Trauma — MCQs
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A 22-year-old male is admitted with a fracture of the left femur. Two days later, he becomes mildly confused, has a respiratory rate of 40/min, and a scattered petechial rash on his upper torso. Chest X-ray shows patchy alveolar opacities bilaterally. His arterial blood gas analysis is abnormal. What is the most likely diagnosis?
Growth disturbance, nonunion, elbow instability, and late ulnar nerve palsy are commonly seen in which type of fracture?
What is the change in Gissane's angle in an intra-articular fracture of the calcaneum?
What is the last step in fracture healing?
Which nerve is most commonly involved in a fracture of the neck of the humerus?
A bucket handle tear occurs at the knee joint due to which of the following injuries?
Which of the following are considered non-rigid fixation devices?
What is the most important sign of Volkmann's ischemia?
A 22-year-old man is brought to the emergency department following a rugby injury. Which of the following statements is false regarding the fracture shown?
What is the maximum weight typically allowed in skeletal traction?
Trauma Indian Medical PG Practice Questions and MCQs
Question 651: A 22-year-old male is admitted with a fracture of the left femur. Two days later, he becomes mildly confused, has a respiratory rate of 40/min, and a scattered petechial rash on his upper torso. Chest X-ray shows patchy alveolar opacities bilaterally. His arterial blood gas analysis is abnormal. What is the most likely diagnosis?
- A. Cerebral edema with early neurogenic pulmonary edema
- B. Pulmonary thromboembolism
- C. Chest contusion
- D. Fat embolism (Correct Answer)
Explanation: **Explanation:** The clinical presentation of a long bone fracture (femur) followed by a **"latent period" of 24–72 hours**, respiratory distress (tachypnea), neurological symptoms (confusion), and a **petechial rash** (typically in the axilla, neck, and conjunctiva) is the classic triad of **Fat Embolism Syndrome (FES)**. 1. **Why Fat Embolism is correct:** In FES, fat globules are released from the bone marrow into the systemic circulation. These globules cause mechanical obstruction and trigger a biochemical inflammatory response (free fatty acid release), leading to endothelial damage. The "Snowstorm appearance" on Chest X-ray (patchy alveolar opacities) and hypoxemia on ABG are hallmark findings. 2. **Why other options are incorrect:** * **Pulmonary Thromboembolism:** Usually occurs later (1–2 weeks post-injury) and does not present with a petechial rash. * **Chest Contusion:** This would present immediately after trauma, not after a 2-day delay, and would be associated with direct thoracic injury. * **Cerebral Edema:** While confusion is present, it does not explain the petechial rash or the bilateral pulmonary opacities. **Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis. Major criteria include axillary/subconjunctival petechiae, hypoxemia ($PaO_2 < 60$ mmHg), and CNS depression. * **Earliest Sign:** Tachycardia and Tachypnea. * **Most Specific Sign:** Petechial rash (found in only 20–50% of cases but highly diagnostic). * **Management:** Primarily supportive (Oxygenation/Ventilation). Early stabilization of the fracture is the best preventive measure. * **Investigation of Choice:** Pulse oximetry (screening); ABG (confirmatory for hypoxemia).
Question 652: Growth disturbance, nonunion, elbow instability, and late ulnar nerve palsy are commonly seen in which type of fracture?
