Trauma — MCQs
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What is true about post-traumatic fat embolism syndrome?
A person is hit from behind by a scooter. The rider is thrown off and lands with their head hitting the kerb. They do not move, complain of severe pain in the neck, and are unable to turn their head. Well-meaning bystanders attempt to make them sit up. What is the best course of action in this situation?
What is the treatment of choice for a linear, non-displaced fracture of the body of the mandible in a patient with a full complement of teeth?
What is the treatment for a severely comminuted fracture of the patella that cannot be reduced?
Which nerve is most commonly damaged in posterior dislocation of the hip?
Positive Trendelenburg's sign is seen in all EXCEPT?
Trendelenburg test would be positive in which of the following conditions?
An elderly female presents with a history of a fall and inability to move. Following the fall, her leg was noted to be in an externally rotated position. There is tenderness in Scarpa's triangle, and limb movement is significantly limited due to pain. Initial X-ray ruled out hip fracture. What is the next diagnostic step?
What is the characteristic position of the arm in an anterior shoulder dislocation?
Which statement is not true regarding the Langenbeck-Kocher operation?
Trauma Indian Medical PG Practice Questions and MCQs
Question 631: What is true about post-traumatic fat embolism syndrome?
- A. Fracture mobility is a risk factor. (Correct Answer)
- B. Associated diabetes poses a risk.
- C. Bradycardia occurs.
- D. All of the above.
Explanation: **Explanation:** Fat Embolism Syndrome (FES) is a systemic inflammatory response to fat globules released into the circulation, most commonly following fractures of long bones (like the femur) or the pelvis. **Why Option A is correct:** Fracture mobility is a significant risk factor. Movement at the fracture site increases intramedullary pressure and causes mechanical agitation, which forces fat droplets from the bone marrow into the torn venous sinusoids. This is why **early stabilization and internal fixation** of long bone fractures are the most effective ways to prevent FES. **Why other options are incorrect:** * **Option B:** Diabetes is not a recognized risk factor for FES. The primary risk factors are mechanical (multiple fractures, conservative management of long bone fractures) and physiological (hypovolemia/shock). * **Option C:** FES typically presents with **Tachycardia**, not bradycardia. The systemic inflammatory response and hypoxia (due to pulmonary involvement) trigger a sympathetic surge, leading to an increased heart rate. **NEET-PG High-Yield Pearls:** 1. **Gurd’s Criteria:** Used for diagnosis. Major criteria include **Axillary Petechiae** (pathognomonic but seen in only 20-50%), respiratory insufficiency/hypoxia, and CNS depression (confusion/coma). 2. **Classic Triad:** Dyspnea, Confusion, and Petechial rash (usually appearing 24–72 hours post-injury). 3. **Snowstorm Appearance:** Characteristic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). 4. **Treatment:** Primarily **supportive** (Oxygenation and maintenance of intravascular volume). Corticosteroids are controversial and not routinely recommended.
Question 632: A person is hit from behind by a scooter. The rider is thrown off and lands with their head hitting the kerb. They do not move, complain of severe pain in the neck, and are unable to turn their head. Well-meaning bystanders attempt to make them sit up. What is the best course of action in this situation?
- A. Prop the individual up and give them water to drink.
- B. Do not prop the individual up; turn them onto their face and rush them to the hospital.
- C. Turn the individual onto their back, place a support behind their neck, and transport them to the nearest hospital. (Correct Answer)
- D. Do not move the individual at all; carry them to the nearest hospital in the same position they have been in since their fall.
