Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 71: What is the commonest cause of pathological fracture in generalized affection?

A. Carcinoma
B. Osteoporosis (Correct Answer)
C. Cyst
D. All of the above

Explanation: ### Explanation **Correct Answer: B. Osteoporosis** **Understanding the Concept:** Pathological fractures occur when normal stress is applied to a bone weakened by an underlying disease process. These are broadly classified into **localized** (affecting a single bone) and **generalized** (affecting the entire skeleton) causes. **Osteoporosis** is the most common cause of pathological fractures in **generalized** bone disease. It is characterized by a reduction in bone mass and micro-architectural deterioration, making the entire skeleton fragile. The most frequent sites for osteoporotic fractures include the vertebral bodies (compression fractures), distal radius (Colles’ fracture), and the neck of the femur. **Analysis of Incorrect Options:** * **A. Carcinoma:** While metastatic carcinoma is the most common cause of pathological fractures in **adults** (specifically secondary to malignancies of the breast, prostate, or lung), it is typically considered a **localized** or multifocal cause rather than a systemic metabolic bone disease. * **C. Cyst:** Bone cysts (like Unicameral or Aneurysmal bone cysts) are common causes of pathological fractures in **children**, but they are strictly **localized** lesions. * **D. All of the above:** This is incorrect because the question specifically asks for the "commonest" cause in a "generalized" context, which points specifically to a systemic metabolic condition. **NEET-PG High-Yield Pearls:** * **Commonest cause of pathological fracture (Overall/Generalized):** Osteoporosis. * **Commonest cause of pathological fracture in children:** Unicameral Bone Cyst (UBC). * **Commonest cause of pathological fracture in elderly (Localized/Malignant):** Secondary Metastasis. * **Commonest site of a pathological fracture:** Vertebral body (Compression fracture). * **Commonest primary bone tumor causing pathological fracture:** Giant Cell Tumor (GCT).

Question 72: Which nerve is injured in a fracture of the medial epicondyle of the humerus?

A. Anterior interosseous nerve
B. Median nerve
C. Ulnar nerve (Correct Answer)
D. Radial nerve

Explanation: **Explanation:** The **ulnar nerve** is the correct answer because of its specific anatomical relationship with the humerus. It travels along the posterior aspect of the **medial epicondyle** in a groove called the ulnar sulcus (cubital tunnel). Any fracture, displacement, or significant swelling in this region directly threatens the nerve, leading to acute palsy or late-onset complications like tardy ulnar nerve palsy. **Analysis of Incorrect Options:** * **Anterior Interosseous Nerve (AIN):** This is a motor branch of the median nerve. It is most commonly injured in **Supracondylar fractures** of the humerus (specifically the extension type). * **Median Nerve:** While it passes through the cubital fossa anteriorly, it is more commonly injured in supracondylar fractures or elbow dislocations rather than isolated medial epicondyle fractures. * **Radial Nerve:** This nerve runs in the spiral groove of the humerus and passes anterior to the **lateral epicondyle**. It is typically injured in shaft of humerus fractures (Holstein-Lewis fracture). **NEET-PG High-Yield Pearls:** * **Medial Epicondyle Fracture:** Most common in children (avulsion injury); associated with ulnar nerve injury. * **Supracondylar Fracture:** Most common nerve injured is the **AIN** (Anterior Interosseous Nerve), followed by the Radial nerve. * **Tardy Ulnar Nerve Palsy:** Most commonly occurs as a late complication of **Lateral Condyle** fractures due to resultant cubitus valgus deformity. * **Clinical Sign:** Ulnar nerve injury leads to "Claw Hand" (involvement of intrinsic hand muscles) and a positive **Froment’s sign**.

Question 73: An elderly lady presents with a history of a fall in the washroom and pain in the gluteal region. Her limb is noted to be in lateral rotation. An X-ray of the pelvis is normal, but the pain persists even after 24 hours. What is the next step?

