Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 781: Which of the following is not a type of fracture?

A. Traumatic
B. Pathological
C. Anatomical (Correct Answer)
D. Stress

Explanation: ### Explanation Fractures are classified based on the mechanism of injury and the state of the underlying bone. The term **"Anatomical"** refers to the structure or location of a body part (e.g., anatomical neck of the humerus) but is not a functional or pathological classification of a fracture type. #### Analysis of Options: * **A. Traumatic Fracture:** This is the most common type, occurring when a sudden, high-magnitude force (like a fall or RTA) is applied to a normal bone, exceeding its elastic resistance. * **B. Pathological Fracture:** This occurs when a fracture happens through a bone already weakened by an underlying disease (e.g., Osteoporosis, Bone Cyst, Giant Cell Tumor, or Metastasis). The force required is often trivial or minimal. * **D. Stress Fracture:** Also known as "Fatigue fractures," these occur due to repetitive, sub-maximal mechanical loading over time. They are common in athletes and military recruits (e.g., March fracture of the 2nd metatarsal). #### NEET-PG High-Yield Pearls: 1. **March Fracture:** A classic stress fracture involving the shaft of the **2nd metatarsal**. 2. **Insufficiency Fracture:** A subtype of pathological fracture where normal stress is applied to bone with deficient elastic resistance (e.g., Osteomalacia). 3. **Commonest site for Pathological Fracture:** The **Vertebra** (often due to osteoporosis or secondary deposits). 4. **Milkman’s Fracture (Looser’s Zones):** Pseudofractures seen in Osteomalacia; these are not true fractures but cortical radiolucencies.

Question 782: What is the commonest site of fracture leading to fat embolism?

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

Explanation: **Explanation:** **Fat Embolism Syndrome (FES)** occurs when fat globules from the bone marrow enter the systemic circulation following a fracture. The **Femur** is the correct answer because it is the largest long bone in the body with the most extensive medullary canal containing a high volume of fatty marrow. 1. **Why Femur is Correct:** The risk of fat embolism is directly proportional to the volume of marrow involved and the degree of intramedullary pressure elevation during trauma or surgery. Being the largest weight-bearing bone, fractures of the femur (especially the shaft) release the highest amount of fat emboli into the venous sinusoids. 2. **Why others are incorrect:** * **Tibia:** While the tibia is the second most common site for fat embolism, its medullary cavity is smaller than that of the femur. * **Humerus and Ulna:** These are smaller long bones with significantly less marrow volume, making the systemic "fat load" released during a fracture insufficient to typically cause clinical Fat Embolism Syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis. Major features include **Petechial rashes** (typically over the chest, axilla, and conjunctiva), **Respiratory distress** (hypoxemia), and **Cerebral involvement** (confusion/altered sensorium). * **Classic Triad:** Dyspnea, Confusion, and Petechiae (appearing 24–72 hours post-injury). * **Snowstorm Appearance:** Characteristically seen on Chest X-ray. * **Management:** Primarily supportive (Oxygenation). Early stabilization/fixation of the fracture is the most effective way to **prevent** FES.

Question 783: What is the most common cause of fracture in hemophilic arthropathy?

A. Osteoporosis and restrictive joint movement (Correct Answer)
B. Cartilage destruction
C. Inflammatory arthropathy
D. Osteosclerosis

Explanation: In hemophilic arthropathy, the predisposition to fractures is primarily driven by a combination of **disuse osteoporosis** and **mechanical stress**. ### **Explanation of the Correct Answer** * **Osteoporosis:** Recurrent hemarthrosis (bleeding into joints) leads to chronic synovitis. The resulting hyperemia and the release of inflammatory cytokines stimulate osteoclast activity, leading to periarticular osteopenia. Furthermore, repeated painful episodes lead to prolonged immobilization, causing systemic and localized disuse osteoporosis. * **Restrictive Joint Movement:** Chronic inflammation causes synovial fibrosis and joint contractures. These stiff, "frozen" joints lose their ability to act as shock absorbers. When a mechanical force is applied, the lack of joint flexibility transfers the energy directly to the brittle, osteoporotic bone, resulting in a fracture. ### **Analysis of Incorrect Options** * **B. Cartilage destruction:** While cartilage destruction is a hallmark of late-stage hemophilic arthropathy (leading to joint space narrowing), it causes joint pain and deformity rather than being the direct physiological cause of bone fragility. * **C. Inflammatory arthropathy:** This describes the *process* (synovitis) but not the *mechanism* of the fracture itself. The inflammation is the precursor to the osteoporosis. * **D. Osteosclerosis:** This refers to increased bone density. In hemophilia, the bone density is decreased (osteoporosis), not increased. ### **NEET-PG High-Yield Pearls** * **Target Joint:** Defined as a joint with $\geq 3$ spontaneous bleeds within 6 months. The **knee** is the most common target joint in hemophilia. * **Radiological Sign:** Squaring of the inferior pole of the patella (Jordan’s Sign) and enlargement of the femoral intercondylar notch are classic X-ray findings. * **Management:** The primary goal is factor replacement (prophylaxis) and physiotherapy to maintain range of motion and bone density.

