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Tim Brock and Rishi Dhir
Anterior Tibial Artery
(continues as Dorsalis Pedis)
Lateral Tarsal Artery
Artery of the Tarsal Sinus
Medial Tarsal
Branches
Artery of the
Tarsal Sling
Inferior Talar
Neck Branches
Figure 15.39 Blood supply of the talus
1. Posterior tibial artery
Via artery of tarsal canal (dominant
supply) and supplies majority of talar
body.
Deltoid branch of posterior tibial artery,
which supplies medial portion of talar
body and may be only remaining blood
supply with a displaced fracture.
2. Anterior tibial artery
Supplies head and neck.
3. Perforating peroneal artery via artery of
tarsal sinus.
Supplies head and neck.
The lateral plantar artery does not supply the
talar neck.
16. Answer D. Metaphyseal fracture (junction of
metaphysis and physis)
Pathognomic injuries (high speci ficity) for nonaccidental injury include metaphyseal fractures,
posterior rib fractures and femoral fractures in a
non-ambulatory child.
The classic metaphyseal lesion (CML)is a
fracture at the junc tion of metaphysis and physis
(primary spongiosa) (Figure 15.40). The fracture
is regarded as highly specific for NAI.
These microfractures occur in immature
mineralised bone almost entirely in children
under the age of 2 years because:
Peroneal Artery
Posterior
Tibial Artery
Vascular plexus
from Calcaneal
branches of the
Posterior Tibial
Artery
Artery of the
Tarsal Canal
Deltoid Branch
Figure 15.40 Metaphyseal
corner fracture
▪ they are small enough to be shaken
▪ they cannot protect their limbs.
Variants include a corner fracture and bucket
handle fracture.
A corner fracture is a discrete avulsion of the
metaphysis.
A bucke t handle fracture is a horizontal avulsion fracture; the central and peripheral components give the appearance of a bucket handle.
17. Answer D. Failure of scapholunate ligament –
failure of lunocapitate ligament – failure of
lunotriquetral ligament – lunate dislocates into
carpal tunnel
The injury is a lunate dislocation. Be able to
recognise this injury on plain radiographs.
334
Trauma I Structured SBA
There is a misalignment of the first Gilula arc in
which the lunate ‘overlaps’ the capitate and the
scaphoid. The lunate bone has a triangular
appearance on AP projection, with displacement
and volar rotation on the lateral film. There is
also a diffuse reduction of bone attenuation.
This SBA is testing Mayfield’ s classification
system, which refers to the predicta ble sequence
of pathoanatomy (in which the injury occurs to
the carpal bones) (Figure 15.41).
Figure 15.41
Mayfield radiocarpal
injury
Mayfield I: Failure of scapholunate ligament.
Mayfield II: Failure of lunocapitate ligament.
Mayfield III: Failure of lunotriquetral
ligament (‘perilunate’).
Mayfield IV: Lunate dislocates usually into
carpal tunnel (‘lunate dislocation’).
Mayfield JK, Johnson RP, Kilcoyne RK. Carpal
dislocations: pathomechanics and progre ssive
perilunar instability. J Hand Surg Am.
1980;5:226–241.
18. Answer C. It is indicated in proximal pole
fractures
The volar approach between FCR and the radial
artery can be used for waist and distal pole fractures and also those with humpback flexion
deformities. Proximal pole fractures ideally
should be approached via a dorsal approach, as
the trajectory of the screw implant is easier via a
dorsal approach.
19. Answer C. Peroneus longus
This SBA is testing anatomy (Figure 15.42).
There are four compartments of the leg: (1)
anterior, (2) lateral, (3) posterior superficial and
(4) posterior deep.
Contents of the anterior compartment
include:
- Tibialis anterior.
- Extensor hallucis longus.
- Extensor digitorum longus.
- Peroneus tertius.
Peroneus longus is a content of the lateral co mpartment, not anterior compartment.
Lezak B, Summers S. Anatomy, Bony Pelvis
and Lower Limb, Leg Anterior Compartment.
Treasure Island, FL: StatPearls Publishing; 2020.
20. Answer A. May be associated with wasting of
the first dorsal interosseus
Lateral condyle fractures are the second most
common fracture in the paediatric elbow, with
a higher risk of non-union, malunion and AVN
than other paediatric elbow fractures. The
internal oblique view is the best view to visualise
fracture displacement, as the fracture fragment is
most commonly lying posterolateral.
