Year 5 – Ortem – Trauma

Front 1

Rule for automatic acceptance in major trauma centre in poly trauma?

Back 1

A, B or C

A) Haemodynamic instability

B) Visceral laceration ⊙ fractured (long bone/pelvis/spine)

C) Significant injury ⊙ Injury requiring specialty care at major trauma centre

Front 2

Rule for automatic acceptance in major trauma centre in neuro trauma?

Back 2

A or B

A) Penetrating head injury

B) Head injury with CT changes

Front 3

Rule for automatic acceptance in major trauma centre in spine trauma?

Back 3

A) Unstable spinal injury (any level)

B) Spinal injury with neurology

C) Open spin fracture

Front 4

Rule for automatic acceptance in major trauma centre in thoracic trauma?

Back 4

A) Penetrating chest injury

B) Flail chest in ≥3 segments

C) Rupture bronchus or diaphragm

D) Blood loss of >0.5L immediately following insertion of chest drain or 0.25L/hour for ≥3h

D) Suspected aortic transection

E) Cardiac tamponade

Front 5

Rule for automatic acceptance in major trauma centre in pelvis trauma?

Back 5

Haemodynamic instability

Pelvic or acetabular fracture requiring surgery

Front 6

Rule for automatic acceptance in major trauma centre in extremities trauma?

Back 6

De-vascularised limb

Open fracture of lower limb or (upper limb ⊙ requiring debridement/soft tissue cover)

Front 7

Rule for automatic acceptance in major trauma centre in burns?

Back 7

Multiple injuries ⊙ burn injury

Front 8

How is the Major Trauma Centre contacted?

Back 8

Call 2222 and state "Adult trauma call to JR ED Resus"

Front 9

To whom is the call transferred when 2222 is called with "Adult trauma call to JR ED Resus" is activated and what is her/their role?

Back 9

Crash bleep of...

Trauma FY2 (Scribe)

Trauma registrar (Primary survey)

ICU registrar (Airway)

General surgeon registrar

Surgery SHO

ED senior (Trauma Team Leader)

Front 10

True or false: imaging can hopefully be acquired and analysed faster in a case of a trauma call because the radiographer and radiologist are also paged following 2222 call

Back 10

True

Front 11

Which number should be called to activate Major Haemorrhage Pack?

Back 11

4444

Front 12

Patient is actively bleeding large amounts. What should you do?

Back 12

1) Administer tranexamic acid (TXA) - 1g bolus followed by 1g infusion

2) Call switchboard on 4444

3) Request MHP Pack 1

4) Take blood and send to lab while waiting: X-match, FBC, PT, aPTT, Fibrinogen, U&E, Ca (2 purple, 1 blue, 1 green)

5) Give MHP Pack 1

6) Reassess

Front 13

What does the Major Haemorrhage Protocol Pack 1 contain?

Back 13

6 units of RBC

4 units of FFP

Emergency O blood if required

Front 14

What is the deadly triad of a patient who is bleeding?

Back 14

Hypothermia

Acidosis

Coagulopathy

Front 15

Why is it important to minimise movements in major trauma?

Back 15

Avoid dislodging a clot which would cause haemorrhage

Front 16

Patient with major trauma has been stabilised with ABC. What is the next step in investigation?

Back 16

CT Trauma scan (head/neck/thorax/abdo/pelvis with contrast)

Front 17

Patient has sustained trauma and has reduced consciousness level (GCS = 7). What do you do regarding airways?

Back 17

Endotracheal intubation since airway reflexes have been lost

Front 18

AVPU and GCS threshold for endotracheal intubtaion

Back 18

AVPU ≤ P
GCS ≤ 8

Front 19

What is triple immobilisation in trauma?

Back 19

Cervical collar

Blocks placed on both side of the head

Tape across the forehead and chin

Front 20

Name 6 chest emergency that may cause death due to impaired breathing

Back 20

Airway obstruction (transection of bronchus)

Tension pneumothorax

Open pneumothorax

Massive haemothorax

Flail chest

Cardiac tamponade

Front 21

Management of open pneumothorax

Back 21

Close wound and chest drain

If not available: place a bandage and attach it at three corners creating a one-way valve allowing air to escape during expiration.

Front 22

Diagnosis of cardiac tamponade

Back 22

USS

Front 23

What defines severe traumatic brain injury and moderate TBI?

Back 23

Severe TBI: GCS ≤ 8

Moderate TBI: 9 ≤ GCS ≤ 12

Front 24

Define cerebral perfusion pressure

Back 24

Mean arterial pressure - ICP

Front 25

Patient has a GCS of 7. You achieve endotracheal intubation and start ventilation. But the patient keeps deteriorating. What do you do?

