Emergencies

Question 1

A 36-year-old male sustains a grade IIIb open tibia. He has a debridement and external fixation four hours post injury. Forty eight hours later he has a “second look” under general anesthesia, he has an 8cm by 2cm wound which is contaminated and requires second debridement. What should the next operation be?

Answer 1

Pedicle local flap with split skin graft to donor area
Pedicle flap with SSG; the tibia will not heal unless there is soft tissue coverage which can be achieved by either a local or free flap. A local flap has the advantage of not requiring microvascular anastomosis, restricts surgical injury to the already damaged limb and does not preclude a free flap at a later date if required.

Question 2

An 18-year-old driver is trapped in his car for four hours post RTA. On arrival in the Emergency department he has an open tibia with gross soft tissue destruction, no pulses distally and no sensation. Although this is his only injury he has lost a significant amount of blood from his limb, is cold and in hypovolaemic shock. Post resuscitation what should his next operation be?

Answer 2

Amputation; this limb is destroyed in terms of its bones, soft tissues, nerves and vessels. The patient is sick and the last thing he needs is a long operation with additional blood loss that has got a small chance of restoring a functional limb but may well reperfuse dead tissue that then makes the patient toxic.

Question 3

A 42-year-old man presents with a 48 hour history of painful shoulder. The pain is worse on initial movement and he is unable to abduct the shoulder beyond 10 degrees.

Answer 3

Rotator cuff tear

Complete/partial tear of the supraspinatus tendon commonly occurs between the ages of 35-60 years.

The patient is unable to initiate abduction of the shoulder because the supraspinatus and the deltoid help early phase of abduction; supraspinatus causes the first 10-15 degrees of abduction followed by deltoid which helps in further 90-100 degrees of abduction.

Hyperabduction of the shoulder joint is caused by scapular rotation.

Question 4

A 59-year-old lady presents with a four month history of painful shoulder. The pain is worse during the mid phase of abduction and when bringing the hand down. However, there is no pain during the two extremes of movement.

Answer 4

Painful arc syndrome

In painful arc syndrome, there is pain on abduction between 45-160 degrees (middle 1/3 rd of the arc), but the extremes of movements are painless.

Frozen shoulder is commonly seen in the elderly. The pain is worst at the night. Active and passive movements are reduced; abduction and external rotation (less than 30 degrees) is reduced. It may be associated with cervical spondylosis.

Question 5

A 25-year-old rugby player presents with sudden, painful shoulder after a game. He has loss of shoulder contour.

Answer 5

Dislocated shoulder

Shoulder dislocation is common after trauma. Anterior dislocation is the commonest type (in contrast to posterior type in the hip joint). Shoulder dislocation may be associated with injury to the axillary nerve which causes loss of sensation over the upper outer aspect of the deltoid region (‘badge’ area).

Question 6

A 22-year-old lady presents with a closed fracture of the midshaft of her tibia with minimal displacement. On arrival in the emergency department she has lost active movement of her foot and passive stretch results in severe pain.

Answer 6

Four compartment fasciotomy
Four compartment fasciotomy. This lady has clinically got compartment syndrome; the first thing lost is active movement, then passive, then sensation and lastly pulses. If one waits for sensory change to occur there will be irreversible muscle loss. With active movement gone and passive movement being this painful she should undergo fasciotomy as an emergency procedure.

Question 7

A 22-year-old man presents with a grade 1 open fracture of the midshaft of his tibia/fibula sustained during indoor five-a-side football.

Answer 7

Intramedullary nail +/- wound debridement
Intramedullary nail and wound debridement. The fracture is open and communication exists between the fracture haematoma and the outside world. The dead tissue must be excised and copious irrigation performed to reduce the risk of osteomyelitis. The intramedullary nail will allow early weight bearing/mobility and reduce complications of muscle wastage/DVT, etc.

Question 8

A 32-year-old male was involved in an road traffic accident as a front seat passenger 90 minutes ago; the impact was on the left and there is intrusion of the passenger cage.
On arrival in the emergency department his pulse is 90 bpm and his systolic pressure is 110 mmHg. His abdomen is tender in the left upper quadrant and a focussed abdominal sonography for trauma (FAST scan) shows evidence of fluid in the spleno-renal angle.
The plan at the moment would be to follow which of the above options?

Answer 8

CT scan
It is essential to assess the severity of the presumed splenic injury. The FAST scan does not provide this information. There may be other injuries as well. Young patients may initially maintain their pulse and BP despite significant bleeding.

One tries, wherever possible, to preserve the spleen and so he should be closely monitored in high dependency and be reviewed clinically at one to two hourly intervals with serial abdominal examinations. He should undergo serial (daily) ultrasound scans of his spleen/abdomen to ensure there is no continuing bleeding. Any evidence of continuing bleeding may require laparotomy and splenectomy. Splenic repair is possible but seems to be more often discussed than practised.