A. Closed reduction under general anesthesia
B. The patient is discharged home with analgesics, as a fracture has been ruled out.
C. Bone scan within the next 72 hours
D. MRI within 24 hours (Correct Answer)

Explanation: **Explanation:** The clinical presentation of an elderly patient with a fall, gluteal pain, and a limb in **lateral rotation** is highly suspicious of a **hip fracture** (specifically a femoral neck or intertrochanteric fracture), even if the initial X-ray is normal. **1. Why MRI within 24 hours is the correct answer:** In approximately 2–10% of hip fractures, the initial plain radiograph is negative (occult fracture). In an elderly patient with persistent pain and clinical signs (lateral rotation), the diagnosis must be pursued. **MRI is the gold standard** for diagnosing occult hip fractures, with nearly 100% sensitivity. It can detect marrow edema and fracture lines within hours of the injury. Current guidelines recommend MRI within 24 hours to allow for early surgical intervention, which reduces morbidity and mortality in the elderly. **2. Why other options are incorrect:** * **Option A:** Closed reduction is a treatment, not a diagnostic step. One cannot reduce a fracture that hasn't been visualized or confirmed. * **Option B:** Discharging the patient is dangerous. A missed hip fracture in an elderly patient can lead to avascular necrosis (AVN), non-union, or life-threatening complications like pulmonary embolism due to immobility. * **Option C:** While a Bone Scan (Technetium-99m) can detect fractures, it may take **48–72 hours** to show "increased uptake" (hot spot) in the elderly due to a delayed osteoblastic response. MRI is faster and more sensitive. **Clinical Pearls for NEET-PG:** * **Occult Fracture:** A fracture not visible on initial X-rays. Most common sites: Hip, Scaphoid, and Tibial plateau. * **Imaging Hierarchy for Occult Hip Fracture:** MRI (Gold Standard) > CT scan (if MRI is contraindicated) > Bone Scan (if others are unavailable). * **Positioning:** A classic hip fracture presents with **shortening and external (lateral) rotation**. * **Mortality:** Early fixation (within 24-48 hours) of hip fractures in the elderly significantly reduces the 30-day mortality rate.

Question 74: Avascular necrosis of the hip may occur following which of the following fractures?

A. Intertrochanteric fracture of the hip
B. Subtrochanteric fracture
C. Transcervical fracture of the neck of femur (Correct Answer)
D. Fracture of the posterior lip of the acetabulum

Explanation: ### Explanation **Correct Answer: C. Transcervical fracture of the neck of femur** **Why it is correct:** The blood supply to the femoral head is predominantly retrograde, provided by the **medial circumflex femoral artery** via its retinacular branches. These vessels run along the surface of the femoral neck. An intracapsular fracture, such as a **transcervical fracture**, disrupts these vessels and the intraosseous blood flow. Furthermore, the fracture causes an intracapsular hematoma, increasing pressure (tamponade effect) which further compromises capillary flow, leading to a high incidence of **Avascular Necrosis (AVN)**. **Why the other options are incorrect:** * **A & B (Intertrochanteric and Subtrochanteric fractures):** These are **extracapsular** fractures. The blood supply to the femoral head remains intact because the fracture line is distal to the attachment of the hip capsule and the entry point of the retinacular vessels. These areas are highly vascular (cancellous bone), so they rarely result in AVN but are more prone to malunion. * **D (Fracture of the posterior lip of the acetabulum):** While this can be associated with posterior hip dislocation (which *can* cause AVN), the fracture of the acetabulum itself does not directly compromise the blood supply to the femoral head. **High-Yield Clinical Pearls for NEET-PG:** * **Garden’s Classification:** Used for neck of femur fractures; Stages III and IV have the highest risk of AVN. * **Most important artery:** Medial circumflex femoral artery (specifically the posterosuperior retinacular branch). * **Pauwels’ Classification:** Based on the angle of the fracture line; higher angles (vertical fractures) have higher shear forces and higher risks of non-union/AVN. * **Management Rule:** In elderly patients with displaced transcervical fractures, **Arthroplasty** is preferred over internal fixation due to the high risk of AVN.

