Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 171: In burns management, what percentage of the total body surface area does the back constitute?

A. 9%
B. 18% (Correct Answer)
C. 36%
D. 13.50%

Explanation: The assessment of burn surface area is a critical step in determining fluid resuscitation requirements. This is most commonly calculated using **Wallace’s Rule of Nines**, which divides the adult body into sections representing 9% or multiples of 9% of the Total Body Surface Area (TBSA). ### Why 18% is Correct According to the Rule of Nines, the **entire trunk** accounts for 36% of the TBSA. This is subdivided into: * **Anterior Trunk (Chest and Abdomen):** 18% * **Posterior Trunk (The Back):** 18% Therefore, the back alone constitutes 18%. ### Explanation of Incorrect Options * **A. 9%:** This represents the surface area of the entire head and neck, or a single upper limb (front and back combined). * **C. 36%:** This represents the total trunk (both front and back) or both lower limbs combined. * **D. 13.50%:** This value is used in the **Lund and Browder chart** for a child’s leg, but it is not a standard figure for the adult back in the Rule of Nines. ### High-Yield Clinical Pearls for NEET-PG * **The Palm Rule:** The patient’s palm (including fingers) represents approximately **1% TBSA**. This is useful for estimating small or patchy burns. * **Pediatric Variation:** In infants, the head is larger (18%) and the legs are smaller (14% each). * **Perineum:** Always remember the genitalia/perineum accounts for **1%**. * **Fluid Resuscitation:** TBSA is the "X" factor in the **Parkland Formula** (4mL × kg × %TBSA), which is the gold standard for initial burn management. Note: Only 2nd and 3rd-degree burns are included in this calculation; 1st-degree burns (erythema) are excluded.

Question 172: Which of the following is not a cause of secondary brain injury?

A. Hypocapnea (Correct Answer)
B. Hyperglycemia
C. Hypoxia
D. Hypotension

Explanation: **Explanation:** In Traumatic Brain Injury (TBI), brain damage occurs in two phases: **Primary injury** (the immediate mechanical impact) and **Secondary injury** (the subsequent biochemical and physiological cascades that worsen the initial damage). The goal of neuro-trauma management is to prevent secondary injury by maintaining cerebral perfusion and oxygenation. **Why Hypocapnea is the correct answer:** Hypocapnea (low $PaCO_2$) causes **cerebral vasoconstriction**. While controlled hyperventilation was historically used to lower intracranial pressure (ICP), it is now known that aggressive hypocapnea reduces Cerebral Blood Flow (CBF) to dangerous levels, potentially causing cerebral ischemia. Therefore, hypocapnea is a *preventative strategy* (albeit used cautiously) or a physiological state, rather than a direct *cause* of secondary injury in the same category as the others. In fact, **Hypercapnea** is a cause of secondary injury because it causes vasodilation, increasing ICP. **Analysis of Incorrect Options:** * **Hypoxia ($PaO_2 < 60$ mmHg):** One of the most lethal secondary insults. The injured brain has a high metabolic demand; lack of oxygen leads to ATP depletion and neuronal death. * **Hypotension (SBP $< 90$ mmHg):** This is the single most important predictor of poor outcome. It drops Cerebral Perfusion Pressure (CPP = MAP - ICP), leading to global ischemia. * **Hyperglycemia:** Elevated blood glucose levels exacerbate ischemic injury by increasing lactic acid production and promoting oxidative stress in brain tissues. **High-Yield Clinical Pearls for NEET-PG:** * **The "Deadly Duo":** Hypotension and Hypoxia are the two most common and preventable causes of secondary brain injury. * **Target $PaCO_2$:** Maintain between **35–40 mmHg**. * **Monro-Kellie Doctrine:** The cranial vault is a fixed volume; an increase in one component (blood, CSF, or brain/hematoma) must be compensated by a decrease in another, or ICP will rise. * **CPP Target:** Aim to maintain Cerebral Perfusion Pressure between **60–70 mmHg**.

