Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5211_Библиотеки_им_академика_М_И_Перельмана
.pdf
Trauma II Structured SBA
from within 3cm of the acromion and distally.
The radial nerve was visualised and preserved.
Which of the following deficits is this patient
likely to have?
A. Inability of finger abduction and adduction
and loss of sensation to the little finger in the
hand
B. Inability to abduct the arm and loss of sensa-
tion in lateral aspect of the shoulder
C. Inability to extend the wrist and loss of sensa-
tion to the first web space of the hand dorsally
D. Loss of contraction of pectoralis major and
minor muscles
E. Weakness in flexing the elbow and loss of
sensation to the lateral aspect of the forearm
21. A 23-year-old presented to the clinic with a
humeral shaft fracture. He is unable to extend
his wrist and fingers and has altered sensation
over the radial aspect of the dorsum of his hand.
You have decided to treat this conservatively.
Which of the following motor functions is
expected to recover last?
A. Elbow extension
B. Finger abduction and adduction
C. Index finger hyperextension at the MCPJ
D. Ring finger extension at the MCPJ
E. Wrist extension
22. Which of the following open tibia l fractures is
more likely to require an open reduction
internal fixation and free flap soft tissue
reconstruction?
A. A Gustilo IIIA midshaft spiral tibia fracture
B. A Gustilo IIIB intra-articular displaced
bicondylar fracture of the proximal tibia
C. A Gustilo IIIB intra-articular distal tibia
fracture
D. A Gustilo IIIB proximal tibia lateral condyle
depression and long split fracture to midshaft
tibia
E. A Gustilo IIIB transverse tibia fracture
23. Which of the following ways can be utilised to
overcome distal femur anterior breach in antegrade nailing for the femur?
A. A more posterior entry point for the nail
proximally
B. A lateral proximal entry point
C. Ensuring the radius of curvature of the nail
matches closely to the femur
D. Ensuring the radius of curvature of the nail is
less than that of the femur
E. Lateral patient positioning
24. A 30-year-old base jumper presented with a
mangled extremity and underwent an aboveknee amputation. He presents to clinic complaining of his amputated leg pointing away from his
contralateral normal leg while sitting or walking.
His gait assessment reveals a side lurch, and he
gets exhausted quickly with mobilisation.
What important step during the amputation
was not done?
A. Bevelling of the distal femur after amputation
B. Dividing the sciatic nerve while on stretch to
allow it toretract into the posterior thigh muscles
C. Loose closure of skin to cover the distal
stump
D. Myodesis of the adductor tendon
E. Prominence of the bone due to inadequate
muscle coverage of the distal femur
25. An obese 35-year-old fell from a ladder, landing
on his left foot and sustaining an isolated
Schatzker II tibial plateau fracture.
Which of the following injuries is most frequently associated with this fracture?
A. Anterior cruciate ligament rupture
B. Lateral collateral ligament rupture
C. Lateral meniscal tear
D. Medial collateral ligament rupture
E. Medial meniscal tear
26. A patient attends the emergency department sus-
taining a supination adduction type of ankle
fracture.
When planning to internally fix his medial
malleolus, what form of plating will be
required?
A. Bridge plating
B. Buttress/anti-glide plating
C. Compression plating
D. Neutralisation plating
E. Tension-band plating
27. A 48-year-old patient has sustained a Schatzker
II proximal tibia fracture.
351
Nayef Aslam-Pervez
Which substance used to fill the void after
elevation of joint line has the highest compressive strength?
A. BMP-impregnated collagen spong e
B. Calcium phosphate cement
C. Cancellous autograft
D. Cancellous autograft freeze-dried
E. Tricalcium phosphate
28. A patient is brought to clinic to check on the
healing of a conservatively treated anterior
column pelvic fracture.
Which view will help best assess this area?
A. Anteroposterior radiograph of the pelvis
B. Inlet view
C. Judet – iliac oblique view
D. Judet – obturator oblique view
E. Outlet view
29. A 40-year-old man is admitted to the ED
following a fall. He presents with haematuria.
Radiograph is shown in Figure 16.1.
30. A 24-year-old polytrauma patien t came off a
motorcycle. He sustained axial loading on a fully
abducted arm and extended elbow (Figure 16.2).
What is his most likely injury?
Figure 16.2 Clinical picture
on admission to ED
Figure 16.1 Anteroposterior (AP) pelvis
His injury is likely to be where?
