Trauma — MCQs

A 24-year-old male reports that during a basketball game, he tripped while driving the ball to the basket and fell on his outstretched right hand with the palm down. Three days later, the patient presented with right wrist pain. On examination, the wrist was slightly swollen and tender but without deformity. The doctor instructed the patient to extend the right thumb, thereby accentuating the anatomical "snuffbox," which is extremely tender to deep palpation. An X-ray of the wrist was advised. What is the most likely injured part?

Q603Easy

Hanging cast is used in the management of:

Q604Medium

A young college student injures his left knee while playing football and is unable to bear weight. The provisional X-ray report indicates that there are no fractures seen. He presents the next morning to the emergency department with a severely swollen, painful left knee and severe pain in the foot. On examination, the foot is pale, cold, and pulseless. What is the most likely diagnosis?

Q605Easy

A tripod fracture is also known as a malar fracture. Which facial bone is most commonly fractured in a tripod fracture?

Q606Easy

Which of the following is NOT an intra-articular fracture?

Q607Easy

What is the most common complication of a Colles fracture?

Q608Easy

Which of the following is true about fat embolism?

Q609Medium

A patient presents with a tibia fracture and swelling of the lower leg. The pulse is feeble but palpable, and intracompartmental pressure is elevated. What is the next step in management?

Q610Medium

A 50-year-old man sustained posterior dislocation of his left hip in an accident. The dislocation was reduced after 3 days. Six months later, he began complaining of pain in his left hip. X-rays of the pelvis were normal. What is the most relevant investigation at this stage?

Trauma Indian Medical PG Practice Questions and MCQs

Question 601: The Drawer test is used for assessing damage to which of the following?

A. Meniscus
B. Cruciate ligament (Correct Answer)
C. Collateral ligament
D. Articular cartilage

Explanation: The **Drawer test** is a clinical examination used to assess the stability of the knee joint, specifically targeting the **Cruciate ligaments**. The test relies on the anatomical function of these ligaments in preventing excessive anteroposterior translation of the tibia relative to the femur. ### Why the Correct Answer is Right: * **Anterior Drawer Test:** With the knee flexed at 90°, the examiner pulls the tibia forward. Excessive forward displacement indicates a tear of the **Anterior Cruciate Ligament (ACL)**. * **Posterior Drawer Test:** The examiner pushes the tibia backward. Excessive posterior displacement indicates a tear of the **Posterior Cruciate Ligament (PCL)**. ### Why Other Options are Incorrect: * **Meniscus:** Injuries to the menisci (medial/lateral) are typically assessed using the **McMurray test**, **Apley’s Grind test**, or **Steinmann test**. * **Collateral Ligament:** Stability of the Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) is assessed using **Valgus and Varus stress tests**, respectively. * **Articular Cartilage:** Damage to the joint surface (e.g., chondromalacia patellae) is often evaluated via the **Patellar Grind (Clarke’s) test** or imaging like MRI. ### NEET-PG High-Yield Pearls: * **Lachman Test:** This is the **most sensitive** clinical test for an acute ACL tear (performed at 20-30° flexion). * **Pivot Shift Test:** This is the **most specific** test for ACL deficiency, indicating anterolateral rotatory instability. * **Sag Sign:** Also known as the Godfrey’s test, it is a classic sign of a PCL injury where the tibia "sags" posteriorly due to gravity.

Question 602: A 24-year-old male reports that during a basketball game, he tripped while driving the ball to the basket and fell on his outstretched right hand with the palm down. Three days later, the patient presented with right wrist pain. On examination, the wrist was slightly swollen and tender but without deformity. The doctor instructed the patient to extend the right thumb, thereby accentuating the anatomical "snuffbox," which is extremely tender to deep palpation. An X-ray of the wrist was advised. What is the most likely injured part?