- A. Fracture of the supracondylar humerus
- B. Fracture of the medial condyle
- C. Fracture of the lateral condyle (Correct Answer)
- D. Fracture of the head of the radius
Explanation: **Explanation:** Fracture of the **lateral condyle of the humerus** is the correct answer because it is an **intra-articular fracture** that often involves the growth plate (Salter-Harris Type IV). 1. **Why it is correct:** The lateral condyle is a "fracture of necessity" (usually requiring ORIF) because the fragment is pulled by the extensor muscles, leading to displacement. * **Nonunion:** Synovial fluid inhibits callus formation, and the pull of extensors causes constant motion. * **Growth Disturbance:** Damage to the physis leads to **Cubitus Valgus** deformity. * **Late Ulnar Nerve Palsy (Tardy Ulnar Nerve Palsy):** As the cubitus valgus deformity progresses, the ulnar nerve is chronically stretched over the medial epicondyle, leading to delayed palsy years after the injury. 2. **Why other options are wrong:** * **Supracondylar Humerus:** Most common pediatric elbow fracture. Complications include Volkmann’s Ischemic Contracture and **Cubitus Varus** (Gunstock deformity), but nonunion is rare as it is extra-articular. * **Medial Condyle:** Rare injury. While it can cause ulnar nerve issues, it does not typically result in the classic triad of nonunion, cubitus valgus, and tardy palsy associated with lateral condyle fractures. * **Radial Head:** Common in adults; usually results in restricted forearm rotation (pronation/supination) rather than late ulnar nerve palsy. **Clinical Pearls for NEET-PG:** * **Milch Classification** is used for lateral condyle fractures. * **Tardy Ulnar Nerve Palsy** is most classically associated with **Lateral Condyle Nonunion**. * **Cubitus Varus** = Supracondylar fracture; **Cubitus Valgus** = Lateral condyle fracture.
Question 653: What is the change in Gissane's angle in an intra-articular fracture of the calcaneum?
- A. Reduced
- B. Increased (Correct Answer)
- C. Not changed
- D. Variable
Explanation: **Explanation:** In intra-articular fractures of the calcaneum (typically caused by a fall from height), the axial loading force drives the talus downward into the calcaneum. This mechanical impact leads to the collapse of the calcaneal body and specific changes in radiographic angles. **1. Why the Correct Answer is Right (Increased):** The **Angle of Gissane** (also known as the "Critical Angle") is formed by the downward slope of the lateral facet of the posterior talar articular surface and the upward slope of the calcaneal beak. In a normal foot, this angle is typically between **120° and 145°**. When an intra-articular fracture occurs, the posterior facet is depressed or crushed downward. This depression causes the angle to open up or flatten, resulting in an **increase** (usually >145°) in the Angle of Gissane. **2. Why Incorrect Options are Wrong:** * **Reduced:** This is incorrect for Gissane’s angle. However, it is the classic finding for **Bohler’s Angle** (normal 20°–40°), which decreases or becomes negative in calcaneal fractures. * **Not changed:** Calcaneal fractures are characterized by significant architectural distortion; therefore, these angles are almost always altered. * **Variable:** While the degree of change depends on severity, the consistent pathological trend in intra-articular fractures is an increase in Gissane’s angle due to facet depression. **High-Yield Clinical Pearls for NEET-PG:** * **Bohler’s Angle:** Decreases in calcaneal fractures (Normal: 20°–40°). * **Gissane’s Angle:** Increases in calcaneal fractures (Normal: 120°–145°). * **Mondor’s Sign:** Ecchymosis extending to the sole of the foot; pathognomonic for calcaneal fracture. * **Associated Injury:** Always rule out **compression fractures of the lumbar spine (L1)** in patients with calcaneal fractures (Don Juan Syndrome/Lover's Fracture). * **Gold Standard Investigation:** CT Scan (Broden’s views are the specific X-ray views).
Question 654: What is the last step in fracture healing?
