Trauma
Chapter 14 Pelvic trauma
source p. 776
Introduction#
There are several areas of pelvis/acetabulum that candidates need to be familiar with and other areas that are within a subspecialty interest.
Acetabular/pelvic radiology is usually discussed at the beginning of a viva and should be slickly and quickly answered so as to move on and to get onto the main testing area of the viva.
A basic appreciation of the various surgical approaches to fix an acetabular fracture is reasonable, but it is unlikely candidates will need to know this ingreat detail. Management of the open-book pelvis and the resuscitation around this is an A-list topic.
Familiarize and pattern-recognize various acetabular/pelvic fractures from either a large trauma book or website (usually radiology based) and be able to effortlessly describe out loud the pertinen t/salient features.
Know the various classification systems, as although there isless emphasis on them these days, the viva invariably ends up at some point with the opportunity for a candidate to discuss them.
source p. 777
Structured oral examination question 1#
EXAMINER
A 25-year-old professional motorbike racer came off his bike at more than 60 miles/hour speed. His only area of pain is his left hip. This is an X -ray of his pelvis. What does it show (Figure 14.1a)?
A 25-year-old professional motorbike racer came off his bike at more than 60 miles/hour speed. His only area of pain is his left hip. This is an X -ray of his pelvis. What does it show (Figure 14.1a)?
CANDIDATE
Anteroposterior pelvis radiograph of a skeletally mature adult marking out the iliopectineal and ilioischial lines (representing landmarks of the anterior and posterior columns) ... [Silence] Keep talking about the acetabular lines. The candidate has stopped too soon. They should have continued on and mentioned that the iliopectineal line represents the anterior column and the ilioischial line the posterior column. The medial aspect of the acetabulum is represented by the teardrop and the weight-bearing dome by the sourcil.
Anteroposterior pelvis radiograph of a skeletally mature adult marking out the iliopectineal and ilioischial lines (representing landmarks of the anterior and posterior columns) ... [Silence] Keep talking about the acetabular lines. The candidate has stopped too soon. They should have continued on and mentioned that the iliopectineal line represents the anterior column and the ilioischial line the posterior column. The medial aspect of the acetabulum is represented by the teardrop and the weight-bearing dome by the sourcil.
EXAMINER
[Candidate prompt] Tell me about pelvic anatomy. What acetabular lines do you know and are any disrupted?
[Candidate prompt] Tell me about pelvic anatomy. What acetabular lines do you know and are any disrupted?
COMMENT
Practise out loud describing disrupted acetabular lines on pelvic radiographs until it all comes together. Big-volume trauma books or internet image searches are the best sources. The aim is to get through this info in the first minute rather than geting bogged down and stuck as a candidate is losing scoring opportunities in not get ing to the next stage of the viva. The posterior wall is larger, more lateral and more easily visualized than the smaller, more medial anterior wall. The acetabular dome appears intact; Shent online is intact. My concern is a possible posterior wall injury. The right sacroiliac joint appears wider than the left. The reis a small bony avulsion in the pubic symphysis area. Both hip joints appear concentric.
Practise out loud describing disrupted acetabular lines on pelvic radiographs until it all comes together. Big-volume trauma books or internet image searches are the best sources. The aim is to get through this info in the first minute rather than geting bogged down and stuck as a candidate is losing scoring opportunities in not get ing to the next stage of the viva. The posterior wall is larger, more lateral and more easily visualized than the smaller, more medial anterior wall. The acetabular dome appears intact; Shent online is intact. My concern is a possible posterior wall injury. The right sacroiliac joint appears wider than the left. The reis a small bony avulsion in the pubic symphysis area. Both hip joints appear concentric.
EXAMINER
What will you do next?
What will you do next?
CANDIDATE
This is a high-energy injury and the patient should be assessed according to ATLS protocols so that life-threatening injuries are not missed. As per ATLS protocols I will reassess the patient, performing primary and secondary surveys to identify any other injuries than the left hip. I will assess the range of movements in the left hip joint, distal neurovascular status and examine the left knee and left ankle. I will check the pulser ate, blood pressure and respiratory rate trend. In the initial leadin question the examiner has implied that the injury is an isolated closed injury and doesn’t want the ALTS talk. However, the candidate isn’t assuming anything as the examiner hasn’t made this point absolutely crystal clear. If, however the ATLS talk has already been done in the previous viva question then a candidate should default to ‘Assuming the injury is an isolated closed injury and ATLS protocols have been performed I will assess range of movements in the left hip joint ... etc.’
This is a high-energy injury and the patient should be assessed according to ATLS protocols so that life-threatening injuries are not missed. As per ATLS protocols I will reassess the patient, performing primary and secondary surveys to identify any other injuries than the left hip. I will assess the range of movements in the left hip joint, distal neurovascular status and examine the left knee and left ankle. I will check the pulser ate, blood pressure and respiratory rate trend. In the initial leadin question the examiner has implied that the injury is an isolated closed injury and doesn’t want the ALTS talk. However, the candidate isn’t assuming anything as the examiner hasn’t made this point absolutely crystal clear. If, however the ATLS talk has already been done in the previous viva question then a candidate should default to ‘Assuming the injury is an isolated closed injury and ATLS protocols have been performed I will assess range of movements in the left hip joint ... etc.’
source p. 778
If exam tactics are really not your strongpoint, then if allthings fail at least you should avoid mentioning the ‘ATLS talk’ for all six of the trauma viva topics – now that will really annoy the examiners who are looking for an excuse to moan!
EXAMINER
Left hip movements are limited to a jog of movements by pain; the rest of the examination is unremarkable. What is the next step?
Left hip movements are limited to a jog of movements by pain; the rest of the examination is unremarkable. What is the next step?
CANDIDATE
I will ensure the patient has adequate analgesia and frequent neurovascular assessment of the left leg. I will request a CT scan of the pelvis and both hips.
I will ensure the patient has adequate analgesia and frequent neurovascular assessment of the left leg. I will request a CT scan of the pelvis and both hips.
EXAMINER
Would you order a CT scan in the middle of the night?
Would you order a CT scan in the middle of the night?
CANDIDATE
The timing of the C T scan would depend on the timing of thein jury, the admiting hospitals facilities and an y associated injuries. If the injury occurred during the day it should be fairly straighfoorward in most hospitals to obtain an urgent CT scan that day. If the injury presents in the middle of the night, say 2 a.m., it could wait until the following morning, as the scan does not need to be performed immediately. If a CT scan is required for some other area of concern such as to exclude an abdominal injury, then it may be reasonable to also include the pelvis and both hips rather than have to rescan again in the next day or so. This question tests real-life decisions and the rationale (and evidence) behind your choice – what you will do in an actual situation with a real patient in front of you. The question is examining higher-order judgement in the real world and not facts from a book. This is the highest level of knowledge the examination sets out to test. This is the score 7 and 8 opportunity that if a viva gets stuck down on competency questions the candidate will never get to.
The timing of the C T scan would depend on the timing of thein jury, the admiting hospitals facilities and an y associated injuries. If the injury occurred during the day it should be fairly straighfoorward in most hospitals to obtain an urgent CT scan that day. If the injury presents in the middle of the night, say 2 a.m., it could wait until the following morning, as the scan does not need to be performed immediately. If a CT scan is required for some other area of concern such as to exclude an abdominal injury, then it may be reasonable to also include the pelvis and both hips rather than have to rescan again in the next day or so. This question tests real-life decisions and the rationale (and evidence) behind your choice – what you will do in an actual situation with a real patient in front of you. The question is examining higher-order judgement in the real world and not facts from a book. This is the highest level of knowledge the examination sets out to test. This is the score 7 and 8 opportunity that if a viva gets stuck down on competency questions the candidate will never get to.
EXAMINER
These are axial CT scans of both hips and SI joints. Describe the injury (Figures 14.1c and 14.1d).
These are axial CT scans of both hips and SI joints. Describe the injury (Figures 14.1c and 14.1d).
CANDIDATE
The axial section of the left hip shows an intra-articular fragment, marginal impaction of the posterior wall, and loss of concentricity of the hip joint. There is no subluxation of hip or evidence of femoral head/neck injury. There is also a cystic lesion in the femoral head that looks benign. Both SI joints appear symmetric and there are no other injuries that I can identify.
The axial section of the left hip shows an intra-articular fragment, marginal impaction of the posterior wall, and loss of concentricity of the hip joint. There is no subluxation of hip or evidence of femoral head/neck injury. There is also a cystic lesion in the femoral head that looks benign. Both SI joints appear symmetric and there are no other injuries that I can identify.
EXAMINER
What is the definitive management of this injury?
What is the definitive management of this injury?
CANDIDATE
Non-operativ e management is not recommended due to the intra-articular fragment. This will result in early degenerative changes and post-traumatic osteoarthritis. The aims ofo per at ive management are to remove intra-articular fragments, reduce the marginal impaction, bone gr aft the bony defect if needed, then but iress plate fixation of the posterior wall. The amount of comminution could make fracture reduction difficult.
Non-operativ e management is not recommended due to the intra-articular fragment. This will result in early degenerative changes and post-traumatic osteoarthritis. The aims ofo per at ive management are to remove intra-articular fragments, reduce the marginal impaction, bone gr aft the bony defect if needed, then but iress plate fixation of the posterior wall. The amount of comminution could make fracture reduction difficult.
EXAMINER
When will you operate?
When will you operate?
CANDIDATE
The surgery should be performed by an orthopaedic surgeon with interest in pelvic and acetabular fracture fixation. Surgery should be performed ideally within 5 days as per BOAST guidelines.
