Trauma — MCQs

A nine-year-old girl with a simple, undisplaced fracture of the shaft of her right tibia has been treated with an above-knee plaster cast. Four years prior, she was affected by poliomyelitis. What is the best possible advice you can offer her parents regarding the prognosis of the fractured limb's union?

Q66Medium

A 3-year-old child presents with a fracture of the femoral shaft, which has been immobilized on traction for two months. What is the next step in management?

Q67Easy

Rolando's fracture is:

Q68Medium

Which of the following is not an indication for secondary nerve repair?

Q69Medium

Which of the following is NOT true about intracapsular neck fracture?

Q70Easy

Tennis elbow is defined as:

Trauma Indian Medical PG Practice Questions and MCQs

Question 61: A patient presents to the emergency department with a hip exhibiting flexion, adduction, and internal rotation. What is the most likely diagnosis?

A. Anterior dislocation of the hip
B. Posterior dislocation of the hip (Correct Answer)
C. Femur neck fracture
D. Femur head fracture

Explanation: ### Explanation **1. Why Posterior Dislocation is Correct:** The clinical presentation of a hip in **Flexion, Adduction, and Internal Rotation (FADIR)** is the classic "textbook" posture for a **Posterior Dislocation of the Hip**. This occurs because the femoral head is forced posteriorly out of the acetabulum (often due to a "dashboard injury"), and the tension from the surrounding ligaments and muscles pulls the limb into this characteristic position. It is the most common type of hip dislocation (approx. 90%). **2. Why Other Options are Incorrect:** * **Anterior Dislocation of the Hip:** This presents with the opposite deformity: **Extension, Abduction, and External Rotation**. (Note: If it is an *obturator* type of anterior dislocation, the hip may be flexed, but it will still be abducted and externally rotated). * **Femur Neck Fracture:** Typically presents with **Shortening and External Rotation**. The limb is usually held in extension, not flexion. * **Femur Head Fracture:** While often associated with dislocations (Pipkin classification), a fracture alone does not dictate this specific gross deformity unless accompanied by a dislocation. **3. NEET-PG High-Yield Pearls:** * **Mechanism:** Most commonly caused by a head-on motor vehicle accident where the knee strikes the dashboard (Dashboard Injury). * **Nerve Injury:** The **Sciatic Nerve** (specifically the peroneal division) is the most commonly injured nerve in posterior dislocations. * **Complications:** Avascular Necrosis (AVN) of the femoral head is a major risk; hence, it is an **orthopaedic emergency** requiring reduction within 6 hours. * **X-ray Finding:** In a posterior dislocation, the femoral head appears **smaller** than the contralateral side on an AP view (due to being closer to the film/further from the beam). In anterior dislocation, it appears larger.

Question 62: Symptomatic spinal injury without radiological evidence is most commonly found in which patient population?

A. Children (Correct Answer)
B. Elderly
C. Teenagers
D. Young adults

Explanation: **Explanation:** The correct answer is **Children (Option A)**. This clinical entity is known as **SCIWORA (Spinal Cord Injury Without Radiologic Abnormality)**. **Why Children?** SCIWORA is almost exclusively seen in the pediatric population (most commonly under age 8) due to the unique biomechanical properties of the young spine: 1. **Ligamentous Laxity:** Children have highly elastic ligaments and joint capsules. 2. **Shallow Facet Joints:** The horizontal orientation of facets allows for significant translation. 3. **Incomplete Ossification:** The vertebral bodies are often wedge-shaped and cartilaginous. 4. **Large Head-to-Body Ratio:** This creates a higher fulcrum of motion (usually at C2-C3). These factors allow the spinal column to stretch significantly (up to 2 inches) without fracturing or dislocating. However, the spinal cord is anchored and inelastic; it cannot tolerate this degree of stretching, leading to neural injury (ischemia or traction) despite a "normal" X-ray or CT scan. **Why other options are incorrect:** * **Elderly (B):** This population is prone to **Central Cord Syndrome**, often due to hyperextension injuries on a background of pre-existing cervical spondylosis. While they may have "minor" trauma, radiological evidence of degenerative changes is usually present. * **Teenagers (C) and Young Adults (D):** As the skeleton matures, the spine becomes more rigid. Trauma in these groups typically results in visible fractures or dislocations (Radiologic Abnormalities) rather than SCIWORA. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** **MRI** is the investigation of choice for SCIWORA to visualize cord edema, hemorrhage, or ligamentous injury. * **Most Common Site:** Cervical spine. * **Management:** Rigid immobilization (3–12 weeks) and avoidance of high-risk activities to prevent recurrent injury. * **Prognosis:** Often involves a "latent period" where neurological deficits appear hours or days after the initial insult.

