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(a) (b)
Trauma I Structured SBA
Figure 15.16 (a) Anteroposterior (AP)
radiograph right humerus and (b) clinical
photograph upper limb
32. A 33-year-old male falls down a flight of stairs,
sustaining an injury to his right upper arm.
Anteroposterior (AP) radiograph is shown in
Figure 15.16(a) and clinical photograph is shown
in Figure 15.16(b). The injury is isolated. On
clinical examination, he is unable to dorsiflex
his wrist and extend his fingers at the MCPJs.
The most appropriate next step in management
would be which of the following?
A. Coaptation splint followed by functional brace
B. Humeral nailing
C. Open reduction, internal fixation and explor-
ation of the median nerve
D. Open reduction, internal fixation and explor-
ation of the radial nerve
E. Urgent nerve conduction studies and MRI
upper limb
33. A 41-year-old woman undergoes a radial head
fixation for a Mason II radial head fracture. The
Kaplan approach is used.
Post-operatively, what complication is most
likely?
A. Inability to abduct the fingers
B. Inability to extend the wrist in radial
deviation
C. Inability to extend the wrist in ulnar
deviation
D. Inability to flex the wrist in radial deviation
E. Inability to flex the wrist in ulnar deviation
34. A77-year-oldwomanresidentofanursinghome
with limited functional ability falls onto concrete
sustaining a closed injury. She has radiographs
performed, which confirm the injury (Figure
15.17).
Figure 15.17 Lateral
radiograph elbow
What is themost appropriate managementoption?
A. Total elbow replacement
B. Tension-band wiring of the olecranon
C. Conservative treatment
D. Open reduction, internal fixation w ith
locking plate
E. Excision and triceps advancement
35. A 31-year-old man falls off his motor bike. sus-
taining the isolated inju ry shown in Figure 15.18.
He is neurovascularly intact and is initially resuscitated in the ED.
What is the most appropriate definit ive
management?
A. Closed reduction, examination under anaes-
thetic and early range of motion
B. Radial head arthroplasty and coronoid open
reduction internal fixation
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Tim Brock and Rishi Dhir
Figure 15.18 Lateral radiograph elbow
C. Radial head arthroplasty, coronoid open
reduction internal fixation and lateral collateral ligament repair
D. Radial head fixation and coronoi d open
reduction internal fixation
E. Radial head fixation, coronoid open reduc-
tion internal fixation and medial collateral
ligament repair
D. Sling immobilisation and early mobilisation
E. Total shoulder replacement
37. A 39-year-old motorcyclist presents with con-
tinuing residue discomfort 4 months after intramedullary nailing of a midshaft tibial fracture.
Inflammatory markers are normal. Radiographs
are shown in Figure 15.20.
36. A 63-year-old golfer falls awkwardly onto his left
shoulder. He is neurovascularly intact.
Anteroposterior (AP) radi ograph demonstrates
a three-part fracture of the proximal humerus
involving the surgical neck and the greater tuberosity (Figure 15.19). There is posterior and
superior displacement of the greater tuberosity
by 1cm.
Figure 15.19
Anteroposterior radiograph
(AP) shoulder
What is the most appropriate treatment?
A. Hemiarthroplasty
B. Open reduction and internal fixation
C. Reverse polarity total shoulder arthroplasty
Figure 15.20 (a) Anteroposterior (AP) and (b) lateral radiographs
right tibia
What is the next appropriate treatment?
A. Dynamisation of the tibial nail
B. Exchange tibial nailing
C. Functional bracing and observation
D. Low-intensity pulsed ultrasound
E. Nail removal and open reduction internal
fixation
38. A 26-year-old cyclist falls over his handlebars at
high speed. Following initial resuscitation, he is
found to have the injury shown in Figure 15.21.
In the consent process, what statement is incorrect with regard to non-operative versus operative management?
A. Return to sport is quicker with operative
management
B. There is a higher re-operative rate with
operative management
322
Figure 15.21 Lateral radiograph clavicle
C. There is a hi gher symptomatic mal-union
rate in non-operative management
D. There is better short-term function with
operative management
E. There is no difference between non-union
rates
39. A 26-year-old undergoes scapula fixation
following polytrauma via a Judet approach. He
awakes with deep posterior shoulder pain and
weakness with abduction.
During the approach, where is the nerve most
likely to be damaged?
A. By inadvertently dissecting inferior to teres
minor
B. During exposure of the posterior deltoid
muscle belly
C. During retraction of infraspinatus
D. During retraction of teres minor
E. Inadvertently dissecting out the quadrangular
space
40. A 7-year-old girl falls off a climbing frame, sustaining the injury shown in Figure 15.22. She
sustains a neurological injury.
Figure 15.22 Lateral
radiograph elbow
Trauma I Structured SBA
Based on her injury, what muscle(s) are most
likely to be deficient?
A. 4th and 5th lumbricals
B. Abductor digiti minimi
C. Abductor pollicis longus
D. Extensor pollicis lon gus
E. Pronator quadratus
41. A 16-year-old male sustains the injury to his hip
shown in Figure 15.23 following a motor vehicle
accident. There is no neurovascular deficit and
no other associated injuries. The on-call registrar
is able to reduce the hip in the ED under
sedation.
Figure 15.23 Anteroposterior (AP) radiograph hip
What is the next step in management?
A. Abduction brace
B. CT scan of pelvis
C. MRI scan of pelvis
D. Protected weight bearing
E. Skeletal traction
42. A 23-year-old man is brought into ED after a fall
from a height of 6 feet. Following resuscitation,
an anteroposterior (AP) radiograph demonstrates an isolated closed injury (Figure 15.24).
Which of the following is false in the management of this injury?
A. A Leadbetter manoeuvre may be performed
to aid reduction
B. Open reduction relies on an internervous
plane between the superior gluteal and femoral nerves
C. Quality of reduction is the most important
factor in influencing outcome
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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
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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
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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.
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