A number of classification systems, including
Milch and Weiss, are used. The Weiss classification system (types I–III) states that type I fractures (<2mm with an intact cartilaginous hinge)
can be treated in a cast; type II (>2mm but
<4mm displacement with intact articular cartilage on arthrogram) can be treated by closed
reduction and fixation; type III (>4mm displacement with disrupted articular cartilage on
arthrogram) should be treated by open reduction
internal fixation. Typically, 1.6mm K-wires in a
laterally placed divergent configur ation are used.
One of the reported complications (10%) due to
lateral physeal arrest is cubitus valgus, which
may be associated with a tardy ulnar palsy, one
of the features of which is wasting of the first
dorsal interosseus.
21. Answer B. Intramedullary nailing is more cost-
effective compared with locking plates
This is an extra-articular distal tibial fracture.
The fixDT trial published by Costa et al.
335
Tim Brock and Rishi Dhir
Figure 15.42 Cross anatomy diagram lower leg
(2018), which was conducted in 28 UK acute
trauma centres from 2013–2017, recruited 321
adult patients and randomised them to fixation
by intramedullary nailing or plating. The primary outcome measure was the Disability
Rating Index (DRI) score and secondary outcomes were the Olerud-Molander Ankle Score
(OMAS), quality of life index (EQ-5D) and
complications such as infection and further
surgery.
There were similar disability ratings at 6
months and no difference in infection rates but
recovery rates were greater for intramedullary
nailing and costs were lower (intramedullary
nailing was more cost-effective). Further surgery
was also more common in the locked plate group
(12% compared with 8% at 12 months).
Costa M et al. Intramedullary nail fixation
versus locking plate fixation for adults with a
336
fracture of the distal tibia: the UK FixDT RCT.
Health Technol Assess. 2018;22:1–148.
22. Answer A. They can be used for comminuted
forearm fractures
Principles of elastic nails incl ude:
▪ Use for length stable fractures, e.g. transverse
fractures. They are contraindicated for length
unstable fractures, e.g. comminuted or long
spiral fractures.
▪ Entry point of the nail should be 2.5–3cm
proximal to the physis.
▪ The apex of the bow of the elastic nails should
be at the level of the fracture.
▪ They should be pre-bent to three times the
diameter of the isthmus.
Slongo TF. Fracture treatment in childhood.
Injury 2005;36(Suppl. 1):A1.
Trauma I Structured SBA
23. Answer E. Increase the outer diameter
The pull-out strength of a screw can be increased
by increasing the difference between the outer
and inner core diameter (increase the outer,
decrease the inner), decrease the pitch (increased
thread density) or increase cortex thickness.
Törnkvist H, Hearn TC, Schatzker J. The
strength of plate fixation in relation to the
number and spacing of bone screws. J Orthop
Trauma. 1996;10:204–208.
24. Answer C. Extensor pollicis longus
EPL (extensor pollicis longus) tendon ruptures
occur in up to 9% of distal radius fractures.
Treatment typically consists of a tendon transfer
of the extensor indicis proprius as the tear is
attritional, which makes repair impractical.
Roth KM et al. Incidence of extensor pollicis
longus tendon rupture after nondisplaced distal
radius fractures. J Hand Surg A. 2012;37:942–947.
25. Answer E. Emergency closed reduction under GA
This is a locked posterior dislocation until
proven otherwise because of a Hill–Sachs
lesion (reverse). This is likely to be a missed
chronic injury. Closed reduction can potentially cause a proximal humerus fractu re and
should not be attempted as an emergency. A
scheduled closed reduction can be attempted
under general anaesthesia. The reduction manoeuvres must be done gently and carefully.
Most dislocations have a chance to reduce with
closed manipulation, if the injury is <6 weeks
old. The prognosis is good if the reverse Hill–
Sachs lesion is <25% of the humeral head
articular surface.
A CT scan should also be done. Treatments
depend on the size of the defect and may
include a McClaughlin procedure (subscapularis tenotomy +/– lesser tuberosity), femoral
head allograft reconstruction, rotational
osteotomy or reverse shoulder arthroplasty as
afinalsalvage.
Aydin N, Kayaalp M, Asansu M,
Karaismailoglu B. Treatment options for locked
posterior shoulder dislocations and clinical outcomes. EFORT Open Rev. 2019;4:194–200.
26. Answer C. 7.
Age: 1 (30 –50).
