Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 451: In which of the following femoral fractures is avascular necrosis common?

A. Perotrochanteric
B. Transcervical (Correct Answer)
C. Subtrochanteric
D. Shaft of femur

Explanation: **Explanation:** The risk of **Avascular Necrosis (AVN)** in femoral fractures is primarily determined by the anatomical location of the fracture relative to the joint capsule and the blood supply to the femoral head. **Why Transcervical is Correct:** The femoral head receives its primary blood supply from the **medial circumflex femoral artery** via the **retinacular vessels**. A transcervical fracture is an **intracapsular** fracture. Because these vessels run along the surface of the femoral neck, a fracture in this region frequently shears or compresses them. Furthermore, the intracapsular environment lacks a periosteal layer (limiting healing) and is bathed in synovial fluid, which contains fibrinolysins that inhibit clot formation, further predisposing the head to ischemia and subsequent AVN. **Why Other Options are Incorrect:** * **Perotrochanteric & Subtrochanteric:** These are **extracapsular** fractures. The blood supply to the femoral head remains proximal to these fracture lines and is generally undisturbed. These areas have a rich cancellous bone supply and a thick periosteum, leading to high union rates but no significant risk of AVN. * **Shaft of Femur:** This is far distal to the femoral head's vascular supply. While it carries risks of fat embolism or malunion, it has no association with AVN of the femoral head. **NEET-PG High-Yield Pearls:** * **Garden’s Classification:** Used for subcapital/transcervical fractures; Stages III and IV have the highest risk of AVN. * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (Type III) indicate greater instability and shear force. * **Clinical Sign:** In neck of femur fractures, the limb is typically **shortened and externally rotated.** * **Management:** In elderly patients with displaced transcervical fractures, **Hemiarthroplasty or Total Hip Replacement** is preferred over fixation due to the high risk of AVN and non-union.

Question 452: The Hawkins Classification is used for which type of fracture?

A. Tibial fracture
B. Calcaneum fracture
C. Radius head fracture
D. Talus fracture (Correct Answer)

Explanation: The **Hawkins Classification** is the gold-standard system used to categorize **talar neck fractures**. It is clinically significant because it predicts the risk of **Avascular Necrosis (AVN)** of the talus, which has a tenuous retrograde blood supply (primarily via the artery of the tarsal canal). ### **Classification Breakdown:** * **Type I:** Undisplaced fracture (AVN risk: 0–15%). * **Type II:** Displaced fracture with subluxation/dislocation of the **subtalar joint** (AVN risk: 20–50%). * **Type III:** Displaced fracture with dislocation of both **subtalar and tibiotalar joints** (AVN risk: nearly 100%). * **Type IV:** Type III plus dislocation of the **talonavicular joint** (Canale and Kelly modification). ### **Analysis of Incorrect Options:** * **A. Tibial fracture:** Commonly classified by the **Schatzker** system (for tibial plateau) or **Lauge-Hansen/Danis-Weber** (for distal tibia/malleoli). * **B. Calcaneum fracture:** The most common classification used is the **Sanders Classification** (based on CT findings) or **Essex-Lopresti**. * **C. Radius head fracture:** Categorized using the **Mason Classification**. ### **High-Yield Clinical Pearls for NEET-PG:** * **Hawkins Sign:** A subcortical radiolucency (osteopenia) seen on X-ray 6–8 weeks post-injury. Its presence indicates intact vascularity (no AVN), while its absence suggests AVN. * **Aviator’s Astragalus:** Another name for talus fractures, historically caused by sudden dorsiflexion during plane crashes. * **Blood Supply:** The **Posterior Tibial Artery** (via the artery of the tarsal canal) provides the major blood supply to the talar body.

Question 453: What is the earliest ischemic feature following a supracondylar fracture reduction?

A. Coldness
B. Pain (Correct Answer)
C. Swelling
D. Tingling

Explanation: **Explanation:** The correct answer is **Pain**. This question refers to the early detection of **Volkmann’s Ischemia** or **Compartment Syndrome**, which are the most dreaded complications following a supracondylar fracture of the humerus. **1. Why Pain is the Correct Answer:** Pain is the **earliest and most reliable** clinical indicator of ischemia. Specifically, it is characterized as "pain out of proportion" to the injury and **pain on passive extension** of the fingers (stretch sign). This occurs because ischemic muscle tissue becomes highly sensitive to stretching long before nerves or vessels are completely compromised. **2. Analysis of Incorrect Options:** * **Coldness (A):** This is a late sign of vascular compromise (Poikilothermia). By the time the limb is cold, significant irreversible damage may have already occurred. * **Swelling (C):** While swelling is a common finding in trauma and contributes to increased compartmental pressure, it is a physical finding rather than a primary "ischemic feature" used for early diagnosis. * **Tingling (D):** Paresthesia (tingling/numbness) indicates nerve ischemia. While it is an early sign, it typically follows the onset of severe, unremitting pain. **Clinical Pearls for NEET-PG:** * **The 5 P’s of Compartment Syndrome:** Pain (earliest), Pallor, Paresthesia, Pulselessness (late), and Paralysis (very late). * **Pulselessness:** The presence of a radial pulse **does not** rule out compartment syndrome. * **Management:** If ischemia is suspected post-reduction, the first step is to remove all tight bandages and extend the elbow. If symptoms persist, urgent fasciotomy is indicated. * **Contracture:** If untreated, this leads to **Volkmann’s Ischemic Contracture (VIC)**, characterized by a "claw-like" hand deformity.

