Trauma — MCQs
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Pond's fracture is most common in which age group?
A patient with blunt abdominal trauma presents with a blood pressure of 90/60 mm Hg and a pulse rate of 124. What is the most appropriate initial investigation to perform in this patient?
A 64-year-old man with a history of good health is admitted following a head injury and ruptured spleen sustained in a motor vehicle accident. He underwent laparotomy and splenectomy and received 5% dextrose in 0.5% normal saline at 125 mL/h for the first 4 days. His daily fluid outputs were 450-600 mL of nasogastric drainage and 700-1000 mL of urine. The patient was somnolent but easily arousable until the morning of the 5th hospital day, when he became deeply comatose and began having seizures by the afternoon. His laboratory data are as follows: Serum electrolytes (mEq/L): Na+ 130, K+ 1.9, Cl- 96, HCO3- 19. Serum osmolality: 260 mOsm/L. Urine electrolytes (mEq/L): Na+ 61, K+ 18. Which of the following statements about the diagnosis or treatment of this patient's condition is TRUE?
Which of the following methods is NOT used to lower intracranial pressure in patients with head injury?
According to the "rule of nine" in burns, what is the percentage of burns if both the upper limbs and lower limbs are involved?
What is the minimum possible score on the Glasgow Coma Scale?
Gastric ulcer seen in burns is called?
In case of an amputated finger requiring transplantation, what is the appropriate storage method?
A 42-year-old female is admitted to the hospital after a traumatic landing while skydiving. Radiographic examination reveals a ruptured spleen. An emergency splenectomy is performed. Which of the following peritoneal structures must be carefully manipulated to prevent intraperitoneal bleeding?
Extradural haemorrhage is most commonly caused by the rupture of which of the following vessels?
Trauma Indian Medical PG Practice Questions and MCQs
Question 221: Pond's fracture is most common in which age group?
- A. Children (Correct Answer)
- B. Adults
- C. Elderly
- D. No relation with age
Explanation: **Explanation:** **Pond’s fracture** (also known as a "ping-pong" fracture) is a type of depressed skull fracture specifically seen in **infants and young children**. **1. Why Children is the correct answer:** The underlying medical concept is the unique biomechanical property of the pediatric skull. In neonates and infants, the skull bones are thin, highly resilient, and poorly mineralized. Unlike the brittle adult skull, the pediatric skull is "pliable." When a blunt force is applied, the bone indents inward without a complete loss of continuity, much like a dent in a ping-pong ball. This is analogous to a "greenstick fracture" of the long bones. **2. Why other options are incorrect:** * **Adults & Elderly:** As the skull matures, it becomes thicker, more mineralized, and rigid. In adults and the elderly, the bone is brittle; therefore, trauma results in a comminuted or linear fracture rather than a smooth indentation. * **No relation with age:** This is incorrect because the occurrence of a Pond’s fracture is strictly dependent on the high elasticity of the skull found only in the pediatric age group. **NEET-PG High-Yield Pearls:** * **Mechanism:** Usually caused by blunt trauma (e.g., a fall or use of forceps during delivery). * **Clinical Feature:** A shallow, smooth-walled depression is palpable on the cranium. * **Management:** Many are managed conservatively as they may spontaneously elevate. If persistent or causing neurological deficit, they can be elevated using a vacuum extractor or a small surgical burr hole (Strohmeyer’s method). * **Differentiate:** Do not confuse this with a **Cup-and-Saucer fracture**, which is a type of depressed fracture seen in adults where the inner table is fractured more extensively than the outer table.
Question 222: A patient with blunt abdominal trauma presents with a blood pressure of 90/60 mm Hg and a pulse rate of 124. What is the most appropriate initial investigation to perform in this patient?
