EXAMINER: What do you see?

Here the next minute belongs to the candidate and you can take it whichever way you want to. However, there are essentials to be covered. In the first 30 seconds you are expected to comment on the following:

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  Site of radiograph and its suitability – also always ask for two views if only one is given.

  
  
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  Adult or paediatric skeleton.

  
  
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  General features: fracture of the proximal tibia with depression of the lateral tibial plateau.

In the next 30 seconds the candidate is expected to comment (without any prompt from the examiner) on the exact nature of the injury, such as Schatzker III fracture with more than 10 mm depression in the articular surfaces, comminuted, concern about the fracture going through the tibial spines and whether the medial side is intact.

EXAMINER: How would you investigate further?

CANDIDATE: A computed tomography (CT) scan to evaluate the fracture pattern as this helps to plan surgery, particularly with regard to approaches to the fracture and the philosophy of implant choice. (The examiner is then likely to produce slices of the CT.)

EXAMINER: What are the treatment options?

CANDIDATE: [Take the next 30 seconds to describe operative and non-operative options in the generality. This must be based on the particular patient (recent alignment of consenting processes) and it is critical here that the information will be given to the patient clearly regarding the impact of differing treatment strategies on that particular patient with that particular injury.]

EXAMINER: What is a buttress plate?

CANDIDATE: A plate applied perpendicular to the force that is trying to resist. It is one of the modes of plate uses, along with compression, bridging and tension band, for example.

EXAMINER: What is the role of knee arthroscopy?

CANDIDATE: It is potentially of use in three areas. One, to assess the reduction of the articular surface. Second, to ensure soft tissues (lateral meniscus) are not trapped in the fracture. Third, to assess intra-articular ligament damage. (Be clear to state that pressure pumps are not to be used in order to avoid iatrogenic compartment syndrome due to extravasation of fluid, as well as the fact that you will use a bladder syringe through the arthroscopy cannula to wash out the haemarthrosis before viewing the joint – this gives the examiner the impression that you have done the procedure before.)

EXAMINER: What surgical approach will you use?

CANDIDATE: Anterolateral approach with the skin incision being longitudinal and if needed, a reverse L-shaped incision inside. The incision is curved anteriorly over Gerdy’s tubercle and is extended distally, 1 cm lateral to the anterior border of the tibia. Proximally the iliotibial band is incised in line with its fibres and the fascia over tibialis anterior divided and elevated bluntly from the tibia distally.

EXAMINER: What about bone graft?

CANDIDATE: I would prefer to use an impacted cancellous femoral head allograft. I realize that cancellous autograft harvested from the iliac crest is probably the gold standard. However, this procedure involves making a separate incision over the iliac crest to obtain the graft, which may result in significant postoperative pain, neuro/vascular injury, haematoma, infection, fractures and cosmetic concerns.

EXAMINER: Anything else you can use?

CANDIDATE: Injectable calcium phosphate bone cement can be used as a buttress in articular cartilage depression. It is thought to reduce the risk of subsidence of the fracture fragments occurring by maintaining articular congruency until the fracture heals.

EXAMINER: What does the literature say?

CANDIDATE: There is some evidence to support the use of bone graft substitutes to fill fracture voids, but a lack of level I evidence.

EXAMINER: What will you tell the patient about long-term outcome?

CANDIDATE: The reported incidence of post-traumatic radiographic osteoarthritis of the knee following tibial plateau fractures varies from 25% to 45%. Not all patients, however, are symptomatic. The outcome in tibial plateau fractures is more about restoring the mechanical axis rather than accurate reduction of the joint surface. Wasserstein et al. reported that regardless of operative fixation, sustaining a tibial plateau fracture requiring surgery increases the likelihood of TKA by 5.3 times.¹ Older patients and those with a more significant fracture were more likely to need TKA.

EXAMINER: Please comment on the radiograph (Figure 11.2).

CANDIDATE: The pelvic radiograph shows a displaced left-sided intracapsular neck of femur fracture in the presence of early degenerative changes of the hip joint. (Always ask for the lateral radiograph.)