Back 25

Mannitol + Hyperventilation

Front 26

What clinical sign may suggest coning?

Back 26

Cushing's triad

Bradycardia

Hypertension

Irregular breathing

Front 27

Describe the Glasgow Coma Scale

Back 27

Front 28

True or false: trauma is a disease

Back 28

True since a disease is a particular abnormal condition, adisorder of a structure or function, that affects part orall of an organism.

Front 29

Back 29

Front 30

Define fracture

Back 30

Break or discontinuity in the cortex of a bone

Front 31

Outline the 5 step description of fractures

Back 31

1) Bone

2) Part of the bone

3) Type of fracture

a. Simple (spiral, oblique transverse)

b. Wedge

c. Complex

d. Intraarticular

4) Deformity

a. Translation

b. Angulation

c. Rotation

d. Shortening

5) Soft tissues and joints:

a. Open/Closed

b. Joint (dislocated, subluxated)

c. Neurovascular status

Front 32

3 types of extra-articular fractures

Back 32

Front 33

3 types of partially articular fractures

Back 33

Front 34

3 types of articular fractures

Back 34

Front 35

For extra-articular fractures, name:

3 simple

3 wedge

3 complex fractures

Back 35

Front 36

5 broad approaches of fracture management

Back 36

1) Non-surgical external immobilisation (eg POP)

2) Surgical external fixation (eg frames)

3) Internal fixation: extramedullary (eg plate)

4) Internal fixation: intramedullary (eg nail)

5) Replacement

Front 37

3 ✔ and 3 ✘ of external immobilisation of fractures

Back 37

✔ Cheap

✔ Quick

✔ No surgery

✘ Muscle disuse

✘ Joint stiffness

✘ Inability to weight bear

Front 38

3 ✔ and 3 ✘ of surgical external fixation of fractures

Back 38

✔ Reduced surgery

✔ Reduced soft tissue damage

✔ Increased rigidity

✘ Pin site infection

✘ Cosmetics

✘ Unable to weight bear

✘ Uncomfortable

✘ Long healing

Front 39

4 main ✔︎ and 1 major ✘ of surgical approaches (internal fixation) of fractures

Back 39

✔ Improved control and stability

✔ Improved restoration of anatomy

✔ Earlier return of function

✔ Cosmetics

✘ Infection

Front 40

What is a patient with patent foramen ovale at risk of in fractures?

Back 40

Fat emboli leading to strokes (embolus forms in the veins and bypasses the pulmonary circulation to go to systemic circulation)

Front 41

Name 4 goals of fracture reduction from most to least urgent

Back 41

1) Reduce pain

2) Avoid neurovascular compromise and prevent further fat emboli

3) Restore function

4) Cosmetic

Front 42

4 steps in fracture reduction

Back 42

1) Exaggerate the deformity

2) Reverse mechanism of injury

3) Reduce

4) Three-point fixation (2 on the side distal to injury)

Front 43

Why is fracture of the pelvis particularly worrying?

Back 43

Because up to 2L of blood can be lost.

If the blood is lost from a vein, then a clot should form. But, if the pelvis opens at the pubic symphysis ⟹ Pelvic volume increases ⟹ Pelvic pressure decreases ⟹ Clotting decreases ⟹ First thing to do is to close it asap to guarantee clotting

If the blood is lost from an artery (or too big a vein), then clots don't form.

Front 44

Define open fracture

Back 44

A break in the skin and underlying soft tissueleading directly into or communicating with thefracture and its hematoma

Front 45

What is the Gustillo and Anderson classification useful for?

Back 45

Prognosis of open fracture (Level I is best, IIIC is worst)

Front 46

T/F: Inside-out open fractures are usually of better prognosis that outside-in

Back 46

True

Front 47

What is the periosteum?

Back 47

Dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints

Front 48

Outline (roughly) the pathological features of the Gustillo and Anderson classification of open fracture

Back 48

I – Inside-out injury

II – Outside-in

IIIa – II with extensive soft tissue laceration

IIIb – IIIa with periosteal stripping and bone exposure
IIIc – IIIb with major vascular injury

Front 49

8 steps of open fracture management

Back 49

1. Stop bleeding

2. Neurovascular assessment

3. Debride
4. Cover (bioclusive)

5. Antibiotics

6. Tetanus assessment and active + passive immunisation if non-immunised

7. Take a picture

8. Splint

Front 50

Define compartment syndrome

Back 50

Raised pressure within a closedosteofascial compartmentresulting in tissue ischaemia andnecrosis

Front 51

Pathogenesis of compartment syndrome

Back 51

Compartment pressure ➚ ⟹ Capillary blood flow ➘ ⟹ Oedema ⟹ Pressure ➚ even more ⟹ Venous flow and lymphatic drainage ➘ ⟹ Pressure ➚ even more ⟹ Arteriolar blood flow ➘ ⟹ Ischaemia and necrosis

Front 52

Clinical criteria for the diagnosis of compartment syndrome

Back 52

Compartment pressure between 30 and 45mmHg (upper limit set because higher pressure suggests the probe is misplaced)

or

|Compartment pressure - DBP| < 30mmHg

Front 53

How often should the compartment pressure be assessed in compartment syndrome?