A surgical ward with the problems of low ratio staffing is not an appropriate place for this type of patient.

Additionally, he should be cautioned that delayed splenic rupture can occur after a week or two (the textbooks say 10 days but nothing in surgery is that predictable) when any haematoma liquefies and causes a raise in intracapsular pressure.

Question 9

An 18-year-old male has been drinking alcohol and becomes involved in a fight. He is incoherent on arrival in the emergency department and has a 2 cm stab wound in the left lower posterior chest.
Clinical examination of his chest is normal but his abdomen is impossible to assess objectively. His pulse is 135 bpm and he has a systolic pressure of 80 mmHg.
The plan at the moment would be to follow which of the above options?

Answer 9

Laparotomy
This man has at least grade 3 if not grade 4 shock; never attribute an injured person’s reduced level of consciousness to alcohol until you have excluded all organic causes.

This degree of shock comes from:

Chest - tension pneumothorax, massive haemothorax, cardiac tamponade
Abdomen - major vessel injury, splenic injury, liver injury
Bones - pelvic disruption, long bone fractures
Other - major vessel injury.
The normal chest examination excludes the tension pneumothorax and the haemothorax; also the stab is low. The posterior position makes tamponade extremely unlikely (and it is a very rare occurrence and should be a diagnosis of exclusion other than in penetrating wounds over the surface landmark of the heart).

There are no associated bony injuries or evidence of injury to other vessels.

The site of the stab is over the surface marking of the spleen (place your right hand across your left lower chest and reach as far back as you can, this is approximately the site of your spleen).

If you waste time in the emergency department getting scans/x rays this man will either die or continue to haemorrhage until he is cold, coagulopathic and descending into renal dysfunction secondary to acute tubular necrosis: he obviously needs immediate surgery, so go to theatre.

Question 10

An 18-year-old male is admitted with a gun shot wound to the abdomen. The weapon is believed to have been a hand gun at a range of 2 - 3 metres.
The patient has an entry wound 4 cm to the right of the umbilicus with an exit wound in the back 4 cm to the right of midline at the umbilical level. The patient has a pulse of 105 bpm and a systolic blood pressure of 110 mmHg.

Answer 10

Laparotomy
Laparotomy: this man has been shot at close range, consequently the calibre/type of weapon is largely irrelevant because the projectile is travelling with maximal speed and thus has a huge amount of kinetic energy (E = ½ mv2) which can be “dumped” into tissue.
The projectile appears to have entered and exited along a straight path. However, it may have deflected off bony surfaces and caused damage to anything inside the peritoneal cavity, retroperitoneum, pelvis and indeed thorax. In the absence of an exit wound an abdominal/chest CT would be required prior to a laparotomy. Also the projectile may have caused a pressure wave which causes severe damage to any hollow viscus.

Question 11

An 18-year-old male is admitted with a stab wound to the abdomen. The patient has an entry wound 8 cm to the right of the umbilicus without an exit wound. The patient has a pulse of 85 bpm and a systolic blood pressure of 110mmHg. Digital examination of the wound indicates that the peritoneum has been breached.

Answer 11

Laparoscopy
Laparoscpy: The ATLS protocol advises inserting a finger into the wound. If the peritoneum has been breached it warrants at least a laparoscopy. He is a stable patient and CT scan will not pick up small penetrating injuries.p>

Question 12

A 40-year-old man is involved in a head-on collision while driving to work. In the resuscitation room he opens his eyes to pain, is mumbling inappropriately and tries to stop the SHO putting a cannula in his arm.

Answer 12

10
Eye opening to pain: 2
Mumbling - words but incomprehensible: 3
Localises to pain: 5

Question 13

A 50-year-old woman jumps from the seventh floor of an office block in an attempt to commit suicide. In the resuscitation room there is no eye opening or speech. She does not respond when her nail bed is pressed.

Answer 13

3
No responses for eye opening, speech or pain.
1 each = 3

Question 14

A 60-year-old man has been celebrating his daughter’s wedding. He gets in a fight with his son-in-law and is knocked unconscious.
When he arrives at the Emergency department he will open his eyes when asked, but is unsure of where he is and why. When asked to take his tie off he does so.

Answer 14

13
Eye opening when asked: 3
Confused speech: 4
Normal movements: 6

The Glasgow coma scale was introduced in 1974 and is widely used as an objective measurement of a patient’s conscious level. Three variables are assessed and scored as in the table below.

