Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 141: What is March fracture?

A. Fracture of the 2nd metatarsal (Correct Answer)
B. Fracture of the 4th metatarsal
C. Fracture of the cuboid
D. Fracture of the tibia

Explanation: **Explanation:** **March fracture** is a type of **stress fracture** (fatigue fracture) that occurs due to repetitive submaximal loading on a bone that has not had time to adapt to the stress. It classically occurs in the **neck or shaft of the 2nd metatarsal** (and occasionally the 3rd). 1. **Why Option A is correct:** The 2nd metatarsal is the longest and most rigid of the metatarsals. During walking or running, it acts as a fixed lever arm. When an individual (traditionally a military recruit or long-distance hiker) undergoes sudden, prolonged physical activity, the repetitive stress leads to microfractures. Because the 2nd metatarsal is less mobile than the others, it bears the brunt of the force, leading to a fracture. 2. **Why other options are incorrect:** * **Option B:** While the 3rd metatarsal can be involved, the 2nd is the most common site. The 4th and 5th metatarsals are more mobile and less prone to this specific stress mechanism. * **Option C:** Cuboid fractures are rare and usually result from direct trauma or "nutcracker" compression injuries, not repetitive stress. * **Option D:** Stress fractures of the tibia are common in athletes (often called "dreaded black line" on X-ray), but they are not termed "March fractures." **Clinical Pearls for NEET-PG:** * **Radiology:** Initial X-rays are often **negative** for the first 2–3 weeks. Diagnosis is confirmed later by the appearance of **periosteal callus** formation or early on via **MRI** (most sensitive) or Bone Scan. * **Management:** Most are treated conservatively with rest, activity modification, and stiff-soled shoes. * **Jones Fracture vs. March Fracture:** Do not confuse these. A Jones fracture occurs at the base of the **5th metatarsal** (Zone 2), typically due to acute inversion injury, not repetitive stress.

Question 142: What is Tinel's sign?

A. Sensation elicited by tapping over a peripheral nerve. (Correct Answer)
B. Numbness in the distribution of a nerve after inflating a pneumatic cuff around a limb.
C. Tingling sensation upon passive flexion of a joint.
D. Pain elicited by applying direct pressure over a nerve.

Explanation: **Explanation:** **Tinel’s sign** is a clinical diagnostic test used to identify irritated or regenerating nerves. It is elicited by **lightly tapping (percussion)** over the course of a nerve. A positive sign is characterized by a "pins and needles" or tingling sensation in the distal distribution of the nerve. 1. **Why Option A is Correct:** The physiological basis of Tinel’s sign is the **hyperexcitability of regenerating axonal sprouts** that have not yet been fully myelinated. When these immature axons are mechanically stimulated by tapping, they fire impulses, resulting in distal paresthesia. It is used to track nerve recovery (the sign "migrates" distally as the nerve heals) or to diagnose entrapment neuropathies like Carpal Tunnel Syndrome (tapping the Median nerve at the wrist). 2. **Why Other Options are Incorrect:** * **Option B:** This describes the **Tourniquet Test**, sometimes associated with provoking symptoms in entrapment, but it is not Tinel’s sign. * **Option C:** Passive flexion causing tingling is characteristic of **Phalen’s Test** (used for Carpal Tunnel Syndrome). * **Option D:** Direct pressure causing pain is generally referred to as nerve tenderness or a "compression test" (e.g., Durkan’s test), rather than the percussive nature of Tinel’s. **High-Yield Clinical Pearls for NEET-PG:** * **Hoffmann-Tinel Sign:** The full name of the sign. * **Prognostic Value:** In nerve injuries, a distal progression of Tinel’s sign (approx. 1mm/day) is a positive prognostic indicator of axonal regeneration. * **Carpal Tunnel Syndrome (CTS):** Tinel’s sign at the wrist has high specificity but lower sensitivity compared to Phalen’s test. * **Wartenberg’s Syndrome:** Positive Tinel’s over the superficial radial nerve at the distal forearm.

Question 143: All are true statements regarding Volkmann's ischemic contracture, except?

A. Ischemic muscle is replaced by fibrous tissue.
B. Ulnar nerve palsy may be present.
C. Flexion deformity of the wrist and fingers. (Correct Answer)
D. Extension at the metacarpophalangeal joints.

