Trauma — MCQs

A 44-year-old woman suffers a fall while rock climbing, landing on her buttocks and falling forward. Despite prolonged airlift to the ED, she is hemodynamically stable. She complains of bilateral pain in her legs, distal to her knees. She has profound weakness in her bilaterally extensor hallucis longi and gastrocsoleus complexes and has marked saddle anesthesia. MRI shows a large, midline herniated disc, compressing each of the traversing nerve roots and entire cauda equina below its level, but sparing the exiting nerve roots. Which disc is most likely involved in this injury?

Q480Medium

A 18-year-old boy presents with a history of anterior shoulder dislocation. What is the typical position of the affected arm?

Trauma Indian Medical PG Practice Questions and MCQs

Question 471: Frieberg osteochondritis involves which of the following?

A. 2nd metatarsal head (Correct Answer)
B. 2nd metatarsal base
C. 5th metatarsal head
D. 5th metatarsal base

Explanation: **Explanation:** **Freiberg’s disease** (or Freiberg’s infraction) is a form of avascular necrosis (osteochondritis) affecting the metatarsal heads. It most commonly involves the **2nd metatarsal head (Option A)** in approximately 68% of cases, followed by the 3rd metatarsal head. **Pathophysiology:** The 2nd metatarsal is the longest and most fixed of the metatarsals. During the toe-off phase of the gait cycle, it is subjected to repetitive microtrauma and excessive loading. This leads to subchondral vascular compromise, causing collapse and flattening of the articular surface. It is most frequently seen in adolescent females (ratio 3:1) during their growth spurt. **Analysis of Incorrect Options:** * **Option B (2nd metatarsal base):** Osteochondritis typically affects the epiphysis/articular surface (head) rather than the base. The base of the 2nd metatarsal is clinically significant in **Lisfranc injuries**, not Freiberg’s. * **Option C (5th metatarsal head):** While any metatarsal head can be affected, the 5th is the least common due to its increased mobility, which dissipates stress more effectively than the rigid 2nd metatarsal. * **Option D (5th metatarsal base):** This is the site of **Jones fractures** or **Pseudo-Jones (avulsion) fractures**, but not Freiberg’s osteochondritis. **NEET-PG High-Yield Pearls:** 1. **Radiology:** Look for "flattening and sclerosis" of the metatarsal head. 2. **Treatment:** Initial management is conservative (activity modification, orthotics/metatarsal pads). Surgery (debridement or osteotomy) is reserved for refractory cases. 3. **Differential Diagnosis (Eponymous Osteochondritis):** * **Kohler’s disease:** Navicular bone. * **Sever’s disease:** Calcaneal apophysis. * **Panner’s disease:** Capitellum of the humerus. * **Kienbock’s disease:** Lunate bone.

Question 472: What is a known complication of a Colles' fracture?

A. Radial nerve palsy
B. Stiffness of the wrist joint (Correct Answer)
C. Ulnar nerve palsy
D. None of the above

Explanation: **Explanation:** A **Colles' fracture** is a distal radius fracture occurring within 2.5 cm of the wrist joint, characterized by dorsal displacement and angulation (Dinner Fork deformity). **1. Why Stiffness of the Wrist Joint is the Correct Answer:** Stiffness is the **most common complication** of a Colles' fracture. It occurs due to prolonged immobilization in a plaster cast, post-traumatic edema, and adhesions involving the extensor and flexor tendons. If the fracture involves the articular surface (intra-articular extension), the risk of secondary osteoarthritis and subsequent joint stiffness increases significantly. **2. Why Incorrect Options are Wrong:** * **Radial Nerve Palsy (A):** The radial nerve is rarely involved in distal radius fractures. It is more commonly injured in **humeral shaft fractures** (Holstein-Lewis fracture). * **Ulnar Nerve Palsy (C):** While the ulnar nerve is near the wrist, it is seldom injured in a Colles' fracture. However, the **Median nerve** is frequently at risk, leading to acute Carpal Tunnel Syndrome. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Complication:** Stiffness of the wrist and fingers. * **Most Common Late Complication:** Secondary Osteoarthritis. * **Specific Tendon Rupture:** Rupture of the **Extensor Pollicis Longus (EPL)** tendon is a classic late complication (due to ischemia or friction at Lister’s tubercle). * **Sudeck’s Atrophy:** Also known as Complex Regional Pain Syndrome (CRPS), this is a feared complication characterized by pain, swelling, and vasomotor instability. * **Malunion:** Leads to the characteristic "Dinner Fork Deformity."

Question 473: What is the recommended treatment for a complete rupture of the tendo calcaneum?

