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Tim Brock and Rishi Dhir
compartment syndrome, arterial injury requiring
repair, gross contamination with marine or agricultural waste and polytrauma. Otherwise, these
injuries should be treated in daylight hours by
combined senior orthoplastics teams in
conjunction.
BOAST 4: British Orthopaedic Association
and British Association of Plastic,
Reconstructive and Aesthetic Surgeons Audit
Standards for Trauma: Open Fractures. https://
www.boa.ac.uk/resource/boast-4-pdf.html.
52. Answer D. Serum lactate
The serum lactate is the most sensitive indicator
of adequate perfusion. A normal value is
<2.5mmol/L. According to Vallier et al. (2013),
<4 can be used as an indicator of resuscitation.
Vallier HA, Wang X, Moore TA, Wilber JH,
Como JJ. Timing of orthopaedic surgery in mul-
tiple trauma patients: development of a protocol
for early appropriate care. J Orthop Trauma.
2013;27:543–551.
53. Answer D. Increase the working length
Rigidity refers to the resistance of a structure to
deformation. There are a number of factors that
can be used to increase rigidity, the most important of which is reducing the fracture. Pin factors
include increasing the pin diame ter and number
of pins. Bar factors include cross-linking and
reducing the distance between the bars and the
skin. Working length refers to the distance
between the pins either side of the fracture.
Decreasing rather than increasing the working
length increases rigidity.
54. Answer B. Paraesthesia over the dorsum of the
foot
The L5 nerve root crosses the sacral ala. It is at
risk if the sacroiliac screw is directed more than
20° laterally and penetrates the anterior cortex.
For this reason, bicortical screw fixation is not
recommended.
55. Answer D. Treat PCL and PLC operatively
within 2 weeks, ACL within 6 weeks and MCL
conservatively in a brace
Multi-ligament injuries are common after a knee
dislocation and it is recommende d that the PCL
and PLC are operated within 2 weeks and ACL at
6 weeks once the swelling has subsided. The MCL
can be treated conservatively in a brace
56. Answer B. 14
The Injury Severity Score (ISS) is made up of the
sum of the squares for the highest Abbreviated
Injury Scale (AIS) grades in the three most
severely injured regions. The ISS is based on
scores of nine anatomical regions:
1. Head.
2. Face.
3. Neck.
4. Thorax.
5. Abdominal and pelvic region.
6. Spine.
7. Upper extremity.
8. Lower extremity.
9. External.
In this case the three highest scores are 3 (severe
for lower extremity); 2 (moderate for chest
injury); and 1 (mild for face). The squares are
2+22+12
3
=9+4+1=14
57. Answer C. Supination adduction type 2
Lauge-Hansen classification looks at the mechanism of injury and foot position at the time of
injury. The radiograph in Figure 15.32 shows a
supination adduction type 2 injury and must be
treated with a buttress plate.
58. Answer C. Severe soft tissue injury has the
highest impact on a surgeon’s decision making
The Lower Extremity Assessment Project (LEAP)
was a multicentre study of severe lower extremity
trauma in the US civilian population. Severe soft
tissue trauma has the highest impact on a surgeon’s decision-making process and absence
of plantar sensation has the second highest
impact on a surgeon’s decision making. Poor
outcomes were found for both reconstruction
and amputation groups. The most important
factor in patient outcome is the ability to return
to work.
MacKenzie EJ, Bosse MJ. Factors influencing
outcome following limb-threatening lower limb
trauma: lessons learned from the Lower
Extremity Assessment Project (LEAP). JAm
Acad Orthop Surg. 2006;14:S205S210.
344
Trauma I Structured SBA
59. Answer D. The nail diameter should be 60% of
the isthmus diameter
Elastic nailing is used in children up to 50kg. The
nails should be 40% the diameter of the isthmus,
and the nail s should be pre-bent to three times
the diameter of the medullary canal. The apex of
nail crossover should be at the fracture site, and
the entry point of a retrograde femoral nail
should be proximal to the physis.
60. Answer E. Superficial peroneal nerve and tibial
nerve
The posterolateral approach utilises the internervous plane between the peroneal muscles (superficial peroneal nerve) and flexor hallucis longus
(tibial nerve). The posterolateral approach can be
performed in the lateral or prone position.
