Download - SCHHS Emergency Department

Orthopaedics SAQs
Q.1
A 27 year old motorcyclist sustains an isolated injury to his left wrist in a motor vehicle
accident.
E
a) Describe the abnormalities seen in the x-ray
 AP
o Abnormal alignment of lunate relative to other carpal bones – “piece of pie”
sign
o Fractured ulna styloid
 Lateral
o Lunate has lost articulation with radius and capitate
o Capitate displaced dorsally
o “spilled tea cup” sign
(3 marks)
b)
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
What is the diagnosis?
Lunate dislocation
Fractured ulna styloid
Closed injury
(3 marks)
c) What is the most important acute complication of this injury?
 Median nerve compression
(1 mark)
d)
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List 3 long term complications of this injury
Carpal instability leading to degenerative arthritis
Delayed union
Malunion
Non-union
Avascular necrosis
(3 marks)
Ref: Tintinalli p. 1812-13
Q.2
This 45 year old man presented following a fall from a ladder. He has suffered an injury to
his right arm.
a)
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

Describe the injuries shown in this x-ray
Posterior dislocation of the elbow
Likely displaced laterally; need AP view to confirm
Intra-articular bone fragments – likely coronoid process fracture
(2 marks)
b) What are the acute complications for this injury that should be sought on initial
examination?
 Neurovascular status – these structures may be entrapped
o Brachial
o Ulnar N
o Median N
o Radial N
(4 marks)
c) How would you reduce this?
 Procedural sedation
 Longitudinal traction on wrist and forearm with assistant applying counter-traction
on the upper arm
 At same time correct medial or lateral displacement
 Apply down-ward pressure on the proximal forearm to disengage the coronoid
process from the olecranon fossa
 Reassess neurovascular state
 Check full ROM and instability
 Long arm slab
 Check x-ray
(6 marks)
d) What will you check for in the post-reduction x-ray?
 medial epicondyle entrapment
 intra-articular fragments
(2 marks)
e)
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What mandates orthopaedic admission?
Neurovascular compromise
Inability to reduce closed
Other fractures
Instability post-reduction
Open dislocations
(3 marks)
f) What are the potential late complications?
 Post-traumatic stiffness
 Posterolateral joint instability
 Ectopic ossification
 Occult distal radioulnar joint disruption
(2 marks)
Ref: Tintinalli p. 1824-25
Q.3
A 38 year old woman presents with severe pain in her right foot after a fall from her
motorcycle 2hours earlier. She has no other injuries.
AP
Lateral
a) Describe the abnormalities seen in the x-rays
 AP
o Lateral displacement of the 2nd metatarsal from 1st metatarsal > 1mm
o Avulsion fracture 2nd metatarsal
o Lateral displacement of 3rd metatarsal too
 Lateral
o No dorsal/plantar misalignment seen
(3 marks)
b) What is the diagnosis?
 Lis Franc fracture/dislocation
(1 mark)
c) What has been disrupted?
 Disruption of the Lis Franc ligament
(1 mark)
d) What further imaging could you obtain?
 CT
(1 mark)
e) What is the definitive management?
 Reduction in OT by orthopaedics
(1 mark)
f) What is the acute complication of this type of injury?
 Compartment syndrome
(1 marks)
Ref: Tintinalli p. 1876-77
Q.4
A 65 year old woman has been brought to your emergency department after being struck by
a car at a pedestrian crossing. She has a painful right leg. Her AP and Lateral X-rays are
shown
a) Describe the bony injuries in these x-rays
 AP
o Transverse fracture through proximal tibia (metaphysis); no displacement;
no separation; no rotation
o Comminuted & transverse fracture through proximal fibula (metaphysis); 1
mm separation and lateral displacement
 Lateral
o Transverse fracture through the proximal tibia (metaphysis)
o Impacted
o Distal fragment displaced 2 mm plantar direction (slight displacement)
o Distal fragment angulated 30° plantar
(6 marks)
b)
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What other abnormalities can be seen on the x-rays?
Calcification vessels posterior distal femur
2 round lucencies in proximal tibia; holes from previous plates?
Splint/bandage
(3 marks)
c) What are the acute complications that could arise from this injury?
 Common peroneal nerve injury
 Popliteal artery injury
 Compartment syndrome
(2 marks)
d)
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What are the late complications that could arise from this injury?
Non-union
Malunion
Traumatic arthritis
Reflex sympathetic dystrophy
Loss of function
(3 marks)
Ref: Tintinalli p. 1787-89; 1795; 1865
Q.5
A previously well 3 year old boy is brought to the emergency department by his parents
following a fall from play equipment at home. He has injured her left leg. An X-ray has been
taken.
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a) Describe the abnormalities on the x-ray
Mid-shaft spiral fracture of femur
Complete separation 1-2 cm
Rotated
closed
(4 marks)
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b) Describe your management
Resuscitation
o Potential for major haemorrhage
o IV access x 2
o Manage circulatory compromise with fluids and blood
Definitive
o Splint
o Will likely need traction – Thomas splint
o Likely will need sedation for application
Supportive
o Analgesia
o Maintain normothermia
o Calm environment
o Distraction
o Parental involvement and reassurance
Monitoring
o Neurovascular for compartment syndrome
(8 marks)
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c) What are your options for analgesia?
Background PO paracetamol +/- codeine
IN fentanyl 1.5 mcg/kg
IV opiates (morphine 0.1 mg/kg)
Femoral N block
(3 marks)

