Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 721: Limb salvage can be done in all except?

A. Nerve injury
B. Vascular injury (Correct Answer)
C. Bone injury
D. Muscle injury

Explanation: ### Explanation In the context of orthopaedic trauma, **Limb Salvage** refers to the surgical effort to preserve a limb that has sustained severe injury, rather than performing a primary amputation. The decision-making process is often guided by scoring systems like the **Mangled Extremity Severity Score (MESS)**. **Why Vascular Injury is the Correct Answer:** While the question asks where limb salvage can be done "except," it highlights a critical clinical threshold. In cases of severe trauma, a **prolonged period of warm ischemia** (typically >6 hours) due to unrepaired vascular injury is the most significant contraindication to limb salvage. If the blood supply is not restored within this window, irreversible muscle necrosis and nerve death occur, leading to a non-functional, gangrenous limb. In such scenarios, salvage is often impossible or life-threatening (due to crush syndrome/reperfusion injury), making amputation the safer choice. **Analysis of Other Options:** * **Bone Injury (C):** Modern fixation techniques (ILIZAROV, intramedullary nailing, or bone grafting) allow for the salvage of limbs even with massive bone loss or comminution. * **Muscle Injury (D):** Extensive soft tissue loss can be managed with debridement and plastic surgical procedures like flaps or skin grafts. * **Nerve Injury (A):** While a "painless, paralyzed limb" was once an indication for amputation, primary nerve repair or secondary tendon transfers now allow for functional salvage in many cases. **NEET-PG High-Yield Pearls:** * **MESS Score:** A score of **≥ 7** is highly predictive of the need for amputation. * **Components of MESS:** Skeletal/soft tissue injury, Limb ischemia (the most weighted factor), Shock, and Age. * **The "Golden Period":** Revascularization must ideally occur within **6 hours** to prevent irreversible damage. * **Absolute Contraindication:** Complete anatomical disruption of the posterior tibial nerve in adults (traditionally considered an indication for amputation, though now controversial).

Question 722: Tenderness in the anatomical snuff box is characteristic of which carpal bone fracture?

A. Scaphoid (Correct Answer)
B. Capitate
C. Lunate
D. Triquetrum

Explanation: **Explanation:** **Scaphoid fracture** is the most common carpal bone fracture, typically resulting from a fall on an outstretched hand (FOOSH). The scaphoid forms the floor of the **anatomical snuff box**. Therefore, localized tenderness in this area is considered pathognomonic for a scaphoid injury until proven otherwise. **Why the other options are incorrect:** * **Capitate:** This is the largest carpal bone, located centrally in the distal row. Fractures are rare and usually associated with complex perilunate injuries; tenderness would be deep and central, not in the snuff box. * **Lunate:** Located medial to the scaphoid, it is more prone to dislocation (leading to Median nerve compression) or avascular necrosis (Kienböck's disease) rather than isolated fractures. Tenderness is typically over the dorsum of the wrist, distal to Lister’s tubercle. * **Triquetrum:** This is the second most common carpal fracture (often a dorsal chip fracture). Tenderness is localized to the ulnar (medial) aspect of the wrist, distal to the ulnar styloid. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** The scaphoid has a **retrograde blood supply** (from the distal pole to the proximal pole). This makes the proximal pole highly susceptible to **Avascular Necrosis (AVN)** and non-union. * **Radiology:** Fractures may not appear on initial X-rays. If clinical suspicion is high despite a normal X-ray, the wrist should be immobilized in a **Scaphoid cast** (thumb spica) and re-imaged after 10–14 days. * **Anatomical Snuff Box Boundaries:** Lateral (Abductor pollicis longus, Extensor pollicis brevis) and Medial (Extensor pollicis longus).

Question 723: Tardy ulnar nerve palsy is most commonly associated with which type of fracture?