A. Bladder
B. Bulbous urethra
C. Membranous urethra
D. Prostatic urethra
E. Ureter
352
A. Brachial plexus injury
B. Dislocated shoulder
C. Proximal humeral fracture
D. Scapula fracture
E. Vascular injury
31. How would you reduce this fracture (Figure 16.3)?
Figure 16.3
Anteroposterior
(AP) radiograph
ankle
A. Pronation of the foot and abduction
B. Pronation of the foot and external rotation
C. Pronation of the foot and internal rotation
Trauma II Structured SBA
D. Supination of the foot and adduction
E. Supination of the foot and internal rotation
32. A 70-year-old patient underwent a femoral nail
following an RTA. The next day she was found to
be confused, short of breath and had a petechial rash.
Which of the following parameters is this
patient most likely to also have?
A. PaO
70mmHg
2
B. Hypothermia
C. pH 7.5
D. Raised platelet count.
E. Sudden fall in haematocrit
33. A 50-year-old motorcyclist is admitted with an
intra-articular fracture of the right acetabulum
involving the anterior column only.
Which structures are more at risk during the
open approach to fix this fracture?
A. Bladder, Corona mortis, External iliac vessels,
Obturator neurovascular bundle
B. Bladder, Obturator neurovascular bundle,
External iliac vessels, rectum, Urethra
C. Sciatic nerve, Bladder, Inferior gluteal neuro-
vascular bundle, Superior gluteal neurovascular bundle
D. Sciatic nerve, femoral nerve, Inferior gluteal
neurovascular bundle, Superior gluteal neurovascular bundle
E. Sciatic nerve, Inferior gluteal neurovascular
bundle, Superior gluteal neurovascular bundle
34. Which of these options is the correct limitation
for approaches for tibial plateau fracture
fixation?
A. Hockey stick anterolateral approach limited
distally approximately 30cm from joint line
due to danger to superficial peroneal nerve
B. Posterolateral approach (Frosch) limited 5cm
distally from joint due to trifurcation of
vessels at interosseous membrane
C. Posteromedial approach (Lobenhoffer)
limited distally due to arch of soleus and
posterior neurovascular bundle
D. Posteromedial approach (Lobenhoffer)
limited distally due to trifurcation of vessels
at interosseous membrane
E. Posteromedial approach (Lobenhoffer)
limited proximally by medial head of
gastrocnemius
35. A 25-year-old sustains an open book pelvic fracture with disruption of the right sacroiliac joint
and a right anterior column fracture. Numerous
radiographic techniques have been described to
assist in fixation.
Which one of these combinations is NOT
correct?
A. Iliac (External) oblique view to view posterior
column and anterior wall
B. Lateral sacral view for insertion of sacroiliac
screw in midpoint of the sacral alae
C. Obturator (Internal) oblique view to view
anterior column and posterior wall
D. Outlet view helps with superior – inferior
sacroiliac screw placement in the S1 body
E. Outlet view of the pelvis will help in anterior –
posterior sacroiliac screw placement in the S1
body
36. After fixation of a subtrochanteric femur fracture with an antegrade nail which muscles most
likely lead to the most common deformity after
fixation?
A. Abductors of the hip and iliopsoas
B. Abductors of the hip and qua driceps
C. External rotators of the hip and hamstrings
D. External rotators of the hip and quadriceps
E. Hamstrings and iliopsoas
353
Nayef Aslam-Pervez
TRAUMA II STRUCTURED SBA ANSWERS
1. Answer A. CT scan of the ankle followed by
open reduction 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
A recent review of practice by Solan and
Sakellariou (2017) has made best practice recommendations for fixation of ankle fractures with a
posterior malleolus component. CT scans are
recommended in the context of complex fractures with a posterior malleolar element to help
identify fracture configuration to plan fixation. It
is recommended to start with provisionally reducing the posterior malleolus to ensure the fibula
comes to length. AP screws are not recommended, as they may push the fragment away.
Posterolateral approach provides a good view of
the posterior malleolar reduction and allows
access to the fibula from a separate window.
Option A allows this 35-year-old to weight bear
early once the soft tissues have healed.
PMID 29092978
Solan MC, Sakellariou A. Posterior malle-
olus fractures: worth fixing. Bone Joint J.
