Lower limb Trauma Structured oral examination question 2
Lower limb Trauma Structured oral examination question 2
A 79-year-old woman fell in her garden sustaining this injury. She is generally quite independent, has a history of angina which is controlled and likes meet- ing her friends at the local social club every Wednesday.
Minute 1
In the first 30 seconds you are expected to comment on the name of the patient, site of radiograph and the exact nature of the injury:
EXAMINER: Please comment on the radiograph. (Figure 8.2.)
CANDIDATE: She has got a left-sided intracapsular neck of femur fracture in the presence of early degenerative changes of the hip joint. [Always ask for the lateral radiograph.]
EXAMINER: How will you manage this patient?
CANDIDATE: I’d like to assess the whole patient. The degree of mobility prior to injury, comorbidities, any systemic illness, red flag signs for any pathological lesions, drug history, cause of fall and appropriate investigations. In addition, I would perform a full clinical examination of the patient including the left lower limb. [Be a safe surgeon but not hesitant.]
Minutes 2 and 3
EXAMINER: She has well-controlled angina and is otherwise independent.
CANDIDATE: In this patient group surgery would be my preferred option so as to avoid the known complications of non-operative management. These include the risks from a period of bed rest (HEAD TO TOE: depression, confusion, chest infections, pnuenomia, constipation, ileus, urinary tract infection, renal calculi, pressure sores, DVT/PE, muscle wasting, osteoporosis, joint contractures) and a probable painful non-union of the fracture. We can perform either an uncemented or cemented hip hemiarthroplasty. I would generally only use an uncemented hemiarhroplasty in very frail high risk patients as the implant can work loose in the femur, rattle around and cause pain. Cement allows a firm fixation of
Figure 8.2 Anteroposterior (AP) pelvis radiograph demonstrating intracapsular fractured left neck of femur.
implant to bone, reduces the need for revision surgery and allows better mobility with less thigh pain. My choice [authors’ opinion] in this situation would be a total hip arthroplasty rather than a cemented hemiarthroplasty in line with current NICE guidelines.
EXAMINER: Why do you prefer a THA rather than hemiarthroplasty? It is more expensive!
CANDIDATE: [At this stage you should take the presented opportunity to talk and cover the whole subject!] The THA has a better functional outcome than hemiarthroplasty and has better survivorship results. My choice will be a cemented double-tapered polished stem with long-term proven results (such as Exeter) with a cemented highly cross-linked PE and a relatively large head (such as 32 mm). We have data from the Swedish hip registry favouring THA for functional results.
Recent NICE guidelines have endorsed such a practice in the selected population, which include mentally alert patient with good pre-injury mobility levels and who are relatively healthy. This patient ticks all the criteria and will benefit from THA. My practice is to use a relatively larger head such as 32 mm, to reduce the risks of dislocation. I would aim for correct orientation of components, good soft tissue balancing and restoration of leg length. The management would continue with aggressive rehabilitation including early mobilization with full weightbearing and repatriation to the place of usual abode. It also includes addressing any underlying metabolic abnormalities such as osteoporosis, risk assessment for falls and nutritional deficiency. Ideally the management will be carried out by a multidisciplinary team.
Minute 4
EXAMINER: She arrives at 18:00 to your ward. When will you undertake the surgery?
CANDIDATE: The surgery should be undertaken as soon as safely possible. It should not be rushed in the middle of the night, however, so if the patient is fit for anaesthesia then aim for surgery on the next morning’s trauma list with the necessary theatre staff, kit and consultant cover available. It is important to optimize any correctable causes prior to surgery. This should be undertaken in an objective and efficient manner to avoid ‘unnecessary’ delay.
Minute 5
The examiner may talk about the potential compli- cations of THA in this patient group, which may include higher risk of dislocation due to a previously mobile hip as opposed to stiff arthritic hip with cap- sular fibrosis, leg length discrepancy, cement reaction, infection, early loosening etc.