Question 63: Volkmann's ischemic contracture is commonly caused by which of the following?

A. A tight plaster cast
B. A tight splint
C. Both a tight plaster cast and a tight splint (Correct Answer)
D. Neither a tight plaster cast nor a tight splint

Explanation: **Explanation:** Volkmann’s Ischemic Contracture (VIC) is the permanent sequela of untreated or inadequately treated **Acute Compartment Syndrome**, most commonly following a supracondylar fracture of the humerus or fractures of the forearm bones. **Why Option C is Correct:** The underlying pathophysiology of VIC is a rise in intra-compartmental pressure which compromises capillary perfusion, leading to muscle and nerve ischemia. This pressure increase can be caused by: 1. **Intrinsic factors:** Edema or hemorrhage within the muscle compartment. 2. **Extrinsic factors:** External compression that prevents the expansion of the limb. Both **tight plaster casts** and **tight splints** act as rigid external constraints. As the injured limb swells, these non-circumferential (splint) or circumferential (cast) applications restrict the volume of the compartment, rapidly elevating tissue pressure. Therefore, both are significant external risk factors for the development of ischemia. **Why other options are incorrect:** * **Options A & B:** While both are correct individually, they are incomplete. Since both mechanisms contribute equally to external compression, the most comprehensive answer is "Both." * **Option D:** This contradicts the established clinical understanding that external constriction is a primary preventable cause of compartment syndrome. **NEET-PG High-Yield Pearls:** * **Earliest Sign:** Pain out of proportion to the injury and pain on passive stretching of fingers. * **The "5 Ps":** Pain, Pallor, Pulselessness, Paresthesia, and Paralysis (Note: Pulselessness is a late sign). * **Involved Muscle:** The **Flexor Digitorum Profundus (FDP)** is the most common muscle affected (specifically the infarct core). * **Clinical Feature:** A classic "Volkmann’s Sign" (claw hand) where the wrist flexion allows the fingers to extend, but extending the wrist causes the fingers to flex. * **Management:** Immediate removal of all constrictive dressings/casts. If pressure remains >30 mmHg, emergency **fasciotomy** is indicated.

Question 64: What is the classically described position of the hand during the application of a POP cast for a scaphoid fracture?

A. Boat shaped position
B. Clenched fist position
C. Tumbler holding position (Correct Answer)
D. Boxing position

Explanation: **Explanation:** The management of a scaphoid fracture requires a specific type of immobilization known as the **Scaphoid Cast**. The classically described position of the hand during its application is the **Tumbler holding position** (also referred to as the "Glass holding" or "Beer-can" position). **Why it is correct:** The scaphoid is the most commonly fractured carpal bone. To ensure optimal stability and apposition of the fragments, the wrist must be immobilized in a functional position: **slight radial deviation and dorsiflexion (extension)**, with the **thumb in a position of abduction and opposition**. This specific orientation mimics the way one holds a tumbler, ensuring the thumb is stabilized while maintaining the functional arc of the hand. **Analysis of Incorrect Options:** * **Boat shaped position:** This is a distractor. While the scaphoid is often described as "boat-shaped" (navicular), this does not describe the clinical position for casting. * **Clenched fist position:** This position would cause excessive tension on the carpal bones and prevent proper thumb immobilization, which is crucial for scaphoid healing. * **Boxing position:** This refers to the position used for metacarpal fractures (e.g., Boxer’s fracture), involving flexion at the MCP joints, which is inappropriate for carpal stability. **High-Yield Clinical Pearls for NEET-PG:** * **Cast Extent:** A scaphoid cast typically extends from the upper forearm to the distal palmar crease, including the proximal phalanx of the thumb (**Thumb Spica**). * **Avascular Necrosis (AVN):** The scaphoid has a retrograde blood supply (from distal to proximal). Therefore, fractures at the **proximal pole** have the highest risk of AVN and non-union. * **Tenderness:** The most sensitive clinical sign is tenderness in the **Anatomical Snuffbox**. * **Radiology:** If initial X-rays are negative but clinical suspicion is high, the hand should be immobilized in a scaphoid cast and re-imaged after **10–14 days**.