- A. Hematoma
- B. Callus formation
- C. Remodeling (Correct Answer)
- D. Consolidation
Explanation: **Explanation:** Fracture healing is a continuous biological process typically divided into four distinct histological stages. The correct answer is **Remodeling**, which represents the final and longest phase of bone repair. **1. Why Remodeling is correct:** Remodeling (Phase of Modeling) begins once the fracture has been bridged by firm bone. In this stage, the bulky clinical callus is reshaped. Osteoclasts resorb unnecessary bone (external callus), while osteoblasts lay down lamellar bone along the lines of mechanical stress (**Wolff’s Law**). This process restores the bone to its original shape and restores the medullary canal. It can take months to years to complete. **2. Why other options are incorrect:** * **A. Hematoma:** This is the **first stage** (Inflammation). It occurs within hours of injury, providing a fibrin scaffold for signaling molecules and progenitor cells. * **B. Callus formation:** This occurs in the middle stages. **Soft callus** (cartilage/fibrous tissue) is formed first, followed by **Hard callus** (woven bone), which provides initial structural stability. * **C. Consolidation:** This is the stage where the woven bone of the hard callus is transformed into mature lamellar bone. While it signifies clinical union, it precedes the final structural "fine-tuning" of remodeling. **NEET-PG High-Yield Pearls:** * **Sequence of Healing:** Hematoma → Inflammation → Soft Callus → Hard Callus → Consolidation → Remodeling. * **Primary Bone Healing:** Occurs via absolute stability (e.g., compression plating). There is **no callus formation**; healing happens via "cutting cones." * **Secondary Bone Healing:** Occurs via relative stability (e.g., intramedullary nailing or casts). It involves **callus formation**. * **Wolff’s Law:** Bone grows or remodels in response to the forces or demands placed upon it.
Question 655: Which nerve is most commonly involved in a fracture of the neck of the humerus?
- A. Musculocutaneous nerve
- B. Median nerve
- C. Ulnar nerve
- D. Axillary nerve (Correct Answer)
Explanation: **Explanation:** The **axillary nerve** is the correct answer because of its intimate anatomical relationship with the proximal humerus. It originates from the posterior cord of the brachial plexus (C5, C6) and winds around the **surgical neck of the humerus** through the quadrangular space, accompanied by the posterior circumflex humeral artery. Due to this proximity, any fracture involving the surgical neck or an anterior dislocation of the shoulder joint puts the axillary nerve at high risk of traction or direct injury. **Analysis of Incorrect Options:** * **A. Musculocutaneous nerve:** This nerve pierces the coracobrachialis muscle and is more commonly injured during shoulder surgeries (like the Latarjet procedure) or heavy lifting, rather than humeral neck fractures. * **B. Median nerve:** This nerve runs medially in the arm and is most commonly injured in **supracondylar fractures** of the humerus in children. * **C. Ulnar nerve:** The ulnar nerve is most vulnerable at the elbow as it passes behind the **medial epicondyle**. **NEET-PG High-Yield Pearls:** * **Axillary Nerve Injury:** Clinically presents with weakness in shoulder abduction (Deltoid paralysis) and sensory loss over the lateral aspect of the upper arm (**Regimental Badge area**). * **Radial Nerve:** Most commonly injured in **mid-shaft humerus fractures** (Holstein-Lewis fracture) as it travels in the spiral groove. * **Nerve Injury Rule of Thumb:** * Surgical Neck → Axillary Nerve * Spiral Groove (Shaft) → Radial Nerve * Supracondylar → Median Nerve (specifically AIN) * Medial Epicondyle → Ulnar Nerve
Question 656: A bucket handle tear occurs at the knee joint due to which of the following injuries?
- A. Injury to the medial collateral ligament
- B. Injury to the lateral collateral ligament
- C. Injury to the ligamentum patellae
- D. Injury to the menisci (Correct Answer)
Explanation: **Explanation:** A **Bucket Handle Tear** is a specific type of longitudinal, full-thickness tear of the **meniscus** (most commonly the medial meniscus). In this injury, the inner fragment of the torn meniscus displaces centrally into the intercondylar notch, while the peripheral part remains attached. This displaced fragment resembles the handle of a bucket, hence the name. **Why the correct answer is right:** * **Mechanism:** It typically occurs due to a forceful twisting (rotational) injury on a semi-flexed, weight-bearing knee. * **Clinical Presentation:** The hallmark sign is **"locking" of the knee joint**, where the patient is unable to fully extend the knee because the displaced meniscal fragment mechanically blocks the joint movement. **Why the incorrect options are wrong:** * **Medial/Lateral Collateral Ligaments (MCL/LCL):** These are extracapsular/capsular ligaments. Injuries here lead to joint instability (valgus/varus stress) and localized pain, but they do not cause "bucket handle" mechanical blocks. * **Ligamentum Patellae:** Injury to this structure (patellar tendon rupture) results in a failure of the extensor mechanism, meaning the patient cannot actively extend the knee against gravity; it does not cause a meniscal-style tear. **High-Yield Clinical Pearls for NEET-PG:** 1. **Medial vs. Lateral:** Bucket handle tears are **3 times more common in the Medial Meniscus** because it is less mobile and more firmly attached to the joint capsule. 2. **The "Unhappy Triad" (O'Donoghue):** Often tested alongside meniscal injuries; it involves injury to the **ACL, MCL, and Medial Meniscus**. 3. **Diagnosis:** **MRI** is the gold standard investigation. On MRI, the "Double PCL sign" is a classic indicator of a bucket handle tear. 4. **Treatment:** Definitive management is usually via **Arthroscopic repair** or partial meniscectomy.
