Trauma — MCQs

A 36-year-old woman with sickle cell disease presents with increasing pain in her right hip. She has no fever, chills, back or other bone pain, and there is no history of any trauma. On examination, her temperature is 37.3°C, range of motion in the right hip is reduced, she walks with a limp, and the right leg is shorter than the left. Movements of the hip and walking on it are painful. X-rays of the hip are shown. Which of the following is the most likely diagnosis?

Trauma Indian Medical PG Practice Questions and MCQs

Question 541: Which of the following is the safest test to be performed in a patient with an acutely injured knee joint?

A. Lachmann test (Correct Answer)
B. Pivot shift test
C. McMurray's test
D. Apley's grinding test

Explanation: The correct answer is **Lachman test**. ### **Explanation** In the setting of an **acute knee injury**, the patient often presents with significant pain, hemarthrosis, and protective muscle guarding (spasm of the hamstrings). 1. **Why Lachman is the Safest/Best:** The Lachman test is performed at **20–30° of flexion**. At this angle, the bony geometry of the femoral condyles provides the least stability, and the hamstrings are relatively relaxed, making it the most sensitive and reliable test for an **Anterior Cruciate Ligament (ACL)** tear. Because it requires minimal flexion, it is the least painful and easiest to perform when the joint is swollen or locked. ### **Why the other options are incorrect:** * **Pivot Shift Test:** While this is the most specific test for ACL deficiency, it is **highly uncomfortable** and difficult to perform in an acute setting. It requires a combination of internal rotation and valgus stress while moving the knee from extension to flexion; this often requires anesthesia to overcome muscle guarding. * **McMurray’s Test:** This is used to diagnose **meniscal tears**. It involves maximal flexion and rotation of the knee, which is extremely painful and often impossible in an acutely injured, swollen joint. * **Apley’s Grinding Test:** This also tests for meniscal injuries by applying compression and rotation while the patient is prone. Like McMurray’s, it is provocative and poorly tolerated in the acute phase of trauma. ### **Clinical Pearls for NEET-PG:** * **Most Sensitive Test for ACL Tear:** Lachman Test. * **Most Specific Test for ACL Tear:** Pivot Shift Test. * **Gold Standard Diagnosis:** MRI (Non-invasive) or Arthroscopy (Invasive). * **Segond Fracture:** An avulsion fracture of the lateral tibial condyle; it is pathognomonic for an ACL tear.

Question 542: Which of the following statements regarding shoulder dislocation is true?

A. Anterior dislocation is more common than posterior dislocation.
B. Fixed medial rotation is characteristic of posterior dislocation.
C. Kocher's maneuver is an effective reduction technique for anterior dislocation.
D. All of the above. (Correct Answer)

Explanation: **Explanation:** The shoulder joint is the most commonly dislocated joint in the body due to the shallow glenoid cavity and its wide range of motion. * **Option A:** **Anterior dislocation** is the most frequent type, accounting for approximately **95-97%** of all shoulder dislocations. It typically occurs due to a fall on an outstretched hand with the arm in abduction and external rotation. * **Option B:** **Posterior dislocation** is rare (2-5%) and often associated with seizures or electric shocks. A hallmark clinical sign is **fixed internal (medial) rotation** and an inability to externally rotate the arm. On X-ray, this may present as the "Light Bulb sign." * **Option C:** **Kocher’s Maneuver** is a classic (though now less commonly used due to risk of humeral fractures) method for reducing anterior dislocations. It involves four steps: Traction, External rotation, Adduction, and Internal rotation (Mnemonic: **TEAM**). Since all three statements are clinically accurate, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Axillary nerve (tested via "Regimental Badge Sign" over the deltoid). * **Hill-Sachs Lesion:** A compression fracture of the posterolateral humeral head (seen in anterior dislocation). * **Bankart Lesion:** Avulsion of the anteroinferior glenoid labrum. * **Luxatio Erecta:** A rare inferior dislocation where the arm is held vertically over the head. * **Preferred Reduction Technique:** Hippocratic or Milch maneuvers are often preferred over Kocher’s to minimize complications.

