Trauma Practice Questions

Q: Head and neck burns in an infant constitute what percentage of total body surface area burns?

18%. In pediatric trauma, calculating the Total Body Surface Area (TBSA) of burns requires adjusting the adult "Rule of Nines" to account for the disproportionately large head and smaller lower extremities of infants. **Explanation of the Correct Answer (B):** According to the **Lund and Browder chart** (the most accurate method for children) and the modified pediatric Rule of Nines, an infant’s head and neck account for **18%** of the TBSA. As a child grows, the head becomes relatively smaller while the legs become larger. For every year of age after 1 year, 1% is subtracted from the head and added to the legs until the adult proportions (9% for the head) are reached around age 10. **Analysis of Incorrect Options:** * **A (9%):** This is the percentage for the head and neck in **adults**. Using this for an infant would lead to a significant underestimation of fluid requirements. * **C (24%) & D (36%):** These values are physiologically inaccurate for the head and neck at any stage of development. 36% is the approximate TBSA for the entire trunk (front and back) in both adults and children. **High-Yield Clinical Pearls for NEET-PG:** * **The Rule of Palms:** The patient’s palm (including fingers) represents approximately **1%** of their TBSA; this is useful for estimating small or patchy burns. * **Fluid Resuscitation:** The **Parkland Formula** (4mL × kg × %TBSA) is used, but in children, **maintenance fluids** (using the 4-2-1 rule) must be added to the resuscitation volume because their glycogen stores are limited. * **Critical Area:** In infants, the head is the most significant source of evaporative heat and fluid loss due to its large surface area.

Q: A 45-year-old male presents with binocular diplopia and restricted eye movements following facial trauma. What is the immediate treatment plan?

Orbital floor reconstruction and miniplate fixation. ### Explanation The patient presents with classic signs of a **Zygomaticomaxillary Complex (ZMC) fracture**, often referred to as a "Tripod fracture." The presence of **binocular diplopia** and **restricted eye movements** (typically upward gaze) indicates entrapment of the inferior rectus muscle or periorbital fat within an associated orbital floor fracture (Blow-out component). **Why Option D is Correct:** Management of a displaced ZMC fracture requires a two-pronged approach: 1. **Reduction and Internal Fixation (RIF):** Using miniplates at the zygomaticofrontal suture or infraorbital rim to restore the facial projection and malar prominence. 2. **Orbital Floor Reconstruction:** Essential to release entrapped tissues and restore orbital volume, which corrects the diplopia and prevents late-onset enophthalmos. **Analysis of Incorrect Options:** * **Option A:** Addressing only the orbital floor ignores the instability of the zygomatic arch and malar bone, leading to facial asymmetry. * **Option B:** Intraoral elevation (e.g., Keen’s approach) is a technique for reduction but does not provide the rigid internal fixation or orbital floor repair required for complex fractures with diplopia. * **Option C:** While miniplate fixation addresses the bony framework, it fails to address the orbital floor defect causing the functional ocular deficit (diplopia). **Clinical Pearls for NEET-PG:** * **Most common site of orbital floor fracture:** Medial to the infraorbital groove. * **Hanging Drop Sign:** A classic radiological finding on Water’s view representing herniated orbital contents into the maxillary sinus. * **Nerve Involvement:** The **Infraorbital nerve** is the most commonly injured nerve in ZMC fractures, leading to anesthesia of the cheek and upper lip. * **Indications for Surgery:** Persistent diplopia, enophthalmos >2mm, or significant comminution/displacement.

Q: True about blunt trauma abdomen are all, except?

Liver injuries are more common than splenic injury. **Explanation:** In blunt trauma abdomen (BTA), the **Spleen** is the most commonly injured solid organ overall. While the Liver is the most commonly injured organ in *penetrating* trauma, it ranks second in blunt trauma. Therefore, the statement that liver injuries are more common than splenic injuries is incorrect, making it the right choice for this "except" question. **Analysis of Options:** * **Option A:** Solid organ injuries (Spleen/Liver) are indeed more common in children compared to adults. Children have thinner abdominal walls, less protective fat, and a more pliable rib cage that transmits energy directly to the underlying viscera. * **Option C:** Diaphragmatic injuries occur in <5% of blunt trauma cases. They are often occult and difficult to diagnose initially, making them relatively rare compared to solid organ injuries. * **Option D:** The presence of pneumoperitoneum (intraperitoneal gas) on an X-ray in the context of trauma is a pathognomonic sign of a hollow viscus (bowel) perforation and is a definitive indication for emergency laparotomy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organ injured in BTA:** Spleen (followed by Liver). * **Most common organ injured in Penetrating Trauma (Stab):** Liver. * **Most common organ injured in Firearm injury:** Small Bowel. * **Investigation of Choice (Stable patient):** CECT Abdomen. * **Investigation of Choice (Unstable patient):** FAST (Focused Assessment with Sonography for Trauma). * **Kehr’s Sign:** Referred pain to the left shoulder, highly suggestive of splenic rupture.