61. Answer A. Primary ankle arthrodesis with
hindfoot nail
The patient is high risk of complications from
surgery and is low demand. The operation is
salvage surgery and to prevent amputation of
her lower leg. The medial malleolus can be
removed and her ankle joint prepared for fusion
via her open ankle wound which is then closed.
The hindfoot nail can be compressed to allow
fusion in this instance (Figure 15.46).
Figure 15.46
Anteroposterior
(AP) radiograph
ankle and distal
tibia following
nailing
Fadhel WB et al. Outcomes after primary
ankle arthrodesis in recent fractures of the distal
end of the tibia in the elderly: a systematic
review. International Orthopaedics (SICOT)
2022;46:1405–1412.
345
Section 3
Chapter
15
Trauma
Trauma I Structured SBA
Tim Brock and Rishi Dhir
TRAUMA I STRUCTURED SBA QUESTIONS
1. A 75-year-old female presents with a shoulder
injury following a fall. Radiographs show a fractured proximal humerus (Figure 15.1).
According to Hertel’s study, which of the
following is NOT a good predictor of humeral
head ischaemia?
A. Basic fracture pattern
B. Calcar fragment <8mm
C. Glenohumeral dislocation
D. Integrity of the medial hinge
E. Length of the metaphyseal head extension
2. A 35-year-old male sustains a closed proximal
tibial fracture and elects to undergo intramedullary nailing. His radiographs are shown in Figure
15.2.
Which of the follow ing surgical techniques is
used to prevent a valgus and procurvatum
deformity?
A. Place a coronal Poller (blocking) screw in the
anterior half of the distal aspect of the proximal fragment
B. Place a sagittal Poller (blocking) screw on the
medial convex side of the distal aspect of the
proximal fragment
C. Suprapatellar nailing
D. Use of a nail with a more distally based bend
E. Using a more medial entry point
3. While playing rugby , a 30-year-old male sus-
tained the injury seen in Figure 15.3, taken on
presentation to the ED.
Which of the following is true?
A. If reduced and stable, it does not require
extension splinting
B. It can lead to a Swan neck deformity
C. It has a positive Elson test
D. It is associate d with a volar plate injury
E. It is the most common type of PIPJ
dislocation
4. A 40-year-old roofer fell 10 feet off a ladder onto
his left foot. Radiograph and CT scan are shown
in Figure 15.4.
Regarding this injury, which of the following is
true?
(a) (b)
Figure 15.1 (a) Anteroposterior (AP)
and (b) lateral scapula view radiographs
proximal humerus
313
Tim Brock and Rishi Dhir
(a) (b)
Figure 15.2 (a) Anteroposterior (AP)
and (b) lateral radiographs of the
right tibia
Figure 15.3 Lateral
radiograph finger
Figure 15.4 (a) Lateral radiograph calcaneum and (b) sagittal CT
view calcaneum
A. A reduced angle of Gissane indicates collapse
of the posterior facet
B. An enlarged Böhler’s angle indicates collapse
of the posterior facet
C. Sanders classification is based on the number
of articular fragments on the sagittal CT image
D. The sustentaculum tali (anteromedial) frag-
ment is referred to as the ‘ constant fragment’
E. Double density sign seen on lateral radio-
graphs indicates a superiorly displaced calcaneus fracture/dislocation
5. Regarding radiology for Lisfranc injuries,
which of the following is false?
A. The ‘fleck sign’ is pathognomic and indicates
avulsion of the Lisfranc ligament
B. The ‘step off sign’ is caused by dorsal dis-
placement of the 2nd metatarsal relative to
the cuboid
C. The gap between the 2nd metatarsal and
medial cuneiform is <2mm
D. The medial border of the cuboid should nor-
mally line up with the medial border of the
4th metatarsal on the oblique view
E. The medial edge of the 2nd metatarsal
should normally line up with the medial
edge of the middle cuneiform on the AP
radiograph
6. Which of the following is incorrect concerning
Lisfranc joint anatomy?
A. The 2nd tarsometatarsal joint produces the
so-called ‘keystone’ in the ‘Roman Arch’
B. The dorsal ligaments are stronger than the
plantar ligaments
C. There is no intermetatarsal ligament between
the 1st and 2nd metatarsals
314
Trauma I Structured SBA
D. The Lisfranc ligament runs from the first cunei-
form to the medial base of the 2nd metatarsal
E. The Lisfranc joint is formed by the five meta-
tarsals that articulate with the three cuneiform and cuboid bones
7. Which mode of plating should be ideally used
for the distal radius fracture pattern seen in
Figure 15.5?
