Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 691: What deformity is typically seen in a posterior elbow dislocation?

A. Flexion (Correct Answer)
B. Extension
C. Medial deviation
D. Lateral deviation

Explanation: In a **posterior elbow dislocation**, which is the most common type of elbow dislocation, the radius and ulna are displaced posteriorly and superiorly relative to the distal humerus. ### **Explanation of the Correct Answer** **A. Flexion:** Following the injury, the elbow is typically held in a position of **semi-flexion (approximately 45° to 90°)**. This occurs because the triceps tendon is stretched over the displaced olecranon, acting as a tether, while the brachialis and biceps muscles undergo protective spasms. This position minimizes intra-articular pressure and tension on the surrounding soft tissues. ### **Explanation of Incorrect Options** * **B. Extension:** The elbow cannot be extended due to the mechanical locking of the olecranon against the posterior humerus and the intense pain/spasm of the flexor muscles. * **C & D. Medial/Lateral Deviation:** While minor side-to-side displacement may occur depending on the direction of the force, these are not the characteristic "deformity" positions. The primary clinical presentation is defined by the sagittal plane (flexion). ### **NEET-PG High-Yield Pearls** * **Mechanism of Injury:** Most commonly a fall on an outstretched hand (FOOSH) with the elbow in extension and abduction. * **Clinical Sign:** The **Three-Point Relationship** (the triangle formed by the olecranon and the two epicondyles) is **disturbed** in dislocation, whereas it remains intact in supracondylar fractures. * **Associated Injury:** Always check for **Brachial Artery** and **Median/Ulnar nerve** injuries. * **Radiology:** The "fat pad sign" may be seen, but the diagnosis is confirmed by the posterior displacement of the olecranon on a lateral X-ray. * **Management:** Emergency closed reduction followed by brief immobilization in flexion.

Question 692: Dislocation without fracture is most commonly seen in which part of the spine?

A. Sacral spine
B. Lumbar spine
C. Cervical spine (Correct Answer)
D. Thoracic spine

Explanation: **Explanation:** The **Cervical spine** is the most common site for dislocation without an associated fracture (pure dislocation) due to its unique anatomical configuration. **1. Why Cervical Spine is Correct:** The primary reason is the **orientation of the facet joints**. In the cervical region, the articular facets are oriented more horizontally (approximately 45 degrees to the axial plane). This horizontal alignment provides a wide range of motion but offers less bony resistance against horizontal shearing forces. Consequently, under traumatic stress (like hyperflexion), the inferior articular process of the superior vertebra can "glide" over the superior process of the inferior vertebra, leading to **perched or locked facets** without necessarily breaking the bone. **2. Why Other Options are Incorrect:** * **Thoracic Spine:** This region is the most stable part of the spine due to the splinting effect of the rib cage and the vertical orientation of the facets. Dislocation here almost always requires massive force, which typically results in concomitant fractures (Fracture-Dislocation). * **Lumbar Spine:** The facets in the lumbar region are oriented vertically (sagittal plane), which provides strong mechanical resistance to forward displacement. Therefore, displacement usually requires a "Seat-belt injury" (Chance fracture) or a fracture of the facets themselves. * **Sacral Spine:** The sacral vertebrae are fused into a single bone; therefore, a dislocation between sacral segments is anatomically impossible in adults. **NEET-PG High-Yield Pearls:** * **Most common level for cervical dislocation:** C5-C6 (highest mobility). * **"Jumped facets":** A clinical term for bilateral facet dislocation, often presenting with significant neurological deficits. * **Stability:** The cervical spine is the most mobile but least stable; the thoracic spine is the least mobile but most stable. * **Whiplash injury:** A common mechanism for cervical soft tissue injury without fracture/dislocation.

Question 693: What is a straddle fracture?

