Trauma — MCQs
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Enophthalmos is seen in ?
A patient presents with blunt trauma to abdomen. On investigations patient is found to have hepatic injury which has a ruptured subcapsular hematoma with active bleeding. What is the grade of liver injury?
Which type of fracture of the petrous bone is most likely to cause facial nerve palsy?
A 27 year old patient presented with left sided abdominal pain 6 hours after RTA. He was hemodynamically stable and FAST positive. CT scan showed grade III splenic injury. What will be appropriate treatment
What does the Sunderland classification specifically categorize?
What is the percentage body surface area involved in head and neck in burns?
A patient with a gunshot wound to the thorax has lost 1900 ml of blood and is losing 200 ml of blood per hour. What is the next step in management?
Curling's ulcer is seen in -
What is the primary treatment for rib fractures?
In blunt chest trauma, the first step in management after initial resuscitation is
Trauma Indian Medical PG Practice Questions and MCQs
Question 1131: Enophthalmos is seen in ?
- A. Hyperthyroidism
- B. Radiation Injuries
- C. Diabetes mellitus
- D. Blow-out fracture of orbit wall (Correct Answer)
Explanation: ***Blow-out fracture of orbit wall*** - A **blow-out fracture** typically involves the **orbital floor** or **medial wall**, expanding the orbital volume. - This increase in orbital volume allows the eyeball to drop back into the orbit, causing **enophthalmos**. *Hyperthyroidism* - Hyperthyroidism, particularly **Graves' ophthalmopathy**, is associated with **exophthalmos** (protrusion of the eyeballs), not enophthalmos. - This is due to inflammation and edema of the **retro-orbital tissues** and extraocular muscles. *Radiation Injuries* - While radiation to the orbital region can cause various ocular complications, **enophthalmos** is not a common direct sequela. - Such injuries might lead to tissue scarring, but orbital volume changes leading to enophthalmos are atypical. *Diabetes mellitus* - Diabetes mellitus can lead to various ocular complications like **diabetic retinopathy** and **cataracts**, but not typically enophthalmos. - There is no direct mechanism by which diabetes would cause the eyeball to recede into the orbit.
Question 1132: A patient presents with blunt trauma to abdomen. On investigations patient is found to have hepatic injury which has a ruptured subcapsular hematoma with active bleeding. What is the grade of liver injury?
- A. Grade I
- B. Grade IV (Correct Answer)
- C. Grade II
- D. Grade III
Explanation: ***Grade IV*** - A **ruptured subcapsular hematoma with active bleeding** is classified as **Grade IV** in the **American Association for the Surgery of Trauma (AAST) liver injury grading scale** - The key feature is **active bleeding** from the ruptured hematoma, which indicates ongoing hemorrhage requiring immediate intervention - This distinguishes it from Grade III, where the hematoma may be ruptured but without documented active bleeding - **Grade IV injuries involve 25-75% hepatic lobe disruption or active bleeding from ruptured hematomas** *Grade I* - Involves **subcapsular hematoma <10%** surface area or **capsular tear/parenchymal laceration <1 cm depth** - No active bleeding or hematoma rupture - Represents minimal injury typically managed conservatively *Grade II* - Involves **subcapsular hematoma 10-50%** surface area, **intraparenchymal hematoma <10 cm**, or **laceration 1-3 cm depth and <10 cm length** - No rupture or active bleeding - More significant than Grade I but still relatively stable *Grade III* - Involves **subcapsular hematoma >50%** surface area or expanding, **ruptured subcapsular/parenchymal hematoma without active bleeding**, **intraparenchymal hematoma >10 cm** or expanding, or **laceration >3 cm depth** - The critical difference from Grade IV is the **absence of documented active bleeding** in a ruptured hematoma - In this patient, the presence of active bleeding elevates the injury to Grade IV
Question 1133: Which type of fracture of the petrous bone is most likely to cause facial nerve palsy?
