Trauma — MCQs

Trauma Indian Medical PG Practice Questions and MCQs

Question 711: Tardy ulnar nerve palsy can occur as a delayed sequela of which of the following conditions?

A. Supracondylar fracture of humerus
B. Posterior dislocation of elbow
C. Fracture of the lateral condyle of the humerus in children (Correct Answer)
D. Fracture of the olecranon

Explanation: **Explanation:** **Tardy Ulnar Nerve Palsy** is a delayed-onset neuropathy that occurs years after an elbow injury. The correct answer is **Fracture of the lateral condyle of the humerus in children** because of the specific sequence of events it triggers: 1. **Non-union:** This fracture often fails to unite properly due to the pull of the extensor muscles and bathing of the fracture site in synovial fluid. 2. **Cubitus Valgus:** As the medial side of the humerus continues to grow while the lateral side lags, a progressive "outward" deformity of the forearm (cubitus valgus) develops. 3. **Chronic Stretching:** The ulnar nerve, which runs behind the medial epicondyle, is stretched over a longer distance around the bony prominence. Over years, this chronic friction and tension lead to ischemic changes and palsy. **Analysis of Incorrect Options:** * **A. Supracondylar fracture of humerus:** This is the most common pediatric elbow fracture. It typically leads to **Cubitus Varus** (Gunstock deformity). Since the nerve is not stretched in varus, tardy ulnar palsy is not a feature. It is, however, associated with acute injuries to the median or radial nerves. * **B. Posterior dislocation of elbow:** This usually results in acute nerve injuries (most commonly the ulnar or median nerve) at the time of trauma, rather than a delayed "tardy" presentation. * **C. Fracture of the olecranon:** This may cause acute ulnar nerve irritation due to proximity, but it does not typically result in the progressive valgus deformity required for tardy palsy. **NEET-PG High-Yield Pearls:** * **Latency:** Tardy ulnar nerve palsy typically appears **10–20 years** after the initial injury. * **Clinical Sign:** Look for wasting of intrinsic hand muscles (interossei) and a positive **Froment’s sign**. * **Treatment:** The procedure of choice is **Anterior Transposition of the Ulnar Nerve**, where the nerve is moved from the back of the medial epicondyle to the front to relieve tension.

Question 712: In triage, what does the green color indicate?

A. Ambulatory patients (Correct Answer)
B. Dead or moribund patients
C. High priority treatment or transfer
D. Medium priority or transfer

Explanation: In disaster management, **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of survival with available resources. The most widely used system is the **START (Simple Triage and Rapid Treatment)** protocol, which uses a four-tier color-coding system. ### Explanation of Options: * **A. Ambulatory patients (Correct):** The **Green** tag is assigned to "minor" injuries. These patients are often referred to as the "walking wounded." They are stable, can follow commands, and are capable of self-ambulation. They require minimal care and are the lowest priority for evacuation. * **B. Dead or moribund patients:** These are assigned the **Black** tag. This category includes those who are already deceased or have injuries so catastrophic (e.g., exposed brain matter, cardiac arrest) that survival is unlikely even with maximal care in a mass casualty setting. * **C. High priority treatment or transfer:** These are assigned the **Red** tag (Immediate). These patients have life-threatening injuries (e.g., airway obstruction, tension pneumothorax, or uncontrolled hemorrhage) but have a high chance of survival if treated immediately. * **D. Medium priority or transfer:** These are assigned the **Yellow** tag (Delayed). These patients have serious injuries (e.g., stable fractures, large wounds without massive bleeding) but are currently hemodynamically stable and can wait 1–2 hours for treatment. ### High-Yield Clinical Pearls for NEET-PG: * **Mnemonic for Triage Colors:** **R**ed (Immediate), **Y**ellow (Urgent), **G**reen (Delayed/Ambulatory), **B**lack (Dead). * **The "30-2-Can Do" Rule for Red Tags:** If Respirations >30/min, Capillary refill >2 seconds, or the patient cannot follow simple commands ("Can Do"), they are tagged **Red**. * **Reverse Triage:** In military or combat situations, those who can be returned to the front lines most quickly may be treated first—the opposite of civilian triage. * **Triage Sieve:** The initial rapid assessment of all victims at the scene.

Question 713: Complications of Colles' fracture are all except?