- A. CT abdomen
- B. MRI abdomen
- C. Diagnostic Peritoneal Lavage (DPL)
- D. Focused Assessment with Sonography for Trauma (FAST) (Correct Answer)
Explanation: ### Explanation The patient presents with **hemodynamic instability** (hypotension and tachycardia) following blunt abdominal trauma, indicating a **Class III hemorrhagic shock**. In an unstable patient, the primary goal is to identify the source of bleeding rapidly without moving the patient out of the resuscitation area. **1. Why FAST is the Correct Answer:** **Focused Assessment with Sonography for Trauma (FAST)** is the initial investigation of choice for hemodynamically unstable patients. It is a rapid, non-invasive, bedside tool used to detect free intraperitoneal fluid (hemoperitoneum) or pericardial tamponade. It assesses four areas: Morrison’s pouch (RUQ), splenorenal recess (LUQ), pelvis (pouch of Douglas), and the pericardium. **2. Why Other Options are Incorrect:** * **CT Abdomen:** While it is the "Gold Standard" for diagnosing solid organ injuries, it requires the patient to be **hemodynamically stable**. Moving an unstable patient to the CT suite is dangerous ("Death in the Donut Hole"). * **MRI Abdomen:** MRI has no role in acute trauma management due to the long acquisition time and incompatibility with resuscitation equipment. * **Diagnostic Peritoneal Lavage (DPL):** Although useful in unstable patients when FAST is unavailable or inconclusive, it is invasive and has been largely superseded by FAST. **Clinical Pearls for NEET-PG:** * **Stable + Blunt Trauma:** Initial investigation is **FAST**; if positive, proceed to **CECT**. * **Unstable + Blunt Trauma:** Initial investigation is **FAST**; if positive, proceed to **Emergency Laparotomy**. * **FAST Limitations:** It cannot detect <250 ml of fluid, retroperitoneal bleeds, or hollow viscus perforation. * **E-FAST:** Includes views of the thorax to rule out pneumothorax or hemothorax.
Question 223: A 64-year-old man with a history of good health is admitted following a head injury and ruptured spleen sustained in a motor vehicle accident. He underwent laparotomy and splenectomy and received 5% dextrose in 0.5% normal saline at 125 mL/h for the first 4 days. His daily fluid outputs were 450-600 mL of nasogastric drainage and 700-1000 mL of urine. The patient was somnolent but easily arousable until the morning of the 5th hospital day, when he became deeply comatose and began having seizures by the afternoon. His laboratory data are as follows: Serum electrolytes (mEq/L): Na+ 130, K+ 1.9, Cl- 96, HCO3- 19. Serum osmolality: 260 mOsm/L. Urine electrolytes (mEq/L): Na+ 61, K+ 18. Which of the following statements about the diagnosis or treatment of this patient's condition is TRUE?
- A. Emergency carotid arteriogram is indicated.
- B. Hypokalemia is secondary to metabolic acidosis.
- C. A small quantity of hypertonic saline should be administered. (Correct Answer)
- D. IV infusion of 20 mL of 50% MgSO4 should be given over 4 hours.
Explanation: ### Explanation The patient is presenting with **acute symptomatic hyponatremia** (Na+ 130 mEq/L, Osmolality 260 mOsm/L) complicated by neurological emergencies (coma and seizures). **1. Why Option C is Correct:** The primary cause of this patient's condition is **dilutional hyponatremia** (water intoxication). He received large volumes of hypotonic fluids (5% Dextrose in 0.5% NS) postoperatively, while losing sodium-rich fluids via nasogastric drainage. In the presence of high ADH levels (common after major surgery/trauma), the kidneys cannot excrete free water, leading to cerebral edema. When hyponatremia manifests with **seizures or coma**, it is a medical emergency requiring **hypertonic (3%) saline** to rapidly increase serum tonicity and reduce cerebral swelling. **2. Analysis of Incorrect Options:** * **Option A:** While he had a head injury, the metabolic profile (low Na+, low Osm) and the timeline (5th day) strongly point to a metabolic cause rather than a surgical one like an arterial bleed. * **Option B:** The patient has a low $HCO_3^-$ (19 mEq/L), suggesting metabolic acidosis. In acidosis, $K^+$ usually shifts *out* of cells (hyperkalemia). His severe hypokalemia ($K^+$ 1.9) is likely due to NG losses and renal excretion, not the acidosis itself. * **Option D:** While magnesium deficiency can coexist with hypokalemia, the immediate life-threatening issue causing seizures here is hyponatremia. Furthermore, 20 mL of 50% $MgSO_4$ (10g) is an excessively high dose that could cause toxicity; standard replacement is much lower. **3. NEET-PG High-Yield Pearls:** * **Postoperative ADH:** Surgery is a potent stimulus for ADH release; giving hypotonic fluids (like D5W or 0.45% NS) post-op carries a high risk of hyponatremia. * **Correction Rate:** In symptomatic hyponatremia, the goal is to raise Na+ by **4–6 mEq/L quickly** to stop seizures, but avoid exceeding **8–10 mEq/L in 24 hours** to prevent **Osmotic Demyelination Syndrome (ODS)**. * **Formula:** $3\% \text{ NaCl}$ contains $513 \text{ mEq/L}$ of Sodium.
