Download SAQ practice MH week 2 – orthopaedics and trauma

SAQ practice MH week 2 – orthopaedics and trauma
1. A 19 year old man has presented to your rural ED after falling on to his out-stretched hand
while playing basketball.
He is complaining of wrist pain. There are no wounds visible.
AP and lateral xrays of his wrist are given.
1. List the 2 main abnormalities shown on the xrays. (2 marks)
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2. List the 2 mot serious possible immediate complications of this injury (2 marks)
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You have elected to perform a Bier’s block in your management of this injury.
3. List the steps involved in performing a Birer’s block, including drugs, doses and end-points
where appropriate. ( 6 marks)
1. (trans-scaphoid) Peri-lunate dislocation, scaphoid fracture
2. Median nerve injury, vascular compromise
3.
Consent – 1 mark
Preparation – cardiac monitor, IV access *2 (one each arm – below fracture)
Cuff – inflate to 100mmHg above systolic BP
LA – prilocaine 2.5mg/kg
(Manipulate fracture and plaster) – not essential in this question
Cuff to stay up at least 30min (CRITICAL ERROR) – 1 mark
Deflate cuff and observe 15 min for toxicity
Q3 – ó mark for concept, extra ó mark for specifics
Pass Q3 – 3/6
Total pass – 7/10
2. A 56 year old man has been brought to your tertiary ED after a motorcycle accident.
His pelvic xray is given.
1. Classify his pelvic injury based on the Xray provided. (2 marks)
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2. List 4 possible methods of arresting the blood loss from his pelvic injury.
(4 marks)
CT scans have revealed active arterial haemorrhage related to his pelvic injury, but no other
obvious injuries.
His vital signs are:
GCS 14 E4 V4 M6
Pulse 135 /min
BP 70/40 mmHg
O2 saturation 98% 6L O2 via mask
Temp 36.5 degrees
3. In point form, list your principles of his fluid resuscitation while he is awaiting
definitive management of his pelvic injury. (5 marks)
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1. Grade 3 antero-posterior compression fracture of the pelvis (right side)
Pass 1
2. Pelvic binder, interventional radiology, pelvic packing in OT, ORIF in OT
Pass any 3 out of 4
3. Minimal volume resuscitation
Targets: systolic BP 80mmHg, radial pulse, mentation
Use blood products, minimal crystalloid
Initially O neg then Xmatched
Initiate massive transfusion protocol early
Aim packed cells:FFP:platelets 1:1:1 ratio
(targeted to ROTEM acceptable)
Each point 1 mark but has to show clinical reasoning
Pass 3/5
Total pass 7/11 corrects to 6/10
SAQ 3
A 29 year old man has been brought to your hospital after being hit to the head by a baseball bat.
He has no prior medical history.
His vital signs on arrival to the ED are:
GCS 11 E2 V2 M5
Pulse 110 /min
BP 110/65 mmHg
O2 sats 99% 6L O2 via mask
A CT scan of his head has been performed.
1. List 5 abnormalities on the CT slice. (5 marks)
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2. List your treatment priorities in the ED. Where appropriate, give end-points. (9 marks)
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Large extradural haematoma – high density bi convex lesion left temporal region
Hyperacute extradural with “swirl sign” mixed density
Large scalp haematoma left temporal region
Parietal cerebral contusion left
Significant midline shift to right
Loss of sulci and gyri consistent with raised intracranial pressure
Pass 3 of 5
2.
Immediate neurosurgical referral for surgical drainage of haematoma
Intubation for airway control and management of CO2
Maintain MAP >80 (accept approx.) mmHg with IV N/S +/- noradrenaline infusion
Maintain oxygenation sats >95%
Ventilate for low normal CO2 (35 – 40)
Other neuroprotective measures (max 4 marks)
Well sedated, paralysed
Slightly head-up position
Loosen ties / restriction to venous return
Na high normal range
Normothermia
normoglycaemia
pass 5 of 9
total pass 8 of 14 corrects to 5.5/10
SAQ 4
A 45 year old man has been brought to your ED by ambulance after being stabbed once in the right side of
the chest.
