THEME: HEAD INJURY

A Open skull fracture

B Subarachnoid haemorrhage
C Subaponeurotic scalp haematoma
D Basal skull fracture
E Subdural haematoma
F Concussion
G Extradural haematoma
H Diffuse axonal injury
For each of the case descriptions below, select the most appropriate diagnosis
from the list above.

Scenario 1

Incorrect
A 25-year-old motorcyclist is brought to the Accident and Emergency Department after being
involved in a high speed road traffic accident (RTA). He is unconscious and is noted to have a
periorbital haematoma. On examination, a clear fluid mixed with blood is seen coming out of his
nostrils.

D Correct answer

Fractures of the skull vault may be linear, comminuted or depressed. Bruising over the mastoid
process (retroauricular bruising – Battle sign) (late sign) and periorbital haematoma (Raccoon
eyes) are classical signs of basal skull fractures. Middle fossa fractures present with
rhinorrhoea/otorrhoea (blood mixed with CSF that does not clot), haemotympanum, ossicular
disruption and VIIth and/or VIIIth cranial nerve palsies.

Scenario 2

Incorrect
A 39-year-old man walks into the Accident and Emergency Department after being assaulted
with a baseball bat. He had a momentary loss of consciousness but feels fine at present. Whilst in
the Accident and Emergency Department he gradually becomes confused and later unconscious
with a Glasgow Coma Scale (GCS) score of 8. His right pupil appears dilated.

B Your answer

G Correct answer
Acute extradural haematoma should be suspected after a head injury where the patient has a
fluctuating level of consciousness (though not always). The patient may briefly lose
consciousness but soon recover (lucid interval). It is associated with trauma and is usually seen
in the young. Extradural bleeds are commonly due to direct trauma to the temporal or parietal
bones causing injury to the middle meningeal artery or vein. With increasing bleed (haematoma),
lateralising signs develop, including an ipsilateral dilated pupil and a contralateral hemiparesis.
This may eventually lead to bilateral fixed pupils and a coma that culminates in respiratory
arrest.

Scenario 3

Incorrect
A 56-year-old man presents to the trauma clinic with a fluctuant swelling under his scalp and
bilateral swollen eyelids. He fell off a 5-feet-high step-ladder 5 days ago. On examination, the
swelling extends from the frontal to the occipital region. He is well otherwise and his GCS score
is 15.

C Correct answer

In contrast to a localised scalp haematoma, a subaponeurotic haematoma is diffuse, arising in the

space between the galea and the pericranium. It usually occurs a few days after a head injury. It
presents as a large, diffuse and fluctuant swelling underneath the scalp, extending from the
frontal region to the occiput. It may be associated with swollen eyelids. This haematoma does
not need aspiration as it gradually resolves over a number of weeks.

Scenario 4

Incorrect
An 84-year-old man with dementia is brought to the Accident and Emergency Department with a
left-sided hemiparesis. The carer from the patient’s nursing home believes that he might have hit
his head against the bathtub 10 days ago. Since then, he has complained of recurrent episodes of
headaches and has been noticed to have ‘variation’ in his consciousness level. He takes warfarin
on prescription for atrial fibrillation.

E Correct answer

Most subdural haematomas are secondary to trauma, sometimes trivial, where the patient (or
carer) does not recall the incident. Spontaneous subdural haematomas can occur in elderly
patients with cerebral atrophy due to shearing of the subdural veins (venous plexus); alcoholics,
epileptics and patients on anticoagulants are more susceptible. About 20% of subdural
haematomas are bilateral. In chronic subdural haematoma, the patient may not become
symptomatic for many days or even weeks after the injury. If the haematoma continues to
enlarge, the patient presents with a headache, a fluctuating level of consciousness (not usually
seen in acute subdural haematoma), failing intellect and hemiparesis.

Theme: Correction of haemostatic defects

 
A Cryoprecipitate
B Prothrombin complex concentrate
C Protamine sulphate
D Intravenous vitamin K
E Platelets
F Platelets, fresh frozen plasma and cryoprecipitate

For each of the scenarios below select the most appropriate treatment from the
list of options above. Each option may be used once only, more than once or not
at all.

In patients who are over-anticoagulated with warfarin, treatment depends on the

INR, the presence or absence of spontaneous bleeding and the urgency of the
required correction. Patients with INR >5.0 or who show bleeding should be
reversed, usually with vitamin K although additional fresh frozen plasma may be
required in severe bleeds, urgent situations of very high INRs. Cryoprecipitate
contains only fibrinogen and factor VIII and will not reverse warfarin.