Score Eye opening Verbal response Motor response
6 - - Obeys commands
5 - Speech / Oriented Localises to pain
4 Spontaneous eye opening Confused speech Withdrawal to pain
3 Eye opening to speech Incoherent speech Abnormal flexion to pain
2 Eyes open to pain No words only sounds Extends to pain
1 No eye opening No sounds No movements.
The minimum score is 3. A severe injury would have a GCS of 8 or less (which is the definition of coma), moderate 9-12, minimal 13-15.

A further abbreviated scoring system is sometimes used to assess conscious level of the critically ill in the primary survey - AVPU.

A Alert
V Responds to verbal stimuli
P Responds to pain
U Unresponsive

Question 15

A 20-year-old girl is thrown from her boyfriend’s car after a head on collision. In the resuscitation room her pulse is more than 150 beats per minute with an unrecordable blood pressure.

Answer 15

Class IV

Shock is the clinical manifestation of inadequate organ perfusion and tissue oxygenation. In the trauma situation, shock is haemorrhagic in origin until proven otherwise.

Hypovolaemic shock may be classified according to the amount of blood volume loss and corresponding physiological response.

The percentage blood volume loss can be remembered if one considers a game of tennis scoring system, that is:

Class I 15%
Class II 15-30%
Class III 30-40%, and
Class IV >40%.
The table below shows the expected physiological response for a 70 kg male.

Class I Class II Class III Class IV

Blood loss (ml) Up to 750ml? 750-1500 1500-2000 >2000
Blood loss (% vol) Up to 15% 15-30% 30-40% >40%
Pulse 100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pressure Normal Increased Decreased Decreased Decreased
Resp rate 14-20 20-30 30-40 >35
Urine output >30 20-30 5-15 Negligible

Question 16

A 50-year-old motorcyclist hits a wall at some speed. In the resuscitation room he is bleeding profusely from an open wound in his left lower leg. His pulse is 115 beats per minute, respiratory rate of 25 and decreased pulse pressure although normal blood pressure.

Answer 16

Class III

Class I 15%
Class II 15-30%
Class III 30-40%, and
Class IV >40%.
The table below shows the expected physiological response for a 70 kg male.

Class I Class II Class III Class IV

Blood loss (ml) Up to 750ml? 750-1500 1500-2000 >2000
Blood loss (% vol) Up to 15% 15-30% 30-40% >40%
Pulse 100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pressure Normal Increased Decreased Decreased Decreased
Resp rate 14-20 20-30 30-40 >35
Urine output >30 20-30 5-15 Negligible

Question 17

A 40-year-old falls off his roof while fixing some guttering. He sustains a laceration to his right arm. In the accident department he has a pulse of 80 beats per minute, blood pressure 130 mmHg systolic with a normal pulse pressure.

Answer 17

Class I

Class I 15%
Class II 15-30%
Class III 30-40%, and
Class IV >40%.
The table below shows the expected physiological response for a 70 kg male.

Class I Class II Class III Class IV

Blood loss (ml) Up to 750ml? 750-1500 1500-2000 >2000
Blood loss (% vol) Up to 15% 15-30% 30-40% >40%
Pulse 100 >120 >140
BP Normal Normal Decreased Decreased
Pulse pressure Normal Increased Decreased Decreased Decreased
Resp rate 14-20 20-30 30-40 >35
Urine output >30 20-30 5-15 Negligible

Question 18

A 56-year-old man is involved in a head on collision in his Transit van. Being unrestrained he sustained an extensive injury to the left side of his chest caused by hitting the steering wheel. In the resuscitation room he is tachypnoeic with normal blood pressure and pulse. Trachea is central with normal percussion note but the breath sounds are slightly reduced on the left side. Of note is the fact that on inspiration the left side of the chest appears to decrease in size.

Answer 18

Flail chest

A flail chest occurs as a result of severe crush injury, with the consequence of disruption of normal wall movement. The major problem of a flail segment is the injury to the underlying lung segment. Clinically the chest wall moves paradoxically on inspiration therefore reducing tidal volume and affecting ventilation. Treatment is by analgesia, physiotherapy and careful fluid management. Occasionally, positive pressure ventilation is required.

Question 19

Following an altercation with his girlfriend, a 27-year-old man is admitted to your casualty unit having sustained a stab injury to the left upper chest. On admission, he is tachypnoeic, hypotensive and with a pulse of 140 bpm. Clinical examination reveals increased percussion note on the left side, absent breath sounds and a deviated trachea to the contralateral side.

Answer 19

Tension pneumothorax

Open pneumothorax (sucking chest wound) occurs as a result of large penetrating injuries resulting in an equilibrium of intrathoracic and atmospheric pressures. Should the defect be approximately 2/3 the diameter of the trachea, air will enter the chest via the wound thus reducing ventilation. Immediate management involves placement of an occlusive dressing secured on three sides to produce a flutter valve together with closed tube thoracostomy (chest drain) distant to the wound.

