Trauma — MCQs
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A 32-year-old man was involved in a high-speed motorcycle accident, sustaining multiple injuries including a pelvic fracture and an open left femur fracture. He underwent urgent irrigation and debridement. Due to medical instability, his fractures could not be stabilized initially. On the second day, he became confused, tachypneic, dyspneic, and developed petechiae. His electrocardiogram and chest X-ray were normal. Which of the following is the most likely diagnosis?
From the following neck of femur fractures, which one has the worst prognosis?
Which of the following is NOT included in Gurd's criteria?
Which of the following is a method for long bone fracture fixation?
Pain around the hip with flexion, adduction, and internal rotation of the lower limb in a young adult after a road traffic accident is suggestive of which of the following conditions?
Fat embolism may ensue following which type of fracture?
Which of the following injuries is likely to cause severe vascular damage?
Tietze's syndrome typically affects the costal cartilages of which ribs?
Surgical excision is contraindicated in which of the following anatomical structures?
Adson's test is used to assess vascular compression. It is useful in identifying which of the following conditions?
Trauma Indian Medical PG Practice Questions and MCQs
Question 351: A 32-year-old man was involved in a high-speed motorcycle accident, sustaining multiple injuries including a pelvic fracture and an open left femur fracture. He underwent urgent irrigation and debridement. Due to medical instability, his fractures could not be stabilized initially. On the second day, he became confused, tachypneic, dyspneic, and developed petechiae. His electrocardiogram and chest X-ray were normal. Which of the following is the most likely diagnosis?
- A. Fat embolism (Correct Answer)
- B. Pneumonia
- C. Pulmonary contusion
- D. Pneumothorax
Explanation: **Explanation:** The clinical presentation of a patient with a **long bone fracture** (femur) and **pelvic fracture** who develops the classic triad of **confusion (neurological symptoms), respiratory distress (tachypnea/dyspnea), and petechiae** (typically on the axilla, neck, or conjunctiva) after a 24–72 hour "latent period" is pathognomonic for **Fat Embolism Syndrome (FES)**. 1. **Why Fat Embolism is correct:** FES occurs when fat globules from the bone marrow enter the systemic circulation following trauma. These globules cause mechanical obstruction and a biochemical inflammatory response (free fatty acid release). The diagnosis is clinical (Gurd’s Criteria). The normal initial chest X-ray and ECG help rule out immediate cardiothoracic catastrophes, as FES often shows a "snowstorm appearance" on X-ray only in later stages. 2. **Why other options are incorrect:** * **Pneumonia:** Usually presents later (3–5 days) with fever, productive cough, and localized infiltrates on X-ray. * **Pulmonary Contusion:** Would typically show immediate respiratory distress and opacities on the initial chest X-ray following high-energy trauma. * **Pneumothorax:** Characterized by sudden onset, pleuritic chest pain, and decreased breath sounds; it would be visible on a chest X-ray as a radiolucent area with no lung markings. **High-Yield Pearls for NEET-PG:** * **Classic Triad:** Respiratory distress, Cerebral signs, and Petechial rash (rash is present in only ~20-50% but is highly specific). * **Gurd’s Criteria:** Used for diagnosis. * **Treatment:** Primarily supportive (Oxygenation/Ventilation). Early stabilization of fractures (within 24 hours) is the best preventive measure. * **Most common site of petechiae:** Vestigial (axilla) and subconjunctival.
Question 352: From the following neck of femur fractures, which one has the worst prognosis?
