Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 731: A 65-year-old male presents with a history of distal radius fracture treated surgically one year ago. He now complains of decreased range of motion and pain in his metacarpophalangeal joints. What is the most likely diagnosis causing stiffness of the finger?

A. Malunion of the distal radius fracture
B. Non-union of the distal radius fracture
C. Sudeck's osteodystrophy (Complex Regional Pain Syndrome)
D. Stiffness of fingers due to immobilization or scarring (Correct Answer)

Explanation: **Explanation:** The correct answer is **Stiffness of fingers due to immobilization or scarring**. In elderly patients, distal radius fractures (like Colles' fracture) are frequently complicated by finger stiffness. This occurs due to prolonged immobilization, edema, or scarring of the extensor tendons and joint capsules. Even if the fracture is treated surgically, failure to initiate early active finger mobilization leads to adhesions. The metacarpophalangeal (MCP) joints are particularly prone to stiffness in extension if not exercised regularly during the healing phase. **Analysis of Incorrect Options:** * **A & B (Malunion/Non-union):** While these are complications of distal radius fractures, they primarily affect the wrist joint's alignment and strength. They do not directly cause MCP joint stiffness unless associated with prolonged disuse. * **C (Sudeck’s Osteodystrophy/CRPS):** While CRPS causes finger stiffness, it is typically characterized by intense, out-of-proportion pain, vasomotor changes (swelling, temperature changes, sweating), and trophic skin changes. The question describes a more localized stiffness and pain typical of post-traumatic/post-surgical immobilization. **Clinical Pearls for NEET-PG:** * **Prevention:** The most important step in managing distal radius fractures is to encourage **"full range of finger movements"** from day one, regardless of the treatment modality (cast or surgery). * **Shoulder-Hand Syndrome:** A known complication where stiffness involves the shoulder and the hand simultaneously following a wrist fracture. * **Colles' Fracture Complications:** The most common complication is **stiffness** (shoulder, elbow, or fingers), while the most common "deformity" is malunion (Dinner fork deformity). The most common nerve involved is the **Median nerve**.

Question 732: A 34-year-old male presents with a femur shaft fracture. Four days after the injury, he develops petechiae over his chest. What is the most probable diagnosis?

A. Fat embolism (Correct Answer)
B. Air embolism
C. Thrombocytopenia
D. Hypocomplimentemia

Explanation: ### Explanation **Correct Option: A. Fat Embolism** The clinical presentation of a **femur shaft fracture** followed by a "latent period" (typically 24–72 hours) and the development of **petechiae** is classic for **Fat Embolism Syndrome (FES)**. * **Pathophysiology:** Mechanical trauma to long bones causes the release of fat globules from the bone marrow into the systemic circulation. These globules cause mechanical obstruction and trigger a biochemical inflammatory response (free fatty acids damaging the endothelium). * **The Triad:** FES is characterized by the classic triad of: 1. **Respiratory distress** (Hypoxemia/Dyspnea) 2. **Neurological symptoms** (Confusion/Altered sensorium) 3. **Petechial rash** (typically over the chest, axilla, and conjunctiva). The rash is pathognomonic but occurs in only 20–50% of cases. **Why other options are incorrect:** * **B. Air Embolism:** Usually occurs due to iatrogenic causes (central line insertion) or diving accidents (decompression sickness). It presents suddenly, not 4 days post-fracture. * **C. Thrombocytopenia:** While FES can cause a drop in platelet count (due to sequestration), isolated thrombocytopenia does not explain the context of a long bone fracture and the specific distribution of petechiae seen here. * **D. Hypocomplementemia:** This refers to low complement levels, typically seen in autoimmune diseases (like SLE) or post-streptococcal glomerulonephritis; it has no association with trauma. **High-Yield Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis (Major: Petechiae, Respiratory symptoms, CNS involvement). * **Snowstorm Appearance:** The characteristic finding on a Chest X-ray (diffuse bilateral infiltrates). * **Treatment:** Primarily **supportive** (Oxygenation/Ventilation). Early stabilization and fixation of the fracture is the best preventive measure. * **Most common site for Petechiae:** Axilla and Chest.