Question 75: Anterior dislocation of the shoulder is most commonly complicated by which of the following?

A. Axillary artery injury
B. Circumflex nerve injury (Correct Answer)
C. Recurrent dislocation
D. Axillary nerve injury

Explanation: **Explanation:** The shoulder is the most commonly dislocated joint in the body, with **anterior dislocation** accounting for over 95% of cases. **Why the correct answer is right:** The **Axillary nerve** (also known as the **Circumflex nerve**) is the most common nerve injured in anterior shoulder dislocations. It winds around the surgical neck of the humerus, making it highly vulnerable to traction or compression when the humeral head is displaced anteroinferiorly. Injury typically manifests as weakness in shoulder abduction (deltoid paralysis) and sensory loss over the "regimental badge area." **Analysis of Incorrect Options:** * **A. Axillary artery injury:** While serious, this is a rare complication, occurring more frequently in elderly patients with atherosclerotic vessels or in high-energy trauma. * **C. Recurrent dislocation:** This is the most common **late/chronic** complication of shoulder dislocation (especially in younger patients due to Bankart lesions). However, in the context of immediate neurovascular complications, nerve injury is a classic exam focus. Note: If the question asks for the "most common complication" overall without specifying neurovascular, recurrence is a strong contender, but "Circumflex nerve" is the standard answer for specific structure involvement. * **D. Axillary nerve injury:** While this is technically the same as the circumflex nerve, the question uses "Circumflex nerve" as the primary nomenclature in many classic orthopedic texts (like Maheshwari). In modern exams, these terms are interchangeable, but "Circumflex" is the specific anatomical name for the nerve's path. **NEET-PG High-Yield Pearls:** * **Most common nerve injured:** Axillary (Circumflex) nerve. * **Most common associated fracture:** Greater tuberosity fracture. * **Bankart Lesion:** Avulsion of the anteroinferior glenoid labrum (most common cause of recurrence). * **Hill-Sachs Lesion:** Compression fracture/indentation of the posterolateral humeral head. * **Clinical Sign:** "Hamilton Ruler Test" and "Dugas Test" are positive. The shoulder loses its normal rounded contour (Flattening of the deltoid).

Question 76: What is the first priority in managing a patient with a fractured femur from an acute accident?

A. Secure airway and treat shock (Correct Answer)
B. Splint the fracture
C. Perform a physical examination
D. Obtain X-rays

Explanation: In trauma management, the primary goal is to address life-threatening conditions before limb-threatening ones. This follows the **ATLS (Advanced Trauma Life Support)** protocol, which prioritizes the **ABCDE** approach (Airway, Breathing, Circulation, Disability, Exposure). **1. Why "Secure airway and treat shock" is correct:** A fractured femur is a major orthopedic injury often associated with high-energy trauma. It can lead to significant internal hemorrhage (up to 1.5 liters of blood loss into the thigh), resulting in **hypovolemic shock**. According to ATLS guidelines, stabilizing the airway and managing circulation (shock) takes precedence over the fracture itself to ensure patient survival. **2. Why the other options are incorrect:** * **B. Splint the fracture:** While splinting is crucial to reduce pain and prevent further fat embolism or vascular injury, it is part of the "Secondary Survey" or the end of the "Circulation" phase. It must not delay life-saving resuscitation. * **C. Perform a physical examination:** A detailed head-to-toe physical examination is part of the Secondary Survey, which is only performed once the patient is hemodynamically stable. * **D. Obtain X-rays:** Imaging is a diagnostic tool used after the initial stabilization. "Treat first what kills first" is the rule; an X-ray should never precede resuscitation in an acute setting. **Clinical Pearls for NEET-PG:** * **Blood loss in fractures:** Femur (1–1.5L), Pelvis (2L+), Tibia (0.5L), Humerus (0.5L). * **Thomas Splint:** The classic traction splint used for mid-shaft femur fractures to stabilize the bone and tamponade internal bleeding. * **Fat Embolism Syndrome:** A high-yield complication of long bone fractures, characterized by the triad of dyspnea, confusion, and petechial rashes.

