Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 571: Functional cast bracing is NOT used in which of the following fractures?

A. Humerus
B. Tibia
C. Ulna
D. Thoracolumbar spine (Correct Answer)

Explanation: **Explanation:** **Functional Cast Bracing (Sarmiento Bracing)** is based on the principle of **hydrostatic pressure**. It uses the surrounding soft tissues and muscle bulk to stabilize a fracture while allowing early joint movement. This promotes osteogenesis and prevents "fracture disease" (joint stiffness and muscle atrophy). **Why Thoracolumbar Spine is the Correct Answer:** Functional cast bracing is specifically designed for **long bone fractures** where the surrounding muscle envelope can be compressed to provide stability. The **Thoracolumbar spine** lacks this circumferential muscle envelope required for hydrostatic stabilization. Spinal fractures require rigid immobilization (like a Taylor’s brace or ASH brace) or surgical stabilization to protect the spinal cord, as functional bracing would allow micro-motion that is dangerous in the axial skeleton. **Analysis of Other Options:** * **Humerus (A):** The Sarmiento brace is the gold standard for non-operative management of mid-shaft humeral fractures. It relies on the deltoid and triceps bulk. * **Tibia (B):** Functional bracing is commonly used for distal third tibial fractures after initial swelling subsides, allowing knee and ankle motion. * **Ulna (C):** Isolated ulnar shaft fractures (Nightstick fractures) are frequently treated with functional bracing as the radius acts as a natural splint. **High-Yield Clinical Pearls for NEET-PG:** * **Founder:** Augusto Sarmiento. * **Mechanism:** Hydrostatic pressure in soft tissues. * **Prerequisite:** The fracture must be **stable** and have **intact soft tissue** (muscle) coverage. * **Contraindications:** Massive soft tissue loss, unstable joints, or fractures requiring rigid internal fixation (e.g., intra-articular fractures).

Question 572: Which of the following is true about Colles' fracture?

A. Intra-articular fracture of the distal radius with palmar displacement
B. Intra-articular fracture of the distal radius with dorsal displacement
C. Extra-articular fracture of the distal radius with palmar displacement
D. Extra-articular fracture of the distal radius with dorsal displacement (Correct Answer)

Explanation: **Explanation:** **Colles’ fracture** is the most common fracture of the distal radius, typically occurring in elderly patients following a fall on an outstretched hand (FOOSH). 1. **Why Option D is correct:** By definition, a classic Colles’ fracture is an **extra-articular** fracture (the fracture line does not involve the joint surface) occurring approximately 2.5 cm proximal to the radio-carpal joint. The characteristic deformity is caused by **dorsal displacement** and dorsal tilt of the distal fragment, often accompanied by lateral tilt and impaction. 2. **Why other options are incorrect:** * **Option A & B:** These are incorrect because Colles' is primarily extra-articular. If a distal radius fracture is intra-articular with displacement, it is classified as a **Barton’s fracture** (Dorsal or Volar). * **Option C:** An extra-articular fracture with **palmar (volar) displacement** is known as a **Smith’s fracture** (also called a "Reverse Colles’"). **High-Yield NEET-PG Pearls:** * **Deformity:** Classically described as the **"Dinner Fork Deformity"** due to the dorsal prominence. * **Components of Displacement:** There are six—Dorsal displacement, Dorsal tilt, Lateral displacement, Lateral tilt, Impaction, and Supination. * **Most Common Complication:** Stiffness of the fingers and shoulder (due to immobilization). * **Most Common Late Complication:** Malunion (leading to cosmetic deformity). * **Specific Nerve Injury:** Median nerve compression (Carpal Tunnel Syndrome) can occur acutely or chronically. * **Tendon Rupture:** Spontaneous rupture of the **Extensor Pollicis Longus (EPL)** can occur weeks later due to ischemia or attrition.

Question 573: In Volkmann's contracture, which artery is injured?