Question 454: The time necessary for fracture healing depends on which of the following factors?

A. Age of the patient
B. Location of the fracture
C. Type of the fracture
D. All of the above (Correct Answer)

Explanation: **Explanation:** Fracture healing is a complex biological process influenced by both systemic and local factors. The correct answer is **All of the above** because each factor plays a critical role in determining the rate of union. 1. **Age of the Patient:** This is a primary systemic factor. Fractures heal significantly faster in children due to a thick, active periosteum and high osteogenic potential. For example, a femoral shaft fracture may heal in 3–4 weeks in a newborn, whereas it takes 12–16 weeks in an adult. 2. **Location of the Fracture:** Bone type and blood supply vary by location. Cancellous bone (e.g., metaphyseal regions) has a rich blood supply and a large contact area, leading to faster healing than cortical bone (e.g., diaphyseal shafts). Furthermore, fractures in areas with poor blood supply (e.g., scaphoid waist or femoral neck) are prone to delayed union. 3. **Type of the Fracture:** The nature of the injury dictates the healing environment. Comminuted or displaced fractures take longer to heal than simple, undisplaced ones. Open fractures often involve soft tissue damage and compromised vascularity, further slowing the process. **Why other options are incorrect:** Options A, B, and C are individual components of the healing process. Selecting only one would be incomplete, as they all interact simultaneously to determine the final healing time. **High-Yield Clinical Pearls for NEET-PG:** * **Perkins’ Timetable:** A classic rule of thumb for fracture union in adults: Upper limb (Callus in 2-3 weeks, Union in 4-6 weeks, Consolidation in 6-8 weeks); Lower limb takes double this time. * **Most important local factor:** Blood supply to the fracture fragments. * **Negative factors:** Smoking, diabetes, malnutrition, and corticosteroids significantly delay fracture healing.

Question 455: Trendelenburg's sign is negative in an Inter-Trochanteric fracture because of which structure?

A. Gluteus medius
B. Gluteus maximus
C. Gluteus minimus
D. Tensor fascia lata (Correct Answer)

Explanation: ### Explanation The Trendelenburg sign is used to assess the integrity of the hip abductor mechanism. A positive sign occurs when the pelvis drops on the unsupported side during single-leg standing, indicating weakness or mechanical disadvantage of the abductors on the weight-bearing side. **Why Tensor Fascia Lata (TFL) is the correct answer:** In an **Inter-Trochanteric (IT) fracture**, the fracture line is extracapsular and typically occurs distal to the insertion of the primary abductors (Gluteus medius and minimus) on the greater trochanter. However, the **Tensor Fascia Lata (TFL)** remains functional because it originates from the iliac crest and inserts into the iliotibial tract. In IT fractures, the TFL, along with the intact gluteal attachments to the proximal fragment, often maintains enough lateral stability to prevent a classic Trendelenburg drop. Furthermore, the pain and instability of an IT fracture usually make the test impossible to perform clinically; however, from an anatomical standpoint, the TFL acts as a secondary stabilizer that keeps the sign negative compared to femoral neck fractures where the mechanics are more severely disrupted. **Analysis of Incorrect Options:** * **Gluteus medius & Gluteus minimus:** These are the primary abductors. In conditions like Polio, Superior Gluteal Nerve palsy, or Developmental Dysplasia of the Hip (DDH), their dysfunction leads to a **positive** Trendelenburg sign. In IT fractures, their insertion remains on the proximal fragment. * **Gluteus maximus:** This is primarily a hip extensor and external rotator. It does not play a significant role in the lateral pelvic tilt mechanism associated with the Trendelenburg sign. **Clinical Pearls for NEET-PG:** * **Trendelenburg Test Requirements:** 1. Intact nerve supply (Superior Gluteal Nerve), 2. Strong muscles (Abductors), 3. Stable fulcrum (Femoral head in acetabulum), 4. Intact lever arm (Femoral neck length). * **IT Fractures vs. Neck Fractures:** IT fractures are extracapsular and have a high healing rate due to excellent blood supply, whereas neck fractures are intracapsular and prone to Avascular Necrosis (AVN). * **Reverse Trendelenburg Gait:** Seen in patients with compensated abductor weakness where the trunk lurches *towards* the affected side to maintain balance.