A. Medial condyle fracture
B. Lateral condyle fracture (Correct Answer)
C. Olecranon fracture
D. Distal humerus fracture

Explanation: **Explanation:** **Tardy Ulnar Nerve Palsy** is a delayed-onset ulnar neuropathy that occurs years after an elbow injury. The correct answer is **Lateral condyle fracture** because it is the most common cause of **Cubitus Valgus** (increased carrying angle). 1. **Pathophysiology:** A fracture of the lateral condyle in childhood often results in **non-union**. As the child grows, the medial side of the humerus continues to grow normally while the lateral side lags, leading to a progressive valgus deformity. This deformity increases the distance the ulnar nerve must travel around the medial epicondyle, causing chronic stretching and frictional neuritis, eventually leading to palsy. 2. **Analysis of Incorrect Options:** * **Medial condyle fracture:** While the ulnar nerve is anatomically closer to the medial condyle, fractures here usually cause acute injury or result in *Cubitus Varus*, which does not stretch the nerve. * **Olecranon fracture:** These may cause acute ulnar nerve irritation but are not typically associated with the progressive valgus deformity required for "tardy" palsy. * **Distal humerus fracture (Supracondylar):** The most common complication here is *Cubitus Varus* (Gunstock deformity), which is associated with **Tardy Radial Nerve palsy** (rarely) rather than ulnar. **Clinical Pearls for NEET-PG:** * **Latency:** The symptoms (wasting of intrinsic hand muscles, clawing) typically appear **10–20 years** after the initial injury. * **Treatment of choice:** Anterior transposition of the ulnar nerve. * **Most common cause of Cubitus Varus:** Malunited Supracondylar fracture. * **Most common cause of Cubitus Valgus:** Non-union of Lateral Condyle fracture.

Question 724: What is a condylar fracture with tearing of the skin called?

A. Simple fracture.
B. Compound fracture. (Correct Answer)
C. Complex fracture.
D. Comminuted fracture.

Explanation: ### Explanation The correct answer is **Compound fracture** (also known as an **Open fracture**). **1. Why it is correct:** A fracture is classified as "compound" or "open" when there is a communication between the fracture site (the hematoma) and the external environment through a breach in the skin and underlying soft tissues. In this specific case, a condylar fracture accompanied by tearing of the skin allows for potential bacterial contamination from the outside, which is the hallmark of a compound fracture. **2. Why other options are incorrect:** * **Simple fracture:** Also known as a "closed" fracture, the overlying skin remains intact. There is no communication between the bone and the exterior. * **Complex fracture:** This is a non-specific descriptive term often used for fractures with multiple fragments, difficult reduction, or associated neurovascular injury, but it does not specifically denote skin involvement. * **Comminuted fracture:** This refers to the **pattern** of the break where the bone is splintered or crushed into three or more fragments. A comminuted fracture can be either simple (closed) or compound (open). **3. Clinical Pearls for NEET-PG:** * **Gustilo-Anderson Classification:** The gold standard for grading open fractures (Type I to IIIC) based on wound size, soft tissue damage, and vascular status. * **Golden Period:** Debridement of open fractures should ideally occur within 6 hours to minimize the risk of osteomyelitis. * **Management Priority:** In open fractures, the priority is "Life over Limb" (ATLS protocols), followed by aggressive debridement, antibiotics, and stabilization (often via external fixation). * **Tetanus Prophylaxis:** Always mandatory in the management of any compound fracture.

Question 725: What is the physiological interruption of nerve transmission?

A. Neuropraxia (Correct Answer)
B. Neurotmesis
C. Axonotmesis
D. None of the above

Explanation: The classification of nerve injuries is a high-yield topic for NEET-PG, primarily based on the **Seddon Classification**. ### **Explanation of the Correct Answer** **A. Neuropraxia** is the correct answer because it represents the mildest form of nerve injury. It is a **physiological interruption** of nerve conduction without any anatomical disruption of the axon or the connective tissue sheath. It is typically caused by local compression or ischemia (e.g., Saturday Night Palsy). Since the axon remains intact, there is no Wallerian degeneration, and recovery is complete and rapid (usually within days to weeks) once the pressure is relieved. ### **Analysis of Incorrect Options** * **B. Neurotmesis:** This is the most severe grade. It involves complete anatomical disruption of the entire nerve trunk (axon and all supporting connective tissue sheaths). Recovery is impossible without surgical intervention. * **C. Axonotmesis:** This involves anatomical disruption of the **axon** itself, but the supporting connective tissue frameworks (endoneurium, perineurium, and epineurium) remain intact. Wallerian degeneration occurs distal to the injury, and recovery is slow (1 mm/day) but possible because the intact sheaths guide regenerating sprouts. ### **Clinical Pearls for NEET-PG** * **Wallerian Degeneration:** Occurs in Axonotmesis and Neurotmesis, but **never** in Neuropraxia. * **Tinel’s Sign:** This is **absent** in Neuropraxia (as there is no axonal regeneration) but becomes **positive** in Axonotmesis as the nerve begins to heal. * **Sunderland Classification:** An expansion of Seddon’s; Neuropraxia corresponds to Grade I, Axonotmesis to Grades II-IV, and Neurotmesis to Grade V. * **Recovery Sequence:** In nerve injuries, **Motor** function is the first to go and last to return; **Pain** is the last to go and first to return.