Figure 15.5 Lateral
radiograph distal radius
A. Buttress
B. Neutralisation
C. Bridging
D. Locking
E. Compression
8. Which of the following techniques mainly produces
healing by a high strain fracture environment?
A. Overdrilling the near cortex to 3.5mm and
the far cortex to 2.5mm in a Weber B ankle
fracture
B. Using a partially threaded cancellous screw in
a transverse medial malleolar fracture
C. Drilling an eccentric hole in an LCP plate
D. Using an articulated compression device
E. Using hybrid fixation for a periarticular frac-
ture with metaphyseal comminution
9. Regarding the injury shown in Figure 15.6,
indications for urgent surgical treatment do
NOT include which of the following?
Figure 15.6
Lateral radiograph
supracondylar
fracture elbow
A. Absent radial pulse
B. Threaten ed skin viability
C. Capillary refill time of 5 seconds
D. Displacement greater than 100%
E. Pale hand
10. A 53-year-old male fell down 12 flights of steps
onto his right elbow. His radiographs are shown
in Figure 15.7.
Regarding his injury, which of the following is
NOT a technical objective to achieve maximal
fixation and stability?
(a) (b)
Figure 15.7 (a) Anteroposterior (AP)
radiograph and (b) lateral radiographs
fractured distal right humerus
315
Tim Brock and Rishi Dhir
A. Every screw in the distal fragments should
pass through a plate
B. The screws in the distal fragments should
lock together by interdigitation, creating a
fixed-angle structure
C. Plates should be strong enough and stiff
enough to resist breaking or bending
D. Each screw should be as long as possible
E. Lag screw to be used outside the plate to fix
fracture fragments
11. A 24-year-old male sustains a type II odontoid
fracture following a diving injury.
Regarding anterior pin placemen t for a Halo
device, which of the following is true?
A. If the pins are placed more laterally, then there
is a risk of injury to the orbicularis muscle
B. Should be placed 2cm above the lateral one-
third of the eyebrow
C. Should be placed below the equator of the skull
D. Should be placed medial to the supraorbital
nerve
E. The supraorbital nerve exits the skull at the
level of the frontal sinus
Regarding fixation of radial head fractures,
which of the following is correct?
A. Kocher’s approach is in the interval between
triceps and brachioradialis
B. PIN palsy causes weakness of wrist extension
and abduction
C. Supination should be performed to protect
the posterior interosseus nerve
D. The capsule should not be dissected too far
posteriorly, as the PIN runs over the back of
the posterolateral portion of the elbow
capsule
E. The safe zone of fixation is between the radial
styloid and Lister’s tubercle
14. A 30-year-old patient falls off his motorbike and
sustains the injury shown in Figure 15.8. He has
a blood pressure of 90/60 and pulse of 110 on
arrival in ED.
12. A 26-year-old male patient fell directly on his
right shoulder with the arm in an outstretched
and overhead position. Pain and swelling were
immediate and were associated with a ‘step
deformity’. The patient had limited right shoulder
range of motion (ROM), strength and function.
Regarding this injury, which of the following
statements is correct?
A. Type II injuries involve rupture of the AC
ligament and a CC ligament sprain
B. Type III injuries involve posterior displace-
ment of the lateral clavicle through the
trapezius
C. Type IV injuries involve rupture of both AC
and CC ligaments with increased CC distance
of 25–100%
D. Type VI injuries involve increased CC dis-
tance from 100–300% of contralateral side
E. Type V injuries involve inferior dislocation of
the lateral clavicle
13. A 20-year-old right-handed man sustained a displaced comminuted radial head fracture
following a traffic accident.
Figure 15.8 Anteroposterior (AP) radiograph pelvis
Which of the following would initial management NOT include?
A. Administer tranexamic acid
B. Apply an external fixator
C. Apply a pelvic binder
D. Give FFP and cryoprecipitate
E. Initiate a massive transfusion protocol
15. A 45-year-old woman has sustained a talar neck
fracture following a motor vehicle accident. She
has been added to the trauma list for ORIF. The
CT1 on call at the time of admission has read up
that the possibility of AVN developing in this
fracture is high.
