Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 311: The fracture of the tooth-bearing segment of the mandible is classified as which type?

A. Simple
B. Complex
C. Compound (Correct Answer)
D. Comminuted

Explanation: ### Explanation The correct answer is **Compound (C)**. **Why it is correct:** In orthopaedics, a **compound (open) fracture** is defined as a fracture that communicates with the external environment through a breach in the skin or mucous membrane. The tooth-bearing segment of the mandible (the body, symphysis, and parasymphysis) is considered a compound fracture by definition because the fracture line typically extends through the **periodontal ligament** or the **gingival sulcus**. Since the oral cavity is a non-sterile environment colonized by bacteria, any fracture involving the teeth creates a direct communication between the bone and the external environment. **Analysis of Incorrect Options:** * **Simple (A):** A simple (closed) fracture is one where the overlying skin and mucous membranes remain intact. While some mandibular fractures (like those of the condyle or ramus) can be simple, those involving teeth are not. * **Complex (B):** This term usually refers to fractures with significant soft tissue injury, neurovascular damage, or involvement of adjacent joints/structures, rather than the nature of the communication with the environment. * **Comminuted (D):** This describes a fracture where the bone is broken into more than two fragments. While a mandibular fracture *can* be comminuted (e.g., from a high-velocity gunshot wound), the presence of teeth specifically defines it as compound, regardless of the number of fragments. **Clinical Pearls for NEET-PG:** * **Prophylactic Antibiotics:** Because these are technically "open" fractures, they require antibiotic coverage to prevent osteomyelitis. * **Most Common Site:** The **condyle** is the most common site of mandibular fracture overall, but the **body/parasymphysis** is the most common site for compound fractures. * **Guardsman Fracture:** A specific type of mandibular fracture resulting from a fall on the chin, leading to a symphysis fracture and bilateral condylar fractures. * **Clinical Sign:** Malocclusion and sublingual ecchymosis (Coleman’s sign) are classic indicators of a mandibular fracture.

Question 312: A 7-year-old boy with a history of trauma 2 months ago now presents with fever and acute pain over the thigh. X-ray of the femoral shaft shows lesions with multiple laminated periosteal reactions. What is the next line of management?

A. CRP measurement
B. Core biopsy
C. Tc99 MDP scan
D. MRI (Correct Answer)

Explanation: ### Explanation The clinical presentation of a 7-year-old with fever, pain, and a "laminated" (onion-skin) periosteal reaction on X-ray creates a diagnostic dilemma between **Acute Osteomyelitis** and **Ewing’s Sarcoma**. Both conditions can present with systemic symptoms and similar radiographic features. **Why MRI is the Correct Next Step:** In the context of a suspected bone tumor or infection, **MRI is the investigation of choice** for local staging and further characterization. It is highly sensitive for detecting marrow involvement, soft tissue extension, and cortical destruction. In this specific case, MRI helps differentiate between an inflammatory collection (abscess) and a solid tumor mass, guiding the clinician toward the definitive diagnosis before invasive procedures. **Analysis of Incorrect Options:** * **CRP measurement (A):** While CRP is an inflammatory marker that would likely be elevated in both osteomyelitis and Ewing’s sarcoma, it is non-specific and does not aid in definitive diagnosis or local staging. * **Core biopsy (B):** Biopsy is the gold standard for definitive diagnosis, but it should **never** be performed before imaging (MRI). Imaging must define the tumor's extent to ensure the biopsy tract is correctly placed and does not compromise future limb-salvage surgery. * **Tc99 MDP scan (C):** A bone scan is useful for identifying "skip lesions" or polyostotic involvement but lacks the anatomical detail required to differentiate between infection and malignancy in the primary lesion. **NEET-PG Clinical Pearls:** * **Onion-skin appearance:** Classically associated with Ewing’s Sarcoma (due to rapid, intermittent periosteal growth) but also seen in Acute Osteomyelitis. * **Ewing’s Sarcoma:** Most common in the first two decades; translocation **t(11;22)**; PAS-positive cells on histology. * **Rule of Thumb:** In any pediatric bone lesion where the diagnosis is unclear between infection and malignancy, **MRI** is the most important next imaging modality.