The surgery should be performed by an orthopaedic surgeon with interest in pelvic and acetabular fracture fixation. Surgery should be performed ideally within 5 days as per BOAST guidelines.
COMMENT
It is much better if a candidate avoids pure recitation of the BO AST text and actually thinks about the problem they have in front of them.
It is much better if a candidate avoids pure recitation of the BO AST text and actually thinks about the problem they have in front of them.
EXAMINER
What are BOAST guidelines?
What are BOAST guidelines?
CANDIDATE
British Orthopaedic Association Standards of Trauma guidelines.
British Orthopaedic Association Standards of Trauma guidelines.
source p. 780
Pelvic fractures
First line of management is control of haemorrhage – pelvic binder, blood transfusion, pelvic packing or embolization.
Look for genitourinary tract injury and open fractures – wounds in perineum, rectum or vagina.
Surgical treatment of these injuries as soon as possible.
Early CT scan of pelvis.
Transfer images to local referral unit within 24 hours.
Once haemodynamic and skeletal stabilizations are achieved, the patient should be transferred to a specialist unit for surgery within 5 days if possible.
Figure 14.1a Anteroposterior (AP) radiograph of pelvis.
source p. 781
Figure 14.1b Iliopectineal liner ed); ilioischial line (light green); sacral arcuate lines (yellow); Shenton arc (light blueline of Klein (white); gluteal fat stripe (purple); acetabular roof (pink); medial acetabular wall (dark green); anterior acetabular wall (orange); posterior acetabular wall (dark blue); femoral headline (black).
Figure 14.1c and 14.1d CT scan of pelvis and SI joints.
source p. 782
Acetabular fractures
Urgent reduction of dislocated hips, skeletal traction should be applied. CT scan within 24 hours and images should be transferred to the specialist unit.
Surgery if needed should be performed within 5 days, ideally.
EXAMINER
What approach will you use? What are the significant risks and complications of the approach?
What approach will you use? What are the significant risks and complications of the approach?
CANDIDATE
Posterior Kocher–Langenbeck approach. This allows access to the posterior wall and posterior column of the acetabulum.
Posterior Kocher–Langenbeck approach. This allows access to the posterior wall and posterior column of the acetabulum.
EXAMINER
Take me through this approach.
Take me through this approach.
CANDIDATE
This is a proximal extension of the posterior approach to the hip, which allows access to the posterior column, posterior wall and dome of the acetabulum. The patient is positioned either pr one or in the lateral decubitus position. Bony landmarks include: (1) posterior superior iliac spine, (2) greater trochanter, (3) shaft of femur. The skin incision begins 5 cm anterior to the PSIS, curves over the greater trochanter and runs parallel to the shaft of the femur for 15–20 cm. The superficial dissection involves incision of the fascia lata and gluteus maximus muscle. The deep dissection involves exposing the insertion of the piriformis tendon, the gemelli and the internal obturator muscle. These muscles may have been damaged at the time of injury and their identification may be difficult. The piriformis is divided through its tendon 1–2 cm from its femoral insertion after a stay suture has been passed through it. The tendons of obturator internus, superior and inferior gemelli muscles are tagged, divided 2–3 cm from their femoral insertion and then retracted. Subperiosteal dissection along the retroacetabular surface is performed. The lesser sciatic notch is exposed. It is important to leave a cuff of tissue around the external rotators and avoid dissecting in to quadratus femoris in order to preserve the ascending branch of the medial femoral circumflex artery. The gluteus maximus insertion in to the femur is released which aids retraction and reduces the stretch on the sciatic nerve.
This is a proximal extension of the posterior approach to the hip, which allows access to the posterior column, posterior wall and dome of the acetabulum. The patient is positioned either pr one or in the lateral decubitus position. Bony landmarks include: (1) posterior superior iliac spine, (2) greater trochanter, (3) shaft of femur. The skin incision begins 5 cm anterior to the PSIS, curves over the greater trochanter and runs parallel to the shaft of the femur for 15–20 cm. The superficial dissection involves incision of the fascia lata and gluteus maximus muscle. The deep dissection involves exposing the insertion of the piriformis tendon, the gemelli and the internal obturator muscle. These muscles may have been damaged at the time of injury and their identification may be difficult. The piriformis is divided through its tendon 1–2 cm from its femoral insertion after a stay suture has been passed through it. The tendons of obturator internus, superior and inferior gemelli muscles are tagged, divided 2–3 cm from their femoral insertion and then retracted. Subperiosteal dissection along the retroacetabular surface is performed. The lesser sciatic notch is exposed. It is important to leave a cuff of tissue around the external rotators and avoid dissecting in to quadratus femoris in order to preserve the ascending branch of the medial femoral circumflex artery. The gluteus maximus insertion in to the femur is released which aids retraction and reduces the stretch on the sciatic nerve.
EXAMINER
Would you prefer to position the patient in the lateral position or pr one?
Would you prefer to position the patient in the lateral position or pr one?
COMMENT
This questionist esting higher -order thinking about what a surgeon would do in real life and what are his/her justifications for a particular decision. Higher rates of infection and revision surgery are reported in the prone group. Lateral positioning is more common with most surgeons because it allows easier manoeuverability of the limb and avoids the unfamiliarity of operating in the pr one position.
This questionist esting higher -order thinking about what a surgeon would do in real life and what are his/her justifications for a particular decision. Higher rates of infection and revision surgery are reported in the prone group. Lateral positioning is more common with most surgeons because it allows easier manoeuverability of the limb and avoids the unfamiliarity of operating in the pr one position.
source p. 783
The main disadvantages of the lateral position are:
Difficulty applying manual traction.
Potential for sciatic nerve injury.
Difficulties achieving reduction duet o persistent posterior column displacement as the result of gravity that cannot be eliminated in this position.
Access through the greater sciatic notch for palpation or clamp placement is impaired.
The prone position is particularly indicated for transverse or T-type fractures. It offers the main advantage of gravity elimination and aids in the reduction of the posterior column. The leg can beheld flexed at the knee and extended at the hip to avoid traction on thes cia tic nerve, greatly reducing the chance of nerve injury. Controlled lateral traction can also be applied to help visualize the joint surface through the window of the posterior wall fracture after the posterior column has been reduced.
The posterior column should be fixed first as it provides a stable surface to reduce the posterior wall fracture.
EXAMINER
What are the significant risks and complications of the approach?
What are the significant risks and complications of the approach?
CANDIDATE
Important blood supply to the femoral head is from medial femoral circumflex artery that passes close to the insertions of short external rotators of the hip. During surgery the short external rotators should be divided at least 1 cm from their insertions to protect this artery and avoid avascular necrosis of femoral head. The sciatic nerve should be identified and protected. The superior gluteal nerve and vessels are vulnerable during dissection of the superior border of the greater sciatic notch. It is important to make sure no screws are penetrating the joint using II or intraoperative radiographs. Other risks include infection, D VT, PE, loss of fixation heterotropic ossification and secondary osteoarthritis.
Important blood supply to the femoral head is from medial femoral circumflex artery that passes close to the insertions of short external rotators of the hip. During surgery the short external rotators should be divided at least 1 cm from their insertions to protect this artery and avoid avascular necrosis of femoral head. The sciatic nerve should be identified and protected. The superior gluteal nerve and vessels are vulnerable during dissection of the superior border of the greater sciatic notch. It is important to make sure no screws are penetrating the joint using II or intraoperative radiographs. Other risks include infection, D VT, PE, loss of fixation heterotropic ossification and secondary osteoarthritis.
EXAMINER
Can you think of any technical difficulties that you may encounter when fixing the fracture?
Can you think of any technical difficulties that you may encounter when fixing the fracture?
CANDIDATE
It is important to use a specialized pelvic traction t able that allows controlled traction to be applied. Traction is very important in allowing fracture reduction Traction unloads the joint allowing better joint visualization and assists direct manipulation of the fracture fragments. Manual methods of applying traction are unpredictable and usually difficult. Bone graft may be needed to fill in any fracture gaps.
It is important to use a specialized pelvic traction t able that allows controlled traction to be applied. Traction is very important in allowing fracture reduction Traction unloads the joint allowing better joint visualization and assists direct manipulation of the fracture fragments. Manual methods of applying traction are unpredictable and usually difficult. Bone graft may be needed to fill in any fracture gaps.
EXAMINER
Does this injury have a good or a bad prognosis, historically?
Does this injury have a good or a bad prognosis, historically?
source p. 784
CANDIDATE
Posterior wall fractures have in general poor prognosis due to the damage to articular surface, impaction and difficulty in achieving anatomic reduction.
Posterior wall fractures have in general poor prognosis due to the damage to articular surface, impaction and difficulty in achieving anatomic reduction.
EXAMINER
What will be your postoperative rehabilitation protocol?
What will be your postoperative rehabilitation protocol?
CANDIDATE
I will start hip range of movement exercises from day one and continue with non-w eight- bearing for 3 months.
I will start hip range of movement exercises from day one and continue with non-w eight- bearing for 3 months.
source p. 785
Structured oral examination question 2#
EXAMINER
A 23-year-old professional dancer is involved in a road traffic accident at 5 pm (motorbike rider vs. car). The patient is brought to casualty with GCS of 15, BP 110/70 mmHg, PR 90/min. The patient is complaining of pain around the right buft ock area. Fifteen minutes after arrival the patient’s BP dropped to 70 mmHg systolic. What will you do?
A 23-year-old professional dancer is involved in a road traffic accident at 5 pm (motorbike rider vs. car). The patient is brought to casualty with GCS of 15, BP 110/70 mmHg, PR 90/min. The patient is complaining of pain around the right buft ock area. Fifteen minutes after arrival the patient’s BP dropped to 70 mmHg systolic. What will you do?
