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Tim Brock and Rishi Dhir
Figure 15.24 Anteroposterior radiograph (AP) left hip
D. The lateral femoral cutaneous nerve is at risk
during the approach
E. Time to surgery is the most important factor
in influencing outcome
C. On-table angiogram, temporary vascular
shunt, definitive vascular reconstruction,
skeletal stabilisation, forearm fasciotomies
D. On-table angiogram, temporary vascular
shunt, skeletal stabilisation, definitive vascular reconstruction, forearm fasciotomies
E. On-table angiogram, temporary vascular
shunt, skeletal stabilisation, definitive vascular reconstruction
44. Line 5 in this radiograph of the left hemipelvis
(Figure 15.26) indicates which of the following
structures?
43. A 23-year-old footballer sustains a fracturedislocation of his elbow (Figure 15.25). He has
a pulseless white hand, despite reduction of the
elbow in the ED. There are no imaging modalities available overnight, but the vascular team
are present, and he is taken urgently to theatre.
Figure 15.25 Lateral
radiograph elbow
What is the appropriate sequence in theatre?
A. On-table angiogram, definitive vascular
reconstruction, skeletal stabilisation
B. On-table angiogram, skeletal stabilisation,
definitive vascular reconstruction, forearm
fasciotomies
Figure 15.26 Anteroposterior (AP) pelvis radiograph
A. Acetabular true floor
B. Anterior column
C. Posterior column
D. Posterior wall
E. Weight bearing dome
45. An 80-year-old male falls at home and presents
to the ED with a subtrochanteric hip fracture
(Figure 15.27). He has been scheduled on the
trauma list for an antegrade cephalomedullary
nail.
Regarding the proximal bone fragment, what
muscles are responsible for the ensuing
324
Trauma I Structured SBA
Figure 15.27
Anteroposterior
(AP) radiograph hip
deformity of procurvatum (apex anterior) and
varus?
A. Hip abductors and iliopsoas
B. Hip adductors and hamstrings
C. Iliopsoas and hamstrings
D. Iliopsoas and hi p adductors
E. Quadriceps and short external rotators
46. Regarding traumatic knee dislocation, the ankle–
brachial pressure index is a useful tool for assessing for an associated vascular injury.
What figure is associated with a vascular injury
and warrants urgent arteriography?
A. <0.5
B. <0.6
C. <0.7
D. < 0.8
E. <0.9
Figure 15.28 Lateral
radiograph femur
47. You see an 8-year-old in ED w ith the injury
demonstrated in the radiograph in Figure 15.28.
When explaining the management plan to the
parents, what is the most common complication that you should inform them of, regardless
of your treatment modality?
A. Avascular necrosis
B. Knee stiffness
C. Non-union
D. Overgrowth
E. Refracture
48. An 84-year-old man has a fall and sustains the
injury shown in Figure 15.29. Intraoperatively
you notice the cement mantle is well fixed and
overall the bone appears to be of good quality.
Figure 15.29 Anteroposterior (AP) radiograph left hip
What is the most appropriate treatment option?
A. ORIF using cerclage wire and locking plate
B. Proximal femoral replacement
C. Revision of cemented component to long
cemented taper slip stem
D. Revision of cemented component to long
porous-coated cementless stem and femoral
allograft
E. Revision of cemented component to long
porous-coated cementless stem and fixation
of fracture
49. A 17-year-old falls 20 feet from a building. On
arrival to the ED, he has a pulse of 125, blood
325
Tim Brock and Rishi Dhir
pressure of 70/40 and he is acting aggressively
towards the staff.
What class of hypovolaemic shock is he in?
A. I
B. II
C. III
D. IV
E. V
50. A 57-year-old falls down the stairs intoxicated.
On his pelvic radiographs, there is impaction of
the superomedial roof of the left acetabulum
(Figure 15.30).
Figure 15.31
Open tibial fracture
Figure 15.30 Anteroposterior (AP) radiograph pelvis
What surgical approach is most appropriate?
