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Trauma III Structured SBA
B. It is the most common type of sacral fracture
associated with neurological injuries
C. It represents an abnormal repetitive stress
fracture to the sacrum
D. Low bone elasticity is the main contributing
factor
E. Surgical treatment is usually indicated
23. A 38-year-old left-hand dominant young
accountant who was involved in a jet ski accident
and sustained an isolated injury. His radiographs
are shown in Figure 17.11. After careful examination, the patient chooses to be treated conservatively in a Sarmiento brace. With gentle
manipulation and application of the brace, a
sudden wrist drop was noted.
What is the best next course of action?
A. Continue brace treatment and nerve conduc-
tion studies in 3 months
B. Referral to the peripheral nerve injury unit
within 2 weeks
C. Remove the brace and re-manipulate the
fracture
D. Take to theatre overnight for urgent
exploration
E. None of the above
24. A 69-year-old female with a history of primary
total hip arthroplasty 10 years ago presents with
a ground-level fall while gardening. She was
unable to bear weight. The acetabular component was deemed to be unremarkable, however, a
fracture line was noticed just below the Exeter
stem tip involving the cement mantle only. It
appears that the stem is well-fixed.
Which of the following is the correct
Vancouver Classification for this patient?
A. Vancouver A
B. Vancouver B1
C. Vancouver B2
D. Vancouver B3
E. Vancouver C
25. A healthy young male was brought to the hos-
pital by ambulance after falling from the second
floor. He sustained multiple long bones fracture,
mild abdominal injury and blunt chest trauma.
The decision was to fix his fractures within 36
hours.
Which of the following parameters is indicative
of a good response to resuscitation?
A. Base excess <5.5mmol/l.
B. IL-6 value >500pg/dl.
(a) (b)
Figure 17.11 (a) Anteroposterior (AP) and (b) lateral radiographs left humerus
371
Yusuf Omran Hasan
C. ISS>40.
D. Lactate level <4.
E. pH level <7.25.
26. A 30-year-old male was admitted to the trauma
bay after sustaining a right foot crush injury with
multiple tarsal and metatarsal fractures. His pain
was still uncontrolled with a maximum dose of
opiates. It was decided that he should immediately undergo fasciotomies of all the foot
compartments.
Which of the following muscles is located in the
superficial compartment of the foot?
A. Abductor digiti minimi
B. Abductor hallucis
C. Flexor digiti minimi brevis
D. Flexor digitorum brevis
E. Flexor hallucis brevis
27. A 7-year-old boy sustained an injury to his left
elbow. Radiograph demonstrated a type-II Milch
lateral condyle fracture . The patient undergoes
open reduction and screw fixation. On 12
months follow up, he complains of hard swelling
above his elbow which has not decreased in size.
Which of the follo wing is true regarding this
complication?
A. It is caused by the fracture malunion, espe-
cially with type-II Milch injuries
B. Posterior dissection at the time of open reduc-
tion increases the risk of this complication
C. Resection of the physeal bar in young chil-
dren should be considered to avoid further
deformity
D. The presence of this swelling does not influ-
ence the final range of motion
E. Ulnar nerve neuropraxia is commonly associated
28. A 61-year-old manfell suddenly while going down-
stairs. He was complaining of sharp pain in his
right knee despite not sustaining any direct trauma.
He was able to partially extend his knee but was
unable to straight leg raise. His pulse was intact.
What is the most likely diagnosis?
A. Acute ACL tear
B. Femoral stress fracture
C. Patellar avulsion fracture
D. Quadriceps tendon rupture
E. Ruptured Baker’s cyst
29. While reaming the tibia for intramedullary nail
fixation for fracture of the midshaft of the tibia,
you notice that the intraoperatively placed pressure monitors show an increase of the anterior
and posterior compartments pressure to 33 and
37, respectively.
What is the best next action?
A. Continue reaming and don’t perform
fasciotomy
B. Continue reaming and perform 2 compart-
ments fasciotomy
C. Continue reaming and perform 4 compart-
ments fasciotomy
D. Stop reaming and use small diameter nail
E. Stop reaming, perform fasciotomy and apply
external fixator
30. A 70-year-old woman sustained an intracapsular
fracture of the neck of the femur. She suffers
from Parkinson’s disease and lives alone.
