Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 421: What is the commonest type of elbow dislocation?

A. Anterior
B. Posterior (Correct Answer)
C. Both anterior and posterior are equally common
D. Medial

Explanation: **Explanation:** The elbow is the second most commonly dislocated joint in adults (after the shoulder) and the most common in children. **1. Why Posterior is Correct:** **Posterior (and posterolateral)** dislocations account for approximately **80-90%** of all elbow dislocations. The mechanism of injury is typically a **fall on an outstretched hand (FOOSH)** with the elbow in slight flexion. In this position, the force is transmitted through the forearm, driving the olecranon process of the ulna backward and upward behind the distal humerus. The strong anterior capsule and collateral ligaments are often disrupted during this process. **2. Why Other Options are Incorrect:** * **Anterior:** These are rare and usually occur due to a direct blow to the posterior aspect of the flexed elbow (e.g., a fall on the point of the elbow). They are frequently associated with extensive soft tissue damage and olecranon fractures. * **Medial/Lateral:** These are extremely rare as isolated injuries. They usually occur as components of complex fracture-dislocations or severe high-energy trauma where the collateral ligaments are completely avulsed. **Clinical Pearls for NEET-PG:** * **The "Three-Point Relationship":** In a normal or supracondylar fracture, the olecranon and epicondyles form an isosceles triangle (flexion) or a straight line (extension). In **dislocation**, this relationship is **disturbed**. * **Associated Injuries:** Always check for **Median and Ulnar nerve** status and the **Brachial artery** pulse. * **Complications:** The most common late complication is **decreased range of motion** (stiffness). **Myositis Ossificans** is a specific risk if the injury is managed with forceful passive stretching. * **Terrible Triad of the Elbow:** 1. Posterior dislocation, 2. Coronoid fracture, 3. Radial head fracture.

Question 422: A segmental compound fracture of the tibia with a 12 cm skin wound, crushed tissue, contamination, and adequate soft tissue coverage, occurring in a farm environment, is classified as which type?

A. Type 1
B. Type II
C. Type III A (Correct Answer)
D. Type IIIB

Explanation: ### Explanation The classification of open fractures is based on the **Gustilo-Anderson Classification**, which evaluates the wound size, mechanism of injury, and the degree of soft tissue damage. **Why Type IIIA is correct:** According to the Gustilo-Anderson criteria, **Type III** fractures involve high-energy trauma with extensive soft tissue damage or are >10 cm in length. Specifically, **Type IIIA** is characterized by adequate soft tissue coverage of the fractured bone despite extensive lacerations or flaps. Furthermore, certain injuries are "automatically" upgraded to Type III regardless of wound size: 1. **Segmental fractures** (as seen in this case). 2. **Farm-yard injuries** (high risk of contamination with soil/manure). 3. High-velocity trauma (e.g., gunshot wounds). **Why other options are incorrect:** * **Type I:** Defined by a clean wound <1 cm long, usually a simple spiral or short oblique fracture. * **Type II:** Defined by a wound 1–10 cm long without extensive soft tissue damage, flaps, or avulsions. * **Type IIIB:** Involves extensive soft tissue injury with **periosteal stripping** and inadequate bone coverage, requiring a regional or free flap for closure. Since the question states "adequate soft tissue coverage," it cannot be IIIB. **Clinical Pearls for NEET-PG:** * **Type IIIC:** Any open fracture associated with an **arterial injury** requiring repair, regardless of soft tissue status. * **Antibiotic Choice:** * Type I & II: 1st Gen Cephalosporins (e.g., Cefazolin). * Type III: Add Aminoglycosides (e.g., Gentamicin). * Farm injuries: Add Penicillin to cover *Clostridium* (Anaerobes). * **Time Factor:** The most critical factor in preventing infection is the **time to surgical debridement** and administration of IV antibiotics.

Question 423: Which of the following is not a complication of Colles fracture?