- A. Basicervical
- B. Garden's type 4 (Correct Answer)
- C. Transcervical
- D. Prognosis same in all types
Explanation: **Explanation:** The prognosis of a neck of femur (NOF) fracture is primarily determined by the **risk of Avascular Necrosis (AVN)** and **non-union**. This risk is directly proportional to the degree of displacement and the disruption of the blood supply (mainly the medial circumflex femoral artery). **Why Garden’s Type 4 is the correct answer:** The Garden classification is based on the degree of displacement seen on an AP X-ray: * **Type 1:** Incomplete/Impacted. * **Type 2:** Complete but undisplaced. * **Type 3:** Complete and partially displaced. * **Type 4:** **Complete and fully displaced.** In Type 4 fractures, the femoral head is completely detached from the neck, leading to total disruption of the retinacular vessels. This results in the highest incidence of AVN and non-union among all types, necessitating joint replacement (Hemiarthroplasty or THR) in elderly patients. **Analysis of Incorrect Options:** * **A. Basicervical:** These occur at the base of the neck. Being further from the joint capsule (extracapsular), the blood supply to the head is usually preserved, and they have a better healing potential compared to intracapsular fractures. * **C. Transcervical:** While these are intracapsular and carry a risk of AVN, they are generally considered less severe than a fully displaced (Garden 4) fracture unless specified as displaced. * **D. Prognosis same:** Incorrect, as the risk of AVN increases significantly as the fracture site moves more proximally (closer to the head) and as displacement increases. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** The main supply to the femoral head is the **Medial Circumflex Femoral Artery** (via retinacular vessels). * **Pauwels Classification:** Based on the **angle of the fracture line**. Higher angles (Type III > 50°) indicate high shear forces and a worse prognosis. * **Management:** Undisplaced fractures (Garden 1 & 2) are managed with internal fixation (e.g., Cannulated Cancellous Screws), while displaced fractures in the elderly are treated with Arthroplasty.
Question 353: Which of the following is NOT included in Gurd's criteria?
- A. Central nervous system depression disproportionate to hypoxemia
- B. Tachycardia < 110 bpm
- C. Deep vein thrombosis (Correct Answer)
- D. Axillary or subconjunctival petechiae
Explanation: This question tests your knowledge of **Fat Embolism Syndrome (FES)**, a classic complication following long bone fractures (especially the femur). Diagnosis is primarily clinical, using **Gurd’s and Wilson’s Criteria**. ### Why "Deep Vein Thrombosis" is the Correct Answer Deep Vein Thrombosis (DVT) is a separate thromboembolic complication of trauma but is **not** part of Gurd’s criteria for Fat Embolism. While both involve vascular occlusion, FES is caused by fat globules entering the circulation, whereas DVT involves blood clot formation. ### Analysis of Incorrect Options (Included in Gurd’s Criteria) Gurd’s criteria are divided into Major and Minor categories. Diagnosis requires **at least 1 Major + 4 Minor** (or 2 Major) signs. * **Option A (Major Criterion):** CNS depression (confusion, coma, or seizures) that is disproportionate to the degree of systemic hypoxemia is a hallmark major sign. * **Option D (Major Criterion):** A petechial rash, typically found in the axilla, root of the neck, or subconjunctiva, is the most pathognomonic (though late) sign of FES. * **Option B (Minor Criterion):** Tachycardia (usually **> 110 bpm**) is a recognized minor criterion. While the option says "< 110," in the context of "which is NOT included," DVT is the absolute distractor, as tachycardia (the parameter) is part of the list. ### NEET-PG High-Yield Pearls * **Classic Triad:** Dyspnea (Respiratory), Petechiae (Skin), and Confusion (CNS). * **Earliest Sign:** Hypoxemia/Respiratory distress. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Treatment:** Primarily **supportive** (Oxygenation/Ventilation). Early stabilization/fixation of fractures is the best preventive measure. * **Free Fat Globules:** May be found in urine (lipiduria) or sputum, but this is not specific.
Question 354: Which of the following is a method for long bone fracture fixation?
- A. Intramedullary nail (Correct Answer)
- B. Compression plate
- C. External fixation
- D. Screw
Explanation: **Explanation:** The **Intramedullary (IM) nail** is considered the "gold standard" for the fixation of most diaphyseal (shaft) fractures of long bones, such as the femur and tibia. The underlying biomechanical concept is that an IM nail acts as an **internal splint** and a **load-sharing device**. Unlike plates, it is positioned in the center of the bone (the mechanical axis), allowing for early weight-bearing and promoting secondary bone healing through callus formation. **Analysis of Options:** * **A. Intramedullary nail (Correct):** It is the definitive method for long bone shaft fractures. It preserves the periosteal blood supply because it is inserted using a minimally invasive (closed) technique. * **B. Compression plate:** While used for fractures, plates are **load-bearing** devices. They are typically reserved for articular (joint) fractures or specific long bones like the radius and ulna where anatomical reduction is critical. They require open reduction, which can disrupt the blood supply. * **C. External fixation:** This is generally a temporary stabilization method used in "damage control orthopaedics" for open fractures with severe soft tissue injury or infected non-unions, rather than a primary definitive fixation for simple long bone fractures. * **D. Screw:** A solitary screw cannot provide enough stability to fix a long bone fracture; it is used as a component of other constructs (like lag screws) or for small avulsion fractures. **High-Yield NEET-PG Pearls:** * **Gold Standard:** IM nailing is the treatment of choice for fractures of the femoral and tibial shafts. * **Healing Type:** IM nails lead to **indirect (secondary) bone healing** with callus formation. Plates lead to **direct (primary) bone healing** without callus. * **Complication:** The most common complication of femoral nailing is hip pain; for tibial nailing, it is chronic knee pain.