CANDIDATE
As per ATLS protocols I will perform primary and secondary survey making sure two large- bore cannulae are introduced and blood taken for FBC, U&E, cross-match 6 units of blood. I will apply a pelvic binder and reassess the chest, abdomen, long bones and look for any open wounds that are bleeding.
As per ATLS protocols I will perform primary and secondary survey making sure two large- bore cannulae are introduced and blood taken for FBC, U&E, cross-match 6 units of blood. I will apply a pelvic binder and reassess the chest, abdomen, long bones and look for any open wounds that are bleeding.
EXAMINER
The patient blood pressure stabilized at 110/70 mmHg and 2 units of blood are being transfused. X-ray of pelvis was performed. Describe the injury (Figure 14.2a).
The patient blood pressure stabilized at 110/70 mmHg and 2 units of blood are being transfused. X-ray of pelvis was performed. Describe the injury (Figure 14.2a).
CANDIDATE
This is aver tical shear-type pelvic fracture involving the right hemipelvis with fractures through both superior and inferior pubic rami and through right sacral alae and possibly neural foraminae.
This is aver tical shear-type pelvic fracture involving the right hemipelvis with fractures through both superior and inferior pubic rami and through right sacral alae and possibly neural foraminae.
EXAMINER
Is there a spur sign?
Is there a spur sign?
CANDIDATE
No, I can’t see one. The ‘spur’ sign represents the edge of intact ilium adjacent to the fracture, and is pathognomonic of a both-column fracture.
No, I can’t see one. The ‘spur’ sign represents the edge of intact ilium adjacent to the fracture, and is pathognomonic of a both-column fracture.
EXAMINER
Is there any obturator ring disruption?
Is there any obturator ring disruption?
CANDIDATE
No.
No.
EXAMINER
Is there a fracture of the transverse process of L5?
Is there a fracture of the transverse process of L5?
CANDIDATE
I didn’t see one.
I didn’t see one.
EXAMINER
Why is this important?
Why is this important?
CANDIDATE
A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture.
A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture.
EXAMINER
You mentioned vertical shear, how can you classify pelvic injuries? CANDIDATE 1: [Silence ...] CANDIDATE 2: Judet and Letournel classification. I think you are mixing up acetabular and pelvic classification system names.
You mentioned vertical shear, how can you classify pelvic injuries? CANDIDATE 1: [Silence ...] CANDIDATE 2: Judet and Letournel classification. I think you are mixing up acetabular and pelvic classification system names.
source p. 786
CANDIDATE 3: Pelvic fracture can be classified based on the stability of the pelvic ring.
EXAMINER
Do you know a name?
Do you know a name?
CANDIDATE
Young and Burgess (Table 14.1).
Young and Burgess (Table 14.1).
EXAMINER
How does this classification guide your management?
How does this classification guide your management?
CANDIDATE
This classification is based on the mechanism of injury and the severity of pelvic trauma. Fractures are divided into one of four categories based on the mechanism of injury, two of which are further subdivided according to the severity of injury.
This classification is based on the mechanism of injury and the severity of pelvic trauma. Fractures are divided into one of four categories based on the mechanism of injury, two of which are further subdivided according to the severity of injury.
EXAMINER
What is the typical mechanism of injury for a lateral compression fracture?
What is the typical mechanism of injury for a lateral compression fracture?
CANDIDATE
[Long silence ... ]
[Long silence ... ]
EXAMINER
What are the radiological landmarks/lines you assess for a pelvic fracture? Show them on the normal side.
What are the radiological landmarks/lines you assess for a pelvic fracture? Show them on the normal side.
CANDIDATE
For pelvic fractures I start looking at the pubic symphysis, pubic rami, iliac wing, sacroiliac joints, sacral alae, neural foraminae, sacral bodies, transverse processes of lower lumbar vertebrae, sacral spinous processes. I will also look for associated acetabular fracture by looking at ilioinguinal, ilioischial lines, acetabular dome, anterior and posterior walls, obturator foramen and teardrop.
For pelvic fractures I start looking at the pubic symphysis, pubic rami, iliac wing, sacroiliac joints, sacral alae, neural foraminae, sacral bodies, transverse processes of lower lumbar vertebrae, sacral spinous processes. I will also look for associated acetabular fracture by looking at ilioinguinal, ilioischial lines, acetabular dome, anterior and posterior walls, obturator foramen and teardrop.
EXAMINER
What is this view?
What is this view?
CANDIDATE
This is a Judet view. An iliac oblique view. It demonstrates the anterior rim of the acetabulum and the posterior ilioischial column.
This is a Judet view. An iliac oblique view. It demonstrates the anterior rim of the acetabulum and the posterior ilioischial column.
EXAMINER
Can you identify the lines for me?
Can you identify the lines for me?
CANDIDATE
I am not sure.
I am not sure.
EXAMINER
Have a try.
Have a try.
CANDIDATE
Line one is ilioischial line, line 4 is the iliac crest.
Line one is ilioischial line, line 4 is the iliac crest.
EXAMINER
How is this radiograph taken?
How is this radiograph taken?
CANDIDATE
This is obtained on a supine patient with the injured side of pelvis rotated anteriorly at 45°. The X-ray beam is directed vertically toward the affected hip.
This is obtained on a supine patient with the injured side of pelvis rotated anteriorly at 45°. The X-ray beam is directed vertically toward the affected hip.
EXAMINER
That is the other Judet view, the obturator view.
That is the other Judet view, the obturator view.
COMMENT
The obturator oblique view is obtained on a supine patient with the injured side of pelvis rotated anteriorly at 45°. The X-ray beam is directed vertically toward the affected hip. It is useful to assess the obturator ring, anterior column (iliopectineal line) and posterior wall of the acetabulum. The iliac oblique view is obtained on a supined patient with the unaffected side of the pelvis rotated anteriorly at 45°. The X-ray beam is directed vertically toward the affected hip. It is useful to assess the posterior ilioischial column and anterior wall. The iliac wing ‘flatten’ out on the image should be well demonstrated.
The obturator oblique view is obtained on a supine patient with the injured side of pelvis rotated anteriorly at 45°. The X-ray beam is directed vertically toward the affected hip. It is useful to assess the obturator ring, anterior column (iliopectineal line) and posterior wall of the acetabulum. The iliac oblique view is obtained on a supined patient with the unaffected side of the pelvis rotated anteriorly at 45°. The X-ray beam is directed vertically toward the affected hip. It is useful to assess the posterior ilioischial column and anterior wall. The iliac wing ‘flatten’ out on the image should be well demonstrated.
source p. 787
EXAMINER
How will you manage the patient now?
How will you manage the patient now?
CANDIDATE
I will assess both lower limbs and distal neurovascular status followed by assessment of both upper limbs. I will also look for any open wounds around the perineum, groin, buft ocks vagina, rectum to rule out an open fracture. Until the spine is assessed the patient will have to be logrolled and the neck should be triple immobilized.
I will assess both lower limbs and distal neurovascular status followed by assessment of both upper limbs. I will also look for any open wounds around the perineum, groin, buft ocks vagina, rectum to rule out an open fracture. Until the spine is assessed the patient will have to be logrolled and the neck should be triple immobilized.
EXAMINER
The patient has altered sensation in the S1 nerveroot area of the right foot, but no motor deficit was noted. What do you do?
The patient has altered sensation in the S1 nerveroot area of the right foot, but no motor deficit was noted. What do you do?
CANDIDATE
I will obtain CT scan of cervical spine, chest, abdomen and pelvis to assess for associated injuries and look specifically for any evidence of S1 nerveroot injury due to the pelvic fracture. Then, I will perform distal femoral pin traction once I have ruled out any femoral fracture.
I will obtain CT scan of cervical spine, chest, abdomen and pelvis to assess for associated injuries and look specifically for any evidence of S1 nerveroot injury due to the pelvic fracture. Then, I will perform distal femoral pin traction once I have ruled out any femoral fracture.
EXAMINER
CT scan does not show any other visceral or vascular injuries. No urethral or perineal injuries were identified. What will be the definitive management and the timing?
CT scan does not show any other visceral or vascular injuries. No urethral or perineal injuries were identified. What will be the definitive management and the timing?
CANDIDATE
The images and patient details should be sent to the local specialist unit for a decision on transfer of the patient. Definitive management principles include reduction of the vertical shear, usually by skeletal traction, sacral fixation with sacroiliac screws, pubic ramus fixation with percutaneous ramus screw fixation or open reduction and plate fixation. If the fixation is s till tenuous then external fixation could be used to augment the fixation.
The images and patient details should be sent to the local specialist unit for a decision on transfer of the patient. Definitive management principles include reduction of the vertical shear, usually by skeletal traction, sacral fixation with sacroiliac screws, pubic ramus fixation with percutaneous ramus screw fixation or open reduction and plate fixation. If the fixation is s till tenuous then external fixation could be used to augment the fixation.
EXAMINER
What are the specific risks involved?
What are the specific risks involved?
CANDIDATE
Closed reduction of vertical shear may not be possible. If so, then open reduction of the sacral fractures can be performed with patient prone and stabilization with sacroiliac screws followed by pubic ramus stabilization. The L5 nerveroot is at risk during sacroiliac screw insertion. Other risks include infection, D VT, PE, failure of fixation and persistent low back pain.
Closed reduction of vertical shear may not be possible. If so, then open reduction of the sacral fractures can be performed with patient prone and stabilization with sacroiliac screws followed by pubic ramus stabilization. The L5 nerveroot is at risk during sacroiliac screw insertion. Other risks include infection, D VT, PE, failure of fixation and persistent low back pain.