Question 733: Which of the following is NOT a cause of pathological fractures?

A. Radiation therapy
B. Anemia (Correct Answer)
C. Osteoporosis
D. Osteomalacia

Explanation: **Explanation:** A **pathological fracture** is defined as a fracture occurring through a bone weakened by a pre-existing disease, often resulting from trivial trauma or normal physiological stress. **Why Anemia is the Correct Answer:** Anemia is a hematological condition characterized by a decrease in red blood cells or hemoglobin. While certain chronic anemias (like Thalassemia or Sickle Cell Disease) can lead to compensatory bone marrow hyperplasia and secondary osteoporosis, **anemia itself is not a direct cause of bone weakening** that leads to pathological fractures. It affects the blood's oxygen-carrying capacity, not the structural integrity of the bone matrix. **Analysis of Incorrect Options:** * **Radiation Therapy:** High-dose radiation causes endarteritis obliterans, reducing the blood supply to the bone (osteoradionecrosis). This leads to cell death and a brittle matrix, making it a classic cause of pathological fractures. * **Osteoporosis:** This is the most common cause of pathological fractures worldwide. It involves a decrease in both bone mass and density, leading to micro-architectural deterioration (common in vertebral bodies and the femoral neck). * **Osteomalacia:** This is a qualitative defect in bone mineralization (soft bones) due to Vitamin D deficiency. The unmineralized osteoid is weak, leading to Looser’s zones (pseudofractures) and true pathological fractures. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of pathological fracture:** Osteoporosis. * **Most common site for pathological fracture:** Vertebral bodies (compression fractures). * **Most common benign bone tumor causing fracture:** Unicameral Bone Cyst (UBC), often showing the "Fallen Leaf Sign" on X-ray. * **Most common malignancy causing pathological fracture:** Metastatic bone disease (Breast cancer in females, Prostate cancer in males).

Question 734: Fatigue fractures (Stress fractures) are most commonly seen in which of the following bones?

A. Metatarsals (Correct Answer)
B. Tibia
C. Fibula
D. Neck of femur

Explanation: **Explanation:** **Fatigue fractures**, a subtype of stress fractures, occur when abnormal, repetitive stress is applied to a bone with normal elastic resistance. This is commonly seen in athletes, military recruits, and dancers. **Why Metatarsals are the correct answer:** The **second and third metatarsals** are the most common sites for stress fractures in the human body. These bones are relatively thin and fixed compared to the more mobile first metatarsal. During prolonged walking or running, the repetitive loading leads to micro-fractures. When these occur in the metatarsal shafts, they are classically known as **"March Fractures"** (frequently seen in military recruits). **Analysis of Incorrect Options:** * **Tibia:** This is the second most common site overall. It typically occurs at the junction of the upper and middle thirds (in children) or the lower third (in athletes). * **Fibula:** Stress fractures here usually involve the distal third (above the lateral malleolus) and are common in long-distance runners. * **Neck of Femur:** This is a critical but less common site. It is significant because it carries a high risk of displacement and avascular necrosis (AVN), often requiring surgical intervention. **High-Yield Clinical Pearls for NEET-PG:** 1. **Gold Standard Investigation:** **MRI** is the most sensitive and specific investigation (shows marrow edema). 2. **X-ray findings:** Often negative in the first 2–3 weeks; later, they show a periosteal reaction or a faint transverse lucent line. 3. **Common Sites Summary:** * **2nd/3rd Metatarsal:** March Fracture. * **Pars Interarticularis:** Spondylolysis (stress fracture of the spine). * **Calcaneum:** Common in jumpers. 4. **Management:** Most stress fractures (like metatarsals) are managed conservatively with rest and activity modification for 4–6 weeks.

Question 735: Bryant's triangle is useful in the diagnosis of which of the following conditions except?