Question 224: Which of the following methods is NOT used to lower intracranial pressure in patients with head injury?
- A. Hyperventilation
- B. Administration of Mannitol
- C. Hypothermia
- D. Administration of Nifedipine (Correct Answer)
Explanation: **Explanation:** The management of raised intracranial pressure (ICP) in head injury focuses on the **Monro-Kellie doctrine**, which states that the cranial vault is a fixed volume; an increase in one component (blood, CSF, or brain tissue) must be compensated by a decrease in another. **Why Nifedipine is the correct answer:** Nifedipine is a Calcium Channel Blocker (CCB) that acts as a **potent peripheral and cerebral vasodilator**. Vasodilation in the cerebral vasculature increases cerebral blood volume, which directly **increases intracranial pressure**. Furthermore, it can cause systemic hypotension, which reduces Cerebral Perfusion Pressure (CPP = MAP - ICP), potentially worsening secondary brain ischemia. Therefore, it is contraindicated in acute head injury. **Analysis of other options:** * **Hyperventilation:** This reduces PaCO2, leading to cerebral vasoconstriction. This decreases cerebral blood volume and rapidly lowers ICP. It is typically used as a short-term emergency measure. * **Mannitol:** An osmotic diuretic that draws fluid from the brain parenchyma into the intravascular space, reducing cerebral edema. It also improves blood rheology. * **Hypothermia:** Therapeutic hypothermia reduces the cerebral metabolic rate of oxygen (CMRO2), which in turn reduces cerebral blood flow and ICP. **High-Yield Clinical Pearls for NEET-PG:** * **Target ICP:** Should be maintained below **20–22 mmHg**. * **Target CPP:** Should be maintained between **60–70 mmHg**. * **First-line Osmotherapy:** Hypertonic saline (3%) is increasingly preferred over Mannitol in hemodynamically unstable patients. * **Cushing’s Triad (Late sign of raised ICP):** Hypertension, Bradycardia, and Irregular respirations.
Question 225: According to the "rule of nine" in burns, what is the percentage of burns if both the upper limbs and lower limbs are involved?
- A. 24%
- B. 6%
- C. 54% (Correct Answer)
- D. 72%
Explanation: ### Explanation The **Wallace Rule of Nines** is a standardized clinical tool used to estimate the Total Body Surface Area (TBSA) involved in burn injuries. It divides the body into sections representing 9% or multiples of 9%. **Calculation for this question:** * **Each Upper Limb:** 9% (Left 9% + Right 9% = **18%**) * **Each Lower Limb:** 18% (Left 18% + Right 18% = **36%**) * **Total:** 18% (Upper) + 36% (Lower) = **54%** #### Analysis of Options: * **A. 24%:** This is an incorrect calculation. It might result from misremembering the limbs as 6% each or confusing pediatric scales. * **B. 6%:** This does not correspond to any major anatomical division in the Rule of Nines. * **C. 54% (Correct):** As calculated above, the sum of both upper (18%) and lower (36%) limbs equals 54%. * **D. 72%:** This overestimates the area, likely by doubling the lower limb percentage or including the trunk. #### NEET-PG High-Yield Pearls: 1. **Pediatric Variation:** In children, the head is larger (18%) and the lower limbs are smaller (14% each). For every year of age over 1, subtract 1% from the head and add 0.5% to each leg. 2. **Lund and Browder Chart:** This is the **most accurate** method for TBSA estimation, especially in children, as it accounts for age-related changes in body proportions. 3. **Palmar Method:** The patient’s palm (including fingers) represents approximately **1% TBSA**. This is useful for small or patchy burns. 4. **Exclusion:** First-degree burns (erythema only) are **not** included in the TBSA calculation for fluid resuscitation. 5. **Parkland Formula:** Remember that TBSA is the critical variable in the Parkland formula ($4 \text{ mL} \times \text{weight in kg} \times \% \text{ TBSA}$) for initial fluid management.
Question 226: What is the minimum possible score on the Glasgow Coma Scale?