Shock group: 1 (shock group 2 – BP unstable
in field but responds to fluids).
Energy of injury: 3 – high (gunshot wound:
high velocity).
Ischaemia: 2 – Diminished pulses without
ischaemia.
This results in a score of 7.
Mangled Extremity Severity Score (MESS)
Vascularity/Limb ischaemia
Poor pulse 1
Pulseless and poor CR 2
Totally avascular 3
Score doubled for ischaemia >6/24
Injury Skeletal/Soft tissue
Low Energy 1
Medium Energy 2
High Energy 3
Very High Energy 4
Shock
Systolic BP >90mmHg 0
Hypotensive transiently 1
Persistent hypotension 2
Age (Years)
<30 0
30–50 1
>50 2
27. Answer E. Zone of provisional calcification
Physeal fractures typically occur in the hypertrophic zone, specifically in the zone of prov isional calcification, as this is an area with large
cells but small amounts of matrix and is potentially weak.
28. Answer D. Patients should respond to resusci-
tation with pressor support
Vallier et al.’s (2005) seminal paper on Early
Appropriate Care (EAC) recommends the
following: fractures should be definitively fixed
within 36 h of injury, providing lactate <4, pH
>7.25, Base Excess >5.5mmol/L and patients
must respond to resuscitation without pressor
support.
Vallier H et al. Complications are reduced
with a protocol to standardise timing of fixation
based on response to resuscitation. J Orthop Surg
Res. 2015;10:155.
337
Tim Brock and Rishi Dhir
29. Answer D. MRI and urgent neu rosurgical
consult
A unifacet or bifacet dislocation is a surgical
emergency and requires immediate in-line triple
immobilisation and full spinal precautions while
resuscitation is occurring. Following this, an MRI
should be obtained and early discussion had with
the regional neurosurgical unit regarding potential
transfer. In the neurosurgical unit, if no disc is
present on MRI (which must be excluded due to
the risk of cord transection with closed reduction),
a halo can be applied, or Gardner–Wells tongs
and traction applied under image intensifier and
clinical monitoring for neurology.
If this fails or a disc is present, open reduc-
tion is performed, followed by definitive fixation.
There is controversy over whether to just
proceed with serial tr action weight to reduce
the dislocation without obtaining a prior MRI.
This has been shown to be safe when used with
an awake patient. Rapid decompression of the
cervical spine may improve recovery as opposed
to the delay that will occur waiting to obtain an
MRI. Closed reduction is recognised as a challenging procedure for surgeons, particularly those
in non-spinal centres that only occasionally face
this clinical scenario.
A study investigating delays to decompression of cervical spine cord injury at
centres throughout Australia and New
Zealand noted that median time to open decompression was 22 h compared with 6 h for
closed reduction. They concluded that closed
reduction was effective in minimising time to
decompression. Neurological improvement
was greatest in those patients reduced within
4–8 h from injury with no cases of neurological
worsening.
Star AM, Jones AA, Cotler JM, Balderston
RA, Sinha R. Immediate closed reduction of
cervical spine dislocations using traction. Spine
1990;15:1068–1072.
Storey RN, Singhal R, Inglis T, Kieser D,
Schouten R. Urgent closed reduction of the dis-
located cervical spine in New Zealand. ANZ J
Surg. 2018;88:56–61.
30. Answer D. The complication rate of non-
surgical and surgical treatment of type II fractures in the elderly is higher
Type II fractures sit in a watershed area between
the internal carotid and vertebral artery and therefore are at higher risk of non-union. There is
an increasing body of evidence that surgical treatment is better for type II fractures in the elderly,
especially those with risk factors for non-union.
A fibrous non-union can be managed reasonably
well, but symptomatic non-union can be associated
with high rates of morbidity including atlantoaxial subluxation. The complication profile of nonsurgical and surgical treatment is equivalent.
Atlantoaxial mobility is preserved in odontoid screw fixation through an anterior approach.
It is indicated in cases with transverse or posterior oblique fracture lines. However, in the presence of a comminuted odontoid fracture,
anterior oblique fracture, transverse ligament
rupture, osteoporosis, cervicothoracic kyphosis
or delayed fracture (>6 months), anterior odontoid screw fixation is contraindicated. In these
cases, a posterior approach is recommended.
Iyer S, Hurlbert RJ, Albert T. Management
of odontoid fractures in the elderly: a review of
the literature and an evidence-based treatment
algorithm. Neurosurgery 2018;82:419–430.