Question 543: What is the treatment of choice for a one-week-old fracture of the neck of the femur in a 65-year-old patient?

A. Hemi-replacement arthroplasty
B. Closed reduction and internal fixation by cannulated cancellous screws (Correct Answer)
C. Closed reduction and internal fixation by Austin Moore pins
D. Total hip replacement

Explanation: ### Explanation The management of a femoral neck fracture depends primarily on the **age of the patient**, the **duration of the injury**, and the **degree of displacement**. **1. Why Option B is Correct:** In clinical practice and for NEET-PG purposes, the goal is to preserve the natural femoral head whenever possible. For a **65-year-old** patient with a relatively recent fracture (**one week old**), the standard of care is **Closed Reduction and Internal Fixation (CRIF) with Cannulated Cancellous (CC) screws**. While 65 is often considered the "borderline" age between fixation and replacement, current guidelines favor fixation if the fracture is manageable and the patient is physiologically active, as it preserves the native joint. A one-week delay does not automatically necessitate arthroplasty. **2. Why the Other Options are Incorrect:** * **Option A (Hemi-replacement arthroplasty):** This is typically reserved for elderly, sedentary patients (usually >70–75 years) or those with displaced fractures where the risk of avascular necrosis (AVN) is very high. * **Option C (Austin Moore pins):** This is an obsolete method. Modern orthopaedics utilizes CC screws for better compression and stability. * **Option D (Total Hip Replacement):** THR is preferred in elderly patients with pre-existing osteoarthritis or in very active elderly patients with displaced fractures to allow immediate weight-bearing. It is not the first choice for a one-week-old fracture in a 65-year-old unless fixation fails. **Clinical Pearls for NEET-PG:** * **Garden’s Classification:** Used for displaced vs. undisplaced fractures. Undisplaced (Stage I & II) always get fixation. * **Pauwels' Classification:** Based on the angle of the fracture line; higher angles (Type III) are more unstable. * **The "Biological Age" Rule:** In exams, if the patient is **<65 years**, always aim for **Fixation**. If **>65-70 years**, consider **Arthroplasty**. * **Complications:** The two most common complications of femoral neck fractures are **Avascular Necrosis (AVN)** and **Non-union**.

Question 544: Acute compartment syndrome is characterized by all of the following EXCEPT?

A. Pulselessness
B. Paresthesia
C. Pallor
D. Decreased intracompartmental pressure (Correct Answer)

Explanation: **Explanation:** Acute Compartment Syndrome (ACS) is a surgical emergency caused by increased pressure within a closed osteofascial compartment, leading to impaired local circulation and potential tissue necrosis. **Why "Decreased intracompartmental pressure" is the correct answer:** The fundamental pathophysiology of ACS is an **increase** in intracompartmental pressure (typically >30 mmHg or a Delta pressure <30 mmHg). This elevated pressure exceeds capillary perfusion pressure, leading to ischemia. Therefore, "decreased" pressure is the opposite of what occurs in this condition. **Analysis of other options (The 6 P’s of Ischemia):** * **Paresthesia:** Often the **earliest** neurological sign, indicating nerve ischemia within the compartment. * **Pallor:** Occurs as a result of compromised microvascular perfusion to the overlying skin and distal tissues. * **Pulselessness:** This is a **late and ominous sign**. It is important to note that in early ACS, distal pulses are usually **present** because the intracompartmental pressure rarely exceeds systolic arterial pressure. Its presence indicates advanced tissue death or associated arterial injury. **High-Yield Clinical Pearls for NEET-PG:** 1. **Earliest Clinical Sign:** Pain out of proportion to the injury and **Pain on passive stretching** of the involved muscles. 2. **Most Common Site:** Leg (Tibia fractures), followed by the forearm (Supracondylar fractures of the humerus). 3. **Diagnosis:** Primarily clinical; however, **Stryker’s monitor** is used for objective pressure measurement. 4. **Delta Pressure ($\Delta P$):** Diastolic BP minus Compartmental Pressure. If $\Delta P < 30$ mmHg, fasciotomy is indicated. 5. **Management:** Immediate **Emergency Fasciotomy** (leaving the wound open) to decompress the compartment.