- A. 3 (Correct Answer)
- B. 1
- C. 0
- D. 2
Explanation: The Glasgow Coma Scale (GCS) is a clinical tool used to assess a patient's level of consciousness following a head injury. It evaluates three specific categories of responses: **Eye Opening (E), Verbal Response (V), and Motor Response (M).** ### **Why Option A (3) is Correct:** The GCS is calculated by summing the scores of the three components. The minimum score for each component is **1** (indicating no response), and the maximum scores vary: * **Eye Opening (E):** 1 to 4 * **Verbal Response (V):** 1 to 5 * **Motor Response (M):** 1 to 6 Therefore, the minimum possible total score is **E1 + V1 + M1 = 3**. Even in a state of deep coma or brain death, a patient cannot score lower than 3. ### **Why Other Options are Incorrect:** * **Options B, C, and D (1, 0, 2):** These are incorrect because the scale does not assign a value of zero to any category. Even if a patient is completely unresponsive, they are assigned a score of 1 in each category. ### **High-Yield Clinical Pearls for NEET-PG:** * **Maximum Score:** 15 (Fully conscious). * **Intubation Threshold:** A GCS score of **≤ 8** is the classic indication for securing the airway (Intubate if GCS is 8). * **Severity Classification:** * **Severe Head Injury:** GCS 3–8 * **Moderate Head Injury:** GCS 9–12 * **Mild Head Injury:** GCS 13–15 * **Modified GCS for Intubated Patients:** If a patient is intubated, the Verbal (V) component cannot be assessed. It is recorded as **'T'** (e.g., GCS 10T), where the maximum score becomes 10T and the minimum becomes 2T. * **Most Important Component:** The **Motor (M)** score is considered the most reliable predictor of clinical outcome.
Question 227: Gastric ulcer seen in burns is called?
- A. Peptic ulcer
- B. Cushing ulcer
- C. Curling ulcer (Correct Answer)
- D. Erosive gastritis
Explanation: **Explanation:** **Curling Ulcer (Correct Answer):** A Curling ulcer is an acute gastric erosion or ulcer that occurs as a complication of **severe burns**. The underlying pathophysiology involves severe hypovolemia and hemoconcentration, leading to reduced mucosal blood flow (ischemia). This ischemia compromises the gastric mucosal barrier, allowing gastric acid to cause acute ulceration, most commonly in the fundus and body of the stomach. * **Mnemonic:** "Curling" sounds like "Curling iron" (which causes burns). **Incorrect Options:** * **Cushing Ulcer:** These are stress ulcers associated with **increased intracranial pressure** (due to trauma, tumors, or surgery). They are caused by overstimulation of the vagus nerve, leading to hypersecretion of gastric acid. (Mnemonic: "Cushing" = "Cushion" for the brain). * **Peptic Ulcer:** This is a broad term for chronic ulcers in the stomach or duodenum, typically caused by *H. pylori* infection or NSAID use, rather than acute trauma. * **Erosive Gastritis:** While burns can cause erosions, "Curling ulcer" is the specific eponymous medical term used to describe this clinical entity in the context of thermal injury. **High-Yield Clinical Pearls for NEET-PG:** * **Prophylaxis:** The incidence of Curling ulcers has significantly decreased due to the routine use of **Proton Pump Inhibitors (PPIs)** and early enteral feeding in burn units. * **Location:** Curling ulcers are typically gastric, whereas Cushing ulcers can involve the stomach, duodenum, or esophagus and have a higher risk of perforation. * **Camereon Ulcer:** Linear gastric erosions found in a large hiatal hernia. * **Dieulafoy’s Lesion:** A large tortuous submucosal artery that erodes the overlying mucosa, causing massive GI bleed.
Question 228: In case of an amputated finger requiring transplantation, what is the appropriate storage method?
- A. Plastic bag with wet ice (Correct Answer)
- B. Plastic bag with dry ice
- C. Plastic bag with cold saline
- D. Plastic bag with cold water
Explanation: ### Explanation The primary goal in preserving an amputated part is to maintain **viability** by reducing the metabolic rate of the tissue while preventing direct cellular damage. **Why Option A is Correct:** The gold standard for transporting an amputated digit is the **"Double Bag Technique"** using **wet ice**. 1. **Preparation:** The amputated part is wrapped in saline-soaked sterile gauze. 2. **Primary Bag:** It is placed in a dry, sealed plastic bag. 3. **Secondary Container:** This bag is then placed in a container filled with a mixture of **ice and water (wet ice)**. This method maintains a temperature of approximately **4°C**, which significantly extends the "cold ischemia time" (up to 24 hours for digits) without causing tissue freezing. **Why the Other Options are Incorrect:** * **B. Dry Ice:** Dry ice has a temperature of -78.5°C. Direct or indirect contact causes **frostbite and irreversible cryoinjury**, making the part non-viable for replantation. * **C & D. Cold Saline/Water:** Placing the amputated part directly into liquid (immersion) leads to **tissue maceration** and cellular edema, which complicates the microsurgical repair of vessels and nerves. **High-Yield Clinical Pearls for NEET-PG:** * **Ischemia Times:** Digits can tolerate **8 hours of warm ischemia** and **24 hours of cold ischemia**. Proximal parts (with muscle) only tolerate 6 hours of warm and 12 hours of cold ischemia. * **Never Freeze:** The part should never be in direct contact with ice. * **Do Not Use Antiseptics:** Avoid immersing the part in Formalin, Alcohol, or Povidone-iodine. * **Sequence of Repair in Replantation:** Bone fixation → Extensor tendon → Flexor tendon → Arterial repair → Nerve repair → Venous repair → Skin cover (**Mnemonic: BE FAN V**).
