Trauma — MCQs

A 20-year-old male patient presented with acute pain in the left hip region and inability to bear weight on the left hip. On examination, deformity of the left lower limb was noticed. The lower limb was in slight flexion, adduction, and internal rotation. The patient gave a history of a road accident with sudden braking. Neurovascular examination was normal. Which of the following x-rays will most likely correspond to the above condition?

Trauma Indian Medical PG Practice Questions and MCQs

Question 371: Which manoeuvre is used for diagnosing rupture of the medial collateral ligament?

A. Posterior drawer test
B. Anterior drawer test
C. Lachmann's test
D. Valgus stress test (Correct Answer)

Explanation: **Explanation:** The **Valgus stress test** is the gold standard clinical maneuver for diagnosing a rupture or laxity of the **Medial Collateral Ligament (MCL)**. The MCL is the primary stabilizer against valgus (abduction) stress at the knee. To perform this test, the clinician applies an outward force at the ankle while pushing the knee inward. It is typically performed at **30° of flexion** to isolate the MCL (as the posterior capsule is relaxed) and at **0° (full extension)** to assess for combined injuries (MCL and cruciate ligaments). **Analysis of Incorrect Options:** * **Posterior Drawer Test:** Used to diagnose injuries to the **Posterior Cruciate Ligament (PCL)**. It involves pushing the tibia posteriorly relative to the femur. * **Anterior Drawer Test:** Used to assess the **Anterior Cruciate Ligament (ACL)**. It involves pulling the tibia anteriorly with the knee flexed at 90°. * **Lachman’s Test:** This is the **most sensitive** clinical test for an **ACL** injury. It is performed with the knee in 20-30° of flexion. **High-Yield Clinical Pearls for NEET-PG:** * **MCL** is the most commonly injured ligament of the knee. * **Varus Stress Test** is used to diagnose **Lateral Collateral Ligament (LCL)** injuries. * **O’Donoghue’s Triple (Unhappy Triad):** Simultaneous injury to the **ACL, MCL, and Medial Meniscus** (though recent studies suggest the Lateral Meniscus is more commonly injured in acute settings). * **Pellegrini-Stieda Disease:** Post-traumatic calcification at the site of the MCL's femoral attachment, seen on X-ray after chronic MCL injury.

Question 372: What is the commonest complication of extra capsular fracture of the femur?

A. Non union
B. Mal union (Correct Answer)
C. Avascular necrosis
D. Osteoarthritis

Explanation: **Explanation:** **Extra-capsular fractures** of the femur primarily include **intertrochanteric (IT) fractures**. Unlike intra-capsular fractures, the extra-capsular region has a robust blood supply and consists of cancellous bone with a large surface area, which promotes reliable healing. **1. Why Mal-union is the correct answer:** Because the blood supply is preserved, these fractures almost always heal. However, due to the strong pull of the hip musculature (iliopsoas, abductors, and short rotators), the fragments tend to displace. If not anatomically reduced or if the fixation fails, the fracture heals in a deformed position. The most common deformity is a **Coxa Vara** (decreased neck-shaft angle) associated with shortening and external rotation. **2. Why other options are incorrect:** * **Non-union:** Rare in extra-capsular fractures due to the excellent vascularity and cancellous nature of the bone. It is much more common in intra-capsular (neck of femur) fractures. * **Avascular Necrosis (AVN):** The blood supply to the femoral head (mainly the medial circumflex femoral artery) is located intra-capsularly. Extra-capsular fractures do not typically disrupt this supply, making AVN a rare complication. * **Osteoarthritis:** While it can occur as a long-term secondary result of mal-alignment, it is not the most common immediate or direct complication of the fracture itself. **High-Yield Clinical Pearls for NEET-PG:** * **Intra-capsular fracture:** Commonest complication is **Non-union**, followed by **AVN**. * **Extra-capsular (IT) fracture:** Commonest complication is **Mal-union (Coxa Vara)**. * **Standard Treatment:** The Dynamic Hip Screw (DHS) or Proximal Femoral Nail (PFN) are the implants of choice. * **Clinical Sign:** In IT fractures, the limb shows marked external rotation (up to 90 degrees) and shortening.

Question 373: Regarding the displacement of the distal fragment in a Colles fracture, which statement is true?