A. Stiffness of the wrist
B. Stiffness of the shoulder
C. Carpal tunnel syndrome
D. Wrist drop (Correct Answer)

Explanation: **Explanation:** **Colles fracture** is a distal radius fracture occurring at the cortico-cancellous junction, typically resulting from a fall on an outstretched hand (FOOSH). **Why Wrist Drop is the Correct Answer:** Wrist drop is caused by an injury to the **Radial Nerve** (specifically the mid-shaft humerus fracture or compression in the spiral groove). In a Colles fracture, the radial nerve is not anatomically vulnerable. While nerve injuries can occur in Colles fractures, the most commonly affected nerve is the **Median Nerve** due to its proximity to the carpal tunnel, leading to acute carpal tunnel syndrome, not wrist drop. **Analysis of Incorrect Options:** * **Stiffness of the wrist (A):** This is the **most common complication** of Colles fracture, often resulting from prolonged immobilization or inadequate rehabilitation. * **Stiffness of the shoulder (B):** Also known as "Frozen Shoulder" or "Shoulder-Hand Syndrome." Patients often keep the arm immobilized against the chest to support the cast, leading to secondary adhesive capsulitis. * **Carpal tunnel syndrome (C):** The displaced fracture fragments or subsequent edema can increase pressure within the carpal tunnel, compressing the Median nerve. **High-Yield Clinical Pearls for NEET-PG:** * **Malunion:** The most common late complication, resulting in a "Dinner Fork Deformity." * **Sudeck’s Osteodystrophy (CRPS):** Characterized by pain, swelling, and trophic skin changes. * **EPL Rupture:** Delayed rupture of the **Extensor Pollicis Longus** tendon (usually 4–8 weeks post-injury) occurs due to ischemia or attrition at Lister’s tubercle. * **Deformities:** Remember the "P-D-S" displacement: **P**osterior tilt, **D**orsal displacement, and **S**upination (along with lateral tilt and impaction).

Question 424: What is the most common type of anterior shoulder dislocation?

A. Subglenoid
B. Subcoracoid (Correct Answer)
C. Posterior
D. Complete

Explanation: **Explanation:** **1. Why Subcoracoid is Correct:** Anterior shoulder dislocations account for approximately 95% of all shoulder dislocations. Among the subtypes of anterior dislocation, the **Subcoracoid** variety is the most common. In this type, the humeral head is displaced anteriorly and comes to rest inferior to the coracoid process. This occurs because the mechanism of injury—typically a combination of abduction, extension, and external rotation—forces the humeral head through the weakest part of the capsule (the interval between the superior and middle glenohumeral ligaments). **2. Analysis of Incorrect Options:** * **Subglenoid (A):** This is the second most common type of anterior dislocation. Here, the humeral head rests inferior to the glenoid fossa. It is often associated with greater tuberosity fractures. * **Posterior (C):** This is a different category of dislocation altogether (accounting for only 2-5% of cases). It is classically associated with seizures or electric shocks. * **Complete (D):** This is a general descriptive term for a total loss of contact between joint surfaces, not a specific anatomical subtype of anterior dislocation. **3. NEET-PG High-Yield Pearls:** * **Most common nerve injured:** Axillary nerve (tested via sensation over the "regimental badge" area). * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head (occurs during dislocation). * **Bankart Lesion:** Avulsion of the anteroinferior glenoid labrum (most common cause of recurrence). * **Kocher’s Method:** A classic (though now less preferred due to complication risks) reduction technique involving Traction, External Rotation, Adduction, and Internal Rotation. * **Dugas Test:** Positive if the patient is unable to touch the opposite shoulder with the hand of the injured side.

Question 425: Tardy ulnar nerve palsy is typically seen after which type of injury?

A. Malunited fracture of the humerus above the condyles
B. Malunited lateral condylar fracture of the humerus (Correct Answer)
C. Malunited medial condylar fracture of the humerus
D. Fracture of both bones of the forearm

Explanation: **Explanation:** **Tardy Ulnar Nerve Palsy** is a delayed-onset ulnar neuropathy that occurs years after an elbow injury. The most common cause is a **malunited lateral condylar fracture of the humerus**. **Why Option B is correct:** A malunion or non-union of the lateral condyle leads to a **Cubitus Valgus** deformity (increased carrying angle). This deformity causes the ulnar nerve to take a longer, stretched path around the medial epicondyle. Over time, the chronic stretching and friction during elbow movements lead to progressive nerve ischemia and fibrosis, resulting in "tardy" (late) palsy. **Why other options are incorrect:** * **Option A:** Malunited supracondylar fractures typically result in **Cubitus Varus** (Gunstock deformity). This deformity does not stretch the ulnar nerve; in rare cases, it may cause ulnar nerve shifting, but it is not the classic cause of tardy palsy. * **Option C:** Medial condylar fractures are rare. While they are closer to the nerve, they do not typically produce the specific valgus deformity required for chronic stretching of the nerve. * **Option D:** Forearm fractures do not alter the anatomy of the cubital tunnel or the carrying angle of the elbow. **High-Yield Clinical Pearls for NEET-PG:** * **Latent Period:** The palsy typically appears **10–20 years** after the initial injury. * **Clinical Features:** Clawing of the ring and little fingers, wasting of interossei, and sensory loss over the ulnar 1.5 fingers. * **Treatment of Choice:** **Anterior transposition of the ulnar nerve** (moving the nerve to the front of the medial epicondyle to relieve tension). * **Most common cause of Cubitus Valgus:** Non-union of the lateral condyle. * **Most common cause of Cubitus Varus:** Malunited supracondylar fracture.

Question 426: Which of the following is a complication of a talar fracture?