Question 355: Pain around the hip with flexion, adduction, and internal rotation of the lower limb in a young adult after a road traffic accident is suggestive of which of the following conditions?
- A. Intracapsular fracture of the femoral neck
- B. Extracapsular fracture of the femoral neck
- C. Posterior dislocation of hip (Correct Answer)
- D. Anterior dislocation of hip
Explanation: ### Explanation **Correct Answer: C. Posterior Dislocation of Hip** The clinical presentation of a **shortened, adducted, and internally rotated** limb following high-energy trauma (like a dashboard injury in an RTA) is the classic hallmark of a **Posterior Dislocation of the Hip**. In this condition, the femoral head is pushed out of the acetabulum posteriorly. The tension of the iliofemoral ligament and the position of the displaced head result in the characteristic "FADIR" deformity (Flexion, Adduction, Internal Rotation). **Why the other options are incorrect:** * **A & B (Femoral Neck Fractures):** Both intracapsular and extracapsular fractures typically present with **External Rotation** and shortening. In extracapsular (intertrochanteric) fractures, the external rotation is often more severe (nearly 90 degrees) compared to intracapsular fractures. * **D (Anterior Dislocation of Hip):** This presents with the opposite deformity: **Abduction and External Rotation** (the "FABER" position). The limb may appear lengthened or neutral, but never internally rotated. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Most common cause is a "Dashboard injury" where the knee strikes the dashboard with the hip flexed. * **Most Common Type:** Posterior dislocation accounts for ~90% of all hip dislocations. * **Associated Nerve Injury:** The **Sciatic nerve** (specifically the peroneal division) is the most commonly injured nerve in posterior dislocations. * **Complications:** Avascular Necrosis (AVN) of the femoral head is a dreaded complication; the risk increases if the dislocation is not reduced within 6 hours (**Surgical Emergency**). * **X-ray Sign:** In a posterior dislocation, the femoral head appears smaller than the contralateral side on an AP view (due to being closer to the film/further from the source).
Question 356: Fat embolism may ensue following which type of fracture?
- A. Fracture of spine and ribs
- B. Fractured fibula
- C. Fracture of skull bone
- D. Fracture of long bones (Correct Answer)
Explanation: **Explanation:** **Fat Embolism Syndrome (FES)** occurs when fat globules are released into the systemic circulation, typically following trauma. **Why Option D is correct:** The primary source of fat emboli is the **yellow bone marrow**, which is rich in adipose tissue. Long bones (such as the **femur, tibia, and pelvis**) have extensive marrow cavities. Upon fracture, the disruption of intramedullary blood vessels combined with increased interstitial pressure allows fat globules to enter the venous sinusoids. The femur is the most common bone associated with FES. **Why other options are incorrect:** * **Option A (Spine and Ribs):** While these contain marrow, the volume of yellow marrow is significantly less than in long bones, making FES rare. * **Option B (Fibula):** The fibula is a non-weight-bearing long bone with a much smaller marrow cavity compared to the femur or tibia; thus, it rarely generates enough fat emboli to cause clinical syndrome. * **Option C (Skull):** Skull bones are flat bones with minimal marrow fat and do not typically lead to fat embolism. **NEET-PG High-Yield Pearls:** 1. **Gurd’s Criteria:** Used for diagnosis. Major signs include **petechial rash** (typically over the chest/axilla), **respiratory distress** (hypoxemia), and **cerebral involvement** (confusion/coma). 2. **Classic Triad:** Dyspnea, Restlessness, and Petechiae. 3. **Snowstorm Appearance:** Characteristic finding on Chest X-ray (diffuse pulmonary infiltrates). 4. **Free Fatty Acids:** The biochemical theory suggests that circulating free fatty acids (toxic metabolites) cause direct endothelial damage to the lungs. 5. **Management:** Primarily supportive (Oxygenation/Ventilation). Early stabilization of the fracture is the best preventive measure.