2017;99:1413–1419.
synostosis, it is advised to have separate incisions
for the ulna and radius.
3. Answer B. Exposure via a lateral approach
viewing the reduction of the joint anteriorly
and insert two divergent Kirshner wires for
stabilisation. Removal of the wires in 4–6
weeks’ time in clinic and follo w up over 2 years
Paediatric lateral condyle fractures are fixed
when displaced to allow for accurate reduction
and normal growth. Accurate reduction may be
facilitated with open reduction. Car e should be
taken to avoid soft tissue stripping posteriorly, as
it will disrupt the blood supply. Divergent K-wire
fixation maintains reduction. In contrast, convergent wires are inferior in maintaining reduction. Wires can be left buried or outside the skin.
A recent study did not show reduced infection
rates with burying K-wires. Remov al is done at
4–6 weeks, and follow up is required to ensure
normal growth. Inadequate reduction may lead
to abnormal growth with valgus and consequently a tardy ulnar nerve palsy.
PMID 29263760
Wormald JC, Park CY, Eastwood DM. A
systematic review and meta-analysis of adverse
outcomes following non-buried versus buried
Kirschner wires for paediatric lateral condyle
elbow fractures. J Child Orthop. 2017;11:465–471.
2. Answer 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
Generally, it is best to fix the radius first to
restore the radial bow using a modified Henry’s
approach. The ulna often comes to good alignment to allow for fixation. It is preferred to
develop the incision over the midshaft of the
radius first and then follow this proximally to
allow better identification of anatomical structures and muscular planes. While dissection is
being carried out to expose the proximal radius,
the forearm is kept supinated to avoid damage to
the PIN. For the midshaft of the radius, deep
dissection is done with the forearm in pronation
for similar reasons. To avoid radioulnar
354
4. Answer 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
It is important that patients with a pathological
fracture are worked up prior to surgical management with intramedullary nailing. In option C,
the patient has a RCC and therefore will be at
risk of catastrophic bleeding intraoperatively. A
consideration for preoperative embolisation of
the lesion is needed to reduce the bleeding risk.
In option A, the patient may have a primary
bone tumour at risk of seeding further distally
with nailing. They will need discussing with the
local bone tumour unit for definitive management. In option D, the likelihood is that the
patient has breast cancer metastasis leading to
the pathological fracture. Despite the likelihood,
a definitive diagnosis is needed, with appropriate
Trauma II Structured SBA
investigations prior to nailing. This is the same
for option A. In option E, we know the patient
has breast cancer with metastasis in her organs
and bone and therefore directly proceeding to
nailing will be beneficial.
5. Answer 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
The TLICS scoring system w as devised to guide
surgical treatment for patients with spinal fractures (Table 16.1). It has excellent validity and is
widely used. However, it should be noted that
almost all the papers that mention the safety and
reliability of TLICS belong to the authors that
have developed the system.
In option A, the patient has sustained a
SCIWORA (spinal cord injury without radiological abnormality). Closely observing these
patients is recommended to assess for return on
neurology.
In option C, the TLICS is 2 and therefore not
likely to require surgical intervention. Follow up
will assess kyphotic deformity and healing. Burst
fractures need assessment on a case by case basis
and therefore just relying on the TLICS may not
be wise.
In option D, the patient’ s TLICS is 1 and
therefore will be treated conservatively.
In option E, the patient has osteoporotic frac-
tures. She will require screen ing for myeloma.
In option B, the patient has a TLICS of 9 or
10 and therefore most likely to benefit from
surgical fixation.
PMID: 27943230
Yuksel MO, Gurbuz MS, Is M, Somay H. Is
the Thoracolumbar Injury Classification and
Severity Score (TLICS) superior to the AO
Thoracolumbar Injury Classification System for
guiding the surgical management of unstable
thoracolumbar burst fractures without neurological deficit? Turk Neurosurg. 2018;28:94–98.