Question 456: A 30-year-old man sustained a femur fracture in a road traffic accident. Two days later, he developed sudden breathlessness. What is the most probable cause?

A. Pneumonia
B. Congestive heart failure
C. Bronchial asthma
D. Fat embolism (Correct Answer)

Explanation: **Explanation:** The clinical presentation of sudden breathlessness following a long bone fracture (like the femur) after an asymptomatic interval of 24–72 hours is a classic hallmark of **Fat Embolism Syndrome (FES)**. **Why Fat Embolism is correct:** FES occurs when fat globules are released from the bone marrow of a fractured long bone into the systemic circulation. These globules cause mechanical obstruction in the pulmonary capillaries and trigger a biochemical inflammatory response. The "lucid interval" (typically 24–48 hours) followed by the triad of **dyspnea, confusion (neurological symptoms), and a petechial rash** (usually over the chest and axilla) is pathognomonic for this condition. **Why other options are incorrect:** * **Pneumonia:** While it causes breathlessness, it typically presents with fever, productive cough, and takes longer than 48 hours to develop post-trauma. * **Congestive Heart Failure:** This is unlikely in a young 30-year-old patient without a prior cardiac history or massive fluid overload. * **Bronchial Asthma:** This would present with wheezing and usually a known prior history of atopy or triggers, rather than being a direct complication of a femur fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis (Major: Petechial rash, respiratory insufficiency, CNS depression). * **Snowstorm Appearance:** The characteristic finding on a Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Early Fixation:** The most effective way to prevent FES is the early stabilization/internal fixation of the fracture. * **Treatment:** Primarily supportive (Oxygenation/Ventilation). Steroids are controversial but sometimes mentioned.

Question 457: In nonunion of scaphoid, which vascularized muscle pedicle graft is taken from?

A. Pronator teres
B. Brachioradialis
C. Pronator quadratus (Correct Answer)
D. Extensor pollicis longus

Explanation: ### Explanation **Correct Answer: C. Pronator quadratus** The scaphoid is notorious for **avascular necrosis (AVN)** and nonunion due to its retrograde blood supply. When conservative management fails, vascularized bone grafting is preferred over non-vascularized grafts to improve healing rates. The **Pronator Quadratus (PQ) pedicle bone graft** (Kasten’s procedure) is a classic technique for scaphoid nonunion. The graft is harvested from the volar aspect of the distal radius, keeping it attached to the PQ muscle. The muscle acts as a "pedicle," providing a continuous blood supply to the bone graft via the **anterior interosseous artery**. This vascularity promotes faster osteogenesis compared to traditional grafts. **Analysis of Incorrect Options:** * **A. Pronator teres:** This muscle inserts into the mid-shaft of the radius. It is too proximal and lacks a suitable bony attachment for a pedicled graft to reach the scaphoid. * **B. Brachioradialis:** While the brachioradialis tendon inserts near the radial styloid, it is not the standard muscle used for a vascularized pedicle in scaphoid nonunion. (Note: The 1,2-intercompartmental supraretinacular artery (1,2-ICSRA) is a common *vessel-only* pedicle used, but not the brachioradialis muscle itself). * **D. Extensor pollicis longus (EPL):** The EPL is a muscle of the dorsal compartment. While dorsal vascularized grafts exist (e.g., based on the 1,2-ICSRA), the EPL muscle itself is not used as a pedicle. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** 80% of scaphoid blood supply comes from the **dorsal carpal branch of the radial artery**, entering at the dorsal ridge (retrograde flow). * **Most Common Site of Nonunion:** The **proximal pole** (due to the most precarious blood supply). * **Standard Vascularized Graft:** Pronator quadratus (Volar approach) or the 1,2-ICSRA graft (Dorsal approach). * **Pre-op Investigation:** MRI is the gold standard to assess the vascularity of the proximal pole before surgery.

Question 458: What is the recommended position for the arm in a cast when a fracture of both forearm bones occurs at the same level?