Explanation: ### Explanation **1. Why the Correct Answer is Right:** The clinical presentation (high-impact trauma, severe neck pain, and inability to move the head) is highly suggestive of a **Cervical Spine Injury**. In such cases, the primary goal is to prevent secondary spinal cord injury caused by the movement of unstable vertebral fragments. The standard protocol involves **immobilization and stabilization**. Turning the patient onto their back (supine) on a firm surface allows for the application of a cervical collar or makeshift neck support (sandbags/rolled clothes) to maintain a **neutral position**. This prevents flexion, extension, or rotation of the neck during transport, protecting the spinal cord from permanent damage (quadriplegia). **2. Analysis of Incorrect Options:** * **Option A:** Propping the patient up or giving water is contraindicated. Sitting up causes gravitational stress and flexion of the cervical spine, potentially severing the cord. Water poses an aspiration risk if the patient has a decreased level of consciousness or neurogenic shock. * **Option B:** Turning a patient onto their face (prone) is dangerous as it obstructs the airway and makes resuscitation impossible. It also necessitates significant neck rotation, which can be fatal in cervical fractures. * **Option D:** While "not moving" sounds safe, leaving a patient in a distorted or prone position during transport is impractical and risky. Controlled movement to a supine, neutral position with neck support is the gold standard for safe evacuation. **3. Clinical Pearls for NEET-PG:** * **Log-rolling:** If the patient must be moved, use the "log-roll" technique (minimum 3-4 people) to keep the head, neck, and torso in a straight line. * **Clearing the C-Spine:** In the ER, use the **NEXUS criteria** or **Canadian C-Spine Rules** to determine if imaging is needed. * **Imaging Gold Standard:** **CT scan** is the investigation of choice for suspected spinal fractures; **MRI** is superior for evaluating cord edema or ligamentous injury. * **Neurogenic Shock:** Characterized by hypotension and **bradycardia** (due to loss of sympathetic tone), unlike hypovolemic shock.
Question 633: What is the treatment of choice for a linear, non-displaced fracture of the body of the mandible in a patient with a full complement of teeth?
- A. Kirschner wire
- B. Circumferential wiring
- C. External pin fixation
- D. Interdental fixation (Correct Answer)
Explanation: ### Explanation The primary goal in managing mandibular fractures is the restoration of pre-traumatic **dental occlusion** and stable immobilization to allow bony union. **Why Interdental Fixation is Correct:** For a **linear, non-displaced fracture** in a patient with a **full complement of teeth**, the teeth themselves act as natural anchors. **Interdental fixation** (specifically **Intermaxillary Fixation or IMF** using Erich arch bars or eyelet wires) is the treatment of choice. It uses the patient's stable occlusion to "splint" the fracture internally. Since there is no displacement, invasive open reduction and internal fixation (ORIF) with plates is unnecessary, and conservative stabilization via the teeth provides excellent results with minimal morbidity. **Why Other Options are Incorrect:** * **Kirschner wire (A):** K-wires do not provide sufficient rotational stability for the mandible and are rarely used as primary treatment due to the risk of migration and infection. * **Circumferential wiring (B):** This technique is primarily used in **edentulous patients** (those without teeth) to secure a denture or a Gunning splint to the mandible. It is not indicated when a full complement of teeth is available. * **External pin fixation (C):** This is reserved for complex, comminuted fractures, infected non-unions, or massive bone loss (e.g., gunshot wounds) where internal fixation is not feasible. It is too invasive for a simple, non-displaced fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Mandible Fracture:** Condyle (overall), followed by Angle and Symphysis. * **Weakest points of Mandible:** Condylar neck, Angle (especially if third molar is impacted), and Mental foramen. * **"Guardsman Fracture":** A midline symphysis fracture associated with bilateral condylar fractures (caused by a fall on the chin). * **Muscle Pull:** The masseter, temporal, and medial pterygoid muscles tend to displace fractures of the mandibular angle superiorly and medially.
Question 634: What is the treatment for a severely comminuted fracture of the patella that cannot be reduced?
- A. Insertion of screws and wires
- B. Physiotherapy alone
- C. Patellectomy (Correct Answer)
- D. Removal of the smallest piece only
Explanation: ### Explanation The primary goal in managing patellar fractures is to restore the articular surface and the continuity of the extensor mechanism. **Why Patellectomy is the Correct Answer:** In cases of **severely comminuted fractures** (often termed "stellate" fractures) where the fragments are too small or numerous to be anatomically reconstructed, internal fixation is impossible. In such scenarios, a **total patellectomy** is performed. The procedure involves removing all bone fragments and meticulously repairing the quadriceps tendon and patellar ligament (extensor apparatus) to ensure functional knee extension. **Analysis of Incorrect Options:** * **A. Insertion of screws and wires:** This refers to **Tension Band Wiring (TBW)** or lag screw fixation. These are the treatments of choice for simple, transverse, or minimally comminuted fractures where anatomical reduction is achievable. They cannot be used if the bone is "shattered" beyond repair. * **B. Physiotherapy alone:** This is contraindicated for displaced or comminuted fractures. Without surgical intervention, the extensor mechanism remains disrupted, leading to a permanent loss of knee extension. * **D. Removal of the smallest piece only:** This describes a **partial patellectomy**. It is indicated when one pole (usually the inferior pole) is comminuted while the rest of the patella is intact. In a *severely* comminuted fracture involving the whole bone, this is insufficient. **High-Yield Pearls for NEET-PG:** * **Tension Band Wiring (TBW):** Converts distracting tensile forces into compressive forces at the fracture site. It is the **Gold Standard** for most patellar fractures. * **Patellar Function:** The patella acts as a fulcrum; its removal (patellectomy) results in approximately a **30% loss of quadriceps strength** and an extension lag. * **Indication for Surgery:** Surgery is generally indicated if there is >2mm of articular displacement or >3mm of fragment separation.