Back 53

Every 30min

Front 54

Treatment of compartment syndrome

Back 54

Fasciotomy

Front 55

Early management of compartment syndrome while waiting for fasciotomy?

Back 55

1) Elevate leg above the heart

2) Analgesia

3) Review compartment pressure in 30min

4) Ice

5) Anti-inflammatory

6) Give a lot of O2 to avoid acidosis

7) Monitor the required morphine as increasing PRN is a sign of compartment syndrome

Front 56

Outline the compartments of the lower leg and their content

Back 56

Front 57

Outline the compartments of the thigh and their content

Back 57

Front 58

When should dislocated joint be reduced?

Back 58

ASAP

Front 59

In which direction do hip mostly dislocate? How about shoulder?

Back 59

Hip – Posteriorly (90%)

Shoulder – Anteriorly (90%)

Front 60

4 features of dislocated hip on XR

Back 60

Femoral head lateral and superior to acetabulum

# posterior rim of acetabulum

Femur in internal rotation and adduction

Femoral head appear smaller due to magnification (AP scan)

Front 61

One common NV complication of hip dislocation and its clinical manifestation. Ho common is it?

Back 61

Sciatic nerve injury (10% of dislocations)

Sensation – Foot, lower leg (apart from medial side)

Muscles – Flexion of the knee, foot inversion and plantar flexion
Reflex – Ankle jerk

Front 62

Back 62

Knee dislocation

Front 63

What ligament(s) must be damaged to cause knee dislocation?

Back 63

Typically all four: ACL, PCL, MCL, LCL

Front 64

What NV structures are at risk of damage in knee dislocation (2)? For nervous structure, outline the clinical features.

Back 64

Popliteal artery – 10% (40% in anterior/posterior dislocations)

Common peroneal nerve – 25%

Foot drop

Sensory loss in dorsum of foot

Front 65

T/F: knee dislocation can occur with low energy ligament if there is an axial component

Back 65

False: it mostly occurs in high-energy impact and occurs in low energy impact if there is rotational component

Front 66

Back 66

Patella dislocation

Front 67

Which gender and which morphologies are most at risk of patella dislocation?

Back 67

Tall females

Front 68

Most likely direction of dislocation of patella

Back 68

Laterally

Front 69

How are patellar dislocations reduced?

Back 69

Hyperextension of the knee and medialward pressure on patella

Front 70

Indication for surgery in patellar dislocations

Back 70

If it occurs with very minor (eg walking) indicating a structural defect

Front 71

What forced movement causes anterior shoulder dislocation?

Back 71

Abduction + External rotation

Front 72

Patient complains of pain in the shoulder after seizure. Likely diagnosis

Back 72

Posterior shoulder dislocation

Front 73

Patient complains of pain in the shoulder after playing rugby. Likely diagnosis

Back 73

Anterior shoulder dislocation (abduction + external rotation)

Front 74

Patient complains of pain in the shoulder after FOOSH. Likely diagnosis

Back 74

Anterior shoulder dislocation (abduction + external rotation)

Front 75

Patient complains of pain in the shoulder after electric shock. Likely diagnosis

Back 75

Posterior shoulder dislocation

Front 76

Patient complains of pain in the shoulder. XR reveals light bulb appearance. Likely diagnosis

Back 76

Posterior shoulder dislocation

Front 77

Why do electric shock and seizures cause posterior shoulder dislocation rather than the more common anterior shoulder dislocation?

Back 77

Because they cause powerful pectoral muscles to contract, causing internal rotation of shoulder which puts it in a position to dislocate posteriorly.

Front 78

Back 78

Posterior shoulder dislocation (light bulb appearance)

Front 79

Back 79

Anterior shoulder dislocation

Front 80

Common NV complication of anterior shoulder dislocation and its manifestations

Back 80

Axillary nerve damage

Motor – Difficulty abducting shoulder after 15°

Sensation – Loss in regimental badge area

Front 81

What two muscles are responsible for abduction of the shoulder?

Back 81

Supraspinatus – 0-15°

Deltoid – 15-90°

Front 82

Name 4 complications of shoulder dislocation. For each, state the condition in which they occur.