316
Trauma I Structured SBA
The blood supply to the talar neck does NOT
include which of the following?
A. Anterior tibial artery
B. Artery to tarsal canal
C. Deltoid branches
D. Lateral plantar artery
E. Peroneal artery
16. A toddler was brought to the ED with irritability.
In an investigation of non-accidental injury,
which of the following has a high specificity
for NAI?
A. Complex skull fractures
B. Digital fractures
C. Femoral fracture in an ambulatory child
D. Metaphyseal fracture (junction of metaphysis
and physis)
E. Vertebral body fractures
17. A 30-year-old, right hand-dominant man sus-
tained an isolated injury to the right wrist after
a fall from a height of approximately 15 feet. The
patient reported that he fell on his outstretched
hand with the wrist in extension. The right wrist
was painful, swollen and tender to palpation. The
hand was neurovascularly intact with no sensory
deficit in the distribution of the median nerve.
His radiographs are shown in Figure 15.9.
In the pathoanatomy of the injury, which of the
following lists the events in the correct order?
A. Failure of lunocapitate ligament – failure of
scapholunate ligament – failure of
lunotriquetral ligament – lunate dislocates into
carpal tunnel
B. Failure of lunotriquetral ligament – failure of
lunocapitate ligament – failure of scapholunate
ligament – lunate dislocates into carpal tunnel
C. Failure of lunotriquetral ligament – failure of
scapholunate ligament – failure of lunocapitate ligamen t – lunate dislocates into carpal
tunnel
D. Failure of scapholunate ligament – failure of
lunocapitate ligament – failure of lunotriquetral ligament – lunate dislocates into carpal
tunnel
E. Failure of scapholunate ligament – failure of
lunotriquetral l igament- failure of lunocapitate ligamen t – lunate dislocates into carpal
tunnel
18. An 18-year-old tennis player attended the orthopaedic clinic complaining of radial-sided wrist
pain after a fall on an outstretched hand.
Radiographs have shown a displaced waist of
scaphoid fracture.
Regarding the volar approach to the scaphoid,
which of the following statement is false?
A. It is indicated in distal pole fractures
B. It is indicated in humpback flexion
deformities
C. It is indicated in proximal pole fractures
D. It is indicated in waist fractures
E. It utilises the interval between FCR and the
radial artery
(a)
Figure 15.9 (a) Anteroposterior (AP)
and (b) lateral radiographs right wrist
(b)
317
Tim Brock and Rishi Dhir
(a) (b)
Figure 15.10 (a) Anteroposterior (AP) and (b) lateral radiograph child’s elbow
19. Which of the following is NOT a content of the
anterior compartment of the leg?
A. Extensor digitorum longus
B. Extensor hallucis longus
C. Peroneus longus
D. Peroneus tertius
E. Tibialis anterior
20. A 6-year-old boy falls off a trampoline onto his
left elbow and sustains the injury noted on radiographs shown in Figure 15.10.
Regarding the elbow fracture, which of the
following statements is correct?
A. May be associated with wasting of the first
dorsal interosseus
B. Minimally displaced fractures (<2mm gap)
should be treated with open reduction
internal fixation
C. The external oblique view is the most accur-
ate view to show fracture displacement
D. The fracture fragment most often lies
anterolateral
E. When fixed with K-wires, 2mm K-wires
should be used
21. A 46-year-old motorcyclist sustains an isolated
closed injury (Figure 15.11) after falling off his
motorbike at high speed.
Regarding the initial management of this
injury, which of the following is correct?
A. Intramedullary nailing has better disability
ratings at 6 months
B. Intramedullary nailing is more cost-effective
compared with locking plates
Figure 15.11
Anteroposterior (AP) and lateral
radiographs tibia
C. Recovery rates for IM nailing and locking
plates are equivalent
D. There is a statistically higher infection rate
when using lockin g plates compared with
intramedullary nailing
E. There is no difference in further surgery
between IM nailing and locking plates
22. Principles of elastic (TENS) nails include all of
the following except which?
A. They can be used for comminuted forearm
fractures
B. Nail diameter should be no more than 40% of
the isthmus of the medullary canal
C. They should be pre-bent to three times the
diameter of the isthmus
318
Trauma I Structured SBA
D. The apex of the bow of the elastic nail should
be at the level of the fracture
E. The entry point for the nail should be
2.5–3cm proximal to the physis
23. Which of the following increases the pull-out
strength of a screw in bone?