Question 635: Which nerve is most commonly damaged in posterior dislocation of the hip?
- A. Sciatic nerve (Correct Answer)
- B. Femoral nerve
- C. Obturator nerve
- D. Superior gluteal nerve
Explanation: **Explanation:** **1. Why Sciatic Nerve is Correct:** The **sciatic nerve** is the most commonly injured nerve in posterior hip dislocations (occurring in approximately 10–20% of cases). This is due to its anatomical proximity; the nerve exits the pelvis through the greater sciatic foramen and descends directly **posterior** to the acetabulum and the femoral head. When the femoral head is forced posteriorly out of the acetabulum (typically via a "dashboard injury"), it directly compresses or stretches the sciatic nerve. Specifically, the **peroneal division** of the sciatic nerve is more frequently affected than the tibial division. **2. Why Other Options are Incorrect:** * **Femoral Nerve:** Located **anterior** to the hip joint. It is more likely to be injured in *anterior* hip dislocations, which are much less common than posterior ones. * **Obturator Nerve:** Located **medially** and passes through the obturator canal. It is rarely injured in hip trauma but may be affected in medial wall acetabular fractures or anterior-inferior dislocations. * **Superior Gluteal Nerve:** Runs superior to the piriformis muscle. While it can be injured during surgical approaches (like the Hardinge approach), it is not typically damaged by the displacement of the femoral head in a posterior dislocation. **3. NEET-PG High-Yield Pearls:** * **Mechanism of Injury:** Most common is a "Dashboard Injury" (force applied to a flexed knee with the hip flexed and adducted). * **Clinical Presentation:** The limb is held in **Flexion, Adduction, and Internal Rotation** (F-AD-IR). * **Complications:** Avascular Necrosis (AVN) of the femoral head is the most serious late complication; Sciatic nerve palsy is the most common early neurological complication. * **Management:** Emergency closed reduction (e.g., Allis maneuver) should be performed within 6 hours to minimize AVN risk.
Question 636: Positive Trendelenburg's sign is seen in all EXCEPT?
- A. Paralysis of gluteus Maximus (Correct Answer)
- B. Paralysis of gluteus medius and minimus
- C. Fracture neck femur
- D. Intertrochanteric fracture
Explanation: **Explanation:** The **Trendelenburg sign** is a clinical indicator of a dysfunctional **hip abductor mechanism**. For a stable pelvis during the single-leg stance phase of walking, three components must be intact: the **Power** (Gluteus medius and minimus), the **Fulcrum** (Head of the femur in the acetabulum), and the **Lever arm** (Neck of the femur). **Why Option A is the Correct Answer:** The Trendelenburg sign specifically tests the **Gluteus medius and minimus** (supplied by the Superior Gluteal Nerve). The **Gluteus maximus** (supplied by the Inferior Gluteal Nerve) is a primary extensor of the hip, not an abductor. Its paralysis leads to a "Gluteus Maximus Lurch" (extensor lurch) but does **not** result in a positive Trendelenburg sign. **Analysis of Other Options:** * **Option B (Paralysis of Gluteus medius/minimus):** This directly eliminates the "Power" source of the abductor mechanism, causing the pelvis to drop on the unsupported side. * **Option C (Fracture neck femur):** This disrupts the "Lever arm" and the structural integrity of the fulcrum, making it impossible for the abductors to stabilize the pelvis. * **Option D (Intertrochanteric fracture):** Similar to neck fractures, this causes a loss of the stable lever arm and painful inhibition of the abductor muscles, leading to a positive sign. **NEET-PG High-Yield Pearls:** * **The Sign:** When standing on the affected limb, the pelvis **drops** on the normal (unsupported) side. * **The Gait:** A compensated Trendelenburg sign results in a **Lurching gait** (the trunk shifts toward the affected side to maintain the center of gravity). * **Other Causes:** Congenital Dislocation of the Hip (CDH/DDH), Coxa Vara, and Slipped Capital Femoral Epiphysis (SCFE) all produce a positive Trendelenburg sign due to fulcrum or lever arm disruption.