A. Anteriorly and medially
B. Posteriorly and laterally (Correct Answer)
C. Anteriorly and laterally
D. Posteriorly and medially

Explanation: ### Explanation **1. Why the Correct Answer is Right:** A **Colles fracture** is a fracture of the distal radius occurring within 2.5 cm of the wrist joint, typically resulting from a fall on an outstretched hand (FOOSH). The hallmark of this fracture is the specific displacement of the **distal fragment**. Due to the mechanism of injury and the pull of the brachioradialis and extensor tendons, the distal fragment is displaced **posteriorly (dorsally)** and **laterally (radially)**. The classic "Dinner Fork Deformity" is a direct result of this dorsal (posterior) displacement and dorsal tilting. The lateral (radial) displacement, along with radial shortening and tilt, leads to the prominence of the ulnar styloid. **2. Analysis of Incorrect Options:** * **Option A & C (Anteriorly):** Anterior (ventral/volar) displacement is characteristic of a **Smith’s fracture** (also known as a "Reverse Colles"). This occurs from a fall on the back of a flexed wrist. * **Option D (Medially):** Medial (ulnar) displacement does not occur in Colles fractures. Instead, there is radial (lateral) deviation because the distal fragment shifts toward the thumb side, often associated with a fracture of the ulnar styloid process. **3. Clinical Pearls for NEET-PG:** * **The 6 Displacements of Colles:** (1) Dorsal displacement, (2) Dorsal tilt, (3) Lateral displacement, (4) Lateral tilt, (5) Impaction/Shortening, and (6) Supination. * **Dinner Fork Deformity:** Caused by dorsal displacement/tilt. * **Most Common Complication:** Stiffness of the fingers and shoulder (due to neglect during casting). * **Most Common Late Complication:** Malunion (leading to a weak grip). * **Specific Tendon Rupture:** Spontaneous rupture of the **Extensor Pollicis Longus (EPL)** can occur weeks after the injury due to ischemia or attrition at Lister’s tubercle.

Question 374: Myositis ossificans is due to:

A. Ossification
B. New bone formation
C. Ossification of subperiosteal haematoma
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Myositis Ossificans (Traumatic)** is a condition characterized by the formation of heterotopic non-neoplastic bone in soft tissues, most commonly following blunt trauma or repeated injury to a muscle (frequently the brachialis or quadriceps). 1. **Why "All of the above" is correct:** The pathophysiology begins with a traumatic injury that causes a **subperiosteal or intramuscular haematoma**. Instead of being resorbed, this haematoma undergoes organization. Osteoblasts (derived from the periosteum or primitive mesenchymal cells) migrate into the area, leading to **ossification** (the process of laying down new bone material). This results in the **new bone formation** within the soft tissue. Therefore, all three descriptors (ossification, new bone formation, and subperiosteal haematoma involvement) are integral stages of the disease process. 2. **Analysis of Options:** * **Ossification of subperiosteal haematoma:** This is the specific initiating event where blood trapped under the periosteum begins to mineralize. * **New bone formation & Ossification:** These are the broader pathological descriptions of the end result—ectopic bone where it should not exist. **High-Yield Clinical Pearls for NEET-PG:** * **Common Site:** Brachialis muscle (following supracondylar fracture or elbow dislocation). * **Clinical Feature:** A painful, firm mass in the muscle with a decreasing range of motion. * **Radiology:** Characterized by the **"Zonal Phenomenon"** (mature lamellar bone at the periphery and immature osteoid in the center). This helps distinguish it from Osteosarcoma, which has central mineralization. * **Management:** **Rest and immobilization** in the acute phase. Massage and passive stretching are strictly **contraindicated** as they aggravate the condition. Surgery is only considered after the bone matures (usually 6–12 months).

Question 375: Sudeck's atrophy is more common in which of the following conditions?

A. Malunited Colles' fracture (Correct Answer)
B. Malunited fracture of the femur
C. Pott's fracture
D. Carries spine

Explanation: ### Explanation **Sudeck’s atrophy**, also known as **Complex Regional Pain Syndrome (CRPS) Type 1**, is a post-traumatic condition characterized by autonomic dysfunction leading to pain, swelling, and vasomotor instability, followed by patchy osteoporosis. **Why Option A is correct:** Sudeck’s atrophy most frequently affects the **distal upper limb**, particularly following a **Colles' fracture**. The incidence is significantly higher in cases of **malunion** or when the cast is applied too tightly, leading to chronic irritation of the sensory nerves and prolonged immobilization. The classic presentation includes a "shoulder-hand syndrome" where the patient develops a painful, stiff hand with trophic skin changes (shiny, red skin) and radiographic evidence of "speckled" or patchy osteoporosis. **Why other options are incorrect:** * **B & C (Femur and Pott’s fracture):** While CRPS can occur in the lower limbs, it is statistically much less common than in the upper extremity. Colles' fracture remains the classic textbook association for Sudeck’s atrophy. * **D (Caries Spine):** This is a chronic infectious/granulomatous condition (Tuberculosis). Sudeck’s atrophy is specifically a **post-traumatic** or post-surgical sympathetic phenomenon, not an infectious process. **High-Yield Clinical Pearls for NEET-PG:** * **Radiographic hallmark:** Patchy/speckled osteoporosis (sudden loss of bone density). * **Clinical Stages:** 1. Hyperemic (Acute), 2. Dystrophic (Ischemic), 3. Atrophic. * **Key Treatment:** Active exercises of the joints (fingers and shoulder) are the best preventive and therapeutic measures. * **Diagnosis:** Primarily clinical; Triple-phase bone scan (TPBS) shows increased uptake in the delayed phase.