Figure 14.2a Anteroposterior (AP) radiograph of pelvis.
source p. 788
Figure 14.2b Radiograph of Iliac oblique view. 1, ilioischial line (posterior column); 2, anterior acetabular wall; 3, roof of acetabulum; 4, iliac crest.
source p. 789
Figure 14.2c Obturator oblique view. 1, iliopectineal line; 2, posterior acetabular wall; 3, acetabular roof; 4, obturator foramen.
Table 14.1 Young and Burgess classification.
Vertical shear Vertical displacement, anterior and posterior through sacroiliac joint
source p. 790
Combination of other injury patterns: lateral compression/vertic al shear or lateral compression/anterior posterior compression
source p. 791
Structured oral examination question 3#
EXAMINER
A 75-year-old gentleman who lives in a hostel, independently mobile, not on any medications sustained a fall while coming downstairs. He used to smoke 30 cigarettes a day and drinks ‘a lot’. This is an X-ray of his pelvis. Describe the injury (Figure 14.3a).
A 75-year-old gentleman who lives in a hostel, independently mobile, not on any medications sustained a fall while coming downstairs. He used to smoke 30 cigarettes a day and drinks ‘a lot’. This is an X-ray of his pelvis. Describe the injury (Figure 14.3a).
CANDIDATE
This is a right acetabular fracture with medialization of femoral head. Both ilioinguinal and ilioischial lines are broken. Acetabular dome, anterior and posterior wall are also involved.
This is a right acetabular fracture with medialization of femoral head. Both ilioinguinal and ilioischial lines are broken. Acetabular dome, anterior and posterior wall are also involved.
EXAMINER
How will you manage this patient initially?
How will you manage this patient initially?
CANDIDATE
I will examine the pa tientas per ATLS protocols and make sure that there are no other injuries or any distal neurovascular deficits. I will apply distal femoral pin traction after making sure there is no femoral fracture. CT scan of pelvis including both hips should be done as soon as possible. The images will be transferred to a local specialist unit along with patient details for consideration towards surgical management.
I will examine the pa tientas per ATLS protocols and make sure that there are no other injuries or any distal neurovascular deficits. I will apply distal femoral pin traction after making sure there is no femoral fracture. CT scan of pelvis including both hips should be done as soon as possible. The images will be transferred to a local specialist unit along with patient details for consideration towards surgical management.
EXAMINER
Why do you want a CT scan? What is a CT scan going to tell you that a plain X-ray will not? Plain films were good enough 30 years ago before CT scanners were invented.
Why do you want a CT scan? What is a CT scan going to tell you that a plain X-ray will not? Plain films were good enough 30 years ago before CT scanners were invented.
CANDIDATE
Although radiographic examination is the fir st-line investigation for acetabular classification, CT is extremely helpful in visualizing complex fracture patterns. It also depicts soft -tissue complications, such as involvement of the sciatic nerve and the superior and inferior gluteal arteries. It is good at picking up subtle or non-displaced fractures and sacral or quadrilateral surface fractures.
Although radiographic examination is the fir st-line investigation for acetabular classification, CT is extremely helpful in visualizing complex fracture patterns. It also depicts soft -tissue complications, such as involvement of the sciatic nerve and the superior and inferior gluteal arteries. It is good at picking up subtle or non-displaced fractures and sacral or quadrilateral surface fractures.
EXAMINER
What info will a CT provide that will change your management?
What info will a CT provide that will change your management?
CANDIDATE
It will help you to identify the degree of fracture displacement more accurately.
It will help you to identify the degree of fracture displacement more accurately.
EXAMINER
CT scan axial views are shown in Figures 14.3b–14.3d. What type of fracture is it? How can you classify acetabular fractures?
CT scan axial views are shown in Figures 14.3b–14.3d. What type of fracture is it? How can you classify acetabular fractures?
CANDIDATE
Acetabular fractures can be classified by the Judet and Letournel classification. There are five elementary fracture patterns: Posterior wall. Posterior column. Transverse. Anterior column. Anterior wall.
Acetabular fractures can be classified by the Judet and Letournel classification. There are five elementary fracture patterns: Posterior wall. Posterior column. Transverse. Anterior column. Anterior wall.
source p. 792
There are also five associated patterns, which are a combination of the elementary patterns:
Posterior wall and posterior column.
Transverse and posterior wall.
T-shaped.
Anterior wall/column and posterior hemitransverse.
Bilateral column.
This fracture involves both anterior and posterior columns. There is an area of intact acetabular dome. Based on the image shown, this fracture looks like anterior wall and column fracture with a posterior hemitransverse fracture.
It is more common in older age groups due to associated osteoporosis. Hence, these fractures are often due to low-energy injuries, such as a fall from standing height.
EXAMINER
What is your definitive management?
What is your definitive management?
CANDIDATE
Definitive management includes non-operativ e and operative management. Non-operativ e management accepts some degree of malunion and if this becomes symptomatic a total hip replacement can be performed. Skeletal traction for 6 weeks followed by a further 6 weeks of non- weight-bearing but hip range of movements are started. Operative management could be either just internal fixation with plate and screws or internal fixation and total hip replacement.
Definitive management includes non-operativ e and operative management. Non-operativ e management accepts some degree of malunion and if this becomes symptomatic a total hip replacement can be performed. Skeletal traction for 6 weeks followed by a further 6 weeks of non- weight-bearing but hip range of movements are started. Operative management could be either just internal fixation with plate and screws or internal fixation and total hip replacement.
EXAMINER
What are the advantages and disadvantages of just ORIF versus ORIF and THA?
What are the advantages and disadvantages of just ORIF versus ORIF and THA?
CANDIDATE
ORIF means the native hip joint can be salvaged. However, apa tien t has to be non-weight- bearing for 3 months. Risk of failure of fixation is higher duet o osteoporosis. Even if fixation does not fail, due to the increased risk of secondary osteoarthritis, a patient could still f ace a relatively big second operation Technically, total hip arthroplasty could be performed with relative ease as the fracture should have healed and will provide a stable base for the acetabular cup. ORIF and THA avoid the risks of fixation failure and secondary osteoarthritis. Also , the patient could potentiallys tart weight-bearing earlier. However, it is a larger procedure associated with increased risks of dislocation and infection.
ORIF means the native hip joint can be salvaged. However, apa tien t has to be non-weight- bearing for 3 months. Risk of failure of fixation is higher duet o osteoporosis. Even if fixation does not fail, due to the increased risk of secondary osteoarthritis, a patient could still f ace a relatively big second operation Technically, total hip arthroplasty could be performed with relative ease as the fracture should have healed and will provide a stable base for the acetabular cup. ORIF and THA avoid the risks of fixation failure and secondary osteoarthritis. Also , the patient could potentiallys tart weight-bearing earlier. However, it is a larger procedure associated with increased risks of dislocation and infection.
source p. 793
Figure 14.3a Anteroposterior (AP) radiograph of pelvis.
Figure 14.3b–14.3d CT scan axial views of pelvis.
source p. 794
Structured oral examination question 4#
EXAMINER
A 48-year-old man known to have mental health issues jumped off a bridge from a height of 30 feet, landing on a concrete pavement. In A&E his injuries identified are all orthopaedic injuries. Lumbar spinal fractures at L2, L3 burst fractures, pelvic and hip injuries as shown in this X-ray (Figure 14.4a), fracture of left radius and ulna, closed intra-articular pilon fracture of left distal tibia. How do you manage this patient?
A 48-year-old man known to have mental health issues jumped off a bridge from a height of 30 feet, landing on a concrete pavement. In A&E his injuries identified are all orthopaedic injuries. Lumbar spinal fractures at L2, L3 burst fractures, pelvic and hip injuries as shown in this X-ray (Figure 14.4a), fracture of left radius and ulna, closed intra-articular pilon fracture of left distal tibia. How do you manage this patient?
CANDIDATE
This patient has sustained multiple significant injuries. As per ATLS protocols I will perform primary and secondary surveys. Closed reduction of left hip as soon as possible and distal femoral pin traction. Logrolling, neurological assessment, triple immobilization. Soft -tissues tatus of pilon fracture. Below-knee backslab and below-elbow backslab application. Adequate analgesia. Regular neuro observations, haemodynamics tatus. Once haemodynamic stability is achieved, CT scan of neck, chest, abdomen and pelvis is performed to rule out other injuries and better identify the fracture patterns.
This patient has sustained multiple significant injuries. As per ATLS protocols I will perform primary and secondary surveys. Closed reduction of left hip as soon as possible and distal femoral pin traction. Logrolling, neurological assessment, triple immobilization. Soft -tissues tatus of pilon fracture. Below-knee backslab and below-elbow backslab application. Adequate analgesia. Regular neuro observations, haemodynamics tatus. Once haemodynamic stability is achieved, CT scan of neck, chest, abdomen and pelvis is performed to rule out other injuries and better identify the fracture patterns.
EXAMINER
What are his injuries on X-ray?
What are his injuries on X-ray?
CANDIDATE
Posterior dislocation of left hip with possible fracture, cannot say where the bony fragment has come from. Pubic rami fractures on left side. Both sacroiliac joints, right hip joint, obturator foramen, pubic symphysis appear normal. Cystogram has been performed which does not show any extravasation of dye.
Posterior dislocation of left hip with possible fracture, cannot say where the bony fragment has come from. Pubic rami fractures on left side. Both sacroiliac joints, right hip joint, obturator foramen, pubic symphysis appear normal. Cystogram has been performed which does not show any extravasation of dye.
EXAMINER
Axial CT scans of pelvis are shown in Figures 14.4b and 14.4c. What do they show?