6. Answer C. Transfer of the extensor indicis
tendon to restore thumb ext ension
The tendon most commonly ruptured with
undisplaced distal radius fractures is the extensor
pollicis longus (EPL). Thi s results in a loss of
thumb extension. Therefore, it is imperative this
tendon is examined on routine follow ups and
the patient is made aware of the risk so they may
seek treatment early. Reconstruction of the EPL
Table 16.1 Thoracolumbar Injury Classification and Severity (TLICS) Score
TLICS Three independent predictors
1 Morphology
Immediate stability
2 Integrity of Intact 0
PLC Suspected 2 MRI
Long-term Injured 3
stability
3 Neurological Intact 0
status Nerve root 2 Physical
Predicts Need for surgery 0–3
Compression Burst Translation/rotation Distraction 1
2
3
4
Complete cord 2 examination
Incomplete 3
cord
Cauda equina 3
4
>4
Radiographs CT
Non-surgical
Surgeon’s choice
Surgical
355
Nayef Aslam-Pervez
can be done using EI, APL or the FDS. EI is most
suitable as it most complies with tendon transfer
principles with similar excursion, least sacrifice
of movement and same line of pull.
7. Answer E. Lumbrical muscles and vinculum
longus
The tendon torn is the FDP. This injury is also
referred to as the ‘Jersey finger’. The lumbricals
originate on the FDP tendon and therefore are
overactive when the torn FDP is actively flexed.
This leads to the paradoxical extension of the IP
joints on attempted grip. This is referred to as the
lumbrical plus finger. Restriction of the FDP
retraction is due to attachments of the vinculum
longus and lumbricals. The other structures do
not attach to the FDP and therefore do not
restrict its retraction.
8. Answer A. A medial malleolar osteotomy
The main blood supply of the talus enters via the
deltoid ligament from branches of the posterior
tibial artery. Therefore, it is imperative the deltoid ligament is protected. A posteromedial
approach will destroy this blood supply and
therefore is not recommended. A medial malleolar osteotomy will preserve the deltoid and provide adequate access to the medial talar body for
fixation. An anterior or anteromedial approach
will not provide sufficient exposure to fix the
talar body.
9. Answer 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
Stress risers are a common pitfall after fixation of
these fractures. This is mainly related to around
the proximal tip of retrograde nails and when the
locking plate construct ends distal to the femoral
stem. A locking plate in isolation that spans from
the distal to proximal femur may be suitable, but
new evidence is coming to light that early weight
bearing can be permitted with a combination of
nail and plate construct.
PMID: 34836629
Garala K, Ramoutar D, Li J, Syed F, Arastu
M, Ward J, Patil S. Distal femoral fractures: A
comparison between single lateral plate fixation
and a combined femoral nail and plate fixation.
Injury. 2022 Feb;53(2):634–639.
356
10. Answer 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
This patient presents with an acutely ischaemic
limb.Itisbesttocallthevascularsurgeonsfor
immediate assessment and a plan made
together. A vascular bypass shunt initially will
reperfuse the limb and reduce ischaemia time.
An external fixator is then applied, taking into
account the need for posterior access to the knee
by the vascular surgeons. The external fixator
will allow for stability for the vascular surgeons.
This is best followed by an on table angiogram
to identify the vascular lesion and proceed to
vascular reconstruction. A fasciotomy may be
required at the end, depending how long the
limb was exposed to ischaemia. The external
fixator can be removed in 4–6 weeks and a
manipulation under anaesthesia performed
under general anaesthetic. Reconstruction of
the ligaments can be delayed. Reconstruction
strategy will be informed by findings from
MRI and clinical evaluation.
PMID: 32296548.
Ng JWG, Myint Y, Ali FM. Management of
multiligament knee injuries. EFORT Open Rev.
2020 Mar 2;5(3):145–155.
11. Answer D. External rotation of the proximal
fragment
The proximal fragment will have unopposed
external rotation due to the short external rotators. Internal rotation of the proximal fragment
can be facilitated with a joystick guidewire for
better reduction. There is a deforming adduction force on the distal fragment that can be
countered by a bduction enough to ensure
adequate proximal entry for wire entry and
the nail. Traction of the limb allows countering
the shortening effects of the quadriceps.
Extension of the hip may help counter the
flexion force of the proximal fragment,
although, due to discontinuity, distal fragment
extension may not alter the proximal fragment
position.
12. Answer A. Medial Incision: extensor hallucis
longus; Lateral incision: peroneal artery
Trauma II Structured SBA
Please refer to this BAPRAS document for a
revision of fasciotomy anatomy: www.bapras
.org.uk/docs/default-source/commissioningand-policy/standards-for-lower-limb.pdf?
sfvrsn=0.