Question 637: Trendelenburg test would be positive in which of the following conditions?
- A. L4-L5 disc herniation (Correct Answer)
- B. L5-S1 disc herniation
- C. Synovitis of the hip
- D. Femoroacetabular impingement syndrome
Explanation: ### Explanation The **Trendelenburg test** assesses the stability of the hip and the functional integrity of the **hip abductors** (primarily Gluteus medius and minimus). A positive test occurs when the pelvis drops toward the unsupported side (the side with the foot off the ground) due to weakness or paralysis of the abductors on the weight-bearing side. **1. Why L4-L5 disc herniation is correct:** The Gluteus medius and minimus muscles are innervated by the **Superior Gluteal Nerve**, which carries fibers from the **L4, L5, and S1** nerve roots. In an **L4-L5 disc herniation**, the **L5 nerve root** is typically compressed (the traversing root). Since L5 is the primary contributor to the superior gluteal nerve, its compression leads to abductor weakness, resulting in a positive Trendelenburg sign. **2. Analysis of Incorrect Options:** * **L5-S1 disc herniation:** This typically compresses the **S1 nerve root**. While S1 contributes to the superior gluteal nerve, the motor deficit is usually manifested as weakness in plantar flexion (Gastrocnemius/Soleus) and loss of the ankle jerk, rather than significant hip abductor paralysis. * **Synovitis of the hip:** While painful, transient synovitis usually causes a painful (antalgic) gait rather than a true Trendelenburg sign, which requires a mechanical or neurological failure of the abductor mechanism. * **Femoroacetabular impingement (FAI):** This is a structural issue causing pain and restricted range of motion (especially internal rotation). It does not typically cause the abductor weakness required for a positive Trendelenburg test. **Clinical Pearls for NEET-PG:** * **The Trendelenburg Trio:** A positive test requires three intact components: (1) Power of abductors, (2) A stable fulcrum (intact femoral head/neck), and (3) A stable lever arm. * **Other causes:** Polio, Superior Gluteal Nerve injury (e.g., post-surgery), Congenital Dislocation of the Hip (CDH/DDH), and Coxa Vara. * **Trendelenburg Gait:** Also known as a "lurching gait." If bilateral, it is called a **Waddling gait**.
Question 638: An elderly female presents with a history of a fall and inability to move. Following the fall, her leg was noted to be in an externally rotated position. There is tenderness in Scarpa's triangle, and limb movement is significantly limited due to pain. Initial X-ray ruled out hip fracture. What is the next diagnostic step?
- A. MRI (Correct Answer)
- B. Repeat X-ray after one week
- C. Joint aspiration
- D. Administer analgesics and attempt manipulation
Explanation: **Explanation:** The clinical presentation of an elderly patient with a fall, external rotation of the limb, and tenderness in **Scarpa’s triangle** is highly suggestive of a **hip fracture** (specifically a femoral neck fracture). However, in elderly patients with osteoporosis, fractures can be **occult** (not visible on initial radiographs). 1. **Why MRI is Correct:** MRI is the **gold standard** for diagnosing occult hip fractures. It has nearly 100% sensitivity and can detect bone marrow edema and fracture lines within 24 hours of injury. When clinical suspicion is high but X-rays are negative, MRI is the immediate next step to prevent fracture displacement or avascular necrosis (AVN). 2. **Why other options are incorrect:** * **Repeat X-ray after one week:** While callus formation might eventually show a fracture, delaying diagnosis in an elderly patient leads to prolonged immobilization, increasing the risk of DVT, pneumonia, and pressure sores. * **Joint aspiration:** This is primarily used to diagnose septic arthritis or crystal arthropathy, not trauma-related fractures. * **Analgesics and manipulation:** Attempting manipulation without a diagnosis is dangerous and may displace an undisplaced fracture, compromising the blood supply (medial circumflex femoral artery). **Clinical Pearls for NEET-PG:** * **Occult Fracture:** A fracture that is clinically suspected but not visible on initial X-rays. * **Imaging Hierarchy:** If MRI is unavailable or contraindicated (e.g., pacemaker), a **CT scan** or **Bone Scan** (after 48-72 hours) are alternatives. * **Scarpa’s Triangle Tenderness:** A classic sign of intracapsular hip fractures. * **Positioning:** Femoral neck fractures typically present with **shortening and external rotation**.