A. Observation and no intervention
B. Physiotherapy alone
C. Arthrodesis
D. Surgical repair (Correct Answer)

Explanation: **Explanation:** **Tendo Calcaneum (Achilles tendon) rupture** is a common injury, typically occurring 2–6 cm proximal to its insertion on the calcaneus (the watershed area). For a **complete rupture**, surgical repair is the preferred treatment, especially in young, active individuals and athletes. **1. Why Surgical Repair is Correct:** Surgical repair (primary end-to-end anastomosis) is the gold standard because it restores the optimal length-tension relationship of the gastrocnemius-soleus complex. Compared to conservative management, surgery significantly **reduces the rate of re-rupture** (approx. 2–5% vs. 10–15% in conservative) and provides superior plantar flexion strength, allowing a faster return to sports. **2. Why Other Options are Incorrect:** * **Observation (A):** A complete rupture will not heal spontaneously with functional strength; it leads to permanent disability and a "calcaneus gait." * **Physiotherapy alone (B):** While rehab is vital *after* surgery or casting, it cannot bridge a complete gap in the tendon. Conservative management requires immobilization in an equinus cast, not just physiotherapy. * **Arthrodesis (C):** This is joint fusion (e.g., ankle or subtalar). It is not indicated for a soft tissue tendon injury unless there is associated end-stage arthritis. **Clinical Pearls for NEET-PG:** * **Simmonds/Thompson Test:** The most reliable clinical test. Squeezing the calf fails to produce plantar flexion of the foot. * **Matles Test:** With the patient prone and knees flexed to 90°, the affected foot is more dorsiflexed than the normal side. * **Drug Association:** Fluoroquinolones (e.g., Ciprofloxacin) and systemic steroids increase the risk of rupture. * **Radiology:** Ultrasound is the initial investigation, but **MRI** is the gold standard for differentiating partial from complete tears.

Question 474: Freiberg's disease is a recognized osteochondritis affecting which of the following bones?

A. Head of the 2nd and 3rd metatarsal (Correct Answer)
B. Lunate bone
C. Hip
D. Navicular bone

Explanation: **Explanation:** **Freiberg’s disease** is a form of avascular necrosis (osteochondritis) that typically affects the **head of the 2nd metatarsal** (most common) or the **3rd metatarsal**. It is most frequently seen in adolescent girls (aged 12–15) and is thought to be caused by repetitive microtrauma or chronic stress on the metatarsal head, which is often longer than the first metatarsal in affected individuals. Radiologically, it presents as flattening and sclerosis of the metatarsal head with joint space widening. **Analysis of Incorrect Options:** * **B. Lunate bone:** Osteochondritis of the lunate is known as **Kienböck’s disease**, which leads to wrist pain and decreased grip strength. * **C. Hip:** Osteochondritis of the femoral head epiphysis in children is known as **Legg-Calvé-Perthes disease**. * **D. Navicular bone:** Osteochondritis of the tarsal navicular bone is known as **Köhler’s disease**, typically seen in young children (3–5 years). **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Freiberg’s is the only osteochondritis more common in **females**. * **Common Site:** The 2nd metatarsal is most involved because it is the most fixed and longest part of the forefoot. * **Other Eponyms to Remember:** * **Panner’s disease:** Capitellum of the humerus. * **Sever’s disease:** Calcaneal apophysis. * **Osgood-Schlatter disease:** Tibial tuberosity. * **Scheuermann’s disease:** Intervertebral joints (Ring epiphysis).

Question 475: Excision of the head of the radius in a child should not be done because:

A. It produces instability of the elbow joint.
B. It leads to secondary osteoarthritis of the elbow.
C. It causes subluxation of the inferior radio-ulnar joint. (Correct Answer)
D. It causes myositis ossificans.

Explanation: **Explanation:** The radial head plays a critical role in maintaining the longitudinal stability of the forearm. In children, the radial head is not just a joint surface but also contains the **proximal radial epiphysis**, which is responsible for the longitudinal growth of the radius. **Why Option C is Correct:** When the radial head is excised in a growing child, the stimulus for longitudinal growth of the radius is lost. As the ulna continues to grow normally, a **length discrepancy** develops between the two bones. The relatively shorter radius is pulled proximally, leading to a proximal migration of the radial shaft. This results in a disruption of the **Distal (Inferior) Radio-Ulnar Joint (DRUJ)**, causing subluxation, wrist pain, and significant loss of forearm rotation and grip strength. **Analysis of Incorrect Options:** * **Option A:** While the radial head is a secondary stabilizer against valgus stress, its excision in children is primarily avoided due to growth disturbances rather than immediate joint instability. * **Option B:** Secondary osteoarthritis may eventually occur due to altered mechanics, but it is a late complication and not the primary contraindication in the pediatric age group. * **Option D:** Myositis ossificans is a complication of trauma or aggressive massage, not a direct consequence of radial head excision. **Clinical Pearls for NEET-PG:** * **Management Rule:** In children, radial head fractures should always be managed **conservatively** or via **ORIF/CRIF**. Excision is strictly contraindicated. * **Essex-Lopresti Fracture-Dislocation:** This involves a radial head fracture, interosseous membrane tear, and DRUJ disruption. Excision of the radial head in this condition (even in adults) leads to proximal migration of the radius. * **Safe Excision:** In adults, radial head excision is generally permissible if there is no associated ligamentous injury or interosseous membrane damage.