Scenario 2 is clearly disseminated intrvascular coagulation (DIC) secondary to

sepsis, and despite to comparatively mild haematological abnormalities and the
lack of bleeding, aggressive treatment with plasma and platelets is required. In
this case cryoprecipitate should be added to help support the fibrinogen which is
dramatically reduced.

FFP (compared to prothrombin complex concentrate) only has a partial effect and
is not the optimal treatment and should never be used for the reversal of warfarin
anticoagulation in the presence of severe bleeding. FFP contains insufficient
concentration of vitamin K factors to reverse the bleeding deficiency.

Scenario 1

Incorrect
A 68-year-old man on long term warfarin therapy for atrial fibrillation is admitted to the ward 48
h prior to elective TURP. He complains of minor gingival bleeding only and has an INR of 7.5.
D Correct answer

Intravenous vitamin K

Scenario 2

Incorrect
A 32-year-old woman is admitted with acute cholecystitis. Despite antibiotic treatment, her
condition deteriorates and she becomes hypotensive, oliguric and hypoxic. There is no bleeding
but investigations show platelets 21 x 109/l, prothrombin time 21 s (control 16 s), activated
partial thromboplastin time 69s (control 36 s), fibrinogen 0.2 g/dl (normal range 2–4 g/dl).

F Correct answer

Platelets, fresh frozen plasma and cryoprecipitate

Scenario 3

Incorrect
A 43-year-old woman on warfarin for a prosthetic mitral valve has increasing confusion
following a fall. There is radiographic evidence of an acute subdural haematoma that requires
urgent surgical drainage. Her INR is 4.5.

B Correct answer

Prothrombin complex concentrate

Theme: Lung segments

A Apical
B Superior lingular
C Lateral basal (left)
D Medial (right)
E Medial (left)
F Inferior lingular

Pick the most appropriate option from the above list. Each option may be used
once only, more than once or not at all.
 

Scenario 1

Incorrect
A three-year-old child has inhaled a foreign body – where is it most likely to be embedded?

D Correct answer

Medial (right)

Inhaled foreign objects that enter the bronchial tree most frequently lodge in the medial right
lung segment as the right main bronchus is wider and more vertical.

Scenario 2

Incorrect
A 67-year-old has tuberculosis – which lobe is most likely to be affected?

A Correct answer

Apical

Scenario 3

Incorrect
A 27-year-old has pneumonia – which lobe is most likely to be affected?

B Your answer

C Correct answer

Lateral basal (left)

Pneumonia tends to affect the basal segments as the lungs are not so well ventilated.

Scenario 4

Incorrect
20-year-old footballer is kicked in the mouth and inhaled a tooth. Where is this likely to impact?
C Your answer

D Correct answer

Medial (right)

Inhaled foreign objects that enter the bronchial tree most frequently lodge in the medial right
lung segment as the right main bronchus is wider and more vertical.

Theme: Types of shock

A Anaphylactic
B Cardiogenic
C Class 1 haemorrhagic
D Class 2 haemorrhagic
E Class 3 haemorrhagic
F Class 4 haemorrhagic
G Endocrine-related
H Iatrogenic
I Neurogenic
J Non-haemorrhagic hypovolaemic
K Septic
L Spinal

The following are descriptions of shock. Please select the most appropriate
diagnosis from the above list. The items may be used once, more than once, or
not at all.

Scenario 1

Incorrect
A 32-year-old man is stabbed in the left side of the chest. Initial assessment reveals engorged
neck veins, respiratory rate 30 breaths/min, pulse rate 120/min and blood pressure 80/40 mmHg
despite attempts at fluid resuscitation; on auscultation heart sounds are muffled. His urine output
has not been assessed.

B Correct answer
B – Cardiogenic

This patient has Beck’s classic triad of tachycardia, muffled heart sounds and engorged neck
veins with hypotension resistant to fluid therapy suggesting cardiac tamponade. Cardiac
tamponade, a well-recognised cause of cardiogenic shock, results in impairment of cardiac
function and effective failure of the heart to maintain the circulation by ‘pump failure’. It has a
90% mortality, prompt pericardiocentesis providing the only relief.

Scenario 2

Incorrect
A 72-year-old man presents with sudden onset of severe central abdominal pain radiating to the
back. On examination, he is very anxious, with respiratory rate 33 breaths/min, pulse rate
120/min and blood pressure 90/40 mmHg. He has passed 15 ml of urine since he was
catheterised 1 h ago. Both femoral pulses are only faintly palpable.