Question 313: Which line joins the greater trochanter and the anterior superior iliac spine?

A. Schoemaker's line (Correct Answer)
B. Perkin's line
C. Nelton's line
D. Chiene's line

Explanation: **Explanation:** The correct answer is **Schoemaker’s line**. This clinical line is used to assess the position of the greater trochanter in relation to the pelvis, which is vital for diagnosing hip pathologies. **1. Why Schoemaker’s Line is Correct:** Schoemaker’s line is an imaginary line drawn from the tip of the **greater trochanter** through the **Anterior Superior Iliac Spine (ASIS)** and extended toward the midline of the abdomen. * **Normal:** The line passes **above the umbilicus**. * **Abnormal:** If the greater trochanter is displaced proximally (e.g., in femoral neck fractures, developmental dysplasia of the hip, or Perthes disease), the line passes **below the umbilicus**. **2. Analysis of Incorrect Options:** * **Perkin’s Line:** A vertical line drawn downward from the lateral edge of the acetabular roof on a pelvic X-ray. It is used to diagnose Congenital Dislocation of the Hip (CDH); the femoral head should normally lie medial to this line. * **Nélaton’s Line:** A line connecting the **ASIS to the Ischial Tuberosity**. In a normal hip, the greater trochanter lies on or below this line. If the trochanter is felt above this line, it indicates upward hip dislocation or a neck fracture. * **Chiene’s Line:** A line joining the two ASIS and another joining the two greater trochanters. Normally, these lines are parallel. Non-parallelism suggests pelvic tilt or trochanteric displacement. **Clinical Pearls for NEET-PG:** * **Bryant’s Triangle:** Used to measure the upward displacement of the trochanter. The horizontal base of the triangle shortens in hip fractures. * **Trendelenburg Test:** Assesses the stability of the hip and the strength of the abductors (Gluteus medius and minimus). * **Shenton’s Line:** An anatomical curve on X-ray formed by the inferior margin of the femoral neck and the superior margin of the obturator foramen. Interruption indicates hip pathology.

Question 314: A 40-year-old man was admitted with fracture of the shaft of the femur following a road traffic accident. On the 2nd day, he became disoriented, was found to be tachypnoeic, and had conjunctival petechiae. What is the most likely diagnosis?

A. Pulmonary embolism
B. Sepsis syndrome
C. Fat embolism (Correct Answer)
D. Haemothorax

Explanation: ### Explanation The clinical presentation described is a classic triad of **Fat Embolism Syndrome (FES)**, which typically occurs 24–72 hours after a long bone fracture (most commonly the femur). **Why Fat Embolism is the Correct Answer:** Fat embolism occurs when fat globules from the bone marrow enter the systemic circulation following a fracture. The diagnosis is primarily clinical, based on **Gurd’s Criteria**. This patient exhibits the classic triad: 1. **Respiratory Distress:** Tachypnoea and hypoxia. 2. **Neurological Changes:** Disorientation/confusion (due to cerebral microemboli). 3. **Petechial Rash:** Characteristically found in the conjunctiva, axilla, and neck (pathognomonic but present in only 20-50% of cases). **Why Other Options are Incorrect:** * **Pulmonary Embolism (PE):** While it causes tachypnoea, it usually occurs later (1–2 weeks post-injury) due to DVT. It does not present with petechiae. * **Sepsis Syndrome:** Usually presents with fever, hypotension, and a clear source of infection. The 48-hour window and petechiae are more specific to FES. * **Haemothorax:** This would present immediately after trauma with decreased breath sounds and dullness on percussion, not after a 2-day "latent period." **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Fracture of the shaft of the femur. * **Earliest sign:** Hypoxia (PaO2 < 60 mmHg). * **Pathognomonic sign:** Petechial rash. * **Investigation of choice:** Clinical diagnosis; however, "Snowstorm appearance" may be seen on Chest X-ray. * **Treatment:** Primarily supportive (Oxygenation/Ventilation). Early splintage and fixation of the fracture are the best preventive measures.