A. Extended iliofemoral
B. Hardinge
C. Ilioinguinal
D. Kocher–Langenbeck
E. Modified Stoppa
51. A footballer attends the ED at 23.00h, having
sustained an open tibial fracture (Figure 15.31)
that evening during a football match after a tackle.
Which of the following is not a reason for an
emergency operation in the middle of the night?
A. A wound size >10cm
B. Arterial injury which needs to be repaired
C. Compartment syndrome
D. Contamination with farmyard manure
E. He is going to theatre for a laparotomy and
treatment of multiple other injuries
52. A 27-year-old man falls from his motorbike. He
has an open olecranon fracture and fractures of
his hip, femur and tibia. He has a significant
chest injury with pulmonary contus ions and
associated rib fractures.
What is the most sensitive indicator to determine whether he is adequately resuscitated?
A. Blood pressure
B. Gastric mucosal pH
C. Pulse rate
D. Serum lactate
E. Urine output
53. You are asked to put on an external fixator for a
fracture dislocation of the ankle, which is very
unstable with excessive swelling.
Which of these cannot be used to increase
rigidity of your construct?
A. Decrease the distance between the bars and
the skin
B. Increase pin diameter
C. Increase the number of multiplanar cross-
links
D. Increase the working length
E. Reduce the fracture
326
Trauma I Structured SBA
54. A patient undergoes sacroiliac joint fixation with
percutaneous screws for a lateral compression
fracture. It was noted on the post-operative
radiographs that one of the screws has penetrated
the anterior cortex.
What symptom may the patient experience?
A. Bladder dysfunction
B. Paraesthesia over the dorsum of the foot
C. Paraesthesia over the popliteal fossa
D. Weakness with ankle plantar flexion
E. Weakness with quadriceps extension
55. Following a dislocated native knee joint, a 22-
year-old male has an MRI that confirms a multiligament knee injury comprising the ACL, PCL,
posterolateral corner and MCL.
Which of the following is true?
A. Treat ACL and PCL within 2 weeks and PLC
and MCL operatively at 6 weeks
B. Treat ACL operatively within 2 weeks, PCL
and PLC within 6 weeks and MCL conservatively in a brace
C. Treat ACL, PCL and PLC at 6 weeks once the
swelling has subsided and MCL
conservatively
D. Treat PCL and PLC operatively within 2
weeks, ACL within 6 weeks and MCL conservatively in a brace
E. Treat PCL and PLC operatively within 2
weeks, MCL within 6 weeks and ACL at 3
months
56. A 35-year-old male involved in a motorcycle
versus car accident is brought into the resuscitation department with the following injuries
after initial resuscitation: a 10cm open fracture
of the tibia (which is severe but stable); moderate
chest injury; minor facial injuries; and a minor
head injury.
What is the Injury Severity Score?
A. 11
B. 14
C. 17
D. 18
E. 24
57. A 41-year-old male presents to the ED following
a twisting left ankle injury. Anteroposterior (AP)
ankle radiograph is shown in Figure 15.32.
Figure 15.32
Anteroposterior
(AP) radiograph
left ankle
According to the Lauge–Hansen classification
for ankle fractures, how can the injury can be
classified?
A. Pronation abduction
B. Pronation external rotation
C. Supination adduction type 2
D. Supination external rotation type 4
E. Supination external rotation type 4
58. Regarding the LEAP study (Lower Extremity
Assessment Project), which of the following is
true?
A. Absence of plantar sensation has the
highest impact on a surgeon’s decisionmaking process
B. Good outcomes were found for both recon-
struction and amputation groups
C. Severe soft tissue injury has the highest
impact on a surgeon’s decision making
D. The least important factor in patient outcome
is the abilit y to return to work
E. There is a significant improvement in return
to work in reconstruction compared with
amputation at 2 years
59. Regarding principles of elastic nailing, which of
the following is false?
A. The apex of the nail crossover should be at
the fracture site
B. The diameter of the nail should be 40% of the
isthmus diameter
C. The entry point of a retrograde femoral elas-
tic nail should be proximal to the physis
327
Tim Brock and Rishi Dhir
D. The nail diameter should be 60% of the isth-
mus diameter
E. The nails should be pre-bent to three times
the diameter of the medullary canal
60. A 27-year-old man falls down three stairs whilst
carrying some boxes. His ankle radiographs and
CT images are shown in Figure 15.33.