Question 77: What is true about lunate dislocation?

A. The lunate dislocates anteriorly, while other carpal bones remain in place. (Correct Answer)
B. The lunate stays in place while other carpal bones dislocate posteriorly.
C. The ulnar nerve is most commonly involved.
D. None of the above.

Explanation: **Explanation:** Lunate dislocation is a high-energy wrist injury typically resulting from forced dorsiflexion. It represents the final stage (Stage IV) of **Mayfield’s classification** of perilunate instability. **1. Why Option A is Correct:** In a **Lunate Dislocation**, the lunate is displaced anteriorly (volarly) into the carpal tunnel, while the rest of the carpal bones (capitate, radius, etc.) maintain their normal linear alignment. On a lateral X-ray, this is classically described as the **"Spilled Teacup" sign**, as the lunate tilts forward and loses its contact with both the radius and the capitate. **2. Why Other Options are Incorrect:** * **Option B:** This describes a **Perilunate Dislocation**. In this injury, the lunate remains in its normal relationship with the distal radius, while the rest of the carpal bones (the "perilunate" structures) dislocate posteriorly. * **Option C:** The **Median nerve** is the most commonly involved nerve, not the ulnar nerve. Because the lunate dislocates anteriorly into the carpal tunnel, it causes acute compression of the median nerve, often leading to acute carpal tunnel syndrome. **3. High-Yield Clinical Pearls for NEET-PG:** * **X-ray Signs:** * **AP View:** "Piece of Pie" sign (triangular appearance of the lunate). * **Lateral View:** "Spilled Teacup" sign. * **Mechanism:** Progressive tearing of carpal ligaments (starting with the scapholunate ligament). * **Management:** Emergency reduction is required to decompress the median nerve, followed by surgical ligamentous repair. * **Complication:** Kienböck’s disease (avascular necrosis of the lunate) can occur due to disrupted blood supply.

Question 78: Epiphyseal plate fractures are classified by:

A. Herring's classification
B. Salter-Harris classification (Correct Answer)
C. Garden's classification
D. Pauwel's classification

Explanation: **Explanation:** The **Salter-Harris classification** is the gold standard system used to categorize fractures involving the epiphyseal plate (growth plate) in children [1]. This classification is crucial because the growth plate is the weakest part of the pediatric skeleton, and injuries here can lead to permanent growth disturbances [1]. * **Type I:** Slipped (Separation through the physis) [1]. * **Type II:** Above (Physis + Metaphysis) – **Most common type.** [1] * **Type III:** Lower (Physis + Epiphysis) – Intra-articular [1]. * **Type IV:** Through (Metaphysis + Physis + Epiphysis) [1]. * **Type V:** Erased/Crush (Compression of the physis) – Worst prognosis [1]. **Analysis of Incorrect Options:** * **Herring’s Classification:** Used for **Legg-Calvé-Perthes disease** (Lateral Pillar classification) to determine prognosis based on the height of the lateral pillar of the femoral head. * **Garden’s Classification:** Used for **Fracture Neck of Femur** in adults, based on the degree of displacement (Stages I-IV). * **Pauwel’s Classification:** Also used for **Fracture Neck of Femur**, but based on the **angle of the fracture line** relative to the horizontal plane (predicts shear force stability). **High-Yield Clinical Pearls for NEET-PG:** * **Thurston-Holland Sign:** A triangular metaphyseal fragment seen in Salter-Harris **Type II** fractures [1]. * **Prognosis:** Types I and II generally have a good prognosis and can often be managed conservatively. Types III and IV require anatomical reduction to prevent growth arrest and joint incongruity [1]. * **Most Common:** Salter-Harris Type II is the most frequently encountered clinical presentation [1].

