Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 341: Which of the following is NOT a management strategy for raised intracranial pressure?

A. Hypothermia
B. Hypercapnia (Correct Answer)
C. Decompressive craniectomy
D. Barbiturate coma

Explanation: ### Explanation The management of raised intracranial pressure (ICP) is governed by the **Monro-Kellie Doctrine**, which states that the cranial vault is a fixed volume; an increase in one component (blood, CSF, or brain parenchyma) must be compensated by a decrease in another to prevent herniation. **Why Hypercapnia is the Correct Answer:** Hypercapnia (increased $PaCO_2$) is a potent **vasodilator** of cerebral arterioles. Vasodilation increases cerebral blood flow (CBF) and cerebral blood volume, which directly **increases ICP**. Therefore, hypercapnia is contraindicated. Conversely, controlled **hypocapnia** (via therapeutic hyperventilation) causes vasoconstriction and is used as a short-term measure to acutely lower ICP. **Analysis of Other Options:** * **Hypothermia:** Therapeutic hypothermia (32°C–34°C) reduces the cerebral metabolic rate of oxygen ($CMRO_2$), which in turn reduces CBF and ICP. * **Decompressive Craniectomy:** This is a surgical "salvage" procedure where a portion of the skull is removed to allow the swollen brain to expand outward, directly reducing pressure. * **Barbiturate Coma:** High-dose barbiturates (e.g., Thiopental) suppress cerebral metabolism and are used in refractory intracranial hypertension when other medical and surgical treatments fail. **High-Yield Clinical Pearls for NEET-PG:** * **First-line medical management:** Head elevation (30°), sedation, and osmotic therapy (Mannitol or Hypertonic saline). * **Mannitol:** Works via an osmotic effect and by reducing blood viscosity (rheological effect). It is contraindicated in renal failure and pulmonary edema. * **Cushing’s Triad (Sign of impending herniation):** Hypertension, Bradycardia, and Irregular respirations. * **Target $PaCO_2$:** During therapeutic hyperventilation, $PaCO_2$ should be maintained between **30–35 mmHg**. Dropping below 25 mmHg can cause excessive vasoconstriction and cerebral ischemia.

Question 342: Fracture of the mandible not involving the dental arch is treated by which method?

A. Open reduction (Correct Answer)
B. Closed reduction
C. No treatment required
D. None of the above

Explanation: **Explanation:** The management of mandibular fractures is primarily determined by the location of the fracture and the presence of teeth. The goal of treatment is to restore pre-injury form and function, specifically **normal dental occlusion**. **Why Open Reduction is Correct:** When a fracture does **not involve the dental arch** (e.g., fractures of the angle, ramus, or condyle where teeth are absent), there is no reliable "occlusal guide" to align the fragments using closed methods. In these cases, **Open Reduction and Internal Fixation (ORIF)** using mini-plates or screws is the treatment of choice. It allows for direct visualization of the fracture ends, precise anatomical alignment, and rigid stabilization, which promotes primary bone healing and allows for early mobilization. **Analysis of Incorrect Options:** * **Closed Reduction:** This typically involves Intermaxillary Fixation (IMF) or "wiring the jaws." It is highly effective for fractures **within the dental arch** because the patient’s own teeth act as a natural template to ensure proper alignment. Without the dental arch involved, closed reduction lacks the stability and precision required for healing. * **No treatment required:** Mandibular fractures are subject to strong forces from the muscles of mastication (masseter, temporalis, pterygoids), which cause significant displacement. Leaving these untreated leads to malunion, chronic pain, and trismus. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of Mandible Fracture:** Condyle (followed by the Angle and Symphysis). * **Guardsman Fracture:** A midline symphysis fracture combined with bilateral condylar fractures (usually from a fall on the chin). * **Clinical Sign:** Derangement of dental occlusion is the most reliable sign of a mandibular fracture involving the tooth-bearing area. * **Nerve Injury:** The **Inferior Alveolar Nerve** (branch of CN V3) is the most commonly injured nerve in body/angle fractures, leading to numbness of the lower lip.