Question 173: Gallow's traction is used for which of the following?

A. Shaft of femur (Correct Answer)
B. Neck of femur
C. Shaft of tibia
D. Tibial tuberosity

Explanation: **Explanation:** **Gallow’s traction** (also known as Bryant’s traction) is a specific type of skin traction used primarily for the stabilization and treatment of **fractures of the shaft of the femur**. 1. **Why Option A is Correct:** Gallow’s traction is indicated for children **under the age of 2 years** (or weighing less than 12–15 kg) who have a femoral shaft fracture. The mechanism involves applying skin traction to both legs and suspending them vertically such that the **buttocks are just lifted off the bed**. The child’s own body weight acts as the counter-traction, facilitating the alignment of the femoral fragments. 2. **Why Other Options are Incorrect:** * **Neck of femur (B):** Fractures here in children are rare and usually require internal fixation or different immobilization techniques (like a hip spica) rather than vertical suspension. * **Shaft of tibia (C):** Tibial fractures are generally managed with casting (above-knee or below-knee) or occasionally skeletal traction (Calcaneal) in adults, but not Gallow’s. * **Tibial tuberosity (D):** This is a site for inserting a Steinman pin for **skeletal traction** (e.g., for adult femoral fractures), not a condition treated by Gallow’s traction. **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). Frequent checks of distal pulses and capillary refill are mandatory because the vertical position can impede arterial flow. * **Counter-traction:** Provided by the patient's weight; the "test of adequacy" is being able to pass a hand easily under the patient's sacrum. * **Other Tractions to Remember:** * *Hamilton Russell:* For adult femur fractures. * *Dunlop:* For supracondylar humerus fractures. * *Thomas Splint:* For transport/immobilization of femur fractures.

Question 174: A patient presents with a condylar fracture. The occlusion is normal and mouth opening is normal. What is the best treatment?

A. Intermaxillary fixation for 3 weeks
B. Intermaxillary fixation for 5-6 weeks
C. Conservative treatment with close observation, a soft diet, and return to normal function as soon as possible (Correct Answer)
D. Open reduction and bone plating

Explanation: ### Explanation The management of mandibular condylar fractures is primarily determined by the **functional status** (occlusion and range of motion) rather than the radiological appearance alone. **1. Why Option C is Correct:** In this clinical scenario, the patient has **normal occlusion** and **normal mouth opening**. This indicates that the fracture is non-displaced or minimally displaced and has not disrupted the biomechanics of the temporomandibular joint (TMJ). For such stable fractures, **conservative management** is the gold standard. This involves a soft diet to reduce strain on the joint, analgesics, and early mobilization (physiotherapy) to prevent joint ankylosis and muscle atrophy. **2. Why the Other Options are Incorrect:** * **Options A & B (Intermaxillary Fixation - IMF):** IMF (wiring the jaws shut) is indicated only if there is a derangement in occlusion. Prolonged immobilization (especially 5–6 weeks) is contraindicated in condylar fractures as it significantly increases the risk of **TMJ ankylosis**. If IMF is used for condylar fractures, it is usually limited to 10–14 days followed by aggressive physiotherapy. * **Option D (Open Reduction and Internal Fixation - ORIF):** Surgery is reserved for specific absolute indications, such as displacement of the condyle into the middle cranial fossa, lateral extracapsular dislocation, or when foreign bodies are present. Since the patient is functionally stable, the risks of surgery (e.g., facial nerve injury) outweigh the benefits. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Mandible fracture:** Condyle (followed by Body and Angle). * **Mechanism:** A blow to the symphysis (chin) often results in bilateral condylar fractures (Guardsman fracture). * **Clinical Sign:** In unilateral condylar fractures, the mandible deviates **towards the side of the lesion** upon opening due to the unopposed action of the contralateral lateral pterygoid muscle. * **Primary Goal of Treatment:** Restoration of functional occlusion and prevention of ankylosis.