A. Scaphoid (Correct Answer)
B. Radius
C. Ulna
D. Lunate

Explanation: **Explanation:** The clinical presentation is a classic case of a **Scaphoid fracture**, the most common carpal bone fracture. **1. Why Scaphoid is correct:** The mechanism of injury—falling on an outstretched hand (FOOSH) with the wrist in extension—puts maximum stress on the scaphoid. The hallmark clinical sign is **tenderness in the anatomical snuffbox**, which is bounded medially by the extensor pollicis longus (EPL) and laterally by the abductor pollicis longus (APL) and extensor pollicis brevis (EPB). Tenderness here, even with a normal initial X-ray, must be treated as a scaphoid fracture until proven otherwise. **2. Why other options are incorrect:** * **Radius:** A distal radius fracture (e.g., Colles’ fracture) typically presents with a visible "dinner fork" deformity and tenderness over the radial metaphysis, not localized to the snuffbox. * **Ulna:** Isolated ulnar fractures are rare in FOOSH injuries and would present with medial (ulnar) side pain. * **Lunate:** Lunate injuries usually present with tenderness over the dorsum of the wrist (distal to Lister’s tubercle) and are often associated with carpal instability or dislocations rather than snuffbox tenderness. **Clinical Pearls for NEET-PG:** * **Blood Supply:** The scaphoid has a **retrograde blood supply** (entering via the distal pole). Therefore, fractures at the **waist** or **proximal pole** carry a high risk of **Avascular Necrosis (AVN)** and non-union. * **Radiology:** Initial X-rays may be negative in 10-20% of cases. If clinical suspicion persists, the wrist should be immobilized in a **thumb spica cast** and re-X-rayed after 10–14 days. * **Gold Standard:** MRI is the most sensitive investigation for detecting occult scaphoid fractures early.

Question 603: Hanging cast is used in the management of:

A. Colles' fracture
B. Humeral shaft fracture (Correct Answer)
C. Fracture both bones of the forearm
D. Fracture olecranon

Explanation: **Explanation:** The **Hanging Cast** is a classic conservative management technique specifically designed for **displaced fractures of the humeral shaft**, particularly those with shortening or angulation. **Why it is correct:** The primary mechanism of the hanging cast is **gravity-assisted traction**. The weight of the cast, applied from the level of the axilla to the wrist with the elbow flexed at 90°, exerts a continuous downward pull on the distal fragment. This overcomes the muscle spasm (primarily the deltoid and biceps) that causes shortening, thereby maintaining alignment and length. It is most effective for oblique or spiral fractures of the middle third of the humerus. **Why other options are incorrect:** * **Colles' fracture:** Managed with a Colles' cast (below-elbow) in slight palmar flexion and ulnar deviation. Gravity traction is not required here. * **Fracture both bones forearm:** Requires a long arm cast (above-elbow) to prevent rotation (supination/pronation). A hanging cast would provide unnecessary traction and fail to stabilize the radio-ulnar relationship. * **Fracture olecranon:** Usually requires surgical fixation (Tension Band Wiring) or a posterior splint. A hanging cast would put undue stress on the triceps pull. **Clinical Pearls for NEET-PG:** * **Positioning:** The patient must remain **upright or semi-reclining** (even while sleeping) for the traction to remain effective. * **Adjustment:** Angulation can be corrected by adjusting the **length of the neck sling**: * Shorten the sling to correct **lateral** (valgus) angulation. * Lengthen the sling to correct **medial** (varus) angulation. * **Contraindication:** It should not be used in transverse fractures (risk of distraction/non-union) or in patients who cannot remain upright.

Question 604: A young college student injures his left knee while playing football and is unable to bear weight. The provisional X-ray report indicates that there are no fractures seen. He presents the next morning to the emergency department with a severely swollen, painful left knee and severe pain in the foot. On examination, the foot is pale, cold, and pulseless. What is the most likely diagnosis?

A. Traumatic deep vein thrombosis
B. Gastrocnemius muscle tear
C. Traumatic arteriovenous fistula
D. Posterior knee dislocation with thrombosed popliteal artery (Correct Answer)

