Lower limb Trauma Structured oral examination question 5
Lower limb Trauma Structured oral examination question 5
A 21-year-old motorcyclist was involved in a road traffic accident. He was brought to A&E fully con- scious and alert, and formal assessment following ATLS protocol showed that this was an isolated closed injury. (Figure 8.6.)
Minute 1
EXAMINER : Tell me how would you manage this injury?
CANDIDATE: This is an intra-articular fracture, around the right ankle, as a result of high energy trauma. There is a pilon fracture, fractured fibula, disruption of the syndesmosis and possibly a fractured talus.
lower leg.
I will take a relevant history and perform a detailed clinical examination, including the skin and soft tissue condition, realign the foot into a better position, relieve pressure on the skin to avoid skin necrosis, perform a neurovascular assessment of the involved limb and exclude compartment syndrome. The limb should be splinted and elevated. Regular monitoring of neurovascular status and detection of a developing compartment syndrome is of paramount importance.
Minute 2
CANDIDATE: My principles of treatment are
‘Span–Scan–Plan’.
● Span: to reduce fracture and joint, and immobilize the injured limb using spanning external fixator. This will restore
alignment and allow soft tissue resuscitation and monitoring. This will also give us time to plan definitive surgery.
● Scan: CT scan will provide more details of fracture type and pattern, therefore allowing for informed planning of
definitive treatment.
● Plan: Definitive treatment in details; approach, how to fix the fragments, what implant to use, timing of
surgery, obtaining consent from the patient and to
get an indication of what can be achieved and possible outcome.
Minute 3
EXAMINER: When are you going to fix this fracture?
CANDIDATE: There are many factors to be considered, this is a serious injury and it must be treated properly in one operation. The patient needs to be resuscitated; the soft tissue envelope needs to be in a good condition (this may take 2–3 weeks to settle), a CT scan needs to be performed and the required surgical expertise and implant should be available.
EXAMINER: How are you going to fix this fracture?
CANDIDATE: Principles of intra-articular fracture fixation are anatomical reduction, fracture stabilization and early mobilization. My approach would be tailored depending on fracture configuration, which would identified by a CT scan prior to surgery and with fluoroscopy during surgery. Looking at the fractures in the radiographs provided, I would favour an anterolateral approach that will allow me to reduce the pilon fracture, and approach the fibula as well as the talus. I would aim for anatomical reduction of the pilon fracture and stabilization using an anterolateral plate and then go on to address the fibula and talus on their relative merits. Exposure of the talus can be improved by extending the release of the ATFL through a subperiosteal approach. I would anatomically reduce and fix the talus fracture with screws making sure any loose debris is removed from the joint.
Minutes 4 and 5
EXAMINER: What is the functional outcome following a pilon fracture?
CANDIDATE: Well, generally a poor outcome. A patient may end up with a stiff ankle with a poor soft tissue envelope and there is considerable risk of post-traumatic osteoarthritis which may require an ankle arthrodesis or ankle arthroplasty.
EXAMINER: What is Hawkins’ sign – is it a good or bad sign?
CANDIDATE: It is the appearance of osteopenia in subchondral bone of the talar dome, 6–8 weeks following a talar neck fracture. It is a good sign and means that the talar dome is well perfused and has a viable blood supply. It indicates that bone healing is likely to occur without the development of avascular necrosis.
Lower limb Trauma Structured oral examination question 5
A 21-year-old motorcyclist was involved in a road traffic accident. He was brought to A&E fully con- scious and alert, and formal assessment following ATLS protocol showed that this was an isolated closed injury. (Figure 8.6.)
Minute 1
EXAMINER : Tell me how would you manage this injury?
CANDIDATE: This is an intra-articular fracture, around the right ankle, as a result of high energy trauma. There is a pilon fracture, fractured fibula, disruption of the syndesmosis and possibly a fractured talus.
lower leg.
I will take a relevant history and perform a detailed clinical examination, including the skin and soft tissue condition, realign the foot into a better position, relieve pressure on the skin to avoid skin necrosis, perform a neurovascular assessment of the involved limb and exclude compartment syndrome. The limb should be splinted and elevated. Regular monitoring of neurovascular status and detection of a developing compartment syndrome is of paramount importance.
Minute 2
CANDIDATE: My principles of treatment are
‘Span–Scan–Plan’.
● Span: to reduce fracture and joint, and immobilize the injured limb using spanning external fixator. This will restore
alignment and allow soft tissue resuscitation and monitoring. This will also give us time to plan definitive surgery.
● Scan: CT scan will provide more details of fracture type and pattern, therefore allowing for informed planning of
definitive treatment.
● Plan: Definitive treatment in details; approach, how to fix the fragments, what implant to use, timing of
surgery, obtaining consent from the patient and to
get an indication of what can be achieved and possible outcome.
Minute 3
EXAMINER: When are you going to fix this fracture?
CANDIDATE: There are many factors to be considered, this is a serious injury and it must be treated properly in one operation. The patient needs to be resuscitated; the soft tissue envelope needs to be in a good condition (this may take 2–3 weeks to settle), a CT scan needs to be performed and the required surgical expertise and implant should be available.
EXAMINER: How are you going to fix this fracture?
CANDIDATE: Principles of intra-articular fracture fixation are anatomical reduction, fracture stabilization and early mobilization. My approach would be tailored depending on fracture configuration, which would identified by a CT scan prior to surgery and with fluoroscopy during surgery. Looking at the fractures in the radiographs provided, I would favour an anterolateral approach that will allow me to reduce the pilon fracture, and approach the fibula as well as the talus. I would aim for anatomical reduction of the pilon fracture and stabilization using an anterolateral plate and then go on to address the fibula and talus on their relative merits. Exposure of the talus can be improved by extending the release of the ATFL through a subperiosteal approach. I would anatomically reduce and fix the talus fracture with screws making sure any loose debris is removed from the joint.
Minutes 4 and 5
EXAMINER: What is the functional outcome following a pilon fracture?
CANDIDATE: Well, generally a poor outcome. A patient may end up with a stiff ankle with a poor soft tissue envelope and there is considerable risk of post-traumatic osteoarthritis which may require an ankle arthrodesis or ankle arthroplasty.
EXAMINER: What is Hawkins’ sign – is it a good or bad sign?
CANDIDATE: It is the appearance of osteopenia in subchondral bone of the talar dome, 6–8 weeks following a talar neck fracture. It is a good sign and means that the talar dome is well perfused and has a viable blood supply. It indicates that bone healing is likely to occur without the development of avascular necrosis.