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MyPasTest: MRCS A Online - Jan Exam 201522. Surgical Specialities; Trauma & Orthopaedic Surgery (76Qs)
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01. Theme: Treatment options in fracture management
A Broad arm sling (polysling)
B Cast-brace
C Cerclage wires
D Dynamic screw fixation
E External fixation
F Hanging cast Page
G Hemiarthroplasty 1305
H Intramedullary nailing
I K-wires
J Plaster cast
K Plate and screw fixation
L Screw fixation
M Tension band wiring
N Traction.
All of the above are employed in the management of fractures. For the following fractures please choose
the most appropriate method of fracture fixation from the list. Each item may be used once, more than
once, or not at all.
Scenario 1
A closed, two-part fracture to the middle third of the clavicle (low-impact mechanism).
A - Broad arm sling (polysling)« CORRECT ANSWER.
A – Broad arm sling:
Fractures of the clavicle, despite representing 5% of all fractures (and 44% of shoulder girdle fractures),
seldom excite much interest. They are usually treated conservatively in a broad arm sling (or polysling),
although surgical fixation may be indicated. Operative treatment is reserved for those patients with: open
fractures, polytrauma, neurovascular injury (NB proximity of brachial plexus), compromise of the
overlying skin, floating shoulder, symptomatic non-union and fractures of the lateral third proximal to, or
between, the conoid and trapezoid ligaments.
Scenario 2
An inter-trochanteric fracture to the left neck of the femur in a 75-year-old woman.
B - Cast-brace« YOUR ANSWER
D - Dynamic screw fixation« CORRECT ANSWER.
D – Dynamic screw fixation:
For an extracapsular fracture, where blood supply to the femoral head is
not significantly compromised (such as that described in this scenario), the
ideal method of fixation is with dynamic screw fixation, specifically a
dynamic hip screw. This is a plate and sliding screw fixator that permits
compression at the fracture site. It allows good anatomical fixation of the
fracture and early mobilisation of the patient.
Scenario 3
An isolated femoral shaft fracture in a 4-year-old boy.
C - Cerclage wires« YOUR ANSWER
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
22. Surgical Specialities; Trauma & Orthopaedic Surgery (76Qs)
----------------------------------------------------------------------------------------------------------------------------------
N - Traction« CORRECT ANSWER.
N – Traction:
Paediatric femoral shaft fractures are commonly treated by skin or skeletal traction. This allows fracture
union before the child then commences mobilisation in an appropriate cast. It is important to note that
fixation of fractures in young children can disturb bone growth (particularly intramedullary nailing
through an epiphyseal growth plate), leading to shortening and malformation of the affected limb. Hence Page
it is restricted to the management of the polytraumatised child when plate fixation or external fixation may 1306
be used with care.
Scenario 4
A Gustilo III comminuted tibial fracture in a 35-year-old man.
D - Dynamic screw fixation« YOUR ANSWER
E - External fixation« CORRECT ANSWER.
E – External fixation:
Indications for external fixation in trauma encompass: compound (open) long bone fractures with
extensive tissue devitalisation (especially of the tibia), closed fractures with degloving skin injuries, ‘open
book’ pelvic fractures, polytrauma, peri-articular and metaphyseal fractures. The unique characteristics of
external fixation include: rapid skeletal stabilisation using connecting frames and percutaneous pins,
remote from the site of injury; versatility (different injuries with differing anatomy); ability to adjust
alignment and fixation during fracture healing; and ease of access to surrounding soft tissues.
02. Theme: The painful knee
A Anterior cruciate injury
B Chondromalacia patellae
C Infrapatellar bursitis
D Lateral collateral injury
E Medial collateral injury
F Meniscal tear
G Osgood–Schlatter disease
H Osteoarthritis
I Osteochondritis dissicans
J Pre-patellar bursitis
K Recurrent dislocation of the patella
L Rheumatoid arthritis
M Septic arthritis
N Tendinitis.
The following are descriptions of patients with a painful knee(s). Please select the most appropriate
diagnosis from the above list. The items may be used once, more than once, or not at all.
Scenario 1
A 43-year-old woman is seen with a history of chronic pain and swelling of the knee. On examination, flexion and
extension of the knee are limited and a marked valgus deformity is noted. This is particularly apparent on
standing.
A - Anterior cruciate injury« YOUR ANSWER
L - Rheumatoid arthritis« CORRECT ANSWER
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
22. Surgical Specialities; Trauma & Orthopaedic Surgery (76Qs)
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L – Rheumatoid arthritis:
This can occasionally start in the knee as a monoarticular synovitis. With chronicity, the joint may
become increasingly deformed. Although deformity can also occur (with chronic pain and swelling) in
osteoarthritis, a valgus deformity is characteristic of rheumatoid arthritis whereas a varus deformity is
frequently seen with severe osteoarthritis.