A. Malunion
B. Non-union (Correct Answer)
C. Sudeck's dystrophy
D. Rupture of extensor pollicis longus

Explanation: **Explanation:** Colles' fracture is a distal radius fracture occurring within 2.5 cm of the wrist joint, characterized by dorsal displacement and angulation (dinner fork deformity). **Why Non-union is the Correct Answer:** Non-union is **extremely rare** in Colles' fracture. The distal end of the radius is composed of cancellous bone, which has an abundant blood supply and a large surface area for healing. Consequently, while these fractures may heal in a poor position (malunion), they almost always achieve bony union. **Analysis of Incorrect Options:** * **Malunion (A):** This is the **most common complication**. It results in the classic "dinner fork deformity" and can lead to a weak grip and limited range of motion. * **Sudeck’s Osteodystrophy (C):** Also known as Complex Regional Pain Syndrome (CRPS) Type 1. It is a common sequela characterized by post-traumatic pain, swelling, and vasomotor instability of the hand. * **Rupture of Extensor Pollicis Longus (D):** This is a classic late complication. It occurs due to ischemia or attrition of the tendon as it passes over the irregular dorsal surface (Lister’s tubercle) of the fractured radius. **High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Malunion. * **Most common late complication:** Stiffness of fingers and wrist. * **EPL Rupture:** Usually occurs 4–8 weeks post-injury; treated with **Extensor Indicis Proprius (EIP) tendon transfer**. * **Median Nerve Injury:** Can occur acutely (carpal tunnel syndrome symptoms). * **Dinner Fork Deformity:** Produced by five displacements (Dorsal tilt, Dorsal displacement, Lateral tilt, Lateral displacement, and Impaction/Supination).

Question 714: In which of the following conditions is oronasal intubation NOT indicated?

A. Le Fort I fracture
B. Le Fort II and III fractures (Correct Answer)
C. Parietal bone fracture
D. Mandibular fracture

Explanation: **Explanation:** The primary concern in maxillofacial trauma is the integrity of the **cribriform plate of the ethmoid bone**. In **Le Fort II and III fractures**, the fracture lines involve the naso-ethmoidal complex. This often results in a comminuted fracture of the cribriform plate, creating a direct communication between the nasal cavity and the anterior cranial fossa. **Why Option B is correct:** In Le Fort II and III fractures, attempting nasotracheal (or oronasal) intubation is strictly contraindicated. The tube can inadvertently pass through the fractured cribriform plate and enter the **brain parenchyma**, leading to catastrophic intracranial injury, meningitis, or cerebrospinal fluid (CSF) leakage. In such cases, orotracheal intubation is the preferred initial method; if that fails or is contraindicated, a surgical airway (cricothyroidotomy or tracheostomy) is indicated. **Why other options are incorrect:** * **Le Fort I fracture (A):** This is a horizontal fracture of the maxilla above the level of the teeth. It does not involve the orbit or the ethmoid bone, so the cribriform plate remains intact. * **Parietal bone fracture (C):** A fracture of the parietal bone involves the vault of the skull and does not typically compromise the nasopharyngeal anatomy or the skull base. * **Mandibular fracture (D):** These fractures involve the lower jaw. While they may cause airway obstruction due to tongue displacement, they do not involve the skull base. In fact, nasotracheal intubation is often *preferred* here to allow the surgeon to establish proper dental occlusion during repair. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Sign:** Look for "CSF Rhinorrhea" or the "Halo Sign" in Le Fort II/III, indicating a base of skull fracture. * **Raccoon Eyes:** Highly suggestive of Le Fort II/III or basilar skull fractures. * **Rule of Thumb:** If there is any suspicion of a midface fracture involving the nose or a suspected basilar skull fracture (Battle’s sign, hemotympanum), **avoid the nasal route** for both intubation and Nasogastric (NG) tube insertion.

Question 715: A patient presented with a history of fall on an outstretched hand, complains of pain in the anatomical snuffbox, and clinically, no deformities are visible. What is the most likely diagnosis?

A. Colles' fracture
B. Lunate dislocation
C. Barton's fracture
D. Scaphoid fracture (Correct Answer)

Explanation: ### Explanation **Correct Option: D. Scaphoid Fracture** The scaphoid is the most commonly fractured carpal bone. The classic mechanism of injury is a **fall on an outstretched hand (FOOSH)** with the wrist in dorsiflexion. The hallmark clinical sign is **tenderness in the anatomical snuffbox**. The absence of visible deformity is common in scaphoid fractures, unlike distal radius fractures which often present with "dinner fork" or "spade-like" deformities. **Why the other options are incorrect:** * **Colles' Fracture:** This is a distal radius fracture with dorsal displacement. It typically presents with a visible **"dinner fork" deformity**, which is absent in this case. * **Lunate Dislocation:** While also caused by FOOSH, it typically presents with volar swelling, median nerve compression symptoms, and a "spilled teacup" appearance on a lateral X-ray, rather than localized snuffbox tenderness. * **Barton’s Fracture:** This is an intra-articular fracture-dislocation of the distal radius (can be dorsal or volar). It is usually associated with significant swelling and deformity. **High-Yield Clinical Pearls for NEET-PG:** * **Blood Supply:** The scaphoid receives its blood supply distally from the radial artery. Therefore, a fracture at the **waist or proximal pole** carries a high risk of **Avascular Necrosis (AVN)** and non-union. * **Radiology:** Initial X-rays may be negative in 10-20% of cases. If clinical suspicion persists despite normal X-rays, the wrist should be immobilized in a **thumb spica cast** and re-imaged after 10–14 days. * **Gold Standard Investigation:** MRI is the most sensitive investigation for detecting occult scaphoid fractures early. * **Tenderness Points:** Scaphoid fractures show tenderness in three locations: the anatomical snuffbox, the scaphoid tubercle (volar aspect), and on longitudinal compression of the thumb.

