Trauma — MCQs

A 6-year-old boy has a history of recurrent dislocation of the right shoulder. On examination, the orthopedician puts the patient in the supine position, abducts his arm to 90 degrees with the bed as the fulcrum, and then externally rotates it. However, the boy does not allow the test to be performed. What is the name of the test performed by the orthopedician?

Q236Easy

Resolving arthroplasty is seen in which of the following?

Q237Easy

The term Bennett's fracture is used to describe which of the following?

Q238Medium

The Trendelenburg test is positive in which of the following conditions?

Q239Easy

Traumatic dislocation of the hip is characterized by which of the following deformities?

Q240Easy

Which of the following is not a cause of a positive Trendelenburg sign?

Trauma Indian Medical PG Practice Questions and MCQs

Question 231: In children, which type of fracture displacement demonstrates the best remodelling potential?

A. Angulation in the diaphysis
B. Angulation in the metaphysis (Correct Answer)
C. Rotation in the diaphysis
D. Rotation in the metaphysis

Explanation: ### Explanation The ability of a pediatric fracture to remodel depends on the child's remaining growth potential and the proximity of the fracture to the physis (growth plate). **Why Option B is Correct:** Remodelling is most effective when the fracture is located in the **metaphysis** and the displacement is **angulation** in the plane of motion of the adjacent joint. The metaphysis is highly vascular and located close to the physis; according to **Heuter-Volkmann’s Law**, the physis responds to asymmetrical pressure by altering growth to "straighten" the bone. The closer a fracture is to the growth plate, the greater the potential for spontaneous correction. **Why Other Options are Incorrect:** * **Options A & C (Diaphysis):** The mid-shaft (diaphysis) is further from the physis. Remodelling potential decreases significantly as you move away from the growth plate toward the center of the bone. * **Options C & D (Rotation):** Rotational deformities (torsion) **do not remodel** regardless of age or location. Unlike angulation, the physis cannot compensate for a twist in the long axis of the bone. These must be corrected anatomically during reduction. **High-Yield Clinical Pearls for NEET-PG:** * **Factors favoring remodelling:** Young age (more growth remaining), proximity to the physis, and angulation in the plane of joint motion. * **Exceptions to the rule:** Displaced **intra-articular fractures** and **rotational deformities** never remodel and require precise reduction. * **Overgrowth Phenomenon:** In femoral shaft fractures of children (2–10 years), the hyperemia of healing can cause 1–2 cm of longitudinal overgrowth. Therefore, a small amount of "bayonet apposition" (shortening) is often acceptable.

Question 232: The "Apprehension sign" is seen in dislocation of which joint?

A. Shoulder joint (Correct Answer)
B. Hip joint
C. Elbow joint
D. Patella

Explanation: **Explanation:** The **Apprehension Test** is the hallmark clinical examination for **recurrent anterior instability of the shoulder joint**. 1. **Why Shoulder Joint is Correct:** In patients with a history of anterior shoulder dislocation, placing the arm in a position of **abduction and external rotation** (the most vulnerable position) mimics the mechanism of dislocation. The patient becomes anxious or "apprehensive," fearing the humeral head will slip out of the glenoid cavity. They may resist further movement or contract the pectoralis major to stabilize the joint. This is a positive Apprehension sign, often followed by the **Relocation Test (Jobe’s test)**, where posterior pressure on the humerus relieves the anxiety. 2. **Why Other Options are Incorrect:** * **Hip Joint:** Dislocation is usually traumatic and stable once reduced. Clinical signs focus on limb shortening and rotation (internal for posterior, external for anterior). * **Elbow Joint:** Stability is assessed via varus/valgus stress tests or the Pivot-shift test for posterolateral rotatory instability. * **Patella:** While there is a specific **Fairbank’s Apprehension Test** for recurrent patellar dislocation (lateral displacement of the patella causes apprehension), the standard "Apprehension sign" without qualification traditionally refers to the shoulder in orthopedic nomenclature. **High-Yield Clinical Pearls for NEET-PG:** * **Bankart Lesion:** Avulsion of the anterior-inferior glenoid labrum; the most common cause of recurrent shoulder dislocation. * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head. * **Nerve Injury:** The **Axillary nerve** is the most commonly injured nerve in anterior shoulder dislocations (look for "regimental badge" anesthesia). * **Most Common Dislocation:** Anterior shoulder dislocation is the most common joint dislocation in the body.