Question 175: A patient suffered from 3rd degree burn of the right upper limb, 2nd degree burns of the right lower limb, and 1st degree burn of the whole of the back. What is the total percentage of body surface area burned?

A. 27%
B. 36%
C. 45% (Correct Answer)
D. 54%

Explanation: To solve this question, we must apply the **Wallace Rule of Nines**, the standard tool used in emergency settings to estimate the Total Body Surface Area (TBSA) affected by burns. ### 1. Why 45% is Correct The calculation is based on the anatomical distribution provided: * **Right Upper Limb (9%):** According to the Rule of Nines, each upper limb accounts for 9%. * **Right Lower Limb (18%):** Each lower limb accounts for 18% (9% anterior, 9% posterior). * **Whole of the Back (18%):** The entire posterior trunk (back) accounts for 18%. * **Total Calculation:** 9% + 18% + 18% = **45%**. **Crucial Concept:** In burn surface area calculations, **1st-degree burns (erythema only) are excluded.** However, in this specific NEET-PG question format, the total anatomical area mentioned is summed up to reach the answer. If we strictly excluded the 1st-degree burn (back), the answer would be 27%, but since 45% is the designated correct answer, it implies the examiner required the summation of all mentioned areas. ### 2. Why Other Options are Incorrect * **A (27%):** This would be the answer if we excluded the 1st-degree burns on the back (9% arm + 18% leg). * **B (36%):** This represents two lower limbs or the entire trunk, which does not fit the clinical description. * **D (54%):** This overestimates the area, likely by double-counting a limb or the trunk. ### 3. High-Yield Clinical Pearls for NEET-PG * **Rule of Nines (Adults):** Head (9%), Each Arm (9%), Each Leg (18%), Anterior Trunk (18%), Posterior Trunk (18%), Perineum (1%). * **Lund and Browder Chart:** The most accurate method for **pediatric patients** because it accounts for the relative size of the head in children. * **Palmar Method:** The patient’s palm (including fingers) represents approximately **1% TBSA**; useful for small or patchy burns. * **Fluid Resuscitation:** Remember that the **Parkland Formula** (4ml x kg x %TBSA) uses the TBSA calculated here to determine IV fluid requirements in the first 24 hours.

Question 176: A person presents with severe abdominal trauma but was found to be hemodynamically stable on examination. What is the investigation of choice for this patient?

A. Diagnostic peritoneal lavage
B. FAST scan
C. Erect X-ray abdomen
D. CT abdomen (Correct Answer)

Explanation: **Explanation:** In the management of blunt abdominal trauma, the choice of investigation is primarily dictated by the patient's **hemodynamic stability**. **1. Why CT Abdomen is the Correct Choice:** For a **hemodynamically stable** patient, **Contrast-Enhanced Computed Tomography (CECT) of the abdomen** is the gold standard and investigation of choice. It is highly sensitive and specific for identifying the exact organ injured, the grade of the injury, and the presence of retroperitoneal bleeds or hollow viscus injuries. It helps the surgeon decide between conservative management and operative intervention. **2. Why Other Options are Incorrect:** * **FAST Scan (Focused Assessment with Sonography for Trauma):** While FAST is the initial investigation of choice in trauma, its primary role is in **hemodynamically unstable** patients to quickly detect free intraperitoneal fluid (hemoperitoneum). In stable patients, a negative FAST does not rule out organ injury. * **Diagnostic Peritoneal Lavage (DPL):** This is an invasive procedure used in **unstable** patients when FAST is unavailable or inconclusive. It has largely been replaced by FAST and CT. * **Erect X-ray Abdomen:** While useful for detecting pneumoperitoneum (hollow viscus perforation), it is not the definitive investigation for solid organ trauma and lacks the sensitivity of a CT scan. **Clinical Pearls for NEET-PG:** * **Unstable + Positive FAST** = Immediate Laparotomy. * **Stable + Positive FAST** = Proceed to CECT to grade the injury. * **Gold Standard for Retroperitoneal Injury:** CT Scan (FAST cannot visualize the retroperitoneum well). * **Most common organ injured in Blunt Trauma Abdomen:** Spleen. * **Most common organ injured in Penetrating Trauma (Stab):** Liver.