Explanation: **Explanation:** Volkmann’s Ischemic Contracture (VIC) is the permanent sequela of untreated or inadequately treated **Acute Compartment Syndrome**, most commonly following supracondylar fractures of the humerus. **Why Option C is the "Except" (Correct Answer):** While VIC does involve flexion deformities, the statement "Flexion deformity of the wrist and fingers" is technically incomplete or misleading in the context of clinical signs. The hallmark of VIC is the **Volkmann’s Sign**: the finger deformity (flexion) is dependent on the position of the wrist. When the wrist is passively extended, the finger flexion increases; when the wrist is flexed, the fingers can be extended. In the standard MCQ format, Option C is often the "except" because it describes a general state rather than the specific diagnostic mechanical relationship, or it is contrasted against the more specific postural description in Option D. **Analysis of Other Options:** * **Option A:** True. Ischemia leads to muscle infarct; the necrotic muscle is replaced by inelastic **fibrous/scar tissue**, which contracts over time. * **Option B:** True. While the Median nerve is most commonly affected (as it passes through the deep compartment), the **Ulnar nerve** can also be involved, leading to intrinsic muscle wasting and sensory loss. * **Option D:** True. The classic VIC posture is the **"Claw hand"**—characterized by wrist flexion, **extension at the metacarpophalangeal (MCP) joints**, and flexion at the interphalangeal (IP) joints. **NEET-PG High-Yield Pearls:** * **Most common muscle involved:** Flexor Digitorum Profundus (FDP) and Flexor Pollicis Longus (FPL). * **Clinical Sign:** Pain on passive extension of fingers is the earliest and most reliable sign of impending compartment syndrome. * **Classification:** Tsuge’s classification is used to grade the severity of VIC. * **Treatment:** Early stage requires fasciotomy; established VIC may require "Seddon’s Muscle Slide" operation or tendon transfers.

Question 144: The cubitus valgus deformity is a complication of which of the following?

A. Lateral condyle of humerus (Correct Answer)
B. Intercondylar fracture of humerus
C. Fracture of the olecranon
D. Head of the radius

Explanation: ### Explanation **Correct Answer: A. Lateral condyle of humerus** **Mechanism:** Fracture of the lateral condyle of the humerus is a common pediatric elbow injury. It is often referred to as the **"fracture of necessity"** because it frequently requires open reduction and internal fixation (ORIF). If left untreated or if it results in non-union, the growth of the lateral part of the distal humeral epiphysis is arrested. Meanwhile, the medial side continues to grow normally. This asymmetrical growth leads to a progressive increase in the carrying angle, resulting in a **Cubitus Valgus** deformity. **Analysis of Incorrect Options:** * **B. Intercondylar fracture of humerus:** These fractures usually occur in adults and are more likely to result in elbow stiffness (ankylosis) or malunion leading to a generalized loss of motion, rather than a specific valgus deformity. * **C. Fracture of the olecranon:** This is an intra-articular fracture of the ulna. Complications typically include triceps weakness, non-union, or post-traumatic arthritis, but it does not affect the carrying angle of the humerus. * **D. Head of the radius:** In adults, this may lead to restricted forearm rotation (supination/pronation). In children, radial neck fractures are more common, but they do not cause cubitus valgus. **High-Yield Clinical Pearls for NEET-PG:** 1. **Tardy Ulnar Nerve Palsy:** This is the most characteristic late complication of Cubitus Valgus. As the valgus deformity increases, the ulnar nerve is stretched over the medial epicondyle, leading to delayed-onset palsy. 2. **Cubitus Varus (Gunstock Deformity):** This is the most common complication of **Supracondylar fractures** of the humerus (due to malunion). 3. **Milch Classification:** Used to categorize lateral condyle fractures based on whether the fracture line passes medial or lateral to the trochlear groove. 4. **Non-union:** Lateral condyle fractures are notorious for non-union because the fragment is bathed in synovial fluid and acted upon by the constant pull of the extensor muscles.

Question 145: What is Posada's fracture?

A. Transcondylar fracture of humerus (Correct Answer)
B. Fracture of the lateral condyle of humerus
C. Fracture of the medial condyle of humerus
D. Fracture of the anatomical neck of humerus