Question 726: What is the best treatment for a 3-week-old fracture of the femoral shaft with nonunion?

A. Bone graft with internal fixation (Correct Answer)
B. External fixation
C. Internal fixation only
D. Prosthesis

Explanation: ### Explanation The management of femoral shaft nonunion requires addressing both **mechanical stability** and **biological potential**. **1. Why Bone Graft with Internal Fixation is Correct:** Nonunion is defined as a failure of the bone to heal within the expected timeframe. In the femur, this is often due to either excessive motion at the fracture site or poor biology. **Internal fixation** (usually an intramedullary nail or a compression plate) provides the rigid stability necessary for primary bone healing. However, since the fracture has already progressed to a nonunion state, the local biology is compromised. Adding a **bone graft** (osteoconductive and osteoinductive) provides the necessary cellular scaffold and growth factors to "jump-start" the healing process. **2. Why Other Options are Incorrect:** * **External Fixation:** While useful for open fractures or infected nonunions, it generally provides less stability than internal fixation for a femoral shaft and carries a high risk of pin-tract infection and knee stiffness in long-term management. * **Internal Fixation Only:** In a nonunion, simply providing stability is often insufficient because the fracture environment is biologically "quiet." Without grafting, there is a high risk of hardware failure (fatigue) before union occurs. * **Prosthesis:** This is indicated for fractures of the femoral neck or head (especially in the elderly), not for shaft fractures. **Clinical Pearls for NEET-PG:** * **Definition:** A fracture is typically labeled a "delayed union" at 3 months and a "nonunion" if there is no progress toward healing for 3 consecutive months or at the 6-9 month mark. * **Hypertrophic Nonunion:** Caused by instability; requires better fixation (e.g., exchange nailing). * **Atrophic Nonunion:** Caused by poor biology; requires **bone grafting** plus fixation. * **Gold Standard:** Autologous bone graft (usually from the iliac crest) remains the gold standard for treating nonunions.

Question 727: Complications of Colles' fracture include the following except:

A. Rupture of Extensor Pollicis Brevis tendon (Correct Answer)
B. Rupture of Extensor Pollicis Longus Tendon
C. Malunion
D. Sudek's osteodystrophy

Explanation: **Explanation:** The correct answer is **A. Rupture of Extensor Pollicis Brevis (EPB) tendon**. In Colles' fracture, the most common tendon injury is the rupture of the **Extensor Pollicis Longus (EPL)**, not the EPB. This occurs because the EPL tendon winds around **Lister’s tubercle** on the dorsal aspect of the radius. Following a fracture, the tendon can undergo attrition due to friction against irregular bone fragments or ischemia caused by pressure within the intact extensor retinaculum. This typically occurs 4–8 weeks post-injury (delayed rupture). **Analysis of other options:** * **B. Rupture of Extensor Pollicis Longus:** This is a classic late complication. It is often painless and results in the inability to extend the distal phalanx of the thumb. * **C. Malunion:** This is the **most common complication** of Colles' fracture. It leads to the characteristic "Dinner Fork Deformity" due to residual dorsal tilt and radial shortening. * **D. Sudeck’s Osteodystrophy (CRPS Type 1):** This is a well-known complication characterized by pain, swelling, and vasomotor instability. It is often triggered by a tight cast or excessive pain during immobilization. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Malunion. * **Most common nerve involved:** Median nerve (Carpal Tunnel Syndrome). * **Surgical treatment for EPL rupture:** Tendon transfer (usually using the Extensor Indicis Proprius). * **Dinner Fork Deformity:** Caused by dorsal displacement, dorsal tilt, and lateral tilt of the distal fragment.

Question 728: Duga's test is helpful in which of the following conditions?

A. Dislocation of hip
B. Scaphoid fracture
C. Fracture neck of femur
D. Anterior dislocation of shoulder (Correct Answer)