Which of the following is false regarding the
management of her hip fra cture?
A. Anterolateral approach should be in favour of
posterior approach when inserting a
hemiarthroplasty
B. If hip fracture is suspected despite negative
X-rays, consider CT scan if MRI is not available within 24 hours
C. Offer total hip replacement if the patient is
able to walk out of doors with one stick
D. Offer total hip replacement if the patient is
expected to be able to carry out activities of
daily living independently beyond 2 years
E. Trauma units should aim to have different
options of femoral components for
hemiarthroplasties
372
TRAUMA III STRUCTURED SBA ANSWERS
1. Answer E. Weight bearing radiographs
The treatment of the isolated lateral malleolus
fracture, in particular supination-external rotation
injuries, remains controversial. The majority can
be treated non-operatively. Several studies showed
that medial side tenderness or bruises do not
predict deltoid ligament incompetence. Stress
radiographs are often associated with overestimation of the instability. Weight bearing radiographs performed within 10 days of the injury can
identify the potentially unstable 10% fracture.
However, only a small proportion of unstable
fractures require operative fixation.
Gougoulias N, Sakellariou A. When is a
simple fracture of the lateral malleolus not so
simple? How to assess stability, which ones to fix
and the role of the deltoid ligament. Bone Joint J.
2017;99-B:851–855.
2. Answer A. Admit the patient
Femoral shaft fractures in non-ambulatory children are highly suspicious for non-accidental
injuries. These victims should be carefully
Trauma III Structured SBA
evaluated and recognised by the medical healthcare providers including surgeons. The local children safeguarding protocols must be followed.
These patients should be referred to the local
safeguarding team or the on-call paediatrician.
Photographs should be taken and the body map
completed. Immediate blood tests are required. A
skeletal survey and ophthalmology review must be
completed within 24 hours. Admission is usually
needed. Further radiographs (Figure 17.12) of this
patient show multiple fractures in different stages
of healing.
Femoral fractures in this age group heal rapidly and
a 2-week period of immobilisation is sufficient for
the majority. Non-invasive treatment is the recommended treatment for this age group, and gallows
traction is suitable for patients weighing <10–15kg.
This can be used as definitive management or with
elective substitution for a hip spica. A Pavlik harness is also commonly used in this age group,
particularly in the neonate with a birth fracture.
National Institute for Health and Care
Excellence. NICE Guideline NG76. Child abuse
and neglect: recognising, assessing and responding
to abuse and neglect of children and young people.
(a) (b)
Figure 17.12 (a) Anteroposterior (AP)
radiograph of the right arm and (b) lateral
radiographs left forearm
373
Yusuf Omran Hasan
3. Answer D. Tibial nerve and superficial peroneal
nerve
Haraguchi was the first to classify posterior malleolus fractures based on the fragment size using
transverse CT scans. He described three types:
type I is the posterolateral-oblique fracture, type
II is the medical-extension fracture and type III
represents the small-shell fracture. The posterolateral approach to the ankle provides optimal visualisation to the posterior malleolus utilising the
interval between the flexor hallucis longus medially and the peroneal tendo ns laterally, supplied by
the tibial and the superficial peroneal nerve,
respectively.
Boer Pde, Buckley R, Hoppenfeld S. The foot
and ankle. In Surgical Exposures in Orthopaedics:
The Anatomic Approach. Philadelphia, PA:
Wolters Kluwer; 2022.
Haraguchi N, Haruyama H, Toga H, Kato F.
Pathoanatomy of posterior malleolar fractures of
the ankle. J Bone Joint Surg Am. 2006;88:1085–1092.
4. Answer B. The union rate at 3 months does not
correlate with the functional status of the
patients
The clavicle trial is a UK multicentre RCT to
compare the clinical effectiveness and safety
between operative and non-operative management for displaced midshaft clavicle. The results
showed that the union rate at 3 months was 70%
regardless of the treatment type. However, the
radiographic non-union rates at 9 months were
significantly lower in the surgical treatment group
(<1% vs 11%). The subgroup analysis did not
show higher rates of non-union in smokers. The
Constant-Murley Score and DASH (Disabilities of
the Arm, Shoulder and Hand) score were all significantly better in the fixation group at 6 weeks
and 3 months.