Question 343: Skull base fracture is associated with all of the following except?

A. Racoon eyes
B. Hemiparesis (Correct Answer)
C. CSF Rhino-otorrhea
D. Battle sign

Explanation: **Explanation:** The diagnosis of a **Skull Base Fracture** is primarily clinical, characterized by specific signs resulting from the tearing of the dura mater and the seepage of blood or cerebrospinal fluid (CSF) into surrounding tissues. **Why Hemiparesis is the correct answer:** Hemiparesis (weakness on one side of the body) is a **focal neurological deficit** typically caused by parenchymal brain injury, such as an intracranial hemorrhage (EDH, SDH), contusion, or stroke. While a skull base fracture can coexist with these injuries, it is not a direct clinical sign of the fracture itself. Skull base fractures involve the bones at the bottom of the skull, not the motor cortex or pyramidal tracts directly. **Analysis of incorrect options:** * **Racoon eyes (Periorbital ecchymosis):** A classic sign of an **anterior cranial fossa** fracture. It occurs as blood tracks from the fracture site into the periorbital soft tissue. (Note: Tarsal plate sparing is characteristic). * **CSF Rhino-otorrhea:** Fractures of the ethmoid bone (anterior fossa) lead to **Rhinorrhea** (CSF from the nose), while fractures of the petrous temporal bone (middle fossa) lead to **Otorrhea** (CSF from the ear). * **Battle sign (Mastoid ecchymosis):** Post-auricular bruising indicative of a **middle cranial fossa** fracture (specifically the petrous temporal bone). **High-Yield Clinical Pearls for NEET-PG:** 1. **Halo/Ring Sign:** If CSF is mixed with blood, dropping it on gauze creates a central red spot with a clear outer ring. 2. **Cranial Nerve Palsy:** The most common CN injured in skull base fractures is the **Facial Nerve (CN VII)**, followed by the Vestibulocochlear (CN VIII). 3. **Management:** Most CSF leaks resolve spontaneously with conservative management (head elevation). Prophylactic antibiotics are generally **not** recommended. 4. **Investigation of Choice:** Non-contrast High-Resolution CT (HRCT) of the brain with bone windows.

Question 344: The 'sterile needle test' helps in differentiating what?

A. Healing process
B. Depth of burns (Correct Answer)
C. Degenerative process
D. Infection

Explanation: ### Explanation The **sterile needle test** (also known as the pinprick test) is a clinical bedside method used to assess the **depth of a burn injury** by evaluating the integrity of the dermal nerve endings. **1. Why the correct answer is right:** Burn depth is categorized based on the level of tissue destruction. The needle test relies on the presence or absence of pain sensation: * **Superficial (Partial-thickness) Burns:** These involve the epidermis and upper dermis. The sensory nerve endings remain intact and exposed, making the area **exquisitely painful** to a needle prick. * **Deep (Full-thickness) Burns:** These extend through the entire dermis, destroying the nerve endings. Consequently, the area is **anaesthetic** (painless) to a needle prick. Differentiating between these is crucial because superficial burns usually heal spontaneously, whereas deep burns often require surgical intervention (skin grafting). **2. Why the incorrect options are wrong:** * **A & C (Healing/Degenerative process):** While nerve regeneration can be part of healing, the needle test is a diagnostic tool for acute assessment, not a longitudinal measure of cellular repair or degeneration. * **D (Infection):** Infection in burns is diagnosed via clinical signs (pus, foul smell, fever) or quantitative wound biopsies/cultures, not by sensory testing. **3. NEET-PG High-Yield Pearls:** * **Jackson’s Burn Zones:** Zone of Coagulation (irreversible necrosis), Zone of Stasis (potentially salvageable), and Zone of Hyperemia (will heal). * **Capillary Refill:** Present in superficial burns (blanching); absent in deep burns. * **Appearance:** Superficial burns are typically red and moist with blisters; deep burns appear leathery, charred, or waxy white. * **Rule of 9s:** Used for calculating the Total Body Surface Area (TBSA) to guide fluid resuscitation (Parkland Formula).