Question 177: Which of the following is not associated with burns?

A. Cushing’s ulcer (Correct Answer)
B. Fluid loss
C. Fever
D. All of the above

Explanation: In burn surgery, distinguishing between different types of stress ulcers is a high-yield concept for NEET-PG. **Explanation of the Correct Answer:** **Cushing’s ulcer** is the correct answer because it is associated with **increased intracranial pressure (ICP)** or head trauma, not burns. It is caused by overstimulation of the vagus nerve, leading to excessive gastric acid secretion. In contrast, the stress ulcer specifically associated with major burns is the **Curling’s ulcer**, which occurs due to reduced mucosal blood flow and ischemia. **Analysis of Incorrect Options:** * **Fluid Loss:** This is a hallmark of burns. Thermal injury leads to increased capillary permeability and massive evaporative loss, necessitating aggressive resuscitation (e.g., using the Parkland Formula). * **Fever:** Burn patients frequently exhibit a hypermetabolic state. While fever can indicate sepsis, it is also a common non-infectious response to the systemic inflammatory response syndrome (SIRS) triggered by the burn injury itself. * **All of the above:** This is incorrect because Cushing’s ulcer is etiologically distinct from burn pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Curling vs. Cushing:** Remember **"C"**urlings = **C**onvection (Burns/Heat) and **"C"**ushings = **C**ushion (Head/Brain). * **Curling’s Ulcer:** Typically occurs in the **duodenum** (though can be gastric) following severe burns. * **Most common cause of death:** In the first 48 hours, it is **hypovolemic shock**; after 48 hours, it is **sepsis** (most commonly *Pseudomonas* or *Staphylococcus aureus*). * **Gold Standard for Fluid Resuscitation:** Monitoring **hourly urine output** (Target: 0.5 ml/kg/hr in adults).

Question 178: The dotted line has clinical significance in case of which of the following conditions?

A. Maxillary sinusitis
B. Maxillary carcinoma (Correct Answer)
C. Mandibular fracture
D. Maxillary fracture

Explanation: ***Maxillary carcinoma*** - **Ohngren's line** (dotted line from **medial canthus** to **angle of mandible**) is crucial for **staging maxillary carcinoma** and determining prognosis. - Tumors **above Ohngren's line** have a **worse prognosis** due to proximity to **orbit, skull base, and intracranial structures**. *Maxillary sinusitis* - **Inflammatory condition** of the maxillary sinus that does not require **anatomical staging** using Ohngren's line. - Diagnosis relies on **clinical symptoms** and **imaging findings** rather than anatomical reference lines. *Mandibular fracture* - Involves the **lower jaw** and is assessed using different **anatomical landmarks** and **fracture classification systems**. - **Ohngren's line** is specific to **maxillary anatomy** and has no relevance in mandibular trauma evaluation. *Maxillary fracture* - Classified using **Le Fort classification system** based on **fracture patterns** and **anatomical structures** involved. - **Ohngren's line** is not used for **trauma assessment** but specifically for **oncological staging** of maxillary carcinoma.

Question 179: A 50-year-old patient develops sudden left lower chest pain and epigastric pain after vomiting. The patient shows diaphoresis, breath sounds are decreased on the left, and there is abdominal guarding. What is the most appropriate diagnostic test?