Ahrens PM, Garlick NI, Barber J, Tims EM.
The Clavicle Trial: a multicenter randomized controlled trial comparing operative with nonoperative
treatment of displaced midshaft clavicle fractures. J
Bone Joint Surg Am. 2017;99:1345–1354.
5. Answer A. Age more than 66
The Nottingham Hip Fracture Score (NHFS) was
developed in 2008 as a tool to predict 30-day
mortality for patients with hip fractures. Seven
variables were found to be independent predictors
of 30-day mortality. Age was found to be the
greatest predictor (Table 17.1).
Maxwell MJ, Moran CG, Moppett IK.
Development and validation of a preoperative
scoring system to predict 30 day mortality in
patients undergoing hip fracture surgery. Br J
Anaesth. 2008;101:511–517.
Table 17.1 The Nottingham Hip Score
Nottingham Hip Fracture Score
Variable Value Points
Age 66–85 years 3
86 years 4
Sex Male 1
Admission Hb 10 g/dl 1
Admission MMTS 6 out of 10 1
Living in an institution Yes 1
Number of comorbidities 21
Malignancy Yes 1
6. Answer A. After an init ial thin slice c-spine CT
scan report indicating no fracture, instability or
hematoma
The British Orthopaedics Association has issued
guidance on cervical spine clearance in trauma
patients. A serious spinal injury can be excluded in
an awake patient with normal clinical examination,
or after completing the spinal imaging protocols in
the unconscious patient. It is not recommended to
keep the spinal precautions for more than 48 hours
due tothe risks ofpressure sores. MRI of the cervical
spine or waiting until the patient is extubated is not
necessary before removal of the spinal precautions.
British Orthopaedic Association BOAST 2:
Cervical Spinal Clearance in the Trauma Patient;
2021. https://www.boa.ac.uk/resource/boast-cer
vical-spine-clearance-in-the-trauma-patient.html.
7. Answer B. Post-traumatic arthritis is the most
common complication following this injury
Hawkins classified talar neck injuries (not the talar
body) based on the degree of displacement and the
congruency of the subtalar and ankle joints. He
also described the injury patterns and the AVN
rates. Type I fractures are non-displaced fractures
with AVN incidence rate between 0–15%.
374
Trauma III Structured SBA
Hawkins’ sign seen at 6– 8 weeks is usually
indicating that osteonecrosis is unlikely. Posttraumatic arthritis is widely thought to be more
common than AVN after talar neck injuries.
Hawkins LG. Fractures of the neck of the
talus. J Bone Joint Surg Am. 1970;52:991–1002.
8. Answer A. Capsular incision starts anteriorly on the
femoral shaft and runs along the femoral neck axis
Pipkin classified femoral head fractures as one of
four types (Table 17.2). Pipkin’s Type III fracture
is a high-energy injury associated with a poor
prognosis. The deep branch of the medial circumflex femoral artery (MCFA) can be identified in
the interval between the upper margin of the
quadratus femoris muscle and the inferior border
of the gemellus inferior muscle. When performing
surgical hip dislocation with trochanteric osteotomy, the femoral head can be dislocated posteriorly by applying external rotation of the hip.
Romeo NM, Firoozabadi R. Classifications in
brief: The Pipkin classification of femoral
head fractures. Clin Orthop Relat Res.
2018;476:1114–1119.
Table 17.2 The Pipkin classification of femoral head fractures
Type Description
1 Dislocation associated with a fracture of the
femoral head caudad to the fovea capitis
femoris
2 Dislocation with an associated fracture of the
femoral head cephalad to the fovea capitis
femoris
3 Type I or II injuries associated with a fracture of
the femoral neck
4 Type I or II injuries associated with a fracture of
the acetabular rim
9. Answer E. The fibres of this ribbon-like structure
run sagittal to the axis of the digit
The sagittal band originates from the volar plates
and surrounds each metacarpophalangeal joint
ulnarly and radially to insert on the extensor hood.