Question 345: In severe burns, what is the maximum possible increase in hemoglobin level?

A. 50%
B. 80%
C. 150% (Correct Answer)
D. 100%

Explanation: **Explanation:** The correct answer is **150% (Option C)**. **Underlying Medical Concept:** In severe burn injuries, there is a massive systemic inflammatory response leading to increased capillary permeability (capillary leak syndrome). This results in the rapid shift of fluid, electrolytes, and plasma proteins from the intravascular compartment into the interstitial space. This loss of plasma volume leads to profound **hemoconcentration**. While the absolute number of red blood cells does not increase, the relative concentration of hemoglobin rises sharply because the plasma volume (the solvent) decreases significantly. In cases of severe, untreated, or inadequately resuscitated burns, the hematocrit can rise to 60–70%, and the hemoglobin level can increase by up to **150% of its baseline value**. **Analysis of Incorrect Options:** * **A (50%) & D (100%):** These values represent significant hemoconcentration but do not reach the physiological maximum seen in the acute "ebb phase" of severe burns before fluid resuscitation. * **B (80%):** While closer, it still underestimates the extreme plasma loss possible in major burns (e.g., >50% Total Body Surface Area). **High-Yield Clinical Pearls for NEET-PG:** * **The "Gold Standard" for Resuscitation:** The **Parkland Formula** (4ml x kg x %TBSA) is used to counteract this fluid loss. * **Indicator of Resuscitation:** The most reliable indicator of adequate fluid resuscitation in burns is **Hourly Urine Output** (0.5 ml/kg/hr in adults; 1 ml/kg/hr in children). * **Curling’s Ulcer:** A stress-induced gastroduodenal ulcer specifically associated with severe burns. * **Rule of Nines:** Used for rapid estimation of burn surface area; remember that the patient's palm (including fingers) represents approximately 1% TBSA.

Question 346: A Jefferson fracture is a fracture of which cervical vertebra?

A. C1 (Correct Answer)
B. C2
C. C3
D. C4

Explanation: **Explanation:** **Correct Answer: A (C1)** A **Jefferson fracture** is a burst fracture of the **Atlas (C1)**. It is typically caused by a compressive downward force (axial loading) transmitted through the occipital condyles to the lateral masses of C1. This force causes the ring of the atlas to fracture at its weakest points—the anterior and posterior arches—leading to a lateral displacement of the lateral masses. **Why other options are incorrect:** * **B (C2):** Fractures of the Axis (C2) are common but have specific names. A fracture of the pars interarticularis of C2 is known as a **Hangman’s fracture**, while fractures of the dens are classified as **Odontoid fractures**. * **C & D (C3-C4):** Fractures at these levels are generally referred to as subaxial cervical spine injuries. While they can involve burst fractures or dislocations, they do not carry the eponym "Jefferson." **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Classically seen in divers hitting their head on the bottom of a shallow pool. * **Radiology:** On an **Open-mouth (Odontoid) X-ray view**, the hallmark is the lateral displacement (overhang) of the C1 lateral masses relative to the C2 articular facets. * **Stability:** If the sum of the lateral displacement is **>7mm**, it indicates a rupture of the **Transverse Axial Ligament (TAL)**, rendering the fracture unstable. * **Neurology:** Interestingly, Jefferson fractures are often neurologically intact because the burst mechanism actually increases the diameter of the spinal canal (Spalding’s rule).

Question 347: Which of the following is not seen in third-degree burns?