Question 233: Clavicular fracture is usually treated by

A. Traction
B. Open reduction and internal fixation
C. Figure of eight bandage (Correct Answer)
D. Plate and screw fixation

Explanation: **Explanation:** The clavicle is the most common bone to fracture in the human body, typically occurring at the **middle third** (junction of the medial 2/3 and lateral 1/3). **Why Figure-of-Eight Bandage is Correct:** The vast majority of clavicular fractures are managed **conservatively**. The primary goal of treatment is to counteract the displacement caused by the weight of the arm and the pull of the sternocleidomastoid muscle. A **Figure-of-eight bandage** (or a simple triangular sling) provides sufficient immobilization by pulling the shoulders back, aligning the fragments, and allowing for secondary bone healing via callus formation. Functional outcomes for conservative management are generally excellent. **Analysis of Incorrect Options:** * **Traction (A):** Traction is used for long bone fractures (like the femur) to overcome muscle spasm. It has no role in the management of clavicular fractures. * **Open Reduction and Internal Fixation (B) & Plate and Screw Fixation (D):** While these are surgical methods, they are **not** the standard first-line treatment. Surgery is reserved for specific indications such as neurovascular injury, skin tenting (threatened compound fracture), non-union, or widely displaced fractures in high-demand athletes. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Middle third (80%). * **Mechanism of injury:** Fall on an outstretched hand (FOOSH) or direct blow to the shoulder. * **Deformity:** The medial fragment is displaced **upward** (by the sternocleidomastoid) and the lateral fragment is displaced **downward** (by the weight of the arm). * **Complication:** Malunion is common but usually clinically insignificant; **Non-union** is rare. * **Nerve involvement:** If neurovascular injury occurs, the **subclavian vessels** or **brachial plexus** are most at risk.

Question 234: Avascular necrosis is the commonest following which type of fracture?

A. Garden 1 and 2 fracture of the femoral neck
B. Garden 3 and 4 fracture of the femoral neck (Correct Answer)
C. Sub-trochanteric fracture of the femur
D. Baso-trochanteric fracture of the femur

Explanation: ### Explanation The correct answer is **Garden 3 and 4 fracture of the femoral neck**. **1. Underlying Medical Concept** The blood supply to the femoral head is tenuous and retrograde, primarily derived from the **medial circumflex femoral artery** (via retinacular vessels). In intracapsular fractures of the femoral neck, these vessels are easily disrupted. The **Garden Classification** is based on the degree of displacement: * **Garden 3 (Complete, partially displaced)** and **Garden 4 (Complete, fully displaced)** involve significant disruption of the retinacular vessels and the capsule. * Because the femoral head becomes an isolated "island" of bone with little to no blood supply, the risk of **Avascular Necrosis (AVN)** is highest in these displaced types (up to 30–45%). **2. Analysis of Incorrect Options** * **Garden 1 and 2:** These are undisplaced or impacted fractures. The retinacular vessels usually remain intact, leading to a much lower incidence of AVN compared to displaced fractures. * **Sub-trochanteric and Baso-trochanteric fractures:** These are **extracapsular** fractures. The blood supply to this region is robust due to the surrounding musculature and the fact that the fracture line lies distal to the main vascular ring supplying the femoral head. These fractures are more prone to malunion or non-union rather than AVN. **3. NEET-PG High-Yield Pearls** * **Garden Classification:** Used for intracapsular neck of femur fractures (1: Incomplete/Valgus impacted; 2: Complete/Undisplaced; 3: Partially displaced; 4: Fully displaced). * **Pauwels Classification:** Based on the angle of the fracture line (higher angle = more vertical = higher shear forces and instability). * **Management Rule:** In elderly patients with Garden 3 or 4 fractures, **Arthroplasty** (Hemi or Total) is preferred over internal fixation due to the high risk of AVN and re-operation. * **Most common site of AVN:** Femoral head (overall), but specifically associated with displaced neck fractures.