Tension pneumothorax occurs as a result of air entering the chest cavity with no means of escape. The lung of the ipsilateral side collapses and as further air enters this side of the chest the mediastinum and trachea are deviated to the contralateral side. A tension pneumothorax is a clinical diagnosis and should not be made by use of a CXR. Respiratory distress, trachea deviation to the contralateral side and decreased air entry of the affected side occur. Immediate needle decompression in the second intercostal space (green needle in the mid clavicular line) is indicated initially, with closed tube thoracostomy (chest drain) being definitive.

Massive haemothorax generally occurs due to penetrating trauma but may be a consequence of blunt trauma. Strictly speaking it occurs when 1500 ml or more of blood accumulates in the thoracic cavity. Clinically the patient will show signs of hypovolaemia with associated reduced breath sounds and dullness to percussion on the affected side. Treatment is by closed tube thoracostomy following resuscitation with large bore iv access. Thoracotomy may be indicated following this.

Question 20

A 17-year-old man is involved in a fight outside a pub during which a knife is thrust into his epigastrium with some force. The paramedics deliver him to your Emergency department with a thready pulse of 160 bpm, negligible blood pressure. His neck veins are distended.

Answer 20

Cardiac tamponade may be as a result of penetrating (more common) or blunt trauma.

The pericardium is a fixed fibrous entity and therefore only a small amount of blood may cause tamponade. The traditional triad (Beck’s triad) is not always present, that is, increased central venous pressure (CVP), reduced BP and muffled heart sounds. In this circumstance heart sounds will be of little value. Just think of all the noise in the resus bay.

Kussmaul’s sign may also be present, that is, increased CVP on inspiration.

The treatment of cardiac tamponade is immediate pericardiocentesis, and as little as 15 ml aspirated may improve cardiac output. Successful pericardiocentesis is an indication for thoracotomy by an experienced surgeon.

Question 21

A 25-year-old male presents after being bitten on the hand by a terrier. The wound appears deep and is associated with swelling.
After the wound is cleaned and he has received tetanus immunisation.
Which of the following antibiotic regimes would be most appropriate for this patient?
(Please select 1 option)
Co-amoxiclav oral
Doxycycline oral
Flucloxacillin oral
Penicillin G IM
Trimethoprim oral

Answer 21

Co-amoxiclav

The use of prophylactic antibiotics in dog bites is controversial although evidence supports their use in deep wounds, bites to the hands and signs of infection.

The antibiotic of choice would be oral Augmentin.

Question 22

Fracture of the 5th metacarpal bone

Answer 22

Although there are degenerative changes particularly related to the MCP joints and interphalangeal joints, there is a fracture at the base of the fifth metacarpal bone.

This is subtle, but there should be a smooth contour to the cortex of all bones. This is not present at the base of the fifth metacarpal bone.

There is a sclerotic line and an area of lucency due to the break in the cortex.

Question 23

Ewings

Answer 23

The diagnosis is a Ewing’s tumour.

This is a typical site and age.

The major abnormality here is a ‘sunburst’ spiculated periosteal reaction related to the left iliac wing, although there are a range of x ray abnormalities described to occur in Ewing’s.

An MRI scan is required to clarify the extent of the tumour.

Question 24

Fractured radius

Answer 24

This is a fracture of the distal radius with an abrupt kink in the contour of the radius.

This is a greenstick fracture and one of the commonest fractures in children who will fall off anything they climb onto or ride.

Manipulation under anaesthesia (MUA) is needed only if there is significant angulation. Otherwise, plaster of Paris (POP) immobilization for 4 weeks will suffice.

Question 25

Fractured medial malleolus

Answer 25

There is an avulsion injury of the medial malleolus, represented by the small fragment of bone inferior to the medial malleolus.

This probably occurred whilst he was stretching for the ball with a mistimed tackle.

Question 26

Fractured radius and ulna

Answer 26

There are fractures of the distal radius and ulna with an abrupt kink in the contour of the bones.

Question 27

An 18-month-old boy presents with pain in the right elbow. He was protesting about coming shopping with father, who pulled him up by his arm.
Full term normal delivery, no neonatal problems. Immunisations up to date. No family or social history of note.
On examination the temperature is 36.5°C, respiratory rate 20/min, pulse 100/min. His right hand is held pronated, and he cries when detailed examination is attempted.
What is the most likely diagnosis?
(Please select 1 option)
Erb’s palsy
Osteoid osteoma
Osteomyelitis
Pulled elbow
Shoulder dislocation

Answer 27

Pulled elbow

The patient has sudden onset of elbow pain following a traction injury.

The history suggests a pulled elbow (nursemaid’s elbow), where the annular ligament around the proximal radius is subluxed into the elbow joint.