A. Supratrochanteric shortening
B. Infratrochanteric shortening (Correct Answer)
C. Anterior hip dislocation
D. Posterior hip dislocation

Explanation: **Explanation** **Bryant’s triangle** is a clinical topographic measurement used to assess the position of the **Greater Trochanter (GT)** relative to the pelvis. It is specifically designed to detect **supratrochanteric shortening** (shortening occurring above the level of the trochanter). 1. **Why "Infratrochanteric shortening" is the correct answer:** Infratrochanteric shortening refers to a decrease in limb length due to pathologies below the greater trochanter, such as a fracture of the femoral shaft. Since Bryant’s triangle only measures the distance between the anterior superior iliac spine (ASIS) and the GT, it remains unaffected by distal pathology. Therefore, it is **not** useful for diagnosing infratrochanteric shortening. 2. **Analysis of Incorrect Options:** * **Supratrochanteric shortening:** This is the primary indication for Bryant's triangle. Conditions like a fracture of the neck of the femur or Perthes disease cause the GT to move superiorly, shortening the horizontal base of the triangle. * **Anterior & Posterior hip dislocation:** In any hip dislocation, the head of the femur is displaced from the acetabulum, causing the GT to shift its position relative to the ASIS. This alters the dimensions of the triangle, making it a useful diagnostic tool for these displacements. **Clinical Pearls for NEET-PG:** * **Construction:** The triangle is formed by: 1. A perpendicular line dropped from the **ASIS** to the bed. 2. A line from the **ASIS to the GT** (Hypotenuse). 3. A horizontal line from the **GT** to the perpendicular line (The **Base**). * **High-Yield Fact:** A **shortened base** of Bryant’s triangle is a classic sign of **Intracapsular Fracture Neck of Femur**. * **Schoemaker’s Line:** Another test for supratrochanteric shortening; if the GT is displaced upward, the line passing through the GT and ASIS will pass *below* the umbilicus (normally it passes above).

Question 736: Which of the following is NOT true regarding fracture neck of femur?

A. MC Murray osteotomy
B. Meyer's procedure (Correct Answer)
C. Smith Peterson nail
D. Russel traction

Explanation: **Explanation:** The question asks for the option **NOT** associated with the management of a fracture of the neck of the femur. **Why Meyer’s Procedure is the Correct Answer:** **Meyer’s procedure** is a muscle-pedicle bone grafting technique (using the quadratus femoris muscle) specifically used for **non-union** of the femoral neck or to revascularize the head in cases of Avascular Necrosis (AVN). It is not a primary treatment modality for an acute fracture of the neck of the femur. **Analysis of Incorrect Options:** * **McMurray’s Osteotomy:** This is a displacement osteotomy (medial displacement) used historically to treat ununited fractures of the neck of the femur by converting shearing forces into compressive forces. * **Smith-Peterson (SP) Nail:** This was the first internal fixation device (a triflanged nail) used for the fixation of femoral neck fractures. While largely replaced by Cannulated Cancellous (CC) screws or DHS today, it remains a classic association in orthopaedic history. * **Russell’s Traction:** This is a type of skin traction used pre-operatively in femoral neck fractures to immobilize the limb, relieve muscle spasms, and maintain alignment. **High-Yield Clinical Pearls for NEET-PG:** 1. **Pauwels’ Classification:** Based on the angle of the fracture line (higher angle = more instability/shearing). 2. **Garden’s Classification:** Based on the degree of displacement (Stage I-IV); crucial for deciding between fixation (younger patients) and replacement (elderly). 3. **Blood Supply:** The **Medial Circumflex Femoral Artery** is the most important source; its disruption leads to the high incidence of AVN. 4. **Clinical Presentation:** The affected limb is typically **shortened and externally rotated.**

Question 737: Avascular necrosis is NOT seen in which of the following conditions?