Axial CT scans of pelvis are shown in Figures 14.4b and 14.4c. What do they show?
CANDIDATE
This view shows bilateral sacral alae and neural foraminal fractures. In conjunction with the pubic rami fractures, this is an unstable pelvic fracture.
This view shows bilateral sacral alae and neural foraminal fractures. In conjunction with the pubic rami fractures, this is an unstable pelvic fracture.
EXAMINER
What other reconstruction view is essential to look at?
What other reconstruction view is essential to look at?
CANDIDATE
The sagift al view of the sacrum will show whether there are any transverse sacral fractures. If there is also a transverse sacral fracture, then the fracture pattern is ‘H’-shaped and it is asp ino pelvic dissociation.
The sagift al view of the sacrum will show whether there are any transverse sacral fractures. If there is also a transverse sacral fracture, then the fracture pattern is ‘H’-shaped and it is asp ino pelvic dissociation.
EXAMINER
What is the definitive management plan for this pelvic fracture and its timing?
What is the definitive management plan for this pelvic fracture and its timing?
CANDIDATE
Once the patient is stable enough for surgical fixation the left hip is stressed under fluoroscopy to decide whether it is stable. The pelvic fracture fixation is withs pino pelvic stabilization with pedicle screws and a rod system connecting the fitih lumbar vertebra and posterior iliac spines followed by pubic ramus fracture fixation with plate and screws or percutaneous screw fixation.
Once the patient is stable enough for surgical fixation the left hip is stressed under fluoroscopy to decide whether it is stable. The pelvic fracture fixation is withs pino pelvic stabilization with pedicle screws and a rod system connecting the fitih lumbar vertebra and posterior iliac spines followed by pubic ramus fracture fixation with plate and screws or percutaneous screw fixation.
Figure 14.4a Anteroposterior (AP) radiograph of pelvis.
Figure 14.4b and 14.4c CT scan axial views of pelvis.
source p. 796
Structured oral examination question 5#
EXAMINER
A 65-year-old lady front-seat passenger of a car involved in an RT Ais brought to A&E complaining of pain in her pelvic area and abdomen. GCS is 15, observations are stable. She is obese, suffers from hypertension, NIDDM, has had several laparatomies for diverticulitis, adhesions total hysterectomy. This is a reconstruction of a C T scan of her pelvis (Figure 14.5a). What is the fracture pattern?
A 65-year-old lady front-seat passenger of a car involved in an RT Ais brought to A&E complaining of pain in her pelvic area and abdomen. GCS is 15, observations are stable. She is obese, suffers from hypertension, NIDDM, has had several laparatomies for diverticulitis, adhesions total hysterectomy. This is a reconstruction of a C T scan of her pelvis (Figure 14.5a). What is the fracture pattern?
CANDIDATE
There are pubic rami fractures in the left hemipelvis along with comminuted fracture of left sacral foraminae and alae. There is also vertical displacement along with fractures of left transverse process of fourth and fitih lumbar vertebrae. This is aver tic ally unstable fracture.
There are pubic rami fractures in the left hemipelvis along with comminuted fracture of left sacral foraminae and alae. There is also vertical displacement along with fractures of left transverse process of fourth and fitih lumbar vertebrae. This is aver tic ally unstable fracture.
EXAMINER
What are you looking for in examination of this patient?
What are you looking for in examination of this patient?
CANDIDATE
As per ATLS protocols, I will perform primary and secondary surveys. I will look for any associated chest and abdominal injuries, distal neurovascular status.
As per ATLS protocols, I will perform primary and secondary surveys. I will look for any associated chest and abdominal injuries, distal neurovascular status.
EXAMINER
This is a CT scan axial view (Figure 14.5b). Describe the injury.
This is a CT scan axial view (Figure 14.5b). Describe the injury.
CANDIDATE
There is a fracture of the left half of the sacrum along the neural foraminae that is displaced.
There is a fracture of the left half of the sacrum along the neural foraminae that is displaced.
EXAMINER
Do you know of any classification for sacral fractures?
Do you know of any classification for sacral fractures?
CANDIDATE
Yes, Denis classification. Type I – sacral ala fracture. Type II – fracture through neural foraminae. Type III – fracture medial to neurol foraminae. This fracture is Type II.
Yes, Denis classification. Type I – sacral ala fracture. Type II – fracture through neural foraminae. Type III – fracture medial to neurol foraminae. This fracture is Type II.
EXAMINER
What is your management plan?
What is your management plan?
CANDIDATE
Adequate analgesia. Left distal femoral pin traction. Regular assessment of left leg neurological status. Transfer of images and patient information to specialist unit.
Adequate analgesia. Left distal femoral pin traction. Regular assessment of left leg neurological status. Transfer of images and patient information to specialist unit.
EXAMINER
What are the options for managing the pelvic injury?
What are the options for managing the pelvic injury?
CANDIDATE
Iliosacral fixation with percutaneous screws after closed reduction with traction or posterior transiliac rods. Anterior stabilization with plate and screws via Pfannesteil approach.
Iliosacral fixation with percutaneous screws after closed reduction with traction or posterior transiliac rods. Anterior stabilization with plate and screws via Pfannesteil approach.
EXAMINER
What peri operative difficulties do you anticipate?
What peri operative difficulties do you anticipate?
CANDIDATE
If posterior transiliac rods fixation is planned, then positioning the patient may be difficult.
If posterior transiliac rods fixation is planned, then positioning the patient may be difficult.
source p. 797
Intraoperative fluoroscopic images will be suboptimal duet o obesity.
Poor bone quality with poor bone purchase of screws.
Due to previous abdominal procedures, exposing pubic ramus and symphysis may be difficult due to adhesions of bowel and urinary bladder.
Figure 14.5a Anteroposterior (AP) radiograph of pelvis.
Figure 14.5b CT axial view of pelvis.
source p. 798
Structured oral examination question 6#
EXAMINER
A 16-year-old male pedestrian was hit by a car at about 40 miles/hour speed. GCS at scene was 5–6. Hence, he was intubated at scene. Systolic blood pressure is around 90 mmHg, PR 100/min and peripheral pulses are well felt. Trauma series show no chest or neck injury, but pelvic X-ray has been taken. Describe the injury (Figure 14.6a).
A 16-year-old male pedestrian was hit by a car at about 40 miles/hour speed. GCS at scene was 5–6. Hence, he was intubated at scene. Systolic blood pressure is around 90 mmHg, PR 100/min and peripheral pulses are well felt. Trauma series show no chest or neck injury, but pelvic X-ray has been taken. Describe the injury (Figure 14.6a).
CANDIDATE
There is a posterior dislocation of the left hip with associated acetabular fracture and anterior dislocation of right hip with associated acetabular fracture. Iliac apophysis is still open.
There is a posterior dislocation of the left hip with associated acetabular fracture and anterior dislocation of right hip with associated acetabular fracture. Iliac apophysis is still open.
EXAMINER
CT scan of head, neck, chest, abdomen, pelvis was done. It showed cerebral oedema, fluid in the abdomen and the injury to both hips as seen in Figures 14.6b–14.6d. How will you manage the orthopaedic injuries?
CT scan of head, neck, chest, abdomen, pelvis was done. It showed cerebral oedema, fluid in the abdomen and the injury to both hips as seen in Figures 14.6b–14.6d. How will you manage the orthopaedic injuries?
CANDIDATE
Both hip dislocations require urgent reduction and regular check of distal vascular status.
Both hip dislocations require urgent reduction and regular check of distal vascular status.
EXAMINER
What are you worried about?
What are you worried about?
CANDIDATE
The right femoral head is probably very close to the external iliac artery and could compress it along with compressing or stretching the femoral nerve.
The right femoral head is probably very close to the external iliac artery and could compress it along with compressing or stretching the femoral nerve.
EXAMINER
After closed reduction of both hips what will you do?
After closed reduction of both hips what will you do?
CANDIDATE
I will assess distal vascular status. I will perform distal femoral pin traction for both lower limbs, organize a CT angiogram to confirm the patency of the external iliac artery even if there are good pulsations distally. There is collateral circulation possible that will provide distal blood supply even if there is external iliac artery blockade.
I will assess distal vascular status. I will perform distal femoral pin traction for both lower limbs, organize a CT angiogram to confirm the patency of the external iliac artery even if there are good pulsations distally. There is collateral circulation possible that will provide distal blood supply even if there is external iliac artery blockade.
EXAMINER
What will be your definitive management?
What will be your definitive management?
CANDIDATE
I will transfer the images to the local specialist unit. When the patient is safe for transfer, patient will undergo open reduction and internal fixation of both acetabular fractures either in the same siting or asas taged procedure.
I will transfer the images to the local specialist unit. When the patient is safe for transfer, patient will undergo open reduction and internal fixation of both acetabular fractures either in the same siting or asas taged procedure.
source p. 799
Figure 14.6a Anteroposterior (AP) radiograph of pelvis.
Figure 14.6b–14.6d CT scan axial views of pelvis.
source p. 800
Structured oral examination question 7#
EXAMINER
A 29-year-old male cyclist has been admift ed to casualty after being hit by a car. A trauma call has been putout. He has had pelvic radiographs taken by the A&E team involved with his initial c are (Figure 14.7a). What do they show?
A 29-year-old male cyclist has been admift ed to casualty after being hit by a car. A trauma call has been putout. He has had pelvic radiographs taken by the A&E team involved with his initial c are (Figure 14.7a). What do they show?