Explanation: ### Explanation **1. Why Option D is Correct:** The clinical presentation of a high-energy knee injury followed by a **"pale, cold, and pulseless"** foot is a classic triad indicating **acute limb ischemia**. In the context of a knee injury without a fracture, the most critical diagnosis to rule out is a **knee dislocation**. Even if the knee has spontaneously reduced (explaining why X-rays might appear normal), the popliteal artery is tethered at the adductor hiatus and the soleal arch, making it highly susceptible to intimal tears or thrombosis during the displacement. The severe swelling and inability to bear weight further support a major ligamentous disruption (dislocation). **2. Why Other Options are Incorrect:** * **A. Traumatic DVT:** DVT typically presents with a warm, swollen, and cyanotic limb (phlegmasia), not a cold, pale, and pulseless one. It does not cause an acute loss of arterial pulses. * **B. Gastrocnemius muscle tear:** While common in sports, this causes localized calf pain and swelling. It would not result in global foot ischemia or loss of distal pulses. * **C. Traumatic AV Fistula:** This usually presents chronically with a thrill, bruit, or venous insufficiency. It does not cause acute, limb-threatening ischemia immediately following trauma. **3. Clinical Pearls for NEET-PG:** * **"The Knee that Reduced":** Always suspect a knee dislocation in high-energy trauma even if X-rays are normal; 50% reduce spontaneously before reaching the ER. * **Popliteal Artery:** It is the most commonly injured artery in knee dislocations (up to 40% of cases). * **Management Priority:** If pulses are absent, the next step is urgent surgical exploration or CT Angiography. The "Golden Period" for revascularization is **6 hours** to prevent amputation. * **Peroneal Nerve:** The most common nerve injured in knee dislocations (leads to foot drop).

Question 605: A tripod fracture is also known as a malar fracture. Which facial bone is most commonly fractured in a tripod fracture?

A. Mandible
B. Maxilla
C. Nasal bone
D. Zygoma (Correct Answer)

Explanation: **Explanation:** A **Tripod Fracture**, also known as a **Zygomaticomaxillary Complex (ZMC) fracture**, involves the separation of the zygoma from its three primary attachments. The **Zygoma (Option D)** is the correct answer because it is the central bone involved in this injury pattern. The term "tripod" refers to the three fracture lines typically seen: 1. **Zygomaticofrontal suture** (superiorly) 2. **Zygomaticotemporal suture** (laterally/Zygomatic arch) 3. **Infraorbital rim and Zygomaticomaxillary suture** (medially) **Why other options are incorrect:** * **Mandible (A):** While the mandible is the most common facial bone fractured overall (excluding the nose), it is not part of the ZMC complex. * **Maxilla (B):** Although the fracture line extends into the maxilla (infraorbital rim), the primary bone displaced and defining the "tripod" configuration is the zygoma. Maxillary fractures are typically classified under the Le Fort system. * **Nasal bone (C):** This is the most frequently fractured bone in the face due to its prominent position, but it is not involved in a ZMC/Tripod fracture. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Patients often present with flattening of the cheek (loss of malar prominence), subconjunctival hemorrhage, and **infraorbital nerve anesthesia** (numbness of the upper lip/cheek). * **Trismus:** Difficulty opening the mouth may occur if the zygomatic arch impinges on the coronoid process of the mandible. * **Imaging:** The **Water’s View** (Occipitomental projection) is the classic X-ray used to visualize ZMC fractures, though CT is the gold standard. * **Diplopia:** May occur due to entrapment of the inferior rectus muscle if the orbital floor is involved.

Question 606: Which of the following is NOT an intra-articular fracture?

A. Rolando fracture
B. March fracture (Correct Answer)
C. Bennett's fracture
D. Baon's fracture

Explanation: **Explanation:** The core concept tested here is the anatomical location of specific fractures relative to the joint capsule. An **intra-articular fracture** is one where the fracture line extends into the joint surface, often leading to long-term complications like post-traumatic osteoarthritis if not perfectly reduced. **Why March Fracture is the correct answer:** A **March fracture** is a stress fracture of the metatarsal shaft (most commonly the 2nd or 3rd metatarsal). It occurs due to repetitive microtrauma, typically in military recruits or long-distance hikers. Because it involves the **diaphysis (shaft)** of the bone and does not involve the joint surface, it is an extra-articular fracture. **Analysis of incorrect options:** * **Bennett’s Fracture:** This is an oblique, **intra-articular** fracture at the base of the 1st metacarpal. It involves a single volar lip fragment that remains attached to the anterior oblique ligament. * **Rolando Fracture:** This is a comminuted (T or Y-shaped), **intra-articular** fracture at the base of the 1st metacarpal. It is essentially a more complex version of Bennett's fracture and carries a worse prognosis. * **Barton’s Fracture:** This is an **intra-articular** fracture-dislocation of the distal radius involving the dorsal or volar rim. It must be distinguished from Colles' or Smith's fractures, which are extra-articular. **Clinical Pearls for NEET-PG:** * **Bennett vs. Rolando:** Both occur at the base of the thumb; Bennett is 2-part (simple), Rolando is 3-part or more (comminuted). * **March Fracture Diagnosis:** Initial X-rays are often negative; a bone scan or MRI is more sensitive in early stages. Callus formation on X-ray after 2–3 weeks is a classic finding. * **Management:** Intra-articular fractures (Bennett, Rolando, Barton) usually require **ORIF** (Open Reduction Internal Fixation) to restore joint congruicity, whereas March fractures are managed conservatively with rest.