Rotating the hand to the supinated position whilst pressing on the radial head reduces the dislocation with a palpable click and instant relief of symptoms.

Question 28

A 12-year-old boy is a passenger in the right rear seat of a car in a road traffic accident (RTA) at 30 mph.
He is thrown forward in the frontal impact but is restrained by his 3-point seatbelt.
He had a full term normal delivery with no neonatal complications. His immunisations are up to date. There is no family or social history of note.
On examination he is apyrexial, with respiratory rate 15/min, and pulse 100/min. He is pale and sweaty with a capillary refill time of 3 seconds. He has bruising across his lower abdomen. His abdomen is tender to touch generally.
Which organ is most likely to be injured?
(Please select 1 option)
Aorta
Liver
Lumbar spine
Peritoneum
Spleen

Answer 28

Spleen

The history is of deceleration injury during an RTA. The seat belt will run across the left side of the abdomen.

This can cause injuries to the lumbar spine and intra-abdominal organs. Lap-belts give much poorer restraint that 3-point restraints.

The most mobile structure is most at risk. This is likely to be the spleen.

Question 29

A 45-year-old bee-keeper is brought to the emergency unit following a bee sting.
On examination, he appears pale, has difficulty in breathing and has an increased respiratory rate. His blood pressure is 122/70 mmHg and his pulse rate is 120 beats/minute.
Chest examination reveals an inspiratory stridor.
Clinically, he is diagnosed to have an anaphylactic shock.
Which of the following is the most appropriate treatment?
(Please select 1 option)
Intramuscular adrenaline 0.5 mg
Intravenous chlorpheniramine maleate 10 mg
Intravenous dopamine 50 mg
Intravenous hydrocortisone 100 mg
Nebulised salbutamol 5 mg

Answer 29

Intramuscular adrenaline 0.5 mg

The clinical signs of anaphylactic shock include

Shortness of breath
An increased respiratory rate
Tachycardia
Inspiratory stridor
and sometimes

Evidence of peripheral shutdown.
Patients diagnosed to have an anaphylactic shock should be placed in a comfortable, reclining position. High flow of oxygen should be administered and intravenous access secured.

Adrenaline is the first choice drug in the management of anaphylactic shock.

An anti-histamine drug such as chlorpheniramine maleate is useful to reduce the symptoms.

Hydrocortisone has a role in the treatment of anaphylactic shock although its action is delayed.

An inhaled agonist such as salbutamol is useful to treat the bronchospasm associated with the shock.

Dopamine does not have any role in the management of anaphylactic shock.

See Resuscitation Council Guidelines http://resus.org.uk/pages/reaction.pdf

Question 30

A 21-year-old professional footballer presents to the emergency department with severe, stabbing pain just above his right knee joint. He states that the pain was of sudden onset and happened whilst he was sprinting during a match.
On examination, he walks with a limp and is unable to extend the leg. There is a swelling over the supra-patellar region and is identified to have a low-lying patella. Knee jerk is absent.
(Please select 1 option)
Fracture of patella
Injury to the posterior cruciate ligament
Tear of adductor magnus muscle
Tear of biceps femoris tendon
Tear of quadriceps tendon

Answer 30

Tear of quadriceps tendon This is the correct answerThis is the correct answer
A quadriceps tear may occur in both young athletes and older patients. The usual mechanism of injury is from kicking, sprinting or whilst being engaged in a sports activity which exerts sudden strain to the quadriceps tendon.

Patients with tear of the quadriceps tendon typically present with acute knee pain, swelling, and functional loss following a stumble or a fall.

The common clinical presentations include

Painful gait
Inability to extend the knee
Inability to straight leg raise
Supra-patellar swelling.
There may be a palpable defect in the supra-patellar area and a low-lying patella, but swelling initially may obscure this finding.

Neurological examination of the thigh and knee may be normal except for decreased quadriceps motor function and an absent knee jerk.

Question 31

A 7-year-old boy is brought to the emergency department with a painful and swollen right elbow after he fell off whilst climbing a tree.
On examination there is tenderness around the elbow region with obvious deformity. Radial pulse is present but feeble. He is unable to flex his right index finger and has loss of sensation over the thenar eminence and the thumb. Radiological investigation reveals a supra-condylar fracture of the right humerus with the upper fragment penetrating the skin.
Which nerve is most likely to be injured in this patient?
(Please select 1 option)
Median nerve
Median pectoral nerve
Musculocutaneous nerve
Radial nerve
Ulnar nerve

Answer 31

Median nerve

Median nerve is formed by the C5 to C7 roots from the lateral cord of the brachial plexus and from the C8 and T1 roots from the medial cord.

In the arm it runs in close proximity to the brachial artery and may be injured following supracondylar fractures of the humerus. Thus the radial pulse may be feeble or absent.

