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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:
343
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
16
Trauma
Trauma II Structured SBA
Nayef Aslam-Pervez
TRAUMA II STRUCTURED SBA
QUESTIONS
1. A 35-year-old scaffolder carrying a heavy weight
steps into a shallow pit and twists his ankle,
sustaining a tri-malleolar fracture of his ankle.
He has a Weber B fibular, medial malleolus and
posterior malleolus fracture. The posterior malleolus involves approximately 40% of the articular surface.
What is the best management option for him to
allow early weight bearing?
A. CT scan of the ankle followed by open reduc-
tion and internal fixation of the posterior
malleolus with a buttress plate and fibula
plating (posterolateral approach) and
medial malleolus fixation with cannulated
screws (medial approach) +/– syndesmosis
stabilisation
B. CT scan of the ankle followed by open reduc-
tion and internal fixation of the fibula (lateral
approach) followed by fixation of the medial
malleolus (medial approach)
C. Open reduction and internal fixation of the
fibula (lateral approach) followed by fixation
of the medial malleolus (medial approach)
+/– syndesmosis stabilisation
D. Open reduction and internal fixation of the
fibula (lateral approach) followed by fixation
of the medial malleolus (medial approach)
followed by anterior to posterior screws of
the posterior malleolus +/– syndesmosis
stabilisation
E. Spanning external fixation of the ankle joint
with 5mm pins to his tibia, calcaneum and
4mm to the 1st metatarsal
2. A 45-year-old female fell while wall climbing and
landed on her right forearm, sustaining a closed
displaced fracture at the junction of proximal
one-third to midshaft radius and midshaft ulna
fracture.
What is the best approach for open reduction
and fixation of the radius and ulna fracture
with plates and screws?
A. Approach the midshaft of the radius via the
brachioradialis/flexor carpi radialis first with
the forearm pronated during deep dissection
and then work proximally between brachioradialis/pronator teres with the forearm
supinated. Then fix the ulna through a separate approach
B. Approach the midshaft of the radius via the
brachioradialis/flexor carpi radialis first with
the forearm pronated and then work proximally between brachioradialis/pronator teres
with the forearm supinated. Approach the
ulna through the incision for the radius and
fix the ulna with plates and screws
C. Approach the midshaft of the radius via the
brachioradialis/flexor carpi radialis first with
the forearm supinated during deep dissection
and then work proximally between brachioradialis/pronatorteres with the forearm pronated.
Then fix the ulna through a separate approach
D. Approach the proximal radius first through
the brachioradialis/pronator teres interval
with forearm supinated and then the midshaft of the radius via the brachioradialis/
flexor carpi radialis with the forearm pronated during deep dissection. Then fix the
ulna through a separate approach
E. Approach the ulna first and fix the fracture
with plates and screws. Then approach the
midshaft of the radius via the brachioradialis/flexor carpi radialis first with the forearm
pronated and then work proximally between
brachioradialis/pronator teres with the forearm supinated
346
Trauma II Structured SBA
3. A 9-year-old girl has fallen from monkey bars
and landed on her hand. Radiographs demonstrate a lateral condyle distal humerus fracture
with 5mm displacement and rotation with extension into the trochlear groove.
Which management approach will give her the
best outcome?
A. A closed reduction of the fracture with the
arm in an above-elbow cast with the forearm
in neutral rotation
B. Exposure via a lateral approach viewing the
reduction of the joint anteriorly and insert
two divergent Kirschner wires for stabilisation. Removal of the wires in 4–6 weeks’ time
in clinic and follow up over 2 years
C. Exposure via a lateral approach viewing the
reduction of the joint posteriorly and insert
two divergent Kirschner wires for stabilisation. Removal of the wires in 4–6 weeks’ time
in clinic and follow up over 2 years
D. Exposure via a lateral approach viewing the
reduction of the joint anteriorly and insert
two convergent Kirschner wires for stabilisation. Removal of the wires in 4–6 weeks’ time
in clinic and follow up over 2 years
E. Exposure via posterior approach to the distal
humerus and reducing the fracture with
direct visualisation of the joint surface. Once
reduced, place two divergent Kirschner wires
for fixation. Removal of the wires in 4–6
weeks’ time in clinic and follow up over 2
years
4. Which of these patients can most likely proceed
directly for intramedullary nailing?