Question 235: A 6-year-old boy has a history of recurrent dislocation of the right shoulder. On examination, the orthopedician puts the patient in the supine position, abducts his arm to 90 degrees with the bed as the fulcrum, and then externally rotates it. However, the boy does not allow the test to be performed. What is the name of the test performed by the orthopedician?

A. Apprehension test (Correct Answer)
B. Sulcus test
C. Dugas test
D. McMurray's test

Explanation: The clinical scenario describes the **Apprehension Test**, which is the gold standard for diagnosing **Anterior Shoulder Instability**. ### Why the Correct Answer is Right The test is performed by placing the patient in a supine position, abducting the arm to 90°, and then applying external rotation. This maneuver mimics the position of most frequent dislocations (anteroinferior). In a patient with recurrent instability, this movement causes the humeral head to glide anteriorly, creating a sensation of impending dislocation. The "positive" sign is not pain, but rather the patient’s **apprehension** (anxiety or resistance) and refusal to allow further movement. ### Explanation of Incorrect Options * **B. Sulcus test:** Used to assess **inferior or multidirectional instability**. It is performed by pulling the arm downward (inferior traction); a positive result is a visible "gap" or sulcus between the acromion and the humeral head. * **C. Dugas test:** Used to diagnose **acute shoulder dislocation**. A patient with a dislocated shoulder cannot touch the opposite shoulder with their hand while the elbow is touching the chest. * **D. McMurray's test:** A physical exam maneuver used to identify **meniscal tears in the knee**, involving rotation of the tibia on the femur. It is irrelevant to shoulder trauma. ### NEET-PG High-Yield Pearls * **Relocation Test (Jobe’s Test):** If the apprehension test is positive, applying a posterior pressure on the humeral head relieves the apprehension, confirming anterior instability. * **Bankart Lesion:** The most common cause of recurrent anterior dislocation, involving an avulsion of the anteroinferior labrum. * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head, often seen on X-ray (Stryker notch view) in these patients.

Question 236: Resolving arthroplasty is seen in which of the following?

A. Shoulder dislocation (Correct Answer)
B. Elbow dislocation
C. Knee dislocation
D. Hip dislocation

Explanation: **Explanation:** The term **"Resolving Arthroplasty"** (also known as "Spontaneous Arthroplasty") refers to a unique clinical phenomenon where a joint, despite being chronically dislocated, retains a functional and painless range of motion. This is most characteristically seen in **Shoulder Dislocations**, particularly in elderly patients with chronic unreduced anterior dislocations. **Why Shoulder Dislocation is Correct:** In the shoulder, the lack of weight-bearing requirements and the presence of a wide range of compensatory movements (scapulothoracic motion) allow the body to adapt. Over time, the humeral head forms a "false socket" against the scapula. In elderly patients with low functional demands, the joint "resolves" into a state where it is stable enough for activities of daily living without significant pain, despite the anatomical deformity. **Why Other Options are Incorrect:** * **Elbow Dislocation:** Chronic dislocation leads to severe stiffness, myositis ossificans, and significant functional loss due to the complex hinge anatomy. * **Knee Dislocation:** This is a limb-threatening emergency involving multi-ligamentous injury. Chronic dislocation results in gross instability or severe secondary osteoarthritis, making it non-functional. * **Hip Dislocation:** As a major weight-bearing joint, an unreduced hip dislocation leads to rapid avascular necrosis (AVN) of the femoral head and permanent crippling. It cannot achieve a "painless functional" state without surgical intervention. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type of shoulder dislocation:** Anterior (95%). * **Most common nerve injured in shoulder dislocation:** Axillary nerve (Regimental badge sign). * **Hill-Sachs Lesion:** Compression fracture of the posterolateral humeral head (seen in anterior dislocation). * **Bankart’s Lesion:** Avulsion of the anteroinferior glenoid labrum. * **Treatment of choice for Resolving Arthroplasty:** Conservative management is often preferred in elderly, sedentary patients as surgical reduction carries a high risk of complications.

Question 237: The term Bennett's fracture is used to describe which of the following?