A. Full supination
B. 10 degrees of supination
C. Full pronation
D. Mid-pronation (Correct Answer)

Explanation: **Explanation:** The management of both-bone forearm fractures depends heavily on the level of the fracture relative to the insertions of the forearm rotators (the pronators and supinators). **Why Mid-pronation is correct:** When both bones are fractured at the **same level** (usually the middle third), the proximal fragment is acted upon by the supinator and the distal fragment is acted upon by the pronator teres. To neutralize these opposing rotational forces and maintain alignment of the interosseous space, the **mid-prone (neutral) position** is recommended. This position balances the pull of the supinator and pronator muscles, preventing rotational deformity. **Analysis of Incorrect Options:** * **Full Supination (A):** This is indicated for fractures in the **proximal third** (above the insertion of the pronator teres). In these cases, the proximal fragment is strongly supinated by the biceps brachii and supinator; therefore, the distal fragment must be brought into supination to match it. * **10 degrees of Supination (B):** While some texts suggest slight supination for middle-third fractures, "Mid-pronation" remains the standard textbook answer for fractures at the same level in the middle third. * **Full Pronation (C):** This is indicated for fractures in the **distal third**. Here, the pronator quadratus and pronator teres pull the proximal fragment into pronation, so the distal fragment must be pronated to align. **High-Yield NEET-PG Pearls:** * **Rule of Thumb:** "Proximal third = Supination; Middle third = Mid-prone; Distal third = Pronation." * **Interosseous Space:** The primary goal of casting in forearm fractures is to maintain the maximum width of the interosseous space to preserve rotational function. * **Surgical Note:** In adults, both-bone forearm fractures are considered "articular fractures" of the forearm complex; hence, **ORIF with dynamic compression plates (DCP)** is the gold standard treatment, rather than casting.

Question 459: What is the term for an incomplete fracture?

A. Woodcrumble fractures
B. Compression fractures
C. Greenstick fractures (Correct Answer)
D. Salter fractures

Explanation: **Explanation:** **Greenstick fractures** are the classic example of an **incomplete fracture**, occurring primarily in children. Because pediatric bones are more resilient, flexible, and have a thick, active periosteum, they tend to bend rather than snap completely. In a Greenstick fracture, the bone cortex breaks on the convex (tension) side while the concave side remains intact or merely buckled, mimicking the way a young, "green" branch breaks. **Analysis of Incorrect Options:** * **Woodcrumble fractures:** This is a distractor term and does not exist in standard orthopedic nomenclature. * **Compression fractures:** These occur when the bone is crushed or flattened (common in vertebral bodies due to osteoporosis). While the cortex may remain intact, it is classified by mechanism rather than the "incomplete" nature of the break. * **Salter fractures:** This refers to the **Salter-Harris classification**, which categorizes injuries involving the **epiphyseal growth plate** in children. These can be complete or incomplete but specifically involve the physis. **High-Yield Clinical Pearls for NEET-PG:** * **Torus (Buckle) Fracture:** Another type of incomplete pediatric fracture where the cortex "buckles" due to axial loading, typically at the distal radius. * **Plastic Deformation:** A unique pediatric condition where the bone bends permanently without any visible cortical break on X-ray. * **Management:** Greenstick fractures often require reduction to complete the break (to prevent gradual bowing) followed by immobilization. * **Remodeling:** Children have a high potential for spontaneous correction of angulation due to the active periosteum, especially if the fracture is near a joint.

Question 460: A 50-year-old male with a fracture neck of femur presents after 3 days. What is the treatment of choice?

A. Hemiarthroplasty
B. Total hip replacement
C. Hip spika
D. Closed reduction and internal fixation (CR & IF) (Correct Answer)

Explanation: ### Explanation The management of **fracture neck of femur** is primarily determined by two factors: the **age of the patient** and the **duration/displacement** of the fracture. **1. Why Option D is Correct:** In patients younger than 60–65 years (this patient is 50), the primary goal is **head preservation**. Even though the patient presented after 3 days, the fracture is considered "fresh" (usually defined as <3 weeks). For a 50-year-old, the biological priority is to save the natural femoral head to avoid the long-term complications of prostheses (like loosening or wear). Therefore, **Closed Reduction and Internal Fixation (CR & IF)** using Cannulated Cancellous Screws (CCS) is the gold standard to achieve union and prevent avascular necrosis (AVN). **2. Why Other Options are Incorrect:** * **A & B (Hemiarthroplasty/THR):** These are **replacement** surgeries. They are preferred in elderly patients (>60–65 years) where the bone healing potential is low and the risk of AVN is high. In a 50-year-old, these are avoided as primary treatments because implants have a limited lifespan. * **C (Hip Spica):** This is a conservative management tool. Fracture neck of femur is an intra-capsular fracture with poor callus formation; conservative management leads to non-union and is not indicated in adults. **3. High-Yield Clinical Pearls for NEET-PG:** * **Garden’s Classification:** Used to assess displacement; Type III and IV are unstable. * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (Type III) have higher shear forces and risk of non-union. * **The "Golden Period":** Fixation should ideally be done within 6–24 hours to minimize AVN risk, but head preservation is attempted in young patients even if they present late. * **Treatment Summary:** * <60 years: Fixation (Screws). * >60 years (Active): Total Hip Replacement. * >60 years (Sedentary/Debilitated): Hemiarthroplasty (Austin Moore or Thompson prosthesis).

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Fracture Complications

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Trauma — MCQs

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