A. A 35-year-old male with a pathological frac-
ture through a lytic area in the subtrochanteric region of the femur
B. A 69-year-old male with lung cancer treated
10 years ago with a lobectomy who presents
with a pathological fracture through a lytic
area in the subtrochanteric region of the
femur
C. A 70-year-old male with known renal cell
carcinoma who presents with a pathological
fracture through a lytic area in the subtrochanteric region of the femur
D. A 71-year-old female admitted with a patho-
logical fracture through a lytic area in the
subtrochanteric region of the femur, who
has been complaining of an irregular hard
mass in her right breast
E. A 78-year-old female with known breast
cancer with metastasis in her liver and vertebrae undergoing radiotherapy with a pathological fracture through a lytic area in the
subtrochanteric region of the femur
5. Which of the following will most likely benefit
from posterior stabilisation of the spine?
(Posterior ligament complex – PLC)
A. A 12-year-old male has fallen out of a third-
floor balcony and found to have isolated
compression fracture to his L1 with 60% loss
of anterior height of the vertebral body. He
has no sensation or movement from L1 below
and an MRI shows no injury to his spinal
cord or compromise of the PLC
B. A 25-year-old male is involved in an accident
as a front seat passenger. He is found to have
a fracture extending from the anterior aspect
of the L2 vertebral body passing all the way
posteriorly with widening of the interspinous
area. He has reduced sensation over his knee,
medial malleolus and posterior calf and
reduced power with knee extension, ankle
dorsiflexion and great toe extension
C. A 38-year-old male falls from a low bridge
and sustains a burst fracture of the L2 vertebrae. He has normal neurology, no posterior
midline tenderness and mild canal encroachment on CT. On MRI his PLC is intact
D. A 45-year-old male falls from the first floor
with a compression fracture of the spine
involving <50% of the anterior vertebral
body with normal neurology. On MRI his
PLC is intact
E. A 78-year-old female with vertebral compres-
sion fractures of the L1 and L2 vertebrae after
a fall from standing height. She is found to
have some midline tenderness over L1 and L2
and normal neurology
6. A tendon rupture is most commonly encountered with undisplaced fractures of the distal
radius.
Which of the following reconstruction techniques is advised?
347
Nayef Aslam-Pervez
A. Transfer of the abductor pollicis longus
tendon to restore thumb extension
B. Transfer of the abductor pollicis longus
tendon to restore thumb abduction
C. Transfer of the extensor indicis tendon to
restore thumb extension
D. Transfer of the flexor digitorum superficialis
tendon to the ruptured tendon to restore
thumb extension
E. Transfer of the flexor digitorum superficialis
tendon to the ruptured tendon to restore
thumb flexion
7. A 30-year-old male is unable to flex his DIPJ of the
middle finger following pulling on an opponent’s
shirt. Radiography of the finger does not show any
fractures. Onattempting to make a grip, his middle
finger interphalangeal joints extend. An ultrasound demonstrates the torn end of the tendon
over the proximal interphalangeal joint (PIPJ).
What structure limits the movement of the
tendon end to this region?
A. A1 pulley
B. A2 pulley
C. Interossei muscles and vinculum longus
D. Joint capsule of the PIPJ
E. Lumbrical muscles and vinculum longus
8. A 33-year-old motorcyclist is admitted following
a fracture dislocation of the talus. There is dislocation of the tibiotalar and subtalar joints with
comminution of the talus medially. Once it is
reduced, the surgeon requires fixation of the talar
body medially.
Which approach is best utilised for fixation and
to ensure the blood supply of the talus is least
compromised?