Question 607: What is the most common complication of a Colles fracture?

A. Stiffness of fingers (Correct Answer)
B. Malunion
C. Sudeck's osteodystrophy
D. Rupture of EPL tendon

Explanation: **Explanation:** **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 Fingers is the Correct Answer:** Stiffness of the fingers and shoulder is the **most common complication** of a Colles fracture. This occurs primarily due to prolonged immobilization in a plaster cast and the patient’s reluctance to move the fingers during the healing phase. Edema and lack of muscle pump action lead to adhesions around the small joints of the hand. Early mobilization of the fingers is the most critical step in preventing this complication. **2. Analysis of Incorrect Options:** * **B. Malunion:** This is the **most common late complication** of Colles fracture, often resulting in a "dinner fork deformity." While frequent, finger stiffness remains the most prevalent clinical issue affecting functional outcomes. * **C. Sudeck’s Osteodystrophy (CRPS Type 1):** This is a serious complication characterized by pain, swelling, and vasomotor instability. While it is a classic association with Colles fracture, it is not as common as simple joint stiffness. * **D. Rupture of EPL Tendon:** This is a **delayed complication** (usually occurring 4–8 weeks post-injury) caused by ischemia or attrition of the Extensor Pollicis Longus tendon at Lister’s tubercle. It is relatively rare. **Clinical Pearls for NEET-PG:** * **Most common complication:** Stiffness of fingers/shoulder. * **Most common late complication:** Malunion. * **Most common nerve involved:** Median nerve (Carpal Tunnel Syndrome). * **Treatment of choice:** Closed reduction and below-elbow cast (Colles cast). * **Deformities in Colles:** Dorsal tilt, Lateral tilt, Supination, Impaction, and Radial deviation.

Question 608: Which of the following is true about fat embolism?

A. Usually ensues after fracture of the lower limb (Correct Answer)
B. An uncommon complication of fracture
C. A spontaneously reversible process
D. All of the above

Explanation: **Explanation:** **Fat Embolism Syndrome (FES)** is a clinical diagnosis characterized by the systemic release of fat globules into the circulation. 1. **Why Option A is Correct:** Fat embolism most commonly follows fractures of **long bones**, particularly the **femur and tibia** (lower limbs), and the pelvis. These bones contain large amounts of fatty yellow marrow. Trauma disrupts the intramedullary pressure, forcing fat droplets into the venous sinusoids. 2. **Why Option B is Incorrect:** While subclinical fat embolism occurs in nearly 90% of all major fractures, the clinical *syndrome* (FES) is a **common and serious complication** rather than an "uncommon" one in the context of high-energy trauma. It is a leading cause of morbidity in orthopedic patients. 3. **Why Option C is Incorrect:** FES is **not** a spontaneously reversible process in the sense of being benign. It is a potentially fatal condition (mortality rate 5-15%) that requires aggressive supportive care, including oxygenation and often mechanical ventilation. It does not simply "resolve" without clinical monitoring. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis. Major criteria include **Respiratory insufficiency** (hypoxemia), **Cerebral involvement** (confusion/coma), and **Petechial rash** (typically over the chest, axilla, and conjunctiva). * **Latent Period:** Symptoms typically appear **24–72 hours** after the injury. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Treatment:** Primarily **supportive** (Maintenance of PaO2). Early stabilization/fixation of the fracture is the best preventive measure.

Question 609: A patient presents with a tibia fracture and swelling of the lower leg. The pulse is feeble but palpable, and intracompartmental pressure is elevated. What is the next step in management?