E Correct answer

E – Class 3 haemorrhagic

This patient most likely has a leaking abdominal aortic aneurysm associated with a 30–40%
blood volume loss (approximately 2000 ml in a 70-kg adult). Patients with this volume of blood
loss almost always present with the classic signs of inadequate peripheral perfusion, marked
tachycardia and tachypnoea, significant changes in mental status, and a measurable fall in
systolic pressure. Management includes urgent fluid resuscitation, blood transfusion and
emergency surgical repair.

Scenario 3

Incorrect
A 61-year-old man becomes acutely confused day 3 postabdominal aortic aneurysm repair.
Examination reveals temperature 38°C, respiratory rate 36 breaths/min, pulse rate 140/min and
blood pressure 90/40 mmHg despite attempts at fluid resuscitation. He has passed a negligible
volume of urine since he was catheterised 1 h ago. Ironically his peripheries are warm to the
touch.

K Correct answer

K – Septic

This patient has developed septic shock. Circulating endotoxins, commonly from Gram-negative
organisms, produce vasodilatation – producing a widened pulse pressure and warm peripheries –
and impair energy utilisation at a cellular level. Tissue hypoxia can occur even with normal or
high oxygen delivery rates because of increased tissue oxygen demands and direct impairment of
cellular oxygen uptake. In addition, the endotoxin causes capillary wall hyperpermeability,
worsened by the stimulation of proteolytic enzymes, leading to poorly controlled fluid transfer
from the intravascular to the interstitial space, effectively resulting in hypovolaemia. The
situation is aggravated by the negatively inotropic effect of bacterial endotoxin on the
myocardium.

Theme: Drugs used in critical care

A Adenosine
B Adrenaline
C Amiodarone
D Amrinone
E Atropine
F Digoxin
G Dobutamine
H Dopamine
I Dopexamine
J Lignocaine
K Nitroglycerin
L Noradrenaline

The following are descriptions of drugs used in the management of the critically ill
patient. Please select the most appropriate drug from the list. The items may be
used once, more than once, or not at all.

Scenario 1

Incorrect
A predominant ß1-agonist, used to improve cardiac output in patients with myocardial failure,
provided intravascular volume is satisfactory.

G Correct answer

G – Dobutamine

Dobutamine stimulates both ß1- and ß2-receptors. Stimulation of ß1-receptors produces a good
cardiac inotropic and chronotropic response, leading to improved cardiac output, and stimulation
of ß2-receptors produces a degree of vasodilatation, especially in skeletal muscle
(‘inodilatation’). Dobutamine can be used in combination with noradrenaline if sepsis and
hypotension are a problem. Studies have demonstrated that dobutamine is more effective than
dopamine (dosage-dependent roles, for example at low doses it is a D1A-agonist, at intermediate
doses ß1-adrenoreceptor effects appear, and at high doses a1-effects predominate) when
improvements in oxygen delivery [D(O2)] and uptake [V(O2)] are considered.

Scenario 2

Incorrect
A phosphodiesterase III inhibitor; acting as both a positive inotrope and a peripheral vasodilator;
it is effective in cardiogenic shock.

D Correct answer

D – Amrinone

Amrinone (and enoximone) are phosphodiesterase III inhibitors that increase intracellular cyclic
AMP. They improve hypotension, principally caused by cardiogenic shock, by their dual action
of increasing cardiac output and decreasing systemic vascular resistance (‘inodilatation’). The
addition of dobutamine is considered to be synergistic.

Scenario 3

Incorrect
A predominant a1-agonist; the first line in patients with septic shock.

L Correct answer

L – Noradrenaline

Noradrenaline stimulates a1-adrenoreceptors with minor ß1- and ß2-effects. It is employed

conventionally when increased systemic vascular resistance (to increase the blood pressure by
increasing left ventricular after-load) is required to maintain the mean arterial pressure after fluid
replacement and dobutamine infusion have proved inadequate. This is commonly the case in
septic shock where inflammatory mediator activation causes systemic vasodilatation.
Theme: Priorities in immediate trauma care
A Airway management
B Anteroposterior chest X-ray
C Anteroposterior pelvis X-ray
D Chest drain
E Chest X-ray
F Cross-match and blood transfusion
G Intravenous access and fluid resuscitation
H Lateral cervical spine X-ray
I Pericardiocentesis
J Pneumatic anti-shock garment
K Rewarming
L Urgent neurological opinion

The following scenarios describe road traffic accidents where the patient has been
brought in by ambulance with cervical spine immobilisation and 100% oxygen
administered by mask. However, no other active management has been instigated.
From the list above please select the most appropriate resuscitation measure with
the highest priority. A measure may be chosen once, more than once, or not at
all.