Question 357: Which of the following injuries is likely to cause severe vascular damage?
- A. Closed posterior dislocation of the knee
- B. Elbow dislocation (Correct Answer)
- C. Fracture of the middle third of the clavicle
- D. Tibial plateau fracture
Explanation: **Explanation:** The correct answer is **Elbow dislocation**. This is because of the intimate anatomical relationship between the distal humerus and the **brachial artery**. In a posterior elbow dislocation (the most common type), the brachial artery is frequently compressed or tethered between the sharp edge of the displaced distal humerus and the bicipital aponeurosis. This can lead to arterial spasm, intimal tears, or complete rupture, potentially resulting in **Volkmann’s Ischemic Contracture**. **Analysis of Options:** * **A. Closed posterior dislocation of the knee:** While knee dislocations are notorious for **popliteal artery** injuries, the question asks which is "likely" to cause severe damage in a comparative context. Statistically, in many clinical datasets, elbow injuries (including supracondylar fractures and dislocations) are more frequent precursors to acute limb-threatening ischemia in the upper extremity. *Note: Some textbooks debate the priority between knee and elbow, but for NEET-PG, the elbow-brachial artery link is a classic high-yield association.* * **C. Fracture of the middle third of the clavicle:** These are common and usually benign. While the subclavian vessels lie inferiorly, they are rarely injured unless there is high-energy comminution or penetrating trauma. * **D. Tibial plateau fracture:** These are primarily intra-articular fractures. While they can cause compartment syndrome, direct "severe vascular damage" to major trunks is less common than in knee dislocations. **Clinical Pearls for NEET-PG:** * **Highest Risk:** The most common orthopedic injury causing vascular compromise is the **Supracondylar fracture of the humerus** (Gartland Type III). * **Golden Rule:** Always check the **radial pulse** before and after reduction of any elbow or knee dislocation. * **Management:** If the pulse is absent after reduction, the next step is an **Angiography** (or CT Angio) to localize the lesion.
Question 358: Tietze's syndrome typically affects the costal cartilages of which ribs?
- A. First and second ribs
- B. Second to fifth ribs (Correct Answer)
- C. Sixth to eighth ribs
- D. All seven ribs
Explanation: **Explanation:** **Tietze’s Syndrome** is a benign, inflammatory condition characterized by painful swelling of the costochondral or costosternal joints. 1. **Why the correct answer is right:** The syndrome most commonly involves the **second to fifth costal cartilages**. The **second rib** is the most frequently affected site. Unlike simple costochondritis, Tietze’s syndrome is distinguished by the presence of **palpable, localized swelling** and tenderness. It is usually unilateral and often follows a history of minor trauma, excessive coughing, or physical exertion. 2. **Analysis of incorrect options:** * **Option A (First and second ribs):** While the second rib is the most common site, the syndrome typically spans a broader range (2nd–5th). Isolated involvement of the first rib is rare. * **Option C (Sixth to eighth ribs):** These are lower ribs. Pain in this region is more likely associated with "Slipping Rib Syndrome" or abdominal pathology rather than classic Tietze’s. * **Option D (All seven ribs):** Tietze’s is characteristically localized to one or two joints; diffuse involvement of all true ribs is not seen in this clinical entity. **High-Yield Clinical Pearls for NEET-PG:** * **Tietze’s vs. Costochondritis:** The hallmark of Tietze’s is **swelling** (edema of cartilage). Costochondritis presents with pain but **no swelling**. * **Demographics:** It usually affects younger adults (under 40), whereas costochondritis is more common in patients over 40. * **Diagnosis:** It is a clinical diagnosis. Investigations (X-ray, ECG) are primarily done to rule out life-threatening causes of chest pain like Myocardial Infarction or Pleurisy. * **Management:** Conservative treatment with NSAIDs, rest, and reassurance, as it is a self-limiting condition.
Question 359: Surgical excision is contraindicated in which of the following anatomical structures?
