Trauma — MCQs
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A young woman presented with mild quadriparesis following an accident. Her lateral X-ray of the cervical spine revealed a C5-C6 fracture-dislocation. What is the most appropriate line of management?
A 72-year-old man presents to the emergency room after sustaining a right knee injury in a car accident. The pain, which began shortly after the accident, progressed to severe swelling and excruciating pain, significantly impairing ambulation. Physical examination reveals a warm, swollen knee with an effusion that is extremely painful to flex. Radiographs of the knee exclude fracture. Arthrocentesis yields opaque fluid containing rhomboid crystals with weak-positive birefringence. What is the most appropriate next step in management?
Which nerve is commonly injured due to a lunate dislocation?
What is meant by Clergyman's knee?
A 32-year-old man involved in a motor vehicle accident sustained an injury to his left arm and complains of an inability to open his left hand and loss of sensation to a portion of his left hand. What is the most likely injury?
Which of the following fractures is known for non-union?
The management of fat embolism includes all of the following except?
A Bennet's fracture is difficult to maintain in a reduced position because of the pull of which muscle?
What is the recommended re-implantation time for a lower limb injury?
What is the management for the depicted condition?
Trauma Indian Medical PG Practice Questions and MCQs
Question 551: A young woman presented with mild quadriparesis following an accident. Her lateral X-ray of the cervical spine revealed a C5-C6 fracture-dislocation. What is the most appropriate line of management?
- A. Immediate anterior decompression
- B. Cervical traction followed by instrumented fixation (Correct Answer)
- C. Hard cervical collar and bed rest
- D. Cervical laminectomy
Explanation: ### Explanation **Core Concept: The Principle of "Reduction before Fixation"** In cases of cervical spine fracture-dislocation with neurological deficits (like quadriparesis), the primary goal is to restore the spinal canal's diameter and stabilize the column. The standard management protocol follows a sequence: **Reduction → Stabilization → Rehabilitation.** **Why Option B is Correct:** 1. **Cervical Traction (Reduction):** Immediate application of skeletal traction (e.g., Gardner-Wells tongs) is the first step. It uses longitudinal force to "unlock" the dislocated facets and realign the vertebrae. This achieves indirect decompression of the spinal cord by restoring the normal anatomy. 2. **Instrumented Fixation (Stabilization):** Once reduction is achieved (or attempted), definitive surgical fixation (anterior or posterior) is required to maintain stability, prevent further cord injury, and allow early mobilization. **Why Other Options are Incorrect:** * **Option A:** While anterior decompression is often part of the surgery, "immediate" surgery without attempting closed reduction via traction is generally not the first step unless there is a specific contraindication to traction or an extruded disc is seen on MRI. * **Option C:** A hard collar and bed rest are insufficient for unstable fracture-dislocations. These injuries are highly unstable (Three-column injury) and carry a high risk of worsening neurological deficit without rigid fixation. * **Option D:** Laminectomy (posterior decompression) is rarely indicated as a primary treatment for fracture-dislocations because it can further increase spinal instability. **Clinical Pearls for NEET-PG:** * **Three-Column Theory (Denis):** Fracture-dislocations involve all three columns and are inherently unstable. * **Initial Management:** Always follow ATLS protocols (Airway with C-spine protection). * **MRI:** The best modality to visualize cord edema or disc herniation before surgical intervention. * **Steroids:** The use of high-dose Methylprednisolone (NASCIS trial) is now controversial and no longer considered the absolute standard of care due to side effects.
Question 552: A 72-year-old man presents to the emergency room after sustaining a right knee injury in a car accident. The pain, which began shortly after the accident, progressed to severe swelling and excruciating pain, significantly impairing ambulation. Physical examination reveals a warm, swollen knee with an effusion that is extremely painful to flex. Radiographs of the knee exclude fracture. Arthrocentesis yields opaque fluid containing rhomboid crystals with weak-positive birefringence. What is the most appropriate next step in management?