Robinson Y, Robinson A, Olerud C.
Systematic review on surgical and nonsurgical
treatment of type II odontoid fr actures in the
elderly. Biomed Res Int. 2014;2014:231948.
31. Answer E. Surgical stabilisation
Management of spinal fractures is determined by
the Thoracolumbar Injury Classification score
(TLICS) by Vaccaro et al. (2005), which looks
at three parameters: fracture morphology,
neurology and PLL (posterior longitudinal ligament) injury. A final score of 0–3 is treated nonoperatively; 4 can be treated operatively or nonoperatively and >4 is treated operatively. Bony
chance fractures with stable posterior elements
(no PLL injury), no neurological deficits and less
than 15° kyphosis can be treated conservatively
with immobi lisation in a thoracolumbar orthosis
in extension with 2-week follow-up for nonunion and degree of kyphosis. Ligamentous
chance fractures and unstable posterior elements
with neurological deficits should be treated by
emergent open reduction and stabilisation surgery. Decompression surgery is inadequate for
stabilising the spine. Traditionally, this was three
338
Trauma I Structured SBA
levels above and two levels below, but modern
pedicle screw techniques have changed this to
one level above and one level below.
In this particular case, the fracture is a chance
fracture (flexion-distraction), which scores 4 for
morphology; there is incomplete neurology, which
scores 3; and there is possibly a posterior ligamentous injury. Therefore, he is scoring at least 7 or
possiblymore, which should betreated operatively.
AlJallaf M, AlDelail H, Hussein L. Let’s
review Chance fracture. BMJ Case Rep. 2015.
doi:10.1136/bcr-2014-206924.
Vaccaro AR et al. A new classification of
thoracolumbar injuries: the importance of injury
morphology, the integrity of the posterior ligamentous complex and neurological status. Spine
2005;30:2325–2333.
32. Answer A. Coaptation splint followed by func-
tional brace
This patient presents with a radial nerve palsy
following a closed humeral shaft fracture. The fracture is within the criteria for acceptable alignment
o
(<20
anterior angulation, <30ovarus/valgus
angulation,<3cm shortening). In terms of the fracture itself, it does not require surgical treatment.
The overall incidence of radial nerve injuries
after humeral shaft fractures is 11.8%, but controversy exists on treatment of these injuries.
Absolute indications for early exploration are
open fractures or iatrogenic injury (e.g. after
humeral bracing). Relative indications are polytrauma or floating elbow.
The majority of nerve palsies (85–90%)
recover spontaneously without intervention in 3
months.
In the answer options, the median nerve is
not affecte d in this case, and nerve conduction
studies are not meaningful before 6 weeks (as
there is a latency period). Exploration of the
radial nerve and fixation is not required unless
it is an open fracture, iatrogenic injury, polytrauma, floating elbow or the fracture mandates
it. Humeral nailing should not be done in the
presence of a radial nerve injury, as there is a
high risk of injury to the nerve.
Rocchi M et al. Humerus shaft fracture com-
plicated by radial nerve palsy: is surgical exploration necessary? Musculoskelet Surg. 2016;100
(Suppl. 1): S53–S60.
33. Answer C. Inability to extend the wrist in ulnar
deviation
The Kaplan’s approach to the elbow is a more
anterior approach and occurs between ECRB and
EDC (Figure 15.43). It is not a true internervous
plane, as both are innervated by the posterior
interosseus nerve (although some cadaveric studies have shown that in 15% of cases ECRB is
innervated by the radial nerve proper). The posterior interosseous nerve (PIN) is at risk during
this approach and during plating of radial head
fractures. The bicipital tuberosity marks the distal limit of plate placement before endangering
the nerve. The wrist does not extend in ulnar
deviation due to extensor carpi ulnaris being
innervated by the PIN. The extensor carpi radialis longus is supplied by the radial nerve proper
and therefore will still allow wrist extension with
radial deviation. Flexion and abduction are not
caused by the posterior interosseus nerve.
Figure 15.43 Surgical approach elbow
34. Answer C. Conservative treatment
The radiograph shows a displaced olecranon fracture with possible comminution. A ran-domised
controlled trial of displaced olecranon fractures
in the over-75-years group found no difference
in DASH scores at 6 weeks, 3 months, 6 months
and 1-year post-injury between non-operative and
operative management. There was an unacceptably high complication rate associated with
surgery in this age group; therefore, in the elderly
patient, particularly low demand olecranon fractures should be managed non-operatively regardless of displacement or comminution.