EXAMINER: How will you manage this patient?

CANDIDATE: I would like to assess the whole patient. The degree of mobility prior to injury, comorbidities, ‘red flag’ features for any pathological lesions, drug history, cause of fall and appropriate investigations. This will include clinical examination of the patient including the left lower limb.

EXAMINER: She has well-controlled angina and is otherwise independent.

CANDIDATE: Operative treatment is preferred in this patient group to avoid complications of non-operative management. This will involve a discussion around arthroplasty, either hemiarthroplasty (HA) or total hip arthroplasty (THA). My choice is THA using a well-proven cemented prosthesis provided the patient meets the NICE guidelines of being fit for anaesthesia, not cognitively impaired and able to mobilize independently pre-injury.¹

EXAMINER: Why do you prefer THA rather than hemiarthroplasty? It is more expensive!

CANDIDATE: A THA has a better functional outcome than HA and has better survivorship results. My choice will be a cemented tapered polished stem of long-term proven results with a cemented, highly cross-linked polyethylene cup using a relatively large head. There are data from a BMJ systematic review which suggest better functional outcome and lower re-operation rates in those patients treated with THA. Recent NICE guidelines endorse such practice in a selected population, which includes mentally alert patients with good pre-injury mobility levels and who are relatively healthy. This patient ticks all the criteria and will benefit from THA.

My practice is to use a relatively larger head, such as 32 mm or 36 mm, to counter the increased risk of hip dislocation.^{2, 3} Surgical technique should focus on the correct orientation of components, good soft-tissue balancing, restoration of hip offset and equalization of leg lengths.

Postoperative management continues with aggressive rehabilitation including early mobilization with full weight-bearing and repatriation to place of usual abode. It also includes addressing any underlying bone abnormalities such as osteoporosis, risk assessment for falls and nutritional deficiency. Ideally, the management should be carried out by a multidisciplinary team. With regards to price and impact on quality of life, THA is considered more cost-effective.³

EXAMINER: You keep mentioning NICE guidelines. What is a NICE guideline?

CANDIDATE: NICE clinical guidelines are recommendations for the care of individuals in specific clinical conditions or circumstances within the NHS.

EXAMINER: So why do we use them?

CANDIDATE: NICE guidelines can be used to develop standards to assess the clinical practice of health professionals and can also be used in the education and training of health professionals. They are based on the best available research evidence.

EXAMINER: What’s the problem with using NICE guidelines?

CANDIDATE: NICE guidelines do not replace a surgeon’s knowledge and skills, they are only guidelines to help a surgeon make an informed decision.

EXAMINER: She arrives at 1800 to your ward. When will you undertake the surgery?

CANDIDATE: The surgery should be undertaken as soon as safely possible and ideally within 36 hours.⁴ It should not be rushed in the middle of the night; however, if the patient is fit for anaesthesia then the aim is for surgery on the next morning list with all the theatre staff, kit and consultant cover available. It is important to optimize any correctable medical causes prior to surgery. This should be undertaken in an objective and efficient manner to avoid ‘unnecessary’ delay.

EXAMINER: This 49-year-old lady fell on some steps. Her left foot is very painful, bruised, swollen and she can’t weight-bear. The junior doctor went to see her in the Emergency Department, but he is not sure what the problem is, what do you think? (Figure 11.3.)

CANDIDATE: These are anteroposterior (AP) and oblique radiographs of the left foot. There is a diastasis between the base of the first and second metatarsals; features suggestive of ‘Lisfranc’ tarsometatarsal fracture dislocation. There is a small avulsed fragment of bone in that interval. This is an avulsion fracture and could be from the insertion of the Lisfranc ligament (medial cuneiform–second metatarsal) into the base of the second metatarsal (‘fleck sign’). Normal alignment on the AP view is demonstrated by examining the lateral borders of the first and second metatarsals, which should line up with the lateral borders of the medial and lateral cuniforms, respectively. The oblique internal rotated view also demonstrates that the medial border of the fourth metatarsal lines up with the medial border of the cuboid.