Figure 15.33
Lateral radiograph
ankle
In terms of surgical approach, which interner vous plane is utilised for fixation?
A. Sural nerve and tibial nerve
B. Deep peroneal nerve and sural nerve
C. Superficial peroneal nerve and sural nerve
D. Saphenous nerve and tibial nerve
E. Superficial peroneal nerve and tibial nerve
61. A morbidly obese , diabetic patient with neur-
opathy falls when mobilising from her bed to
the toilet. She normally walks with a frame. Her
X-rays are shown in Figure 15.34. She has a large
open medial wound that will close primarily.
What is the most appropriate method of
management?
A. Primary ankle arthrodesis with hindfoot nail
B. Fibula nail
C. Open reduction fixation of ankle
D. External fixation
E. MUA and total contact cast
(a) (b)
Figure 15.34 (a) Anteroposterior (AP)
and (b) lateral radiographs ankle
328
TRAUMA I STRUCTURED SBA ANSWERS
1. Answer C. Glenohumeral dislocation
Hertel et al.’s (2004) seminal paper evaluated predictors of humeral head ischaemia after intracapsular humerus fractures by drilling a borehole into
the central part of the humeral head intraoperatively and observing backflow and measuring laser
Doppler flowmetry.
They demonstrated the significance of metaphyseal head extension. Metaphyseal head extension is a radiographic measurement of the
articular fragment from the head–neck junction
to the inferior extent of the medial cortex.
Good predictors of ischaemia were the length
of the metaphyseal head extension (with a calcar
fragment <8mm); the integrity of the medial
Trauma I Structured SBA
hinge and certain basic fracture patterns (anatomical neck).
Poor predictors of ischaemia included glenohumeral dislocation, tuberosity displacement,
angular displacement of the head and fractures
consisting of three and four fragments (Figure
15.35 (a) and (b)).
Hertel R et al. Predictor s of humeral head
ischaemia after intracapsular fractu re of the proximal humerus. J Shoulder Elbow Surg.
2004;13:427–433.
2. Answer C. Suprapatellar nailing
Proximal tibial fractures can be very challenging
to treat with an intramedullary nail because of the
tendency of the proximal fragment to extend (procurvatum) due to the patellar tendon, and distal
Figure 15.35(a) Metaphyseal head
extension is a radiographic measurement
of the articular fragment from the head–
neck junction to the inferior extent of the
medial cortex
Figure 15.35(b) Integrity of the hinge
is a predictor of both ischaemia and
practical feasibility of reduction
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Tim Brock and Rishi Dhir
fragment, flex due to the hamstrings and possible
valgus deformity. This particularly occurs during
hyperflexion when using an infrapatellar nail to
get the entry point. Therefore, using a semiextended position, which a suprapatellar nail
affords, helps to avoid this. Poller (blocking)
screws can be used to block the pathway of the
nail and guide it down a more ‘ favourable’ route.
In this case, a sagittal lateral blocking screw and
coronal posterior blocking screw would guide the
nail into a preferential anterior and lateral position in the metaphysis. Unicortical one-third
tubular plates can be used as a temporising measure while making the entry point and passing the
guide wire to reduce the fracture and prevent the
procurvatum deformity. Finally, a more lateral
entry point should be used to decrease the valgus
deformity. A medial entry point would increase
the valgus deformity.
Fractures that are proximal to nail bend will
cause the proximal fracture fragment to translate
anteriorly up to 1cm. It has been noted that the
proximal bend in a nail acts as a wedge that
displaces the proximal fragment anteriorly as the
nail is driven distally. The use of a nail with a
more proximally based bend has less of a wedging
effect.
Hak DJ. Intramedullary nailing of proximal
third tibial fractures: techniques to improve
reduction. Orthopedics 2011;34:532–535.