CANDIDATE
This is an AP pelvic radiograph which shows an open-book pelvis fracture with diastasis of the pubic symphysis. This is a significant injury usually sustained through high-energy trauma and is often associated with other severe injuries. I would immediately ask for the patient to be transferred totheR esus room of the Emergency department and I would assess with the other members of the trauma team according to ATLS principles and apply a pelvic binder.
This is an AP pelvic radiograph which shows an open-book pelvis fracture with diastasis of the pubic symphysis. This is a significant injury usually sustained through high-energy trauma and is often associated with other severe injuries. I would immediately ask for the patient to be transferred totheR esus room of the Emergency department and I would assess with the other members of the trauma team according to ATLS principles and apply a pelvic binder.
EXAMINER
What are the ATLS principles?
What are the ATLS principles?
CANDIDATE
ATLS is a system used by the trauma team to assess and treat multiply -injured patient sin a consistent manner. It involves a primary and secondary survey. The primary survey involves: (1) Assessment of airway with cervical spine control. (2) Breathing and ventilation. (3) Circulation with haemorrhage control. (4) Disability/neurologic assessment. (5) Exposure of the patient. The secondary survey is a ‘head to toe’ evaluation of the patient including full history, examination and reassessment of all vital signs. The first time you mention an A TLS evaluation you should describe it in detail unless asked not to do so. In subsequent questions it is not necessary to go through ATLS in detail unless told otherwise.
ATLS is a system used by the trauma team to assess and treat multiply -injured patient sin a consistent manner. It involves a primary and secondary survey. The primary survey involves: (1) Assessment of airway with cervical spine control. (2) Breathing and ventilation. (3) Circulation with haemorrhage control. (4) Disability/neurologic assessment. (5) Exposure of the patient. The secondary survey is a ‘head to toe’ evaluation of the patient including full history, examination and reassessment of all vital signs. The first time you mention an A TLS evaluation you should describe it in detail unless asked not to do so. In subsequent questions it is not necessary to go through ATLS in detail unless told otherwise.
EXAMINER
Who would you want to be in the trauma team? Who should lead the team?
Who would you want to be in the trauma team? Who should lead the team?
CANDIDATE
The trauma team is a multidisciplinary team consisting of doctors and nurses from different specialties. The t eam leader should ideally be an Accident and Emergency Consultant. Furthermore, we would require an A, B and C doctor focusing on Airway, Breathing and Circulation, respectively. The Airway doctor should be someone competent in difficult airway management, usually an anaesthetist These doctors should each have a nurse assisting them.
The trauma team is a multidisciplinary team consisting of doctors and nurses from different specialties. The t eam leader should ideally be an Accident and Emergency Consultant. Furthermore, we would require an A, B and C doctor focusing on Airway, Breathing and Circulation, respectively. The Airway doctor should be someone competent in difficult airway management, usually an anaesthetist These doctors should each have a nurse assisting them.
EXAMINER
You mentioned a pelvic binder earlier , how would you apply this?
You mentioned a pelvic binder earlier , how would you apply this?
CANDIDATE
The pelvic binder is positioned a t the level of the greater trochanters and is tightened at this level.
The pelvic binder is positioned a t the level of the greater trochanters and is tightened at this level.
source p. 801
EXAMINER
What could you do if one is not available?
What could you do if one is not available?
CANDIDATE
If a pelvic binder is not available, a sheet wrapped around the patient at the level of the greater trochanters can be used in conjunction with internally rotating the legs. The aim of this or the binder is to splint the bony pelvis and reduce haemorrhage from venous disruption.
If a pelvic binder is not available, a sheet wrapped around the patient at the level of the greater trochanters can be used in conjunction with internally rotating the legs. The aim of this or the binder is to splint the bony pelvis and reduce haemorrhage from venous disruption.
EXAMINER
The patient is found to be profoundly hypotensive despite fluid resuscitation. It is f elt the patient is bleeding into their pelvis and it is suggested that the major haemorrhage protocol is activated What do you know about this protocol?
The patient is found to be profoundly hypotensive despite fluid resuscitation. It is f elt the patient is bleeding into their pelvis and it is suggested that the major haemorrhage protocol is activated What do you know about this protocol?
CANDIDATE
The major haemorrhage protocol varies slightly from hospital to hospital but is activated when apa tien t is identified who would benefit from a large-volume blood transfusion. The protocol is activated by a senior member of the trauma team. By activating the protocol, it ensures the rapid availability of blood products which include red blood cells, platelets and FFP. These should be transfused in a 1:1:1 ratio to prevent coagulopathy following large-volume transfusion. In addition to these, tranexamic acid can be administered.
The major haemorrhage protocol varies slightly from hospital to hospital but is activated when apa tien t is identified who would benefit from a large-volume blood transfusion. The protocol is activated by a senior member of the trauma team. By activating the protocol, it ensures the rapid availability of blood products which include red blood cells, platelets and FFP. These should be transfused in a 1:1:1 ratio to prevent coagulopathy following large-volume transfusion. In addition to these, tranexamic acid can be administered.
EXAMINER
Is your hospital 1:1:1?
Is your hospital 1:1:1?
CANDIDATE
I think my own hospital is 2:1:1 and I think most hospitals, unless an MT Care 4:4:1.
I think my own hospital is 2:1:1 and I think most hospitals, unless an MT Care 4:4:1.
EXAMINER
How does tranexamic acid work?
How does tranexamic acid work?
CANDIDATE
It acts as an anti fibrinolytic by reversibly binding to lysine receptor sites on plasminogen. This prevents plasmin from binding to and subsequently degrading fibrin.
It acts as an anti fibrinolytic by reversibly binding to lysine receptor sites on plasminogen. This prevents plasmin from binding to and subsequently degrading fibrin.
Figure 14.7a Anteroposterior (AP) pelvic radiograph demonstrating open-book pelvis.
source p. 802
Figure 14.7b Radiograph of pelvic binder in situ. Candidates should be able to recognize binder placement on a pelvic radiograph and if incorrect position.
The CRASH trial showed that it reduced mortality.1
EXAMINER
How much tranexamic acid?
How much tranexamic acid?
CANDIDATE
1 g IV loading dose within 3 hours of injury followed by a second dose 1 g over 8 hours. The CRASH trial showed that it reduced mortality if given within 3 hours, but if given after this time mortality was increased.2
1 g IV loading dose within 3 hours of injury followed by a second dose 1 g over 8 hours. The CRASH trial showed that it reduced mortality if given within 3 hours, but if given after this time mortality was increased.2
EXAMINER
Whatabout crystalloids and vasopressin?
Whatabout crystalloids and vasopressin?
CANDIDATE
I would avoid using them.
I would avoid using them.
EXAMINER
Why?
Why?
CANDIDATE
Because they interfere with the resuscitation process.
Because they interfere with the resuscitation process.
EXAMINER
How?
How?
CANDIDATE
I am not sure. Large amounts of early high-dose crystalloids can cause an imbalance of coagulation haemostasis. This may increase hydrostatic pressure in injured vessels, dislodge haemostatic blood clots (loss of the first clot), induce dilution alc oagulopathy with an acceleration of haemorrhage and also result in hypothermia. Giving blood early is a better alternative and a move away from the traditional A TLS teaching of 2 lof crystalloids stat.
I am not sure. Large amounts of early high-dose crystalloids can cause an imbalance of coagulation haemostasis. This may increase hydrostatic pressure in injured vessels, dislodge haemostatic blood clots (loss of the first clot), induce dilution alc oagulopathy with an acceleration of haemorrhage and also result in hypothermia. Giving blood early is a better alternative and a move away from the traditional A TLS teaching of 2 lof crystalloids stat.
EXAMINER
What is permissive hypotension?
What is permissive hypotension?
CANDIDATE
This refers to managing trauma patients by restricting thea mount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury.
This refers to managing trauma patients by restricting thea mount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury.
EXAMINER
Do you know any common complications from massive transfusion?
Do you know any common complications from massive transfusion?
CANDIDATE
Hypothermia, thrombocytopaenia from dilution metabolic alkalosis and hypocalcaemia due to citrate from the transfused RBCs binding calcium are all recognized complications.
Hypothermia, thrombocytopaenia from dilution metabolic alkalosis and hypocalcaemia due to citrate from the transfused RBCs binding calcium are all recognized complications.
EXAMINER
Despite this, the patient continues to remain hypotensive. There are no other obvious injuries apart from the pelvis injury. How would you manage this patient now?
Despite this, the patient continues to remain hypotensive. There are no other obvious injuries apart from the pelvis injury. How would you manage this patient now?
CANDIDATE
The patient still appears to be bleeding into the pelvis. There are two options. The patient could either betaken to theatre and pelvic packing performed in order to tamponade the bleeding. The alternative is angiographic embolization performed by an interventional radiologist. The choice between the two would depend on resource availability and surgical experience.
The patient still appears to be bleeding into the pelvis. There are two options. The patient could either betaken to theatre and pelvic packing performed in order to tamponade the bleeding. The alternative is angiographic embolization performed by an interventional radiologist. The choice between the two would depend on resource availability and surgical experience.
EXAMINER
Selective or non-selectiv e embolization?
Selective or non-selectiv e embolization?
CANDIDATE
I would definitely prefer selective embolization.
I would definitely prefer selective embolization.
EXAMINER
Why?
Why?
CANDIDATE
Non-selectiv e embolization may lead to an increased risk of wound-healing complications, increased risks of hip ON, fracture non-union peripelvic soft -tissue necrosis and infection You shotgun the internal iliac artery and are causing a wide ischaemic insult to the surrounding soft tissues with an increased risk of severe sepsis occurring. One hopes a well-perfused collateral circulation will compensate, but non-selectiv e angiography is not without its consequences.