A. Fracture of the skull
B. Fracture of the C5 vertebra
C. Multiple rib fractures on both sides of the midline
D. Pelvic fracture (Correct Answer)

Explanation: **Explanation:** A **Straddle Fracture** is a specific type of unstable pelvic fracture characterized by **bilateral fractures of the superior and inferior pubic rami**. It is typically caused by a direct blow to the midline of the symphysis pubis, such as falling onto a hard object (e.g., a manhole cover or a bicycle frame). **Why the correct answer is right:** * **Pelvic Fracture:** The term "straddle" refers to the mechanism of injury involving the perineum. This injury results in a "floating" anterior segment of the pelvis. It is clinically significant because it is associated with a high incidence (up to 20%) of **genitourinary injuries**, particularly ruptures of the posterior urethra or bladder. **Why the incorrect options are wrong:** * **A. Fracture of the skull:** Skull fractures are classified by location (vault, base) or type (depressed, linear), but "straddle" is not a term used in neurotrauma. * **B. Fracture of C5 vertebra:** Cervical fractures have specific names like Jefferson (C1) or Hangman’s (C2). C5 is a common site for burst fractures, but not straddle fractures. * **C. Multiple rib fractures:** This describes a **Flail Chest** (if 3 or more ribs are broken in 2 or more places), which causes paradoxical respiration. **High-Yield Clinical Pearls for NEET-PG:** * **Malgaigne Fracture:** The most common vertical shear pelvic fracture (ipsilateral rami fracture + sacroiliac joint disruption). * **Duverney Fracture:** Isolated fracture of the iliac wing (stable). * **Open Book Injury:** Disruption of the pubic symphysis with injury to the sacroiliac ligaments. * **Investigation of Choice:** AP view X-ray is the initial screening tool, but **CT Scan** is the gold standard for defining pelvic ring stability. * **Management:** In hemodynamically unstable pelvic fractures, the first step is **Pelvic Binding** to reduce pelvic volume and tamponade bleeding.

Question 694: Which of the following statements is NOT true regarding anterior dislocation of the hip?

A. Femoral nerve is more commonly injured.
B. The limb is rotated laterally.
C. Associated with lengthening of the limb.
D. Associated with shortening of the limb. (Correct Answer)

Explanation: **Explanation:** In hip dislocations, the clinical presentation is determined by the final position of the femoral head relative to the acetabulum. In **Anterior Dislocation of the Hip**, the femoral head is displaced anteriorly and usually inferiorly (obturator type) or superiorly (pubic type). **1. Why Option D is the Correct Answer (The "False" Statement):** In anterior dislocations, the femoral head is displaced away from the acetabulum in a manner that typically results in **lengthening** of the limb, not shortening. Shortening is a hallmark feature of **posterior** hip dislocations. Therefore, the statement "Associated with shortening of the limb" is incorrect regarding anterior dislocation. **2. Analysis of Other Options:** * **Option A (Femoral nerve injury):** In anterior dislocations, the femoral head moves forward, putting direct pressure on the **femoral nerve** and vessels. (In contrast, the sciatic nerve is at risk in posterior dislocations). * **Option B (Lateral rotation):** The displacement of the head anterior to the axis of the femur causes the limb to assume a position of **external (lateral) rotation** and abduction. * **Option C (Lengthening):** As the head is displaced inferiorly and anteriorly, the effective length of the limb increases. **Clinical Pearls for NEET-PG:** | Feature | Posterior Dislocation (Most Common) | Anterior Dislocation | | :--- | :--- | :--- | | **Attitude** | Flexion, Adduction, **Internal Rotation** | Flexion, Abduction, **External Rotation** | | **Limb Length** | **Shortening** | **Lengthening** | | **Nerve Injury** | Sciatic Nerve | Femoral Nerve | | **Mechanism** | Dashboard injury | Forced abduction/extension | * **Mnemonic for Posterior Dislocation:** **S**hortened, **A**dducted, **I**nternally rotated (**SAI**). * **X-ray finding:** In anterior dislocation, the lesser trochanter is more visible due to external rotation.

Question 695: Which of the following fractures can cause cubitus varus deformity as a complication?

