Medial tibial condyle fracture:** These are less common and usually result from a high-energy varus force. * **Calcaneum fracture:** Often called a "Don Juan fracture" or "Lover’s fracture," typically caused by a fall from a height. * **Sacrum fracture:** Usually associated with high-energy pelvic ring injuries or insufficiency fractures in the elderly. **Clinical Pearls for NEET-PG:** * **Classification:** Tibial plateau fractures are classified using the **Schatzker Classification** (Types I–VI). A classic bumper fracture is typically a Schatzker Type I (wedge), II (wedge-depression), or III (pure depression). * **Associated Injuries:** Because of the valgus stress, always look for associated **Medial Collateral Ligament (MCL)** tears and **Anterior Cruciate Ligament (ACL)** injuries. * **Nerve Involvement:** The **Common Peroneal Nerve** wraps around the neck of the fibula; high-energy lateral impacts can lead to foot drop. * **Complication:** The most serious acute complication is **Compartment Syndrome**.

Question 96: All of the following are classifications of C-spine injury except which one?

A. AO Spine classification (Correct Answer)
B. Allen Ferguson Classification
C. Anderson and D'Alonzo Classification
D. Levine and Edwards Classification

Explanation: The correct answer is **A. AO Spine classification**. ### **Explanation** While the AO Spine classification system is widely used for subaxial cervical, thoracic, and lumbar fractures, it is a **universal system** rather than a specific classification for a single anatomical region of the C-spine. In the context of this specific question (often found in older orthopedic texts and exams), the other three options are the "classic" eponymous classifications specifically dedicated to distinct cervical spine injuries. ### **Analysis of Options** * **Allen and Ferguson Classification (Option B):** This is the most common classification for **Subaxial Cervical Spine (C3-C7)** injuries. It is based on the mechanism of injury (e.g., vertical compression, flexive-distraction) and the position of the head at the time of impact. * **Anderson and D'Alonzo Classification (Option C):** This is the gold-standard classification for **Odontoid (Dens) fractures**. It divides fractures into three types based on the location of the fracture line (Type I: Tip; Type II: Base/Neck; Type III: Body of C2). * **Levine and Edwards Classification (Option D):** This is the specific classification for **Hangman’s Fracture** (Traumatic spondylolisthesis of C2). It modifies the Effendi classification to describe the degree of displacement and angulation. ### **NEET-PG High-Yield Pearls** * **Jefferson Fracture:** A burst fracture of **C1** (Atlas) caused by axial loading. * **Hangman’s Fracture:** Bilateral fracture of the pars interarticularis of **C2** (Axis). * **Clay Shoveler’s Fracture:** Avulsion fracture of the spinous process (most common at **C7**). * **Most common site of C-spine injury:** C5-C6 (highest mobility). * **Most common Odontoid fracture:** Type II (also has the highest risk of non-union due to poor blood supply).

Question 97: What is the typical position of the leg in a fracture of the neck of the femur?

A. External rotation with the patella facing inwards.
B. External rotation with the patella facing outwards. (Correct Answer)
C. Internal rotation with the patella facing outwards.
D. Internal rotation with the patella facing inwards.

Explanation: ### Explanation In a **fracture of the neck of the femur**, the characteristic clinical presentation is a shortened limb held in **external rotation**. **Why the correct answer is right:** When the femoral neck fractures, the distal fragment is no longer mechanically connected to the acetabulum. The powerful **iliopsoas muscle**, which inserts into the lesser trochanter, acts as a potent external rotator. Additionally, the weight of the foot naturally pulls the limb into external rotation due to gravity. Because the entire distal segment rotates outward, the **patella faces outwards** (laterally). **Analysis of Incorrect Options:** * **A & D (Patella facing inwards):** This describes internal rotation. Internal rotation is characteristic of **posterior hip dislocations**, not neck of femur fractures. * **C (Internal rotation with patella facing outwards):** This is anatomically contradictory; if the limb is internally rotated, the patella must face medially (inwards). **Clinical Pearls for NEET-PG:** 1. **Degree of Rotation:** In **intracapsular** fractures (Neck of Femur), external rotation is typically moderate (45°–60°) because the capsule limits movement. In **extracapsular** fractures (Intertrochanteric), the rotation is more severe (nearly 90°), often with the lateral border of the foot touching the bed. 2. **Shortening:** True shortening occurs due to the upward pull of the hamstrings and rectus femoris. 3. **Vascularity:** The main blood supply to the femoral head is the **medial circumflex femoral artery** (via retinacular vessels). Fractures here carry a high risk of **Avascular Necrosis (AVN)** and non-union. 4. **Shenton’s Line:** This radiological arc is broken in femoral neck fractures.

Question 98: Management of calcaneal fractures depends upon which of the following?