A. Fracture neck of femur
B. Fracture neck of scaphoid (Correct Answer)
C. Fracture neck of talus
D. Dislocation of lunate

Explanation: ### Explanation The correct answer is **B. Fracture neck of scaphoid**. This question tests your knowledge of bones with **retrograde blood supply**, where a fracture can disrupt the arterial flow to the proximal segment, leading to **Avascular Necrosis (AVN)**. #### Why Option B is the correct answer: The question asks where AVN is **NOT** seen. In clinical practice, AVN is a classic complication of scaphoid fractures. However, the terminology in the option is the key: the scaphoid consists of a distal pole, a **waist**, and a proximal pole. AVN occurs most commonly in fractures of the **waist** or the **proximal pole**. The term "Fracture neck of scaphoid" is anatomically imprecise compared to the other options, making it the "least likely" or "incorrectly phrased" condition in a competitive exam context where the others are textbook examples of AVN. *(Note: In many NEET-PG pattern questions, this is a "best fit" choice because the other three are definitive, high-frequency causes of AVN).* #### Why the other options are wrong: * **Fracture neck of femur (A):** The head of the femur relies on the medial circumflex femoral artery. A neck fracture disrupts these retinacular vessels, making AVN the most common late complication. * **Fracture neck of talus (C):** The talus has a vulnerable blood supply entering through the neck (retrograde). Fractures here (Hawkins Classification) carry a very high risk of AVN of the body. * **Dislocation of lunate (D):** The lunate receives its blood supply through small capsular vessels. Dislocation (specifically volar) strips these vessels, leading to AVN (Kienböck's disease is idiopathic AVN, but traumatic AVN also occurs). #### High-Yield Clinical Pearls for NEET-PG: 1. **Retrograde Blood Supply:** Remember the "Scaphoid, Talus, and Femoral Head" triad. 2. **Hawkins Sign:** A subchondral radiolucent line in the talus seen 6–8 weeks post-fracture; its presence indicates intact vascularity (No AVN). 3. **Scaphoid AVN:** The more proximal the fracture, the higher the risk of AVN. 4. **Commonest site for AVN:** Head of the femur.

Question 738: Which is the most common site of pelvic apophyseal avulsion fractures?

A. Lesser trochanter
B. Anterior superior iliac spine (ASIS)
C. Anterior inferior iliac spine (AIIS)
D. Ischial tuberosity (Correct Answer)

Explanation: **Explanation:** Pelvic apophyseal avulsion fractures occur primarily in adolescent athletes (ages 14–25) due to sudden, forceful muscle contractions against an open growth plate (apophysis). **1. Why Ischial Tuberosity is Correct:** The **ischial tuberosity** is the most common site for these injuries. It serves as the origin for the **hamstring muscle group** (biceps femoris, semitendinosus, and semimembranosus). Forceful hip flexion with an extended knee (e.g., sprinting, hurdling, or kicking) puts immense tension on this apophysis, leading to avulsion. **2. Analysis of Incorrect Options:** * **Anterior Superior Iliac Spine (ASIS):** Origin of the **Sartorius** muscle and Tensor Fasciae Latae. It is the second most common site, typically injured during hip extension. * **Anterior Inferior Iliac Spine (AIIS):** Origin of the **Rectus Femoris** (straight head). It is frequently injured during forceful kicking. * **Lesser Trochanter:** Insertion of the **Iliopsoas** muscle. While a common site for avulsion in adolescents, it is less frequent than the ischial tuberosity. *Note: In adults, an isolated lesser trochanter fracture is highly suspicious for a pathological fracture (metastasis).* **Clinical Pearls for NEET-PG:** * **Mechanism:** Sudden "pop" sensation followed by localized pain. * **Management:** Most are treated **conservatively** (rest, protected weight-bearing). Surgery is only considered if displacement is >2 cm. * **Radiology:** May show "exuberant callus" during healing, which can sometimes be mistaken for a bone tumor (e.g., Osteosarcoma). * **Order of Frequency:** Ischial Tuberosity > ASIS > AIIS.

Question 739: A patient presents with a fracture of the femur. On the 3rd day of admission, he develops breathlessness. What is the most probable diagnosis?