Q: Fracture of the mandible in an edentulous jaw is best treated with:

External fixator. ### Explanation **Correct Answer: A. External fixator** **Why it is correct:** In an edentulous patient (one without teeth), the primary challenge in managing mandibular fractures is the lack of a stable dental scaffold. Traditional methods like Intermaxillary Fixation (IMF) rely on teeth to provide anchorage and restore occlusion. In the absence of teeth, an **External Fixator** (e.g., Morris biphase or Gunning splints with external pins) is preferred because it provides rigid stabilization by anchoring directly into the bone from the outside, bypassing the need for dental support. It is particularly useful in comminuted fractures or when the patient’s dentures are unavailable or broken. **Why the other options are incorrect:** * **B. Minerva plaster cast:** This is used for cervical spine injuries (stabilizing the head, neck, and upper torso) and has no role in the management of mandibular fractures. * **C. Interdental wiring:** This technique requires the presence of healthy, stable teeth to anchor the wires. In an edentulous jaw, there are no teeth to wire together. * **D. Intermaxillary elastic traction:** Similar to wiring, this requires teeth or dental implants to apply the elastic force between the upper and lower jaws. **High-Yield Clinical Pearls for NEET-PG:** * **Gunning Splints:** These are specialized "denture-like" appliances used in edentulous patients to achieve IMF by wiring the splints to the alveolar bone (circum-mandibular and zygomatic wiring). * **Atrophic Mandible:** Edentulous jaws are often atrophic with reduced blood supply (centripetal flow). This makes them prone to non-union; hence, minimal periosteal stripping is vital. * **Most common site of Mandibular Fracture:** Condyle > Angle > Symphysis. * **Clinical Sign:** Derangement of occlusion is the most common sign of a mandibular fracture in dentate patients.

Q: A 62-year-old man presents to the emergency department following head trauma. He is receiving oxygen via a face mask and reservoir bag at 15 L/min, has a cervical collar in place, and an intravenous line. His Glasgow Coma Scale score is E1 (no eye opening except to pain), V2 (incomprehensible sounds), and M4 (flexion withdrawal to painful stimuli). He has no gag reflex when suctioned. What is the next best step in the management of this patient?

Intubate the patient. ### Explanation The management of trauma follows the **ATLS (Advanced Trauma Life Support)** protocol, where the priority is always **ABCDE** (Airway, Breathing, Circulation, Disability, Exposure). **1. Why Intubation is the Correct Answer:** The patient’s Glasgow Coma Scale (GCS) score is **7** (E1 + V2 + M4 = 7). According to ATLS guidelines, any patient with a **GCS ≤ 8** requires definitive airway management (endotracheal intubation). Furthermore, the absence of a **gag reflex** indicates that the patient cannot protect his airway against aspiration. In head trauma, securing the airway is critical to prevent secondary brain injury caused by hypoxia and hypercapnia. **2. Why Other Options are Incorrect:** * **B & D (Surgical Interventions):** Decompressive hemicraniectomy or burr holes are neurosurgical interventions for raised intracranial pressure or hematomas. These are considered only *after* the airway is secured and the patient is stabilized. * **C (CT Head):** While a non-contrast CT is the gold standard for diagnosing intracranial hemorrhage, it should never precede the stabilization of the airway. Sending an unstable patient with a GCS of 7 to the radiology suite without a secured airway is a "fatal" mistake in trauma management. **3. Clinical Pearls for NEET-PG:** * **GCS ≤ 8 = Intubate:** This is a classic high-yield rule. * **Airway First:** In any trauma question, if the airway is compromised or the GCS is low, "Secure the Airway" or "Intubate" is almost always the next best step, regardless of other injuries. * **Cervical Spine:** During intubation in trauma, **Manual In-Line Stabilization (MILS)** must be maintained to protect the cervical spine. * **Secondary Brain Injury:** The primary goal of early intubation in head injury is to maintain PaO₂ > 60 mmHg and avoid hypotension, as these are the strongest predictors of poor outcome.

Q: In craniocerebral trauma, in which of the following situations is a lumbar puncture considered essential?