Question 376: Cock-up splint is used in which of the following conditions?

A. Median nerve injury
B. Radial nerve injury (Correct Answer)
C. Ulnar nerve injury
D. Volkmann's ischemic contracture

Explanation: **Explanation:** **Radial Nerve Injury (Correct Answer):** The radial nerve innervates the extensors of the wrist and fingers. Injury to this nerve (commonly seen in mid-shaft humerus fractures) leads to **Wrist Drop**. A **Cock-up splint** is used to maintain the wrist in 20–30 degrees of extension. This prevents the overstretching of paralyzed extensor muscles and prevents contractures of the flexor tendons, thereby maintaining a functional position of the hand while the nerve recovers. **Analysis of Incorrect Options:** * **Median Nerve Injury:** This leads to "Ape Thumb Deformity" or "Pointed Index Finger." The appropriate orthosis is an **Opponens splint**, which maintains the thumb in opposition. * **Ulnar Nerve Injury:** This results in "Claw Hand" due to paralysis of the intrinsic muscles. The specific splint used is a **Knuckle Bender splint** (to prevent hyperextension at the MCP joints). * **Volkmann’s Ischemic Contracture (VIC):** This is a late sequela of compartment syndrome. While splinting is used, the classic orthosis is a **Turnbuckle splint** or a specialized static-progressive splint to stretch the flexor contractures. **High-Yield Clinical Pearls for NEET-PG:** * **Dynamic Cock-up Splint:** Specifically used for radial nerve palsy to allow active finger flexion while providing passive extension via rubber bands/springs. * **Saturday Night Palsy:** A common cause of radial nerve injury at the spiral groove. * **Functional Position of Wrist:** 20–30° extension with slight ulnar deviation. * **Aeroplane Splint:** Used for Brachial Plexus injuries or Axillary nerve palsy (to maintain abduction).

Question 377: A man presents to the emergency department after an alcohol binge the previous night and sleeping in an armchair. In the morning, he is unable to move his hand and a diagnosis of ulnar palsy is made. What is the next line of management?

A. Knuckle bender splint (Correct Answer)
B. Perform EMG study after 2 days
C. Immediately operate and explore the nerve
D. Wait and watch

Explanation: ### Explanation **1. Why "Knuckle Bender Splint" is correct:** The clinical scenario describes a compression neuropathy of the ulnar nerve (often termed "Saturday Night Palsy" when involving the radial nerve, but here specifically affecting the ulnar nerve due to prolonged pressure against an armchair). This results in **Neuropraxia**—a temporary physiological conduction block without axonal degeneration. In ulnar nerve palsy, the loss of intrinsic muscle function leads to a **"Claw Hand"** deformity (hyperextension at the MCP joints and flexion at the IP joints). A **Knuckle Bender Splint** (also known as an MCP flexion splint) is the management of choice because it: * Corrects the deformity by keeping MCP joints in flexion. * Prevents joint contractures and muscle stretching while waiting for nerve recovery. * Maintains functional hand positioning. **2. Why other options are incorrect:** * **B. Perform EMG study after 2 days:** EMG/NCV changes in Wallerian degeneration take **2–3 weeks** to manifest. Testing after 2 days is premature and will not provide diagnostic utility. * **C. Immediately operate:** Surgery is contraindicated in neuropraxia. Most compression injuries are managed conservatively as they recover spontaneously within weeks to months. * **D. Wait and watch:** While spontaneous recovery is expected, "wait and watch" without splinting is incomplete management. Without a splint, the patient risks developing permanent fixed contractures. **3. Clinical Pearls for NEET-PG:** * **Ulnar Nerve (C8-T1):** Known as the "Musician’s Nerve." * **Froment’s Sign:** Tests for Adductor Pollicis paralysis (Ulnar nerve). * **Ulnar Paradox:** A high ulnar nerve lesion (at the elbow) results in *less* obvious clawing than a low lesion (at the wrist) because the FDP to the ring and little fingers is also paralyzed. * **Splint Summary:** * Radial Nerve (Wrist Drop) → **Cock-up Splint** or Dynamic Extension Splint. * Ulnar Nerve (Claw Hand) → **Knuckle Bender Splint.** * Median Nerve (Ape Thumb) → **Opponens Splint.**

Question 378: Which of the following is NOT a complication of Colles fracture?