A. Avascular necrosis (Correct Answer)
B. Non-union
C. Osteoarthritis of ankle joint
D. Osteoarthritis of subtalar joint

Explanation: **Explanation:** The **talus** is unique because approximately 60% of its surface is covered by articular cartilage, and it has no muscular or tendinous attachments. Its blood supply is **retrograde**, primarily entering through the neck via the artery of the tarsal canal (a branch of the posterior tibial artery). **Avascular Necrosis (AVN)** is the most dreaded and characteristic complication of talar neck fractures. When a fracture occurs, this tenuous retrograde blood supply is easily disrupted. The risk of AVN increases with the severity of displacement, as classified by the **Hawkins Classification**: * Type I (Undisplaced): 0–15% risk * Type II (Subluxation of subtalar joint): 20–50% risk * Type III (Subluxation of subtalar and ankle joints): 85–100% risk **Why other options are incorrect:** * **Non-union:** While it can occur, the talus has a relatively good healing capacity if the blood supply is preserved; AVN is far more frequent than non-union. * **Osteoarthritis (Ankle/Subtalar):** These are common *late* sequelae due to the intra-articular nature of the injury, but AVN is the "classic" and most high-yield complication associated specifically with the talus's unique vascular anatomy. **High-Yield Clinical Pearls for NEET-PG:** 1. **Hawkins Sign:** A subchondral radiolucent line seen on an X-ray at 6–8 weeks post-injury. It indicates intact vascularity (active bone resorption) and is a **positive prognostic sign** (rules out AVN). 2. **Most common site of fracture:** Talar neck. 3. **Snowboarder’s Fracture:** Fracture of the lateral process of the talus. 4. **Aviator’s Astragalus:** Historical term for talar fractures caused by high-energy dorsiflexion.

Question 427: A 60-year-old female presents after a fall in the bathroom, unable to stand. On examination, her right leg is in external rotation, with limited movement and tenderness in Scarpa's triangle. There is no history of fever. X-ray shows no fracture line. What is the next step in management?

A. MRI (Correct Answer)
B. Strict bed rest for 10 days and repeat X-ray
C. Joint aspiration
D. Start proper analgesia and begin mobilization to prevent stiffness

Explanation: **Explanation:** The clinical presentation of an elderly female with a fall, inability to bear weight, and a limb in **external rotation** with tenderness in **Scarpa’s triangle** is highly suspicious of a **fracture of the neck of the femur**, even if the initial X-ray is negative. **1. Why MRI is the Correct Choice:** In approximately 2–10% of hip fractures, the initial plain radiograph is negative or occult. In an elderly patient with a high clinical suspicion of a fracture (inability to walk, external rotation), **MRI is the gold standard** and the investigation of choice. It can detect bone marrow edema and occult fractures within 24 hours of injury with nearly 100% sensitivity. If MRI is contraindicated, a CT scan or Bone Scan (after 48–72 hours) may be considered. **2. Why Other Options are Incorrect:** * **Option B:** Bed rest and repeat X-ray is outdated. Delaying diagnosis in the elderly increases the risk of complications like DVT, pulmonary embolism, and pressure sores. * **Option C:** Joint aspiration is used to rule out septic arthritis. The absence of fever and the history of trauma make an occult fracture much more likely than infection. * **Option D:** Mobilizing a patient with a potential hip fracture without stabilization can lead to displacement of the fracture, damage to the blood supply (increasing the risk of AVN), and severe pain. **Clinical Pearls for NEET-PG:** * **Occult Fracture:** A fracture that is not visible on initial radiographs but is clinically suspected. * **Scarpa’s Triangle Tenderness:** A classic sign of intracapsular hip fractures. * **Garden’s Classification:** Used for femoral neck fractures; Stage I and II are undisplaced, while III and IV are displaced. * **Management Rule:** In elderly patients with hip pain post-trauma and negative X-rays, **always** assume a fracture until proven otherwise by MRI.

Question 428: Bohler's angle is decreased in which of the following fractures?

A. Calcaneum (Correct Answer)
B. Talus
C. Navicular
D. Cuboid

Explanation: **Explanation:** **Bohler’s Angle** (also known as the Tuber-joint angle) is a crucial radiological landmark used to assess the severity of **calcaneal fractures**. It is formed by the intersection of two lines on a lateral X-ray of the foot: 1. A line drawn from the highest point of the anterior process to the highest point of the posterior facet. 2. A line drawn from the highest point of the posterior facet to the highest point of the calcaneal tuberosity. **Why Calcaneum is Correct:** In intra-articular fractures of the calcaneum (the most common tarsal bone fracture), the body of the bone is compressed or "flattened." This collapse causes the posterior facet to sink, leading to a **decrease** in Bohler’s angle. A normal angle ranges between **20° and 40°**; an angle less than 20° suggests a depressed fracture. **Why Other Options are Incorrect:** * **Talus:** Fractures of the talus are assessed using Hawkins’ classification. While the talus articulates with the calcaneus, Bohler’s angle specifically measures the morphology of the calcaneal bone itself. * **Navicular & Cuboid:** These are midfoot bones. Fractures here do not affect the hindfoot geometry measured by Bohler’s angle. **High-Yield Clinical Pearls for NEET-PG:** * **Gissane’s Angle:** Also known as the "Critical Angle," it is another landmark on the calcaneum (normal: 120°–145°). It **increases** in calcaneal fractures. * **Mondor’s Sign:** Ecchymosis extending to the sole of the foot, pathognomonic for calcaneal fractures. * **Associated Injuries:** Always rule out **compression fractures of the lumbar spine (L1)** and bilateral calcaneal fractures in patients who fall from a height (Don Juan Syndrome/Lover's Fracture).