- A. Oral prednisone
- B. Intravenous antibiotics
- C. Oral NSAIDs (Correct Answer)
- D. Acetaminophen
Explanation: **Explanation:** The clinical presentation describes an acute attack of **Pseudogout (Calcium Pyrophosphate Deposition Disease - CPPD)**. In elderly patients, physical trauma (like a car accident) is a common trigger for an acute flare. The diagnosis is confirmed by the arthrocentesis findings: **rhomboid-shaped crystals** with **weakly positive birefringence** under polarized light. 1. **Why Oral NSAIDs are correct:** Non-steroidal anti-inflammatory drugs (NSAIDs) are the **first-line treatment** for acute pseudogout flares to reduce inflammation and pain. In the absence of contraindications (like renal failure or active peptic ulcers), they are preferred over other modalities for rapid symptom control. 2. **Why other options are wrong:** * **Oral Prednisone:** While steroids are used for pseudogout, they are typically reserved for patients who cannot tolerate NSAIDs or colchicine, or those with polyarticular involvement. * **Intravenous Antibiotics:** These are indicated for septic arthritis. While the fluid was "opaque," the presence of specific crystals and the absence of fever/chills point toward crystal-induced arthropathy rather than infection. * **Acetaminophen:** This provides mild analgesia but lacks the potent anti-inflammatory properties required to resolve a CPPD flare. **High-Yield Clinical Pearls for NEET-PG:** * **Crystal Morphology:** Gout = Needle-shaped, Strongly Negative Birefringent (Yellow when parallel); Pseudogout = Rhomboid-shaped, Weakly Positive Birefringent (Blue when parallel). * **Radiology:** Look for **Chondrocalcinosis** (linear calcification of articular cartilage/meniscus) on X-rays. * **Common Triggers:** Trauma, surgery (especially hyperparathyroidism surgery), and dehydration. * **Associated Conditions:** Always screen for "The 3 H's": Hyperparathyroidism, Hemochromatosis, and Hypomagnesemia.
Question 553: Which nerve is commonly injured due to a lunate dislocation?
- A. Median nerve (Correct Answer)
- B. Radial nerve
- C. Axillary nerve
- D. Ulnar nerve
Explanation: **Explanation:** The **lunate** is the most commonly dislocated carpal bone. In a lunate dislocation, the lunate is displaced **volarly** (anteriorly) into the carpal tunnel. Because the carpal tunnel is a rigid space, this displacement directly compresses the **median nerve**, which lies immediately superficial to the lunate. This can lead to acute carpal tunnel syndrome, presenting with paresthesia in the lateral three and a half fingers and weakness of the thenar muscles. **Analysis of Incorrect Options:** * **Radial Nerve:** This nerve travels along the posterior compartment of the arm and the lateral aspect of the forearm. It does not pass through the carpal tunnel and is more commonly injured in humerus shaft fractures (Holstein-Lewis fracture). * **Axillary Nerve:** This nerve is located in the shoulder region. It is most frequently injured during anterior shoulder dislocations or surgical neck of the humerus fractures. * **Ulnar Nerve:** While the ulnar nerve passes through the wrist, it travels via **Guyon’s canal**, which is medial to the carpal tunnel. It is more commonly injured in hook of hamate fractures or distal radius fractures, but not typically in lunate dislocations. **Clinical Pearls for NEET-PG:** * **"Spilled Teacup" Sign:** On a lateral X-ray, the lunate loses its concave relationship with the capitate and tilts volarly, resembling a tipped cup. * **Terry Thomas Sign:** Associated with **scapholunate dissociation** (widening of the gap >3mm), not lunate dislocation. * **Perilunate vs. Lunate Dislocation:** In perilunate dislocation, the lunate remains in line with the radius while other carpals displace; in lunate dislocation, the lunate itself is displaced. Both can cause median nerve injury.
Question 554: What is meant by Clergyman's knee?
- A. Prepatellar bursa
- B. Intrapatellar bursa (Correct Answer)
- C. Olecranon
- D. Ischial bursa
Explanation: **Explanation:** **Clergyman’s Knee** refers to **Infrapatellar bursitis**. This condition involves inflammation of the infrapatellar bursa, located between the patellar ligament and the skin (superficial) or the tibia (deep). 1. **Why Intrapatellar Bursa is correct:** The term originates from the posture of prayer. When a person kneels in an **upright position** (common for clergymen), the pressure is concentrated lower down on the tibial tuberosity and the infrapatellar bursa, leading to inflammation. 2. **Why other options are incorrect:** * **Prepatellar Bursa (Housemaid’s Knee):** This is the most common bursa involved in the knee. It occurs due to kneeling while **leaning forward** (e.g., scrubbing floors), which places direct pressure on the patella. * **Olecranon (Student’s/Miner’s Elbow):** This refers to inflammation of the bursa over the olecranon process of the elbow, usually due to constant leaning on hard surfaces. * **Ischial Bursa (Weaver’s Bottom):** This is inflammation of the bursa between the gluteus maximus and the ischial tuberosity, caused by prolonged sitting on hard surfaces. **High-Yield Clinical Pearls for NEET-PG:** * **Housemaid’s Knee:** Prepatellar bursitis (Leaning forward). * **Clergyman’s Knee:** Infrapatellar bursitis (Kneeling upright). * **Vicar’s Knee:** Another synonym for Clergyman’s knee. * **Treatment:** Usually conservative (rest, NSAIDs, ice). If infected (septic bursitis), aspiration and antibiotics are required. * **Anatomy:** The deep infrapatellar bursa is separated from the knee joint by the infrapatellar fat pad (Hoffa's fat pad).
