Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 761: A 24-year-old male, known epileptic, presented following a seizure with pain in the right shoulder region. Examination revealed that the right upper limb was adducted and internally rotated, and movements could not be performed. Which of the following is the most likely diagnosis?

A. Posterior dislocation of shoulder (Correct Answer)
B. Luxatio erecta
C. Intrathoracic dislocation of shoulder
D. Subglenoid dislocation of shoulder

Explanation: ### Explanation **Correct Option: A. Posterior dislocation of shoulder** **Reasoning:** Posterior shoulder dislocation is a classic "hidden" injury often associated with **seizures** or **high-voltage electric shocks**. During a seizure, the powerful internal rotators (Latissimus dorsi, Pectoralis major, and Subscapularis) overpower the weaker external rotators, forcing the humeral head posteriorly. The clinical hallmark is a limb fixed in **adduction and internal rotation**, with a total loss of external rotation. Radiologically, this may present as the "Light bulb sign" (due to internal rotation) or the "Rim sign." **Analysis of Incorrect Options:** * **B. Luxatio erecta:** This is an inferior dislocation where the arm is held **abducted** (pointing upwards) rather than adducted. It is rare and usually results from hyperabduction forces. * **C. Intrathoracic dislocation:** An extremely rare type of fracture-dislocation where the humeral head is driven between the ribs into the thoracic cavity; it presents with severe trauma, not typically simple seizures. * **D. Subglenoid dislocation:** This is a subtype of **Anterior dislocation** (the most common type). In anterior dislocations, the arm is typically held in **abduction and external rotation**, which is the opposite of this patient's presentation. **Clinical Pearls for NEET-PG:** * **Triple S:** **S**eizures, **S**hocks, and **S**capular fractures are highly associated with posterior dislocations. * **Most missed dislocation:** Posterior dislocations are missed in up to 50% of initial ER visits because the AP view can look deceptively normal. * **Imaging:** The **Axillary view** or **Scapular Y-view** is the gold standard to confirm the diagnosis. * **Trough Line Sign:** A vertical line on the humeral head caused by an impaction fracture (Reverse Hill-Sachs lesion).

Question 762: A 30-year-old male underwent excision of the right radial head. Postoperatively, the patient developed an inability to extend the fingers and thumb of the right hand. He had no sensory deficit. Which of the following is the most likely cause?

A. Injury to the posterior interosseous nerve (Correct Answer)
B. Iatrogenic injury to the common extensor origin
C. Injury to the anterior interosseous nerve
D. High radial nerve palsy

Explanation: ### **Explanation** The clinical presentation of **inability to extend the fingers and thumb** with **preserved sensation** following surgery near the radial head is a classic description of **Posterior Interosseous Nerve (PIN) palsy.** **1. Why Option A is Correct:** The PIN is the deep motor branch of the radial nerve. It winds around the neck of the radius and passes through the **Arcade of Frohse** (supinator muscle). During radial head excision or fixation, the PIN is highly vulnerable to iatrogenic injury due to its close anatomical proximity to the radial neck. Since the PIN is a purely motor nerve (after providing branches to the ECRB and supinator), its injury results in a **motor-only deficit**: loss of finger and thumb extension (at the MCP joints) without any sensory loss. **2. Why the Other Options are Incorrect:** * **Option B (Common Extensor Origin):** Injury here would cause pain or weakness in wrist extension, but not a complete inability to extend fingers while sparing sensation. * **Option C (Anterior Interosseous Nerve):** The AIN is a branch of the Median nerve. Injury results in the inability to flex the distal phalanges of the thumb and index finger (loss of the "OK" sign), not extension. * **Option D (High Radial Nerve Palsy):** This occurs above the elbow. It would result in **wrist drop** (loss of ECRL/ECRB) and **sensory loss** over the first dorsal web space, neither of which are present here. ### **Clinical Pearls for NEET-PG:** * **PIN Palsy vs. Radial Nerve Palsy:** In PIN palsy, **wrist extension is preserved** (though may show radial deviation) because the Extensor Carpi Radialis Longus (ECRL) is supplied by the radial nerve *above* the level of PIN division. * **Safe Zone:** To avoid PIN injury during the Kocher approach to the radial head, the forearm should be kept in **pronation**, which moves the nerve anteriorly and away from the surgical site. * **Signature Sign:** PIN palsy presents with "Finger Drop" but **not** "Wrist Drop."