Question 476: Pauwel's classification is used for which of the following fractures?

A. Fracture of scaphoid
B. Fracture of neck of radius
C. Fracture of neck of femur (Correct Answer)
D. Fracture of neck of talus

Explanation: **Explanation:** **Pauwel’s classification** is a prognostic classification used for **Fracture Neck of Femur**. It is based on the **angle of the fracture line** relative to the horizontal plane. The underlying medical concept is that as the angle increases, the shear forces at the fracture site increase, leading to higher rates of non-union and avascular necrosis (AVN). * **Type I:** < 30° (Stable; compressive forces dominate) * **Type II:** 30° to 50° (Intermediate) * **Type III:** > 50° (Unstable; shear forces dominate) **Analysis of Incorrect Options:** * **Fracture of scaphoid:** Commonly classified using the **Herbert classification** (based on stability and location). * **Fracture of neck of radius:** Often classified using the **Judet classification** (based on the degree of angulation). * **Fracture of neck of talus:** Classified using the **Hawkins classification**, which is crucial for predicting the risk of AVN. **Clinical Pearls for NEET-PG:** 1. **Garden’s Classification:** The most commonly used classification for neck of femur fractures in clinical practice, based on the degree of displacement (Stages I-IV). 2. **Shear Force:** Pauwel Type III is the most unstable due to high shear forces, often requiring more robust internal fixation. 3. **Blood Supply:** The main blood supply to the femoral head is the **Medial Circumflex Femoral Artery**; its disruption in neck fractures leads to AVN. 4. **Management:** In elderly patients, displaced fractures (Garden III/IV) are usually treated with **Hemiarthroplasty/THR**, whereas in young patients, **internal fixation** is preferred to save the head.

Question 477: Myositis ossificans is most common around which joint?

A. Knee
B. Elbow (Correct Answer)
C. Wrist
D. Hip

Explanation: **Explanation:** **Myositis Ossificans (Traumatic Ossification)** refers to the formation of heterotopic bone within muscles and soft tissues, typically following trauma. **Why the Elbow is the Correct Answer:** The elbow is the most common site for myositis ossificans, specifically involving the **Brachialis** muscle. This occurs frequently after a supracondylar fracture of the humerus or a posterior dislocation of the elbow. The condition is often triggered by "vigorous massage" or passive stretching of the joint following an injury, which leads to hematoma formation and subsequent metaplasia of mesenchymal cells into osteoblasts. **Analysis of Incorrect Options:** * **Knee:** While the knee is the second most common site (specifically the Quadriceps muscle, often called "Rider’s Bone" in the adductors), it occurs less frequently than in the elbow. * **Hip:** Heterotopic ossification around the hip is common after total hip arthroplasty or central nervous system trauma (paraplegia), but post-traumatic myositis ossificans is statistically more prevalent in the elbow. * **Wrist:** This joint is rarely involved as there is minimal bulky muscle mass prone to the deep hematomas required for this pathology. **NEET-PG High-Yield Pearls:** * **Most common muscle involved:** Brachialis (Elbow), followed by Quadriceps (Thigh). * **Classic Provoking Factor:** Forceful massage by traditional bone-setters (frequently tested). * **Radiological Sign:** "Zonal Phenomenon"—the lesion is more mature/calcified at the periphery and immature in the center (helps differentiate it from Osteosarcoma). * **Management:** Rest and immobilization in the acute phase. Surgery is contraindicated until the bone matures (usually 6–12 months), as early excision leads to high recurrence rates.

Question 478: Fracture shaft of femur in adults usually unites by approximately how much time?