Question 545: Which of the following statements regarding eponymous fractures is NOT TRUE?

A. Monteggia fracture is a fracture of the proximal third of the ulna with radial head dislocation.
B. Galeazzi fracture is a fracture of the distal third of the radius with dislocation of the distal radio-ulnar joint.
C. Colles fracture is a fracture at the cortico-cancellous junction of the distal end of the radius with dorsal tilt.
D. Pott's fracture is a trimalleolar ankle fracture. (Correct Answer)

Explanation: ### Explanation The correct answer is **D**. While Pott’s fracture is a general term used for various ankle fractures involving the malleoli, it is classically defined as a **bimalleolar fracture** (involving the lateral and medial malleoli). A **trimalleolar fracture** (involving the lateral, medial, and posterior malleolus of the tibia) is specifically known as a **Cotton’s fracture**. #### Analysis of Options: * **A. Monteggia Fracture:** This is correctly described as a fracture of the proximal 1/3rd of the ulna associated with dislocation of the proximal radio-ulnar joint (radial head). Remember the mnemonic **MUGR** (Monteggia-Ulna / Galeazzi-Radius). * **B. Galeazzi Fracture:** This is correctly described as a fracture of the distal 1/3rd of the radius with dislocation of the distal radio-ulnar joint (DRUJ). It is often called a "fracture of necessity" because it almost always requires ORIF in adults. * **C. Colles Fracture:** This is a classic extra-articular fracture of the distal radius at the cortico-cancellous junction (approx. 2cm proximal to the joint). It is characterized by **dorsal** displacement and tilt, producing the "dinner fork deformity." #### NEET-PG High-Yield Pearls: * **Reverse Monteggia:** Fracture of the proximal radius with dislocation of the proximal ulna. * **Smith’s Fracture:** Often called a "Reverse Colles," it involves **volar** (palmar) displacement/tilt of the distal radial fragment. * **Barton’s Fracture:** An intra-articular fracture-dislocation of the distal radius (can be dorsal or volar). * **Chauffeur’s Fracture:** An isolated fracture of the radial styloid process.

Question 546: A person with multiple injuries develops fever, restlessness, tachycardia, tachypnea, and periumbilical rash. What is the likely diagnosis?

A. Air embolism
B. Fat embolism (Correct Answer)
C. Pulmonary embolism
D. Bacterial pneumonitis

Explanation: **Explanation:** The clinical presentation of **Fat Embolism Syndrome (FES)** typically follows a latent period of 24–72 hours after a long bone fracture (e.g., femur or tibia) or pelvic injury. The classic triad includes **respiratory distress** (tachypnea, hypoxia), **neurological symptoms** (restlessness, confusion), and a **petechial rash**. The rash, found in only 20–50% of cases but highly pathognomonic, typically appears on the chest, axilla, neck, and conjunctiva; a periumbilical distribution is also a recognized variant. **Why other options are incorrect:** * **Air Embolism:** Usually occurs following sudden decompression, venous catheterization, or surgery. It presents with a "mill-wheel murmur" and sudden cardiovascular collapse, not a petechial rash. * **Pulmonary Embolism (Thromboembolism):** Typically occurs 1–2 weeks post-injury due to DVT. While it causes tachycardia and tachypnea, it does not present with a petechial rash or immediate restlessness. * **Bacterial Pneumonitis:** Presents with productive cough, high-grade fever, and localized lung consolidation on X-ray, usually developing later in the clinical course. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis. Major criteria include axillary/subconjunctival petechiae, hypoxemia ($PaO_2 < 60$ mmHg), and CNS depression. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Free fat globules** may be seen in urine or sputum (though not highly sensitive). * **Management:** Primarily supportive (Oxygenation/Ventilation). Early stabilization and internal fixation of fractures are the best preventive measures.