3. Answer C. It has a positive Elson test
This is a radiograph of a volar PIPJ dislocation. It
is the less common type of PIPJ dislocation (the
most common being dorsal). It is associated with a
central slip injury and therefore has a positive
Elson test and causes a boutonnière deformity.
By definition, it is an unstable injury and must
be treated in a PIPJ hyperextension splint. A
dorsal PIPJ dislocation is associated with a volar
plate injury and causes a Swan neck deformity. It
can be mobilised immediately if stable after
reduction.
4. Answer D. The sustentaculum tali (anterome-
dial) fragment is referred to as the ‘constant
fragment’
Calcaneus fractures are the most common tarsal
bone fracture and often have associated injuries
including open fractures (17%), vertebral
fractures, especially L1 (10%), and contralateral
calcaneus fractures (10%).
The most imp ortant facet is the posterior facet
(main weight-bearing facet). An increasing crucial
angle of Gissane (normally 120–145°) or reduced
Böhler’s angle (normally 20–40°) indicates collapse of the posterior facet. The anteromedial
fragment is known as the sustentaculum tali (‘shelf
of talus’) and is known as the ‘constant fragment’
as it remains fixed or ‘constant’ due to the medial
talocalcaneal and interosseus ligaments.
Classifications include Essex–Lopresti and
Sanders, which is based on the number of articular
fragments on a coronal CT image at the widest
point of the posterior facet.
In most calcaneal fractures, the double density
is the result of a depressed lateral fragment relative
to the constant sustentaculum within the contour
of the calcaneal body. With the ‘locked-lateral’
fracture dislocation variant, the lateral fragment
is due to the superior dislocation of the fracture
fragment, which is visible as a second density
located superior to the sustentaculum overlapping
with the talus.
Schepers T, Backes M, Schep NW, Goslings
JC, Luitse JS. Functional outcome following a
locked fracture-dislocation of the calcaneus. Int
Orthop. 2013;37:1833–1838.
Rider CM, Olinger CR, Szatkowski JP,
Richardson DR. ‘Locked-lateral’ calcaneal
fracture-dislocation treated with primary subtalar
fusion: a case report. JBJS Case Connector 2020;10
e0467.
5. Answer B. The ‘step off sign’ is caused by dorsal
displacement of the 2nd metatarsal relative to
the cuboid
Radiology for suspected Lisfranc injuries should
include AP, lateral and oblique radiographs. On
the AP view, we should see a ‘fleck sign’, which
indicates avulsion of the Lisfranc ligament and is
often pathognomic for Lisfranc injuries. The
medial border of the 2nd metatarsal should normally line up with the medial border of the middle
cuneiform on the AP view (Figure 15.36). On the
oblique view, the medial border of the 4th metatarsal should normally line up with the medial
border of the cuboid. On the lateral view, we
should check for dorsal/plantar displacement of
the metatarsals.
:
330
Trauma I Structured SBA
Figure 15.36
Anteroposterior
foot X-ray
demonstrating
Lisfranc injury (the
medial border of
the 2nd metatarsal
does not line up
with that of the
middle cuneiform)
The ‘step off sign’ is caused by dorsal displace-
ment of the 2nd metatarsal relative to the medial
cuneiform seen on a lateral weight bearing film.
6. Answer B. The dorsal ligaments are stronger
than the plantar ligaments
The Lisfranc joint consists of the five metatarsals
that articulate with the three cuneiforms and
cuboid bones.
Bony stability is determined by the trapezoidal
shape of the base of the first three metatarsals,
with their respective cuneiform bones, forming a
stable arch known as a ‘Roman Arch’ with the
second TMTJ as the ‘keystone’.
Ligamentous stabilisers include the dorsal and
plantar TMT ligaments that cross each TMT joint,
and the dorsal ligaments are weaker; hence, displacement is often dorsal.
Intermetatarsal ligaments join the 2nd to the
5th metatarsals, but there is no intermetatarsal
ligament between the 1st and 2nd metatarsal.
Moracia-Ochagavia I, Rodriguez Merchan E.
Lisfranc fracture-dislocations: current management. EFORT Open Rev. 2019;4 :430 – 444.