13. Answer B. Isolated closed reduction of radial
head and placed into cast after procedure with
110° elbow flexion and supination
This patient has sustained a Monteggia fracture
dislocation. This is Bado type I due to the anterior
radial head dislocation. Operative treatment went
well with good post-operative reduction of the
fracture and dislocation; however, flexion was only
80° at the elbow. Most of the time, this may suffice
but, in this patient, has resulted in a recurrent
radial head dislocation. As the fracture of the ulna
continues to be well reduced in the repeat radiographs, manipulation under anaesthesia and casting in 110° of flexion at the elbow with the forearm
in supination will suffice. Pronation will not help
with reduction, and revision of the ulna fixation
will not make any difference as the ulna is not the
problem here. Open reduction of the radial head is
rarely required if there is soft tissue interposition –
this would have transpired had the radial head not
reduced with the primary operation.
16. Answer B. Carry out an all epiphyseal femoral
tunnel and transphyseal tibial tunnel (hybrid)
for his ACL reconstruction using hamstrings
and a medial meniscal repair
Adolescents at age 14 sustaining an ACL tear
benefit from ACL reconstruction with hamstrings.
It has shown to reduce chondral and meniscal
damage as it avoids continuing instability. In the
setting of an associated meniscal tear, the case for
an ACL reconstruction is even more strong.
With regards to the type of tunnel, an all
epiphyseal femoral tunnel avoids traversing the
posterolateral aspect of the femoral physis with a
transphyseal femoral tunnel and therefore avoids
future deformity.
A transphyseal tibial tunnel kept below 9mm has
shown to have minimal effect on future growth.
Using a more vertical tunnel and avoiding hardware/bone plugs across the physis make it less likely
for growth-related complications to develop.
Therefore, a delay in ACL reconstruction until
the physis fuses is not necessary. The repair of
the meniscus will benefit from ACL reconstruction
in the same sitting to ensure integrity and superior
healing rates. A partial medial meniscectomy in
the context of the injuries sustained is not good for
the patient's knee in the long term.
14. Answer A. Dislocation rate (within 4 years of
index procedure)
A recent review article found increased dislocation
rates with THA within 4 years of the index procedure compared with hemiarthroplasty. There were
no differencesin mortality rates andpost-operative
infection. THA had lower reoperation rates and
better quality of life and functional scores.
PMID 31060915.
Lewis DP, Wæver D, Thorninger R,
Donnelly WJ. Hemia rthroplasty vs total hip
arthroplasty for the management of displaced
neck of femur fractures: a systematic review and
meta-analysis. J Arthroplasty 2019;34 :1837 – 1843.
15. Answer A.
Due to the non-union, the implant has been
working above its endurance limit and therefore
ultimately fails. In B the implant is under itsendurance limit and thereforecannot fail.In D and C,the
implant has not reached breaking point. Figure E
represents creep, which is a viscoelastic property
and not related to implant failure.
17. Answer C. Inserting a piriformis fossa entry nail
through a greater trochanter tip insertion point
Inserting a piriformis entry nail through a
greater trochanter (GT) tip insertion point will
lead to a varus fixation of the subtrochanteric
fracture. The GT is lateral to the axis of the
femur. As the straight piriformis nail is inserted
into the GT, the GT axis and femoral axis
become co-linear, leading to varus.
Insertionoftheball-tippedguidewirelaterallyin
the distal femur will not leadtoavarusdeformity.In
obese patients, it is preferred to fix the fracture with a
GT entry nail with maximal leg adduction.
PMID: 29326763.
Sadagatullah AN, Nazeeb MN, Ibrahim S.
Incidence of varus malalignment post interlocking nail in proximal femur shaft fractures comparing two types of entry points. Malays Orthop
J. 2017;11:31.
18. Answer A. An 85-year-ol d female with osteo-
porosis and a severely comminuted distal
humerus fracture
357
Nayef Aslam-Pervez
Although the optimal treatment of distal
humerus fractures has yet to be determined,
there is a well-described indication of total elbow
replacement (TER) for comminuted distal
humerus fractures in the elderly. Studies have
shown poor results with open reduction and
internal fixation (ORIF) of distal humerus fractures in the elderly. There was a 25% conversion
to TER following failure of ORIF. Elderly
patients who underw ent TER primarily had
excellent outcomes. Non-unions in younger
patients are better dealt with ORIF +/– bone
grafting. Dislocated elbows with transolecranon
fractures are more amenable to fixation +/–
elbow stabilisation with ligament reconstruction.