A. Loss of skin appendages
B. No vesicles
C. Red color
D. Extremely painful (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Extremely painful**. In third-degree (full-thickness) burns, the damage extends through the entire epidermis and dermis, reaching the subcutaneous fat. This process results in the **complete destruction of dermal nerve endings**. Consequently, these burns are characteristically **painless or anesthetic** to touch and pinprick. **Analysis of Options:** * **A. Loss of skin appendages:** Correct. Since the entire thickness of the dermis is destroyed, hair follicles, sweat glands, and sebaceous glands are lost. Healing can only occur from the edges or via skin grafting. * **B. No vesicles:** Correct. Vesicles (blisters) are a hallmark of second-degree (partial-thickness) burns. In third-degree burns, the surface is typically dry, leathery, and charred (eschar). * **C. Red color:** Incorrect (it is not seen). Third-degree burns typically appear **pearly white, charred (black), or leathery brown**. They do not blanch on pressure because the dermal capillary network is destroyed. **Clinical Pearls for NEET-PG:** * **Rule of Nines:** Used for TBSA (Total Body Surface Area) estimation; remember that first-degree burns are **excluded** from this calculation. * **Parkland Formula:** $4 \text{ ml} \times \text{Body Weight (kg)} \times \% \text{ TBSA}$. Give half in the first 8 hours. * **Jackson’s Burn Zones:** Zone of Coagulation (irreversible necrosis), Zone of Stasis (potentially salvageable), and Zone of Hyperemia (will recover). * **Pain Profile:** First-degree (painful), Second-degree (exquisitely painful), Third-degree (painless).

Question 348: Chronic subdural hematoma is caused by which of the following?

A. Fracture of skull bones
B. Hypertension
C. Rupture of bridging veins (Correct Answer)
D. Subarachnoid hemorrhage

Explanation: **Explanation:** **1. Why "Rupture of bridging veins" is correct:** Chronic Subdural Hematoma (cSDH) typically occurs due to the tearing of **bridging veins** as they traverse the subdural space to drain into the dural venous sinuses. In elderly patients or those with chronic alcoholism, brain atrophy leads to an increase in the distance between the brain surface and the skull. This stretches the bridging veins, making them highly susceptible to rupture even from minor, often forgotten, head trauma. The bleeding is venous (low pressure), allowing the hematoma to accumulate slowly over weeks to months. **2. Why the other options are incorrect:** * **Fracture of skull bones:** While fractures can cause intracranial bleeding, they are most classically associated with **Epidural Hematomas (EDH)** due to the rupture of the Middle Meningeal Artery (MMA). * **Hypertension:** This is the leading cause of **Spontaneous Intracerebral Hemorrhage** (e.g., in the basal ganglia or thalamus), not typically subdural hematomas. * **Subarachnoid hemorrhage:** This is most commonly caused by the rupture of **berry aneurysms** or Arteriovenous Malformations (AVMs), resulting in bleeding into the subarachnoid space rather than the subdural space. **High-Yield Clinical Pearls for NEET-PG:** * **Imaging:** On CT scan, cSDH appears as a **crescent-shaped (concave)**, **hypodense** (dark) collection. Acute SDH is hyperdense (white). * **Risk Factors:** Elderly age, chronic alcoholism, and use of anticoagulants. * **Clinical Presentation:** Often presents as a "Great Imitator" with fluctuating levels of consciousness, progressive dementia, or focal neurological deficits. * **Management:** Symptomatic cSDH is treated via **burr-hole evacuation**.

Question 349: Which of the following is true about blunt abdominal trauma with splenic rupture?

A. Kehr's sign is characterized by discoloration around the umbilicus.
B. The spleen is the most common organ to be involved in blunt abdominal trauma.
C. Splenectomy is the treatment of choice for splenic rupture. (Correct Answer)
D. Cullen's sign is observed.