7. Answer A. Buttress
A volar Barton’s fracture is an example of a shear
fracture treated by a buttress (anti-glide) plate,
which works by trapping the apex of the fracture
(Figure 15.37).
A compression plate is used, for example, in a
forearm fracture, producing absolute stability.
Figure 15.37 Buttress plating
in a volar Barton’s fracture
A bridging plate works as an internal external
fixator, for example, in a clavicle fracture, producing relative stability.
A neutralisation plate works by neutralising
torsional forces, for example, after fixation by a
lag screw in a Weber B fracture.
A locking plate is not a true mode of plating .
8. Answer E. Using hybrid fixation for a periarti-
cular fracture with metaphyseal comminution
Primary fracture healing requires direct reduction
and absolute stability. This requires increased
fracture stability and a low fracture strain (2%)
environment. There is Harversian remodelling
and no callus formation.
Secondary fracture healing requires indirect
reduction and relative stability. This needs a high
strain (2%) fracture environment and occurs
with endochondral/intramembranous ossification.
The callus/cartilage becomes mineralised and
replaced by bone.
Cutting cones are produced in primary bone
healing. This relies on interfragmentary compression. This can be produced by the following
techniques:
Lag screw technique (overdrilling the near cortex to
3.5mm, which becomes the ‘glide hole’ and drilling the
far cortex to 2.5mm, which becomes the ‘pilot hole’),
e.g. in a Weber B ankle fracture.
Using a partially threaded cancellous screw in
cancellous bone in a medial malleolar transverse
fracture (lag screw technique); using a compression
plate in a forearm fracture (by eccentric drilling).
Using an articulated compression device provides
absolute stability with no callous formation.
331
Tim Brock and Rishi Dhir
An intramedullary nail, cast, external fixator and
bridging plate produce relative stability, which
produces callus for healing (secondary bone
healing).
In reality, most fixations involve components
of both types of healing.
Hybrid fixation involves a combination of
absolute and relative stability principles. An
example is a peri-articular distal femoral fracture
with extensive meta-diaphyseal comminution,
direct reduction and absolute stability for the
articular block with bridge plating and relative
stability for the meta-diaphysis.
9. Answer D. Displacement greater than 100%
In the BOAST guidelines for supracondylar fractures, indications for urgent (night-time) operating include absent radial pulse, threatened skin
viability and evidence of impaired perfusion
(including increased capillary refill time or a pale
hand). Fracture displacement on its own is not an
indication for urgent operating. Discussion with
the vascular on-call team should take place if a
child presents with an ischaemic limb.
10. Answer E. Lag screw to be used outside the
plate to fix fracture fragments Failure of distal
humerus intra-articular fractures, when it occurs,
typically occurs at the supracondylar level
through loss of fixation in the distal fragments.
To prevent such failure and maximise the potential for union and full elbow mobility after a
severely fractured distal humerus, according to
O’Driscoll’s seminal paper (2005), the following
principles must be satisfied:
1. Fixation in the distal fragment must be
maximised.
2. All fixation in distal fragments should
contribute to stability between the distal
fragments and the shaft.
There are 8 technical objectives to achieve these
principles:
1. Every screw in the distal fragments should
pass through a plate.
2. Each screw should engage a fragment on the
opposite on the opposite side that is also fixed
to a plate.
3. Place as many screws as possible in the distal
fragments.
4. Each screw should be as long as possible.
5. Each screw should engage as many articular
fragments as possible.
6. The screws in the distal fragments should
lock together by interdigitation, creating a
fixed-angle fracture.
7. Plates should be applied such that
compression is achieved at the supracondylar
level for both columns.
8. The plates should be strong enough and stiff
enough to resist breaking or bending before
union occurs at the supracondylar level.
O’Driscoll SW. Optimizing stability in distal
humeral fracture fixation. J Shoulder Elbow
Surg. 2005;14(1 Suppl. S):186S–194S.
11. Answer C. Should be placed below the equator
of the skull
Four pins are used in a halo device: two anterior
and two posterior.