A. Type of fracture
B. Subtalar joint dislocation
C. Duration of presentation
D. All of the above (Correct Answer)

Explanation: The management of calcaneal fractures is complex and multifactorial, requiring a tailored approach based on the specific clinical scenario. **1. Why "All of the Above" is Correct:** * **Type of Fracture (Option A):** This is the most critical factor. Fractures are classified into **Extra-articular** (usually managed conservatively) and **Intra-articular** (often requiring surgery). The **Sanders Classification** (based on CT scans) determines the surgical approach; Type I is non-operative, while Types II and III often require Open Reduction and Internal Fixation (ORIF). * **Subtalar Joint Dislocation (Option B):** The involvement and displacement of the subtalar joint significantly impact the prognosis. If the joint is dislocated or severely comminuted, the goal of management shifts toward restoring articular congruity to prevent debilitating post-traumatic arthritis. * **Duration of Presentation (Option C):** Timing is vital due to the high risk of soft tissue complications. In acute settings with massive swelling or fracture-blisters, surgery is delayed (7–14 days) until the **"wrinkle sign"** appears. Conversely, late presentations (neglected fractures) may require primary arthrodesis rather than ORIF. **Clinical Pearls for NEET-PG:** * **Mechanism of Injury:** Usually a fall from height (Don Juan Syndrome); always screen for associated **compression fractures of the lumbar spine (L1)**. * **Bohler’s Angle:** Normal is **25°–40°**. A decrease in this angle indicates a depressed calcaneal fracture. * **Angle of Gissane:** Normal is **120°–145°**; it increases in intra-articular fractures. * **Gold Standard Investigation:** CT scan (Coronary and Axial planes). * **Most Common Complication:** Post-traumatic subtalar arthritis (leading to pain on uneven ground).

Question 99: Which nerve is most at risk in the injury shown in the accompanying radiograph?

A. Median nerve
B. Radial nerve (Correct Answer)
C. Posterior interosseous nerve
D. Ulnar nerve

Explanation: ***Radial nerve*** - The **radial nerve** travels in the **spiral groove** (radial groove) on the posterior aspect of the mid-shaft humerus, making it highly vulnerable in **humeral shaft fractures**. - **Radial nerve palsy** presents with **wrist drop**, inability to extend the wrist and fingers at the metacarpophalangeal joints, and loss of sensation in the **first web space**. *Median nerve* - The **median nerve** runs medially in the arm and is protected from humeral shaft injuries by the **brachial artery** and surrounding soft tissues. - It is more commonly injured in **supracondylar fractures** or **carpal tunnel syndrome**, not mid-shaft humeral fractures. *Posterior interosseous nerve* - This is a **branch of the radial nerve** that passes around the **neck of the radius** and is at risk in **proximal radial fractures**. - It would not be directly affected by a **humeral shaft fracture** as it branches distally from the main radial nerve. *Ulnar nerve* - The **ulnar nerve** travels medially and posteriorly in the **cubital tunnel** at the elbow, making it susceptible to **medial epicondylar** or **olecranon fractures**. - It is anatomically distant from the **humeral shaft** and would not be injured in this fracture pattern.

Question 100: A 30-year-old male who is positive for HIV and on antiretroviral therapy presents with pain in the right hip region. He has had a flexion, abduction, and external rotation deformity of the right hip for 2 months. What is the most likely diagnosis?

A. Avascular necrosis
B. Tuberculous arthritis of the hip (Correct Answer)
C. Transient synovitis
D. Septic arthritis

Explanation: ### Explanation The correct diagnosis is **Tuberculous (TB) arthritis of the hip**. **1. Why Tuberculous Arthritis is Correct:** The clinical presentation follows the classic stages of hip tuberculosis. The deformity described—**flexion, abduction, and external rotation**—is the hallmark of the **Stage of Synovitis (Stage I)**. In this stage, there is an increase in synovial fluid (effusion), and the joint adopts this specific position to accommodate the maximum intra-articular volume and minimize pain. Furthermore, the patient is **HIV positive**, which significantly increases the risk of extrapulmonary tuberculosis due to impaired cell-mediated immunity. A 2-month duration indicates a chronic process, consistent with TB rather than acute infections. **2. Why Other Options are Incorrect:** * **Avascular Necrosis (AVN):** While common in HIV patients (often due to ART or the virus itself), AVN typically presents with painful limitation of movements (especially internal rotation) rather than a fixed "FABER" deformity. * **Transient Synovitis:** This is a self-limiting condition primarily seen in children (3–8 years) following a viral infection. It does not persist for 2 months. * **Septic Arthritis:** This is an acute emergency. Patients present with high-grade fever, systemic toxicity, and an inability to bear weight. A 2-month history is too prolonged for untreated pyogenic arthritis. **3. Clinical Pearls for NEET-PG:** * **Stages of Hip TB:** * **Stage I (Synovitis):** Flexion, Abduction, External Rotation (Apparent lengthening). * **Stage II (Arthritis):** Flexion, Adduction, Internal Rotation (Apparent shortening). * **Stage III (Erosion/Destruction):** Further deformity with true shortening (Wandering Acetabulum). * **Triad of TB Hip:** Pain, Limp, and Muscle Wasting (especially of the glutei and thigh). * **Radiology:** Look for **Phemister’s Triad**: Juxta-articular osteopenia, peripheral osseous erosions, and gradual narrowing of the joint space.

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Principles of Fracture Management

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Upper Limb Fractures

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Lower Limb Fractures

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Spinal Trauma

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Pelvic and Acetabular Fractures

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Open Fractures

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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

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Trauma — MCQs

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