- A. Longitudinal fractures
- B. Transverse fractures (Correct Answer)
- C. Oblique fractures
- D. Mastoid fractures
Explanation: ***Transverse fractures*** - **Transverse petrous bone fractures** run perpendicular to the long axis of the petrous pyramid, directly traversing the **fallopian canal** where the facial nerve is housed. - This direct involvement of the facial nerve's bony canal makes them highly prone to severing or severely damaging the nerve, leading to **facial nerve palsy**. *Longitudinal fractures* - **Longitudinal petrous bone fractures** run parallel to the long axis of the petrous pyramid, usually sparing the **fallopian canal** and thus causing facial nerve palsy less frequently. - They are more commonly associated with **ossicular chain disruption** and conductive hearing loss rather than direct facial nerve injury. *Mastoid fractures* - **Mastoid fractures** involve the mastoid portion of the temporal bone and are less likely to directly impact the **intratemporal course** of the facial nerve within the petrous bone itself. - While facial nerve injury can occur with extensive temporal bone trauma, specific mastoid fractures are not the primary cause of facial nerve palsy related to petrous bone involvement. *Oblique fractures* - **Oblique fractures** are a less specific classification and their propensity to cause facial nerve palsy depends on their trajectory and whether they intersect the **fallopian canal**. - Without specific information on their angulation relative to the facial nerve's path, they are not as specifically associated with facial nerve palsy as truly transverse fractures.
Question 1134: A 27 year old patient presented with left sided abdominal pain 6 hours after RTA. He was hemodynamically stable and FAST positive. CT scan showed grade III splenic injury. What will be appropriate treatment
- A. Conservative management
- B. Splenic artery embolization (Correct Answer)
- C. Splenectomy
- D. Splenorrhaphy
Explanation: ***Splenic artery embolization*** - This patient is **hemodynamically stable** with a **Grade III splenic injury**, making him a candidate for non-operative management with adjunctive intervention. - **Grade III splenic injuries** have a higher failure rate with observation alone due to deeper lacerations (>3 cm) and involvement of trabecular vessels. - **FAST positive** indicates hemoperitoneum, suggesting significant bleeding has occurred, which increases the risk of delayed hemorrhage. - **Splenic artery embolization (SAE)** is the **current standard of care** for hemodynamically stable patients with Grade III-IV splenic injuries, as it significantly reduces the failure rate of non-operative management while preserving the spleen. - SAE provides targeted hemostasis by blocking bleeding vessels while maintaining overall splenic function and avoiding the risks of splenectomy. *Conservative management (observation alone)* - While **non-operative management** is appropriate for stable patients, **observation alone without SAE** is more suitable for **Grade I-II injuries**. - For **Grade III injuries**, conservative management alone has a **higher failure rate** (10-20%) compared to SAE + observation (failure rate <5%). - Modern trauma guidelines recommend adjunctive SAE for Grade III-IV injuries to improve success rates and reduce need for delayed splenectomy. *Splenorrhaphy* - **Splenorrhaphy** (surgical repair) requires laparotomy and is more invasive than angioembolization. - Reserved for hemodynamically unstable patients requiring laparotomy for other injuries, where spleen preservation is attempted. - Not the first choice for isolated splenic injury in a stable patient when less invasive options are available. *Splenectomy* - **Splenectomy** is reserved for **hemodynamically unstable patients** with uncontrolled hemorrhage or very high-grade injuries (Grade IV-V) that fail non-operative management. - This patient is **stable**, making splenectomy unnecessarily aggressive and exposing him to risks of **overwhelming post-splenectomy infection (OPSI)**. - Should be avoided when spleen-preserving options are feasible.
Question 1135: What does the Sunderland classification specifically categorize?
