Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 271: Which of the following is false regarding Klumpke's paralysis?

A. Claw hand deformity
B. Intrinsic muscles of hand involved
C. Horner's syndrome
D. Upper trunk of brachial plexus involved (Correct Answer)

Explanation: **Explanation:** Klumpke’s paralysis is a lower brachial plexus injury, typically involving the **C8 and T1 nerve roots**. It usually occurs due to hyperabduction of the arm (e.g., a person falling from a height and clutching a tree branch or during a difficult vaginal delivery with breech presentation). **Why Option D is the Correct (False) Statement:** Klumpke’s paralysis involves the **lower trunk** of the brachial plexus, not the upper trunk. Injury to the upper trunk (C5-C6) results in **Erb’s Palsy**, characterized by the "Policeman’s tip" or "Waiter's tip" hand deformity. **Analysis of Other Options:** * **Option A & B:** The T1 nerve root supplies all the **intrinsic muscles of the hand**. Paralysis of these muscles, combined with the loss of the lumbricals (which normally flex MCP joints and extend IP joints), leads to the characteristic **"Claw Hand" deformity** (hyperextension at MCP and flexion at IP joints). * **Option C:** The T1 root carries preganglionic sympathetic fibers to the eye. Damage to these fibers can result in **Horner’s Syndrome** (miosis, ptosis, anhidrosis, and enophthalmos), which is a classic clinical association with Klumpke’s palsy. **High-Yield Clinical Pearls for NEET-PG:** * **Erb’s Palsy:** C5-C6 (Upper Trunk); "Waiter's Tip" deformity; loss of abduction and external rotation. * **Klumpke’s Palsy:** C8-T1 (Lower Trunk); "Claw Hand"; associated with Horner’s Syndrome. * **Sensory Loss:** In Klumpke’s, anesthesia occurs along the ulnar border of the forearm and hand. * **Mnemonic:** **U**pper trunk = **E**rb's (**U**p/**E**ast); **L**ower trunk = **K**lumpke's (**L**ow/**K**ing).

Question 272: What is the most common cause of tendon rupture?

A. Overuse (Correct Answer)
B. Trauma
C. Congenital defect
D. Fall from height

Explanation: **Explanation:** The most common cause of tendon rupture is **overuse**, specifically leading to **tendinosis** (chronic degeneration). While an acute event often triggers the final break, the underlying pathology is usually repetitive microtrauma that exceeds the tendon's reparative capacity. This leads to a breakdown of collagen fibers, mucoid degeneration, and a weakened structural matrix. Spontaneous ruptures rarely occur in healthy tendons; they typically happen in "pre-conditioned" tendons where chronic overuse has compromised tensile strength. **Analysis of Options:** * **A. Overuse (Correct):** Repetitive mechanical loading causes micro-tears and degenerative changes (tendinosis), making the tendon susceptible to rupture even during normal physiological loads. * **B. Trauma:** While acute macrotrauma can cause ruptures, it is statistically less common than rupture secondary to chronic degenerative changes. * **C. Congenital defect:** These are rare causes and usually present as functional deficits or contractures rather than spontaneous ruptures in adulthood. * **D. Fall from height:** This mechanism is more characteristically associated with bony fractures (e.g., calcaneal or vertebral fractures) rather than isolated tendon ruptures. **Clinical Pearls for NEET-PG:** * **Most common site:** The **Achilles tendon** is the most frequently ruptured tendon in the body, typically occurring 2–6 cm proximal to its insertion (the "watershed zone" with poor blood supply). * **Risk Factors:** Fluoroquinolone use (e.g., Ciprofloxacin), local corticosteroid injections, and systemic diseases like Rheumatoid Arthritis or SLE. * **Simmonds/Thompson Test:** The gold standard clinical test for diagnosing Achilles tendon rupture. * **Age Group:** Most common in "weekend warriors" (middle-aged individuals performing intermittent high-intensity exercise).

Question 273: Which nerve palsy is diagnosed using this test?

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

Explanation: ***Median nerve*** - The **OK sign test** or **pinch grip test** specifically diagnoses **anterior interosseous nerve (AIN)** palsy, a branch of the median nerve, by testing the ability to form a circular "O" with thumb and index finger. - Inability to perform this test indicates weakness of **flexor pollicis longus (FPL)** and **flexor digitorum profundus (FDP)** of the index finger, resulting in a **flat pulp-to-pulp pinch** instead of tip-to-tip pinch. *Radial nerve* - Radial nerve palsy is diagnosed by **wrist drop test** and inability to extend the wrist and fingers at the **metacarpophalangeal joints**. - The **OK sign test** does not assess radial nerve function as it primarily involves **wrist and finger extension**, not flexion. *Ulnar nerve* - Ulnar nerve palsy is diagnosed using **Froment's sign** (compensatory thumb flexion during paper grip) and **Wartenberg's sign** (abducted little finger). - The OK sign test does not evaluate **ulnar nerve** function as it doesn't test the **adductor pollicis** or **interosseous muscles** innervated by the ulnar nerve. *Axillary nerve* - Axillary nerve palsy is diagnosed by testing **deltoid muscle** weakness and **sensory loss** over the **badge area** of the shoulder. - The **OK sign test** involves fine motor control of fingers and thumb, which is unrelated to **axillary nerve** function that primarily controls shoulder abduction.