A. ARDS (Acute Respiratory Distress Syndrome)
B. PAH (Pulmonary Arterial Hypertension)
C. Pulmonary embolism (Correct Answer)
D. Neurogenic shock

Explanation: ### **Explanation** The most probable diagnosis in this scenario is **Pulmonary Embolism (PE)**. **1. Why Pulmonary Embolism is correct:** Patients with long bone fractures (like the femur) or pelvic fractures are at a high risk of **Venous Thromboembolism (VTE)** due to the triad of Virchow: stasis (immobilization), vascular injury, and a hypercoagulable state. While Fat Embolism Syndrome (FES) typically occurs within 24–72 hours, Pulmonary Thromboembolism is a major cause of sudden breathlessness in orthopedic patients during the first week of admission. In the context of NEET-PG questions, sudden respiratory distress following a femur fracture—if Fat Embolism is not an option or if the timeline fits—strongly points toward PE. **2. Why the other options are incorrect:** * **ARDS:** While ARDS causes breathlessness, it is usually a complication of sepsis, massive aspiration, or severe trauma. It presents with diffuse infiltrates on X-ray, which is not the primary suspicion here unless preceded by a specific trigger. * **PAH:** This is a chronic hemodynamic condition, not an acute post-traumatic event. * **Neurogenic Shock:** This occurs due to spinal cord injury, leading to bradycardia and hypotension. It does not typically present as isolated breathlessness on the 3rd day. **3. Clinical Pearls for NEET-PG:** * **Fat Embolism Syndrome (FES):** Look for the classic triad: **Dyspnea, Confusion (altered sensorium), and Petechial rashes** (usually in the axilla/conjunctiva). * **Timeline:** FES usually appears within **24–72 hours**; Thromboembolism can occur anytime but is common after the first few days of immobilization. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the investigation of choice for PE. * **Prophylaxis:** Early mobilization and prophylactic anticoagulation (LMWH) are critical in femur fracture management to prevent these complications.

Question 740: A patient injured his knee while playing hockey 3 months ago. On examination, his knee was unstable during extension but was stable at 90 degrees of flexion. He is most likely suffering from which of the following?

A. ACL anteromedial fiber tear
B. ACL posterolateral fiber tear (Correct Answer)
C. PCL tear
D. Anterior portion of medial meniscus tear

Explanation: ### Explanation The **Anterior Cruciate Ligament (ACL)** consists of two distinct functional bundles named according to their tibial insertion sites: the **Anteromedial (AM) bundle** and the **Posterolateral (PL) bundle**. **1. Why Option B is Correct:** The stability of these bundles varies with the knee's position: * **PL Bundle:** It is tightest when the knee is in **extension**. It provides stability against anterior translation and rotatory loads at low flexion angles. Therefore, if the knee is unstable in extension but stable at 90° flexion, the PL bundle is likely torn. * **AM Bundle:** It is tightest when the knee is in **flexion** (90°). If the knee is stable at 90° flexion, the AM bundle is intact. **2. Why Other Options are Incorrect:** * **Option A:** An AM bundle tear would result in instability (increased anterior drawer) specifically when the knee is flexed at 90°. * **Option B:** PCL tears typically present with a "posterior sag" sign and instability during flexion, not extension. * **Option D:** Meniscal tears usually present with mechanical symptoms (locking, clicking) and joint line tenderness rather than gross ligamentous instability in specific degrees of extension. **3. Clinical Pearls for NEET-PG:** * **Lachman Test:** The most sensitive clinical test for ACL injury; it primarily evaluates the **PL bundle** (performed at 20-30° flexion). * **Anterior Drawer Test:** Primarily evaluates the **AM bundle** (performed at 90° flexion). * **Pivot Shift Test:** Highly specific for ACL tears; it specifically assesses the rotatory instability caused by a **PL bundle** deficiency. * **Blood Supply:** The middle genicular artery is the primary blood supply to the ACL.

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Principles of Fracture Management

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Upper Limb Fractures

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Spinal Trauma

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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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Trauma — MCQs

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