It runs perpendicular to the plane of the extensor
tendons. The ulnar sagittal band is considered to
be stronger and denser than the radial sagittal
band. Instability due to the rupture of the ulnar
sagittal is less commonly seen or reported.
Young CM, Rayan GM. The sagittal band:
anatomic and biomechanical study. J Hand Surg
Am. 2000;25:1107–1113.
10. Answer B. Gluteus medius
The superior gluteal nerve and vessels are the
only structures that exit the pelvis through the
greater sciatic foramen superior to the piriformis
muscle. The superior gluteal nerve innervates the
gluteus medius, gluteus minimus and tensor fasciae latae muscles.
The iliopsoas muscle is supplied by the
lumbar spinal nerves and branches of the femoral nerve.
The nerve to quadratus femoris, the nerve to
obturator internus and the inferior gluteal nerve
(innervates gluteus maximus) exit the pelvis
through the greater sciatic notch below the
piriformis.
Jacobs LG, Buxton RA. The course of the
superior gluteal nerve in the lateral approach to
the hip. J Bone Joint Surg Am. 1989;71:1239–1243.
11. Answer B. The brachialis muscle can be dis-
sected or retracted medially
The extended deltopectoral approach is used to
access fractures involving the proximal 4/5 of the
humeral shaft. The anterior fibres of the deltoid
can be partially released and retracted laterally.
The pectoralis major receives dual motor innervation by the medial pectoral nerve and the lateral
pectoral nerve and is retracted medially. The
lateral cutaneous nerve of the forearm is at risk
when extending the incision of the sup erficial
fascia of the upper arm. The radial nerve enters
the anterior compartment through the lateral
intermuscular septum. The brachialis is supplied
by the radial and the musculocutaneous nerves.
It is usually dissected within the neurovascular
plane. Alternatively, it can be retracted medially.
Ruedi TP, Buckley RE, Moran CG. 6.2.2
Humerus, shaft. In AO Principles of Fracture
Management. Davos: AO Publishing; 2007.
12. Answer B. Bado I – Flexion and supination
Bado classified Monteggia injuries according to
the level and angulation of ulna shaft fracture
and the direction of dislocation of the radial
head. Type I is a fracture of the proximal ulna
and radial head dislocation directed anteriorly.
375
Yusuf Omran Hasan
This is the most common type in children. Type
II is a fracture of the ulna with posterior dislocation of the radial head. This is the most common
type in adults. Type III is lateral dislocation of
the radial head. Type IV is a fracture of the radial
and ulnar shafts with dislocation of the radial
head. Bado types I and III are most stable when
immobilised in >90° of flexion and full
supination.
Rehim SA, Maynard MA, Sebastin SJ, Chung
KC. Monteggia fracture dislocations: a historical
review. JHandSurgAm.2014;39:1384–1394.
13. Answer A. It is unlikely that this patient will
present with sensory symptoms only
The elbow is the most common site for entrapment of the ulnar nerve. It occurs less commonly
at Guyon’s canal in the wrist. In the wrist, Zone I
compression at the proximal Guyon’s canal
results in a mixed motor and sensory deficit
and is most likely caused by the hook of hamate
fractures or ganglion. Zone II compression is
purely motor. Zone III compression occurs secondary to compression of the superficial sensory
branch and is usually vascular in origin. Golf,
cricket and racquet sports have been associated
with hook of the hamate fractures. Carpal tunnel
views can aid in the diagnosis. Jeanne’s sign is a
sign of loss of adductor pollicis muscle power
which is innervated by the deep motor branch
of the ulnar nerve which runs between the pisiform and hamate.
Parker RD, Berkowitz MS, Brahms MA,
Bohl WR. Hook of the hamate fractures in ath-
letes. Am J Sports Med. 1986;14:517–523.
14. Answer E. Tibialis posterior tendon
The tibialis posterior tendon is the closest structure to the medial malleolus behind the distal
tibia. It can be injured during the incision, dissection or drilling for the distal locking of tibial
nails. A prominent posteriorly placed screw can
cause further irritation. The structures behind
the medial malleolus in order (closest first) are:
posterior tibial tendon, flexor digitorum longus,
posterior tibial artery, posterior tibial vein, tibial
nerve and flexor hallucis longus.