In the cubital fossa the median nerve passes between the two heads of pronator teres. It then travels between flexor digitorum superficialis and flexor digitorum profundus before emerging between the flexor digitorum superficialis and the flexor carpi radialis.

The median nerve then passes through the carpal tunnel where it may be compressed to cause the carpal tunnel syndrome.

Question 32

A 4-year-old child is brought in to the Emergency Department after being knocked over by a car.
You are the Emergency Department doctor who initially has to assess him. The Emergency Department nurse in the resuscitation area with you performs a set of observations as soon as the child arrives.
What would you expect the normal physiological observations of a child in this age group to be?
(Please select 1 option)
HR 90, RR 80, RR 75, RR 70, RR 60, RR

Answer 32

HR 75, RR 90, RR 80, RR 75, RR 70, RR 60, RR

Question 33

A 4-year-old girl falls off a kitchen table onto which she has climbed.
She is witnessed by her mother as falling on to her left upper limb. She cries immediately and is brought to the emergency department. Her elbow is x rayed and a displaced supracondylar fracture of her humerus is found.
What nerve is most likely to be injured by this fracture?
(Please select 1 option)
Anterior interosseous
Axillary nerve
Posterior interosseous
Superficial branch of radial nerve
Ulna nerve

Answer 33

Anterior interosseous

The anterior interosseous branch of the median nerve is the most likely to be damaged in supracondylar fractures of the humerus.

Displaced fractures can cause compromise to the vascular supply of the forearm by injuring the brachial artery.

The anterior interosseous branch of the median nerve is the most likely nerve to be damaged. This can be tested by asking the child to make an ‘O’ shape with their thumb and index finger.

Question 34

A 15-year-old boy is playing rugby and sustains an anterior dislocation of his left shoulder.
He attends the Emergency department, where the humerus is put back into joint under sedation.
Where would you test sensation for the nerve most likely to have been damaged when he dislocated his shoulder?
(Please select 1 option)
First dorsal web space
Little finger
Regimental badge distribution
Second dorsal web space
Thumb

Answer 34

Regimental badge distribution

The nerve that is most likely to have been damaged during the dislocation is the axillary nerve. This supplies an area of skin overlying the upper part of the arm.

Motor sensation could be assessed by examining the deltoid muscle, which is also supplied by the axillary nerve.

Question 35

A 24-year-old man is playing football. He is tackled heavily and sustains and isolated fracture of his right tibia with an intact fibula.
The injury is closed. He is placed into an above knee backslab in the accident and Emergency department. He is comfortable in this. He is referred to you as the on call trauma SHO.
What should you do next?
(Please select 1 option)
Admit the patient to the ward for observation
Discharge patient allowing weight bearing as able with fracture clinic follow up
Discharge patient non-weight bearing with fracture clinic follow up
Inform trauma theatre immediately so that the patient can have emergency surgery
Organise an emergency CT scan from Emergency department

Answer 35

Admit the patient to the ward for observation

One of the major complications of this type of fracture is compartment syndrome.

This patient is at particular risk as his muscular compartments will already be pumped with blood from exertion. He should therefore not be sent home, but admitted to the ward for elevation of his leg and closed monitoring for compartment syndrome.

The fracture may be treated conservatively and may not need any surgical fixation.

Question 36

A 72-year-old lady, who is a keen golfer and is normally independently mobile, trips and falls at home. She is brought to the emergency department by her son where she is complaining of severe hip pain.
An x ray of her pelvis is taken which reveals an undisplaced intracapsular fracture. There are no signs of osteoarthritis on the x ray.
What treatment would you advise?

Answer 36

Cannulated screw fixation

Most patients with fractures of their neck of femur would have surgical fixation.

As the patient has an undisplaced intracapsular fracture, fixation with cannulated screws would be appropriate.

If the patient had an osteoarthritic hip and was independently mobile a total hip replacement would then be more appropriate.

The dynamic hip screw is used for extracapsular fracture fixation.

Question 37

A 24-year-old teacher falls onto her right (dominant) hand whilst playing netball. She suffers immediate pain and is brought to the emergency department.
On examination, she is particularly tender over the anatomical snuffbox area. An x ray is ordered but no fracture is seen.
What is the most likely bone to have been injured?
(Please select 1 option)
First metacarpal
Lunate
Radius
Scaphoid
Ulna

Answer 37

Scaphoid

The scaphoid can be injured by a fall onto the outstretched hand and is the most likely bone to be injured in someone of this age group.

It is uncommon for the fracture line not to be seen on initial x ray.

A high index of suspicion is needed, however, as the bone can undergo avascular necrosis. This particularly affects the proximal pole of the scaphoid.

