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Trauma II Structured SBA
Rotation
II
IV
I
II
III
I
Avulsion
II
II
IV
A
B
Figure 16.6 Lauge–Hansen Classification of ankle fractures
Treatment is focused on prevention with
Fracture due to supination-eversion (SE)
II
Shear
Fracture due to supination-adduction (SA)
stages I, II, III, and IV
I
Avulsion
stages I, II, III, and IV
early stabilisation of long bone fractures.
Mechanical ventilation with high levels of
PEEP is the recommended treatment for
acute presentation.
Major (1)
○ Hypoxaemia (PaO
< 60). (N = 75–100)
2
○ CNS depression (changes in mental
status)
○ Petechial rash
○ Pulmonary oedema
Minor (4)
○ Tachycardia
○ Pyrexia
○ Retinal emboli
○ Fat in urine or sputum
○ Thrombocy topenia
○ Decreased HCT
Additional
○ PCO
2
>55
○ pH <7.3
○ RR >35
○ Dyspnoea
○ Anxiety
C
D
Fracture due to pronation-eversion (PS)
I
Avulsion
Fracture due to pronation-adduction (PA)
stages I, II, III, and IV
III
stages I, II, and III
III
II
II
Two theories are postulated for the occurrence of
FES.
First, there is the mechanical theory by Gassling
and Pellegrini (1982) which states that large fat
droplets are released into the venous system;
these droplets are deposited in the pulmonary
capillary beds and travel through arteriovenous
shunts to the brain. Microvascular lodging of
the droplets produces local ischaemia and
inflammation, with concomitant release of
inflammatory mediators and vasoactive amines
and platelet aggregation.
The biochemical theory states that hormonal
changes caused by trauma and/or sepsis
induce systemic release of free fatty acids as
chylomicrons. Acute-phase reactants, such as
C-reactive proteins, cause the chylomicrons
to coalesce and create the physiological
reactions described above.
Gossling HR, Pellegrini VD Jr. Fat embolism
syndrome: a review of the pathophysiology and
physiological basis of treatment. Clin Orthop
Relat Res. 1982;165:68–82. PMID: 7042168.
33. Answer A. Bladder, Corona mortis, External
iliac vessels, Obturator neurovascular bundle
361
Nayef Aslam-Pervez
This question requires the candidate to think
about the various approaches to the pelvis. With
anterior column and acetabular involvement, the
recommended approaches are the ilio-inguinal
and Stoppa’sapproach.Stoppa’sapproachismore
popular amongst pelvic surgeons due to better
reduction, operative time and complications.
This approach provides clear acetabular access,
including access to the pubic body, superior
ramus and pubic root, the ilium above and below
the pectineal line, the quadrilateral plate, and the
medial aspect of the posterior column, sciatic
buttress and anterior sacroiliac joint.
The structures in option A refer to the
dangers of the Stoppa’s approach. The corona
mortis is a leash of vessels forming the anastomosis between the external iliac and obturator
vessels.
34. Answer B. Posterolateral approach (Frosch)
limited 5cm distally from joint due to trifurcation of vessels at interosseous membrane
This SBA is testing knowledge of the posterolateral approach to the tibia to fix a posterolateral
tibial plateau fracture. These fractures require
anatomic articular reduction and buttress plate
fixation on the posterior aspect. This is difficult
to achieve through a lateral or anterolateral
approach. A modified posterolateral approach
can be used.
Option A: The Hockey stick incision can be
continued distally and is not limited by the
superficial peroneal nerve. The extension will be
similar to the lateral incision for a fasciotomy.
Option B: The Frosch approach is limited
distally due to the trifurcation. It allows visualisation through two windows, anterolateral and
posterolateral. Further advantages include the
avoidance of a fibular osteotomy as described
by the posterolateral Lobenhoffer approach.
Option C: The arch of soleus can be lifted and
the posterior neurovascular bundle is usually
protected in distal extension. If further distal
extension is required, the medial fasciotomy incision can be followed.
Option D: The trifurcation is encountered
with distal extension of the Frosch approach
and not the posteromedial Lobenhoffer.