Kavuri VC, Earasi K, Varacallo M, Harding
SP. Diagnosing posterior tibial tendon tear with
dynamic ultrasound following tibial
intramedullary nailing. J Clin Orthop Trauma.
2019;10:666–668.
15. Answer D. Screw joint penetration is 50% with
surgical fixation
The SWIFFT is a multi-centre trial which compared cast treatment versus surgical fixation of
undisplaced fractures of the scaphoid waist in
adults. The report showed that there were no
differences in pain, function or in the patientrated wrist evaluation (PRWE) score at 52 weeks.
The surgery group experienced more potentially
serious complications and had a penetration of
the screw into the adjacent joints in 42.9% of the
patients. The results of SWIFFT support treating
all undisplaced and minimally displaced waist of
scaphoid fractures in a cast, to investigate for
non-union between 6-12 weeks and fix all the
confirmed cases immediately.
Dias JJ et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the
scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial.
Lancet 2020;396:390–401.
16. Answer C. Primary re-alignment of the urethra
during fracture surgery is recommended
According to the BOAST 14 guideline, primary
re-alignment of the urethra during fracture surgery is not recommended due to the risk of
further damage in the hands of an inexperienced
surgeon. These injuries are difficult to manage
and are associated with a high long-term incidence of urinary and sexual dysfunction. This
should be referred to and managed early by a
named urologist or/and andrologist.
British Orthopaedic Association BOAST 14:
The Management of Urological Trauma
Associated with Pelvic Fractures; 2016. https://
www.boa.ac.uk/static/86c72eff-26aa-4cec98d1e85cda3dac6c/bcdaeccf-0cff-4da8bca1b9519b3a542d/the%20management%20of%
20urological%20trauma%20associated%20with%
20pelvic%20fractures.pdf.
17. Answer A. Aim to maintain the systolic pres-
sure within 20% of pre-induction values
Bone cement implantation syndrome (BCIS) is
defined as hypoxia, hypotension, cardiac dysrhythmia or increased pulmonary vascular
376
Trauma III Structured SBA
resistance during surgery using methyl methacrylate. The pathophysiology of this potentially
fatal condition is not fully understood. The
Association of Anaesthetists of Great Britain
and Ireland, The British Orthopaedic
Association and The British Geriatric Society
published a concise guideline and recommendation to reduce the incidence of BCIS in patients
undergoing cemented hemiarthroplasty for hip
fracture. The three-stage process includes: the
identification of high-risk patients: increasing
age, cardiopulmonary disease, diuretics and
male sex.
Preparation of team and identification of
roles in case of a severe reaction and specific
intraoperative roles such as thoroughly washing
the femoral canal, avoiding pressurisation and
preparing vasopressors in case of cardiovascular
collapse.
Griffiths R et al. Safety guideline: reducing the
risk from cemented hemiarthroplasty for hip fracture. Association of Anaesthetists of Great Britain
and Ireland British Orthopaedic Association
British Geriatric Society. Anaesthesia
2015;70:623–626.
18. Answer E. Volkmann’s ischaemic contracture
usually occurs on the normal side
Bryant’s or gallows traction is used to manage
femoral shaft fractures in children weighing less
than 18kg and typically less than 18 months old.
Adhesive skin strapping is placed on both
legs and suspended vertically with the hips flexed
at 90° and the knees extended. Gallows traction
has been associated with severe compartment
syndrome and Volkmann’s ischaemic contracture. Usually, vascular compromise occurs on
the normal side. The neurovascular status of
both feet should be monitored daily.
Hunter JB. Femoral shaft fractures in children. Injury 2005;36(Suppl. 1):A86–A93.
19. Answer C. Fracture comminution is unusual
Atypical femoral fractures are related to
long-term osteoporosis treatment with
bisphosphonates.
However, the overall risk for femoral fracture
(typical or atypical) is lower in patients who take
bisphosphonate. Atypical fractures typically
located be low the lesser trochante r, start as
thickening in the lateral cortex and then progress
to a transverse or oblique fracture line medially.