EXAMINER: OK, how will you manage this patient?

CANDIDATE: I would start with the patient’s assessment as a whole, following the ATLS (Airway and protect cervical spine, Breathing, Circulation, Disability, Exposure and environment control) protocol with a focused history including mechanism of injury, patient’s general condition, comorbidities, allergies, smoking status as well as occupation and level of function.

I will carry out an examination of the foot noting:

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  Soft tissue swelling, pain and ecchymosis.

  
  
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  Pain on passive abduction/pronation.

  
  
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  Dorsalis pedis pulse if palpable.

  
  
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  Compartment syndrome can be a feature of these injuries and I will include this in my differential.

Following assessment, my initial management includes analgesia, elevation and splinting using a below-knee backslab. On admission to hospital I’ll arrange for regular, serial examination to detect compartment syndrome.

EXAMINER: What would you do if the radiographs were inconclusive in diagnosing this condition?

CANDIDATE: I would arrange further imaging including oblique and lateral view weight-bearing radiographs if this can be tolerated by the patient. I would arrange a computed tomography scan that should pick up any subtle or occult fractures. MRI scan is useful in allowing direct visualization of the Lisfranc ligament itself, but I would discuss the MRI request with an experience musculoskeletal radiologist beforehand as images can sometimes be difficult to interpret.

EXAMINER: How do you treat Lisfranc tarsometatarsal fracture dislocation?

CANDIDATE: This depends on the severity of injury to both the bones and soft tissues and the degree of displacement of the fracture. There is a role for non-operative treatment for an undisplaced stable injury with a cast for 6 weeks with non-weight-bearing and regular clinical and radiological review. However, in the presence of subluxation or dislocation, then accurate reduction and stable fixation is essential. In this case, I would consider open reduction and internal fixation with screws and maybe plating, as required. In the case of a comminuted fracture, then primary arthrodesis of tarsometatarsal joints may be considered, although I would have a full discussion of the treatment options with the patient and record the outcome in the notes.

I would use a dual dorsal incision approach. The first incision is performed between the first and second metatarsals to address the first and second TMT joints. The incision is centred over the TMT joint. The second incision is between the third and fourth metatarsals at the same level.

EXAMINER: What prognosis will you give this patient?

CANDIDATE: This is a serious injury with potentially a poor outcome. Post-traumatic osteoarthritis occurs in over 50% of cases, even if operatively treated with open reduction and internal fixation. Residual pain and a stiff foot is a not uncommon complication of this injury. Early identification of the injury is key – up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. The patient must be informed about the length of the recovery period and implications on lifestyle and work in the future.

EXAMINER: If this patient develops compartment syndrome, then how would you manage it?

CANDIDATE: There is no clear evidence regarding the management of presumed compartment syndrome in the foot. In the BOAST guidelines regarding compartment syndrome, it is stated that there is no clear consensus on optimum management. I would discuss the case with the patient and if possible gain a second opinion from a consultant colleague. In general, for low-energy injuries, I adopt a low threshold for decompression in the foot. For high-energy injuries such as following motorcycle trauma or in the intubated patient, my threshold to intervene would be even lower.

EXAMINER: How would you manage the injury if the soft tissues around the foot were very swollen with significant disruption of the bony anatomy but no compartment syndrome?

CANDIDATE: In this situation a prompt reduction of these injuries improves the alignment and relieves the pressure to the surrounding soft tissues, avoids the potential for skin necrosis, helps avert the development of a compartment syndrome, prevents compromise to the neurovascular structures and allows a safe waiting period to be undertaken until the swelling has decreased, re-epithelialization of blisters has occurred and ‘wrinkling of the skin’ has been noted.

I would be concerned about just applying a back-slab and waiting for the swelling to improve as this may leave a malaligned midfoot that may be difficult to reduce once the swelling has subsided.

EXAMINER: So, what are you going to do?

CANDIDATE: I would use an external fixator, applied to one or both sides of the foot to reduce the bony injury and allow the soft tissues to settle before definitive surgery.