Back 82

Bankart lesion

Injury of anterior (inferior) glenoid labrum

Condition: anterior shoulder dislocation
Similar condition: Bony Bankart when the region of the scapula around the glenoid is itself broken

Hill-Sachs lesion

Depression in the cortex of the posterolateral head of the humerus

Condition: anterior shoulder dislocation

Greater tuberosity fracture

Axillary nerve damage

Front 83

What complication of shoulder dislocation is demonstrated?

Back 83

Fracture of greater tuberosity

Front 84

What complication of shoulder dislocation is demonstrated?

Back 84

Hill-Sachs lesion

Front 85

What complication of shoulder dislocation is demonstrated?

Back 85

Bony Bankart (look at the small fragment at the inferior aspect of the glenoid)

Front 86

Name and describe two techniques for shoulder reduction

Back 86

Modified Milch technique

1. Analgesia: entonox (50% NO, 50% O2) ± lidocaine injection

2. Patient supine, surgeon stands on side of affected arm and apply traction gently until patient "gives".

3. Abduct and externally rotate arm into overhead position
4. Gently push humeral head back into glenoid fossa with thumb

Oxford chair

Pull on arm hanging from chair (picture)

Front 87

Back 87

Front 88

What is a perilunate dislocation? What articulation is affected?

Back 88

Capitate dislocated wrt lunate but lunate-radius articulation is intact.

Red: Capitate

Blue: Lunate

Yellow: Radius

Front 89

What is a lunate dislocation? What articulation is affected?

Back 89

Lunate dislocated with respect to both the capitate and the radius

Red: Capitate

Blue: Lunate

Yellow: Radius

Front 90

What condition often co-occurs with perilunate dislocation?

Back 90

Trans-scaphoid fracture (60%)

Front 91

How can the alignment of carpals be assessed in XR?

Back 91

Gilula's lines

Blue – Proximal edge of scaphoid, lunate, triquetrum

Red – Distal edge of scaphoid, lunate, triquetrum

Yellow – Proximal edge of capitate and hamate

Gilula's lines must be smooth, otherwise, there is likely injury

Front 92

Which of lunate and perilunate dislocations are most common?

Back 92

Perilunate

Front 93

What aspirates can you aspirate in the elbow (3) and in the knee (4)

Back 93

Elbow and knee

Blood

Pus

Fat

Knee

Turbid fluid (crystals)

Front 94

Knee aspiration landmarks

Back 94

Lateral or medial to patella

Front 95

Elbow aspiration landmarks

Back 95

Front 96

What is Haddon's matrix for road traffic collision prevention?

Back 96

Front 97

4E of prevention synthesis

Back 97

Education (teach not to do)

Enforcement (makes it illegal)

Engineering (makes it impossible)

Economics (discourage)

Front 98

4 types of non-accidental injury

Back 98

Neglect

Physical

Sexual

Emotional

Front 99

T/F: non-accidental injury is the commonest cause of injury in < 4y

Back 99

T

Front 100

T/F: the commonest cause of broken femur in a 9m old child is fall

Back 100

False: it's non-accidental injury

Front 101

Commonest cause of fractures in < 1y

Back 101

Non-accidental injury

Front 102

For each of the following level of investigation, name a feature consistent with non-accidental injury:

History

General exam

Exam of the injury

Back 102

Hx – Inconsistent

Exam – Multiple bruises/injuries of differing ages

Exam of injury – Long bone #, corner # (=bucket handle #)

Front 103

Management of non-accidental injury (5)

Back 103

1) Tell senior and safeguarding lead

2) Check child protection register
3) Admit child

4) Paediatric review

5) Skeletal survey

Front 104

What is IMPS

Back 104

Injury minimisation programme for schools

A program in which pupils at school are taught to do CPR, rescue breaths and use defibrillators

Front 105

T/F: as part of the IMPS, pupils are taught to do CPR, rescue breaths and use defibrillators

Back 105

True

Front 106

What is PTC

Back 106

Primary Trauma Care

A foundation that provides training for trauma care in resource-poor environments

Front 107

Define inclination of the hip. What's its normal value?

Back 107

Normal: 130±7°

Front 108

Define anteversion of the hip. What's its normal value?

Back 108

Normal: 10±7°

Note: the angle displayed is the complementary angle

Front 109

Name the 4 arteries supplying the femoral head. Which one is the major contributor? Where is the latter located?

Back 109

Medial femoral circumflex

Lateral femoral circumflex

Intramedullary supply

(Artery of ligamentum teres – Insignificant)

Front 110

Define neck of femur and outline how # of the NOF can be classified based on their location and the impact on complication.