A. Fasciotomy (Correct Answer)
B. External fixation
C. Lower limb venography
D. Interlocking nail

Explanation: ### Explanation The patient is presenting with classic signs of **Acute Compartment Syndrome (ACS)**, a surgical emergency common in tibial fractures. The presence of elevated intracompartmental pressure and swelling, even with a palpable pulse, confirms the diagnosis. **1. Why Fasciotomy is the Correct Answer:** The definitive treatment for ACS is an **emergency fasciotomy**. The underlying pathophysiology involves increased pressure within an osteofascial compartment, which compromises capillary perfusion. This leads to muscle and nerve ischemia. Since the pressure required to occlude a major artery is much higher than that required to stop capillary flow, **distal pulses are often still palpable** in early or mid-stage compartment syndrome. Waiting for the pulse to disappear (a late sign) often results in irreversible necrosis. **2. Why the Other Options are Incorrect:** * **External fixation (B) & Interlocking nail (D):** While these are methods to stabilize a tibia fracture, they do not address the immediate life-and-limb-threatening pressure. In fact, internal fixation (nailing) can further increase compartment pressure. Stabilization should only occur *after* or during the fasciotomy. * **Lower limb venography (C):** This is used to diagnose Deep Vein Thrombosis (DVT). While DVT causes swelling, it does not present with elevated intracompartmental pressure or the acute "pain out of proportion" characteristic of ACS. **3. NEET-PG High-Yield Pearls:** * **Earliest Clinical Sign:** Pain out of proportion to the injury and pain on passive stretching of muscles. * **Most Common Site:** Deep posterior compartment of the leg (often associated with tibia fractures). * **Pressure Threshold:** A delta pressure ($\Delta P$) of **$\leq$ 30 mmHg** (Diastolic BP minus Intracompartmental pressure) is a strong indication for fasciotomy. * **The 6 P’s:** Pain, Pallor, Paresthesia, Paralysis, Pulselessness, and Poikilothermia. Remember: **Pulselessness is a very late sign.**

Question 610: A 50-year-old man sustained posterior dislocation of his left hip in an accident. The dislocation was reduced after 3 days. Six months later, he began complaining of pain in his left hip. X-rays of the pelvis were normal. What is the most relevant investigation at this stage?

A. CRP levels in blood
B. Ultrasonography of the hip
C. Arthrography of the hip
D. MRI of the hip (Correct Answer)

Explanation: **Explanation:** The clinical scenario describes a patient at high risk for **Avascular Necrosis (AVN) of the femoral head**. AVN is a common complication of posterior hip dislocation, especially when reduction is delayed (in this case, 3 days). The blood supply to the femoral head (primarily the medial circumflex femoral artery) is compromised during dislocation, leading to bone ischemia. **1. Why MRI is the correct answer:** The patient presents with hip pain six months post-injury, but X-rays are normal. This indicates **Stage I AVN** (Ficat and Arlet classification), where structural changes haven't yet appeared on plain radiographs. **MRI is the most sensitive and gold-standard investigation** for early diagnosis of AVN, as it can detect marrow edema and signal changes (the "double-line sign") long before bone collapse occurs. **2. Why other options are incorrect:** * **CRP levels:** These are markers of inflammation or infection (e.g., septic arthritis), which is less likely than AVN in a post-traumatic setting without systemic symptoms. * **Ultrasonography:** Useful for detecting joint effusions or soft tissue pathology but lacks the sensitivity to diagnose early intraosseous ischemia. * **Arthrography:** Primarily used to assess joint congruity or labral tears; it does not visualize the internal vascularity or health of the bone marrow. **Clinical Pearls for NEET-PG:** * **Golden Period:** Hip dislocations should ideally be reduced within **6 hours** to minimize the risk of AVN. * **Most common complication:** Osteoarthritis (long-term); AVN (early-to-mid term). * **X-ray findings in late AVN:** Sclerosis, "Crescent sign" (subchondral fracture), and femoral head collapse. * **Classification:** Ficat and Arlet is the most commonly asked classification for AVN in exams.

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Principles of Fracture Management

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Upper Limb Fractures

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Lower Limb Fractures

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Spinal Trauma

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Pelvic and Acetabular 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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Polytrauma Management

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Joint Dislocations

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Trauma — MCQs

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