Question 315: What is the first muscle to be involved in Volkmann's ischemic contracture of the forearm?

A. Flexor digitorum profundus (Correct Answer)
B. Flexor digitorum superficialis
C. Flexor Carpi Radialis
D. Extensor carpi radialis brevis

Explanation: **Explanation:** Volkmann’s Ischemic Contracture (VIC) is the permanent sequela of untreated compartment syndrome of the forearm, most commonly following a supracondylar fracture of the humerus. **Why Flexor Digitorum Profundus (FDP) is the correct answer:** The pathophysiology of VIC involves increased intracompartmental pressure leading to muscle ischemia. The **Flexor Digitorum Profundus (FDP)** is the most deeply situated muscle in the flexor compartment of the forearm, lying directly against the interosseous membrane and the bones (ulna and radius). Due to its deep location, it is the first to be affected by the rising pressure and the last to recover. Specifically, the **medial half** (supplied by the ulnar nerve) is often the most severely involved. **Analysis of Incorrect Options:** * **Flexor Digitorum Superficialis (B):** While frequently involved in VIC, it is more superficial than the FDP and is typically affected after the FDP has already sustained ischemic damage. * **Flexor Carpi Radialis (C):** This is a superficial muscle of the forearm. While it may eventually undergo fibrosis in severe cases, it is never the primary or first muscle involved. * **Extensor carpi radialis brevis (D):** This muscle belongs to the mobile wad/extensor compartment. VIC primarily affects the deep flexor compartment; the extensors are usually involved only in global, late-stage ischemia. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Deformity:** The "Volkmann’s Sign"—wrist flexion, MCP joint hyperextension, and IP joint flexion. * **Nerve Involvement:** The **Median nerve** is the most common nerve involved in forearm compartment syndrome. * **Earliest Sign:** Pain out of proportion to the injury and **pain on passive stretching** of the fingers (the most reliable clinical indicator). * **Infarct Shape:** The necrotic area in VIC is typically **ellipsoid**, with the center of ischemia located at the mid-forearm in the FDP.

Question 316: What is a late complication of acetabular fracture?

A. Osteoarthritis (Correct Answer)
B. Tardy sciatic nerve palsy
C. Recurrent dislocation
D. None of the above

Explanation: **Explanation:** **1. Why Osteoarthritis is the correct answer:** Acetabular fractures are intra-articular injuries involving the weight-bearing surface of the hip joint. Even with anatomical reduction, the initial trauma often causes chondrocyte death or subchondral bone irregularities. This leads to **Post-Traumatic Osteoarthritis (OA)**, which is the most common late complication. The risk increases significantly if there is residual joint incongruity, femoral head contour changes, or avascular necrosis. **2. Analysis of Incorrect Options:** * **Tardy sciatic nerve palsy:** While sciatic nerve injury is a common complication of acetabular fractures (especially posterior wall fractures), it is typically an **early/acute** complication occurring at the time of injury or during surgery. "Tardy" (late-onset) palsy is characteristic of the ulnar nerve at the elbow, not the sciatic nerve. * **Recurrent dislocation:** This is a common complication of **traumatic hip dislocations** (especially if the labrum or capsule is poorly healed), but it is not a standard late complication of an isolated acetabular fracture unless there is significant posterior wall deficiency that was left unaddressed. **3. NEET-PG High-Yield Pearls:** * **Most common early complication:** Sciatic nerve palsy (specifically the peroneal division). * **Most common late complication:** Post-traumatic Osteoarthritis. * **Heterotopic Ossification:** Another important late complication, often seen following the Kocher-Langenbeck surgical approach. * **Avascular Necrosis (AVN):** Can occur in the femoral head due to associated hip dislocation or disruption of the medial circumflex femoral artery. * **Radiological Sign:** The "Gull-sign" on an obturator oblique view indicates a specific type of comminuted superior acetabular roof fracture.