A. A medial malleolar osteotomy
B. A posteromedial approach protecting the
neurovascular structures and dividing the
deltoid ligament which is repaired later
C. A posteromedial approach protecting the
neurovascular structures and splitting the
deltoid ligament in line with its fibres
D. An anterior approach to the ankle joint with
intermuscular plane between the extensor
hallucis and digitorum longus
E. An anteromedial approach to the medial mal-
leolus protecting the long saphenous vein and
nerve with exposure of the talus
9. A 71-year-old fit and well male sustains a frac-
ture of his femur between a hip and knee replacement. The fracture is in the supracondylar area,
3cm above the superior aspect of the knee
replacement. The fixation of either hip or knee
replacement is not involved. You are planning
the fixation and need to decide which modality
of treatment will give you best fixation for early
weight bearing and decrease future
complications.
Which treatment strategy will you choose?
A. Combined retrograde nail from the knee to
the tip of the hip replacement with a locking
plate to the tip of the hip replacement
B. Combined retrograde nail from the knee to the
tip of the hip replacement with a locking plate
to the proximal femur with screws around the
femoral stem of the hip replacement
C. Locking plate fixation from the distal femur
to the proximal femur with screws around
the femoral stem of the hip replacement
D. Locking plate fixation from the distal femur
to the tip of the hip replacement
E. Retrograde nail from the knee reaching close
to the tip of the hip replacement
10. A 25-year-old sustains an isolated knee dislocation. On examination his foot is pale, and pulses
are absent. Reduction of the knee is performed
and maintained in a back slab, the pulses remain
absent and the foot continues to remain pale.
What is the best sequence of management for
this patient?
A. External fixation to maintain reduction in
theatre, On table angiography, Vascular
bypass shunt, Vascular repair/reconstruction
+/ fasciotomy, Delayed knee ligament
reconstruction following MRI of the knee
B. External fixation to maintain reduction in
theatre, Vascular bypass shunt, On table angiography, Vascular repair/reconstruction, +/
fasciotomy, Delayed knee ligament reconstruction following MRI of the knee
C. On table angiography of the limb in theatre,
Vascular bypass shunt, External fixator to
maintain reduction, Vascular repair/reconstruction, Delayed knee ligament reconstruction following MRI of the knee
D. On table angiography of the limb in theatre,
Vascular repair/reconstruction +/ fasciotomy,
348
Trauma II Structured SBA
Maintain reduction with a back slab, Delayed
knee ligament reconstruction following MRI of
the knee
E. Vascular bypass shunt in theatre, External
fixation to maintain reduction, On table angiography, Vascular repair/reconstruction +/
fasciotomy, Delayed knee ligament reconstruction following MRI of the knee
11. Which of the following manoeuvres is least
likely to help with reducing subtrochanteric
femoral fractures?
A. Abduction of the distal fragment
B. Adduction of the proximal fragment
C. Extension of the hip joint
D. External rotation of the proximal fragment
E. Traction of the limb in a supine position
12. When performing dual incision fasciotomies of
the leg with compartment syndrome, which of
the following structures are not encountered
with your incisions?
A. Medial incision: extensor hallucis longus;
Lateral incision: peroneal artery
B. Medial incision: long saphenous vein; Lateral
incision: superficial peroneal nerve
C. Medial incision: posterior tibial artery;
Lateral incision: peroneus longus and brevis
D. Medial incision: soleus; Lateral incision:
superficial peroneal nerve
E. Medial incision: tibial nerve; Lateral incision:
extensor digitorum longus
13. A 14-year-old male with a proximal ulna fr acture
and anterior radial head dislocation underwent
fixation with plates and screws of the proximal
ulna and manipulation of the radial head. Postoperative radiographs show excellent reduction
of the fracture and radio humeral articulation.
He was placed in a cast with 80° of elbow flexion
and supination. After one week, a repeat radiograph in clinic shows a recurrent dislocation of
the radial head anteriorly with maintained reduction of the ulna. He has been listed on your
trauma list.
What would be the best management?