Question 784: Which of the following fractures in children, if left untreated, is known for nonunion?

A. Intercondylar fracture of humerus
B. Fracture shaft of humerus (Correct Answer)
C. Fracture shaft of femur
D. Fracture distal 1/3rd of tibia

Explanation: **Explanation:** In pediatric orthopaedics, most fractures heal rapidly due to a thick, osteogenic periosteum and excellent blood supply. However, certain fractures are notorious for **nonunion** if not managed correctly. **Why Fracture Shaft of Humerus is the Correct Answer:** While humeral shaft fractures in adults usually heal well with conservative management, in children, specific patterns (especially those with soft tissue interposition or severe displacement) can lead to nonunion if left untreated. More importantly, in the context of NEET-PG questions, the **Lateral Condyle of the Humerus** is the most common site for nonunion in children; however, among the options provided, the **Shaft of the Humerus** is recognized for its potential for nonunion due to the distraction of fragments by gravity and muscle pull (deltoid/pectoralis major) if stability is not maintained. **Analysis of Incorrect Options:** * **Intercondylar fracture of humerus:** These are extremely rare in children (more common in adults). In children, supracondylar or lateral condyle fractures are more frequent. * **Fracture shaft of femur:** These have an excellent blood supply and a thick periosteal sleeve in children. They almost always heal (often with overgrowth due to hyperemia), making nonunion exceptionally rare. * **Fracture distal 1/3rd of tibia:** While the distal tibia is a site of poor vascularity in adults, in children, the biological healing potential remains high, and nonunion is not a standard characteristic. **Clinical Pearls for NEET-PG:** * **Most common site of nonunion in children:** Lateral Condyle of Humerus (due to synovial fluid interference and the pull of extensor muscles). * **Most common site of malunion in children:** Supracondylar fracture of humerus (leading to Cubitus Varus/Gunstock deformity). * **Fracture with highest remodeling potential:** Those near the physis (e.g., proximal humerus) and in the plane of joint motion.

Question 785: What is a Tripod fracture?

A. Displaced fracture of calcaneum
B. Zygomaticomaxillary fracture (Correct Answer)
C. Sphenoid wing fracture
D. Coronal shear pilon fracture

Explanation: ### Explanation **Correct Answer: B. Zygomaticomaxillary fracture** A **Tripod fracture**, also known as a **Zygomaticomaxillary Complex (ZMC) fracture**, is a common facial injury typically resulting from a direct blow to the cheek. It is called a "tripod" fracture because it involves the disruption of the three primary cortical attachments of the zygoma to the rest of the face: 1. **Zygomaticofrontal suture** (Superiorly) 2. **Zygomaticomaxillary suture** (Medially) 3. **Zygomaticotemporal suture** (Laterally at the zygomatic arch) *Note: Modern anatomy often includes the fourth attachment—the zygomaticosphenoid suture—leading some to prefer the term "tetrapod fracture."* **Analysis of Incorrect Options:** * **A. Displaced fracture of calcaneum:** These are often referred to as "Don Juan fractures" or "Lover’s fractures" (associated with axial loading/falls from height). * **C. Sphenoid wing fracture:** These are usually part of complex skull base fractures or Le Fort III injuries, but are not termed tripod fractures. * **D. Coronal shear pilon fracture:** This refers to a specific pattern of distal tibial fracture involving the articular surface, often requiring specialized plating. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Flattening of the malar prominence (cheek), infraorbital nerve anesthesia (numbness of the upper lip/cheek), and diplopia (due to orbital floor involvement). * **Trismus:** Difficulty opening the mouth may occur if the zygomatic arch impinges on the coronoid process of the mandible. * **Imaging:** The **Water’s View** (Occipitomental projection) is the classic X-ray used to visualize ZMC fractures, though CT is the gold standard.

Question 786: A transverse fracture of the medial malleolus is most commonly caused by which of the following forces?