Question 65: A nine-year-old girl with a simple, undisplaced fracture of the shaft of her right tibia has been treated with an above-knee plaster cast. Four years prior, she was affected by poliomyelitis. What is the best possible advice you can offer her parents regarding the prognosis of the fractured limb's union?

A. Fracture will unite slowly.
B. Fracture will not unite.
C. Fracture will unite normally. (Correct Answer)
D. Fracture will unite upon attaining puberty.

Explanation: ### Explanation The correct answer is **C. Fracture will unite normally.** **1. Why the correct answer is right:** In patients with poliomyelitis, the primary pathology involves the destruction of anterior horn cells in the spinal cord, leading to lower motor neuron (LMN) paralysis. While the affected limb often exhibits muscle atrophy, osteopenia (due to lack of mechanical loading), and circulatory changes, the **biological process of fracture healing remains intact**. Bone healing depends on the local blood supply and the presence of osteoprogenitor cells. Despite the limb being "paralyzed," the physiological inflammatory and reparative cascades required for callus formation are not significantly impaired. Therefore, a fracture in a polio-affected limb heals at a rate comparable to a normal limb. **2. Why the incorrect options are wrong:** * **Option A & B:** There is no clinical evidence to suggest that poliomyelitis causes non-union or delayed union. While the bone may be thinner (gracile) and more prone to fractures (stress/insufficiency fractures), the healing potential is preserved. * **Option D:** Fracture healing is independent of puberty. While growth plates (epiphyses) close at puberty, the secondary union of a diaphyseal fracture is governed by local stability and biology, not the onset of adolescence. **3. Clinical Pearls for NEET-PG:** * **Bone Quality in Polio:** Bones in polio-affected limbs are often **osteoporotic and gracile** (narrower diameter) due to the loss of muscle pull (Wolff’s Law). * **Fracture Risk:** These patients are at a higher risk of fractures due to frequent falls (muscle weakness) and fragile bone structure. * **Management:** Undisplaced fractures are treated conservatively. However, if surgery is needed, the narrow medullary canal and poor bone quality can make internal fixation technically challenging. * **Key Concept:** Neurological deficits (Polio, Paraplegia) do not prevent bone union; in fact, in some neurological conditions like Head Injuries, fracture healing may actually be accelerated (hypertrophic callus).

Question 66: A 3-year-old child presents with a fracture of the femoral shaft, which has been immobilized on traction for two months. What is the next step in management?

A. Hip spica cast and, if necessary, internal fixation (Correct Answer)
B. Callow traction for 2 months
C. Open reduction and Kuntscher's intramedullary nailing or plating
D. Traction by Thomas splint

Explanation: **Explanation:** The management of femoral shaft fractures in children is primarily age-dependent. For a **3-year-old child**, the standard of care involves a period of traction followed by a **Hip Spica cast**. 1. **Why Option A is correct:** In children aged 6 months to 5 years, the goal is non-operative management due to the high remodeling potential of the bone. Typically, "Gallows" or "Thomas" traction is used for 2–3 weeks until the fracture site becomes "sticky" (early callus formation), followed by a Hip Spica cast for 6–8 weeks to maintain alignment. If conservative methods fail to maintain acceptable reduction, internal fixation (usually with Titanium Elastic Nails - TENS) is considered. 2. **Why Option B is wrong:** While Gallows (overhead) traction is used for children under 2 years (or <12-15kg), 2 months is an excessively long duration for traction alone, leading to complications like skin breakdown and joint stiffness. 3. **Why Option C is wrong:** Open reduction with K-nailing or plating is avoided in young children. K-nails are contraindicated because they are rigid and can damage the trochanteric apophysis or blood supply to the femoral head. Plating is reserved only for specific polytrauma cases. 4. **Why Option D is wrong:** Thomas splint traction is a component of the initial management but is not the definitive "next step" after the immobilization phase; the transition to a cast is necessary for mobilization. **Clinical Pearls for NEET-PG:** * **0–6 months:** Pavlik harness or Spica cast. * **6 months – 5 years:** Traction followed by Hip Spica (Gold Standard). * **5–12 years:** Titanium Elastic Nailing System (TENS) is the treatment of choice. * **>12 years/Skeletally mature:** Intramedullary interlocking nailing (Lateral entry). * **Overgrowth Phenomenon:** Femoral fractures in children (2–10 years) often result in 1–2 cm of compensatory overgrowth due to hyperemia; hence, a small amount of "side-to-side" (bayonet) apposition is acceptable.