On arrival, his vital signs are:
GCS 15 E4 V4 M6
Pulse 120 /min
BP 85/40 mmHg
O2 sats 94% 15L O2 via non-rebreather mask
A chest Xray has been performed.
1. Give the main abnormality on the chest Xray, with supporting evidence. (3 marks)
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2. List the steps involved in inserting an intercostal catheter in this patient. (9 marks)
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Right sided tension haemothorax (CRITICAL)
- Veiled opacity to right hemi-thorax
- Significant rim of fluid around lateral lung edge
- Mediastinal shift to left
1 mark for haemothorax, ó marks for – tension, 3 other bits
pass 2 of 3
2.
Verbal consent / explanation
(sedation optional)
(Gown / gloves / mask / goggles)
Clean chest with anti-septic (appreciate this is a time critical procedure)
Local anaesthesia – lignocaine 1% with adrenaline 20mL
Location - 5th interspace mid-axillary line
Incision with scalpel
Blunt dissection to pleural space / finger sweep
Insertion ICC 28-32 Fr
Connection to underwater seal
Suture and dressing
Pass 7 of 9
Total pass 9/12 corrects to 7.5/10
Question 5
A 25 year-old male involved in a motorbike accident was brought to the ED at a tertiary level
centre. A trauma series was performed with a normal CXR and C-spine Xray. The following
radiological imaging was undertaken.
Vital signs are: RR 20 sat 99% on room air HR 115 BP 80/50 GCS 15
1. List the abnormalities on this Xray (2 marks)
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
pubic symphysis diastasis – APC or VS injury
contrast leakage consistent with urethral rupture
2. What clinical signs are associated with this injury on examination (1 mark)
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high riding or boggy prostate
blood at the urethral meatus
perineal or scrotal haematoma
3. Give the 4 most likely causes of hypotension in this patient (2 marks)
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pelvic venous or arterial haemorrhage
intra- abdominal heamorrhage
spinal shock/ injury
long bone fracture
NB need all 4 to score 2 marks, 2-3 scores 1 mark, 0-1 scores 0
4. List the five most important treatment and disposition priorities, as the team leader, in
treating this patient’s hypotension. Give details (5 marks)
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
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pelvic immobilisation – external binder/ sheet, minimal pelvic movements
resuscitation - massive transfusion protocol – blood/ platelets/ FFP 1:1:1, cryoprecipitate,
tranexamic acid
FAST scan – angiography and laparotomy if positive; angiography if –ve and readily available
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urgently notify theatres/ interventional radiology/ orthopaedic surgeon/ trauma surgeon/
anaesthetist/ blood bank/ prepare staff and equipment for transfer – monitors, IV access, drugs for
intubation/ analgesia
maintain normothermia – warm fluids, external radiant heater
SAQ 6
A 42 year old man fell off his bicycle when travelling at 20km/h. He complained of left
forearm pain. He had the following X-rays taken.
1. What are the abnormalities on the X-ray? (2 marks)
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transverse fracture through the mid shaft of the left radius, which is associated wit
h 100% dorsal displacement and shortening of 1.5cm
distal radius is angulated 15 degrees in the palmar direction
distal ulnar-carpal joint is dislocated with dorsal displacement of the ulnar head
2. List the 2 most likely nerve injuries (2 marks)
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ulnar nerve
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interosseous branch of median nerve
3. Your registrar decides to perform procedural sedation. Outline your checklist with details
of each of the major area. (6 marks)
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consent
assessment of patient – fasting status, allergies,meds, MP, ASA
check airway equipment – CO2, airway, mask, ETT, laryngoscope, suction
iv with fluids running
medications labelled
monitoring – sats, BP, ECG, CO2
SAQ 7
A 5 year old boy has been brought to your emergency department after a road traffic accident.