A. Fracture-dislocation of the metacarpophalangeal joint of the thumb
B. Interphalangeal fracture-dislocation of the thumb
C. Anterior marginal fracture of the distal end of the radius
D. Fracture-dislocation of the trapezometacarpal joint (Correct Answer)

Explanation: **Explanation:** **Bennett’s fracture** is an intra-articular fracture-dislocation occurring at the **base of the first metacarpal**. The correct answer is **D** because the base of the first metacarpal articulates with the trapezium to form the **trapezometacarpal (TMC) joint**. **Mechanism and Anatomy:** The fracture occurs when a small volar-ulnar fragment remains attached to the strong **anterior oblique ligament**, while the rest of the metacarpal shaft is displaced proximally, radially, and posteriorly by the pull of the **Abductor Pollicis Longus (APL)** muscle. This results in the characteristic "fracture-dislocation." **Analysis of Incorrect Options:** * **Option A & B:** Bennett’s fracture specifically involves the base of the metacarpal (TMC joint), not the metacarpophalangeal (MCP) or interphalangeal (IP) joints. * **Option C:** An anterior (volar) marginal fracture of the distal radius is known as a **Volar Barton’s fracture**, not Bennett’s. **High-Yield Clinical Pearls for NEET-PG:** * **Rolando Fracture:** A comminuted, T- or Y-shaped intra-articular fracture at the base of the first metacarpal (worse prognosis than Bennett's). * **Gamekeeper’s Thumb:** An injury to the Ulnar Collateral Ligament (UCL) of the thumb MCP joint. * **Management:** Bennett’s fracture is inherently unstable due to muscle pull (APL); therefore, it usually requires **Closed Reduction and Internal Fixation (CRIF)** with K-wires or Open Reduction (ORIF). * **Radiology:** Best visualized on a "Robert’s view" (AP view of the thumb).

Question 238: The Trendelenburg test is positive in which of the following conditions?

A. Dislocation of the hip
B. Fracture of the neck of the femur
C. Coxa vara
D. All the above (Correct Answer)

Explanation: The **Trendelenburg test** is a clinical assessment used to evaluate the integrity of the hip abductor mechanism, primarily the **Gluteus medius and Gluteus minimus** muscles. ### **The Underlying Concept** For a negative (normal) Trendelenburg test, three components must be intact: 1. **The Power:** Intact nerve supply (Superior Gluteal Nerve) and muscle strength. 2. **The Fulcrum:** A stable, painless hip joint (Head of the femur in the acetabulum). 3. **The Lever:** A normal length and angle of the femoral neck (the distance between the fulcrum and the insertion of the muscles). If any of these components are compromised, the pelvis drops on the **unsupported (swing) side** when the patient stands on the affected limb. ### **Explanation of Options** * **A. Dislocation of the hip:** The **fulcrum** is lost because the femoral head is no longer stable within the acetabulum. * **B. Fracture of the neck of the femur:** The **lever** is broken, and the stability of the fulcrum is lost, preventing the abductors from exerting effective tension. * **C. Coxa vara:** This condition involves a decrease in the neck-shaft angle (<120°). This leads to the shortening of the lever arm and **approximation of the origin and insertion** of the glutei (active insufficiency), weakening their mechanical advantage. Since all three conditions disrupt the abductor mechanism, **Option D (All the above)** is correct. ### **Clinical Pearls for NEET-PG** * **Trendelenburg Gait:** Also known as a "lurching gait." If bilateral, it is called a **Waddling gait** (common in Duchenne Muscular Dystrophy or bilateral CDH). * **False Positive:** Can occur in pain (antalgic hip) or poor balance. * **Nerve Root:** The muscles involved are supplied by roots **L4, L5, S1**. * **Other causes:** Polio (muscle weakness) and Perthes disease.

Question 239: Traumatic dislocation of the hip is characterized by which of the following deformities?