A. Fracture of the lateral condyle of the humerus
B. Supracondylar fracture of the humerus (Correct Answer)
C. Fracture of the radial head
D. Chronic osteomyelitis

Explanation: **Explanation:** **Supracondylar fracture of the humerus** is the most common cause of **Cubitus Varus** (also known as "Gunstock deformity"). This deformity occurs primarily due to the **malunion** of the distal fragment, specifically when there is a failure to correct the **medial tilt, internal rotation, and posterior displacement**. While it is a cosmetic deformity rather than a functional one, it is a high-yield topic for NEET-PG. **Analysis of Options:** * **Option A (Lateral Condyle Fracture):** This fracture typically leads to **Cubitus Valgus** (increased carrying angle) due to non-union or growth arrest of the lateral epiphysis. Cubitus valgus is classically associated with **Tardy Ulnar Nerve Palsy**. * **Option C (Radial Head Fracture):** This involves the proximal radius and usually results in restricted forearm rotation (pronation/supination) or elbow stiffness, but does not typically alter the carrying angle of the humerus. * **Option D (Chronic Osteomyelitis):** While it can cause growth disturbances or bone destruction, it is not a primary or common cause of cubitus varus compared to the mechanical malunion of a supracondylar fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication of Supracondylar Fracture:** Stiffness (overall); **Cubitus Varus** (most common deformity). * **Most serious complication:** Volkmann’s Ischemic Contracture (VIC) due to brachial artery injury or compartment syndrome. * **Nerve Injuries:** The **Anterior Interosseous Nerve (AIN)** is the most common nerve injured in extension-type fractures; the Ulnar nerve is most common in flexion-type. * **Baumann’s Angle:** Used radiologically to assess the reduction and predict the risk of cubitus varus.

Question 696: A 4-year-old child sustained a fall on an outstretched hand. X-rays revealed a fracture line at the physis with a small metaphyseal fragment. There was no epiphyseal fracture. What type of injury is this according to the Salter-Harris Classification?

A. Type I
B. Type II (Correct Answer)
C. Type III
D. Type IV

Explanation: ### Explanation The **Salter-Harris Classification** is the standard system for describing pediatric physeal (growth plate) fractures. The correct answer is **Type II** based on the specific anatomical involvement described. #### Why Type II is Correct: In a **Salter-Harris Type II** injury, the fracture line travels through the **physis** (growth plate) and then exits through the **metaphysis**. The presence of a "small metaphyseal fragment" (known as the **Thurston-Holland sign**) is the pathognomonic feature of this type. It is the most common type of physeal injury, typically occurring in children older than 2 years. #### Why Other Options are Incorrect: * **Type I:** The fracture occurs exclusively through the physis. There is no bony involvement of the metaphysis or epiphysis. It is often a clinical diagnosis as X-rays may appear normal. * **Type III:** The fracture line passes through the physis and exits through the **epiphysis** into the joint space. This is an intra-articular fracture. * **Type IV:** The fracture line is vertical/oblique and passes through all three elements: the **metaphysis, physis, and epiphysis**. This carries a high risk of growth arrest. #### NEET-PG High-Yield Pearls: * **Mnemonic (SALTER):** * **S** (Type I): **S**ame/Straight across (Physis only) * **A** (Type II): **A**bove (Metaphysis) — *Most Common* * **L** (Type III): **L**ower (Epiphysis) — *Intra-articular* * **T** (Type IV): **T**hrough/Two (Metaphysis + Epiphysis) * **ER** (Type V): **ER**asure/Crush (Compression of physis) — *Worst Prognosis* * **Thurston-Holland Sign:** The triangular metaphyseal fragment seen in Type II fractures. * **Prognosis:** Types III and IV require anatomical reduction because they involve the joint surface and the germinal layer of the physis. Type V has the highest risk of premature physeal closure.

Question 697: All of the following are types of avascular nonunion of fracture except?