Explanation: **Explanation:** **1. Why Option C is Correct:** In the context of traditional surgical teaching and many standardized exams, **splenectomy** remains the definitive treatment of choice for significant splenic rupture, especially when the patient is hemodynamically unstable. While modern trauma management increasingly favors Non-Operative Management (NOM) for stable patients, the surgical standard for a ruptured spleen (Grade IV/V or unstable) is splenectomy to prevent life-threatening exsanguination. **2. Why the Other Options are Incorrect:** * **Option A:** **Kehr’s sign** is referred pain in the **left shoulder** caused by diaphragmatic irritation from blood (hemoperitoneum). Discoloration around the umbilicus is Cullen’s sign. * **Option B:** While the spleen was historically considered the most common, recent literature and ATLS guidelines often cite the **liver** as the most commonly injured organ in blunt abdominal trauma (though the spleen remains a very close second and is the most common organ requiring surgery). *Note: In many exams, the spleen is still the "classic" answer, but the phrasing here makes C a more definitive surgical truth.* * **Option D:** **Cullen’s sign** (periumbilical ecchymosis) and **Grey Turner’s sign** (flank ecchymosis) are typically associated with **acute hemorrhagic pancreatitis** or ruptured ectopic pregnancy, rather than acute splenic rupture. **Clinical Pearls for NEET-PG:** * **Ballance’s Sign:** Fixed dullness in the left flank and shifting dullness in the right flank (indicative of splenic hematoma/rupture). * **Post-Splenectomy Complications:** The most feared is **OPSI (Overwhelming Post-Splenectomy Infection)**, primarily caused by *Streptococcus pneumoniae*. * **Vaccination:** Post-splenectomy patients must receive vaccines against *S. pneumoniae*, *H. influenzae type B*, and *N. meningitidis* (ideally 14 days before elective surgery or 14 days after emergency surgery). * **Investigation of Choice:** **CECT Abdomen** is the gold standard for stable patients; **FAST** is the initial investigation for unstable patients.

Question 350: Acute flaccid paralysis with areflexia and loss of perianal reflexes below the level of spinal cord injury is most likely due to which of the following?

A. Spinal shock (Correct Answer)
B. Denervation
C. Malingering
D. Upper motor neuron paralysis

Explanation: **Explanation:** The correct answer is **Spinal Shock**. **1. Why Spinal Shock is Correct:** Spinal shock refers to the immediate, temporary loss of all neurological activity (motor, sensory, and autonomic) below the level of an acute spinal cord injury. It is characterized by **flaccid paralysis**, **areflexia** (loss of deep tendon reflexes), and loss of **sacral reflexes** (such as the bulbocavernosus and perianal reflexes). This occurs due to the sudden withdrawal of tonic facilitatory impulses from the higher brain centers. The hallmark of the end of spinal shock is the return of the bulbocavernosus reflex. **2. Why Incorrect Options are Wrong:** * **Denervation:** This refers to the loss of nerve supply to a specific muscle or organ. While it causes flaccidity, it is a permanent anatomical state rather than the acute, systemic physiological response seen immediately after spinal trauma. * **Malingering:** This is the intentional feigning of symptoms for secondary gain. While a patient may mimic paralysis, they cannot voluntarily suppress involuntary autonomic reflexes like the perianal or bulbocavernosus reflexes. * **Upper Motor Neuron (UMN) Paralysis:** While spinal cord injury eventually results in UMN signs (spasticity, hyperreflexia, and Babinski sign), these features only develop **after** the phase of spinal shock has resolved (usually 24–72 hours to weeks later). **3. NEET-PG High-Yield Pearls:** * **First reflex to return:** Bulbocavernosus reflex (S3-S4). * **Spinal Shock vs. Neurogenic Shock:** Spinal shock is a *neurological* state (loss of reflexes); Neurogenic shock is a *hemodynamic* state (hypotension and bradycardia due to loss of sympathetic tone, typically seen in injuries above T6). * **Duration:** Spinal shock typically lasts 24 hours to several weeks. * **Priapism:** May be seen during spinal shock due to uncontrolled parasympathetic activity.

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