Scenario 2 Page
A 14-year-old girl is seen with a 3-month history of knee pain. There is no history of trauma. The pain is felt 1307
principally in front of the knee and is exacerbated on ascending and descending stairs.
B - Chondromalacia patellae« CORRECT ANSWER.
B – Chondromalacia patellae:
Softening of the articular cartilage of the patella is often associated with anterior knee pain in teenage
girls. The exact aetiology is unknown, however, it is thought to result from overload of the patellar
articular surface as a result of mal-tracking of the patella during flexion and extension. On clinical
examination, pain can be elicited by the patella friction test. Treatment is rest, analgesia and
physiotherapy.
Scenario 3
A 19-year-old man presents with a history of intermittent pain and swelling in his left knee. In addition, he
complains of his knee locking, which he relieves by manoeuvring the leg. He also complains of his knee „giving
way.‟ There is no history of trauma. On examination a small effusion is noted and a small mobile „body‟ is felt in
the suprapatellar pouch.
C - Infrapatellar bursitis« YOUR ANSWER
I - Osteochondritis dissicans« CORRECT ANSWER.
I – Osteochondritis dissicans:
This is a condition where a small osteocartilaginous fragment separates from one of the femoral condyles
(usually the medial condyle) and is rendered avascular. Patients tend to be young and present with
intermittent pain and swelling of the knee. Attacks of ‘locking’ may occur as the loose body becomes
trapped between the joint surfaces. Between attacks the loose body may be palpable, particularly in the
suprapatellar pouch. Treatment involves removal of the loose body if small. Large fragments may be fixed
back into position, particularly if complete separation has not occurred.
03. Theme: Common fracture eponyms
A Barton’s fracture
B Bennett’s fracture
C Colles’ fracture
D Galeazzi’s fracture dislocation
E Garden II fracture
F Garden III fracture
G Garden IV fracture
H Hill–Sachs fracture
I Lisfranc fracture dislocation
J Monteggia’s fracture dislocation
K Rolando’s fracture
L Smith’s fracture
M Weber A fracture
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
22. Surgical Specialities; Trauma & Orthopaedic Surgery (76Qs)
----------------------------------------------------------------------------------------------------------------------------------
N Weber B fracture
O Weber C fracture.
The following are descriptions of fractures. Please select the most appropriate fracture eponym from the
above list. Each item may be used once, more than once, or not at all. These are all commonly used in
current clinical practice (and so remain important).
Page
Scenario 1 1308
A comminuted, intra-articular fracture to the base of the first metacarpal.
A - Barton‟s fracture « YOUR ANSWER
K - Rolando‟s fracture« CORRECT ANSWER.
K – Rolando’s fracture:
This description could be one of a Bennett’s fracture, but the comminuted nature distinguishes it as a
Rolando’s fracture. There are usually three fragments forming either a Y-shape or a T-shape on
radiograph.
Scenario 2
A distal fibular fracture at the level of the syndesmosis, with or without a malleolar fracture.
B - Bennett‟s fracture « YOUR ANSWER
N - Weber B fracture« CORRECT ANSWER.
N – Weber B fracture:
The Weber (or Danis–Weber) classification describes the severity of tibio- fibular ligament injury by the
level of fibular fracture. This is a Weber B fracture as it is sited at the level of the syndesmosis. A Weber A
fracture is infra-syndesmotic while a Weber C fracture occurs above the level of the syndesmosis. The
Lauge–Hansen classification is an alternative method of describing fractures of the distal tibia and fibular.
It takes into account foot position and direction of deforming forces, and is preferred by senior
orthopaedic surgeons. For your purposes the Weber system is sufficient as the Lauge–Hansen is
complex and not all fractures fit the classical pattern.
Scenario 3
A complete fracture through the femoral neck, with rotation of the femoral head within the acetabulum,
demonstrating minimal displacement.
C - Colles‟ fracture « YOUR ANSWER
F - Garden III fracture « CORRECT ANSWER.
F – Garden III fracture:
The Garden classification is used to describe intra-capsular fractures of the neck of the femur. It is
important to distinguish these from extra-capsular fractures, as there is a bearing on blood supply, and
ultimately, treatment. The capsule contributes the majority of the blood supply to the head of the femur,
via the medial and lateral circumflex arteries from the profunda femoris. A compromise in the blood
supply can result in avascular necrosis.
The Garden system consists of four grades (I–IV) as follows:
1. Garden I – incomplete or impacted fracture
2. Garden II – non-displaced fracture through both cortices
3. Garden III – minimally displaced fracture with rotation of the femoral head in the acetabulum
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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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