Option E: The posteromedial Lobenhoffer
approach is limited by the medial head of
gastrocnemius, but the head can be incised and
repaired later to overcome the limitation and
achieve better visualisation more laterally.
A limitation of the posterolateral approach
(Frosch) is that it cannot be extended distally
because of the trifurcation vessels that traverse
the interosseous membrane approximately 5 cm
below the joint line. However, because the lateral
tibial metaphysis has a posterior inclination angle
of approximately 45°and the posterolateral split
fracture segment is usually less than 4 cm in cortical length, this limitation does not seem to be a
problem in practice. Iatrogenic injuries to vascular
structures do not tend to occur in practice.
Frosch KH, Balcarek P, Walde T, Stürmer
KM. A new posterolateral approach without
fibula osteotomy for the treatment of tibial plateau fractures. JOrthopTrauma.2010;24:515–520.
PMID: 20657262
Raschke MJ, Kittl C, Domnick C. Partial
proximal tibia fractures. EFORT Open Rev.
2017;2:241–249.
Figure 16.7 An anatomic drawing of the lateral and posterolateral
region of the knee. Dashed black line: skin incision; 1: lateral standard
arthrotomy; and 2: blunt dissection of the popliteal fossa between
M. soleus and M. gastrocnemius (lateral head).
362
Biceps
femoris
Popliteal Artery
Lateral head
gastrocnemius
Popliteus
muscle
Figure 16.8 In the distal direction, the soleus and the peroneal
nerve border the situs. In the medial direction, the operation site is
bordered by the popliteal artery and nerve. Superiorly the operation
site is bordered by the popliteus and in the lateral direction by the
fibular head, the lateral collateral ligament, the biceps femoris, and
the peroneal nerve. The dissected area at the tibial is approximately
3 cm wide superiorly, L-shaped, and approximately 4 to 5 cm length
from a cranial to caudal direction. Figure reused with permission by
Wolters Kluwer Health
Peroneal
nerve
Fibula head
Trauma II Structured SBA
35. Answer E. Outlet view of the pelvis will help in
anterior – posterior sacroiliac screw placement
in the S1 body
The way to remember the Outlet view is to think
of the various ‘O’s that can be seen, the bilateral
Obturator foramen ‘O’s as well as the sacral
foramen ‘O’s for the exiting nerve roots. This
view allows for the Superior-Inferior placement
of the sacroiliac screw insertion.
The correct description is Option D. The
answer (Option E) is the correct combination
utilising the Inlet view and not the Outlet view.
The optimal angulation for an inlet view is
25° caudal tilt, and 60° cranial tilt for the outlet
view.
Inlet view: This is a cranial tilt (X-ray tube
angle toward head and photons beamed in a
caudal direction). The beam is perpendicular to
the S1 end plate.
Outlet view: This is a caudal tilt (X-ray tube
angled toward feet and beamed in cranial direction). Demonstrates cranial-caudal displacement
of the pelvic ring and sacral morphology.
Do not mix up inlet and outlet views with
Judet views.
Inlet view
45deg. cephalad
Outlet view
45deg. caudad
Figure 16.9 Inlet and outlet views. The optimal angulation for an inlet view is 25° caudal tilt, and 60° cranial tilt for the outlet view
363
Nayef Aslam-Pervez
36. Answer A. Abductors of the hip and iliopsoas
The most common deformity after antegrade
nailing for a sub-trochanteric femoral fracture
is varus and procurvatum. This is due to the
action of the abductors and iliopsoas on the
proximal fragment and the adductors on the
distal fragment. The article referenced below
talks about an interesting method to help reduce
this deformity with intramedullary nailing. The
concepts discussed allow an in-depth understanding of the different generations of nails
and how important the technique for the entry
portal on the femur is, in avoiding subsequent
deformity.
Russell TA, Mir HR, Stoneback J, Cohen J,
Downs B. Avoidance of malreduction of prox-
imal femoral shaft fractures with the use of a
minimally invasive nail insertion technique
(MINIT). J Orthop Trauma 2008;22:391–398.
PMID: 18594303.