EXAMINER: This is a radiograph of his foot and ankle (Figure 11.4a). What are your thoughts?

CANDIDATE: This is a lateral radiograph of the left foot. It shows a displaced comminuted intra-articular fracture of the calcaneus with reduced calcaneal height, flattening or even reversal of Bohler’s angle, increased angle of Gissane and a fracture of the calcaneal tuberosity.

Regardless of the hindfoot trauma, the patient has had a significant fall, so initially I would assess the patient as a whole following ATLS protocol and screen for potential associated injuries. Vertebral compression fractures (10–15% of cases), fracture of proximal femur, knee (tibial plateau), ankle (pilon fractures) and other foot injures (contralateral calcaneum) must be looked for and excluded.

EXAMINER: Assume that there is no other injury. How would you manage this closed calcaneal fracture?

CANDIDATE: My management plan can be broken down into initial resuscitation followed by further investigation and planning for definitive treatment.

Initial management includes analgesia, splinting, foot elevation and monitoring for compartment syndrome of the foot. The key is managing the soft-tissue envelope, which may require cryotherapy and use of foot pumps to reduce swelling. I would organize a CT scan to assess the fracture personality and plan definitive treatment. Patient factors such as comorbidities (diabetes and peripheral vascular disease) should be considered as well as smoking status, occupation and other functional demands.

EXAMINER: This is the CT scan you requested (Figure 11.4b), what can you see and what would you do next?

CANDIDATE: This CT scan axial section demonstrates shortening, varus deformity and considerable comminution. There is a large sustentacular fragment, depressed middle fragment and blow out of the lateral wall. It also shows considerable heel widening.

EXAMINER: Do you know any classification systems for calcaneal fractures?

CANDIDATE: The Sanders classification is a CT classification based on the number of articular fragments seen on a coronal view at the widest point of the posterior facet (Figure 11.4c).

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  Type 1: Undisplaced posterior facet (regardless of number of fracture lines).

  
  
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  Types 2, 3 and 4 are displaced fractures.

  
  
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  Type 2: One fracture line (two-part intra-articular fracture). Divided into three subgroups on the basis of fracture line localization.

  
  
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  Fracture line is lateral in Type 2 A fractures, central in Type 2B and medial in Type 2C fractures.

  
  
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  Type 3: Two fracture lines in the posterior facet (three-part intra-articular fracture).

  
  
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  Type 4: Comminuted fracture with more than three fracture lines in the posterior facet (four or more fragments).

I would discuss treatment options with the patient including open reduction and internal fixation once the soft-tissue envelope is suitably resuscitated. I would base my decision on the fracture pattern, soft-tissue status and patient factors. This fracture pattern will benefit from surgical intervention, but it will depend heavily on several patient factors including smoking, occupation, comorbidities and the expectations of the patient.

EXAMINER: Following discussion with the patient you have decided to proceed with internal fixation. What are the aims/goals of surgery?

CANDIDATE: The aims of surgery are restoration of articular congruity while restoring calcaneal height, length and heel width and minimizing soft-tissue complications.

EXAMINER: How will you fix the fracture?

CANDIDATE: I would take full informed consent, in particular concentrating on the risks and benefits of both operative and non-operative management. The patient will be under general anaesthesia with prophylactic antibiotics, tourniquet and in the lateral decubitus position with fluoroscopy control. I would use an L-shaped lateral incision halfway between fibula and Achilles tendon avoiding damage to the sural nerve. I would employ full-thickness flaps by taking the incision down to the bone and use bent K-wires as retractors. I would take off the lateral wall, manipulate the fracture fragments to restore the length and height of the calcaneum as well as correction of varus deformity, reconstruct the articular surface and then reapply the lateral wall. I would use K-wires for temporary stability and then fixation using a fragment specific plate. My preference is a low-profile lateral calcaneal plate, the size of which depends on the patient’s calcaneus and I would contour the plate prior to application. The key is to capture the sustentacular fragment under fluoroscopy.

Postoperatively, the patient would mobilize non-weight-bearing for 6 weeks followed by a further 6 weeks of partial weight-bearing.