Question 429: What is the earliest sign of compartment syndrome of the leg?

A. Tingling or numbness
B. Skin mottling
C. Pulselessness
D. Pain on passive stretch (Correct Answer)

Explanation: **Explanation:** Compartment syndrome occurs when increased interstitial pressure within a closed osteofascial space compromises local perfusion. **Why "Pain on passive stretch" is the correct answer:** Pain is the most sensitive and earliest clinical indicator of compartment syndrome. Specifically, **pain out of proportion to the injury** and **pain on passive stretching** of the muscles within the affected compartment are the hallmark early signs. This occurs because stretching ischemic muscle fibers triggers an immediate nociceptive response before nerve conduction is lost or arterial flow is completely halted. **Analysis of Incorrect Options:** * **A. Tingling or numbness (Paresthesia):** This indicates nerve ischemia. While an important sign, it typically develops *after* the initial onset of ischemic pain. * **B. Skin mottling:** This is a late sign indicating significant vascular compromise and impending tissue necrosis. * **C. Pulselessness:** This is a **very late and ominous sign**. Because compartment pressure rarely exceeds systolic arterial pressure, distal pulses often remain palpable even when the tissue within the compartment is dying. Relying on pulselessness for diagnosis often leads to missed opportunities for limb salvage. **High-Yield Clinical Pearls for NEET-PG:** * **The 6 P’s:** Pain (earliest), Pallor, Paresthesia, Paralysis, Pulselessness (latest), and Poikilothermia. * **Diagnosis:** Primarily clinical. However, if uncertain, intra-compartmental pressure can be measured (e.g., Stryker device). * **Critical Pressure:** A **Delta pressure (Diastolic BP – Compartment Pressure) < 30 mmHg** is an absolute indication for fasciotomy. * **Most common site:** Deep posterior and anterior compartments of the leg (often following tibial fractures). * **Management:** Immediate emergency fasciotomy. Do not elevate the limb, as this reduces arterial inflow.

Question 430: Which among the following patients with a fracture requires the 1st priority to be informed to a senior?

A. Patient's finger is blackening (Correct Answer)
B. Patient cannot extend his arm
C. A 10 cm abrasion
D. Intra-articular fracture of the elbow joint

Explanation: ### Explanation The correct answer is **A. Patient's finger is blackening**. **1. Why Option A is the Priority:** A blackening finger in the context of a fracture is a clinical sign of **impending gangrene** or severe **vascular compromise**. This is a surgical emergency. It indicates that the blood supply to the distal extremity is severely restricted, likely due to arterial injury, tight casting, or advanced **Compartment Syndrome**. If not addressed immediately (via vascular repair or fasciotomy), it leads to irreversible tissue necrosis and permanent loss of the limb. In triage, "Life over Limb, Limb over Function" is the rule; vascular compromise represents a threat to the limb. **2. Analysis of Incorrect Options:** * **B. Patient cannot extend his arm:** This suggests a nerve injury (e.g., Radial nerve palsy) or mechanical block. While serious, nerve injuries are rarely immediate emergencies compared to vascular compromise. * **C. A 10 cm abrasion:** This is a superficial soft tissue injury. While it requires cleaning and dressing to prevent infection, it is not limb-threatening. * **D. Intra-articular fracture:** These require anatomical reduction and surgery to prevent long-term secondary osteoarthritis, but they do not require the same "minutes-to-hours" urgency as a pulseless or blackening limb. **3. Clinical Pearls for NEET-PG:** * **The 5 P’s of Compartment Syndrome/Ischemia:** Pain (out of proportion), Pallor, Paresthesia, Pulselessness, and Paralysis. * **Earliest Sign:** Pain on passive stretching of muscles. * **Late Sign:** Pulselessness and blackening (indicates necrosis). * **Golden Hour:** Vascular repairs should ideally be performed within **6 hours** to prevent irreversible ischemic contracture (Volkmann’s Ischemic Contracture).

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Spinal Trauma

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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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Polytrauma Management

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Trauma — MCQs

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