A. Adduction and internal rotation deformity (Correct Answer)
B. Abduction and external rotation deformity
C. Adduction and external rotation deformity
D. Abduction and internal rotation deformity

Explanation: ### Explanation The correct answer is **A. Adduction and internal rotation deformity.** **1. Understanding the Mechanism (Posterior Dislocation)** In orthopaedic trauma, **Posterior Dislocation** is the most common type of hip dislocation (accounting for >90% of cases), typically occurring due to a "dashboard injury" where a force is applied to the knee while the hip is flexed. * **The Deformity:** The femoral head is pushed superiorly and posteriorly behind the acetabulum. Due to the tension of the surrounding ligaments (specifically the iliofemoral ligament) and the position of the femoral head relative to the pelvis, the limb is locked in **Flexion, Adduction, and Internal Rotation (FADIR).** **2. Why the other options are incorrect:** * **Option B (Abduction and External Rotation):** This is the classic presentation of an **Anterior Hip Dislocation**. In this rare injury, the limb is typically held in flexion, abduction, and external rotation (FABER). * **Option C (Adduction and External Rotation):** This is the hallmark of a **Fracture of the Neck of Femur**. In fractures, the limb is shortened and externally rotated because the pull of the iliopsoas and short rotators is no longer resisted by the intact femoral neck. * **Option D (Abduction and Internal Rotation):** This combination is not a standard clinical presentation for common hip pathologies. **3. Clinical Pearls for NEET-PG:** * **Sciatic Nerve Injury:** The most common neurological complication of posterior hip dislocation (specifically the peroneal branch). * **Avascular Necrosis (AVN):** This is the most serious late complication; the risk increases if the dislocation is not reduced within 6 hours ("The Golden Period"). * **X-ray Sign:** On an AP view, the femoral head appears **smaller** than the contralateral side in posterior dislocation and **larger** in anterior dislocation (due to magnification). * **Reduction Maneuvers:** Common methods include Bigelow’s, Stimson’s, and the Allis maneuver.

Question 240: Which of the following is not a cause of a positive Trendelenburg sign?

A. Paralysis of the gluteus maximus (Correct Answer)
B. Congenital dislocation of the hip
C. Un-united fracture of the femoral neck
D. Coxa vara

Explanation: ### Explanation The **Trendelenburg sign** is a clinical indicator of a dysfunctional **hip abductor mechanism**. To maintain a level pelvis when standing on one leg, the hip abductors (primarily **Gluteus medius** and **Gluteus minimus**) must contract effectively. #### Why Option A is the Correct Answer **Paralysis of the gluteus maximus** does not cause a positive Trendelenburg sign. The gluteus maximus is a powerful **extensor** of the hip, not an abductor. Paralysis of this muscle leads to a "Gluteus Maximus Lurch" (the trunk lurches backward during the stance phase to maintain balance), but the pelvis remains stable in the coronal plane. #### Why the Other Options are Incorrect A positive Trendelenburg sign occurs when any component of the abductor mechanism is disrupted: * **B. Congenital Dislocation of the Hip (CDH/DDH):** The "fulcrum" (the femoral head in the acetabulum) is lost, making the abductors mechanically disadvantaged and unable to stabilize the pelvis. * **C. Un-united Fracture of the Femoral Neck:** This creates a "non-rigid lever arm." Since the femur is not a continuous bone, the force of the gluteus medius cannot be effectively transmitted to the shaft to lift the pelvis. * **D. Coxa Vara:** A decrease in the neck-shaft angle (<120°) leads to the shortening of the distance between the origin and insertion of the abductors (active insufficiency) and brings the greater trochanter closer to the ilium, weakening the muscle's leverage. #### NEET-PG High-Yield Pearls * **The Nerve:** The Gluteus medius and minimus are supplied by the **Superior Gluteal Nerve (L4, L5, S1)**. Injury to this nerve (e.g., during a poorly placed intramuscular injection) causes a positive Trendelenburg sign. * **The Sign vs. The Gait:** A positive **sign** is observed when the patient stands on the affected leg and the opposite side of the pelvis drops. A Trendelenburg **gait** (or dipping gait) is the compensatory trunk tilt toward the affected side during walking to keep the center of gravity over the hip. * **Bilateral Positive:** If the sign is positive on both sides, it results in a **Waddling Gait** (commonly seen in MD, CDH, or bilateral Coxa Vara).

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Trauma — MCQs

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