A. Decrease the cortex thickness
B. Decrease the outer diameter
C. Decrease the thread density (increased dis-
tance between threads)
D. Increase the inner diameter
E. Increase the outer diameter
24. Undisplaced distal radius fractures are most
associated with the rupture of which structure?
A. Extensor digitorum communis
B. Extensor indicis proprius
C. Extensor pollicis longus
D. Flexor pollicis brevis
E. Flexor pollicis longus
25. A 30-year-old patient sustains an epileptic fit and
attends the ED complaining of severe right
shoulder pain. An anteroposterior (AP) shoulder
radiograph is shown in Figure 15.12. It is irreducible in the ED.
C. Rotational osteotomy
D. Subscapularis transfer +/– lesser tubero sity
E. Emergency closed reduction under GA
26. A 35-year-old man is found 6 hours after sustain-
ing a comminuted fracture of his right tibia secondary to a high-velocity gunshot wound. He hasa
systolicBP of 90 butresponds wellto fluids. He has
a weak dorsalis pedis pulse but good capillary refill.
What is his MESS value?
A. 5
B. 6
C. 7
D. 8
E. 9
27. Paediatric fractures occur through which layer
of the physis ?
A. Maturation zone
B. Primary spongiosa
C. Proliferative zone
D. Reserve zone
E. Zone of provisional calcification
28. A 25-year-old male was resuscitated after coming
off a motorbike at 50mph. He sustained an open
humerus fracture, femur and tibia fracture and
spinal fracture. His ISS score was 20. After he
was resuscitated initially, the trauma team
wanted to plan for fixation of his injuries.
In the Early Appropriate Care (EAC) protocol
which of the following is incorrect regarding
fracture fixation?
A. Base excess should be >5.5mmol/L
B. Definitive fixation should be performed
within 36 h of injury
C. Lactate should be <4mmol/L
D.
Patients should respond to resuscitation with
pressor support
E. pH should be >7.25
Figure 15.12 Anteroposterior (AP) radiograph right shoulder
Which of the following is NOT a recommended
treatment option?
A. Femoral head allograft reconstruction
B. Reverse shoulder arthroplasty
29. A 74-year-old man falls downstairs while intoxi-
cated and attends ED complaining of neck pain.
Plain lateral radiograph cervical spine is shown
in Figure 15.13. He is awake and alert.
Which of the following is the most appropriate
initial management following resuscitation?
A. Closed reduction in Gardner–Wells tongs
with serial traction
319
Tim Brock and Rishi Dhir
Figure 15.13 Lateral
radiograph cervical spine
B. Immediate anterior discec tomy and fusion
C. Halo application
D. MRI and urgent neurosurgical consult
E. Immediate posterior discectomy and fusion
30. An 80-year-old male presented to the ED with
neck pain following a mechanical fall at home.
Coronal CT image cervical spin is shown in
Figure 15.14.
surgical treatment in elderly patients (65–85
years)
D. The complication rate of non-surgical and
surgical treatment of type II fractures in the
elderly is higher
E. Type II fractures sit in a watershed area and
have a greater risk of non-union
31. A 35-year-old male came off a motorbike.
Following resuscitation, he complained of weakness in both legs and lower back pain. Clinical
examination revealed bruising and swelling over
his lumbar spine with M3 power in both legs and
bilateral paraesthesia. Sagittal CT imaging is
shown in Figure 15.15.
Figure 15.14 Coronal CT scan cervical spine
Which of the following statements is false in
elderly patients with this injury pattern?
A. Anterior screw fixation is indicated with
transverse or posterior oblique fracture lines
B. Posterior fusion has higher union rates than
anterior fixation in type II fractures
C. Surgical stabilisation of type II fractures
improves survival compared with non-
320
Figure 15.15 Sagittal CT image lumbar spine
What is the most appropriate management
following initial resuscitation?
A. Mobilise with a spinal brace with flexion and
extension views at 6 weeks
B. Mobilise with physiotherapy with no brace
with flexion and extension views at 6 weeks
C. Prolonged bed rest with full spinal
precautions
D. Surgical decompression
E. Surgical stabilisation
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