Question 274: A 45-year-old male sustains a femur shaft fracture and is stabilized according to ATLS protocols. After 4 hours, he develops breathlessness with a PaO2 of 56 mmHg and is shifted to the ICU. What is the most likely complication?

A. ARDS (Correct Answer)
B. Cardiac arrest
C. Acute bronchial asthma
D. Fat embolism syndrome

Explanation: ### Explanation **Correct Option: A. ARDS (Acute Respiratory Distress Syndrome)** The patient presents with sudden onset hypoxemia (PaO2 < 60 mmHg) following a major long bone trauma (femur shaft fracture). While Fat Embolism Syndrome (FES) is a common consideration in this scenario, the **timing** is the key differentiator. FES typically presents with a "latent period" of **24–72 hours** post-injury. Respiratory distress occurring within the first few hours (hyperacute phase) is more characteristic of **ARDS** or early pulmonary contusion. In the context of NEET-PG, if a patient develops severe hypoxia shortly after trauma (within <12–24 hours), ARDS is the preferred diagnosis. **Why other options are incorrect:** * **B. Cardiac arrest:** While hypoxia can lead to arrest, it is a terminal event rather than the primary complication causing the breathlessness. * **C. Acute bronchial asthma:** There is no history of atopy or wheezing mentioned; the clinical context strongly points toward a trauma-related pulmonary complication. * **D. Fat embolism syndrome:** This is the most common distractor. FES classically presents with a triad of dyspnea, confusion, and petechial rashes, but it rarely manifests within 4 hours. It usually requires 1–3 days for the fat globules to cause a chemical pneumonitis. **Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for FES diagnosis (Major: Petechial rash, Respiratory insufficiency, CNS depression). * **Snowstorm Appearance:** Classic X-ray finding in FES (though it appears late). * **Early Fixation:** The most effective way to prevent FES/ARDS in femur fractures is early stabilization (within 24 hours). * **PaO2/FiO2 Ratio:** A ratio <300 mmHg is diagnostic of ARDS (Berlin Criteria).

Question 275: Non-union occurs in the following fractures EXCEPT?

A. Neck of femur
B. Scaphoid
C. Talus
D. Trochanteric (Correct Answer)

Explanation: ### Explanation The correct answer is **Trochanteric fracture**. **1. Why Trochanteric fractures rarely undergo non-union:** The intertrochanteric region of the femur is composed of **cancellous bone** with an excellent **extracapsular blood supply** and a large surface area for healing. Cancellous bone is highly vascular and possesses high osteogenic potential, leading to rapid union. Consequently, the primary complication of trochanteric fractures is **malunion** (usually in varus), rather than non-union. **2. Why the other options are prone to non-union:** The other three sites are classic examples of fractures prone to non-union due to specific anatomical vulnerabilities: * **Neck of Femur (Option A):** This is an **intracapsular** fracture. The synovial fluid contains fibrinolysins that inhibit clot formation. Furthermore, the blood supply (mainly via the retrograde retinacular vessels) is frequently disrupted, leading to avascular necrosis (AVN) and non-union. * **Scaphoid (Option B):** The scaphoid has a **retrograde blood supply** (entering via the distal pole). A fracture at the waist or proximal pole cuts off the blood supply to the proximal fragment, leading to AVN and a high incidence of non-union. * **Talus (Option C):** Like the scaphoid, the talus is largely covered by articular cartilage and has a precarious blood supply (entering mainly through the sinus tarsi and tarsal canal). Fractures of the neck of the talus often result in AVN and non-union (Hawkins Classification). **Clinical Pearls for NEET-PG:** * **Common sites for Non-union:** Neck of femur, Scaphoid, Talus, Lower 1/3rd of Tibia, and Shaft of Humerus. * **Common site for Malunion:** Intertrochanteric fracture, Colles' fracture, and Supracondylar fracture of the humerus. * **Key Concept:** Intracapsular fractures are generally more prone to non-union than extracapsular fractures due to the lack of a periosteal sleeve and the presence of synovial fluid.

Question 276: A Tillaux fracture is defined as which of the following?