A. Adduction force
B. Abduction force (Correct Answer)
C. Inversion force
D. Flexion force

Explanation: **Explanation:** The morphology of a medial malleolus fracture is determined by the mechanism of injury, specifically the direction of the talar movement within the mortise. 1. **Why Abduction is correct:** In an **abduction (eversion) injury**, the talus tilts laterally, putting the strong deltoid ligament under extreme tension. This results in an **avulsion fracture** of the medial malleolus. Because it is an avulsion injury, the fracture line is typically **transverse** (horizontal) and located at or below the level of the tibial plafond. This is a classic feature of Lauge-Hansen’s Pronation-Abduction injuries. 2. **Why other options are incorrect:** * **Adduction (Inversion) force:** This causes the talus to push against the medial malleolus. This "push-off" mechanism results in a **vertical or oblique fracture** line, often associated with impaction of the supramalleolar purlieu. * **Flexion force:** While plantar or dorsiflexion can occur during ankle trauma, they typically result in anterior or posterior lip fractures (Pott’s fracture variants) rather than a pure transverse medial malleolar fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Lauge-Hansen Classification:** The most common mechanism of ankle fracture is **Supination-External Rotation (SER)**. * **Transverse = Avulsion:** Always remember that transverse fractures in the ankle are generally avulsion injuries (tension), while vertical/oblique fractures are due to impaction (compression). * **Mortise View:** The best X-ray view to assess the distal tibiofibular syndesmosis and the medial clear space. * **Danis-Weber Classification:** Based on the level of the **fibula** fracture relative to the syndesmosis (A: below, B: at, C: above).

Question 787: In high ulnar nerve lesions, such as those resulting from elbow fractures or dislocations, the degree of clawing is markedly less than in low ulnar nerve lesions. This phenomenon is called the ulnar paradox. What is the reason for the ulnar paradox?

A. The ulnar half of the flexor digitorum profundus (FDP) is paralyzed, leading to no active flexion at the interphalangeal (IP) joints. (Correct Answer)
B. The lumbrical muscles are spared, preventing the development of clawing.
C. The median nerve compensates for the function of the ulnar nerve.
D. The interosseous muscles increase their tone and extend the IP joints.

Explanation: **Explanation:** The **Ulnar Paradox** states that a "higher" lesion (at or above the elbow) results in a less severe deformity than a "lower" lesion (at the wrist). This is counterintuitive because, generally, more proximal nerve injuries lead to greater functional loss. **1. Why Option A is Correct:** Clawing is characterized by hyperextension at the metacarpophalangeal (MCP) joints and **flexion at the interphalangeal (IP) joints**. In a **low lesion**, the Flexor Digitorum Profundus (FDP) remains intact because it is supplied by the ulnar nerve in the forearm. The intact FDP pulls the IP joints into deep flexion, making the clawing prominent. In a **high lesion**, the ulnar half of the FDP is paralyzed. Without the FDP’s pulling force, the IP joints remain relatively straight, making the clawing appear "less" severe. **2. Why Other Options are Incorrect:** * **Option B:** The 3rd and 4th lumbricals are supplied by the ulnar nerve *distal* to the elbow. They are paralyzed in both high and low lesions, not spared. * **Option C:** The median nerve supplies the radial half of the FDP and the first two lumbricals; it does not compensate for the ulnar-innervated muscles in the ring and little fingers. * **Option D:** The interossei are paralyzed in both high and low lesions, leading to the loss of MCP flexion and IP extension, which *causes* clawing rather than preventing it. **Clinical Pearls for NEET-PG:** * **Claw Hand Components:** MCP hyperextension (loss of lumbricals) + IP flexion (unopposed FDP). * **Froment’s Sign:** Tests for Adductor Pollicis palsy (Ulnar nerve); patient flexes the thumb IP joint (via FPL/Median nerve) to hold a piece of paper. * **Wartenberg’s Sign:** Inability to adduct the little finger due to palmar interossei weakness. * **Rule of Thumb:** The closer the lesion is to the muscle it supplies, the more obvious the deformity (in ulnar nerve injuries).

Question 788: Which carpal bone is commonly injured and is adjacent to the scaphoid?

A. Trapezium (Correct Answer)
B. Trapezoid
C. Lunate
D. Capitate

Explanation: **Explanation:** The correct answer is **Trapezium**. The scaphoid is the most commonly fractured carpal bone. When considering injuries involving the scaphoid and its adjacent structures, the **Trapezium** is the most clinically relevant neighbor. Anatomically, the scaphoid articulates distally with the Trapezium and Trapezoid. However, the Trapezium is more frequently involved in combined injury patterns (like axial loading) and is the site of the clinically significant **scaphoid-trapezium-trapezoid (STT) joint**, which is a common site for osteoarthritis. **Analysis of Options:** * **Trapezium (Correct):** It sits directly distal to the scaphoid. It is a frequent site of injury and degenerative changes alongside the scaphoid. * **Trapezoid:** While it also articulates with the scaphoid, it is the least commonly injured carpal bone due to its protected position and strong ligamentous attachments. * **Lunate:** It is medial to the scaphoid. While the scaphoid and lunate are frequently involved in dissociative injuries (Scapholunate dissociation), the question specifically points toward the bone most commonly associated with adjacent injury/articulation in this context. * **Capitate:** It is the largest carpal bone and lies medial to the scaphoid. While it articulates with the scaphoid, it is not the primary "adjacent" bone associated with common distal scaphoid injury patterns. **High-Yield Clinical Pearls for NEET-PG:** 1. **Scaphoid Fracture:** Most common carpal fracture; risk of **Avascular Necrosis (AVN)** because the blood supply enters distally (retrograde flow). 2. **Tenderness:** Always check the **Anatomical Snuffbox** for scaphoid injury. 3. **Terry Thomas Sign:** A gap >3mm between the scaphoid and lunate on X-ray, indicating scapholunate dissociation. 4. **Kienbock’s Disease:** Avascular necrosis of the Lunate.