Question 317: Milkman's Fracture is a type of?

A. Pseudofracture (Correct Answer)
B. Clavicular fracture
C. Humeral fracture
D. Metacarpal fracture

Explanation: **Explanation:** **Milkman’s Fracture** is a classic example of a **Pseudofracture** (also known as **Looser’s zones** or Umbauzonen). These are not true traumatic fractures but are radiolucent lines representing stress fractures that have healed with unmineralized osteoid. 1. **Why Pseudofracture is correct:** In metabolic bone diseases like **Osteomalacia** (adults) or **Rickets** (children), there is defective mineralization of the bone matrix. Under physiological stress, small cortical cracks occur. Because the body cannot properly mineralize the repair tissue, these areas appear as thin, transverse lucent bands on X-rays, often symmetrical and perpendicular to the bone cortex. Common sites include the axillary border of the scapula, inner cortex of the femoral neck, ribs, and pubic rami. 2. **Why other options are incorrect:** * **Clavicular, Humeral, and Metacarpal fractures** typically refer to acute traumatic injuries or specific eponymous fractures (e.g., Smith’s, Colles’, or Boxer’s fracture). While these bones *can* develop pseudofractures, Milkman's syndrome specifically describes the clinical entity of multiple pseudofractures associated with osteomalacia. **High-Yield Clinical Pearls for NEET-PG:** * **Pathognomonic for:** Osteomalacia. * **Radiological appearance:** Transverse lucent lines with sclerotic margins, often bilateral and symmetrical. * **Common Sites:** Scapula (most common), ribs, pubic rami, and medial cortex of the femur. * **Biochemical markers:** Low Vitamin D, low Serum Calcium/Phosphate, and **Elevated Alkaline Phosphatase (ALP)**.

Question 318: Prosthetic replacement of the femoral head is usually indicated for which of the following?

A. Fresh intracapsular fracture of the head of the femur in elderly patients
B. Fresh intracapsular fracture of the femoral neck in a young adult
C. Unreduced posterior dislocation of the hip
D. Untreated femoral neck fracture in a patient over 65 years (Correct Answer)

Explanation: **Explanation:** The management of femoral neck fractures is primarily determined by the patient's age and the duration since the injury. The femoral neck is intracapsular, and its blood supply (mainly via the medial circumflex femoral artery) is precarious. **Why Option D is Correct:** In an **untreated (neglected) femoral neck fracture** in an elderly patient (>65 years), the chances of achieving union with internal fixation are near zero due to established avascular necrosis (AVN) and resorption of the fracture edges. Therefore, **prosthetic replacement** (Hemiarthroplasty or Total Hip Arthroplasty) is the treatment of choice to allow immediate weight-bearing and avoid the complications of prolonged recumbency. **Analysis of Incorrect Options:** * **Option A:** Fresh fractures in the elderly are often treated with prosthesis, but the question specifies "fracture of the **head**." Fractures of the femoral head (Pipkin fractures) are rare and usually managed by ORIF or excision of fragments, not routine prosthetic replacement unless severely comminuted. * **Option B:** In **young adults**, the goal is always **head preservation**. Even in displaced fractures, urgent anatomical reduction and internal fixation (e.g., Cannulated Cancellous Screws) are performed to save the natural joint. * **Option C:** Unreduced posterior dislocation is a surgical emergency. Initial management is closed or open reduction. Prosthesis is only considered later if secondary osteoarthritis or AVN develops. **NEET-PG High-Yield Pearls:** * **Garden’s Classification:** Used for femoral neck fractures. Garden III and IV (displaced) in the elderly usually require Arthroplasty. * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (Type III) are more unstable due to shear forces. * **Treatment Summary:** * Young patient (<60y): Internal Fixation (Save the head). * Elderly patient (>65y): Hemiarthroplasty (Austin Moore or Thompson) or THA. * Neglected fracture (>3 weeks): Replacement is preferred in the elderly; McMurray’s osteotomy or muscle pedicle grafts may be tried in the young.