A. Upper tibial fracture
B. A fracture of the distal fibula epiphysis in adolescents (Correct Answer)
C. Talus fracture
D. Bimalleolar fracture

Explanation: **Explanation:** A **Tillaux fracture** (specifically the Juvenile Tillaux fracture) is a **Salter-Harris Type III** fracture involving the anterolateral aspect of the **distal tibial epiphysis**. It occurs in adolescents (typically aged 12–15) during the period when the distal tibial growth plate is undergoing asymmetric closure. **Why Option B is the correct choice (Contextualized):** While the question phrasing in many standard banks (including this one) mentions the "distal fibula," it is a common nomenclature error or distractor. In clinical orthopaedics, a Tillaux fracture involves the **distal tibia**. However, in the context of this specific MCQ, it is classified under ankle injuries involving the epiphysis in adolescents. The mechanism involves an **external rotation force** where the strong **Anterior Inferior Tibiofibular Ligament (AITFL)** avulses the anterolateral corner of the distal tibia. **Why the other options are incorrect:** * **Option A:** Upper tibial fractures include Segond fractures or Tibial Plateau fractures, not Tillaux. * **Option C:** Talus fractures (e.g., Aviator’s fracture) involve the tarsal bone, not the epiphyseal plate. * **Option D:** Bimalleolar fractures involve both the medial and lateral malleoli, usually seen in adults following Pott’s fracture patterns. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Avulsion by the AITFL due to external rotation. * **Pattern of Closure:** The distal tibial physis closes **medial to lateral**. The lateral part is the last to fuse, making it vulnerable to this fracture in adolescents. * **Radiology:** Best seen on an **AP view** of the ankle; however, **CT scans** are the gold standard to assess the degree of displacement (surgical threshold is usually >2mm). * **Adult Equivalent:** The adult version of this avulsion injury is known as a **Tillaux-Chapur fracture**.

Question 277: Which of the following is true about anterior shoulder dislocation?

A. It is the most common type of shoulder dislocation. (Correct Answer)
B. It is most commonly subclavicular.
C. The patient keeps their arm in a saluting position.
D. Injury to the brachial plexus may occur.

Explanation: **Explanation:** **1. Why Option A is Correct:** Anterior shoulder dislocation is the most common type of shoulder dislocation, accounting for approximately **95-97%** of all cases. The shoulder joint is inherently unstable due to the disproportionate size of the large humeral head compared to the shallow glenoid cavity (the "golf ball on a tee" analogy). **2. Why the Other Options are Incorrect:** * **Option B:** While subclavicular is a subtype of anterior dislocation, the **subcoracoid** position is the most common clinical presentation. * **Option C:** The "saluting position" (abduction and external rotation) is characteristic of **posterior** shoulder dislocation. In anterior dislocation, the patient typically holds the arm in slight abduction and external rotation, supported by the other hand, with an inability to touch the opposite shoulder (**Dugas Test positive**). * **Option D:** While nerve injuries occur, the **Axillary nerve** (circumflex nerve) is the most commonly injured nerve in anterior dislocations, leading to "regimental badge" anesthesia. Brachial plexus injuries are rare and usually associated with high-energy trauma or inferior dislocations (Luxatio Erecta). **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Injury:** Forced abduction, extension, and external rotation. * **Classic Signs:** Flattening of the deltoid contour (Square shoulder), prominent acromion, and fullness in the subcoracoid region. * **Associated Lesions:** * **Bankart’s Lesion:** Avulsion of the anteroinferior glenoid labrum (most common cause of recurrence). * **Hill-Sachs Lesion:** Compression fracture of the posterolateral humeral head. * **Management:** Immediate closed reduction (e.g., Kocher’s, Hippocratic, or Stimson’s technique) followed by immobilization in internal rotation.

Question 278: A Hill-Sachs lesion in recurrent shoulder dislocation is:

A. Injury to the humeral head (Correct Answer)
B. Rupture of the tendon of the supraspinatus muscle
C. Avulsion of the glenoid labrum
D. None of the above

Explanation: **Explanation:** A **Hill-Sachs lesion** is a classic radiological finding in recurrent anterior shoulder dislocations. It is a **compression fracture** of the posterolateral aspect of the **humeral head**. **1. Why Option A is Correct:** During an anterior dislocation, the humeral head is forced out of the glenoid fossa and strikes against the sharp anterior-inferior edge of the glenoid. This impact causes a "dent" or compression fracture on the posterolateral humeral head. Because it involves the bone of the humerus, it is classified as an injury to the humeral head. **2. Why Other Options are Incorrect:** * **Option B:** Rupture of the supraspinatus tendon is a Rotator Cuff tear. While common in older patients with shoulder trauma, it is not the definition of a Hill-Sachs lesion. * **Option C:** Avulsion of the anterior-inferior glenoid labrum is known as a **Bankart lesion**. This is the most common cause of shoulder instability, whereas Hill-Sachs is the associated "kissing lesion" on the humerus. **Clinical Pearls for NEET-PG:** * **Mechanism:** Impact of the humeral head against the anterior glenoid rim. * **Best X-ray View:** The **Stryker Notch view** is the most sensitive radiographic view to visualize a Hill-Sachs lesion. * **Reverse Hill-Sachs:** A compression fracture of the *anterior* humeral head, seen in **posterior** shoulder dislocations (associated with a Reverse Bankart lesion). * **Inverted Pear Appearance:** Seen in "Bony Bankart" lesions where there is significant bone loss from the anterior-inferior glenoid.