He has had a blood transfusion commenced by the retrieval service for haemorrhagic shock.
The second unit has already been commenced.
1. What is the definition of massive transfusion in this child? (2 marks)
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Transfusion of more than 40 mls/kg (blood volume of children older than a neonate is
approximately 80 mls/kg.
2. List eight potential complications of massive transfusion for this child (4 marks)
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hyperkalaemia
hypocalcaemia
Acid base derangement and lactic acidosis
Dilutional thrombocytopenia
disseminated intravascular coagulation
Systemic hypothermia
Transfusion reactions
TRALI: transfusion related acute lung injury
3. If he was to have a cardiac arrest. What are the 4 likely causes (4 marks)
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Hypoxia
Tension pneumothorax
Tamponade
Hypovolaemia from blood loss
Question 8
A 20yo male attends with a grossly swollen painful hand from a punching injury at 36 hours.
There is broken skin over the 3rd MCP joint.
(a) What complications may arise from this injury? (20%)
(b) Outline your examination (20%)
(c) Given the appearance of the hand shown, what investigations would you request, assuming no
comorbidities and that this is an isolated injury? (20%)
(d) What are the indications for admission? (20%)
Answers:
1a.
Joint penetration
Septic arthritis
Metacarpal fracture
Extensor tendon laceration
Extensor tendon sheath infection
Extensor tendon rupture
Marking. 20% of the total for question 1
pass =4/6 =10% of total for question 1, add
5% for each additional correct item up to a
total of 20%
1b.
Anatomic assessment of skin wound (position, depth, and visible involvement of
underlying structures.
Signs of infection: Local and spread (lymphangitis, nodes, and temperature)
Functional assessment: nerve, extensor tendon, joint, bone and vascular
Survey for other injuries
Question 9
Whist restraining a 47yo male with a convulsive seizure a nurse was kneed in the cheek,
including the orbit and nose. She experienced immediate epistaxis, facial pain and visual
blurring. (photo)
(a) Assuming that this is an isolated facial injury without loss of consciousness, list six potential
immediate ocular complications that you would exclude. (25%)
(b) What non-occular complications would you seek to exclude? (25%)
(c) Describe your management of a probable acutely fractured nose. (25%)
(d) What are the clinical signs of orbital compartment syndrome? What is the immediate
management? (25%)
7a.
Globe rupture, hyphaema, retinal tear and detachment, vitreous haemorrhage and
detachment, choroidal tear/rupture, iris injury, traumatic iritis, lens detachment, corneal
abrasion, commotion retinae, orbital fracture, orbital compartment syndrome, orbital content
entrapment in the fractured orbital floor.
7b. Inferior orbital nerve injury (sensory loss), nasal septal haematoma (fractured nose),
depressed fractured maxilla), orbital floor fracture and entrapment of orbital fat
(enophthalmos) and inferior rectus (diplopia). Pass = 4 complications
7c.
Analgesia, control epistaxis, exclude/drain septal haematoma, only image in
the context of surveying for facial fractures, exclude orbital injury and inferior orbital
nerve injury, no evidence for antibiotics but argued for and given by many on risk of severe
infection (divided debate), Pass must be reasonable and include exclude/drain septal
haematoma, no imaging unless excluding facial fractures
SAQ 1 (Acute agitation)
A 38 year old man walks up to the triage desk. He is agitated, shouting and uncooperative with simple instructions
He is poorly kempt, clammy and tremulous.
1. List five differential diagnostic categories you would consider when trying to assess this man?
Give two examples from each category.
2. Briefly describe two different strategies for gaining the cooperation of this man?
3. List the legal principles that guide your management?
Answers
Q 1.
Category
Trauma
Toxidrome
Acute withdrawal
Electrolyte disorder
Environmental
Psychiatric
Endocrine
Sepsis
Post-ictal
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
1.
2.
Q2.
Example
Major visceral injury with blood loss
Head injury (bleed, concussion)
Amphetamines, opiates, cannabis,
usual antipsychotic medication e.g.