Explanation: **Explanation:** **Dugas’ Test** is a classic clinical sign used to diagnose **Anterior Dislocation of the Shoulder**. In a normal shoulder, a person can touch the opposite shoulder with their hand while the elbow is in contact with the chest. In an anterior dislocation, the humeral head is displaced from the glenoid labrum, causing the shoulder to lose its normal contour. Consequently, the patient is **unable to touch the opposite shoulder with the hand of the affected side while the elbow is touching the chest.** If the hand is forced onto the opposite shoulder, the elbow will lift away from the chest, and vice versa. **Analysis of Incorrect Options:** * **Dislocation of Hip:** Diagnosed using tests like the **Allis test** or **Bigelow’s maneuver**. Clinical features include limb shortening and rotation (internal for posterior, external for anterior). * **Scaphoid Fracture:** Characterized by tenderness in the **Anatomical Snuffbox** and pain on axial loading of the thumb. * **Fracture Neck of Femur:** Presents with external rotation and shortening of the limb. Key clinical signs include **Bryant’s triangle** distortion and **Nelaton’s line** abnormality. **Clinical Pearls for NEET-PG:** * **Hamilton’s Ruler Test:** In shoulder dislocation, a ruler can touch both the acromion and the lateral epicondyle simultaneously (impossible in a normal shoulder). * **Callaway’s Test:** The axillary girth is increased in shoulder dislocation. * **Regimental Badge Sign:** Indicates injury to the **Axillary Nerve**, the most common nerve injured in anterior shoulder dislocations. * **Most common type:** Subcoracoid dislocation is the most frequent subtype of anterior dislocation.

Question 729: What is the most consistent sign of a fresh fracture?

A. Crepitus (Correct Answer)
B. Bony tenderness
C. Deformity
D. Abnormal mobility

Explanation: ### Explanation In clinical orthopaedics, signs of a fracture are categorized into **Probable (Suggestive)** and **Definitive (Diagnostic)** signs. **Why Crepitus is the Correct Answer:** Crepitus is defined as the palpable or audible grating sensation produced by the friction of two fractured bone ends rubbing against each other. It is considered the **most consistent and pathognomonic sign** of a fresh fracture. If crepitus is present, a fracture is definitively diagnosed. However, clinicians should not deliberately elicit it as it causes significant pain and potential soft tissue damage. **Analysis of Incorrect Options:** * **Bony Tenderness:** While this is the most common and earliest sign, it is **non-specific**. It can be present in contusions, infections (osteomyelitis), or bone tumors without an actual break in the cortex. * **Deformity:** This is a suggestive sign but not always present (e.g., in undisplaced or impacted fractures). Conversely, deformities can occur in dislocations or congenital anomalies without a fracture. * **Abnormal Mobility:** This is a definitive sign (moving a limb where no joint exists), but it may be absent in **impacted fractures** or greenstick fractures, making it less "consistent" than the presence of crepitus in a fresh, complete break. **Clinical Pearls for NEET-PG:** * **Definitive Signs of Fracture:** Crepitus, Abnormal Mobility, and Radiological evidence. * **Impacted Fractures:** These are unique because they often lack crepitus and abnormal mobility; the only clinical clue may be localized tenderness and loss of function. * **Safety Note:** Always prioritize splinting and imaging over physical maneuvers like eliciting crepitus to prevent secondary neurovascular injury.

Question 730: The first sign of Volkman's ischemia is?

A. Paresthesia
B. Pain on passive extension of fingers (Correct Answer)
C. Pain on active extension of fingers
D. Swelling of fingers

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 Option B is Correct:** The **earliest and most reliable clinical sign** of impending compartment syndrome/ischemia is **pain out of proportion to the injury**, which is specifically elicited or aggravated by **passive stretching** of the muscles within that compartment. In the forearm (volar compartment), the finger flexors are affected first; therefore, passive extension of the fingers stretches these ischemic muscles, triggering intense pain. This sign appears before neurological deficits or pulse changes. **Analysis of Incorrect Options:** * **A. Paresthesia:** While an early sign of nerve ischemia, it usually follows the onset of ischemic pain. It indicates that the pressure is high enough to affect nerve conduction but is typically not the *first* sign. * **C. Pain on active extension:** Active extension involves the contraction of the extensor muscles (dorsal compartment). While it may be painful, it does not specifically stretch the primary ischemic flexor muscles like passive extension does. * **D. Swelling of fingers:** Swelling is a common finding in trauma but is non-specific and does not diagnostic for ischemia or compartment syndrome. **NEET-PG High-Yield Pearls:** * **The 5 P’s:** Pain, Pallor, Paresthesia, Paralysis, and Pulselessness. Remember: **Pain** is the first sign; **Pulselessness** is a very late and often unreliable sign (as distal pulses can remain intact despite high intracompartmental pressure). * **Gold Standard Diagnosis:** Measurement of intracompartmental pressure (using a Stryker monitor). A **Delta pressure** (Diastolic BP – Compartment Pressure) of **<30 mmHg** is an indication for fasciotomy. * **Definitive Treatment:** Urgent **Fasciotomy** to decompress the compartments.

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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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