Question 657: Which of the following are considered non-rigid fixation devices?
- A. Transosseous wire
- B. Kirschner wire
- C. Both transosseous wire and Kirschner wire (Correct Answer)
- D. None of the above
Explanation: **Explanation:** In orthopedic trauma, fixation is classified based on the stability it provides to the fracture site. **Non-rigid (flexible) fixation** allows for micromotion at the fracture gap, which promotes **indirect bone healing** through the formation of a periosteal callus. 1. **Why Option C is Correct:** * **Kirschner wires (K-wires):** These are thin, smooth stainless steel pins. While they provide alignment and resist translational forces, they offer minimal resistance to rotation, bending, or axial loading. Because they lack rigid compression and allow slight movement, they are classic examples of non-rigid fixation. * **Transosseous wires (Cerclage/Hemicerclage):** These wires are used to loop around bone fragments. While they can hold fragments together, they do not provide absolute stability or rigid compression against physiological loads. They are often used as supplemental fixation rather than primary rigid constructs. 2. **Analysis of Incorrect Options:** * **Options A and B** are partially correct but incomplete, as both devices fall under the non-rigid category. * **Option D** is incorrect because both mentioned devices are standard non-rigid implants. **High-Yield Clinical Pearls for NEET-PG:** * **Rigid Fixation:** Examples include **Compression Plates** (e.g., DCP, LC-DCP). These provide "Absolute Stability," leading to **Primary Bone Healing** (no callus formation). * **Non-Rigid/Semi-Rigid Fixation:** Examples include **K-wires, Intramedullary Nails, and External Fixators.** These provide "Relative Stability," leading to **Secondary Bone Healing** (callus formation). * **K-wire uses:** Commonly used in pediatric supracondylar fractures, Hand/Wrist fractures (Colles’ fracture), and as temporary fixation during ORIF. * **Tension Band Wiring (TBW):** Converts distracting forces into compressive forces (e.g., Patella or Olecranon fractures); it is a specific application of wires to achieve functional stability.
Question 658: What is the most important sign of Volkmann's ischemia?
- A. Stretch pain (Correct Answer)
- B. Pallor
- C. Numbness
- D. Obliteration of radial pulse
Explanation: **Explanation:** Volkmann’s Ischemia is the precursor to Volkmann’s Ischemic Contracture (VIC), resulting from untreated **Compartment Syndrome**, most commonly following a supracondylar fracture of the humerus. **Why "Stretch Pain" is the correct answer:** The hallmark of early compartment syndrome is **pain out of proportion to the injury**. Specifically, **pain on passive stretching** of the finger extensors (for the forearm) is the **earliest and most sensitive clinical sign**. This occurs because the increased intracompartmental pressure compromises microcirculation to the muscles; stretching these ischemic muscles triggers intense nociceptive signals before nerve or skin changes occur. **Analysis of Incorrect Options:** * **B. Pallor:** This is a late sign indicating severe arterial compromise. In many cases of compartment syndrome, the limb remains pink because the capillary refill may still be present. * **C. Numbness (Paresthesia):** While an important sign of nerve ischemia, it usually appears after the onset of ischemic muscle pain. * **D. Obliteration of radial pulse:** This is the **least reliable and latest sign**. Compartment pressure rarely exceeds systolic arterial pressure; therefore, a palpable distal pulse does not rule out Volkmann’s ischemia. **NEET-PG High-Yield Pearls:** * **The 5 P’s:** Pain (earliest), Pallor, Paresthesia, Pulselessness (latest), and Paralysis. * **Most sensitive sign:** Pain on passive stretch. * **Gold Standard Diagnosis:** Measurement of intracompartmental pressure (using a Stryker monitor). A **Delta pressure** (Diastolic BP – Compartment Pressure) **< 30 mmHg** is diagnostic. * **Immediate Management:** Remove tight casts/bandages; if no improvement, urgent **Fasciotomy**.