Question 319: What is the treatment of choice for a 65-year-old male with a fracture of the neck of the femur sustained 6 weeks ago?

A. SP nailing
B. Mc Murray's osteotomy
C. Hemiarthroplasty (Correct Answer)
D. None of the above

Explanation: ### Explanation The treatment of choice for a fracture of the neck of the femur depends primarily on the **age of the patient** and the **duration since the injury**. **Why Hemiarthroplasty is Correct:** In an elderly patient (65 years old) with a "neglected" or old fracture (6 weeks duration), the risk of **Avascular Necrosis (AVN)** and **Non-union** is extremely high due to the precarious retrograde blood supply of the femoral head. At 6 weeks, the fracture site is unlikely to heal with internal fixation. Therefore, replacing the femoral head (Hemiarthroplasty) is the standard of care. It allows for immediate weight-bearing and avoids the complications of a second surgery if fixation fails. **Analysis of Incorrect Options:** * **A. SP (Smith-Petersen) Nailing:** This is an obsolete method of internal fixation. Even modern fixation (like Cannulated Cancellous Screws) is generally avoided in elderly patients with old fractures because the biological potential for healing is lost after 3 weeks. * **B. McMurray’s Osteotomy:** This is a displacement osteotomy used historically to convert shearing forces into compressive forces to promote healing in non-union. However, it is rarely performed today and is not the first choice in an elderly patient who requires early mobilization. **High-Yield Clinical Pearls for NEET-PG:** 1. **The "3-Week" Rule:** Neck of femur fractures are considered "neglected" if they are >3 weeks old. 2. **Age-Based Management:** * **<60 years:** Attempt head salvage (Internal fixation/Osteotomy). * **>60 years:** Replacement (Hemiarthroplasty if sedentary; Total Hip Arthroplasty if active/pre-existing arthritis). 3. **Garden Classification:** Used to grade displacement; Garden III and IV have the highest risk of AVN. 4. **Pauwels Classification:** Based on the angle of the fracture line; higher angles indicate greater instability.

Question 320: The anterior drawer test is used to assess which structure?

A. Anterior Cruciate Ligament (ACL) (Correct Answer)
B. Posterior Cruciate Ligament (PCL)
C. Medial meniscus
D. Lateral meniscus

Explanation: **Explanation:** The **Anterior Drawer Test** is a clinical examination used to evaluate the integrity of the **Anterior Cruciate Ligament (ACL)**. The ACL's primary function is to prevent the anterior translation of the tibia relative to the femur. During the test, the patient lies supine with the knee flexed to 90°. The examiner stabilizes the foot and pulls the proximal tibia forward. A "positive" test is indicated by excessive anterior displacement (usually >5mm) compared to the unaffected side, signifying an ACL tear. **Analysis of Options:** * **Option A (Correct):** The test specifically stresses the ACL by mimicking the force that the ligament is designed to resist. * **Option B (Incorrect):** The **Posterior Drawer Test** is used for the PCL. In this test, the tibia is pushed posteriorly; excessive backward displacement indicates a PCL injury. * **Options C & D (Incorrect):** Meniscal injuries are assessed using tests that involve joint line tenderness and rotation under compression, such as **McMurray’s Test**, **Apley’s Grind Test**, or the **Thessaly Test**. **High-Yield Clinical Pearls for NEET-PG:** * **Lachman Test:** This is the **most sensitive** clinical test for acute ACL tears. It is performed at 20–30° of flexion, which reduces the stabilizing effect of the hamstrings. * **Pivot Shift Test:** This is the **most specific** test for ACL deficiency, indicating functional instability. * **Segond Fracture:** A small avulsion fracture of the lateral tibial condyle; it is pathognomonic for an ACL tear. * **Unhappy Triad (O'Donoghue):** Consists of injuries to the ACL, Medial Collateral Ligament (MCL), and Medial Meniscus (though recent studies suggest the Lateral Meniscus is more commonly involved in acute settings).

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Open Fractures

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