Lower limb Trauma Structured oral examination question 2
A 79-year-old woman fell in her garden sustaining this injury. She is generally quite independent, has a history of angina which is controlled and likes meet- ing her friends at the local social club every Wednesday.
Minute 1
In the first 30 seconds you are expected to comment on the name of the patient, site of radiograph and the exact nature of the injury:
EXAMINER: Please comment on the radiograph. (Figure 8.2.)
CANDIDATE: She has got a left-sided intracapsular neck of femur fracture in the presence of early degenerative changes of the hip joint. [Always ask for the lateral radiograph.]
EXAMINER: How will you manage this patient?
CANDIDATE: I’d like to assess the whole patient. The degree of mobility prior to injury, comorbidities, any systemic illness, red flag signs for any pathological lesions, drug history, cause of fall and appropriate investigations. In addition, I would perform a full clinical examination of the patient including the left lower limb. [Be a safe surgeon but not hesitant.]
Minutes 2 and 3
EXAMINER: She has well-controlled angina and is otherwise independent.
CANDIDATE: In this patient group surgery would be my preferred option so as to avoid the known complications of non-operative management. These include the risks from a period of bed rest (HEAD TO TOE: depression, confusion, chest infections, pnuenomia, constipation, ileus, urinary tract infection, renal calculi, pressure sores, DVT/PE, muscle wasting, osteoporosis, joint contractures) and a probable painful non-union of the fracture. We can perform either an uncemented or cemented hip hemiarthroplasty. I would generally only use an uncemented hemiarhroplasty in very frail high risk patients as the implant can work loose in the femur, rattle around and cause pain. Cement allows a firm fixation of
Figure 8.2 Anteroposterior (AP) pelvis radiograph demonstrating intracapsular fractured left neck of femur.
implant to bone, reduces the need for revision surgery and allows better mobility with less thigh pain. My choice [authors’ opinion] in this situation would be a total hip arthroplasty rather than a cemented hemiarthroplasty in line with current NICE guidelines.
EXAMINER: Why do you prefer a THA rather than hemiarthroplasty? It is more expensive!
CANDIDATE: [At this stage you should take the presented opportunity to talk and cover the whole subject!] The THA has a better functional outcome than hemiarthroplasty and has better survivorship results. My choice will be a cemented double-tapered polished stem with long-term proven results (such as Exeter) with a cemented highly cross-linked PE and a relatively large head (such as 32 mm). We have data from the Swedish hip registry favouring THA for functional results.
Recent NICE guidelines have endorsed such a practice in the selected population, which include mentally alert patient with good pre-injury mobility levels and who are relatively healthy. This patient ticks all the criteria and will benefit from THA. My practice is to use a relatively larger head such as 32 mm, to reduce the risks of dislocation. I would aim for correct orientation of components, good soft tissue balancing and restoration of leg length. The management would continue with aggressive rehabilitation including early mobilization with full weightbearing and repatriation to the place of usual abode. It also includes addressing any underlying metabolic abnormalities such as osteoporosis, risk assessment for falls and nutritional deficiency. Ideally the management will be carried out by a multidisciplinary team.
Minute 4
EXAMINER: She arrives at 18:00 to your ward. When will you undertake the surgery?
CANDIDATE: The surgery should be undertaken as soon as safely possible. It should not be rushed in the middle of the night, however, so if the patient is fit for anaesthesia then aim for surgery on the next morning’s trauma list with the necessary theatre staff, kit and consultant cover available. It is important to optimize any correctable causes prior to surgery. This should be undertaken in an objective and efficient manner to avoid ‘unnecessary’ delay.
Minute 5
The examiner may talk about the potential compli- cations of THA in this patient group, which may include higher risk of dislocation due to a previously mobile hip as opposed to stiff arthritic hip with cap- sular fibrosis, leg length discrepancy, cement reaction, infection, early loosening etc.