Question 547: Which of the following factors does NOT facilitate non-union of a fracture?

A. Hematoma formation (Correct Answer)
B. Periosteal injuries
C. Absence of nerve supply
D. Chronic infection

Explanation: **Explanation:** The correct answer is **A. Hematoma formation.** Fracture healing is a complex biological process, and the **fracture hematoma** is the essential first stage (Stage of Hematoma). It acts as a scaffold for fibrin and provides a source of signaling molecules (cytokines and growth factors like TGF-beta and BMPs) that trigger the inflammatory cascade and recruit osteoprogenitor cells. Far from causing non-union, a healthy hematoma is a **prerequisite for normal bone healing.** **Analysis of other options:** * **B. Periosteal injuries:** The periosteum is the primary source of blood supply and osteoblasts for the external callus. Extensive stripping or injury to the periosteum severely impairs the healing potential, leading to non-union. * **C. Absence of nerve supply:** While bone can heal in denervated limbs, clinical evidence (especially in spinal cord injuries or leprosy) suggests that intact neurotrophic factors and neuropeptides play a role in regulating bone remodeling. However, in the context of this question, it is a recognized factor that can delay or complicate the biological environment of healing compared to a healthy hematoma. * **D. Chronic infection:** Infection (Osteomyelitis) causes tissue necrosis, persistent inflammation, and bone resorption. It is one of the most common causes of "infected non-union." **NEET-PG High-Yield Pearls:** * **Most common site of non-union:** Scaphoid, Neck of Femur, and Lower 1/3rd of Tibia (due to poor blood supply). * **Hypertrophic Non-union:** Caused by **inadequate fixation** (mechanical failure); characterized by "Elephant foot" appearance on X-ray. * **Atrophic Non-union:** Caused by **poor biology/blood supply**; characterized by tapered bone ends. * **Smoking** is a significant systemic risk factor for non-union due to peripheral vasoconstriction.

Question 548: A 26-year-old male sustained a mid-arm injury, resulting in wrist drop, finger drop, and loss of sensation on the dorsum of the hand. The patient can perform elbow extension. What is the most likely diagnosis?

A. Very high radial nerve injury
B. High radial nerve injury (Correct Answer)
C. Low radial nerve injury
D. Posterior interosseous nerve injury

Explanation: ### Explanation The clinical presentation of **wrist drop**, **finger drop**, and **sensory loss** on the dorsum of the hand, while maintaining **elbow extension**, is classic for a **High Radial Nerve Injury**, typically occurring at the level of the spiral groove (mid-shaft humerus). #### 1. Why High Radial Nerve Injury is Correct: The radial nerve originates from the posterior cord (C5-T1). It gives off branches to the **Triceps** (elbow extension) in the axilla and upper arm *before* entering the spiral groove. * **Motor:** In a mid-shaft injury, the triceps is spared (elbow extension is preserved), but muscles distal to the injury—the Brachioradialis, Extensor Carpi Radialis Longus (ECRL), and all muscles supplied by the PIN—are paralyzed, leading to wrist and finger drop. * **Sensory:** The superficial branch is affected, causing sensory loss over the first dorsal web space. #### 2. Why Other Options are Incorrect: * **Very High Radial Nerve Injury (Axilla):** Occurs above the branches to the triceps. This would result in a **loss of elbow extension** in addition to wrist/finger drop. * **Low Radial Nerve Injury:** Usually refers to an injury distal to the elbow. Since the ECRL (wrist extensor) is supplied above the elbow, a low injury often spares wrist extension or results in "radial deviation" rather than a complete wrist drop. * **Posterior Interosseous Nerve (PIN) Injury:** The PIN is a purely motor branch (except for wrist joint proprioception). An injury here causes **finger drop** but **spares sensation** and usually spares wrist extension (due to ECRL being supplied by the main radial nerve). #### Clinical Pearls for NEET-PG: * **Holstein-Lewis Fracture:** A spiral fracture of the distal 1/3rd of the humerus commonly associated with radial nerve palsy. * **Saturday Night Palsy:** Compression of the radial nerve in the spiral groove. * **Splinting:** Use a **Cock-up splint** or Dynamic Finger Extension splint to prevent contractures. * **Recovery:** Most traumatic radial nerve palsies are neuropraxic and recover spontaneously (90% within 3-4 months).