Question 763: An oblique fracture of the olecranon, if displaced proximally, what is the treatment?

A. Excision and resuturing
B. Tension band wiring (Correct Answer)
C. Elbow immobilization by cast
D. Open reduction and external fixation

Explanation: **Explanation:** The olecranon is an intra-articular structure and forms a key part of the elbow's extensor mechanism. When an olecranon fracture is displaced, it indicates that the **Triceps brachii** muscle has pulled the proximal fragment superiorly. **Why Tension Band Wiring (TBW) is the Correct Choice:** The gold standard for displaced, transverse, or short oblique fractures of the olecranon is **Tension Band Wiring**. This technique operates on the "conversion of forces" principle: it converts the distracting (pulling) force of the triceps muscle into a **compressive force** across the fracture site during elbow flexion. This promotes primary bone healing and allows for early range-of-motion exercises, preventing elbow stiffness. **Analysis of Incorrect Options:** * **A. Excision and resuturing:** This is only considered in elderly, low-demand patients with highly comminuted fractures where internal fixation is impossible. It is not the primary treatment for a standard oblique fracture. * **C. Elbow immobilization by cast:** This is reserved for undisplaced fractures. In displaced fractures, conservative management leads to non-union and loss of elbow extension. * **D. Open reduction and external fixation:** External fixation is rarely used for the olecranon; it is typically reserved for open fractures with severe soft tissue loss or active infection. **High-Yield Clinical Pearls for NEET-PG:** * **Indication for Plate Fixation:** If the fracture is highly comminuted, distal to the coronoid process, or an **oblique fracture extending distal to the midpoint of the trochlear notch**, a locking compression plate is preferred over TBW. * **Complication:** The most common complication of TBW is **symptomatic hardware** (prominent K-wires), often requiring secondary removal. * **Nerve Injury:** The **Ulnar nerve** is the most common nerve at risk during surgical approaches to the olecranon.

Question 764: Which of the following is NOT true about posterior dislocation of the hip?

A. Often associated with dashboard injuries.
B. A vascular sign of Narath may be observed.
C. Risk of sciatic nerve injury is present.
D. Trendelenberg test is typically negative. (Correct Answer)

Explanation: In posterior hip dislocation, the femoral head is displaced out of the acetabulum, leading to a loss of the fulcrum required for the hip abductors (Gluteus medius and minimus) to function. This results in a **positive Trendelenburg test**, making Option D the incorrect statement and thus the correct answer. ### Explanation of Options: * **Option A (Dashboard Injury):** This is the most common mechanism. A force applied to the knee while the hip and knee are flexed (as in a car crash) drives the femoral head posteriorly out of the acetabulum. * **Option B (Vascular Sign of Narath):** In posterior dislocations, the femoral head is no longer behind the femoral artery in the femoral triangle. Consequently, the femoral artery pulsations feel weak or "empty" because the bony support is missing. This is a classic clinical sign. * **Option C (Sciatic Nerve Injury):** The sciatic nerve runs immediately posterior to the acetabulum. It is injured in approximately 10–20% of cases, most commonly involving the peroneal division (leading to foot drop). ### High-Yield Clinical Pearls for NEET-PG: * **Clinical Presentation:** The limb is typically held in **Flexion, Adduction, and Internal Rotation** (Shortened). * **X-ray Finding:** The femoral head appears smaller than the contralateral side (Shenton’s line is broken). * **Management:** It is an orthopedic emergency. Reduction should be done within 6 hours to prevent **Avascular Necrosis (AVN)** of the femoral head. * **Commonest Type:** Posterior dislocation is the most common type of hip dislocation (approx. 90%).