339
Tim Brock and Rishi Dhir
Duckworth AD et al. Prospective random-
ised trial of non-operative versus operative management of olecranon fractures in the elderly.
Bone Joint J. 2017;99-B:964–972.
35. Answer C. Radial head arthroplasty, coronoid
open reduction internal fixation and lateral
collateral ligament repair
This injury refers to the terrible triad of elbow
dislocation, coronoid fracture and radial head
fracture. This injury is inherently unstable as
there is loss of both the primary (ulnohumeral
joint via the coronoid), medial and lateral collateral ligaments and secondary stabilisers (radiohumeral joint via radial head, flexor and extensor
muscles). This is described as O’Driscoll’s fortress. Therefore, such an injury mandates surgical
intervention.
Operative fixation is complicated. A CT scan
of the elbow should be performed to assess the
suitability of radial and coronoid fractures for
repair or replacement.
The sequence of events is to approach the
radial head, which can be fixed or replaced
depending on the comminution; fix the lateral
collateral ligament (LUCL) using suture anchors
or transosseous sutures and then check the stability. If unstable, the coronoid is repaired using
either sutures, anchors or screws, depending on
the size of the fragment and exposure. The fixation should be solid enough to allow an early
range of movement without instability.
If the elbow is unstable after repair of the
coronoid, radial head ORIF or replacement and
LCL repair, then the MCL can be repaired. Some
surgeons advocate prophylactic decompression
of the ulnar nerve at this stage. The use of a
hinged external fixator in persistent instability
has been shown to improve outcome.
O’Driscoll JB, Jupiter JB, King GJ,
Hotchkiss RN, Morrey BF. The unstable elbow.
Instr Course Lect. 2001;50:89–102.
abduction and also defunction the cuff. More
complex fracture configurations are more likely
to have complications with fixation. Reverse
polarity total shoulder arthroplasty is indicated
in lower-demand individuals or older patients
with non-reconstructable tuberosities (as the cuff
is effectively defunctioned). Younger patients
with non-reconstructable configurations may
favour hemiarthroplasty.
37. Answer A. Dynamisation of the tibial nail
The patient may go onto a hypertrophic nonunion. The most appropriate option at this stage
is to dynamise the nail, which may just tip the
balance to allow the fracture to heal by reducing
the gap at the fracture site.
In this situation, the interfragmentary strain
(movement at the fracture site) is excessive;
hence, there is no progression through the different stages of Perren’s theory of secondary bone
healing, and bony bridging by hard callus is not
possible.
38. Answer E. There is no difference between non-
union rates
There is often controversy over management of
midshaft clavicle fractures. Numerous studies,
including the Canadian Orthopaedic Trauma
Society (COTS) trial, have shown higher union
rates in displaced clavicle fractures with operative
treatment. There is a quicker return to work and
sport with operative treatment. In the short-term,
clinical outcomes are better in operative cases but
there is little evidence to suggest this is long term.
Patients who undergo surgery may require
implant removal at a later date due to irritation
hence there is a higher re-operation rate.
Altamimi SA, McKee MD. Nonoperative
treatment compared with plate fixation of displaced midshaft clavicular fractures: surgical
technique. J Bone Joint Surg Am. 2008;90(Suppl.
2 pt 1):1–8.
36. Answer B. Open reduction and internal fixation
Supraspinatus, infraspinatus and teres minor
externally rotate the greater tuberosity.
Indications for open reduction and internal fixation include displacement of the greater tuberosity of more than 5mm. Non-operative
treatment is likely to cause impingement with
340
39. Answer C. During retraction of infraspinatus
The Judet approach to the scapular involves the
internervous plane between the suprascapular
(infraspinatus) and axillary (teres minor) nerves.
This patient presents with a suprascapular nerve
palsy. This is most commonly caused during
forceful retraction of the infraspinatus muscle.
Trauma I Structured SBA
Retracting the infraspina tus superiorly reduces
the likelihood of this.
40. Answer E. Pronator quadratus
The injury displayed is an extension-type supracondylar fracture of the humerus. The anterior
interosseus nerve, which is a branch of the
median nerve, is most commonly injured with
this type of fracture. It supplies pronator quadratus, flexor digitorum profundus (index and
middle fingers) and flexor pollicis longus.