A. 1 month
B. 3-4 months (Correct Answer)
C. 6-7 months
D. 1 year

Explanation: The fracture of the femoral shaft is a major injury involving the largest and strongest bone in the body. In adults, the healing process follows a predictable timeline based on the bone's cortical thickness and blood supply. ### **Explanation of the Correct Answer** **Option B (3-4 months)** is the correct answer. In a healthy adult, the average time for clinical and radiological union of a femoral shaft fracture is **12 to 16 weeks**. * **Clinical Union:** Occurs when the fracture site is no longer tender and there is no movement between fragments (usually by 8-10 weeks). * **Radiological Union:** Occurs when bridging callus is visible across the fracture site on X-ray, typically completing the process by the 4th month. ### **Analysis of Incorrect Options** * **Option A (1 month):** This is too early for a long bone fracture in adults. While primary callus starts forming, it lacks the structural integrity for union. This timeline is more characteristic of neonatal or infant femoral fractures. * **Option C (6-7 months):** If a femur fracture has not united by 6 months, it is often classified as a **delayed union**. * **Option D (1 year):** This timeframe suggests **non-union** or the completion of the remodeling phase (Wolff’s Law), rather than the initial union. ### **NEET-PG High-Yield Pearls** * **Healing in Children:** Femur fractures heal much faster in children (Birth: 3 weeks; Age 8: 8 weeks; Age 12: 12 weeks). * **Standard Treatment:** The gold standard for adult femoral shaft fractures is **Intramedullary (IM) Interlocking Nailing**. * **Common Complication:** Fat Embolism Syndrome is a high-yield systemic complication associated with long bone fractures like the femur. * **Blood Loss:** A closed fracture of the femur can result in internal blood loss of **1000–1500 ml**, potentially leading to hemorrhagic shock.

Question 479: A 44-year-old woman suffers a fall while rock climbing, landing on her buttocks and falling forward. Despite prolonged airlift to the ED, she is hemodynamically stable. She complains of bilateral pain in her legs, distal to her knees. She has profound weakness in her bilaterally extensor hallucis longi and gastrocsoleus complexes and has marked saddle anesthesia. MRI shows a large, midline herniated disc, compressing each of the traversing nerve roots and entire cauda equina below its level, but sparing the exiting nerve roots. Which disc is most likely involved in this injury?

A. L2-3
B. L3-4
C. L4-5 (Correct Answer)
D. L5-S1

Explanation: ### Explanation This patient presents with **Cauda Equina Syndrome (CES)**, a surgical emergency characterized by compression of multiple lumbosacral nerve roots. To identify the level of the disc herniation, we must correlate the clinical deficits with the anatomy of the spinal canal. **1. Why L4-5 is Correct:** * **Extensor Hallucis Longus (EHL):** Primarily supplied by the **L5** nerve root. * **Gastrocsoleus Complex:** Primarily supplied by the **S1** nerve root. * **Saddle Anesthesia:** Involvement of **S2-S4** roots. * **Anatomical Rule:** In the lumbar spine, a **paracentral/midline disc herniation** typically compresses the **traversing** nerve root (the one going to the level below). At the **L4-L5** level, the L4 root has already exited; the traversing roots are **L5, S1, and all subsequent sacral roots**. Compression here explains the loss of L5 (EHL), S1 (Gastrocsoleus), and S2-S4 (Saddle anesthesia) functions. **2. Why the others are Incorrect:** * **L2-3:** Compression here would involve L3 and below. While it would cause the symptoms described, it would *also* cause weakness in knee extension (Quadriceps - L4), which is not mentioned. * **L3-4:** This would involve L4 and below. It would typically present with a diminished patellar reflex and weak foot inversion/dorsiflexion (Tibialis Anterior - L4). * **L5-S1:** A midline herniation here would spare the L5 root (which has already exited). Therefore, the **EHL (L5) would be spared**, contradicting the clinical presentation. **Clinical Pearls for NEET-PG:** * **Most common level for CES:** L4-L5. * **Earliest sign of CES:** Urinary retention (high sensitivity). * **Surgical Window:** Decompression is ideally performed within **24–48 hours** to prevent permanent neurological deficit. * **Root Rule:** Lumbar discs affect the *lower* (traversing) root; Cervical discs affect the *same-level* (exiting) root.

Question 480: A 18-year-old boy presents with a history of anterior shoulder dislocation. What is the typical position of the affected arm?

A. Abduction and internal rotation
B. Abduction and external rotation (Correct Answer)
C. Flexion
D. Extension

Explanation: ### Explanation **Correct Answer: B. Abduction and external rotation** **Mechanism and Clinical Presentation:** Anterior shoulder dislocation is the most common type of shoulder dislocation (approx. 95%). It typically occurs due to a fall on an outstretched hand or a direct blow to the shoulder while the

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