A. Radial artery
B. Brachial artery (Correct Answer)
C. Ulnar artery
D. Subclavian artery

Explanation: **Explanation:** **Volkmann’s Ischemic Contracture (VIC)** is the permanent flexion deformity of the wrist and fingers resulting from untreated **Compartment Syndrome**, most commonly following a **Supracondylar fracture of the humerus** in children. The **Brachial artery** is the primary vessel involved. It can be injured via direct laceration by the proximal bone fragment, kinking, or, most frequently, by intense vasospasm triggered by the injury. This arterial compromise leads to ischemia of the muscles in the deep flexor compartment of the forearm (specifically the *Flexor Digitorum Profundus* and *Flexor Pollicis Longus*). If ischemia persists for more than 6–8 hours, muscle necrosis occurs, followed by fibrosis and shortening, leading to the characteristic "claw-like" deformity. **Analysis of Incorrect Options:** * **Radial and Ulnar Arteries:** These are terminal branches of the brachial artery. While they may be affected by increased compartmental pressure in the forearm, the primary inciting event in the classic Supracondylar fracture scenario is proximal to their bifurcation, involving the Brachial artery. * **Subclavian Artery:** This artery is located much more proximally (near the clavicle and first rib). Injuries here would cause global limb ischemia rather than the localized forearm compartment syndrome seen in VIC. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** Severe pain on passive extension of fingers. * **Most Sensitive Sign:** Pain out of proportion to the injury. * **Nerve Involved:** The **Median nerve** is the most commonly affected nerve in the forearm compartment. * **Infarct Shape:** The necrotic area typically takes an **ellipsoid shape** (Volkmann’s Ischemic Ellipsoid) at the level of the mid-forearm. * **Treatment:** Immediate removal of tight bandages/casts; if no improvement, urgent **Fasciotomy** is required.

Question 574: Finkelstein's test is positive in which of the following conditions?

A. Perilunate dislocation
B. Scaphoid fracture
C. Dislocation of shoulder
D. De Quervain's tenosynovitis (Correct Answer)

Explanation: **Explanation:** **De Quervain’s Tenosynovitis (Correct Answer):** This condition involves stenosing tenosynovitis of the **first dorsal compartment** of the wrist, affecting the **Abductor Pollicis Longus (APL)** and **Extensor Pollicis Brevis (EPB)** tendons. **Finkelstein’s test** is the pathognomonic clinical maneuver used for diagnosis. It is performed by having the patient deviate the wrist ulnarly while the thumb is flexed and tucked into the palm (clenched fist). A positive test elicits sharp pain over the radial styloid process due to the stretching of the inflamed tendons. **Analysis of Incorrect Options:** * **Perilunate Dislocation:** This is a severe carpal injury involving the disruption of the ligamentous complex around the lunate. Diagnosis is made via X-ray (showing the "spilled teacup" sign) rather than provocative tendon tests. * **Scaphoid Fracture:** While this also presents with radial-sided wrist pain, the hallmark clinical sign is tenderness in the **Anatomical Snuffbox**. Finkelstein’s test does not specifically diagnose bony fractures. * **Dislocation of Shoulder:** This is assessed using tests like the **Apprehension test**, Dugas test, or Hamilton Ruler test. It involves the glenohumeral joint, not the wrist tendons. **High-Yield Clinical Pearls for NEET-PG:** * **Anatomy:** The first dorsal compartment contains APL and EPB. * **Demographics:** Most common in middle-aged women and "new mothers" (due to repetitive lifting of the infant). * **Management:** Initial treatment is conservative (rest, thumb spica splint, NSAIDs, or steroid injection). Surgical release of the first dorsal compartment is reserved for refractory cases. * **Differential:** Do not confuse with **Intersection Syndrome**, which involves pain more proximal and dorsal in the forearm.

Question 575: Which of the following statements regarding fracture of the clavicle is true?

A. The most common complication is malunion. (Correct Answer)
B. It occurs at the junction of the medial third and lateral two-thirds.
C. It usually occurs due to a fall on the elbow.
D. Comminuted fracture is common.

Explanation: **Explanation:** **1. Why Option A is Correct:** Malunion is the most common complication of clavicle fractures. Because the clavicle acts as a strut between the sternum and the acromion, the weight of the arm (pulling the lateral fragment down) and the pull of the sternocleidomastoid muscle (pulling the medial fragment up) often lead to healing with a slight overlap or angulation. While this rarely affects functional outcomes, it is the most frequent sequela. Note: Non-union is rare, and neurovascular injury is even rarer due to the protection provided by the subclavius muscle. **2. Why Other Options are Incorrect:** * **Option B:** The most common site of fracture is the junction of the **medial two-thirds and the lateral one-third**. This is the weakest point of the bone where the curvature changes and the cross-section transitions from cylindrical to flattened. * **Option C:** The most common mechanism of injury is a **fall on an outstretched hand (FOOSH)** or a direct blow to the shoulder. A fall on the elbow is less common. * **Option D:** Clavicle fractures are typically **undisplaced or simple** (greenstick in children). Comminuted fractures are less common and usually occur only in high-energy trauma. **High-Yield Clinical Pearls for NEET-PG:** * **Most common bone to fracture** in the human body and during birth (obstetric injury). * **First bone to ossify** in the fetus (5th–6th week) and the only long bone to ossify in **membrane** (except the ends). * **Management:** Most are treated conservatively with a **Figure-of-eight bandage** or a triangular sling. Surgery (ORIF) is reserved for skin tenting, neurovascular compromise, or extreme shortening (>2cm). * **Subclavius muscle** acts as a cushion, protecting the underlying subclavian vessels and brachial plexus from bone fragments.