Question 789: Which of the following are features of common peroneal nerve injury?

A. Inversion inability, Loss of sensation of sole, Foot drop
B. Loss of sensation of sole, Foot drop, Loss of extension of great toe
C. Foot drop, Loss of extension of great toe, Seen in fibular neck fracture (Correct Answer)
D. Inversion inability, Loss of sensation of sole, Foot drop, Loss of extension of great toe, Seen in fibular neck fracture

Explanation: **Explanation:** The **Common Peroneal Nerve (CPN)**, also known as the common fibular nerve, is the most frequently injured nerve in the lower limb due to its superficial course as it winds around the **neck of the fibula**. **1. Why Option C is Correct:** The CPN divides into the Deep and Superficial Peroneal nerves. * **Deep Peroneal Nerve:** Supplies the anterior compartment muscles (Tibialis anterior, Extensor Hallucis Longus, Extensor Digitorum Longus). Injury leads to **loss of extension of the great toe** and **Foot Drop** (loss of dorsiflexion). * **Superficial Peroneal Nerve:** Supplies the lateral compartment (Peroneus longus and brevis), responsible for **eversion**. * **Anatomy:** Its proximity to the fibular neck makes it highly vulnerable to fractures in that region or compression from tight casts. **2. Why Other Options are Incorrect:** * **Inversion Inability:** Inversion is primarily performed by the Tibialis Anterior (Deep Peroneal) and **Tibialis Posterior (Tibial Nerve)**. In a pure CPN injury, inversion is often preserved or only partially weakened because the Tibial nerve remains intact. * **Loss of Sensation of the Sole:** The sole of the foot is supplied by the **medial and lateral plantar nerves**, which are branches of the **Tibial Nerve**. CPN injury causes sensory loss on the lateral aspect of the leg and the dorsum of the foot (sparing the first web space if only superficial is involved, or involving only the first web space if only deep is involved). **High-Yield Clinical Pearls for NEET-PG:** * **Gait:** Patients with CPN injury exhibit a **High Steppage Gait** to prevent the toes from dragging. * **Sensory:** The "classic" sensory deficit for the Deep Peroneal nerve is the **first dorsal web space**. * **Differential:** If a patient has foot drop **AND** loss of inversion/plantarflexion, suspect a **Sciatic Nerve** injury or an **L5 Radiculopathy**.

Question 790: What is the recommended treatment for a fracture of the neck of the humerus in a female patient?

A. Triangular sling (Correct Answer)
B. Hemiarthroplasty
C. Chest arm bandage
D. Internal fixation

Explanation: **Explanation:** Fractures of the proximal humerus (neck of the humerus) are common in elderly individuals, particularly post-menopausal females, due to osteoporosis. The management depends on the **Neer Classification**, which assesses the displacement of the four anatomical segments (head, greater tuberosity, lesser tuberosity, and shaft). **Why Option A is Correct:** The vast majority (approx. 80%) of proximal humerus fractures are **undisplaced or minimally displaced**. For these stable fractures, conservative management is the gold standard. A **triangular sling** (or U-slab/Velpeau bandage) provides sufficient immobilization to allow for secondary bone healing. Early mobilization (pendulum exercises) is usually started within 1–2 weeks to prevent adhesive capsulitis (frozen shoulder). **Why Other Options are Incorrect:** * **B. Hemiarthroplasty:** Reserved for complex, comminuted 4-part fractures or head-splitting fractures where the blood supply to the humeral head is compromised (risk of avascular necrosis). * **C. Chest arm bandage:** While it provides immobilization, it is cumbersome and less commonly used than a simple triangular sling for standard neck fractures. * **D. Internal fixation (ORIF):** Indicated for displaced 2-part, 3-part, or 4-part fractures in active individuals where closed reduction is unsuccessful. **Clinical Pearls for NEET-PG:** * **Most common nerve injured:** Axillary nerve (test sensation over the "regimental badge" area). * **Most common artery injured:** Anterior circumflex humeral artery (though the posterior circumflex provides more blood supply to the head). * **Neer’s Definition of Displacement:** A segment is considered displaced if it is separated by **>1 cm** or angulated **>45 degrees**. * **Commonest Complication:** Stiffness of the shoulder joint.

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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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Trauma — MCQs

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