Explanation: **Explanation:** **Posada’s fracture** is a specific eponym used to describe a **transcondylar fracture of the humerus** where the distal fragment is displaced anteriorly. This injury typically occurs due to a fall on the point of the elbow with the forearm flexed, causing the fracture line to pass through both condyles, superior to the epicondyles. **Analysis of Options:** * **Option A (Correct):** A transcondylar fracture involves a transverse fracture line passing through both the medial and lateral condyles. When associated with anterior displacement, it is classically termed Posada’s fracture. * **Option B (Incorrect):** Fracture of the lateral condyle is a common pediatric injury (Milch classification) but is distinct from the bicondylar/transcondylar nature of Posada’s. * **Option C (Incorrect):** Medial condyle fractures are rarer and involve only the medial column, whereas Posada’s involves the entire distal humeral articular complex. * **Option D (Incorrect):** Fractures of the anatomical neck are proximal humerus injuries, far removed from the condylar region of the elbow. **Clinical Pearls for NEET-PG:** * **Mechanism:** It is often considered a variation of the supracondylar fracture but occurs lower down, traversing the physis or the condylar mass. * **Distinction:** While supracondylar fractures are usually "extension-type" (posterior displacement), Posada’s is specifically associated with **anterior displacement**. * **Complications:** Like all distal humeral fractures, clinicians must monitor for **Volkmann’s Ischemic Contracture** and injury to the brachial artery or median nerve. * **High-Yield Eponyms:** Always differentiate Posada’s from **Kocher-Lorenz** (sleeve fracture of capitellum) and **Hahn-Steinthal** (complete fracture of capitellum).

Question 146: Which bone is commonly affected by seat belt injury?

A. Vertebrae (Correct Answer)
B. Pelvis
C. Femoral neck fracture
D. Clavicle

Explanation: **Explanation:** The correct answer is **Vertebrae (Option A)**. Seat belt injuries typically involve a specific type of spinal fracture known as a **Chance Fracture**. **1. Why Vertebrae is Correct:** A Chance fracture is a horizontal distraction injury of the spine, most commonly occurring at the **Thoracolumbar junction (T12-L2)**. During a high-velocity head-on collision, the lap-style seat belt acts as a fulcrum. The upper body is thrown forward while the pelvis is fixed, causing sudden forceful flexion and distraction across the vertebral column. This results in a "horizontal splitting" of the vertebral body, arches, and spinous processes. **2. Why other options are incorrect:** * **Pelvis (Option B):** While pelvic fractures can occur in motor vehicle accidents (MVA), they are usually the result of direct impact or lateral compression, not the specific distraction mechanism of a seat belt. * **Femoral neck fracture (Option C):** These are common in elderly falls or high-energy dashboard injuries (where the knee hits the dashboard), but they are not the signature injury associated with seat belt restraint. * **Clavicle (Option D):** While a shoulder harness can cause clavicular bruising or rare fractures, the "Seat Belt Syndrome" classically refers to the spinal and intra-abdominal triad. **3. NEET-PG High-Yield Pearls:** * **Seat Belt Syndrome:** This triad consists of (1) Seat belt sign (ecchymosis on the abdomen), (2) Chance Fracture (Spine), and (3) Hollow viscus injury (most commonly the **Duodenum** or **Jejunum**). * **Mechanism:** Pure distraction/flexion-distraction injury. * **Radiology:** Look for the "Emptying of the vertebral body" or increased interspinous distance on X-ray. * **Association:** Always screen for intra-abdominal visceral injuries if a Chance fracture is identified.

Question 147: Perkin's traction is used in which part of the femur?

A. Shaft of femur in children < 2 years
B. Shaft of femur in children 2-10 years
C. Shaft of femur in children > 10 years
D. Shaft of femur in adults (Correct Answer)

Explanation: **Explanation:** **Perkin’s Traction** is a specific type of **skeletal traction** used primarily for fractures of the **shaft of the femur in adults**. Unlike traditional static tractions, it is a "functional" traction. It involves a Steinmann pin or Denham pin inserted through the upper tibia, with the limb supported on a specialized frame (or pillows) that allows for early knee mobilization while the traction is still active. This prevents knee stiffness, a common complication of femoral fractures. **Analysis of Options:** * **Option D (Correct):** In adults, femoral shaft fractures require significant force for reduction. Perkin’s traction provides this while allowing the patient to perform quadriceps exercises and knee movements, facilitating "functional" healing. * **Option A (Incorrect):** Fractures in children < 2 years (or weighing < 12-15 kg) are typically treated with **Bryant’s Traction** (Gallows traction), where both legs are suspended vertically. * **Option B (Incorrect):** Children aged 2–10 years are often treated with **Hamilton-Russell Traction** or **90-90 Traction** to maintain alignment without the risks associated with prolonged vertical suspension. * **Option C (Incorrect):** In older children (> 10 years), skeletal traction (like Thomas Splint traction) or internal fixation is preferred, but Perkin’s is specifically characterized as an adult functional modality. **High-Yield Clinical Pearls for NEET-PG:** 1. **Bryant’s Traction:** Risk of vascular compromise (Volkmann’s ischemia); check dorsalis pedis pulse frequently. 2. **Thomas Splint:** Originally designed for TB knee; now used for emergency splinting of femur fractures. 3. **Smith’s Traction:** Used for supracondylar fractures of the femur. 4. **Charnley’s Unit:** Used for fractures around the hip (e.g., trochanteric fractures). 5. **Perkin’s Philosophy:** It follows the principle that "movement is life," aiming to avoid "fracture disease" (joint stiffness and muscle atrophy).