Question 38

A 26-year-old engineer is brought to the Emergency department after being involved in a road traffic accident where he was an unrestrained front seat passenger. He was flung sideways.
He was unable to walk after the accident and is brought to Emergency department complaining of severe hip pain.
On examination, the leg is short and lies adducted.
An x-ray is taken which shows a posterior dislocation of the hip.
What should you do next?
(Please select 1 option)
Admit to ward and wait for space on a trauma list
Arrange urgent CT to determine whether there is an acetabular fracture
Attempt closed reduction in Emergency department using local block
Attempt closed reduction in Emergency department using sedation
Send the patient to theatre immediately for closed reduction

Answer 38

Send the patient to theatre immediately for closed reduction

Dislocation of a hip is a true orthopaedic emergency. The longer the patient waits to have his hip put back into socket, the greater the risk of avascular necrosis.

Due to the force involved the hip is very unlikely to be reduced in the Emergency department. The patient must be sent to the theatre immediately for closed reduction of the hip under anaesthetic.

Question 39

The description is of a Galeazzi fracture-dislocation.

The Monteggia fracture-dislocation is of the ulna with disruption of the proximal joint.

The other three fractures named are of the distal radius.

Answer 39

Galeazzi

The description is of a Galeazzi fracture-dislocation.

The Monteggia fracture-dislocation is of the ulna with disruption of the proximal joint.

The other three fractures named are of the distal radius.

Question 40

A 33-year-old man is injured whilst riding a motorbike. He sustains a fracture of his tibial plateau.
The orthopaedic registrar decides to provide initial stability by placing a quadrilateral frame (external fixator frame). This consists of two pins being placed and then linked by rods. The first pin is placed in the proximal tibia and the second through the calcaneum in a medial to lateral direction. The site of entry of the calcenal pin is 2.5 cm superior and towards the toes away from the heel.
What nerve in this area could be damaged if the pin is incorrectly placed?
(Please select 1 option)
Deep peroneal nerve
Lateral plantar nerve
Medial plantar nerve
Superficial peroneal nerve
Sural nerve

Answer 40

Median plantar nerve

The medial plantar nerve runs in this area and could be damaged by incorrect pin placement.

Question 41

An 83-year-old lady has been gardening on a sunny bank holiday when she slips on her garden path, falling onto her outstretched left hand. She hears a ‘crack’ and due to severe pain attends her local emergency department.
An x ray shows what the casualty officer thinks to be a Colles’ fracture.
Which options describes the fracture displacement seen in a Colles’ fracture?
(Please select 1 option)
Displaced and angulated dorsally and radially
Displaced and angulated dorsally and ulnarwards
Displaced and angulated in a volar and radial direction
Displaced and angulated in a volar and ulnar direction
Displaced and volar fracture with an intra-articular fracture

Answer 41

Displaced and angulated dorsally and radially

The Colles’ fracture was first described by Abraham Collins, a Dublin surgeon in 1814. He described a ‘dinner fork’ deformity of the distal radius.

A plain film x ray will show a fracture which is displaced and angulated in a dorsal and radial direction.

Question 42

A 10-year-old boy falls whilst running in the school playground, injuring his right forearm. He is tender over his distal radius.
An x ray shows a displaced fracture through the distal epiphysis with a fragment of metaphyseal bone also broken.
How would you classify this injury in the commonly used Salter Harris classification?
(Please select 1 option)
Salter Harris type 1
Salter Harris type 2
Salter Harris type 3
Salter Harris type 4
Salter Harris type 5

Answer 42

Salter Harris type 4

The Salter Harris classification system for physeal injuries is one of the most commonly used in orthopaedics. It was first described by Salter and Harris in 1963.

A type 1 fracture is through the hypertrophic zone of the growth plate.

A type 2 fracture is through the physis with a metaphyseal fracture.

A type 3 fracture splits the epiphysis then moves transversely to one side.

A type 4 fracture is similar but extends into the metaphysic.

A type 5 fracture is a compression injury.

Question 43

A 10-year-old boy falls whilst running in the school playground, injuring his right forearm. He is tender over his distal radius.
An x ray shows a displaced fracture through the distal epiphysis with a fragment of metaphyseal bone also broken.
How would you classify this injury in the commonly used Salter Harris classification?
(Please select 1 option)
Salter Harris type 1
Salter Harris type 2
Salter Harris type 3
Salter Harris type 4
Salter Harris type 5

Answer 43

Salter Harris type 4

The Salter Harris classification system for physeal injuries is one of the most commonly used in orthopaedics. It was first described by Salter and Harris in 1963.

A type 1 fracture is through the hypertrophic zone of the growth plate.

A type 2 fracture is through the physis with a metaphyseal fracture.

A type 3 fracture splits the epiphysis then moves transversely to one side.

A type 4 fracture is similar but extends into the metaphysic.