A. Torsion wedge nonunion
B. Oligotrophic nonunion (Correct Answer)
C. Comminuted nonunion
D. Defect nonunion

Explanation: Nonunion is broadly classified into two categories based on biological activity and vascularity: **Hypertrophic** (Hypervascular) and **Atrophic/Avascular** (Hypovascular). ### 1. Why Oligotrophic Nonunion is the Correct Answer **Oligotrophic nonunion** is a type of **Hypertrophic nonunion**. Unlike other hypertrophic types (like "Elephant foot"), it does not show exuberant callus on X-ray, making it look biologically inactive. However, biological studies and bone scans prove it is **highly vascular**. It occurs due to major displacement of fragments or inadequate fixation, rather than a lack of blood supply. Because it has a preserved blood supply, it has excellent healing potential if stability is improved. ### 2. Explanation of Incorrect Options (Avascular Types) The following are types of **Avascular (Atrophic) nonunion**, characterized by a lack of blood supply and biological inactivity: * **Torsion Wedge Nonunion (A):** Contains an intermediate fragment (wedge) that has lost its blood supply. It usually heals on one side while the other remains ununited. * **Comminuted Nonunion (C):** Results from multiple necrotic intermediate fragments (sequestra) that lack vascularity, often due to high-energy trauma. * **Defect Nonunion (D):** Occurs when a segment of the bone shaft is missing (due to open injury or resection). The ends are viable, but the gap is too large to bridge. ### 3. NEET-PG High-Yield Pearls * **Elephant Foot Nonunion:** Hypertrophic type with massive callus; caused by **inadequate fixation/instability**. * **Atrophic Nonunion:** No callus, bone ends are osteoporotic/tapered; caused by **poor biology/vascularity**. * **Treatment Principle:** Hypertrophic nonunions generally require **stability** (e.g., compression plating/nailing), while Atrophic nonunions require **biology** (e.g., bone grafting). * **Definition:** A nonunion is typically diagnosed when there is no clinical or radiological evidence of healing for **9 months**, with no progress for the last 3 months.

Question 698: A 32-year-old biker sustained an injury over his left hip joint. X-ray revealed a posterior dislocation of the right hip joint. What is the clinical attitude of the affected lower limb?

A. External rotation, extension, and abduction
B. Internal rotation, flexion, and adduction (Correct Answer)
C. Internal rotation, extension, and abduction
D. External rotation, flexion, and abduction

Explanation: ### Explanation In orthopaedic trauma, the "attitude" of a limb refers to the characteristic position it assumes following a specific injury. This is a high-yield topic for NEET-PG, particularly for hip dislocations. **1. Why Option B is Correct:** Posterior dislocation is the most common type of hip dislocation (approx. 90%), typically caused by a "dashboard injury" where a force is applied to the knee while the hip is flexed. In this position, the femoral head is forced out of the acetabulum posteriorly. The resulting clinical attitude is **Flexion, Adduction, and Internal Rotation (FADIR)**. This occurs because the femoral head is displaced behind the acetabulum, and the tension of the surrounding ligaments (specifically the iliofemoral ligament) pulls the limb into this classic "deformity." **2. Why the Other Options are Incorrect:** * **Option D (External rotation, flexion, and abduction):** This is the classic attitude of an **Anterior Hip Dislocation**. In anterior dislocations, the limb is typically held in "FABER" (Flexion, Abduction, and External Rotation). * **Option A (External rotation, extension, and abduction):** This does not correspond to a standard hip dislocation. However, **External Rotation and Shortening** (often with extension) is the hallmark of a **Fracture of the Neck of Femur**. * **Option C:** This combination of movements is anatomically inconsistent with the common mechanisms of hip trauma. **Clinical Pearls for NEET-PG:** * **Posterior Dislocation:** Most common; associated with Sciatic Nerve injury (specifically the peroneal component). * **Anterior Dislocation:** Less common; associated with Femoral Nerve/Vessel injury. * **Mnemonic:** * **P**osterior = **P**igeon-toed (Internal Rotation). * **A**nterior = **A**way from midline (External Rotation/Abduction). * **Management:** This is an orthopaedic emergency. Reduction should be performed within 6 hours to minimize the risk of **Avascular Necrosis (AVN)** of the femoral head.