Scenario 1

Incorrect
An 18-year-old motorcyclist is brought in after being thrown off his bike. He is confused and
there is evidence of blood and vomit around his mouth. Vital signs: blood pressure 130/65
mmHg, pulse rate 110/min, respiratory rate 28 breaths/min.

K Your answer

A Correct answer

A – Airway management

Regardless of the presentation of the patient, the management of this man follows the Advanced
Trauma Life Support (ATLS) criteria of Airways, Breathing and Circulation. It appears that he
has sustained oro-facial trauma, and possibly aspirated. He needs oropharyngeal suction and
insertion of an appropriate airway. Once his breathing has been managed, intravenous access
must be gained to begin fluid resuscitation. He demonstrates signs of Class II haemorrhagic
shock (15–30% blood loss).

Scenario 2
 Incorrect
A 35-year-old woman is brought to casualty after being pinned in her car following collision
with a lamp post. After extrication it is apparent that she had not been wearing a seatbelt. On
examination, after appropriate airway management, she demonstrates central cyanosis, distended
neck veins but equal air entry with marked bruising over her anterior chest wall. Vital signs:
blood pressure 80/40 mmHg, pulse rate 140/min, respiratory rate 50 breaths/min.

I Correct answer

I – Pericardiocentesis

This lady has signs of cardiac tamponade, although a differential diagnosis would have included
tension pneumothorax had she demonstrated unequal air entry. Cardiac tamponade results in the
classic Beck’s triad of raised jugular venous pressure, muffled heart sounds and hypotension.
There would also be a resultant pulsus paradoxus or a large fall in systolic pressure and blood
volume on inspiration. Her hypotension is secondary to a low cardiac output because of
ineffectual myocardial contraction. Immediate pericardiocentesis is necessary, which involves
insertion of a broad-bore needle, attached to a three-way syringe, into a point 1–2 cm inferior to
the left of the xiphochondral junction. The needle should be advanced slowly, while aspirating,
towards the tip of the left scapula, while carefully observing the electrocardiogram trace for
evidence of a ‘current of injury’, eg extreme ST-T waves or widened QRS complexes. This alerts
the operator to the fact that the needle has been inserted into the myocardium.

Scenario 3

Incorrect
A 20-year-old man is brought in after being found under the wheel of a car. He is drowsy,
aggressive but keeps complaining of abdominal and left leg pain. Vital signs: blood pressure
80/40 mmHg, pulse rate 150/min, respiratory rate 38 breaths/min.

G Correct answer

G – Intravenous access and fluid resuscitation

This man has clear signs of Class IV haemorrhagic shock. This is seen following blood loss of
more than 2 litres (> 40%) and results in drowsiness and, occasionally, aggression. Class IV
haemorrhagic shock is classified as a pulse rate > 140/min, decreased blood pressure and pulse
pressure, and a respiratory rate > 35 breaths/min. The likely source of bleeding is from within the
abdomen and a possible long-bone fracture of his lower limb, both of which will also require
attention. However, he requires management according to the A,B,C principles of ATLS, with
specific management of his circulation. In the initial stages, in casualty, this involves crystalloid
fluid replacement followed promptly by blood therapy.
Theme: Management decisions in trauma care
A Abdominal X-ray
B Angiogram
C Chest drain
D Computed tomography scan
E Diagnostic peritoneal lavage
F Emergency laparotomy
G Emergency thoracotomy
H Focused Assessment Sonographically of Trauma (FAST) scan
I Fracture management
J Local wound exploration
K Resuscitation thoracotomy
L Transfer to specialist unit
M Ultrasound

In the following scenarios, each patient has undergone a primary survey, and now
requires a management decision. From the list above, choose the most
appropriate answer. Each item may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 38-year-old cyclist has been brought in to casualty after being knocked off his bicycle by a
lorry. He was extricated from under one of the wheels, which was lying across his abdomen. He
has bruising to this area and is complaining of considerable abdominal pain. He is conscious and
maintaining a blood pressure of 120/70 mmHg, pulse rate 110/min and respiratory rate 20
breaths/min. A FAST scan is negative.