Question 716: If the Glasgow Coma Scale (GCS) score is 8, a head injury is classified as:

A. Mild
B. Moderate
C. Severe (Correct Answer)
D. Very severe

Explanation: **Explanation:** The **Glasgow Coma Scale (GCS)** is the gold standard for assessing the level of consciousness and severity of traumatic brain injury (TBI). It evaluates three components: Eye opening (E), Verbal response (V), and Motor response (M), with a total score ranging from 3 to 15. **Why the Correct Answer is Right:** Head injuries are categorized based on the total GCS score: * **Severe TBI: GCS 3–8.** A score of 8 falls into this category. Clinically, a GCS of ≤8 is the threshold for "coma" and serves as the primary indication for **endotracheal intubation** to protect the airway ("GCS of 8, intubate"). **Why Other Options are Wrong:** * **A. Mild (GCS 13–15):** Patients are usually awake and oriented but may have experienced brief loss of consciousness or concussion. * **B. Moderate (GCS 9–12):** Patients are lethargic or stuporous but do not meet the criteria for coma. * **D. Very Severe:** While clinically used to describe GCS scores of 3–5 or prolonged coma, it is not a standard classification category in the traditional GCS grading system for TBI. **High-Yield Clinical Pearls for NEET-PG:** 1. **Motor Response (M):** This is the most significant prognostic indicator among the three components. 2. **Lowest vs. Highest:** The minimum possible GCS score is **3** (not 0), and the maximum is **15**. 3. **Decerebrate vs. Decorticate:** In the Motor section, **Abnormal Extension** (Decerebrate) scores 2, while **Abnormal Flexion** (Decorticate) scores 3. Remember: "Flexion is better than Extension." 4. **Modified GCS:** For intubated patients, the verbal score is recorded as 'T' (e.g., GCS 8T).

Question 717: Which of the following bacterial meningitis is associated with subdural effusion?

A. Haemophilus influenzae (Correct Answer)
B. Neisseria meningitidis
C. Streptococcus pneumoniae
D. Enterococcus

Explanation: **Explanation:** **Subdural effusion** (a collection of fluid in the subdural space) is a common complication of bacterial meningitis in infants and young children. While it can occur with various pathogens, it is most classically and frequently associated with **Haemophilus influenzae type b (Hib)**. 1. **Why Haemophilus influenzae is correct:** Historically, *H. influenzae* was the leading cause of bacterial meningitis in children aged 2 months to 5 years. Approximately **30–50%** of infants with *H. influenzae* meningitis develop subdural effusions. The effusion typically occurs due to increased permeability of the leptomeningeal vessels during the inflammatory process. 2. **Why other options are incorrect:** * **Streptococcus pneumoniae:** While it is a common cause of meningitis and can cause effusions, it is more frequently associated with more severe neurological sequelae (like hearing loss) or empyema rather than simple sterile effusions. * **Neisseria meningitidis:** This typically presents with a rapid clinical course and petechial rashes; subdural effusions are significantly less common compared to *H. influenzae*. * **Enterococcus:** This is an extremely rare cause of meningitis, usually seen only in post-surgical patients or neonates, and is not classically associated with subdural effusions. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Suspect subdural effusion if a child with meningitis has a **persistent fever**, bulging fontanelle, or enlarging head circumference despite 48–72 hours of appropriate antibiotic therapy. * **Diagnosis:** Transfontanellar ultrasound (in infants) or Contrast-enhanced CT/MRI. * **Management:** Most effusions are asymptomatic and **resolve spontaneously**. Aspiration (subdural tap) is indicated only if there are signs of increased intracranial pressure (e.g., vomiting, seizures) or if an infected empyema is suspected. * **Vaccination Impact:** Since the introduction of the Hib vaccine, the incidence of both *H. influenzae* meningitis and its associated subdural effusions has drastically declined.

Question 718: Headache, apathy, and a deteriorating level of consciousness occurring weeks after a head injury suggest which of the following conditions?