Question 229: A 42-year-old female is admitted to the hospital after a traumatic landing while skydiving. Radiographic examination reveals a ruptured spleen. An emergency splenectomy is performed. Which of the following peritoneal structures must be carefully manipulated to prevent intraperitoneal bleeding?
- A. Coronary ligament
- B. Gastrocolic ligament
- C. Splenorenal ligament (Correct Answer)
- D. Phrenocolic ligament
Explanation: **Explanation:** The **splenorenal (lienorenal) ligament** is a critical structure in splenic surgery. It is a fold of peritoneum that connects the hilum of the spleen to the left kidney. Its clinical significance lies in its contents: it houses the **splenic artery, splenic vein**, and the **tail of the pancreas**. During an emergency splenectomy, failure to carefully ligate these major vessels within the ligament or accidental injury to them leads to massive intraperitoneal hemorrhage. **Analysis of Incorrect Options:** * **A. Coronary ligament:** This attaches the liver to the diaphragm. While important in hepatic surgery, it is anatomically distant from the spleen. * **B. Gastrocolic ligament:** This is part of the greater omentum connecting the stomach to the transverse colon. While it must be divided to access the lesser sac, it does not contain the primary blood supply to the spleen. * **D. Phrenocolic ligament:** This attaches the left colic flexure to the diaphragm. It serves as a "shelf" for the spleen but is relatively avascular and does not contain major vessels. **NEET-PG High-Yield Pearls:** * **Tail of the Pancreas:** It is the most commonly injured structure during a "hurried" splenectomy because it lies within the splenorenal ligament near the splenic hilum. * **Gastrosplenic Ligament:** Contains the **short gastric vessels** and left gastroepiploic vessels. These must also be ligated but are secondary to the main splenic artery in the splenorenal ligament. * **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation from a ruptured spleen (phrenic nerve, C3-C5).
Question 230: Extradural haemorrhage is most commonly caused by the rupture of which of the following vessels?
- A. Middle meningeal artery (Correct Answer)
- B. Middle meningeal vein
- C. Bridging veins
- D. Internal carotid artery
Explanation: **Explanation:** **1. Why Middle Meningeal Artery (MMA) is Correct:** Extradural Hemorrhage (EDH) occurs when blood collects between the inner table of the skull and the dura mater. The most common cause (85-90% of cases) is an arterial bleed, specifically from the **Middle Meningeal Artery**. This vessel is particularly vulnerable where it underlies the **pterion**—the thinnest part of the skull where the frontal, parietal, temporal, and sphenoid bones meet. A blow to the temple often fractures this area, lacerating the artery. Because it is an arterial bleed, the hematoma expands rapidly under high pressure. **2. Why the Other Options are Incorrect:** * **Middle Meningeal Vein:** While it can be involved in EDH, it is far less common than its arterial counterpart. * **Bridging Veins:** Rupture of these veins (which drain the cerebral cortex into the dural venous sinuses) is the classic cause of **Subdural Hemorrhage (SDH)**, not EDH. * **Internal Carotid Artery:** Injury to the ICA within the skull is rare in trauma and usually leads to a carotid-cavernous fistula or massive subarachnoid hemorrhage, rather than a localized extradural collection. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** A "Lucid Interval" (temporary recovery of consciousness before rapid deterioration) is pathognomonic for EDH. * **CT Appearance:** EDH appears as a **Biconvex (Lentiform/Lens-shaped)** hyperdense opacity. It does *not* cross skull sutures because the dura is firmly attached there. * **Source of Bleed in Children:** In pediatric cases, EDH can occur without a fracture due to the elasticity of the skull; here, the source is often the dural venous sinuses. * **Management:** Urgent burr-hole evacuation or craniotomy is required to prevent transtentorial herniation.
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