Question 699: What is a green-stick fracture?

A. Seen mostly in the elderly
B. Fatigue fracture
C. Spiral fracture of long bone
D. Periosteum of cortex is intact and periosteum is crumpled (Correct Answer)

Explanation: ### Explanation **Concept Overview:** A **Greenstick fracture** is an incomplete fracture typically seen in children. Because pediatric bones are more flexible and have a thick, active periosteum, they tend to bend and partially break rather than snap completely. The term is an analogy to a "green" (young) branch of a tree that bends and splinters on one side when stressed, rather than breaking into two distinct pieces. **Why Option D is Correct:** In a greenstick fracture, the bone undergoes **plastic deformation**. The cortex on the convex side (tension side) breaks, while the cortex and **periosteum on the concave side (compression side) remain intact** but often appear "crumpled" or buckled. This intact periosteal hinge provides stability to the fracture, though it can also make anatomical reduction difficult unless the bone is "completed" (broken fully) during manipulation. **Analysis of Incorrect Options:** * **Option A:** These are seen in **children**, not the elderly. Elderly bones are brittle and prone to comminuted or osteoporotic fractures. * **Option B:** A **Fatigue (Stress) fracture** results from repetitive submaximal loading on normal bone (e.g., March fracture in recruits), not a single traumatic bending force. * **Option C:** A **Spiral fracture** is a complete fracture caused by a rotational/twisting force, common in long bones but distinct from the incomplete nature of a greenstick injury. **High-Yield Clinical Pearls for NEET-PG:** * **Common Site:** Forearm (Radius and Ulna). * **Management:** Often requires closed reduction. If the deformity is significant, the surgeon may need to "complete" the fracture to prevent the intact periosteum from pulling the bone back into a malaligned position (recoil). * **Related Pediatric Fracture:** **Torus (Buckle) fracture**, where the cortex bulges due to axial loading without any visible break in the cortex.

Question 700: What is the treatment of choice in a fracture neck of femur in a 40-year-old male presenting after 2 days?

A. Hemiarthroplasty
B. Closed reduction and internal fixation by cancellous screws (Correct Answer)
C. Closed reduction and internal fixation by Austin Moore pins
D. Plaster and rest

Explanation: ### Explanation The management of a fracture of the femoral neck is primarily determined by the **age of the patient** and the **duration since injury**. **1. Why Option B is Correct:** In young adults (typically defined as <60 years), the primary goal is **head preservation**. Even if the fracture is displaced, every attempt must be made to save the natural femoral head to avoid the long-term complications of prostheses (like loosening or wear) in an active individual. **Closed Reduction and Internal Fixation (CRIF)** using **multiple cancellous screws** is the gold standard. A 2-day delay is considered an "early" presentation; internal fixation remains viable as long as there is no radiological evidence of avascular necrosis (AVN). **2. Why Other Options are Incorrect:** * **Option A (Hemiarthroplasty):** This is reserved for elderly patients (>60–65 years) with low functional demands. In a 40-year-old, a prosthesis would likely fail within 10–15 years, necessitating a difficult revision surgery. * **Option C (Austin Moore pins):** These are largely obsolete in modern orthopaedics. Cancellous screws provide superior compression and rotational stability compared to pins. * **Option D (Plaster and rest):** Neck of femur fractures are intra-articular; they have poor healing potential due to the lack of a periosteal layer and the presence of synovial fluid. Conservative management leads to non-union and is not indicated. **Clinical Pearls for NEET-PG:** * **Garden’s Classification:** Used to grade displacement (I & II are undisplaced; III & IV are displaced). * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (Type III) are more unstable and have a higher risk of non-union. * **The "Golden Period":** Ideally, fixation should occur within 6–12 hours to minimize the risk of AVN, though fixation is still attempted in young patients presenting within weeks. * **Complications:** The two most common complications are **Avascular Necrosis (AVN)** and **Non-union**.

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Open Fractures

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Fractures in Children

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Fracture Complications

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Trauma — MCQs

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