When meningitis is suspected. In craniocerebral trauma, the primary role of a Lumbar Puncture (LP) is diagnostic rather than therapeutic. ### **Why Option D is Correct** **Meningitis** is a potential complication of head trauma, particularly in cases involving basilar skull fractures or penetrating injuries that create a communication between the environment (or paranasal sinuses) and the subarachnoid space [3]. If a patient develops fever, neck stiffness, or deteriorating consciousness after trauma, an LP is **essential** to analyze the Cerebrospinal Fluid (CSF) for pleocytosis, low glucose, and organisms to confirm the diagnosis and guide antibiotic therapy [1]. ### **Why Other Options are Incorrect** * **Option A & C:** Lumbar puncture is strictly **contraindicated** in the presence of significantly raised intracranial tension (ICT) or papilledema. Performing an LP in these scenarios can create a pressure gradient that leads to **uncal or tonsillar herniation**, which is often fatal [4]. * **Option B:** In cases of prolonged unconsciousness following trauma, the gold standard investigation is a **Non-Contrast CT (NCCT) Head** [5] to rule out intracranial hemorrhages (EDH, SDH, ICH) or diffuse axonal injury. LP provides no diagnostic value for unconsciousness itself and may be dangerous if an underlying mass lesion exists [2]. ### **High-Yield Clinical Pearls for NEET-PG** * **The Golden Rule:** Always perform a CT scan before an LP in trauma patients to rule out a space-occupying lesion or midline shift. * **CSF Rhinorrhea/Otorrhea:** Suggests a dural tear. The most common organism causing post-traumatic meningitis is *Streptococcus pneumoniae*. * **Xanthochromia:** If an LP is performed and the supernatant is yellow, it indicates older subarachnoid hemorrhage (hemoglobin breakdown), helping differentiate it from a "traumatic tap" [2].

Question 1

Head and neck burns in an infant constitute what percentage of total body surface area burns?

Accepted Answer

18%

Answer

9%

Answer

24%

Answer

36%

Question 2

A 45-year-old male presents with binocular diplopia and restricted eye movements following facial trauma. What is the immediate treatment plan?

Accepted Answer

Orbital floor reconstruction and miniplate fixation

Answer

Orbital floor reconstruction

Answer

Intraoral elevation of zygoma

Answer

Reduction and fixation of fracture with miniplate

Question 3

True about blunt trauma abdomen are all, except?

Accepted Answer

Liver injuries are more common than splenic injury

Answer

Solid organ injury is more common in children than adults in blunt trauma

Answer

Diaphragmatic injuries are rare

Answer

Intraperitoneal gas shadows are pathognomonic of bowel perforation

Question 4

What is the management of flail chest with respiratory failure?

Accepted Answer

Intermittent positive pressure ventilation (IPPV)

Answer

Chest tube drainage

Answer

Oxygen administration

Answer

Internal operative fixation of the fractured segments

Question 5

Fracture of the mandible in an edentulous jaw is best treated with:

Accepted Answer

External fixator

Answer

Minerva plaster cast

Answer

Interdental wiring

Answer

Intermaxillary elastic traction

Question 6

A patient with a suspected pelvic fracture presents with urethral bleeding and an inability to pass urine. What is the most appropriate immediate management?

Accepted Answer

Prepare for surgery and attempt catheterization in the operating theatre.

Answer

Encourage voiding after administering antibiotics and analgesics.

Answer

Immediate Foley catheterization in the ward.

Answer

Apply a hot water bottle and administer carbachol injection.

Question 7

A patient with a head injury presents with rapidly deteriorating sensorium and progressive dilatation and fixation of the pupil. As a surgeon in a primary care setting, with neurosurgical consultation and CT scan unavailable, you decide to perform an emergent burr hole to relieve intracranial pressure. Which of the following sites is most appropriate for the burr hole?

Accepted Answer

In the temporal region ipsilateral to the side of pupillary dilatation

Answer

In the temporal region contralateral to the side of pupillary dilatation

Answer

In the midline if both pupils are equal or the side of pupillary dilatation is unknown

Answer

Refer to a higher center if both pupils are equal or the side of pupillary dilatation is unknown

Question 8

A 62-year-old man presents to the emergency department following head trauma. He is receiving oxygen via a face mask and reservoir bag at 15 L/min, has a cervical collar in place, and an intravenous line. His Glasgow Coma Scale score is E1 (no eye opening except to pain), V2 (incomprehensible sounds), and M4 (flexion withdrawal to painful stimuli). He has no gag reflex when suctioned. What is the next best step in the management of this patient?

Accepted Answer

Intubate the patient

Answer

Urgent decompressive hemicraniectomy

Answer

Urgent non-contrast CT head

Answer

Administer mannitol and perform burr hole surgery

Question 9

All of the following are synthetic dressings used in burn wound management EXCEPT?

Accepted Answer

Dacron

Answer

Opsite

Answer

Biobrane

Answer

Integra

Question 10

In craniocerebral trauma, in which of the following situations is a lumbar puncture considered essential?

Accepted Answer

When meningitis is suspected

Answer

To confirm raised intracranial tension

Answer

In cases of prolonged unconsciousness

Answer

When papilledema is present

Trauma — MCQs

Trauma — MCQs

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