It can be associated with medical spike, and they
can be bilateral.
Larsen MS, Schmal H. The enigma of atyp-
ical femoral fractures: a summary of current
knowledge. EFORT Open Rev. 2018;3:494–500.
20. Answer B. Compression of the third part of the
duodenum by a branch of the aorta
Superior mesenteric syndrome or cast syndrome
is a rare syndrome caused by obstruction of the
third portion of the duodenum. It is caused by
the narrowing of the angle between the aorta and
the superior mesenteric artery. Although rare, it
has been associated with plaster jacket and spica
application, usually due to accentuation of the
lumbar lordosis.
Van Horne N, Jackson JP. Superior
Mesenteric Artery Syndrome. Treasure Island,
FL: StatPearls Publishing; 2022.
21. Answer E. Widening of the interpedicular
distance
Loss of height of the anterior wall of the vertebral
body is seen in compression and burst fractures.
Burst fractures involve injury to the middle
column.
An increase in the interpedicular distance
seen on AP views is suggestive of instability.
The other radiographic signs of unstable injuries
are: w idening of interspinous or interlaminar
distance, articular process fracture, >50% loss
of height. >20° of kyphosis, >50% of canal compromise and associated posterior element
disruption.
McAfee PC, Yuan HA, Lasda NA. The
unstable burst fracture. Spine (Phila Pa 1976)
1982;7:365–373.
22. Answer D. Low bone elasticity is the main con-
tributing factor
Sacral insufficiency fractures have a characteristic appearance on bone scans. The pattern of
uptake resembles a ‘Honda logo’ or ‘H sign’.
These fractures are the results of normal repetitive stress on the abnormal (osteoporotic) bone,
which has a lower elastic modulus and increased
strain to failure compared with the normal bone.
Denis describes three zones of injury to the
377
Yusuf Omran Hasan
sacrum. Zone III injuries that extend into the
spinal canal are associated with the highest rate
of neurological deficit.
Denis F, Davis S, Comfort T. Sacral frac-
tures: an important problem. Retrospective
analysis of 236 cases. Clin Orthop Relat Res.
1988;227:67–81.
Ries T. Detection of osteoporotic sacral fractures
with radionuclides. Radiology 1983;146:783–785.
23. Answer E. None of the abov e
Based on the BOAST peripheral nerve injury
guideline, formal advice from the peripheral
nerve injury unit should be sought within 24
hours if operative management of the fracture
is not indicated, with laceration and penetrating
injuries. If the nerve is damaged intraoperatively,
an immediate referral is recommended. Removal
of the brace and re-manipulating the fracture
risks further damage to the nerve and it is not
advised. In unstable fractures, fixation should be
carried out. Surgical exploration or nerve repair
should be carried out by a specialist peripheral
nerve injuries surgeon.
British Orthopaedic Association BOAST 5:
Peripheral Nerve Injury;2021.https://www.boa.ac
.uk/resource/boast-peripheral-nerve-injury.html.
stabilisation of pelvic, acetabular, femoral and
spinal fractures after appropriate resus citation.
They recommended definitive management of
mechanically unstable fractures within 36 hours
of injury as long as the patient has demonstrated
response to resuscitation based on the improvement of acidosis with a lactate of <4 mmol/l, a
base excess 5.5 mmol/l or pH >7.25.
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.
26. Answer D. Flexor digitorum brevis
There is controversy about the amount of
existing myofascial compartments of the foot.
Early books described four myofascial compartments of the foot. However, recent research suggests the presence of nine myofascial
compartments in the foot (Table 17.3).
Lugo-Pico JG, Aiyer A, Kaplan J, Kadakia
AR. Foot compartment syndrome controversy.
In Mauffrey C, Hak DJ, Martin III MP, ed.
Compartment Syndrome: A Guide to Diagnosis
and Management. Cham: Springer; 2019.