Back 110

NOF – Up to 5cm inferior to the lesser trochanter

In intracapsular #, blood supply to the capsule is at risk.

Front 111

Back 111

Dynamic hip screw

Front 112

Back 112

Intramedullary nail

Front 113

Back 113

Hemiprosthesis

Front 114

Back 114

Total hip replacement

Front 115

Back 115

Cannulated screw fixation

Front 116

Treatment options for extracapsular fracture of the hip. How do we decide which to use?

Back 116

Blood supply maintained ⟹ Preserve neck and head of femur

Dynamic hip screw – Most common

Intramedullary nail – If DHS unstable (torque in IMN is lower because the axis is not offset)

Front 117

Outline Garden's classification of intracapsular fracture of the hip. What is the impact on blood supply?

Back 117

Front 118

How would you treat Garden 4 intracapsular fractures in an otherwise healthy 19 year old? in a 91 year old?

Back 118

19 – Repair (40% failure rate that will require a likely tolerated second operation)

91 – Replace (90% failure rate of repair would require a likely non-tolerated second operation)

Front 119

T/F: Hip surgery in elderly with hip fracture may be delayed by a few days/weeks to increase the chance of a tolerated operation following trauma.

Back 119

False: Benefits of early mobilisation cannot be overemphasised. Operate as soon as possible.

Front 120

Surgical options for intracapsular hip fractures and which would you choose in the following scenarios:

1) Young (< 60) active patient

2) Active independent elderly

3) Non-active or dependent elderly

Back 120

3 Screw fixation – Young active

Dynamic hip screw – Young active

Hemiprosthesis – Non-active/Dependent Elder

Total hip replacement – Active independent elder

Front 121

Which operation(s) for hip # may cause leg length discrepancy?

Back 121

THR
Hemiprosthesis

Front 122

Which operation(s) for hip # may cause non-union?

Back 122

Screws (varus malreduction)

Front 123

Describe and name the cause

Back 123

Shorten and externally rotated leg ⟹ Fracture of neck of femur

Front 124

What articulation enables foot dorsiflexion and plantar flexion?

Back 124

Tibia-Talus

Front 125

Back 125

Front 126

Name 6 important ligaments in the stability of the ankle (and their insertions)

Back 126

Medial

Deltoid – Medial malleolus to talus

Lateral

Calcaneofibular – Lateral malleolus to calcaneus

Talofibular – Lateral malleolus to talus

Tibia to fibula

Syndesmosis of tibia and fibula – This is different from interrosseous membrane which runs along the entire length

Anterior inferior tibiofibular

Posterior tibiofibular

Front 127

What should you never forget on examination of the ankle (2)?

Back 127

Examine medial side

Examine proximal fibula (Maisonneuve #)

Front 128

What is a syndesmosis? Why is it relevant in ankle?

Back 128

An immovable joint in which bones are joined by connective tissue (e.g. between the fibula and tibia at the ankle)

Front 129

How are ankle fracture typically classified?

Back 129

Weber classification (based on level of fibula #)

Weber A – # distal to syndesmosis

Weber B – # at syndesmosis

Weber C – # above syndesmosis

Front 130

Emergency management of ankle fracture (3)

Back 130

Rebax

1) Reduce

2) Backslab (cast with moulding) to correct talar shift

3) Xray

Front 131

One absolute and 3 relative indications for surgery in ankle injury

Back 131

Absolute – Open injury

Relative – Unstable fracture, Displacement, Talar shift

Front 132

Most common operation fix for ankle fracture. Name 4 other operations that can be used.

Back 132

Plates and screws

Nails (calcaneus, talus, tibia or fibula)

Syndesmosis sutures

External:

Ring fixator

Mono-lateral frame ("ex-fix")

Front 133

Why is it important to examine the proximal fibula in ankle injury?

Back 133

Weber C fracture can present with proximal fibula fracture (Maisonneuve #)

If tender around the area, X-ray

If non-tender, report it in the notes (sue-protection)

Front 134

What is a Maisonneuve fracture?

Back 134

Spiral # of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.

Associated with medial malleolus # or rupture of the deep deltoid ligament

Front 135

Treatment of Maisonneuve # (4)

Back 135

Rebax + Referral

1) Reduce

3) Backslab cast with moulding to correct talar shift

3) X-ray

4) Refer to ortho for syndesmosis screws

Front 136

What is wrong with this X-ray?

Back 136

Always reduce ankle fractures first (this X-ray should never have been acquired)

Front 137

Name of the two grooves

Back 137

Front 138

Name of the surface at which the ulna and radius articulate

Back 138

Sigmoid notch

Front 139

Back 139

Front 140

What do volar refer to?