Question 549: What is the most common site for spinal trauma?

A. Cervical (Correct Answer)
B. Thoracic
C. Lumbar
D. Sacrum

Explanation: **Explanation:** The **Cervical spine** is the most common site for spinal trauma due to its unique anatomical and functional characteristics. It is the most mobile segment of the vertebral column, supporting the weight of the head while lacking the structural stability provided by the rib cage (as seen in the thoracic spine). The high range of motion, combined with its relative lack of surrounding muscular protection compared to the lumbar region, makes it highly susceptible to acceleration-deceleration injuries (whiplash), falls, and high-velocity motor vehicle accidents. Within the cervical spine, **C2** is the most common site of fracture, while **C5-C6** is the most common site for subluxation. **Analysis of Incorrect Options:** * **Thoracic Spine:** This is the least mobile segment due to the stabilizing effect of the rib cage and the coronal orientation of the facet joints. It requires significant force to fracture, often associated with high-energy trauma. * **Lumbar Spine:** While the **Thoracolumbar junction (T12-L1)** is the most common site for *osteoporotic* or *wedge compression* fractures, the cervical spine remains the most frequent site for overall traumatic injuries. * **Sacrum:** Fractures here are relatively rare and usually occur in the context of high-energy pelvic ring disruptions or as insufficiency fractures in elderly patients. **NEET-PG High-Yield Pearls:** * **Most common site of spinal injury:** Cervical spine (specifically C2 for fractures, C5-C6 for cord injury). * **Most common site for Thoracolumbar fractures:** T12-L1 (transition zone from rigid thoracic to mobile lumbar). * **Jefferson Fracture:** Burst fracture of C1 (Atlas). * **Hangman’s Fracture:** Traumatic spondylolisthesis of C2 (Axis). * **Chance Fracture:** Horizontal seatbelt injury, most common at L1-L2.

Question 550: A 36-year-old woman with sickle cell disease presents with increasing pain in her right hip. She has no fever, chills, back or other bone pain, and there is no history of any trauma. On examination, her temperature is 37.3°C, range of motion in the right hip is reduced, she walks with a limp, and the right leg is shorter than the left. Movements of the hip and walking on it are painful. X-rays of the hip are shown. Which of the following is the most likely diagnosis?

A. avascular necrosis (AVN) of the femoral head (Correct Answer)
B. osteomyelitis
C. hip fracture
D. septic arthritis

Explanation: ***Avascular necrosis (AVN) of the femoral head*** - **Sickle cell disease** predisposes to AVN due to **vascular occlusion** from sickling of red blood cells, leading to bone infarction and necrosis of the femoral head. - Clinical presentation of **reduced hip range of motion**, **leg length discrepancy**, and **painful walking** without fever are classic signs of AVN in sickle cell patients. *Osteomyelitis* - Typically presents with **systemic symptoms** including high fever, chills, and elevated inflammatory markers, which are absent in this case. - **Sickle cell patients** are prone to osteomyelitis, but the lack of fever and normal temperature make this diagnosis less likely. *Hip fracture* - Requires a **history of trauma** or significant force, which is explicitly absent in this patient's presentation. - **X-ray findings** would show clear fracture lines rather than the changes typical of avascular necrosis. *Septic arthritis* - Usually presents with **high fever**, **acute onset** of severe pain, and **systemic toxicity**, none of which are present here. - The **gradual onset** and **absence of fever** make septic arthritis unlikely despite the patient's underlying sickle cell disease.

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Trauma — MCQs

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