d) What other consideration is there?
Investigation for NAI
(1 mark)
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e) What is the disposition for this child?
OT for traction/ORIF and/or
Admit orthopaedics with paeds involvement re NAI +/- paeds surgery as trauma
(2 marks; reasonable answer)
Q.6
A 45 year old man is brought to your emergency department with severe pain in his right
hip after a fall from his bicycle an hour earlier. He has no other obvious injuries.
a) Describe the abnormalities in this x-ray

Fracture femur
o
o
o
o

Midshaft
Comminuted
Completely off-ended or 100% displacement medially
Medial angulation 45°
Fracture acetabulum
o Transverse
o Impacted
o 50% medial displacement

Fracture pubis
o Transverse
o 2 mm distal displacement


Hip dislocation
Not open
(8 marks)
b) What are your analgesia options and what do you need to consider with those

options?
IV opiates
o Morphine
o Fentanyl

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Consideration – may worsen hemodynamic instability
NO
o Consideration - emesis

Ketamine IV small doses
o Consideration – good for hemodynamic instability but can cause dissociation

Femoral nerve block
o Consideration – effective for femoral fracture but not pelvic
fractures/dislocated hip; maybe difficult without US due to disrupted
anatomy and positioning

PCA
o Consideration – worsening hemodynamic instability; better for analgesia due
to patient control

Fixation
o Consideration – ultimately will help analgesia and haemodynamic instability
(8 marks)
Q.7
An 82 year old man presents following a fall in the shower. He is complaining of a painful
right shoulder. An X-ray has been taken.
a) Describe the abnormalities in this x-ray
 Anterior glenohumeral dislocation
(2 marks)
b) Describe 3 options for reduction
 Stimson
o Patient prone with arm hanging off side of bed and weight applied
o Needs good analgesia
 Milch
o Patient supine
o Slow abduction and external rotation of arm to overhead position
o With elbow extended apply traction
o may need to push on humeral head to get it into the glenoid
o Needs god analgesia, takes time
 Scapular manipulation
o Patient prone, arm hanging off side of bed with weight applied
o One had stabilises the top of the scapula and the other pushes the tip of
scapular medially
o Good analgesia and sedation
o Good success rate
 External rotation method
o Patient supine and arm adducted to patients side
o Elbow 90° flexion
o Externally rotate slowly
o sedation
 Hippocratic (traction-counter traction)
o Traction on abducted arm with counter-traction on patient torso
o May need some internal or external rotation to aid
o Under procedural sedation
(6 marks)
c)
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What complications can occur?
Recurrent dislocation (younger patients)
Axillary A injury (older patients)
Fractures
o Hill-Sachs
 Humeral head
o Bankart
 Glenoid lip
o Greater tuberosity
Traction neuropraxia of the axillary nerve
Rotator cuff tear
Arthritis
Loss of function
(4 marks)
Ref: Tintinalli p. 1834-6
Links to other questions with orthopaedic content
Trauma Q.4, 8