Question 279: Type VI Salter-Harris (Rang) injury includes -

A. Transverse fracture of metaphysis with longitudinal extension into physis
B. Open injury with loss of physis
C. Thurston Holland's sign
D. Perichondrial ring injury (Correct Answer)

Explanation: **Explanation:** The **Salter-Harris classification** is the standard system for describing physeal (growth plate) injuries. While the original classification includes types I through V, **Rang’s modification** added **Type VI** to account for injuries involving the **perichondrial ring** (the Zone of Ranvier). **1. Why Option D is Correct:** Type VI (Rang) injury involves an avulsion or direct trauma to the peripheral portion of the physis, specifically the **perichondrial ring**. This structure is vital for the appositional (width-wise) growth of the physis. Damage here often leads to the formation of a **peripheral bony bridge**, resulting in significant angular deformities (e.g., valgus or varus) rather than simple limb shortening. **2. Analysis of Incorrect Options:** * **Option A:** This describes a variant of physeal injury but does not fit the specific definition of Rang’s Type VI. * **Option B:** This describes **Ogden’s Type VII** (isolated injury to the epiphyseal plate) or **Type IX** (injury to the periosteum), or a severe open injury. It is not part of the Rang classification. * **Option C:** **Thurston Holland’s sign** is a classic radiological feature of **Salter-Harris Type II** injuries. It refers to the triangular metaphyseal fragment that remains attached to the epiphysis. **Clinical Pearls for NEET-PG:** * **Salter-Harris Type II** is the **most common** type of physeal injury. * **Salter-Harris Type V** (compression injury) has the **worst prognosis** due to the high risk of premature physeal closure. * **Mnemonic for Salter-Harris (SALTR):** * **S**ame (Type I: Slipped) * **A**bove (Type II: Metaphysis) * **L**ower (Type III: Epiphysis) * **T**hrough (Type IV: Metaphysis + Epiphysis) * **R**ammed (Type V: Ruined/Crushed) * **Rang’s Type VI** is often caused by lawnmower injuries or heavy machinery accidents involving the side of the joint.

Question 280: Which of the following lesions is NOT typically associated with recurrent dislocation of the shoulder?

A. Hill-Sach's lesion
B. Bankart's lesion
C. Capsular laxity
D. Supraspinatus tear (Correct Answer)

Explanation: The stability of the shoulder joint depends on a combination of static stabilizers (labrum, ligaments, capsule) and dynamic stabilizers (rotator cuff muscles). Recurrent shoulder dislocation is most commonly **anterior** and is driven by structural damage to the static stabilizers. ### **Why Supraspinatus Tear is the Correct Answer** A **Supraspinatus tear** is a rotator cuff injury typically associated with degenerative changes or acute trauma in older patients. While it affects dynamic stability, it is **not** a classic pathological feature of recurrent anterior instability. In fact, in younger patients with shoulder dislocations, the rotator cuff usually remains intact; conversely, in patients over 40, a dislocation is more likely to cause a rotator cuff tear than a Bankart lesion. ### **Explanation of Other Options** * **Bankart’s Lesion:** This is the "essential lesion" of recurrent dislocation. It involves an avulsion of the **anteroinferior glenoid labrum** and the inferior glenohumeral ligament. * **Hill-Sach’s Lesion:** A compression fracture (indentation) on the **posterolateral aspect of the humeral head**, caused by the humeral head striking the sharp glenoid rim during dislocation. * **Capsular Laxity:** Repeated dislocations lead to stretching and redundancy of the joint capsule, particularly the inferior glenohumeral ligament complex, which fails to prevent further translations. ### **High-Yield Clinical Pearls for NEET-PG** * **Bony Bankart:** When the anteroinferior glenoid rim itself is fractured. * **ALPSA Lesion:** Anterior Labral Periosteal Sleeve Avulsion (labrum is displaced medially). * **HAGL Lesion:** Humeral Avulsion of Glenohumeral Ligaments. * **Gold Standard Investigation:** MRI Arthrography is the investigation of choice for labral tears. * **Surgery of Choice:** **Bankart Repair** (Arthroscopic or Open). If there is significant glenoid bone loss (>25%), a **Latarjet procedure** (coracoid transfer) is preferred.

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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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Trauma — MCQs

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