Question 639: What is the characteristic position of the arm in an anterior shoulder dislocation?
- A. By the side (Correct Answer)
- B. In abduction
- C. In adduction
- D. In external rotation
Explanation: In an anterior shoulder dislocation—the most common type of shoulder dislocation (95%)—the humeral head is displaced anteriorly and inferiorly out of the glenoid fossa. **Explanation of the Correct Answer:** The characteristic clinical presentation of a patient with an acute anterior shoulder dislocation is the arm held **by the side** (slightly abducted) and supported by the opposite hand. While the initial mechanism of injury often involves abduction and external rotation, once the dislocation is established, the patient typically presents with the arm fixed in **slight abduction and external rotation**, but functionally held close to the body (by the side) to minimize pain and muscle spasms. **Analysis of Incorrect Options:** * **In Abduction:** While the arm is slightly abducted (the "Hamilton Ruler Test" is positive because the arm cannot touch the side), it is not held in significant or overhead abduction. * **In Adduction:** This is incorrect because the displaced humeral head prevents the arm from being fully adducted to the side of the chest (Dugas Test). * **In External Rotation:** Although the arm is externally rotated, the most defining "positional" description in clinical exams is the arm being held by the side/slightly abducted. **NEET-PG High-Yield Clinical Pearls:** 1. **Flattening of the Shoulder:** Loss of the normal rounded contour of the deltoid (Square shoulder/Epaulette sign). 2. **Dugas Test:** The patient is unable to touch the opposite shoulder with the hand of the affected side. 3. **Hamilton Ruler Test:** A straight edge can touch both the acromion and the lateral epicondyle simultaneously. 4. **Associated Nerve Injury:** The **Axillary nerve** is the most commonly injured nerve (check for "regimental badge" anesthesia). 5. **Common Lesions:** Bankart lesion (labral tear) and Hill-Sachs lesion (compression fracture of the posterolateral humeral head).
Question 640: Which statement is not true regarding the Langenbeck-Kocher operation?
- A. Provides adequate exposure of the posterior segment.
- B. The anterior segment is not visualized adequately.
- C. Superior exposure is very well achieved. (Correct Answer)
- D. Sciatic nerve injury occurs in 10% of cases.
Explanation: The **Kocher-Langenbeck (K-L) approach** is the standard posterior surgical approach to the acetabulum. Understanding its anatomical limitations is crucial for NEET-PG. ### **Explanation of the Correct Option** **Option C is the correct answer (the false statement)** because the K-L approach provides **limited superior exposure**. While it offers excellent access to the posterior column and posterior wall, it does not allow for adequate visualization of the superior aspect of the acetabulum (the "dome" or weight-bearing roof) or the iliac wing. To access the superior or anterior regions, an extended iliofemoral or a combined approach is often required. ### **Analysis of Other Options** * **Option A (True):** It is the "workhorse" approach for the **posterior segment**, providing direct access to the posterior column and posterior wall of the acetabulum. * **Option B (True):** The **anterior segment** (anterior wall and column) cannot be visualized through this posterior incision. Access is blocked by the femoral head and the pelvic anatomy. * **Option D (True):** **Sciatic nerve injury** is a well-documented complication of this approach, occurring in approximately **10%** of cases (range 2-10%). This is usually due to intraoperative traction on the nerve, particularly the peroneal division. ### **High-Yield Clinical Pearls for NEET-PG** * **Patient Positioning:** Usually performed in the prone or lateral position. * **Nerve Protection:** To minimize sciatic nerve tension during the procedure, the **knee must be kept flexed** (90°) and the **hip extended**. * **Structures at Risk:** Sciatic nerve, Superior Gluteal Artery (at the greater sciatic notch), and Inferior Gluteal Artery. * **Indications:** Posterior wall fractures, posterior column fractures, and certain transverse fractures of the acetabulum.
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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