A. Chronic subdural hematoma. (Correct Answer)
B. Pontine hemorrhage.
C. Continuing cerebral edema.
D. Depressed skull fracture.

Explanation: **Explanation:** The clinical presentation of headache, apathy, and deteriorating consciousness occurring **weeks** after a head injury is the classic triad for a **Chronic Subdural Hematoma (cSDH)**. **1. Why Chronic Subdural Hematoma is correct:** cSDH typically occurs due to the tearing of **bridging veins** between the cortex and dural sinuses. In elderly patients or those with brain atrophy, these veins are stretched. Following a minor trauma (which the patient may even forget), a slow leak occurs. Over 2–3 weeks, the blood liquefies and the hematoma expands due to recurrent micro-bleeding from the friable neo-membrane or osmotic shifts. This slow expansion leads to a delayed onset of "neuropsychiatric" symptoms like apathy, confusion, and fluctuating consciousness. **2. Why the other options are incorrect:** * **Pontine Hemorrhage:** This is an acute event characterized by sudden coma, pinpoint pupils, and quadriplegia. It does not present weeks after trauma. * **Continuing Cerebral Edema:** Edema following trauma is an acute process that peaks within 48–72 hours and resolves or stabilizes within a week; it does not manifest for the first time weeks later. * **Depressed Skull Fracture:** While it can cause focal deficits or seizures, it is a structural bony injury diagnosed at the time of trauma. It does not typically cause a delayed, progressive deterioration of consciousness unless complicated by infection or hematoma. **Clinical Pearls for NEET-PG:** * **Imaging Choice:** Non-contrast CT scan is the gold standard. cSDH appears as a **crescent-shaped, hypodense (dark)** collection. * **Risk Factors:** Elderly patients, chronic alcoholics (due to brain atrophy), and patients on anticoagulants. * **Management:** Symptomatic cSDH is usually treated via **burr-hole evacuation**. * **Key Distinction:** Acute SDH is hyperdense (white); Chronic SDH is hypodense (black).

Question 719: A patient presents with enophthalmos and periorbital ecchymosis after being hit by a ball. What is the most likely diagnosis?

A. Le Fort I fracture
B. Zygomatic fracture
C. Orbital blowout fracture (Correct Answer)
D. Nasal bone fracture

Explanation: ***Orbital blowout fracture*** - The clinical presentation of **periorbital ecchymosis** (bruising around the eye) and **enophthalmos** (posterior displacement of the eyeball) following blunt trauma from an object like a ball is classic for an orbital blowout fracture. - This injury often involves the thin orbital floor, leading to herniation of orbital contents into the maxillary sinus and potential entrapment of the **inferior rectus muscle**, which can cause **diplopia** (double vision) on upward gaze. *Zygomatic fracture* - A zygomatic (cheekbone) fracture typically causes facial flattening, a palpable **step-off deformity** along the orbital rim, and numbness over the cheek due to **infraorbital nerve** injury. - While it can be associated with an orbital floor fracture, isolated **enophthalmos** is not its primary presenting sign; facial asymmetry is more prominent. *Nasal bone fracture* - This is the most common facial fracture and presents with localized pain, swelling, deformity of the nasal bridge, and **epistaxis** (nosebleed). - **Enophthalmos** is not a feature of an isolated nasal bone fracture, although periorbital ecchymosis can be present. *Le Fort I fracture* - This is a horizontal fracture of the maxilla, resulting in a **"floating palate"** where the entire upper dental arch is mobile. - It is characterized by **dental malocclusion** and does not typically cause the isolated orbital signs of **enophthalmos** seen in this case.

Question 720: During an explosion, a patient sustains a crushed lower limb injury by collapse of a building. What type of blast injury does this represent?

A. Tertiary
B. Primary
C. Secondary
D. Quaternary (Correct Answer)

Explanation: ***Quaternary*** - This category includes all injuries not caused by primary, secondary, or tertiary mechanisms, such as **crush injuries**, burns, and toxic exposures. - The patient's crushed lower limb from a collapsing building is a classic example of a **quaternary blast injury**. *Primary* - Primary blast injuries are caused by the direct effect of the **blast wave overpressure** on the body. - They typically affect gas-containing organs, leading to conditions like **tympanic membrane rupture** or **blast lung**, which are not described here. *Secondary* - Secondary blast injuries result from being struck by **flying debris or fragments** (shrapnel) propelled by the explosion. - This mechanism causes penetrating or blunt trauma from projectiles, not crush injuries from a structural collapse. *Tertiary* - Tertiary blast injuries occur when the victim is thrown by the **blast wind** and impacts a solid object like a wall or the ground. - This results in blunt force trauma and fractures from the impact, which is different from being crushed by a falling structure.

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