Question 765: A 24-year-old male, known epileptic, presented following a seizure with pain in the right shoulder region. Examination revealed that the right upper limb was adducted and internally rotated, and movements could not be performed. Which of the following is the most likely diagnosis?

A. Posterior dislocation of shoulder (Correct Answer)
B. Luxatio erecta
C. Intrathoracic dislocation of shoulder
D. Subglenoid dislocation of shoulder

Explanation: ### Explanation **Correct Answer: A. Posterior dislocation of shoulder** **Reasoning:** Posterior shoulder dislocation is a classic "hidden" injury often associated with **seizures** or **high-voltage electric shocks**. During a seizure, the powerful internal rotators (Latissimus dorsi, Pectoralis major, and Subscapularis) overpower the weaker external rotators, forcing the humeral head posteriorly. The clinical presentation is pathognomonic: the arm is fixed in **adduction and internal rotation**, with a total loss of external rotation. This matches the patient's presentation perfectly. **Analysis of Incorrect Options:** * **B. Luxatio erecta (Inferior dislocation):** The patient presents with the arm held in **abduction** (pointing upwards/overhead), not adduction. It is rare and usually caused by hyperabduction forces. * **C. Intrathoracic dislocation:** An extremely rare form of violent fracture-dislocation where the humeral head is driven between the ribs into the thoracic cavity. * **D. Subglenoid dislocation:** This is a type of **Anterior dislocation** (the most common type). In anterior dislocations, the arm is typically held in **abduction and external rotation**, which is the opposite of this patient's clinical picture. **High-Yield Clinical Pearls for NEET-PG:** * **Triple E Syndrome:** Posterior dislocations are associated with **E**pilepsy, **E**lectricity, and **E**thanol (withdrawal seizures). * **Radiology (X-ray):** * **Light Bulb Sign:** The internally rotated humeral head appears symmetrical/rounded on AP view. * **Empty Glenoid Sign:** Widening of the glenohumeral joint space (>6mm). * **Rim Sign:** Distance between the medial wall of the humeral head and the anterior glenoid rim is increased. * **Best View:** The **Axillary view** or Scapular Y-view is essential to confirm the diagnosis, as posterior dislocations are frequently missed on standard AP views (up to 50% of cases).

Question 766: A six-year-old child presented with a valgus deformity at his right elbow, which has been gradually progressive for the past 3 years. He has a history of a cast applied for 6 weeks after falling on an outstretched hand 3 years prior. What is the probable diagnosis?

A. Malunited lateral condylar fracture of the humerus (Correct Answer)
B. Malunited supracondylar fracture of the humerus
C. Posterior dislocation of the elbow
D. Fracture of the medial condyle of the humerus

Explanation: **Explanation:** The clinical presentation of a **progressive valgus deformity** (Cubitus Valgus) following a pediatric elbow injury is the hallmark of a **malunited or non-united lateral condylar fracture of the humerus**. **Why Option A is Correct:** The lateral condyle is a physeal (growth plate) injury. If it fails to unite (common due to the pull of extensor muscles and bathing in synovial fluid), it leads to a **growth arrest** of the lateral side of the distal humerus. As the medial side continues to grow normally, the elbow gradually deviates into **valgus**. This is a progressive deformity, often leading to a "Tardy Ulnar Nerve Palsy" years later due to the stretching of the nerve around the medial epicondyle. **Why Incorrect Options are Wrong:** * **B. Supracondylar Fracture:** This is the most common pediatric elbow fracture. Malunion typically results in **Cubitus Varus** (Gunstock deformity), which is a static deformity (not progressive) because it is a structural malalignment rather than a physeal growth arrest. * **C. Posterior Dislocation:** This is an acute emergency. While it can cause stiffness or heterotopic ossification, it does not typically result in a progressive valgus deformity in children. * **D. Medial Condyle Fracture:** This is rare in children. If it leads to growth arrest, it would result in a **Varus** deformity, not valgus. **High-Yield Clinical Pearls for NEET-PG:** * **Lateral Condyle Fracture:** Known as the "Fracture of Necessity" (usually requires ORIF) and the most common cause of **progressive cubitus valgus**. * **Tardy Ulnar Nerve Palsy:** A late complication of cubitus valgus where the ulnar nerve is chronically stretched. * **Milch Classification:** Used to categorize lateral condyle fractures based on the fracture line relative to the trochlear groove. * **Cubitus Varus:** Most common complication of Supracondylar fractures; primarily a cosmetic issue ("Gunstock deformity").