D Correct answer

D – Computed tomography (CT) scan

The CT scanner is also known as the ‘doughnut of death’ to many trauma surgeons, highlighting
the need for a stable patient, an appropriate accompanying team and adequate resuscitation
facilities in the imaging unit. Often this is not the case, making management decisions difficult.
If in doubt about your facilities, then it would be prudent to consider other options, including
proceeding to theatre. If the patient demonstrates any signs of compromise prior to transfer then
delay doing so until resuscitation has been completed. This gentleman appears to have signs of
intraabdominal trauma but is currently stable. Despite its drawbacks, CT imaging is excellent for
assessing the extent of organ damage, retroperitoneal injury and pelvic organ injury and in
therefore assisting decision making regarding operative intervention. It has an accuracy of 92–
98% but can miss small diaphragmatic and bowel injuries.

Scenario 2

Incorrect
A 55-year-old gentleman has been brought in after falling 7 m off his ladder while painting the
outside of his house. His fall was broken by his ladder, and he was unconscious for 3 min before
being found by his wife. He has a large occipital scalp laceration that is bleeding profusely but
there is no underlying skull fracture. He has, however, fractured his left ninth and tenth ribs
posteriorly but has no clinical or radiographical evidence of a pneumothorax. He now has a
Glasgow Coma Score of 14 with blood pressure 60/40 mmHg, pulse rate 140/min and respiratory
rate 36 breaths/min. Despite aggressive fluid resuscitation, his vital signs remain the same. He
has a tender left hypochondrium.

F Correct answer

F – Emergency laparotomy

Despite the evidence of a significant head injury, this gentleman’s immediate threat to life is
hypovolaemia from an ongoing intra-abdominal bleed. This is likely to originate from his spleen,
and is not improving despite resuscitation. The ‘tap’ must be turned off and he needs to undergo
an emergency laparotomy. A FAST scan would confirm free fluid (and would routinely be
performed in units with a radiologist in the trauma team); however, it would not influence
management. The patient should not have a CT scan until after laparotomy.

Increased availability of imaging techniques (CT and FAST scans) has led to a decline in the use
of diagnostic peritoneal lavage. However, its application continues to be described in the ATLS
guidelines for both haemodynamically stable and unstable patients. The Editor’s view is that it
has a role in the haemodynamically unstable with a negative FAST scan where doubt exists
regarding laparotomy but where a CT scan is contraindicated.

Scenario 3

Incorrect
A 24-year-old motorcyclist is brought in after a head-on collision with a car. He was conscious
on arrival but complained of pain in his chest, back and left ankle. Examination reveals a blood
pressure of 100/70 mmHg, pulse rate 90/min and a respiratory rate 28 breaths/min. His ankle is
deformed and painful to move. There is evidence of tracheal shift and the left hemithorax is not
moving. A chest X-ray demonstrates haemopneumothorax and chest drain insertion results in
immediate drainage of 1600 ml blood. Despite initial clinical improvement, the drain continues
to collect fresh blood at a rate of several hundred ml per 10 min.

G Correct answer

G – Emergency thoracotomy

This man was suffering from a massive haemothorax (with a bit of pneumothorax). The chest
drain resolves the respiratory embarrassment but fails to help the haemorrhage, which is on-
going. Thoracotomy is indicated if a surgeon, qualified by training and experience, is present in
the following scenarios:

 >1500 ml blood drains immediately

 >200 ml/h blood drains for > 2–4 h
 persistent transfusions
 penetrating anterior trauma medial to the nipple, or posteriorly, medial to the scapula.

It should be performed in theatre with full equipment. NB This procedure differs from a
resuscitation thoracotomy (ie one performed in The Emergency Department), which has only
two indications:

 penetrating chest injury with witnessed cardiac arrest of < 5 min duration
 uncontrolled life-threatening haemorrhage with tracheo-bronchial bleeding.

Theme: The red eye

A Acute closed-angle glaucoma
B Allergic conjunctivitis
C Anterior uveitis
D Corneal abrasion
E Corneal foreign body
F Corneal ulceration haemorrhage
G Episcleritis
H Hyphaema
I Infective conjunctivitis
J Keratitis
K Scleritis
L Sub-conjunctival
The following patients all present complaining of a red eye. For each, please
select the most appropriate diagnosis from the above list. The items may be used
once, more than once, or not at all.

Scenario 1

Incorrect
A 55-year-old woman with rheumatoid arthritis presents to The Emergency Department minors
department with a 48-h history of progressively worsening pain and florid erythema to her right
eye. She complains of constant watering but has not noticed any discharge. On examination she
has a localised area of inflammation that is extremely tender to pressure. The injected vessels are
in the deep layer of the eye.