Question 555: A 32-year-old man involved in a motor vehicle accident sustained an injury to his left arm and complains of an inability to open his left hand and loss of sensation to a portion of his left hand. What is the most likely injury?
- A. Median nerve injury (Correct Answer)
- B. Ulnar nerve injury
- C. Radial nerve injury
- D. Axillary nerve injury
Explanation: ### Explanation The patient presents with an **inability to open the hand** (specifically the inability to extend the fingers at the interphalangeal joints) and **sensory loss**. This clinical picture points toward a **Median Nerve Injury**. **Why Median Nerve is Correct:** The median nerve supplies the **lateral two lumbricals**. These muscles are responsible for extending the interphalangeal (IP) joints while flexing the metacarpophalangeal (MCP) joints. In a high median nerve palsy, the patient cannot flex the index and middle fingers (Ape thumb deformity/Hand of Benediction when attempting to make a fist). Furthermore, the median nerve provides sensation to the palmar aspect of the lateral 3.5 fingers. The "inability to open the hand" refers to the loss of the precision grip and the coordinated extension required for hand opening. **Why Other Options are Incorrect:** * **Radial Nerve Injury:** This typically presents with **Wrist Drop** and inability to extend the MCP joints. While it affects hand opening, the sensory loss is usually limited to a small area on the dorsal first web space, which is less clinically prominent than median nerve distribution. * **Ulnar Nerve Injury:** This leads to **Claw Hand** (hyperextension of MCP and flexion of IP joints of the ring and little fingers). While it affects hand posture, the primary sensory loss is on the medial 1.5 fingers. * **Axillary Nerve Injury:** This affects the deltoid muscle, leading to loss of shoulder abduction and sensory loss over the "regimental badge" area of the lateral arm, not the hand. **Clinical Pearls for NEET-PG:** * **Hand of Benediction:** Seen when the patient tries to make a fist (Median nerve). * **Claw Hand:** Seen at rest (Ulnar nerve). * **Pointing Index (Straight Finger):** A classic sign of high median nerve palsy due to loss of Flexor Digitorum Profundus (lateral half). * **Mnemonic:** **DR CUM** (Drop = Radial; Claw = Ulnar; Median = Ape hand/Benediction).
Question 556: Which of the following fractures is known for non-union?
- A. Scaphoid fracture
- B. Lateral condyle humerus fracture
- C. Colles' fracture (Correct Answer)
- D. Femoral neck fracture
Explanation: ### Explanation The question asks which fracture is **known for non-union**. In the context of the provided options and standard orthopedic teaching for NEET-PG, the correct answer is **Colles' fracture**, but this requires a specific clarification regarding the terminology of bone healing complications. **1. Why Colles' Fracture?** Colles' fracture (distal radius fracture) occurs through **cancellous bone**. Cancellous bone has a rich blood supply and a large surface area, which typically leads to rapid healing. Therefore, **true non-union is extremely rare** in Colles' fractures. However, they are notorious for **Mal-union** (healing in a deformed position, such as dinner fork deformity). *Note: In many traditional question banks, if the question asks for a fracture "known for" a specific healing complication, Colles' is the classic example of Mal-union, while the others are classic for Non-union.* **2. Analysis of Incorrect Options (The "Non-union" Trio):** The other three options are actually the **most common sites for Non-union** in the body due to precarious blood supply or intra-articular factors: * **Scaphoid Fracture:** High risk of non-union and avascular necrosis (AVN) because the blood supply enters distally (retrograde flow). * **Lateral Condyle Humerus:** An intra-articular fracture in children; it often goes into non-union due to the "pull" of extensor muscles and bathing of the fracture line in synovial fluid. * **Femoral Neck Fracture:** High rate of non-union and AVN due to the retrograde blood supply (medial circumflex femoral artery) and lack of periosteum. **3. NEET-PG Clinical Pearls:** * **Most common site of Non-union:** Scaphoid, Neck of Femur, and Talus. * **Most common site of Mal-union:** Colles' fracture. * **Commonest cause of Non-union:** Inadequate immobilization or poor blood supply. * **Dinner Fork Deformity:** Seen in Colles' fracture due to dorsal displacement and tilt. **Educational Note:** If this question appeared in an exam exactly as phrased, it is likely a "distractor" or a "reverse" question. While Scaphoid, Lateral Condyle, and Femoral Neck are the *kings* of non-union, Colles' is the *king* of mal-union. Always check if the question intended to ask for "Mal-union."