In terms of the other answers, extensor pollicis longus and abductor pollicis longus are supplied by the posterior interosseus nerve; 4th and
5th lumbricals and abductor digiti minimi are
supplied by the ulnar nerve. The majority of
supracondylar fracture nerve injuries are neurapraxias that resolve spontaneously.
41. Answer B. CT scan of pelvis
All hip dislocations should have a post-reduction
CT scan. This is to evaluate the reduction and to
ensure that there are no associated fractures or
loose bodies and to assess for marginal impaction. The radiograph does show a small bony
fragment projected over the femoral neck most
likely representing the posterior lip of the
acetabulum.
42. Answer E. Time to surgery is the most import-
ant factor in influencing outcome
Previously it was believed that time to surgery
was the most important factor in preserving the
blood supply following displaced intracapsular
neck of femur fractures in young patients and
thus operating within 6 h was recommended, but
now it is recognised that the quality of the reduction (and thus an anatomical reduction is
needed) is the most important factor in influencing outcome. Some surgeons will try and
obtain an anatomical reduction using a
Leadbetter manoeuvre, which can be remembered by the mnemonic FATI CAR: Flexion (to
relax the muscles); Adduction (along with flexion
‘books open’ the fracture); Traction (to gain
length); Internal rotation (relaxes the Y ligament); Circumduction; Abduction and
Reduction check. This fracture often requires
an open reduction (Smith–Petersen) approach,
which relies upon an internervous plane between
the femoral and superior gluteal nerves. The
lateral femoral cutaneous nerve is most at risk
in this approach.
43. Answer D. On-table angiogram, temporary vas-
cular shunt, skeletal stabilisation, definitive
vascular reconstruction, forearm fasciotomies
Imaging modalities should not delay reperfusion
surgery. On-table angiogram is the most viable
imaging option in this case. Reperfusion should
be obtained with a temporary shunt, followed by
skeletal stabilisation using an external fixator.
Typically, the pins are put in before the shunt,
but the external fixator is not applied until afterwards. Thereafter, definitive vascular reconst ruction using autologous vein grafts can be
performed. Following reperfusion, the surgeon
should have a low threshold for performing fasciotomy as the rate of compartment syndrome
secondary to reperfusion injury is high.
British Orthopaedic Association Standards
for Trauma (BOAST 6). Management of arterial
injuries associated with fractures and dislocations.
https://www.boa.ac.uk/resource/boast-6-pdf.html.
44. Answer D. Posterior wall
This a straightforward, either-you-know-ordon’t-know SBA that is testing anatomical interpretation of plain anteroposterior pelvis
radiographs.
Line 1 indicates the anterior wall of the
acetabulum.
Line 2 indicates the posterio r wall of the
acetabulum.
Line 3 indicates the weight -bearing dome.
Line 4 is the iliopectineal line and indicates
structural integrity of the anterior column of
acetabulum.
Line 5 is the ilioischial line and indicates integrity
of the posterior column.
Line 6 is the teardrop, which indicates the
acetabular true floor.
45. Answer A. Hip abductors and iliopsoas
The iliopsoas muscle causes the proximal fragment to flex, whereas the hip abductors cause the
fragment to externally rotate (Figure 15.44).
Distally, the hip adductors cause the distal fragment to medialise. This can make it difficult to
341
Tim Brock and Rishi Dhir
Figure 15.44 Deforming muscle forces on the proximal femur
get an anatomical reduction in these cases. As a
result, the most common post-operative deformity is the procurvatum and varus.
46. Answer E. <0.9
Patients with an ABPI of <0.9 should be referred
to vascular intervention for an urgent consultation and further imaging. In a study of 38
patients, 11 who had an ABPI of <0.9 all had
an arterial injury requiring surgical treatment.
The remaining 27 patients had an ABPI of 0.90
or higher and none had a vascular injury detectable by serial clinical examination or duplex
ultrasonography.
Mills WJ, Barei DP. McNair P. The value of
the ankle–brachial index for diagnosing arterial
injury after knee dislocation: a prospective study.
J Trauma. 2004;56:1261–1265.
47. Answer D. Overgrowth
Overgrowth is the most common complication
following femoral shaft fracture in this age
group. In children under 10 years old, it is
common to have overgrowth of between 1.0
and 2.5cm, which occurs predominantly in the
first 2 years after injury, and the parents should
be counselled appropriately about this.