Question 659: A 22-year-old man is brought to the emergency department following a rugby injury. Which of the following statements is false regarding the fracture shown?
- A. Comminuted fracture of the tibia
- B. Does not involve the articular surface
- C. Closed fracture (Correct Answer)
- D. Posteriorly displaced fracture
Explanation: ***Closed fracture*** - This statement is **FALSE** - the fracture is actually an **open (compound) fracture** with visible bone fragments through the skin. - Open fractures require immediate **surgical debridement** and **antibiotic prophylaxis** to prevent infection and are classified using the **Gustilo-Anderson system**. *Comminuted fracture of the tibia* - This statement is **TRUE** - the fracture shows **multiple bone fragments** characteristic of a comminuted pattern. - Common in **high-energy trauma** like sports injuries, requiring complex surgical fixation with **intramedullary nailing** or **external fixation**. *Does not involve the articular surface* - This statement is **TRUE** - the fracture is located in the **mid-shaft (diaphysis)** of the tibia, sparing the joint surfaces. - **Diaphyseal fractures** have better healing potential compared to **intra-articular fractures** which can lead to post-traumatic arthritis. *Posteriorly displaced fracture* - This statement is **TRUE** - the **distal fragment** is displaced posteriorly relative to the proximal fragment. - Posterior displacement can compromise the **popliteal artery** and **posterior tibial nerve**, requiring vascular and neurological assessment.
Question 660: What is the maximum weight typically allowed in skeletal traction?
- A. 5 kg
- B. 10 kg
- C. 20 kg (Correct Answer)
- D. 30 kg
Explanation: **Explanation:** In orthopaedic trauma management, traction is used to reduce fractures and maintain alignment. **Skeletal traction** involves the insertion of a metal pin (e.g., Steinman pin or Denham pin) directly into the bone, allowing for the application of significant force. **1. Why 20 kg is the correct answer:** The maximum weight typically allowed in skeletal traction is **20 kg (or roughly 1/10th to 1/7th of the patient's body weight)**. This higher weight limit is possible because the force is transmitted directly to the skeleton, bypassing the skin. It is most commonly used for femoral shaft fractures or acetabular fractures where powerful muscle groups (like the quadriceps and hamstrings) must be overcome to achieve reduction. **2. Analysis of Incorrect Options:** * **A & B (5 kg - 10 kg):** These weights are more characteristic of **Skin Traction**. Skin traction (e.g., Buck’s traction) cannot exceed **5–7 kg** because higher weights lead to skin stripping, blisters, and pressure necrosis. 10 kg is generally considered the absolute upper limit for skin traction in very large adults but is unsafe for routine use. * **D (30 kg):** This weight is excessive. Applying 30 kg of continuous traction poses a high risk of "over-distraction" of the fracture fragments (leading to non-union), ligamentous injury to the joint (especially the knee), and potential neurovascular stretching. **High-Yield Clinical Pearls for NEET-PG:** * **Common Sites:** The most common site for skeletal traction is the **Upper Tibia** (2 cm posterior and distal to the tibial tuberosity). * **Direction of Pin Insertion:** To avoid injury to the Common Peroneal Nerve, pins at the proximal tibia should be inserted from **Lateral to Medial**. * **Complications:** The most common complication of skeletal traction is **Pin Track Infection**. * **Contraindication:** Skeletal traction should generally be avoided in children with open epiphyses to prevent growth plate damage.
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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