Lithium
Alcohol, serotonin syndrome
Alcohol, cannabis
Opioids
Hypo/hyperglycemia
Hyponatremia, hypercalcemia
Snake bite
Red back spider bite
Schizophrenia
Acute mania
Hyperthyroidism
Adrenal crisis
CNS
Infective endocarditis
Known epilepsy, related to causes
above
Withdrawal seizure
Physical versus chemical
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Q3.
Five person physical restraint
Chemical restraint: benzodiazepine, butyrophenone, phenothiazine
Autonomy vs duty of care
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Competence
Informed consent
SAQ 2 (Chest CT post MVC)
A 28 year old male presents to ED after being involved in a high speed MVC. He was the driver, restrained,
deployed airbag, required extrication.
On arrival he is short of breath and complaining of right sided chest pain
His
SaO2
P
BP
95
105
110/70
%
on 5l/min by Hudson mask
sinus tachycardia
afebrile
He has no significant past history and is on no medication.
A CT chest is performed as part of his workup.
A single axial slice is given
(SAQ 2 contd…)
1. Give an interpretation of the image providing
Five positive findings
Two negative findings
2. List three potential complications of these changes.
3. List three options for the treatment of the changes shown.
Answers
Q1.
Positive findings
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Extensive right and left chest wall surgical emphysema
Epidural air
Pneumo-mediastinum
Right sided pneumothorax
Small emphysematous bleb posteriorly
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No tension
No chest tube
No haemothorax
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Tension pneumothorax
Air embolism; stroke
Airway compromise from tracking to larynx/pharynx
Pneumopericardium progressing to cardiac tamponade
Negative findings
Q2.
Q3.

Conservative: repeat CXR in 24 hours specifically looking for increase in pneumothorax size
with view to ICC
 Small lumen right sided catheter inserted using Seldinger technique for drainage of
pneumothorax
 Small bore ICC inserted using Seldinger technique
 Small bore ICC inserted using incision/surgical technique
 Large bore ICC specifically to treat pneumothorax and possible haemothorax.
Catheters on Heimlich valve/UWSD +/- suction
17. A 10 year old girl has fallen off a wall and presents with a “sore arm”.
X-ray is shown below.
a. Give 3 features which are required to “clear the neck”. (3 marks)
Pt fully conscious
No evidence of intoxication
No neck pain/ midline tenderness
No neurological deficit
No distracting injury
ROM >45o in all directions
Age < 65
b. Describe the x-ray. (1 mark)
Fracture distal shaft of humerus with posterior displacement
c. What is the diagnosis? (1 mark)
Supracondyla fracture humerus
d. What are 2 potential neurological complications of this injury and how would you test for
them? (4 marks)
Median nerve palsy- reduced sensation over the palm, reduced thumb opposition and wrist
palmar flexion
Radial nerve – reduced sensation thumb, reduced wrist dorsiflexion
e. Give an example of one other joint injury that can also give rise to nerve injuries. (1 mark)
Shoulder dislocation- axillary nerve
Neck of fibula fracture- peroneal nerve
19. A 28 year old man has been out kite surfing and was thrown into the water at high speed.
He is brought in on a spinal board with C-spine protection. He is intubated and ventilated and
put on a propofol infusion.
His observations are: Pulse 65 /min, BP 90/60 mmHg and he is warm and well perfused.
The C-spine film and tomogram are shown below.
a. Describe 3 abnormalities on the x-ray. (3 marks)
# body C4, loss of space C3-4, probably soft tissue swelling
Burst fracture
b. Describe 2 aspects of his cardiovascular status. (2 marks).