24. Answer B. Vancouver B1
The Vancouver classification was based on the
location of the fracture relative to the stem, the
stability of the implant and the quality of the
bone stock. Type A fractures occur proximal to
the stem, Type B around the stem or just below it
and Type C are located well distal to the tip of the
prosthesis. Type B fractures are further subd ivided into: B1 fractures with a stable implant that
can be treated by internal fixation, B2 fractures
are associated with a loose implant that requires
revision to another stem, and B3 fractures that
are unstable implants with a bone loss which
requires allograft during revision surgery, or
conversion to megaprosthesis.
Duncan CP, Masri BA. Fractures of the
femur after hip replacement. Instr Course Lect.
1995;44:293–304.
25. Answer D. Lactate level <4
Early appropriate care was popularized by Vallier
and colleagues. The concept is based on the early
378
Table 17.3 Compartment contents
Compartment Contents
Medial Abductor hallucis, flexor hallucis
brevis
Superficial
(superficial
central)
Lateral Abductor digiti minimi
Adductor Oblique head of the adductor
Interossei (four
compartments)
Calcaneal (deep
central)
Flexor digitorum longus
Flexor digitorum brevis
Flexor digiti minimi brevis
hallucis
Each compartment includes the
dorsal and plantar interosseous
muscle of its location
Quadratus plantae
27. Answer D. The presence of this swelling does
not influence the final range of motion
Trauma III Structured SBA
Lateral condyle spur formation is almost universal
following lateral condylar fractures. It occurs in
more than 70% of the cases regardless of the treatment method. It is a result of displacement of the
periosteum followed by new bone formation. It is
important to counsel the parents about this complication before starting treatment. However, lateral spurring is not of functional significance.
It can be a cosmetic problem leading to cubi-
tus pseudovarus.
Pribaz JR, Bernthal NM, Wong TC, Silva M.
Lateral spurring (overgrowth) after pediatric lateral condyle fractures. J Pediatr Orthop.
2012;32:456–460.
28. Answer D. Quadriceps tendon rupture
Quadriceps tendon rupture is more prevalent in
males over 40 years old. Those under age 40
usually have an associated metabolic disorder. It
is usually due to eccentric loading of the extensor
mechanism. Patients with complete tears have an
impaired ability to perform a straight leg raise.
With partial tears, some patients will be able to
walk, and there is impaired knee extension.
Quadriceps tendon rupture is more common
than patellar tendon rupture. It is usually unilateral but there are several case reports of bilateral
rupture in the literature.
Pope JD, El Bitar Y, Mabrouk A,
Plexousakis MP. Quadriceps tendon rupture.
Treasure Island, FL: StatPearls Publishing; 2023.
29. Answer A. Continue reaming and don’t per-
form fasciotomy
A randomised prospective study showed that the
peak average pressures during reaming or nail
insertion in unreamed nailing can reach above 30
mmHg. The average pressures quickly returned
to less than 30mmHg and remained there for 24
hours post-operatively. The ΔP values were
greater than 30mmHg at all times after nail
insertion in both the reamed and unreamed
nailing. Therefore, these values are not indicators
of compartment syndrome, and should not preclude reaming or nail inser tion.
Nassif JM, Gorczyca JT, Cole JK, Pugh KJ,
Pienkowski D. Effect of acute reamed versus
unreamed intramedullary nailing on compartment pressure when treating closed tibial shaft
fractures: a randomized prospective study. J
Orthop Trauma 2000;14:554–558.
30. Answer E. Trauma units should aim to have
different options of femoral components for
hemiarthroplasties
The new (updated in 2023) National Institute for
Health and Care Excellence (NICE) guideline for
the management of hip recommends considering
total hip replacement rather than hemiarthroplasty for patients who were able to walk independently out of doors with no more than the
use of a stick and do not have a condition or
comorbidity that makes the procedure unsuitable
for them and are expecte d to be able to carry out
activities of daily living independently beyond 2
years. In addition, the new guideline encourages
hospitals to aim to use a single type of cemented
femoral component for hemiarthro plasties as
standard treatment for displaced intracapsular
hip fracture management. The committee
believes that medical teams familiar with
implanting one single type of component as
standard is associated with a decrease in cost of
training and potentially the cost of adverse outcomes related to using a new implant.
National Institute for Health and Care
Excellence. NICE guideline CG124. Hip fracture:
management. www.nice.org.uk/guidance/cg124.
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