Lower limb Trauma Structured oral examination question 1
A 35-year-old motorcyclist came off his bike yester- day; he has been resuscitated and has an isolated closed injury of the knee. (Figure 8.1.)
EXAMINER: What are your views?
Minute 1
Here the next 1 minute belongs to the candidate and you can take it whichever way you want to. However, there are essentials to be covered. In the first 30 seconds you are expected to comment on the following:
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Name of the patient. Site of radiograph.
Fracture through the tibia with depression of the lateral tibial plateau and always ask for a lateral radiograph.
In the next 30 seconds the candidate is expected to comment on the exact nature of the injury, such as Schatzker III fracture with more than 10 mm depres- sion of the articular surface, comminution, concern about the fracture going through the tibial spines and whether the medial side is involved. A candidate should end the 30 seconds by mentioning they would assess the whole patient for any co-existing injuries,
(a)
the whole lower limb for other injuries and then arrange further imaging studies.
Minute 2
EXAMINER: What further imaging studies would you arrange?
CANDIDATE: A CT scan to evaluate the fracture pattern and plan surgery.
The examiner is likely to produce promptly two slices of the CT, in sagittal and coronal.
Note: Do not make a stupid remark ‘do you want me to comment on this?’! But it is useful to correlate that it is the same patient’s CT. Describe the findings and end up by offering to discuss the findings with the patient (Brownie points). As well as offering in the closing comments about management options. (Let the examiner ask you about the management options rather than carrying on.)
You should be at this stage by 90 seconds.
EXAMINER: What are the management options?
CANDIDATE: [Take the next 30 seconds to describe operative and non-operative options.] Non-operative management is a poor choice because of the patient’s young age and amount of articular segment depression. Operative management would require a non-compromised soft tissue envelope and exclusion of lower limb neurovascular injury. Assessment of the injury pattern and of any significant knee ligament damage needs to be done prior to surgical intervention.
Minute 3
At the 2-minute mark you should have committed yourself to operative intervention. Before the exam- iner asks, offer your management option because it annoys them to keep asking again and again: what will you do? Stick with the principles.
The principles of management are to restore the articular surface, stabilize and hold the fracture in such a fashion as to allow early mobilization. The aim of the treatment is to have a mobile, pain-free and functional joint.
The options of surgical treatment include direct or indirect reduction, percutaneous or open fixation augmented with plate osteosynthesis or external fix- ation. Before being prompted, suggest your preferred option, which in the authors’ opinion is indirect reduction using a cortical window in the proximal tibia, restoration of articular surface with a raft of
screws augmented with a buttress plate. Suggest at this stage you will perform an assessment under X-ray control for a ligamentous stability and if needed an arthroscopic assessment.
Minute 4
The examiner can lead the viva along two aspects:
EXAMINER: What is a buttress plate?
CANDIDATE: A plate applied perpendicular to the force that it resists.
EXAMINER: What is the role of knee arthroscopy?
CANDIDATE: It is threefold. Firstly, to assess the reduction of articular surface. Secondly, to check that soft tissues are not trapped in the fracture such as lateral meniscus. Thirdly, to assess intra-articular ligament damage. Pressure pumps are not to be used to avoid iatrogenic compartment syndrome due to extravasation of fluid. I will use a bladder syringe through the arthroscopy cannula to wash out the haemarthrosis before viewing the joint. [This gives the examiner the impression that you have done the procedure before.]
EXAMINER: What surgical approach will you use?
CANDIDATE: Anterolateral approach with the skin incision being longitudinal and if needed muscle retraction with a reverse L- shaped incision inside.
The examiner can also talk about a posterolateral approach and a fibula osteotomy for posterolateral fractures. Whilst discussing these issues you should be at the 4-minute stage.
Minute 5
With 1 minute left and if the examiner is discussing rehabilitation and weightbearing status, you know that you are probably winning. Talk about range of motion and protected weightbearing. Assessment of weightbearing will be based on stability of the frac- ture, strength of the fixation, stiffness of the construct and the quality of the host bone plus reliability of the patient. Do not, repeat do not, use absolute numbers such as 20 kg for each patient on day 1. Tailor the management for each individual patient based on host quality of bone, fracture pattern and construct stability.
Warning: Be prepared to be shown a radiograph of metalwork failure with screws cut out into the articular surface. Stay calm. Assess the patient clinic- ally, radiologically (including CT), rule out infection,
soft tissue problems, patient compliance and then proceed from the start, take out the metalwork, align the articular surface, stabilize the fracture and mobil- ize again. It is the same story all over.