Hypotensive and bradycardic/normocardic
c. What is the likely diagnosis? (2 marks)
Spinal shock
d. What 3 signs would support this? (3 marks)
priapism
Pink, well perfused peripheries,
flaccid paralysis below level C4,
increased tendon jerk reflexes below that level (might be absent initially)
loss of sensation,
very weak respiratory effort,
30. A 65 year old male presents following a fall. He complains of a painful swollen left wrist.
An x-ray of his wrist is shown below.
a. Describe his x-ray. (2 marks)
Intra-articular fracture of the distal radius with dorsal angulation
1 mark for intra-articular fracture distal radius
1 mark for dorsal angulation
No marks given for Colles fracture
b. List the contra-indications to performing a Bier's block. (4 marks)
1/2 mark each to maximum of 4 marks from:
Refusal of procedure
Uncooperative patient
Compromised limb circulation
Compartment syndrome of affected limb
Sickle cell disease
Ipsilateral # humerus
LA Sensitivity / allergy
Staff / area / equipment unavailable
Soft tissue injury at tourniquet site
Age <10 / Paediatric patient
Peripheral vascular disease / Raynauds
Systolic >200mmHg
Severe liver disease
Unstable epilepsy
Unable to gain bilateral iv access
Taken from Dunn Emergency Medicine Manual 5th Edition Volume 1 Chp 9 Page 159 and Cameron
Textbook of Adult Emergency Medicine 3rd Edition Chpt 22.2 Pg 701
c. List the key steps in performing a Bier's block. (4 marks)
1/2 mark each for:
1. Consent - ideally written
2. Area / staff / monitoring
3. Bilateral iv access - no marks if only iv access mentioned must specify bilateral
4. Check equipment
5. Inflate cuff - ideally answer should state >100mmHg above systolic
6. Injection of local anaesthetic - prilocaine ideally but accept lignocaine (as per Dunn &
Tintinalli)
7.Perform procedure - MUA wrist
8.Deflate cuff / post-procedural monitoring
Taken from Dunn Emergency Medicine Manual 5th Edition Volume 1 Chp 9 Page 159
60. This 32 year old male lost control of a high pressure injector and comes in with a wound
on his left lower leg.
a. List three complications that are likely to occur within the next 48 hours. (3 marks)
1. Compartment syndrome
2. Tissue necrosis from local trauma
3. Wound infection
b. List the management priorities for this injury. (5 marks)
a.
b.
c.
d.
Elevation
Tetanus
Plain film to rule out other injury
Surgical or orthopaedic admission +/- exploration in OT
c. What factors contribute to damage? (3 marks)
a. Type of liquid injected
b. Location of injury
c. Amount injected
d. Proximity of nozzle
68. You are the director of a tertiary ED which is a level one trauma centre. Recently the
directors of trauma and haematology have both written to you regarding your department’s
haphazard use of blood products in the severely injured. You search your intranet and realise
that you do not have a policy.
a. What are 3 triggers for massive transfusion? (3 marks)
Massive Haemorrhage with shock or anaemia, ie Immediate need for uncrossmatched
blood due to rapid haemorrhage and anaemia
Blood loss exceeding 150 mL/min
Need for at least 4 RBC units in the setting of uncontrolled bleeding
Replacement of 50% of total blood volume within 3 hours (24pprox.. 35mL/kg in an
adult)
Coagulopathy in the setting of blood transfusion
b. Name 4 physiological or biochemical parameters that should be measured early and often.
(2 marks)
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•
•
•
•
•
•
•
Temperature;
Acid–Base Status;
Ionised Calcium;
Haemoglobin;
Platelet Count;
PT/INR;
APTT; and
Fibrinogen Level.
c. What is the indication for Cryoprecipitate delivery? (2 marks)
Cryoprecipitate is used primarily as a source of fibrinogen (but also contains FVIII,
VWF and FXIII). This is found in adequate amounts in FFP, and in dilutional
coagulopathy FFP alone may be adequate. Coexisting DIC may increase fibrinogen
requirements. Empirical use is unnecessary. Use should be guided by fibrinogen
determinations.
d. What are the targets for Hb, Platelets and INR in massive transfusion? (3 marks)
Hb>80g/L;
Platelets >50x109/L; and
PT and APTT<1.5 x control.