Young labourers will not fare well with TER.
PMID: 25035841.
Sørensen BW, Brorson S, Olsen BS. Primary
total elbow arthroplasty in complex fractures of
the distal humerus. World J Orthop. 2014;5:368.
19. Answer D. Stabilise the fracture with an exter-
nal fixator
This patient has sustained a severe head injury
and therefore requires a damage-control
approach, which will rule out nailing as a treatment option currently. The aim is to avoid a
second hit, which may further det eriorate the
patient. With external fixation option available,
traction provides an inferior technique for stabilisation of the femur.
20. Answer B. Inability to abduct the arm and loss
of sensation in lateral aspect of the shoulder
Axillary nerve is at risk when the posterior
approach to the humerus is proximally extended
to within 8cm of the posterolateral tip of the
acromion. This leads to the deficits described in
option B. Option C relates to the radial nerve,
which was found to be preserved. Option E,
musculocutaneous nerve, option A, ulnar nerve,
and option D, medial and lateral pectoral nerves
are not in danger with the approach described.
extensor indicis proprius; therefore, this will
recover last.
22. Answer C. A Gustilo IIIB intra-articular distal
tibia fracture
Open intra-articular fractures of the distal tibia
often require free flap soft tissue reconstruction
due to the lack of local rotational flaps that can
be constructed. In the proximal tibia, a gastrocnemius rotational flap can be utilised and midshaft tibia fractures can be covered with a soleus
rotation flap. Distal tibia fractures can be covered
with a local fasciocutaneous flap or a distally
based sural artery flap, but the incidence of
requiring a free flap is higher as compared with
other regions of the tibia.
PMID:22912523
Kamath JB, Shetty MS, Joshua TV, Kumar
A. Soft tissue coverage in open fractures of tibia.
Indian J Orthop. 2012;46:462.
23. Answer C. Ensuring the radius of curvature of
the nail matches closely to the femur
Several studies have shown that mismatch of the
radius of curvature of the nail with the femur is a
known factor causing anterior cortex perforations in the distal femur. A more anterior entry
starting point proximally can be utilised to avoid
this complication. Lateral entry point and lateral
patient positioning do not have an effect.
PMID: 25104888.
Kanawati AJ, Jang B, McGee R, Sungaran J.
The influence of entry point and radius of curvature on femoral intramedullary nail position in
the distal femur. J Orthop. 2014;11:68–71.
24. Answer D. Myodesis of the adductor tendon
This patient’s abductors are overpowering and not
neutralised; therefore, his limb is abducted, which
leads to a side lurch and extra energy expenditure.
A myodesis of the adductor tendon allows neutralisation of the abductor forces on the femur
and therefore required intraoperatively.
21. Answer C. Index finger hyperextension at the
MCPJ
This patient presents with a radial nerve palsy.
This can be treated conservatively, and the function of the nerve reviewed regularly in clinic. The
last motor supply of the radial nerve is to the
358
25. Answer C. Lateral meniscal tear
Lateral meniscal tears frequently accompany lateral tibial plateau split/depression fractures. The
higher the injury is, the more likely soft tissue
injuries are to result. LCL and PCL ligament ruptures are also known to occur, but lateral meniscal
r
Trauma II Structured SBA
tears are more frequent and require repair at the
time of surgical fixation of the fracture.
26. Answer B. Buttress/anti-glide plating
Supination adduction ankle fractures lead to a
vertical medi al malleolus fracture. This is best
fixed with buttress or anti-glide plating.
27. Answer B. Calcium phosphate cement
The compressive strength of calcium phosphate
cement superseded the other options when studied on cadavers.
PMID: 16314717.
Trenholm A et al. Comparative fixation of
tibial plateau fractures using α-BSM™, a calcium
phosphate cement, versus cancellous bone graft. J
Orthop Trauma 2005;19:698–702.
28. Answer D. Judet – obturator oblique view
Judet views help to assess the pelvic columns and
walls. An iliac oblique view is appropriate to
assess the posterior column and anterior wall.
The obturator oblique view best visualises the
anterior column and posterior wall. The other
options are useful but not best for visualising the
anterior column.
29. Answer C. Membranous urethra
The radiograph demonstrates widening of the
pubic symphysis and the suggestion of a full
bladder. Figure 16.4 is not a cystogram or urethrogram as no white contrast is seen.