Wessel L, Seyfriedt C. Leg length inequality
after childhood femoral fractures – permanent or
temporary phenomenon? [Article in German]
Unfallchirurg. 1996;99:275–282.
48. Answer A. ORIF using cerclage wire and
locking plate
The Vancouver classi fication is useful in allowing
an effective treatment algorithm following periprosthetic fracture. The B type is a fracture
around the stem. If the implan t is not loose (type
B1), this can be treated by ORIF using cerclage
wires and a locking plate.
If a cemented stem is loose but with good
bone sto ck this can be managed with cerclarge
cables and open reduction internal fixation provided the reduction is anatomical. Otherwise a
long, porous-coated cementless stem is utilised.
Generally patients in this cohort are frail with
multiple comorbidities. Fixation over revision
surgery is associated with a lower incidence of
complications and should be the desired treatment in this patient group. With regards to
uncemented stems, revision with a long,
porous-coated cementless stem is recommended.
If there is poor bone stock (type B3), the
femur is revised to either a long, poro us-coated
cementless stem with proximal femoral allograft
or a proximal femoral replacement. It is sometimes difficult to fully differentiate between a
B1and B2 fracture on plain radiographs and so
further imaging with a CT scan may be helpful,
although implant stability may only truly be
appreciated during the time of surgery.
Powell-Bowns MFR et al. Vancouver B periprosthetic fractures involving the Exeter
cemented stem. Bone Joint J. 2021;103-
B:309–320.
49. Answer C. III
This SBA is good revision for the Advanced
Trauma Life Support
®
(ATLS®) classification of
shock (Table 15.1). Class III shock represents
blood loss of 1500–2000ml (30–40% blood
volume). Respiratory rate is >30 and urine
output is 10–20ml/h. Values are represented in
Table 15.1. There is no class V.
342
Trauma I Structured SBA
Table 15.1 ATLS®classification of shock
Class I Class II Class III Class IV
Blood loss (% volume
loss)
Pulse <100 >100 >120 >140
Blood pressure No change Normal systolic BP, raised
Pulse pressure $# # #
Respiratory rate <20 >20 >30 >40
Urine output (ml/h) $$ # ##
GCS $$ # #
Base deficit 0 to –2 mEq/L –2to–6 mEq/L –6to–10 mEq/L –10 mEq/L or less
Need for
blood products
<750ml
(<15%)
Monitor Possible Yes Massive Transfusion
750–1500ml (15–30%) 1500ml–2000ml
(30–40%)
Reduced Reduced/
diastolic BP
2000ml+ (>40%)
unrecordable
Protocol
50. Answer D. Kocher-Langenbeck
A gull sign is present on pelvic radiograph
(Figure 15.45). This sign was first described in
1965 by Berkebile et al. (1965). It is used for
variations of posterior column fractures where
the posterior column displaces and takes the
hind portion of acetabular roof; therefore, the
posterior segment loses its normal relationship
with the segment still attached to anterior
column and forms ‘an image like a gull in flight’.
This sign is pathognomonic of posterior wall
fractures of the acetabulum.
To confuse matters, another hip fracture that
has been called the ‘ gull wing sign’ is a medially
displaced fracture of the acetabular roof where
the medially displaced impacted fragment of the
acetabulum and the lateral part together also
Figure 15.45 Gull sign
form a seagull outline. This fracture is seen in
elderly osteoporotic patients and is associated
with a poor prognosis, with debate in the surgical
literature discussing whether surgical fixation or
total hip replacement is the appropriate choice of
management
The posterior Kocher-Langenbeck approach
Berkebile RD, Fischer D, Albrecht LF. The
Gull-wing sign. Radiology 1965;84:937–939.
Anglen JO, Burd TA, Hendricks KJ,
Harrison P. The ‘Gull sign’: a harbinger of fail-
ure for internal fixation of geriatric acetabular
fractures. J Orthop Trauma. 2003;17:625–634.
is most suited to posterior-based fractures of the
acetabulum. The iliofemoral approach allows
visualisation of both columns, whereas the ilioinguinal approach is more suited to anterior wall
and column fractures. The modified stoppa
allows access to the quadrilateral plate.
51. Answer A. A wound size >10cm
The BOAST (British Orthopaedic Standards for
Trauma) 4 guidelines for management of open
fractures state that there are four reasons for emergent operating in the middle of the night:
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