- A. Nerve injury (Correct Answer)
- B. Muscle injury
- C. Tendon injury
- D. Ligament injury
Explanation: ***Nerve injury*** - The **Sunderland classification** is a widely used system to categorize the severity of **peripheral nerve injuries** based on the degree of damage to the nerve components. - It expands upon the simpler Seddon classification (**neuropraxia, axonotmesis, neurotmesis**) by adding more detailed grades of axon and connective tissue damage. *Muscle injury* - **Muscle injuries** are typically classified using systems that describe the extent of fiber disruption, hematoma formation, and involvement of the fascia, such as the **British Athletics Muscle Injury Classification (BAMIC)**, not the Sunderland classification. - These classifications focus on the structural integrity of muscle tissue and its functional implications. *Tendon injury* - **Tendon injuries** are classified based on their severity (e.g., tendinopathy, partial tear, complete rupture) and location, often using systems like the **Blazina classification** for patellar tendinopathy. - The Sunderland classification is specific to nerve damage, not connective tissues like tendons. *Ligament injury* - **Ligament injuries** are typically graded from I to III, indicating a sprain, partial tear, or complete rupture, respectively, often with associated joint instability. - Classifications for ligament injuries, such as those used for ankle sprains or ACL tears, do not align with the Sunderland system for nerve damage.
Question 1136: What is the percentage body surface area involved in head and neck in burns?
- A. 9% (Correct Answer)
- B. 13%
- C. 15%
- D. 17%
Explanation: ***Correct: 9%*** - The **Rule of Nines**, a common method for estimating burn size in adults, assigns **9% to the entire head and neck region**. - This estimation is crucial for determining fluid resuscitation needs and overall burn management according to the Parkland formula. *Incorrect: 13%* - This percentage is not consistent with the established **Rule of Nines** for any specific body part in adults. - It might be closer to the head and neck percentage in young children (approximately 18% for infants), where the head is proportionally larger. *Incorrect: 15%* - This value does not correspond to a standard burn percentage for the head and neck according to the **Rule of Nines**. - It is significantly higher than the accepted estimate for this body region in adults. *Incorrect: 17%* - This is a disproportionately high percentage for the head and neck area under the **Rule of Nines**. - Such a value would not be used in adult burn assessments for this specific anatomical region.
Question 1137: A patient with a gunshot wound to the thorax has lost 1900 ml of blood and is losing 200 ml of blood per hour. What is the next step in management?
- A. Blood transfusion
- B. Thoracotomy (Correct Answer)
- C. PPV
- D. FFP
Explanation: ***Thoracotomy*** - **Thoracotomy** is the definitive surgical intervention indicated for this patient. - **Indications for emergency thoracotomy in chest trauma:** - Initial chest tube output **>1500 mL** (this patient has 1900 mL) ✓ - Ongoing bleeding **>200 mL/hour for 2-4 consecutive hours** - This patient meets the **primary indication** with >1500 mL initial blood loss, requiring immediate surgical control of hemorrhage. - Direct visualization and repair of the bleeding source is critical for survival in life-threatening thoracic hemorrhage. *Blood transfusion* - While **blood transfusions** are essential for replacing lost blood volume and must be initiated, they do not address the source of ongoing hemorrhage. - Resuscitation alone without surgical control of active bleeding will be futile. - Blood transfusion should be given **simultaneously** while preparing for thoracotomy, not as an alternative. *PPV* - **Positive Pressure Ventilation (PPV)** is a supportive measure for respiratory failure but does not stop active bleeding in the chest. - It may be used as part of resuscitation, but it is not the definitive management for severe hemorrhage. - Can be part of peri-operative support during thoracotomy. *FFP* - **Fresh Frozen Plasma (FFP)** provides clotting factors and is used to correct coagulopathy in massive transfusion protocols. - Like blood transfusion, FFP does not control the active bleeding source and should be administered **in conjunction with** definitive surgical intervention. - Used in 1:1:1 ratio with PRBC and platelets in massive transfusion protocol.