A. Isolated closed reduction of radial head and
placed into cast after procedure with 110°
elbow flexion and pronation
B. Isolated closed reduction of radial head and
placed into cast after procedure with 110°
elbow flexion and supination
C. Isolated open reduction of radial head and
placed into cast after procedure with 80°
elbow flexion and supination
D. Revise proximal ulna fracture fixation and
closed reduction of radial head and placed
into cast after procedure with 80° elbow
flexion and supination
E. Revise proximal ulna fracture fixation and
open reduction of radial head and placed into
cast after procedure with 80° elbow flexion
and supination
14. An 81-year-old man has been admitted with a
displaced intracapsular neck of femur fracture.
He has been listed for a total hip arthroplasty.
Which one of the following factors confers an
advantage towards a hemiarthroplasty rather
than a total hip arthroplasty?
A. Dislocation rate (within 4 years of index
procedure)
B. Mortality rate
C. Post-operative infection
D. Quality of life and functional scoring with the
Harris Hip Score
E. Reoperation rate
15. A 55-year-old diabetic smoker underwent ante-
grade nailing for his subtrochanteric femur fracture. His wound healed well, and he continued to
make good progress until his leg suddenly gave
way after 4 months. Radiographs confirm a nonunion with a fractured nail at the site of the
fracture.
Which image best depicts the mode of failure?
A.
A.
Stress
Cycles
B.
Stress
Cycles
349
Nayef Aslam-Pervez
C.
C.
Stress
Strain
D.
D.
Stress
Strain
E.
E.
Load
Deformation
Time
16. A 14-year-old male footballer sustains a valgus
twisting injury to his knee. His MRI shows an
ACL (anterior cruciate ligament) rupture and a
bucket handle medial meniscus tear. His physis is
still open. He still has open physis around his knee
and his height is 5 feet. His parents are both 6 feet.
What is your management plan?
A. As his physis is still closing, an isolated
physiotherapy programme for his ACL-deficient knee
B. Carry out an all epiphyseal femoral tunnel
and transphyseal tibial tunnel (hybrid) for
his ACL reconstruction using hamstrings
and a medial meniscal repair
C. As his physis is still closing, physiotherapy
for his ACL-deficient knee and an isolated
medial meniscus repair followed by ACL
reconstruction once his physis are fully closed
D. Carry out a transphyseal for both femoral
and tibial ACL reconstruction using hamstrings and medial meniscus repair
E. Carry out a transphyseal for both femoral
and tibial ACL reconstruction using hamstrings and a partial medial meniscectomy
17. A subtrochanteric femoral fracture has been
fixed in a varus deformity.
Which of the following factors has been shown
to lead to this?
A. Inserting a greater trochanter entry nail
through a piriformis fossa insertion point
B. Inserting a lateral entry nail through a piri-
formis fossa insertion point
C. Inserting a piriformis fossa entry nail through
a greater trochanter tip insertion point
D. Inserting the ball-tipped guide wire for the
nail laterally in the distal femur
E. Obese patient fixed with a greater trochanter
entry nail
18. Which of the following elbow fractures will be
most amenable to treatment with a total elbow
replacement?
A. An 85-year-old female with osteoporosis
and a severely comminuted distal humerus
fracture
B. A 45-year-old labourer with an intra-articular
T type distal humerus fractu re
C. A 49-year-old female with non-union of a
supracondylar humerus fracture
D. A 65-year-old male with a coronal fracture of
the distal humerus
E. An 89-year-old female with osteoporosis and
a transolecranon comminuted fracture dislocation of the elbow
19. A 45-year-old motorcyclist has come off his bike,
sustaining an open femoral shaft fracture. He
underwent a splenectomy for splenic haemorrhage and an extradural haemorrhage requiring
invasive intracranial pressure measurement. You
have debrided the femoral shaft fracture wound
and bone edges.
What is the next most appropr iate management plan?
A. Close the wound, place a traction pin in the
tibia and carry out skele tal traction
B. Insert antibiotic beads, close the wound and
place a traction pin in the tibia and carry out
skeletal traction
C. Reamed antegrade intramedullary nailing
D. Stabilise the fracture with an external fixator
E. Unreamed antegrade intramedullary nailing
20. A patient underwent a long spiral comminuted
humerus shaft fracture fixation with the posterior triceps muscle splitting approach and presents with a neurological deficit. As the fracture
extended quite proximally, the incision extended
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