Question 79: Fracture of a mandible with an edentulous jaw is best treated with which of the following?

A. External fixator (Correct Answer)
B. Minerva plaster
C. Interdental wiring
D. Intermaxillary elastic traction

Explanation: **Explanation:** The management of mandibular fractures in an **edentulous jaw** (a jaw without teeth) presents a unique challenge because the standard method of stabilization—**Intermaxillary Fixation (IMF)**—cannot be performed due to the lack of teeth to anchor the wires. **Why External Fixator is Correct:** In an edentulous patient, an **External Fixator** (such as the Morris biphase splint) is the preferred treatment when open reduction is not feasible. It provides rigid stabilization by placing pins into the bone fragments through the skin, bypassing the need for dental anchorage. This allows for fracture healing while maintaining the vertical dimension of the face. **Analysis of Incorrect Options:** * **Interdental wiring (C) and Intermaxillary elastic traction (D):** These techniques require a sufficient number of stable teeth in both the upper and lower jaws to "tie" the mouth shut and align the fracture. In an edentulous patient, there is no substrate for these wires or elastics to grip. * **Minerva plaster (B):** This is a specialized orthopedic cast used for cervical and upper thoracic spine fractures (extending from the head to the hips). It has no role in the stabilization of mandibular fractures. **Clinical Pearls for NEET-PG:** * **Gunning Splints:** If an edentulous patient has existing dentures, they can be modified (Gunning splints) and wired to the jaw (circum-mandibular wiring) to act as a substitute for teeth during fixation. * **Atrophy:** Edentulous mandibles are often severely atrophic (thin). This makes them prone to "non-union" and increases the risk of further fracture during surgical plating. * **Gold Standard:** While external fixators are a classic answer for exams, **Open Reduction and Internal Fixation (ORIF)** with mini-plates is increasingly used in modern practice if the bone quality allows.

Question 80: Pseudarthrosis may be seen in all of the following conditions except?

A. Fracture
B. Idiopathic
C. Neurofibromatosis
D. Osteomyelitis (Correct Answer)

Explanation: **Explanation:** **Pseudarthrosis** (literally "false joint") refers to a permanent failure of bone healing where the fracture site remains mobile, and the medullary canal is sealed by cortical bone, often with a synovial-like membrane forming between the fragments. **Why Osteomyelitis is the correct answer:** Osteomyelitis is an infection of the bone. While chronic osteomyelitis can lead to **Non-union** (specifically infected non-union), it does not typically result in a "Pseudarthrosis." In osteomyelitis, the hallmark pathological features are the **Sequestrum** (dead bone) and **Involucrum** (new bone formation). While the bone may fail to unite, the specific pathological entity of a "false joint" with a fluid-filled cavity is not a characteristic feature of the infection itself. **Analysis of other options:** * **Fracture:** This is the most common cause of acquired pseudarthrosis. If a fracture is inadequately immobilized or has poor blood supply (e.g., scaphoid or neck of femur), the body may form a fibrocartilaginous "false joint" instead of a bony union. * **Idiopathic:** Congenital pseudarthrosis can occur without a known cause, most commonly affecting the tibia in infants. * **Neurofibromatosis (Type 1):** This is a classic association for **Congenital Pseudarthrosis of the Tibia (CPT)**. Approximately 50% of children with CPT have NF-1. It occurs due to a defect in the periosteum, leading to bowing and subsequent fracture that fails to heal. **NEET-PG High-Yield Pearls:** * **Most common site for Congenital Pseudarthrosis:** Distal third of the Tibia. * **Radiological sign of Pseudarthrosis:** Sclerosis of bone ends with closure of the medullary canal (unlike simple non-union where the canal may remain open). * **Treatment:** Usually requires surgical intervention (Ilizarov technique or vascularized fibular graft) as these do not heal spontaneously.

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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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