The two anterior pins should be placed in a
safe zone, which is a 1cm region just above the
lateral one-third of the orbit (eyebrow) at or
below the equator of the skull (Figure 15.38).
This is anterior and medial to the temporalis
muscle.
The two posterior pins are placed on the
opposite side ring from the anterior pins.
Figure 15.38 Safe zones for halo traction
332
Trauma I Structured SBA
The supraorbital nerve is a branch of the
frontal nerve provid ing sensation to the upper
eyelid and forehead/scalp. It emerges just above
the medial one-third of the orbit and is at risk for
injury if halo pins are placed too medial abov e
the orbit.
The halo should be placed below the equator
of the skull to prevent cephalic migration of the
halo.
The supratrochlear nerve exits the skull at the
level of the frontal sinus.
If the pins are placed more laterally, then
there is a risk of injury to the temporalis muscle.
12. Answer A. Type II injuries involve rupture of
the AC ligament and a CC ligament sprain
The SBA refers to Rockwood’s classification of
ACJ injuries. Despite the move away from asking
about classification systems, it still useful to
know especially the difference between type III
and type V injury and also the controversy as to
what to do with a type III injury.
Type I is a sprain of the AC ligament and normal
CC ligament with no instability of the ACJ.
Type II is a torn AC ligament and sprained CC
ligament with horizontal AC instability.
Type III is a torn AC and CC ligament with
increased CC distance of 25–100%.
Type IV is posterior displacement of the lateral
clavicle through the trapezius.
Type V is an increased CC distance 100–300%
compared with the contralateral side
Type VI is inferior dislocation of the lateral
clavicle.
C is incorrect, as this refers to type IV, not
type III.
ACJ injury: Rockwood classification. In
Rockwood CA, Williams GR, Young DC, eds.
Rockwood and Green’s Fractures in Adults, 4th
Ed., 1341–1414. Philadelphia, PA: LippincottRaven; 1996.
13. Answer E. The safe zone of fixation is between
the radial styloid and Lister’s tubercle
Kocher’s approach is often used to approach
radial head fractures. This utilises an internervous
plane between ECU (posterior interosseus nerve)
and anconeus (radial nerve). The safe zone of
fixation is between the radial styloid and Lister’s
tubercle. Full pronation of the forearm moves the
PIN away from the operative field.
The PIN supplies motor innervation to all the
extensor muscles of the wrist and digits: ECRB,
supinator, ECU, EDM, EDC, APL, EPB, EPL and
EIP, except for the extensor carpi radialis longus
(ECRL). ECRL is supplied by a branch from the
radial nerve prior to its division into the PIN and
SRN. ECRL produces wrist extension and abduction.
The interval between triceps and brachioradialis is the lateral approach to the distal
humerus.
The capsule should not be dissected too far
anteriorly, as the PIN runs over the front of the
anterolateral portion of the elb ow capsule.
Caputo AE, Mazzocca AD, Santoro VM.
The nonarticulating portion of the radial head:
anatomic and clinical correlations for internal
fixation. J Hand Surg Am. 1998;23:1082–1090.
14. Answer B. Apply an external fixator
This patient is in hypovolaemic shock and haemodynamically unstable. Primary resuscitative
measures include application of a pelvic binder
(haemostatic device), tranexamic acid (according
to CRASH-2 protocol), initiating a massive
transfusion protocol (comprising red blood cells,
platelets, FFP and cryoprecipitate) and practising
permissive hypotension (aiming at systolic of
90). Secondary resuscitative measures include
angiographic embolisation and pelvic packing,
but these are not initial measures.
External fixators are not very practical to use
in the ED, are often applied incorrectly and are
associated with a high rate of complications.
A pelvic binder should have been applied in a
prehospital setting and is a rapid, safe alternative
for haemorrhage control, and equally has benefits as a simple method for use by the junior
surgeons. If not already applied, this should be
done in the ED as per ATLS protocol.
If an external fixator is to be applied, this is
best performed in theatre under image intensifier
(II) control.
15. Answer D. Lateral plantar artery
The blood supply to the talar neck comes from
three main sources (Figure 15.39):
333
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