Question 557: The management of fat embolism includes all of the following except?
- A. Oxygen
- B. Heparinization
- C. Low Molecular Weight Dextran
- D. Pulmonary Embolectomy (Correct Answer)
Explanation: **Explanation:** Fat Embolism Syndrome (FES) is a systemic inflammatory response to fat globules within the microvasculature, typically occurring 24–72 hours after long bone fractures (e.g., femur). The management is primarily **supportive**, as there is no definitive "clot" to surgically remove. **Why Pulmonary Embolectomy is the Correct Answer (The "Except"):** Pulmonary embolectomy is the treatment for **Acute Massive Pulmonary Thromboembolism** (blood clots), not fat embolism. In FES, the fat globules are microscopic and trigger a chemical pneumonitis and systemic inflammatory response syndrome (SIRS). Because the "emboli" are disseminated at the capillary level rather than a single large proximal obstruction, surgical removal is anatomically impossible and clinically ineffective. **Analysis of Other Options:** * **Oxygen (A):** This is the most critical step. Maintaining arterial oxygenation (often requiring high-flow $O_2$ or mechanical ventilation with PEEP) is the mainstay of treatment to combat ARDS-like lung injury. * **Heparinization (B):** Historically used to clear lipemia by stimulating lipoprotein lipase. While its routine use is now controversial due to bleeding risks, it remains a classic textbook "management option" for FES. * **Low Molecular Weight Dextran (C):** Used to improve microcirculation by decreasing blood viscosity and reducing the aggregation of red blood cells and fat globules. **NEET-PG High-Yield Pearls:** * **Gurd’s Criteria:** Used for diagnosis. Major signs include petechial rash (pathognomonic, usually on the chest/axilla), respiratory insufficiency, and cerebral involvement (confusion). * **Snowstorm Appearance:** Classic finding on Chest X-ray. * **Prevention:** The most effective way to prevent FES is **early stabilization/fixation** of the fracture. * **Steroids:** High-dose corticosteroids are sometimes used prophylactically in high-risk patients but are not standard for acute treatment.
Question 558: A Bennet's fracture is difficult to maintain in a reduced position because of the pull of which muscle?
- A. Extensor pollicis longus
- B. Extensor pollicis brevis
- C. Abductor pollicis longus (Correct Answer)
- D. Abductor pollicis brevis
Explanation: **Explanation:** A **Bennett’s fracture** is an intra-articular fracture-dislocation at the base of the first metacarpal. The fracture pattern involves a small triangular fragment (the "Bennett fragment") that remains attached to the trapezium by the strong anterior oblique ligament, while the rest of the metacarpal shaft is displaced. **Why Abductor Pollicis Longus (APL) is the correct answer:** The instability of this fracture is primarily due to the **Abductor Pollicis Longus (APL)** muscle. The APL inserts onto the base of the first metacarpal. When the fracture occurs, the APL pulls the metacarpal shaft in a **proximal, radial, and dorsal** direction. This constant muscular traction makes the fracture inherently unstable and difficult to maintain in a reduced position through casting alone, often necessitating surgical intervention (K-wire fixation). **Analysis of Incorrect Options:** * **Extensor Pollicis Longus (EPL):** While it acts on the thumb, it inserts on the distal phalanx. It contributes to the adduction deformity (via the adductor pollicis) but is not the primary force causing the proximal displacement of the metacarpal shaft. * **Extensor Pollicis Brevis (EPB):** Inserts on the base of the proximal phalanx; it does not exert a direct deforming pull on the first metacarpal base. * **Abductor Pollicis Brevis (APB):** This is an intrinsic muscle of the thenar eminence. While it may contribute to some rotation, it lacks the mechanical advantage and strength of the extrinsic APL to cause the characteristic displacement. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Axial loading on a partially flexed thumb (e.g., punching). * **Rolando Fracture:** A comminuted (T or Y shaped) intra-articular fracture at the base of the first metacarpal; carries a worse prognosis than Bennett’s. * **Deforming Forces in Bennett’s:** 1. **APL:** Proximal and dorsal displacement. 2. **Adductor Pollicis:** Pulls the shaft toward the palm (adduction). * **Treatment:** Usually requires **Closed Reduction and Internal Fixation (CRIF)** with Percutaneous K-wires.