Question 67: Rolando's fracture is:

A. Fracture distal radius with inferior radioulnar dislocation
B. Fracture distal end of radius with dorsal displacement and angulation
C. Fracture radial styloid
D. Fracture extra-articular surface of the base of the first metacarpal (Correct Answer)

Explanation: **Explanation:** **Rolando’s fracture** is a comminuted intra-articular fracture involving the base of the first metacarpal. It typically presents as a **Y or T-shaped fracture pattern**. While the question identifies it as involving the base of the first metacarpal, it is crucial to note that it is technically **intra-articular** (involving the carpometacarpal joint), distinguishing it from the extra-articular Epibasal fracture. **Analysis of Options:** * **Option D (Correct):** Refers to the base of the first metacarpal. In the context of NEET-PG, Rolando’s and Bennett’s are the two primary fractures of the first metacarpal base. Rolando’s is the more complex, comminuted version. * **Option A (Incorrect):** This describes a **Galeazzi fracture-dislocation** (distal radius fracture with DRUJ disruption). * **Option B (Incorrect):** This describes a **Colles’ fracture** (distal radius fracture with dorsal tilt/displacement). * **Option C (Incorrect):** This describes a **Chauffeur’s fracture** (Hutchinson fracture). **High-Yield Clinical Pearls for NEET-PG:** * **Bennett’s Fracture:** An oblique, intra-articular fracture-dislocation of the base of the first metacarpal. It is simpler (two fragments) than Rolando’s. * **Mechanism:** Rolando’s is usually caused by a significant axial load applied to a partially flexed thumb. * **Prognosis:** Rolando’s has a worse prognosis than Bennett’s due to the difficulty in achieving anatomical reduction of the comminuted articular surface. * **Management:** Often requires Open Reduction and Internal Fixation (ORIF) with a plate or K-wires, though highly comminuted cases may require an external fixator.

Question 68: Which of the following is not an indication for secondary nerve repair?

A. Syndrome of irritation
B. Division of nerve by sharp object (Correct Answer)
C. Delayed presentation of nerve injury
D. Syndrome of incomplete interruption

Explanation: In nerve injuries, the timing of repair is categorized into **Primary Repair** (within 6–24 hours) and **Secondary Repair** (delayed by 3 weeks or more). ### Why "Division of nerve by sharp object" is the Correct Answer A nerve divided by a sharp object (e.g., a clean glass cut or a surgical scalpel) is the classic indication for **Primary Repair**. Because the wound is clean and the nerve ends are not crushed or ragged, they can be easily approximated without tension. Primary repair offers the best functional outcomes as it prevents retraction of nerve ends and minimizes endoneurial scarring. ### Explanation of Incorrect Options (Indications for Secondary Repair) * **Syndrome of Irritation (A):** This involves severe pain or causalgia post-injury. It is managed after the initial inflammatory phase has subsided to identify the specific site of neuroma or compression. * **Delayed Presentation (C):** If a patient presents weeks after the injury, primary repair is no longer an option. The nerve ends will have retracted, requiring mobilization or grafting (Secondary Repair). * **Syndrome of Incomplete Interruption (D):** When a nerve is partially injured, surgeons often wait to observe spontaneous recovery. If recovery plateaus or fails, secondary exploration and repair are performed. ### NEET-PG High-Yield Pearls * **Primary Repair:** Indicated for clean, sharp cuts with no gap. * **Secondary Repair:** Indicated for **crush injuries**, **infected wounds**, or **gunshot wounds** where the zone of injury is not immediately clear. Waiting 3 weeks allows the damaged segment to fibrose, making it easier to identify healthy tissue for suturing. * **Sunderland Classification:** Remember that Grade I (Neuropraxia) and Grade II (Axonotmesis) usually do not require surgical repair, whereas Grade III-V often do. * **Gold Standard:** The best results for nerve repair are achieved using **microsurgical techniques** (epineural or fascicular repair).