Question 576: Gun stock deformity is seen in?

A. Supracondylar fracture humerus (Correct Answer)
B. Lateral condylar fracture of humerus
C. Medial condylar fracture of humerus
D. All of the above

Explanation: **Explanation:** **Gun stock deformity** (also known as **Cubitus Varus**) is the most common late complication of a **Supracondylar fracture of the humerus**, particularly when the fracture is displaced or inadequately reduced. ### Why Supracondylar Fracture is Correct: The deformity occurs due to the **malunion** of the distal humerus fragment. Specifically, it results from a combination of **medial tilt, medial rotation, and posterior displacement** of the distal fragment. This leads to a decrease in the normal carrying angle of the elbow (which is usually 5-15° of valgus), causing the forearm to deviate toward the midline, resembling the stock of a gun. While it is primarily a cosmetic deformity, it rarely affects the functional range of motion. ### Why Other Options are Incorrect: * **Lateral Condylar Fracture:** This injury is more commonly associated with **Cubitus Valgus** (an increase in the carrying angle) due to non-union or growth arrest of the lateral physis. Cubitus valgus can lead to a "Tardy Ulnar Nerve Palsy." * **Medial Condylar Fracture:** While rare, these are more likely to cause cubitus varus if there is a growth arrest, but they are not the classic or most frequent cause associated with the term "Gun stock deformity" in clinical exams. ### High-Yield Clinical Pearls for NEET-PG: * **Most common complication:** Stiffness (overall); **Most common deformity:** Cubitus Varus. * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to brachial artery injury or compartment syndrome. * **Nerve most commonly involved:** Median nerve (specifically the Anterior Interosseous Nerve - AIN) in extension-type fractures; however, the Radial nerve is also frequently cited. * **Treatment of choice for Cubitus Varus:** French Osteotomy (Modified step-cut osteotomy).

Question 577: The commonest nerve injury associated with a Monteggia fracture is?

A. Median nerve
B. Ulnar nerve (Correct Answer)
C. Radial nerve
D. Musculocutaneous nerve

Explanation: **Explanation:** A **Monteggia fracture-dislocation** is defined as a fracture of the proximal third of the ulna associated with a dislocation of the radial head. 1. **Why Ulnar Nerve is Correct:** While the Posterior Interosseous Nerve (PIN) is frequently cited in general literature as a common complication, standard orthopedic textbooks and NEET-PG patterns often highlight the **Ulnar nerve** as the most commonly injured nerve in Monteggia fractures. This is due to the direct trauma or traction applied to the nerve as it passes along the medial aspect of the fractured proximal ulna. 2. **Why Incorrect Options are Wrong:** * **Radial Nerve:** While the Radial nerve (specifically the PIN branch) is the second most common injury due to the radial head dislocation, it is statistically less frequent than ulnar involvement in many clinical series. * **Median Nerve:** This nerve is located anteriorly and is more commonly associated with supracondylar fractures of the humerus or lunate dislocations, rather than proximal ulnar fractures. * **Musculocutaneous Nerve:** This nerve terminates as the lateral cutaneous nerve of the forearm and is rarely involved in forearm shaft fractures. **High-Yield Clinical Pearls for NEET-PG:** * **Bado Classification:** Used to categorize Monteggia fractures based on the direction of radial head dislocation (Type I is most common: Anterior dislocation). * **Galeazzi Fracture:** The "inverse" of Monteggia—fracture of the distal third of the radius with dislocation of the distal radioulnar joint (DRUJ). * **Mnemonic (MUGR):** **M**onteggia = **U**lna fracture; **G**aleazzi = **R**adius fracture. * **Management:** In adults, these require Open Reduction and Internal Fixation (ORIF) because they are unstable "joint-fractures."

Question 578: Complications of elbow dislocation are all EXCEPT:

A. Vascular injury
B. Median nerve injury
C. Myositis ossificans
D. Volkmann's ischemic contracture (Correct Answer)

Explanation: **Explanation:** The question asks for the complication that is **NOT** typically associated with elbow dislocation. While elbow dislocations are serious injuries, **Volkmann’s Ischemic Contracture (VIC)** is classically a late sequela of **Supracondylar fractures of the humerus** (due to brachial artery injury or compartment syndrome), rather than simple elbow dislocations. **Why Option D is the correct answer:** Volkmann’s Ischemic Contracture is the end-stage result of untreated compartment syndrome. While vascular compromise can occur in dislocations, the mechanical obstruction or arterial spasm required to produce the full-blown ischemic contracture is overwhelmingly linked to pediatric supracondylar fractures. In the context of "all except" questions in NEET-PG, VIC is the "most distal" or least common primary complication compared to the others listed. **Analysis of Incorrect Options:** * **Vascular Injury (A):** The **Brachial artery** is at high risk during posterior dislocations as it gets stretched over the displaced distal humerus. * **Median Nerve Injury (B):** Along with the Ulnar nerve, the Median nerve is frequently tethered or compressed during the displacement of the radius and ulna. * **Myositis Ossificans (C):** This is a **very common** complication of elbow trauma. It is often exacerbated by forceful passive stretching or massage following the reduction of a dislocation. **Clinical Pearls for NEET-PG:** * **Most common type:** Posterior/Posterolateral dislocation is the most frequent. * **Terrible Triad of Elbow:** Elbow dislocation + Coronoid fracture + Radial head fracture. * **Management:** Emergency closed reduction under sedation followed by brief immobilization (not exceeding 3 weeks to avoid stiffness). * **Rule of Thumb:** If a question asks for the most common complication of elbow dislocation, the answer is **Stiffness** (decreased range of motion).

Question 579: Which cervical vertebrae are most commonly fractured in an "Undeaker's fracture"?

A. C2-3
B. C3-4
C. C5-6
D. C6-7 (Correct Answer)

Explanation: **Explanation:** The term **"Undertaker’s Fracture"** refers to a fracture-dislocation of the lower cervical spine, specifically occurring at the **C6-C7 level**. **1. Why C6-C7 is the Correct Answer:** This injury is classically described in the context of forensic pathology. It occurs post-mortem when a body is handled roughly or placed into a coffin. Due to the onset of rigor mortis, the neck becomes stiff; if the head is forcibly extended to fit the body into a casket, the lower cervical spine—which acts as a fulcrum between the mobile upper neck and the rigid thoracic spine—snaps. The C6-C7 junction is the most common site for this mechanical failure due to the transition in spinal mobility. **2. Analysis of Incorrect Options:** * **C2-C3 (Option A):** This level is associated with a **Hangman’s Fracture** (traumatic spondylolisthesis of C2), typically caused by hyperextension and distraction. * **C3-C4 & C5-C6 (Options B & C):** While C5-C6 is a very common site for traumatic subluxation in living patients due to high mobility, it is not the classic site described for the "Undertaker’s" eponymous injury. **3. High-Yield Clinical Pearls for NEET-PG:** * **Clay Shoveler’s Fracture:** An avulsion fracture of the spinous process of **C7** (most common) or C6, caused by abrupt rotation of the trunk. * **Jefferson Fracture:** A burst fracture of the **C1** ring (atlas). * **Hangman’s Fracture:** Fracture through the pars interarticularis of **C2**. * **Mechanism Check:** Remember that Undertaker’s fracture is a **post-mortem** injury, unlike most other cervical fractures discussed in orthopaedics.

Question 580: Wrist drop is seen with which of the following conditions?

A. Radial nerve palsy (Correct Answer)
B. Median nerve palsy
C. Ulnar nerve palsy
D. Posterior interosseous nerve palsy

Explanation: **Explanation:** **1. Why Radial Nerve Palsy is Correct:** The radial nerve (C5-T1) is the primary motor supply to the extensors of the forearm. It innervates the **Extensor Carpi Radialis Longus (ECRL)** and **Brevis (ECRB)**, which are essential for extending the wrist. When the radial nerve is injured (commonly due to a humerus shaft fracture or "Saturday Night Palsy"), these muscles are paralyzed. The inability to oppose the flexor muscles results in the hand hanging in a flexed position, clinically known as **Wrist Drop**. **2. Analysis of Incorrect Options:** * **Median Nerve Palsy:** Leads to **"Ape Thumb Deformity"** (loss of thumb opposition) and "Pointing Index" (Ochsner’s clasping test). It affects the flexors of the wrist, not the extensors. * **Ulnar Nerve Palsy:** Characterized by **"Claw Hand"** (hyperextension at MCP joints and flexion at IP joints) due to paralysis of the intrinsic hand muscles. * **Posterior Interosseous Nerve (PIN) Palsy:** This is a branch of the radial nerve. While it causes **Finger Drop** (paralysis of finger extensors), it typically **spares the ECRL**, allowing the patient to still extend the wrist (often with radial deviation). Therefore, a true "Wrist Drop" is not seen in isolated PIN palsy. **Clinical Pearls for NEET-PG:** * **High-yield associations:** Radial nerve injury is most common in **Humerus shaft fractures** (Holstein-Lewis fracture). * **Sensory loss:** In radial nerve palsy, sensory loss is typically noted over the **first dorsal web space**. * **Tendon Transfer:** The standard surgery for permanent radial nerve palsy is **Jones Transfer**. * **Rule of thumb:** If the patient can extend the elbow but has a wrist drop, the lesion is distal to the spiral groove.

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Upper Limb Fractures

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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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Joint Dislocations

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Trauma — MCQs

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