Question 559: What is the recommended re-implantation time for a lower limb injury?
- A. 6 hours
- B. 4 hours
- C. 8 hours (Correct Answer)
- D. 10 hours
Explanation: **Explanation:** The success of re-implantation depends primarily on the **warm ischemia time**, which is the duration a body part remains without blood supply at room temperature. The correct answer is **8 hours** for the lower limb. **1. Why 8 hours is correct:** The lower limb contains large muscle masses (e.g., quadriceps, gastrocnemius). Skeletal muscle is highly sensitive to hypoxia and begins to undergo irreversible necrosis and autolysis after **6 to 8 hours** of warm ischemia. If re-implantation is attempted beyond this window, the risk of "Reperfusion Injury" and "Crush Syndrome" increases significantly, leading to systemic complications like metabolic acidosis, hyperkalemia, and acute renal failure (due to myoglobinuria). **2. Analysis of Incorrect Options:** * **4 & 6 hours (Options A & B):** While re-implantation within these timeframes offers the best prognosis, they are not the "upper limit" or the standard recommended cutoff. However, for major proximal amputations with massive muscle bulk, 6 hours is often considered the ideal limit. * **10 hours (Option D):** This exceeds the safe threshold for muscle survival. By 10 hours of warm ischemia, the muscle tissue is usually non-viable, making re-implantation dangerous due to the high risk of life-threatening systemic toxicity upon restoring blood flow. **Clinical Pearls for NEET-PG:** * **Warm vs. Cold Ischemia:** Cold ischemia (storing the part in a saline-soaked gauze, in a plastic bag, placed on ice) can extend the viability of the limb up to **12–24 hours**. * **Upper Limb vs. Lower Limb:** Upper limb re-implantation is more common and has a better prognosis. Lower limb re-implantation is often discouraged in adults if the injury is distal, as modern prosthetics often provide better functional outcomes than a sensate-deficient, shortened leg. * **Order of Repair:** The standard sequence is **Bone fixation → Extensor tendons → Flexor tendons → Arteries → Nerves → Veins** (Mnemonic: **BE FAN**V).
Question 560: What is the management for the depicted condition?
- A. Closed reduction
- B. Cast immobilization
- C. External fixation
- D. Internal fixation with compression plating (Correct Answer)
Explanation: ***Internal fixation with compression plating*** - **Both-bone forearm fractures** require anatomical reduction to restore the **radial bow** and maintain proper **radioulnar relationship** for forearm rotation. - **Dynamic compression plating** provides rigid fixation allowing early mobilization and optimal functional outcomes in displaced diaphyseal fractures. *Closed reduction* - Inadequate for **displaced both-bone fractures** as it cannot maintain anatomical alignment and **radial bow**. - High risk of **loss of reduction** and malunion leading to **restricted forearm rotation** and functional impairment. *Cast immobilization* - Cannot maintain reduction in **unstable diaphyseal fractures** of both radius and ulna. - Risk of **compartment syndrome** from swelling within the cast and poor functional outcomes due to malunion. *External fixation* - Reserved for **open fractures** with severe soft tissue damage or **infected nonunions**. - Does not provide adequate **rotational control** and anatomical restoration required for optimal forearm function.
Practice by Chapter
Principles of Fracture Management
Practice Questions
Upper Limb Fractures
Practice Questions
Lower Limb Fractures
Practice Questions
Spinal Trauma
Practice Questions
Pelvic and Acetabular Fractures
Practice Questions
Open Fractures
Practice Questions
Fractures in Children
Practice Questions
Fracture Complications
Practice Questions
Nonunion and Malunion
Practice Questions
Polytrauma Management
Practice Questions
Joint Dislocations
Practice Questions
Soft Tissue Injuries
Practice Questions
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