Non-selectiv e embolization may lead to an increased risk of wound-healing complications, increased risks of hip ON, fracture non-union peripelvic soft -tissue necrosis and infection You shotgun the internal iliac artery and are causing a wide ischaemic insult to the surrounding soft tissues with an increased risk of severe sepsis occurring. One hopes a well-perfused collateral circulation will compensate, but non-selectiv e angiography is not without its consequences.
EXAMINER
What about genitourinary injury?
What about genitourinary injury?
CANDIDATE
Widening of the symphysis pubis and sacroiliac joint may predict bladder injury while fractures of the inferior and superior pubic rami are more commonly associated with urethral injuries. Clinical examination may reveal bleeding from the urethral meatus. Where there is suspicion of a urethral or bladder injury a cystourethrogram should be performed. Traumatic urethral injuries also result in strictures, recurrent infection erectile dysfunction and infertility . [Bell]
Widening of the symphysis pubis and sacroiliac joint may predict bladder injury while fractures of the inferior and superior pubic rami are more commonly associated with urethral injuries. Clinical examination may reveal bleeding from the urethral meatus. Where there is suspicion of a urethral or bladder injury a cystourethrogram should be performed. Traumatic urethral injuries also result in strictures, recurrent infection erectile dysfunction and infertility . [Bell]
source p. 804
Structured oral examination question 8#
EXAMINER
You are called totheR esus department to see this 23-year-old who has been hit by a bus while drinking on a night out. His pelvic radiograph is shown here (Figure 14.8a). What does it show?
You are called totheR esus department to see this 23-year-old who has been hit by a bus while drinking on a night out. His pelvic radiograph is shown here (Figure 14.8a). What does it show?
CANDIDATE
This AP pelvis radiograph shows a lateral compression (LC) type pelvis fracture, with fractures to the pubic rami and ipsilateral posterior ilium. LC results from side impaction and causes inward rotation of the hemipelvis and rotational instability.
This AP pelvis radiograph shows a lateral compression (LC) type pelvis fracture, with fractures to the pubic rami and ipsilateral posterior ilium. LC results from side impaction and causes inward rotation of the hemipelvis and rotational instability.
EXAMINER
What are your priorities for this patient?
What are your priorities for this patient?
CANDIDATE
I would want a warm, oxygenated and well-perfused patient. I would want to make sure they had a safe, secure airway, were well-ventila ted and had good oxygen saturation. This is the ATLS talk but in a subtler, less obvious manner.
I would want a warm, oxygenated and well-perfused patient. I would want to make sure they had a safe, secure airway, were well-ventila ted and had good oxygen saturation. This is the ATLS talk but in a subtler, less obvious manner.
EXAMINER
What else?
What else?
CANDIDATE
I would activate the trauma team.
I would activate the trauma team.
EXAMINER
Who is in the trauma team?
Who is in the trauma team?
CANDIDATE
The trauma team is a multidisciplinary team consisting of doctors and nurses from different specialties (see previous question).
The trauma team is a multidisciplinary team consisting of doctors and nurses from different specialties (see previous question).
EXAMINER
It should be consultant-led because this saves lives. What is a sterile handover?
It should be consultant-led because this saves lives. What is a sterile handover?
CANDIDATE
This is where the ambulance crew hand over the patient to the trauma team.
This is where the ambulance crew hand over the patient to the trauma team.
EXAMINER
What else?
What else?
CANDIDATE
The ambulance crew provide a detailed handover of the patient in a quiet area of casualty and the trauma team refrain from treating the patient unless there is an impending airway problem or visible catastrophic haemorrhage. All the team needs to be attentive and focused. It doesn’t really need to take that longas longas everyone is on the same page.
The ambulance crew provide a detailed handover of the patient in a quiet area of casualty and the trauma team refrain from treating the patient unless there is an impending airway problem or visible catastrophic haemorrhage. All the team needs to be attentive and focused. It doesn’t really need to take that longas longas everyone is on the same page.
EXAMINER
What do we mean by ATMIST?
What do we mean by ATMIST?
CANDIDATE
This stands for: Age. Time of incident. Mechanism of injury. Injuries top to toe. Vital signs.
This stands for: Age. Time of incident. Mechanism of injury. Injuries top to toe. Vital signs.
source p. 805
Mode of transport.
EXAMINER
Typically, what other injuries are associated with this type of fracture?
Typically, what other injuries are associated with this type of fracture?
CANDIDATE
Lateral compression fractures are typically associated with head, chest and abdominal injuries. This differs to open-book AP compression type fractures which are typically associated with urethral and bladder injuries and pelvic vascular injuries.
Lateral compression fractures are typically associated with head, chest and abdominal injuries. This differs to open-book AP compression type fractures which are typically associated with urethral and bladder injuries and pelvic vascular injuries.
EXAMINER
You arrive in the emergency department and his observations are: pulse 120, BP 95/55 with a capillary refill time of 3 seconds and feels cool peripherally. He is confused and agitated. What are your thoughts?
You arrive in the emergency department and his observations are: pulse 120, BP 95/55 with a capillary refill time of 3 seconds and feels cool peripherally. He is confused and agitated. What are your thoughts?
CANDIDATE
The patient is haemodynamically unstable. He appears to be in shock. Shock is inadequate perfusion of tissues and is an emergency. His confusion and agitation may be due to hypoperfusion of the brain secondary to his hypovolaemic state, or it may be due to an associated head injury. My priorities are the management of immediate life-threatening injuries. I would want to rapidly assess his physiology and prevent hypoxia, acidosis, coagulopathy and hypothermia. I may wish to consider a definitive airway and want to stop the bleeding.
The patient is haemodynamically unstable. He appears to be in shock. Shock is inadequate perfusion of tissues and is an emergency. His confusion and agitation may be due to hypoperfusion of the brain secondary to his hypovolaemic state, or it may be due to an associated head injury. My priorities are the management of immediate life-threatening injuries. I would want to rapidly assess his physiology and prevent hypoxia, acidosis, coagulopathy and hypothermia. I may wish to consider a definitive airway and want to stop the bleeding.
EXAMINER
How can shock be classified?
How can shock be classified?
CANDIDATE
Shock can be classified by its underlying cause. Haemorrhagic shock is the most important cause of shock in trauma patients Haemorrhagic shock can be divided into four classes depending on the volume of blood loss. Classes 3 and 4 are life-threatening and require blood product transfusion. Other causes of shock include neurogenic shock, septic shock and haemodynamic shock from causes such as cardiac tamponade and tension pneumothorax.
Shock can be classified by its underlying cause. Haemorrhagic shock is the most important cause of shock in trauma patients Haemorrhagic shock can be divided into four classes depending on the volume of blood loss. Classes 3 and 4 are life-threatening and require blood product transfusion. Other causes of shock include neurogenic shock, septic shock and haemodynamic shock from causes such as cardiac tamponade and tension pneumothorax.
EXAMINER
An AB Gis carried out and his lactate is found to be 4.1 mmol/l. What is the significance of this?
An AB Gis carried out and his lactate is found to be 4.1 mmol/l. What is the significance of this?
CANDIDATE
This shows that the patient is inadequately resuscitated. The lactate level acts as an indicator for the amount of anaerobic metabolism by the body and is a good measure for the adequacy of resuscitation. Lactate levels below 2.5 mmol/l are generally accepted to show adequate resuscitation. Lactate values are important in multiply -injured patient sin deciding whether to proceed with damage control orthopaedics. Anything above 4 mmol/l would be an indication for damage control orthopaedics (DCO) while between 2.5 and 4 mmol/l the patient needs to have a period of resuscitation before considering surgery. Below 2.5 mmol/l is usually good for surgery, but this is based on a trend.
This shows that the patient is inadequately resuscitated. The lactate level acts as an indicator for the amount of anaerobic metabolism by the body and is a good measure for the adequacy of resuscitation. Lactate levels below 2.5 mmol/l are generally accepted to show adequate resuscitation. Lactate values are important in multiply -injured patient sin deciding whether to proceed with damage control orthopaedics. Anything above 4 mmol/l would be an indication for damage control orthopaedics (DCO) while between 2.5 and 4 mmol/l the patient needs to have a period of resuscitation before considering surgery. Below 2.5 mmol/l is usually good for surgery, but this is based on a trend.
source p. 806
COMMENT
No need to discuss lactate and DCO. The candidate is out of date with latest developments. The term ‘early appropriate care’ has superseded DCO and early total care. Early appropriate care focuses on the physiological state of the patient and the success of the resuscitative effort. In particular , no single physiological parameter or blood marker can as yet be used to guide intervention, but the accepted level of 2.5 mmol/l for lactate is likely too conservative and is being superseded by a more comprehensive and patien t-centred approach, focusing on physiological improvement and reversal of acidosis reflected by a lactate < 4.0 mmol/l, pH ≥ 7.25, or BE above 5.5 mmol/l.
No need to discuss lactate and DCO. The candidate is out of date with latest developments. The term ‘early appropriate care’ has superseded DCO and early total care. Early appropriate care focuses on the physiological state of the patient and the success of the resuscitative effort. In particular , no single physiological parameter or blood marker can as yet be used to guide intervention, but the accepted level of 2.5 mmol/l for lactate is likely too conservative and is being superseded by a more comprehensive and patien t-centred approach, focusing on physiological improvement and reversal of acidosis reflected by a lactate < 4.0 mmol/l, pH ≥ 7.25, or BE above 5.5 mmol/l.
EXAMINER
On the same ABG the patient’s O2 saturation was 91%. What is the significance of this?
On the same ABG the patient’s O2 saturation was 91%. What is the significance of this?