Question 1138: Curling's ulcer is seen in -
- A. Burn patients (Correct Answer)
- B. Patients with head injuries
- C. Zollinger Ellison syndrome
- D. Analgesic drug abuse
Explanation: ***Burn patients*** - **Curling's ulcer** is an acute **gastric or duodenal ulcer** that develops in patients following severe burns. - The pathogenesis is thought to involve reduced plasma volume, leading to **mucosal ischemia** and **acid hypersecretion**. *Patients with head injuries* - Patients with **head injuries** are more prone to developing **Cushing's ulcers**, which are also acute stress ulcers but result from increased **intracranial pressure** leading to vagal stimulation and acid hypersecretion. - **Cushing's ulcers** are specifically linked to central nervous system trauma or disease, not burns. *Zollinger Ellison syndrome* - **Zollinger-Ellison syndrome** is characterized by multiple, refractory **peptic ulcers** due to a **gastrin-secreting tumor** (gastrinoma), causing extreme **acid hypersecretion**. - These ulcers are typically chronic and recurrent, distinct from the acute stress-induced ulcers seen in burn patients. *Analgesic drug abuse* - **Analgesic drug abuse**, particularly with **NSAIDs**, can cause **peptic ulcers** by inhibiting **prostaglandin synthesis**, which normally protects the gastric mucosa. - These ulcers are chemically induced and chronic, rather than being acute stress ulcers associated with burns.
Question 1139: What is the primary treatment for rib fractures?
- A. Immediate thoracotomy
- B. IPPV
- C. Analgesics (Correct Answer)
- D. Both IPPV and analgesics
Explanation: ***Analgesics*** - **Pain control** is the cornerstone of rib fracture management, as it allows for adequate breathing and prevents complications like **atelectasis** and **pneumonia**. - Effective analgesia can range from oral medications to **intercostal nerve blocks** or **epidural anesthesia**, depending on the severity of pain. *Immediate thoracotomy* - **Thoracotomy** is an invasive surgical procedure typically reserved for life-threatening conditions such as **massive hemothorax**, **cardiac tamponade**, or severe **tracheobronchial injury**. - It is not the primary treatment for isolated rib fractures, which usually heal with conservative management. *IPPV* - **Intermittent Positive Pressure Ventilation (IPPV)** is a form of mechanical ventilation used in cases of **respiratory failure**, often due to flail chest or severe pulmonary contusion. - While it may be necessary in complex rib fracture scenarios causing respiratory compromise, it is not the initial or primary treatment for uncomplicated rib fractures. *Both IPPV and analgesics* - While **analgesics** are crucial, **IPPV** is not routinely indicated for all rib fractures. - IPPV is reserved for cases where respiratory compromise is significant, such as a **flail chest** leading to ventilatory failure, making "both" not the primary or universal treatment.
Question 1140: In blunt chest trauma, the first step in management after initial resuscitation is
- A. CT scan
- B. Angiography
- C. X-ray chest (Correct Answer)
- D. USG
Explanation: ***X-ray chest*** - After initial resuscitation in **blunt chest trauma**, a chest X-ray is the **fastest and most accessible initial imaging modality** to identify life-threatening injuries like **pneumothorax, hemothorax, or major fractures**. - It helps guide immediate interventions and further diagnostic steps by providing crucial information about the **lungs, heart, and bony structures**. *CT scan* - A CT scan provides **more detailed anatomical information** but is generally performed **after initial stabilization** and a plain chest X-ray. It's not the very first imaging step. - While it can detect injuries missed by X-ray, its **time commitment and resource requirements** make it suboptimal for immediate, life-saving decision-making in the initial trauma phase. *Angiography* - Angiography is an **invasive procedure** used to visualize blood vessels, typically reserved for suspected **vascular injuries** identified or highly suggested by other imaging or clinical findings. - It is **not a routine first step** in the immediate management of blunt chest trauma and carries its own risks. *USG* - Ultrasound (USG) can be useful in trauma for detecting **pericardial effusion** (**FAST exam**) or **pleural fluid**, but it offers **limited visualization of the entire chest cavity** compared to X-ray. - It is typically used as an **adjunct** or for specific questions, not as the primary comprehensive initial imaging in blunt chest trauma.
Practice by Chapter
Initial Assessment of Trauma Patient
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Advanced Trauma Life Support (ATLS) Principles
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Chest Trauma
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Abdominal Trauma
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Head Trauma
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Spinal Trauma
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Extremity Trauma
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Vascular Trauma
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Genitourinary Trauma
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Burns Management
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Mass Casualty Management
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Damage Control Surgery
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