Question 69: Which of the following is NOT true about intracapsular neck fracture?

A. Less than 1 inch shortening
B. Less than 45 degrees of external rotation
C. Trivial trauma can cause fracture
D. Severe pain around the hip (Correct Answer)

Explanation: In intracapsular femoral neck fractures, the fracture occurs within the joint capsule. This anatomical location dictates the clinical presentation and distinguishes it from extracapsular (intertrochanteric) fractures. ### **Why "Severe Pain" is the Correct Answer (The "NOT True" Statement)** In an intracapsular fracture, the **joint capsule is inelastic and tight**. When a fracture occurs, the resulting hematoma increases intra-articular pressure, which actually limits the displacement of the fragments. Because the fragments are contained and displacement is minimal compared to extracapsular fractures, the pain is often described as **dull or moderate** rather than severe. In some cases of impacted fractures, the patient may even be able to bear weight. ### **Analysis of Other Options** * **A. Less than 1 inch shortening:** Since the fracture is within the capsule, the attachments of the capsule and the psoas muscle prevent significant proximal migration of the distal fragment. Shortening is typically minimal (usually <2 cm). * **B. Less than 45 degrees of external rotation:** The capsule remains intact, limiting the degree of external rotation. In contrast, extracapsular fractures often show 90 degrees of external rotation (the foot touches the bed). * **C. Trivial trauma:** These fractures are common in elderly osteoporotic patients. A simple trip or a low-energy fall is the most common mechanism of injury. ### **High-Yield Clinical Pearls for NEET-PG** * **Blood Supply:** The main supply is the **Medial Circumflex Femoral Artery**. Intracapsular fractures carry a high risk of **Avascular Necrosis (AVN)** and **Non-union** due to the precarious blood supply and lack of cambium layer in the endosteum. * **Garden’s Classification:** Used to grade displacement (Stage I to IV); it is the most important predictor of prognosis. * **Pauwels' Classification:** Based on the angle of the fracture line; higher angles indicate increased shear forces and instability. * **Management Rule:** "Replace the head in the elderly (Arthroplasty), Save the head in the young (Internal fixation with CC screws)."

Question 70: Tennis elbow is defined as:

A. Inflammation of the lateral epicondyle of the humerus (Correct Answer)
B. Inflammation of the medial epicondyle of the humerus
C. Avulsion injury of the head of the radius
D. Avulsion injury of the olecranon process

Explanation: **Explanation:** **Tennis Elbow (Lateral Epicondylitis)** is a clinical condition characterized by pain and tenderness over the lateral epicondyle of the humerus. It is essentially an overuse injury caused by repetitive strain on the **common extensor origin**, specifically involving the **Extensor Carpi Radialis Brevis (ECRB)** muscle. Chronic repetitive microtrauma leads to angiofibroblastic hyperplasia (degenerative changes) rather than pure acute inflammation. **Analysis of Options:** * **Option A (Correct):** It involves the lateral epicondyle. Clinical tests like **Cozen’s test** and **Mill’s test** are used to elicit pain by resisting wrist extension or stretching the extensors. * **Option B (Incorrect):** Inflammation of the medial epicondyle is known as **Golfer’s Elbow**. It involves the common flexor origin (primarily Pronator teres and Flexor carpi radialis). * **Option C (Incorrect):** Avulsion of the radial head is not associated with tennis elbow. Radial head fractures usually occur due to a fall on an outstretched hand (FOOSH). * **Option D (Incorrect):** Avulsion of the olecranon process involves the insertion of the triceps brachii and is typically a high-energy traumatic injury. **High-Yield Clinical Pearls for NEET-PG:** * **Most common muscle involved:** Extensor Carpi Radialis Brevis (ECRB). * **Clinical Presentation:** Pain during activities like gripping, lifting a cup of tea, or shaking hands. * **Treatment:** Conservative management (Rest, NSAIDs, bracing) is the first line. Refractory cases may require corticosteroid injections or surgical release (Nirschl procedure). * **Differential Diagnosis:** Radial Tunnel Syndrome (compression of the posterior interosseous nerve), which presents with pain distal to the epicondyle.

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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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Soft Tissue Injuries

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Trauma — MCQs

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