Figure 16.10 The muscular deforming forces around the
proximal femur
364
Section 3
Chapter
17
Trauma
Trauma III Structured SBA
Yusuf Omran Hasan
TRAUMA III STRUCTURED SBA
QUESTIONS
1. A 23-year-old male had a twisting injury to his
left ankle while playing in a local Sunday football
league. His radiographs are shown in Figure 17.1.
Figure 17.1 Anteroposterior (AP) and lateral radiographs ankle
Which of the following signs or tests is the best
predictor of the stability of the fracture?
A. Gravity stress views
B. Intraope rative stress views
C. Medial side bruises
D. Medial side tenderness
E. Weight bearing radiographs
2. A 9-month-old child was brought to the ED by
his mother after falling onto his leg. The on-call
ST3 registrar applies a hip spica. The patient is
neurovascularly intact and his pain is controlled.
The radiographs are shown in Figure 17.2.
What is the next step in the management of this
patient?
Figure 17.2 Anteroposterior
(AP) and lateral radiographs
right femur
A. Admit the patient
B. Follow up in 2 weeks with radiographs on
arrival
C. Gallows traction
D. Pavlik harness
E. Reapply the cast as the reduction is not
acceptable
3. During the daily trauma meeting, it was agreed
that the injury represents a Haraguchi Type 1
fracture and requires fixation with a buttress
plate.
Which of the following is the correct internervous plane of the commonly used approach to
fix this fracture?
A. Deep peroneal nerve and superficial peroneal
nerve
B. Tibial nerve and deep peroneal nerve
C. Tibial nerve and femoral nerve
365
Yusuf Omran Hasan
D. Tibial nerve and superficial peroneal nerve
E. There is no true internervous plane
4. A 34-year-old man is brought to the ED after a
road traffic accident. He has a clinically swollen
left shoulder. The radiographs are shown in
Figure 17.3.
Figure 17.3 Anteroposterior (AP) view middle third clavicle
Which of the following is true regarding the
treatment of this fracture?
A. Patient-reported scores are similar with
operative and non-operative treatment at 6
weeks
B. The union rate at 3 months does not correlate
with the functional status of the patients
C. The union rate in smokers is significantly
different between the operatively and nonoperatively treated patients
D. The union rate is around 90% at 3 months
with operative treatment
E. The union rate is higher with operative treat-
ment at 3 months
5. A 68-year-old woman sustained a displaced
intracapsular fracture to the neck of the femur
whilst shopping after a minor fall. She had breast
cancer in the past and suffers from diabetes and
chronic renal disease.
Which of the following risk factors is associated
with the highest mortality risk?
A. Age more than 66
B. AMTS less than 7 and living in a care home
C. Haemoglobin on the admission of less than
80 g/l
D. History of malignancy
E. Multiple comorbidities
6. A 41-year-old man is involved in a road traffic
accident and sustains multiple rib fractures and
chest injury, minor splenic laceration, anterior
acetabular wall fracture and femoral shaft fracture. He was intubated with a Glasgow Coma
Scale of 8 and admitted to the intensive care unit.
When should thespinal precautions be removed?
A. After an initial thin slice c-spine CT scan
report indicating no fracture, instability or
haematoma
B. At 24 hours if there is no suspicion of spinal
cord injury
C. Only after an MRI scan of the c-spine
D. When the patien t is extubated
E. All of the above
7. A young man sustained an isolated injury to the
right ankle while playing football. A CT scan
done in the accident and emergency department
confirms that this is a Hawkins type I fracture.
What of the following is true regarding this
injury?
A. Hawkins classified fractures of the talar body
based on the degree of displacement
B. Post-traumatic arthritis is the most common
complication following this injury
C. Subchondral lucency seen at 8 weeks is a bad
prognostic sign
D. The AVN rate is between 20–30%
E. This injury is associated with a subtalar
dislocation
8. A 41-year-old undergoes fixation of a femoral
head fracture using safe surgical dislocation
through the Kocher–Langenbeck approach.
Which of the following is true?