Back 140

Synonym of palmar in hand

Front 141

Normal angles of radius to interpret X-ray

Back 141

Rule of 11

11° of volar tilt

11mm of dradial offset

22° of radial inclination

Front 142

Characterise this fracture (3) and name one situation in which it occurs

Back 142

Dorsally angulated (dinner fork deformity)

Dorsal displacement
Extra-articular

Situation – FOOSH

Note: Colles' fracture in osteoporosis presents like that

Front 143

Characterise this fracture (3) and name one situation in which it occurs

Back 143

Volarly angulated

Volarly displaced

Extra-articular

Situation – Falling on flexed wrist

Note: Smiths' fracture presents like that

Front 144

Characterise this fracture (3) and name one situation in which it occurs

Back 144

Volarly displaced

Extends into radiocarpal joint

Situation – Fall on flexed wrist

Front 145

One non-surgical and 4 surgical management option of wrist fracture

Back 145

Non-surgical

POP

Surgical

Manipulation under anaesthesia + POP

Manipulation under anaesthesia + Percutaneous K wires

Plates

External fixation

Front 146

Back 146

Percutaneous K wires

Front 147

1) How would you decide to operate on a wrist fracture?

2) How would you decide on which surgical management to choose from in a wrist #)?

Back 147

1) Difficult decision based on:

- Severity (articular involvement?)

- Patient's characteristics

2) K-wires as effective as plates but much cheaper (Drafft trial)

Front 148

Number of cervical, thoracic and lumbar vertebrae

Back 148

7C

12T

5L

Front 149

Specific early management (3) of spine in trauma (and how it integrates with the classical ABCDE)

Back 149

C spine triple immobilisation (during A of ABCD)

ASIA chart for neuro exam during D

Log-roll after ABCDE to look for

◾︎ Penetrating injuries

◾︎ Spinal process tenderness

◾︎ Asymmetry

◾︎ PR (tone, sensation and squeeze)

Front 150

What imaging is used as part of the primary survey in ATLS? What if spinal injury is suspected?

Back 150

CT

If spinal injury suspected and neurological deficit, then MRI as well.

Front 151

What is the first vertebra that we can clearly see on a lateral X-ray of the spine

Back 151

C1

Front 152

What is the first vertebra that we can clearly see on an AP X-ray of the spine

Back 152

C3

Front 153

How can we see C1 in an AP film?

Back 153

Through the mouth with mouth open

Front 154

How do you clinically rule out C spine injury?

Back 154

If all of A-F, then assess G-J and if they are all positive then cervical spine is cleared

A) Patient fully alert and oriented.

B) No head injury

C) No drugs or alcohol

D) No neck pain

E) No abnormal neurology

F) No distracting injury

In the neck

G) No bruising

H) No deformity

I) No tenderness

J) Pain-free range of active movements

Front 155

How do you clinically rule out T and L spine injury?

Back 155

A+B+C

A) Cooperative patient

B) Non tender on log roll

C) No tenderness at rest

Front 156

Some percentages. What fraction of trauma patients have spine fractures? Which of those have C spine fracture? Where do most of the latter occur (1st and 2nd most likely location)?

Back 156

4% of all trauma patients

55% in C spine

55% at C5/6, 20% at C1/2

Front 157

What is the atlas in relation to spine?

Back 157

C1

Front 158

What fracture are patients diving in shallow water at risk of (2)?

Back 158

Jefferson fracture – Burst at C1 due to axial loading

Flexion tear drop fracture

Front 159

What is Jefferson fracture? Mechanism? Example of a cause?

Back 159

Burst fracture of C1 caused bydirect axial loading, eg diving into shallow water

Front 160

What is the axis in relation to spine?

Back 160

C2

Front 161

What are C1 and C2 also called?

Back 161

C1 – Atlas

C2 – Axis

Front 162

Most common fracture of C2? Name another fracture occurring at C2 and its mechanism.

Back 162

Odontoid process # = Peg # = Dens #
Most common

Hangman's fracture

(Picture below)

Lateral part of C2 in the pars interarticularis

Mechanism: hyperextension

Front 163

What does subluxation mean?

Back 163

Partial dislocation

Front 164

A patient underwent flexion distraction injury and rapidly develops neurology. X-ray is displayed. Likely diagnosis?

Back 164

Unifacet dislocation/subluxation (one vertebra dislocating anteriorly to its inferior neighbor)

Unifacet demonstrates < 50% displacement while bifacet demonstrates > 50% displacement

Front 165

Diagnosis

Back 165

Bilateral facet dislocation (> 50% displacement of vertebra)

Front 166

Back 166

Bilateral facet dislocation (> 50% displacement of vertebra)

Front 167

Why is the difference between bilateral and unilateral facet dislocation clinically relevant?