Urethral injuries can be classified into 2
broad categories based on the anatomical site of
the trauma. Posterior urethral injuries are
located in the me mbranous and prostatic
urethra. These injuries are most commonly
related to major blunt trauma such as motor
vehicle collisions and major falls, and most of
such cases are accompanied by pelvic fractures.
Injuries to the anterior urethra are located distal
to the membranous urethra. Most anterior
urethral injuries are caused by blunt trauma to
the perineum (straddle injuries), and many have
delayed manifestation, appearing years later as a
urethral stricture.
30. Answer B. Dislocated shoulder
The clinical picture on admission to the ED
shows a right hyperabducted shoulder with bulging of the axillary skin due to inferior displacement of the humeral head.
Most inferior dislocations of the shoulder are
the result of one of two mechanisms. A direct
axial load on an abducted arm can force the
humeral head inferiorly with respect to the glenoid. Forceful hyperabduction on an already partially abducted arm can lever the humeral neck
against the acromion and force the head inferiorly. Both mechanisms usually occur during a
Anterior urethra {Penile, Bulbar
Posterior urethra {Membranous, Prostatic
Penoscrotal junction
VM
Figure 16.4 Diagram demonstrating
urethra anatomy in male patient.
VM, verumontanum
Bladde
Prostatic urethra
Membranous
urethra
Symmetrical cone of
bulbar urethra
Bulbar urethra
Penile urethra
359
Nayef Aslam-Pervez
fall as a patient attempts to catch himself/herself
with an outstretched arm. Although motor
vehicle accidents or falls from a height are the
most associated mechanism, inferior dislocation
associated with sports have been reported.
The affected arm is locked in a hyperabducted position above the head, usually with the
elbow flexed. The humeral head may be palpable
or visible in the axillary fossa. The arm was
abducted in a ‘hands-up’ position, any movement from this position is painful.
The clinical presentation is distinct when the
affected arm is held above and behind the head
and patient is unable to adduct arm.
This is often associated with nerve injury,
rotator cuff injury, tears in the internal capsule,
and the highest incidence of axillary nerve all
shoulder injuries. Arterial injury is reported in
3.3% of cases and more common in patients over
50 years of age mainly due to an overlying
atherosclerosis.
Sogut O, Yigit M, Karayel E, Demir N.
Luxatio erecta humeri: hands-up dislocation. J
Emerg Med. 2015;49:e53–55.
Yamamoto T, Yoshiya S, Kurosaka M,
Nagira K, Nabeshima Y. Luxatio erecta (inferior
dislocation of the shoulder): a report of 5 cases
and a review of the literature. Am J Orthoped.
2003;32:601–603. PMID: 14713067.
31. Answer C. Pronation of the foot and internal
rotation
Candidates have to use the principles of the
Lauge–Hansen classification. Candidates need to
understand how to reduce an ankle with a spiral
fracture of the distal fibula through the syndesmosis and a transverse medial malleolar fracture.
Table 16.2 Lauge–Hansen Classification
Subtype Fractures Weber
Analogy
Supinationadduction
Supination
external
rotation
Pronationabduction
Pronation
external
rotation
Fibular avulsion
Vertical shear fracture
of the
medial malleolus
Oblique/spiral
fracture of distal
fibula +/ medial
malleolar avulsion
Transverse fibular
fracture at
syndesmosis +/
medial malleolar
fracture +/
butterfly fragment
Suprasyndesmotic
fibular fracture +/
medial malleolar
avulsion
Weber A
Weber B
Weber B
Weber C
Figure 16.5 Right upper extremity at admission. Shown is a
hyperabducted shoulder with bulging axillary skin due to inferior
displacement of the humeral head
360
32. Answer E. Sudden fall in haematocrit
Fat Embolism Syndrome is an acute
respiratory disorder caused by an
inflammatory response to embolised fat
globules that may enter the bloodstream as a
result of acute long bone fractures or
intramedullary instrumentation. Patients
present with hypoxia, changes in mental
status and petechial rash. A decrease in
haematocrit occurs within 24–48 h and is
attributed to intra-alveolar haemorrhage.
Diagnosis is made clinically with presence of
hypoxemia (PaO
< 60), CNS depression,
2
petechial rash and pulmonary oedema.
Соседние файлы в папке Библиотека им академика М.И. Перельмана