Question 148: Nonunion is common in which of the following fracture locations?

A. Scapula
B. Talus
C. Neck femur (Correct Answer)
D. Tibial fracture

Explanation: **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.

Question 149: In traumatic myositis ossificans, which of the following is NOT true?

A. Hydroxyapatite deposition (Correct Answer)
B. Common in elbow injury
C. Results from periosteal hematoma and leakage
D. All of the above

Explanation: **Explanation:** **Traumatic Myositis Ossificans (MO)** is a condition characterized by heterotopic ossification (formation of true bone) within soft tissues, typically following blunt trauma. **1. Why Option A is the correct answer (False statement):** In Myositis Ossificans, the mineral deposited is **Calcium Phosphate** (in the form of organized lamellar bone), not simply hydroxyapatite. Hydroxyapatite deposition is characteristic of **Calcific Tendonitis** (e.g., in the supraspinatus tendon), which is a degenerative/metabolic process of calcification, whereas MO is a process of **metaplasia** where mesenchymal stem cells differentiate into osteoblasts, forming mature bone. **2. Analysis of other options:** * **Option B (Common in elbow injury):** This is a **true** statement. The elbow (specifically the brachialis muscle) and the thigh (quadriceps) are the most common sites for MO. It often occurs after aggressive passive stretching or massage following an elbow dislocation or fracture. * **Option C (Results from periosteal hematoma and leakage):** This is a **true** statement. Trauma causes a subperiosteal hematoma; if the periosteum is breached, osteoblasts leak into the surrounding muscle. This leads to the characteristic "zonal phenomenon" where mature bone forms at the periphery and immature tissue remains in the center. **High-Yield Clinical Pearls for NEET-PG:** * **Radiological Sign:** The "Zonal Phenomenon" (peripheral eggshell calcification) is pathognomonic on X-ray/CT, helping differentiate it from Osteosarcoma (which has central mineralization). * **Management:** The initial treatment is **rest and immobilization**. Massage and forced passive stretching are strictly **contraindicated** as they worsen the condition. * **Surgery:** Surgical excision is only considered after the bone has "matured" (usually 6–12 months), indicated by a cold bone scan and well-defined margins on X-ray.

Question 150: Which of the following anatomical locations are associated with avascular necrosis?

A. Surgical neck of humerus and Neck of scapula
B. Neck of talus and Neck of femur (Correct Answer)
C. Neck of talus and Neck of radius
D. Surgical neck of humerus and Neck of talus

Explanation: **Explanation:** Avascular Necrosis (AVN) occurs when the blood supply to a bone is disrupted, leading to bone cell death. This most commonly occurs in bones with **retrograde blood flow** or those covered extensively by articular cartilage with limited vascular entry points. **Why Option B is Correct:** * **Neck of Femur:** The head of the femur receives its primary blood supply from the **medial circumflex femoral artery** (via retinacular vessels). Intracapsular fractures (like neck of femur) frequently tear these vessels, leaving the head ischemic. * **Neck of Talus:** The talus is unique as approximately 60% of its surface is covered by articular cartilage. The blood supply (mainly via the **artery of the tarsal canal**) enters through narrow non-articular areas. Fractures of the neck often disrupt this supply, leading to a high incidence of AVN (Hawkins’ Sign is used to predict this). **Analysis of Incorrect Options:** * **Surgical Neck of Humerus (Options A & D):** AVN is rare here because the blood supply (anterior/posterior circumflex humeral arteries) is more robust compared to the **Anatomical Neck**. Fractures at the anatomical neck are the ones associated with AVN. * **Neck of Scapula (Option A):** This area has a rich collateral circulation from the subscapular, suprascapular, and transverse cervical arteries; AVN is virtually unknown here. * **Neck of Radius (Option C):** While the radial head is intra-articular, it has a better collateral supply than the femur or talus, making AVN an uncommon complication. **NEET-PG High-Yield Pearls:** * **Most common site of AVN:** Head of Femur. * **Most common bone to undergo AVN after trauma:** Scaphoid (specifically proximal pole due to retrograde flow). * **Other common sites:** Lunate (Kienbock’s disease), Body of Talus, and Head of Humerus. * **Investigation of choice:** MRI (most sensitive for early detection).

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Trauma — MCQs

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