A. Capsular incision starts anteriorly on the fem-
oral shaft and runs along the femoral neck axis
B. Pipkin type II fractures do not involve the
weight-bearing area and can be managed
conservatively
C. Similar to the posterior approach to the hip,
dislocation is achieved by applying traction
and internal rotation of the leg
D. The main arterial supply to the femoral head
can be identified on the lower edge of the
quadratus femoris and should be protected
E. Worst prognosis is seen in femoral head frac-
tures associated with acetabular fractures
9. A 25-year-old medical intern is complaining of
left hand pain after a recent intense cross-fit
366
Trauma III Structured SBA
session at the gym. Clinical photographs of her
left hand are shown in Figure 17.4.
Figure 17.4 Clinical photograph hand
Which of the following is NOT true regarding
the anatomy of the damaged structure?
A. It is the primary stabiliser of the extensor
tendon at the level of the metacarpophalangeal joint
B. It originates from the volar plate at the meta-
carpal neck
C. Sectioning of the ulnar part is less commonly
seen and associated with less instability
D. The collateral ligaments are located deep to
this structure
E. The fibres of this ribbon-like structure run
sagittal to the axis of the digit
performed through the extended deltopectoral
approach. The post-operative radiograph is
shown in Figure 17.5.
Figure 17.5
Anteroposterior
(AP) radiograph
right humerus
Which of the following is true?
A. The brachialis is the only muscle with dual
innervation encountered in this approach
B. The brachialis muscle can be dissected or
retracted medially
C. The lateral cutaneous nerve of the arm is at
risk and can be identified between the biceps
and mobile wad
D. The radial nerve enters the anterior compart-
ment in the distal third of the humerus by
perforating the medial intermuscular septum
E. This approach can be used to access any
humeral shaft fracture
10. During operative fixation of a posterior column
acetabular fracture, a nerve exiting the greater
sciatic foramen directly above the piriformis
muscle was identified.
Which of the follow ing muscles is innervated
by this nerve?
A. Gluteus maximus
B. Gluteus medius
C. Iliopsoas
D. Quadratus femoris
E. Obturator internus
11. An open reduction and internal fixation of
humeral shaft fracture was done for a 51-yearold fit and healthy plumber. The surgery was
12. A 43-year-old construction worker had a fall on
his right elbow and sustained the injury shown in
Figure 17.6.
Which of the following represents the correct
type of the injury and the position of elbow in
the cast aft er treatment?
A. Bado I – Flexion and pronation
B. Bado I – Flexion and supination
C. Bado II – Flexion and pronation
D. Bado III – Flexion and pronation
E. Bado III – Flexion and supination
13. A 29-year-old professional batsman was seen in
the hand clinic for long-standing paraesthesia
and pain in his right ring and little finger.
367
Yusuf Omran Hasan
Figure 17.6 Anteroposterior
(AP) radiograph right forearm
Which of the following is true regarding his
condition?
A. It is unlikely that this patient will present with
sensory symptoms only
B. Jeanne’s sign is always negative
C. Simple radiographs have no diagnostic values
D. The cause is usually vascular in origin
E. The wrist joint is the most common site of
compression of this nerve
14. A 67-year-old male was brought to the hospital
after a motor vehicle accident. He was taken to
the operating room for management of Type 1
open tibial fracture. He was managed by irrigation, debridement and tibial nailing. On day 3
post-operatively the patient was complaining of
localised ankle pain and foot weakness. A
dynamic ultrasound showed an injury to one of
the structures around the right lower leg. Postoperative radiographs are shown in Figure 17.7.
What is the most likely damaged structure?
A. Extensor hallucis longus tendon
B. Flexor hallucis longus tendon
C. Posterior tibial nerve
D. Tibialis anterior tendon
E. Tibialis posterior tendon
Figure 17.7 (a) Anteroposterior (AP) and (b) lateral radiographs tibia
368
Trauma III Structured SBA
15. A fit 20-year-old woman was playing softball
when she fell onto the floor with both hands
outstretched. She is right-hand dominant and a
non-smoker. She sustained the injury shown in
Figure 17.8.
Figure 17.8
Anteroposterior
(AP)
radiograph hand
Which of the following is true regarding the
management of this injury?