Back 167

Bilateral ⟹ High risk of cord injury

Front 168

Diagnosis, likely mechanism and prognosis

Back 168

Spinous process fracture

(aka clay shoveler's fracture)

Mechanism: extension or avulsion (process pulled away forcedly)

Prognosis: stable

Front 169

Diagnosis, most likely location, likely mechanism, and possible structure at risk of damage

Back 169

Compression wedge fracture

C4-C6

Flexion and compression

Posterior longitudinal ligament may rupture.

Front 170

What is clay shoveler's fracture?

Back 170

Spinous process fracture

Front 171

Coup du lapin in English

Back 171

Whiplash

Front 172

Most severe injury of the C spine. Mechanism of injury

Back 172

Flexion teardrop fracture

Violent flexion and compression (eg diving head first, car collisions)

Front 173

Back 173

Flexion teardrop fracture

Front 174

What is peculiar about patients with ankylosing spondylitis when it comes to trauma?

Back 174

Don't immobilise as a normal C spine as the fused bones may break.

Front 175

Difference between adults and children skeleton and its clinical significance

Back 175

Physis (growth plate) between the metaphysis and epiphysis

This is where most fractures occur

Front 176

What is the periosteum?

Back 176

Dense layer of vascular connective tissue enveloping the bones except at the surfaces of the joints

Front 177

T/F: the periosteum in the paediatric skeleton is thinner

Back 177

False: it is thicker

Front 178

T/F: the treatment of this # in a 6 year old is plating.

Back 178

False: remodelling is very effective

Front 179

Name two fracture morphologies that occurs only in children

Back 179

Torus following axial compression due to viscoelasticity of the bone

Greenstick (displayed)

Front 180

Diagnosis and likely mechanism of injury

Back 180

Torus fracture due to axial compression

Front 181

How can we perform a neurological assessment of an injury in a toddler?

Back 181

Sensation

Autonomic – Rub pen along the skin. If it slides easily, then the skin is dry and is not sweating

Front 182

What classification do you know of that helps make a prognosis of epiphyseal fractures?

Back 182

Salter-Harris classification (higher means worse)

Front 183

Draw the metaphysis, physis and epiphysis of a generic bone and outline the fracture morphology in each class of the Salter-Harris classification

Back 183

SALTR

Slipped (I)

Above the physis (II)

Lower than the physis (III)

Through the physis (IV)

Rammed together (V)

Front 184

Most common morphology of epiphyseal fracture in children?

Back 184

Salter-Harris II (75% of all)

Front 185

Salter-Harris class?

Back 185

Lower than the physis (when looked upside down) ⟹ SH III

SALTR

Front 186

Salter-Harris class?

Back 186

Rammed together (tibial physis narrowed see bubble) ⟹ SH V

SALTR

Front 187

Salter-Harris class?

Back 187

Slipped ⟹ SH I

SALTR

Front 188

Salter-Harris class?

Back 188

Above the physis (when looked upside down) ⟹ SH II

SALTR

Front 189

Salter-Harris class?

Back 189

Through the physis ⟹ SH IV

SALTR

Front 190

What is depicted and what is a possible cause?

Back 190

Lateral displacement of the carpus towards the radius due to growth arrest of the radius.

Possible cause: Salter-Harris V fracture

Front 191

What do you see? What is the cause?

Back 191

Fat pad sign

X-ray sign of an otherwise hidden fracture, caused by inflammation around the synovial membrane pushing the fat pads away from the bone (the pattern is therefore Grey ➙ Fat ➙ Grey ➙ Bone)

Note that it can be due to other causes of inflammations in the elbow such as infection.

Front 192

What do you see? What is the cause?

Back 192

Normal anterior fat pad, not displaced (Grey ➙ Fat ➙ Bone rather than Grey ➙ Fat ➙ Grey ➙ Bone)

Front 193

T/F: a posterior fat pad on lateral XR of elbow is always abnormal

Back 193

True (even if it doesn't appear displaced)

Front 194

T/F: an anterior fat pad on lateral XR of elbow is always abnormal

Back 194

False

Front 195

Most likely cause of posterior fat pad sign in a child? adult?

Back 195

Child – Condylar fracture of the hymerus

Adult – Radial head fracture

Front 196

8 year old. Diagnosis, likely mechanism and possible complications (2)

Back 196

Supracondylar fracture

FOOSH from height

Complication:

Brachial artery tear and compartment syndrome

Median nerve injury

Radial nerve injury

Front 197

T/F: supracondylar fracture may appear subtle on XR (only as posterior fat pad sign) but then its prognosis is better.