Question 767: An incomplete tear of a ligament or a complex of ligaments around a joint is known as:

A. Dislocation
B. Subluxation
C. Sprain (Correct Answer)
D. Strain

Explanation: ### Explanation **Correct Answer: C. Sprain** A **sprain** is defined as an injury to a **ligament** or a joint capsule, usually caused by a sudden stretch or twist beyond its normal range of motion. Pathologically, it represents an incomplete tear or stretching of the collagen fibers. Sprains are graded by severity: * **Grade I:** Microscopic tearing (stretch). * **Grade II:** Partial/Incomplete tear (the focus of this question). * **Grade III:** Complete rupture of the ligament. --- ### Why the other options are incorrect: * **A. Dislocation:** This refers to the **complete displacement** of the articular surfaces of the bones that form a joint, resulting in a total loss of contact between them. * **B. Subluxation:** This is a **partial or incomplete displacement** of the joint surfaces. Unlike a dislocation, some contact between the articular surfaces remains. * **C. Strain:** While often confused with a sprain, a strain specifically refers to an injury to a **muscle or a tendon** (the "T" in Strain for Tendon). It occurs due to overstretching or over-contraction of the musculotendinous unit. --- ### High-Yield Clinical Pearls for NEET-PG: 1. **Mnemonic:** Remember **S**prain = **S**upporting structure (Ligament); **S**train = **T**endon/Muscle. 2. **Most Common Site of Sprain:** The **Ankle**, specifically the **Anterior Talofibular Ligament (ATFL)** during an inversion injury. 3. **Management:** The standard initial treatment for sprains and strains is the **RICE** protocol (Rest, Ice, Compression, Elevation), though modern protocols now suggest **POLICE** (Protection, Optimal Loading, Ice, Compression, Elevation). 4. **Joint Stability:** A Grade III sprain (complete tear) often results in joint instability, whereas Grade I and II sprains typically maintain mechanical stability despite pain and swelling.

Question 768: Moneteggia fracture is a fracture of which part of the forearm?

A. Lower one-third of the radius
B. Upper one-third of the radius
C. Lower one-third of the ulna
D. Upper one-third of the ulna (Correct Answer)

Explanation: ### Explanation **Monteggia fracture-dislocation** is a classic orthopedic injury defined as a **fracture of the proximal (upper) third of the ulna** associated with a **dislocation of the radial head** at the proximal radioulnar joint. #### Why the Correct Answer is Right: * **Option D (Upper one-third of the ulna):** By definition, the Monteggia lesion involves the shaft of the ulna, most commonly at the junction of the proximal and middle thirds. The force required to fracture the ulna in this mechanism often results in the secondary displacement of the radial head, making the ulnar fracture the primary bony component of this injury. #### Why Other Options are Wrong: * **Options A & B (Radius fractures):** Fractures of the radius shaft with associated distal radioulnar joint (DRUJ) dislocation are termed **Galeazzi fractures**. Monteggia specifically involves the ulna. * **Option C (Lower one-third of the ulna):** Fractures of the distal ulna are not part of the Monteggia complex. Isolated distal ulnar fractures are often called "Nightstick fractures" if caused by a direct blow. --- ### High-Yield Clinical Pearls for NEET-PG: 1. **Mnemonic (MUGR):** * **M**onteggia: **U**lna fracture (Proximal) + Radial head dislocation. * **G**aleazzi: **R**adius fracture (Distal) + Distal Radioulnar Joint (DRUJ) dislocation. 2. **Bado Classification:** Used to categorize Monteggia fractures based on the direction of radial head dislocation (Type I is Anterior, the most common). 3. **Nerve Injury:** The **Posterior Interosseous Nerve (PIN)**, a branch of the radial nerve, is the most commonly injured nerve in Monteggia fractures due to the radial head dislocation. 4. **Management:** In adults, these require **Open Reduction and Internal Fixation (ORIF)** with a plate and screws to ensure anatomical alignment and stability of the radioulnar joints.