A. Bi-cortical fracture with 2mm displac ement
should be tr eated with surgical fixation
B. Cast immobilisation treatment is associated
with more serious complications
C. Patient-Reported Wrist Evaluation (PRWE)
score is higher with surgical treatment compared with cast immobilisation at 52 weeks
D. Screw joint penetration is nearly 50% with
surgical fixation
E. Suspected non-union at 10 weeks with cast
treatment should be treated with further
immobilisation for 4–6 weeks
16. A 16-year-old pedestrian was hit by a car. He was
brought to the resus zone at the accident and
emergency and ATLS protocol was started. His
physical examination was remarkable for gross
haematuria and ecchymosis around the perineal
area. A urogenital injury was suspected.
Which one of the following statements is false?
A. Bladder injury in the paediatric population is
rare and more complex than in adults
B. Extraperitoneal rupture of the bladder may
be treated by catheter drainage only
C. Primary re-alignment of the urethra during
fracture surgery is recommended
D. The finding of blood-stained urine mandates
a retrograde cystogram
E. The membranous part of the urethra is prone
to injury from pelvic fracture
17. A 72-year-old female had a minor fall and sustained a proximal femoral fracture. During surgery and while inserting the femoral stem, the
anaesthetist noticed a slight drop in the systolic
pressure and a decrease in oxygen saturation.
Which of the following measures would help in
preventing this complication?
A. Aim to maintain the systolic pressure within
20% of pre-induction values
B. Avoiding the use of a pressurised lavage
system
C. Identification of patients at high risk includ-
ing increasing age and female gender
D. The use of a fourth generation cementing
technique with proper pressurisation
E. The use of high-viscosity cement
18. A 14-month-old infant sustained a fracture to the
shaft of the right femur after a non-accidental
injury. The safeguarding protocols were initiated
and the patient was admitted for a Bryant
traction.
Which of the following is true regarding this
treatment method?
A. Non-accidental injury is a contraindication to
the application of this treatment method
B. Skeletal traction is often necessary to obtain
satisfactory limb alignment
C. This is best used for small children older than
12 months
D. Traction is usually applied to the injured limb
only
E. Volkmann’s ischaemic contracture usually
occurs on the normal side
19. A 62-year-old female sustained a left femoral
shaft fracture after long-standing thigh pain.
Her past medical history includes osteoporosis
and breast cancer. Radiographs are shown in
Figure 17.9.
369
Yusuf Omran Hasan
C. Compression of the jejunum by the superior
mesenteric artery
D. Increased intracompartmental abdominal
pressure
E. Side effect to use of opioid analgesics
21. A 34-year-old man presented with acute low
back pain after jumping from a 3-meter height.
On examination, he had severe tenderness on his
back, his score was ASIA D and the rest of his
examination was unremarkable. The CT scan is
shown in Figure 17.10.
Figure 17.9 (a) Anteroposterior (AP) radiographs proximal and (b)
distal femur
Which of the fol lowing is true regarding her
injury?
A. Anatomical reduction and absolute instability
are usually indicated
B. Bilateral injuries are uncommon
C. Fracture comminution is unusual
D. Incomplete fractures involve the medial
cortex only
E. It usually involves the metaphyseal part of the
bone
20. After a skiing accident, a 22-year-old female was
evaluated in the accident and emergency department. CT scan of the chest, abdomen and pelvis
was obtained. It showed an isolated injury to the
thoracolumbar spine. The on-call spinal team
decides to treat this injury with a plaster jacket.
One day later the patient complains of ongoing
nausea and severe vomiting.
What is the most likely cause of the patient’s
symptoms?
A. Associated pancreatic injury
B. Compression of the third part of the duode-
num by a branch of the aorta
Figure 17.10 Sagittal image whole spine CT scan
Which of the following is an indicator of an
unstable injury?
A. 30% canal retropulsion
B. 30% loss of height
C. Associated osteoporosis
D. Loss of the height of the anterior cortex of the
vertebral body
E. Widening of the interpedicular distance
22. A 72-year-old lady was seen in the fracture clinic
with long-standing low back pain and recurrent
falls. She had an X-ray and then a CT scan which
showed a ‘Honda’ fracture of the sacrum.
Which of the fol lowing is true regarding her
fracture?
A. It is part of the Denis classification
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