- A. Olecranon process
- B. Patella
- C. Head of radius
- D. Lateral condyle humerus (Correct Answer)
Explanation: In orthopaedic trauma, surgical excision is generally reserved for non-functional, severely comminuted, or necrotic fragments that cannot be reconstructed. However, it is strictly contraindicated in certain areas due to the risk of profound functional loss or growth disturbances. **Why Lateral Condyle of the Humerus is the Correct Answer:** The lateral condyle of the humerus is a **physeal (growth) plate injury** (usually Milch type II). In children, it is the "capitellum" and serves as a vital growth center. Excision of this fragment leads to: 1. **Severe Valgus Deformity:** Loss of the lateral pillar causes the elbow to collapse outward. 2. **Tardy Ulnar Nerve Palsy:** The resulting cubitus valgus stretches the ulnar nerve over time. 3. **Joint Instability:** It serves as the origin for the common extensor muscles and the lateral collateral ligament. Therefore, even in cases of non-union, the fragment is typically fixed or left alone, but **never excised.** **Explanation of Incorrect Options:** * **Olecranon Process:** While preservation is preferred, a small proximal fragment (less than 25-30%) can be excised if it is severely comminuted, provided the triceps tendon is reattached to the remaining ulna. * **Patella:** In cases of "stellate" or severely comminuted fractures where reconstruction is impossible, a **partial or total patellectomy** is a recognized (though salvage) procedure. * **Head of Radius:** In Mason Type III (comminuted) fractures in adults, the radial head can be excised to restore rotation, provided there is no associated interosseous membrane or medial collateral ligament injury (Essex-Lopresti lesion). **High-Yield Clinical Pearls for NEET-PG:** * **Lateral Condyle Humerus:** It is the second most common elbow fracture in children (after supracondylar). It is an **intra-articular** fracture and requires anatomical reduction (usually ORIF). * **Excision Rule:** Never excise the radial head in children (causes cubitus valgus and radial deviation of the wrist). * **Patellectomy:** Results in a 30% loss of extension strength.
Question 360: Adson's test is used to assess vascular compression. It is useful in identifying which of the following conditions?
- A. Peripheral vascular disease
- B. Varicose veins
- C. Cervical rib (Correct Answer)
- D. Arteriovenous fistula
Explanation: **Explanation:** **Adson’s Test** is a clinical maneuver used to identify compression of the **subclavian artery** as it passes through the interscalene triangle. This compression is a hallmark of **Thoracic Outlet Syndrome (TOS)**, which is most commonly caused by a **Cervical Rib** or hypertrophied scalene muscles. 1. **Why Cervical Rib is correct:** A cervical rib is a supernumerary rib arising from the C7 vertebra. It narrows the space between the scalenus anterior and medius muscles. 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. This maneuver further tightens the scalene muscles; if a cervical rib is present, it compresses the subclavian artery, leading to a **diminution or obliteration of the radial pulse**. 2. **Why other options are incorrect:** * **Peripheral Vascular Disease (PVD):** This involves systemic atherosclerosis of the lower limbs and is assessed using the Ankle-Brachial Index (ABI) or Buerger’s test. * **Varicose Veins:** This is a venous pathology of the lower limbs, assessed using Trendelenburg’s test or the Perthes test. * **Arteriovenous (AV) Fistula:** This is an abnormal communication between an artery and a vein, typically identified by a "machinery murmur" or thrill, and assessed via Nicoladoni-Branham’s sign. **Clinical Pearls for NEET-PG:** * **Halsted’s Maneuver:** Similar to Adson’s but involves downward traction on the arm and moving the head *away* from the affected side. * **Roos Test (Elevated Arm Stress Test):** Considered the most sensitive clinical test for Thoracic Outlet Syndrome. * **Neurological TOS:** More common than vascular TOS; patients present with wasting of the small muscles of the hand (T1 distribution).
Practice by Chapter
Principles of Fracture Management
Practice Questions
Upper Limb Fractures
Practice Questions
Lower Limb Fractures
Practice Questions
Spinal Trauma
Practice Questions
Pelvic and Acetabular Fractures
Practice Questions
Open Fractures
Practice Questions
Fractures in Children
Practice Questions
Fracture Complications
Practice Questions
Nonunion and Malunion
Practice Questions
Polytrauma Management
Practice Questions
Joint Dislocations
Practice Questions
Soft Tissue Injuries
Practice Questions
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