A type 5 fracture is a compression injury.

Question 44

A child aged 6 months is brought to the Emergency department having fallen off a chair the previous day. The child appears clinically well, but he has a boggy occipital swelling.
Which of the following would be the appropriate action?
(Please select 1 option)
Arrange urgent head CT
Confront the parents as you suspect this is a non-accidental injury, given the delay in presenting to hospital
Discharge after warning the parents that suspicions about possible child abuse have been aroused
Discharge and arrange an appointment at the next paediatric clinic
Discharge and notify the duty social worker

Answer 44

Urgent CT

This scenario describes a baby with possible non-accidental injury.

The child presents having fallen off a chair. It is important to ascertain why a baby of 6 months was sitting on a chair unsupervised. The presentation is also delayed. The baby has sustained a fracture and will therefore need to be observed and monitored.

He also needs to be in a place of safety until social service investigations have been carried out.

The boggy swelling suggests a fracture, so a CT head scan needs to be carried out. He also needs a skeletal survey.

Question 45

Which of the following statements is correct regarding basic life support (BLS) in an infant?
(Please select 1 option)
Cardiac compression should only be performed where the pulse is absent during palpation of 10 seconds
Five rescue breaths should be administered to the nose and mouth
The carotid pulse is palpated
The head should be in a flexed position
The palm of the hand is used to perform cardiac compression

Answer 45

Five rescue breaths should be administered to the nose and mouth

In BLS in an infant the head position should be neutral. The infant’s trachea is short and soft and may easily become compressed if the neck is extended. In an older child the head should be placed in a ‘sniffing the air’ (neck slightly extended) position to improve the airway.

Five initial slow rescue breaths are given - rapid breaths cause gastric distension. The infant’s neck is short and fat and the carotid pulse may be difficult to identify, therefore the brachial or femoral pulse is palpated.

Cardiac compression is carried out for absent pulse for up to 10 seconds or heart rate of less than 60 beats per minute with signs of poor perfusion.

Two fingers are used to perform chest compressions, or the hand encircling technique (both hands encircling the chest). The fingers should be placed one fingerbreadth above the xiphisternum.

Question 46

Which of the following is correct regarding near drowning in the child?
(Please select 1 option)
Carries a worse prognosis in salt water immersion
Is rarely associated with cervical spine injury
Requires external rewarming only if the core temperature is above 32°C
Results in apnoea and tachycardia on initial immersion
Survival chances are increased if the rectal temperature on arrival is above 33°C

Answer 46

Requires external rewarming only if the core temperature is above 32°C

On initial immersion the diving reflex occurs, which results in apnoea and bradycardia. Later, as apnoea continues hypoxia results, causing tachycardia, increase in blood pressure and acidosis.

Rapid cooling of the organs to below 33°C is protective and associated with a better prognosis.

Immersion in salt or fresh water carries the same prognosis.

Cervical spine injury should be suspected in all cases of near drowning, as the incidence of this associated injury is high, especially in diving accidents.

External rewarming (removal of wet clothing, warm or heating blankets, infrared lamp) is sufficient for core temperatures of 32°C or above but for lower core temperature, core rewarming becomes necessary (warm intravenous fluids and ventilator gases, gastric/bladder/peritoneal/pleural/pericardial lavage).

Efforts to resuscitate should be continued until the core temperature is at least 32-34°C.

Question 47

In the management of 2-year-old child with burns, which of the following is correct?
(Please select 1 option)
A urine output of 0.5 ml/kg/hr is an indicator of adequate hydration
Inotropic support is rarely required in burns

Answer 47

Lund and Browder chart accurately estimates the percentage of burns

Damp dressings can cause hypothermia in children; therefore, continuous assessment of the child is essential.

Lund and Browder chart takes account of child proportions while the rule-of-nines is useful in adult burns; in children, head makes up 14% of the total body surface area and the legs make up only 14%.

Urine output of at least 1 ml/kg/hr is required in this age group; 0.5 ml/kg/hr is adequate in adults.

Inotropes such as dopamine may be required if the urine output is not satisfactory.

The wound depth should be estimated again after 24-48 hours, since a partial thickness burn may progress to a full-thickness burn, thus altering the management plan.

Question 48

Which of the following statements regarding anaphylaxis is incorrect?
(Please select 1 option)
Causes degranulation of basophils and mast cells
Causes eosinophilia
Causes urticaria
Is produced by Ig E antibody
Occurs 24 hours after the initial stimulus

Answer 48

Occurs 24 hours after the initial stimulus

Anaphylaxis is a type I hypersensitivity reaction and occurs within minutes or hours.

As well as bronchoconstriction, vasodilatation and circulatory collapse with pharyngeal swelling with possible airway obstruction, anaphylaxis may be associated with urticaria and pruritus.