Question 769: Gallows traction is used in the management of fracture of the shaft of which bone?

A. Femur (Correct Answer)
B. Tibia
C. Humerus
D. Ulna

Explanation: **Explanation:** **Gallows traction** (also known as Bryant’s traction) is a specific type of skin traction used for the management of **fracture shaft of the femur** in children. **Why Femur is Correct:** It is indicated for children **under 2 years of age** (or weighing less than 12–15 kg). The mechanism involves applying skin traction to both legs, which are then suspended vertically from an overhead bar. The weight used should be just enough to lift the child's buttocks slightly off the bed. This allows the child's own body weight to act as counter-traction, facilitating the reduction and stabilization of the femoral fracture. **Why Other Options are Incorrect:** * **Tibia:** Fractures of the tibia in children are typically managed with closed reduction and casting (above-knee or below-knee) rather than vertical suspension traction. * **Humerus:** Humeral shaft fractures are managed with U-slabs, hanging casts, or specialized splints (like the Coaptation splint), but never with Gallows traction. * **Ulna:** Forearm fractures are managed with closed reduction and immobilization in an above-elbow cast. **High-Yield Clinical Pearls for NEET-PG:** * **Age/Weight Limit:** Crucial for the exam—only used for children <2 years or <15 kg. * **Complication:** The most serious risk is **vascular compromise** (ischemia) of the feet due to the vertical position. Frequent neurovascular monitoring (checking for pulses and capillary refill) is mandatory. * **Counter-traction:** Provided by the child's own body weight (buttocks must be just clear of the mattress). * **Alternative:** For older children (>2 years), Thomas splint or Hamilton-Russell traction is preferred.

Question 770: Which of the following is a late complication of fracture acetabulum of the hip?

A. Osteoarthritis (Correct Answer)
B. Tardy sciatic nerve palsy
C. Recurrent dislocation
D. None of the above

Explanation: **Explanation:** Fractures of the acetabulum are intra-articular injuries that disrupt the weight-bearing surface of the hip joint. **1. Why Osteoarthritis is the Correct Answer:** Post-traumatic **Osteoarthritis (OA)** is the most common late complication of acetabular fractures. Even with anatomical reduction, the initial impact often causes chondrocyte death or subchondral damage. Any residual articular incongruity leads to abnormal stress distribution, accelerated cartilage wear, and secondary OA. This typically manifests years after the initial injury. **2. Why the Other Options are Incorrect:** * **Tardy sciatic nerve palsy:** While sciatic nerve injury is a common complication of acetabular fractures (occurring in up to 10-15% of cases), it is typically an **early/acute** complication occurring at the time of injury or during surgery. "Tardy" (delayed) palsy is characteristic of the ulnar nerve at the elbow, not the sciatic nerve at the hip. * **Recurrent dislocation:** This is a common complication of **traumatic hip dislocations** (especially if associated with a posterior wall fragment), but it is not a standard "late" complication of the acetabular fracture itself. Once the fracture heals, the joint usually remains stable unless there is significant bone loss. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common early complication:** Sciatic nerve injury (specifically the peroneal division). * **Most common late complication:** Post-traumatic Osteoarthritis. * **Avascular Necrosis (AVN):** Can occur if the fracture is associated with a hip dislocation that disrupts the femoral head's blood supply. * **Heterotopic Ossification:** A frequent complication following the surgical approach (especially the Kocher-Langenbeck approach); Prophylaxis with NSAIDs (Indomethacin) or low-dose radiation is often used. * **Judet Views:** The gold standard X-rays for diagnosis (Iliac oblique and Obturator oblique views).

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Trauma — MCQs

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