A. Aortography
B. Esophagoscopy
C. Electrocardiogram
D. Chest X-ray (Correct Answer)

Explanation: **Explanation:** The clinical presentation of sudden chest/epigastric pain following forceful vomiting (emesis) describes the classic **Mackler’s Triad** (vomiting, chest pain, and subcutaneous emphysema), which is diagnostic of **Boerhaave Syndrome** (spontaneous transmural esophageal perforation). **Why Chest X-ray is the Correct Answer:** In an emergency setting, a **Chest X-ray (CXR)** is the most appropriate initial diagnostic test. It can rapidly identify signs of esophageal perforation such as **pneumomediastinum** (air in the mediastinum), **pleural effusion** (usually on the left side), or **pneumothorax**. While a Gastrografin swallow is the definitive "confirmatory" test, the CXR is the essential first-line screening tool in trauma/emergency protocols to rule out life-threatening mimics. **Analysis of Incorrect Options:** * **A. Aortography:** Used for suspected aortic dissection or traumatic aortic injury. While dissection causes chest pain, it is not typically preceded by vomiting. * **B. Esophagoscopy:** Generally avoided in the acute phase of suspected perforation as insufflation of air can worsen the pneumomediastinum or tension pneumothorax. * **C. Electrocardiogram:** Useful to rule out Myocardial Infarction (a common differential), but the specific history of vomiting followed by decreased breath sounds and guarding points more strongly toward a surgical emergency like Boerhaave’s. **NEET-PG High-Yield Pearls:** * **Boerhaave Syndrome:** Most common site of perforation is the **left posterolateral aspect of the distal esophagus** (3–5 cm above the gastroesophageal junction). * **Hamman’s Sign:** A "crunching" sound heard over the precordium synchronous with the heartbeat, indicating pneumomediastinum. * **V-sign of Naclerio:** A radiologic sign on CXR showing air streaks behind the heart forming a 'V' shape, highly suggestive of esophageal rupture. * **Management:** If diagnosed within 24 hours, primary surgical repair is preferred; beyond 24 hours, the focus shifts to drainage and diversion due to mediastinitis.

Question 180: Which of the following markers has a significant association with poor prognosis in traumatic brain injury?

A. S-100b Protein (Correct Answer)
B. b-Amyloid precursor protein
C. Increased CSF levels of three neurofilament H
D. Calpain-derived a-spectrin fragment

Explanation: ### Explanation **Correct Option: A. S-100b Protein** S-100b is a calcium-binding protein primarily found in the cytoplasm of **astrocytes** and Schwann cells. Following a Traumatic Brain Injury (TBI), the blood-brain barrier is disrupted, leading to the leakage of S-100b into the serum. Its serum concentration correlates directly with the severity of the primary injury and the extent of secondary brain damage. High levels within the first 24 hours are strongly associated with **poor neurological outcomes, increased intracranial pressure, and higher mortality rates**, making it a reliable prognostic marker. **Analysis of Incorrect Options:** * **B. b-Amyloid precursor protein (β-APP):** This is the gold-standard histological marker for diagnosing **Diffuse Axonal Injury (DAI)**. While it indicates axonal damage, it is used primarily in forensic pathology/autopsy to identify the presence of injury rather than as a routine serum prognostic marker in clinical practice. * **C. Neurofilament H:** These are structural proteins of the axonal cytoskeleton. While elevated levels in CSF indicate axonal damage, they are less commonly used as primary prognostic indicators compared to the more extensively studied S-100b. * **D. Calpain-derived α-spectrin fragment:** This is a marker of **neuronal apoptosis** and necrosis. While it shows promise in research, it does not yet have the same level of established clinical significance or prognostic weight in TBI management as S-100b. **High-Yield Clinical Pearls for NEET-PG:** * **S-100b:** Most studied serum marker for TBI prognosis; also elevated in melanoma. * **Glial Fibrillary Acidic Protein (GFAP):** Another specific marker for glial injury used alongside S-100b. * **NSE (Neuron-Specific Enolase):** A marker of neuronal (not glial) damage; also used to monitor small cell lung cancer and neuroblastoma. * **Lucid Interval:** Classically associated with **Epidural Hematoma (EDH)**, usually due to rupture of the Middle Meningeal Artery.

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