A. Malunion
B. Nonunion (Correct Answer)
C. Sudeck's osteodystrophy
D. Rupture of EPL tendon

Explanation: **Explanation:** The correct answer is **Nonunion** because Colles fracture occurs through the **cancellous bone** of the distal radius. Cancellous bone is highly vascular and has a large surface area, which facilitates rapid healing. Consequently, nonunion is extremely rare in Colles fractures; if the fragments don't align, they typically result in malunion rather than failing to unite. **Analysis of Options:** * **Malunion (A):** This is the **most common complication**. It often results in the classic "Dinner Fork Deformity" due to residual dorsal tilt and radial shortening. * **Sudeck’s Osteodystrophy (C):** Also known as Complex Regional Pain Syndrome (CRPS) Type 1. It is a frequent complication characterized by post-traumatic pain, swelling, and vasomotor instability leading to trophic skin changes and osteoporosis. * **Rupture of EPL tendon (D):** This is a classic late complication. It occurs due to ischemia or attrition of the Extensor Pollicis Longus tendon as it turns around **Lister’s tubercle**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Malunion. * **Most common late complication:** Secondary Osteoarthritis (especially of the distal radio-ulnar joint). * **Median Nerve Palsy:** Can occur acutely (Carpal Tunnel Syndrome) due to pressure from the displaced fragments or hematoma. * **Stiffness:** "Frozen shoulder" is a common associated complication because elderly patients often keep the shoulder immobilized while the wrist is in a cast. Always advise shoulder exercises!

Question 379: A boy fell from a height onto his outstretched hand. The X-ray of his forearm is shown below. What is the most likely diagnosis?

A. Galeazzi fracture (Correct Answer)
B. Colles' fracture
C. Rolando fracture
D. Monteggia fracture

Explanation: ***Galeazzi fracture*** - Fracture of the **distal third of the radius** with **distal radioulnar joint (DRUJ) dislocation**, commonly caused by **fall on outstretched hand (FOOSH)**. - The **ulnar head appears prominent** on X-ray due to DRUJ disruption, and there's shortening of the radius relative to the ulna. *Colles' fracture* - Involves a **distal radius fracture** with **dorsal angulation** and **dorsal displacement**, creating a "dinner fork" deformity. - Does **not involve dislocation** of the DRUJ, unlike the Galeazzi fracture pattern. *Rolando fracture* - A **comminuted intra-articular fracture** of the **base of the first metacarpal** (thumb). - Affects the **carpometacarpal joint** of the thumb, not the radius or DRUJ as seen in this case. *Monteggia fracture* - Fracture of the **proximal or mid-shaft ulna** with **radial head dislocation** at the radiocapitellar joint. - The **radiocapitellar line** fails to pass through the capitellum, which is not the pattern described here.

Question 380: A 20-year-old male patient presented with acute pain in the left hip region and inability to bear weight on the left hip. On examination, deformity of the left lower limb was noticed. The lower limb was in slight flexion, adduction, and internal rotation. The patient gave a history of a road accident with sudden braking. Neurovascular examination was normal. Which of the following x-rays will most likely correspond to the above condition?

A. X-ray showing left hip posterior dislocation (Correct Answer)
B. X-ray showing left hip anterior dislocation
C. X-ray showing left femoral neck fracture
D. All of the above

Explanation: ***X-ray showing left hip posterior dislocation*** - The classic **triad** of slight flexion, adduction, and internal rotation is pathognomonic for **posterior hip dislocation**. - **Dashboard injury** mechanism (sudden braking in road accident) with axial loading of the flexed hip causes the femoral head to be driven posteriorly out of the acetabulum. *X-ray showing left hip anterior dislocation* - Anterior hip dislocation presents with the limb in **extension**, **abduction**, and **external rotation** - opposite to this case. - Much less common (10-15% of hip dislocations) and typically occurs with **forced abduction** and external rotation. *X-ray showing left femoral neck fracture* - Femoral neck fractures typically present with **external rotation** and **shortening** of the affected limb, not internal rotation. - More common in **elderly patients** with osteoporosis following low-energy trauma, not young adults in high-energy accidents. *All of the above* - Only **posterior hip dislocation** matches the clinical presentation and mechanism described. - The specific **deformity pattern** and **dashboard injury** mechanism are diagnostic for posterior dislocation only.

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