Back 197

True: this is Gartland class 1 and confers better prognosis while the obvious displacement (displayed) is Gartland class 3 and has high risk of NV damage requiring urgent surgery

Front 198

T/F: Lateral mass/condyle fracture has a better prognosis than supracondylar fracture

Back 198

False: it is usually worse ans is a "not-to-miss" fracture of the elbow in children

Front 199

Name 3 fractures of the elbow that may occur in children

Back 199

Supracondylar fracture

Lateral mass fracture (= lateral condyle fracture)

Medial epicondyle fracture

Front 200

Back 200

Lateral mass # (= lateral condyle #)

Front 201

Likely mechanism of lateral mass #

Back 201

FOOSH

Front 202

What is it and why is it challenging to diagnose?

Back 202

Medial epicondyle fracture

Difficult because the broken epicondyle resembles a centre of ossification ⟹ It is essential to know the order of ossification centres (when they appear)

Front 203

Name the 6 ossification centres in the elbow and the age at which they appear

Back 203

CRITOE

Capitellum – 1y

Radial head – 3y

Internal (medial) epicondyle – 5y

Trochlear – 7y

Olecranon – 9y

External (lateral) epicondyle – 11y

Front 204

4 year old

Back 204

Medial epicondyle fracture (T appears at 7y)

Front 205

8 year old

Back 205

Trochlear ossification centre (T appears at 7y)

Front 206

A 46 year old man involved in a road traffic collision is found to have acute dyspnoea. Likely cause

Back 206

Posterior sternoclavicular joint dislocation

⟹ Clavicle pressed against mediastinum

⟹ Compression of trachea

Front 207

Name 3 possible signs and symptoms (besides injury) of posterior sternoclavicular joint dislocation

Back 207

Dyspnoea

Dysphagia

Paraesthesia of upper limb

Front 208

Back 208

Posterior sternoclavicular joint dislocation

Front 209

A patient presents with a swollen shoulder, pain and paraesthesia in the right arm as well as absent right radial and brachial pulses. He was sent to trauma following a road traffic collision. The X-ray is shown. State what you see on the X-ray and give the diagnosis.

Back 209

Scapulothoracic dissociation

Laterally displaced scapula (edge of scapula displaced by > 1cm from spinous process compared to other side)

Front 210

NV complications of scapulothoracic dissociation (4)

Back 210

Nervous

Brachial plexus

Axillary nerve

Vascular

Subclavian artery

Compound

Flail upper limb (complete loss of sensory and motor functions)

Front 211

What artery is most likely involved in scapulothoracic dissociation?

Back 211

Subclavian

Front 212

Bases of treatment of scapulothoracic dissociations

Back 212

NV repair

± ORIF (open reduction internal fixation)

Front 213

PC

A 34 year old complains of persistent pain in the midfoot.

PMH

Unremarkable apart from a bad fall from a tree on that foot when he was 32 (XR was unremarkable then).

O/E

Deformity

Name and describe a possible cause.

Back 213

Lisfranc injury

Tarsometatarsal fracture-dislocation often missed.

Front 214

Outline the management of Lisfranc fracture

Back 214

No weight bearing for 8/52 (cast)

ORIF + Non-weight bearing for 3/52

Front 215

Outline the scaphoid structure based on areas. Which area is most likely fracture?

Back 215

Waist is most likely to fracture (65%)

Front 216

Main worry in scaphoid fracture. What is the biggest RF for it in scaphoid fracture?

Back 216

Avascular necrosis

More likely if # more proximal (due to retrograde blood flow)

Front 217

Most common mechanism of scaphoid fracture and one example where it occurs

Back 217

Axial load across hyper-extended and radially deviated wrist

Example: contact sports

Front 218

Blood supply to scaphoid

Back 218

Front 219

4 clinical signs of scaphoid fracture

Back 219

Snuffbox tenderness dorsally

Scaphoid tubercle tenderness volarly

Pain with resisted pronation

Pain when thumb is loaded axially

Front 220

Imaging in suspected scaphoid fracture

Back 220

X ray scaphoid view

(30° wrist extension, 20° ulnar deviation)

If negative and high level of suspicion, repeat X ray after 2/52

Front 221

Treatment of scaphoid fracture (3)

Back 221

Cast

Stable, non-displaced or no X-ray sign but high level of suspicion

ORIF

Unstable

Bone graf

If non union

Front 222

What does ATLS stand for?

Back 222

Advanced Trauma Life Support

Front 223

Define distracting injury

Back 223

Another injury which may 'distract' the patient from complaining about a possible spinal injury