CANDIDATE
Oxygen saturation is the percentage of haemoglobin molecules that are saturated by oxygen. A normal value in an individual with no underlying lung disease is above 96%. At levels below 96%, due to the sigmoid shape of the oxygen dissociation curve, the pO2 drops quickly for a decreasing oxygen saturation reading. This will mean there is the potential for inadequate end-organ oxygenation and further anaerobic metabolism.
Oxygen saturation is the percentage of haemoglobin molecules that are saturated by oxygen. A normal value in an individual with no underlying lung disease is above 96%. At levels below 96%, due to the sigmoid shape of the oxygen dissociation curve, the pO2 drops quickly for a decreasing oxygen saturation reading. This will mean there is the potential for inadequate end-organ oxygenation and further anaerobic metabolism.
EXAMINER
You have given him 2 units of blood, his pulse is 120, BP 95/60, O2 saturations 94% on high- flow oxygen. What now?
You have given him 2 units of blood, his pulse is 120, BP 95/60, O2 saturations 94% on high- flow oxygen. What now?
CANDIDATE
I would want to secure a definitive airway and apply a pelvic binder, I would give him tranexamic acid, trigger the massive transfusion protocol. I would want to identify any injuries directly related to the pelvic fracture.
I would want to secure a definitive airway and apply a pelvic binder, I would give him tranexamic acid, trigger the massive transfusion protocol. I would want to identify any injuries directly related to the pelvic fracture.
EXAMINER
Why are you applying a pelvic binder? It isn’t an open-book pelvis. Will it help you with resuscitation of the patient?
Why are you applying a pelvic binder? It isn’t an open-book pelvis. Will it help you with resuscitation of the patient?
CANDIDATE
Pelvic binders control bleeding by compressing and stabilizing fractures, not by significantly reducing pelvic volume. Binders may be used in all fracture patterns and not just open-book injuries. They are indicated for use in haemodynamically unstable patients with a mechanically unstable pelvis.
Pelvic binders control bleeding by compressing and stabilizing fractures, not by significantly reducing pelvic volume. Binders may be used in all fracture patterns and not just open-book injuries. They are indicated for use in haemodynamically unstable patients with a mechanically unstable pelvis.
EXAMINER
What about worsening an injury when a pelvic binder is applied?
What about worsening an injury when a pelvic binder is applied?
CANDIDATE
As a fracture pattern is often unknown before pelvic binder application, it is possible to exacerbate certain injury patterns if excessive force is applied. This is particularly true of severe lateral compression or vertical shear injuries.
As a fracture pattern is often unknown before pelvic binder application, it is possible to exacerbate certain injury patterns if excessive force is applied. This is particularly true of severe lateral compression or vertical shear injuries.
EXAMINER
What are the characteristics of the ideal binder?
What are the characteristics of the ideal binder?
CANDIDATE
The ideal pelvic binder: Should belight and easily applied. Allows access to the abdomen for laparotomy, and to the groins for angioembolization.
The ideal pelvic binder: Should belight and easily applied. Allows access to the abdomen for laparotomy, and to the groins for angioembolization.
source p. 807
May need to stay on for 24 hours or more and thus should be of a soft material that will be comfortable and not induce pressure ulceration.
Should not limit access to the perineum and anus for examination.
Must fit various sizes of patients including children).
Should be washable or cheap enough to be disposable.
EXAMINER
How long would you leave a pelvic binder on for?
How long would you leave a pelvic binder on for?
CANDIDATE
Up to 24 hours.
Up to 24 hours.
EXAMINER
That is probably too long. One would beworried about pressure sores and skin abrasions. What is the function of the pelvic binder?
That is probably too long. One would beworried about pressure sores and skin abrasions. What is the function of the pelvic binder?
CANDIDATE
[Silence ... ] To stop bleeding.
[Silence ... ] To stop bleeding.
EXAMINER
To allow the unhindered formation of clot which wills top the bleeding. If you disturb the clot re-bleeding will occur. In our hospital we aim to have released the pelvic binder by 8 hours. We would make sure the patient is normothermic, haemodynamically stable and any metabolic acidosis corrected. All imaging should have been completed and the fracture should have been fully characterized, and we have a definitive plan of action in place for management if the patient becomes unstable once more.
To allow the unhindered formation of clot which wills top the bleeding. If you disturb the clot re-bleeding will occur. In our hospital we aim to have released the pelvic binder by 8 hours. We would make sure the patient is normothermic, haemodynamically stable and any metabolic acidosis corrected. All imaging should have been completed and the fracture should have been fully characterized, and we have a definitive plan of action in place for management if the patient becomes unstable once more.
COMMENT
The examiner wouldn’t necessarily volunteer any of this info unless it was a mock examination.
The examiner wouldn’t necessarily volunteer any of this info unless it was a mock examination.
EXAMINER
How do you determine if there is a coagulation issue?
How do you determine if there is a coagulation issue?
CANDIDATE
I would check full blood count, U&Es and coagulation screen.
I would check full blood count, U&Es and coagulation screen.
EXAMINER
Anything else?
Anything else?
CANDIDATE
Ensure patient warming, avoid acidosis and perform an INR.
Ensure patient warming, avoid acidosis and perform an INR.
EXAMINER
Have you heard of thromboelastography (TEG) and rotational thr omboelastometry (ROTEM)?
Have you heard of thromboelastography (TEG) and rotational thr omboelastometry (ROTEM)?
CANDIDATE
No. The candidate isn’t scoring well in the viva (possibly 4 or 5). TEG allows real-time assessment of cloting and may be a valuable adjunct in acute resuscitation and guide transfusion of blood products different from a standard 1:1:1 ratio.
No. The candidate isn’t scoring well in the viva (possibly 4 or 5). TEG allows real-time assessment of cloting and may be a valuable adjunct in acute resuscitation and guide transfusion of blood products different from a standard 1:1:1 ratio.
EXAMINER
What next?
What next?
CANDIDATE
I would consider obtaining a CT angiogram to investigate for ongoing sources of bleeding.
I would consider obtaining a CT angiogram to investigate for ongoing sources of bleeding.
EXAMINER
What type of CT angiogram?
What type of CT angiogram?
CANDIDATE
A triple-phase CT contrast angiogram is my modality of choice. The three phases are arterial, portal venous and delayed phase.
A triple-phase CT contrast angiogram is my modality of choice. The three phases are arterial, portal venous and delayed phase.
source p. 808
EXAMINER
You don’t have access to a CT angiogram as it wouldn’t be ready for at least 2 hours as the vascular list has overrun.
You don’t have access to a CT angiogram as it wouldn’t be ready for at least 2 hours as the vascular list has overrun.
CANDIDATE
As the patient is haemodynamically unstable he will need to go to theatre for more definitive pelvic stabilization and for pelvic packing. He may have associated extrapelvic injuries (thoracoabdominal or extremity trauma) or injuries to structures within the pelvis (bladder, rectum, vasculature). We would liaise with the general surgeons so that all teams were available and ready to go.
As the patient is haemodynamically unstable he will need to go to theatre for more definitive pelvic stabilization and for pelvic packing. He may have associated extrapelvic injuries (thoracoabdominal or extremity trauma) or injuries to structures within the pelvis (bladder, rectum, vasculature). We would liaise with the general surgeons so that all teams were available and ready to go.
EXAMINER
What type of pelvic packing?
What type of pelvic packing?
CANDIDATE
Extraperitoneal.
Extraperitoneal.
EXAMINER
What else?
What else?
CANDIDATE
The vast majority of pelvic bleeding originates from the presacral venous plexus and fracture sites – sources that will stop with tamponade – while only 10–20% is related to major arterial injury.
The vast majority of pelvic bleeding originates from the presacral venous plexus and fracture sites – sources that will stop with tamponade – while only 10–20% is related to major arterial injury.
EXAMINER
How do you perform pelvic packing?
How do you perform pelvic packing?
CANDIDATE
I have never seen it performed, but the packing is into the preperitoneal pelvic packing. General candidate advice is that in the exam (it is said that) if you haven’t done a procedure, don’t say you would do it.
I have never seen it performed, but the packing is into the preperitoneal pelvic packing. General candidate advice is that in the exam (it is said that) if you haven’t done a procedure, don’t say you would do it.
EXAMINER
What incision would you use?
What incision would you use?
CANDIDATE
Aver tical incision is preferred to a Pfannenstiel incision.
Aver tical incision is preferred to a Pfannenstiel incision.
EXAMINER
Why?
Why?
CANDIDATE
[Silence ... ] No, not sure. For PP Paver tical midline incision is made from the pubic symphysis extending up 6–8 cm. If a laparotomy is necessary, the two incisions should remain separate or effective tamponade of the pelvic space will be difficult. The laparotomy incision may extend from the xiphoid to just below the umbilicus while the PPP incision is approximately 6 cm away in the suprapubic area. The pelvic haematoma often dissects the space to be packed and is encountered upon entry through the midline fascia. Packs need to be removed after 48 hours.
[Silence ... ] No, not sure. For PP Paver tical midline incision is made from the pubic symphysis extending up 6–8 cm. If a laparotomy is necessary, the two incisions should remain separate or effective tamponade of the pelvic space will be difficult. The laparotomy incision may extend from the xiphoid to just below the umbilicus while the PPP incision is approximately 6 cm away in the suprapubic area. The pelvic haematoma often dissects the space to be packed and is encountered upon entry through the midline fascia. Packs need to be removed after 48 hours.
source p. 809
Figure 14.8a Anteroposterior (AP) radiograph pelvis demonstrating lateral compression injury.
source p. 810
Notes
1. A bland, throw-away statement that doesn’t score a candidate any points.
2. Much better and more strategic than 1.