EXAMINER: What are the complications from surgery?

CANDIDATE: Complications include wound dehiscence, osteomyelitis, post-traumatic osteoarthritis, increased heel width, subtalar stiffness, peroneal tendinitis, sural nerve injury, persistent heel pain, scar hypersensitivity, tarsal tunnel syndrome and CRPS.

EXAMINER: If the wound got infected, how would you deal with it?

CANDIDATE: I would want to prevent direct extension to bone causing osteomyelitis. This needs aggressive antibiotic therapy and a low threshold for radical debridement. I would attempt to keep in place the plate and screws but would remove the metalwork if the infection was not settling. Soft-tissue coverage with local or free flap involving the plastic surgeons should be considered if the wound is very large. Occasionally amputation may be needed.

EXAMINER: The patient complains of pain.

CANDIDATE: There are many causes of pain which include subtalar incongruity, penetration of screws into the subtalar joint or arthritis. Lateral pain may be caused by lateral impingement or peroneal tendinitis. Anterior pain from talar neck impingement or scar tissue. Subtalar osteoarthritis may require a subtalar arthrodesis.

EXAMINER: What prognosis will you give for this patient?

CANDIDATE: A calcaneal fracture is a significant injury with high incidence of long-term pain and disability. There is about a 40% chance the patient will have long-term chronic pain after a significant intra-articular fracture.

EXAMINER: Tell me how you would manage this injury.

CANDIDATE: These are anteroposterior (AP) and lateral views of the distal tibia and ankle joint. This is a complex intra-articular multifragmentary fracture occurring as a result of high-energy trauma. There is a fracture of the distal tibia involving the ankle joint with articular impaction and comminution extending into the metaphysis, a fractured fibula, a disruption of the syndesmosis and possibly a fractured talus.

I will take a concise history and perform a focused examination. I would enquire about smoking, alcohol consumption, a history of diabetes or peripheral vascular disease, etc. which are important risk factors for soft tissue (and bone) healing. Examination would particularly assess the state of the soft-tissue envelope looking for any skin damage, contusion and fracture blisters. I would also obtain tibial shaft and knee radiographs of the affected limb.

I will ensure the patient is comfortable and splint the limb, realigning the foot into a better position, relieving pressure on the skin to avoid any skin necrosis. I will perform a thorough neurovascular assessment of the involved limb including palpation of the posterior tibial and dorsalis pedis artery as well as examination of capillary refill to check for an adequate vascular supply. I would obtain radiographs of the post splinted leg to check for adequacy of reduction and commence serial assessment for compartment syndrome.

COMMENT: Isolated closed injury is coded language to say the examiners just want you to focus on the management of this fracture. No need to mention ATLS.

CANDIDATE: Ruedi and Allgower have classified these injuries into three types:

EXAMINER: How does this classification system help you?

CANDIDATE: The Ruedi–Allgower classification system is based on the severity of comminution and displacement of the articular surface and offers a rough guide to management.

CANDIDATE: My principle of managing this case is: ‘span–scan–plan’. I would prefer a staged management approach for this fracture rather than going for early ORIF. Early ORIF in the face of compromised soft tissues will lead to an increased risk of infection, wound dehiscence, a poor overall clinical outcome and in a worst case scenario may lead to amputation.

EXAMINER: When are you going to fix this fracture?

CANDIDATE: This is a serious and challenging injury to manage. The soft-tissue envelope needs to be resuscitated until it is in a reasonable condition (this may take up to 10–14 days to settle). Definitive surgery should be planned on a defined dedicated trauma list involving a surgeon with an interest in managing these complex fractures in order to achieve the best possible outcome.

EXAMINER: How are you going to fix this fracture?

CANDIDATE: The principles of fixation of an intraarticular fracture are anatomical reduction, interfragmentary compression and absolute stability at the fracture site to allow early mobilization.

COMMENT: This is a generic statement that, while correct, isn’t using viva time efficiently. It is better for candidates to be more fracture-specific if possible.