I Your answer

K Correct answer

K – Scleritis

The sclera and episclera can both become inflamed in autoimmune conditions, particularly
rheumatoid arthritis. Unlike conjunctivitis, inflammation of these layers of the eye produces a
localised region of injection. The distinction between episcleritis and scleritis is related to
severity of symptoms and potential complications. Scleritis is characteristically much more
painful than episcleritis, and the signs of inflammation are more extensive. It may ultimately
result in ocular perforation. All patients require opthalmological review, and steroid eye drops
will provide symptomatic relief and hasten recovery.

Scenario 2

Incorrect
A 60-year-old man attends The Emergency Department in the late evening. He describes the
onset of sudden excruciating pain in his left eye associated with an episode of vomiting and
‘haziness’ of vision. He tells you that this has occurred twice in the past, and was relieved by
going to sleep. On closer examination you note that his eye is inflamed and tender. The cornea is
cloudy, and the pupil is semi-dilated and fixed in response to light.

A Correct answer

A – Acute closed-angle glaucoma

This scenario depicts a typical presentation of acute closed-angle glaucoma. This includes the
rapid onset of pain, characteristically in the evening, when the pupil becomes semi-dilated (light
intensity decreases). Prior episodes that have been relieved by sleep, when the pupil constricts,
are also distinctive in this disease. In acute closed-angle glaucoma apposition of the lens to the
back of the iris prevents the flow of aqueous from the posterior chamber to the anterior chamber.
Accumulation of aqueous behind the iris pushes it forwards on to the trabecular meshwork,
preventing normal drainage of aqueous from the eye. This causes an acute rise in intraocular
pressure, requiring emergency intervention to preserve sight. Acetazolamide given intravenously
and pilocarpine eye drops should be rapidly administered until definitive surgical/laser
decompression can be achieved.

Scenario 3

Incorrect
A 35-year-old golfer attends the emergency eye clinic after his golfing partner accidentally
caught him in the left orbit with his club. He complains of double vision and discomfort to his
eye, and there is a laceration to his upper eyelid. You notice that his left eye movements are
restricted during your examination, and that he has blood in the anterior chamber of his eye.
Palpation reveals crepitus in the peri-orbital tissues.

H Correct answer

H – Hyphaema

Blood in the anterior chamber of the eye is known as a hyphaema. Commonly resulting from
blunt trauma to the globe, this must be treated as an emergency as further bleeding may increase
intraocular pressure and compromise sight. Other important sequelae of blunt ocular trauma are
also demonstrated in this case. When the eye itself absorbs impact, transmitted forces to the orbit
can result in a ‘blow-out’ fracture, particularly of the thin orbital floor. Clues to such an
occurrence include diplopia, defective eye movements (related to inferior rectus muscle prolapse
through the fracture site), emphysema (fracture through a sinus) and recession of the eye
(enophthalmus).

Scenario 4

Incorrect
A 24-year-old man is seen in the ophthalmology outpatient department after referral by his
general practitioner for recurrent attacks of uncomfortable red eyes. On closer questioning he
describes a prodromal history of pain and morning stiffness to his lower back. On inspection of
the affected eye injection is most pronounced around the iris, and his pupil is irregular in outline.

C Correct answer
C – Anterior uveitis

Inflammation of the iris and ciliary body is known as anterior uveitis. At risk groups for such
disorders include those with seronegative arthropathies, particularly if they are positive for HLA-
B27 histocompatability antigen (in this case the young man has symptoms of ankylosing
spondylitis). Other causes include sarcoidosis, and several infections such as herpes zoster
ophthalmicus, syphilis and tuberculosis. It is important to treat the underlying cause and ensure
that there is no disease in the rest of the eye that is giving rise to signs of an anterior uveitis
(including more posterior inflammation, a retinal detachment, or an intraocular tumour).The
pupil is irregular because of adhesions of the iris to the lens (posterior synechiae). Topical
steroids help to reduce inflammation.

Theme: Acute loss of vision

A Acute closed-angle glaucoma
B Blunt traumatic loss of vision
C Endophthalmitis
D Giant cell (temporal) arteritis
E Ischaemic optic neuropathy
F Migraine
G Occipital lobe ischaemia
H Occipital lobe trauma
I Optic nerve trauma
J Optic neuritis
K Orbital cellulitis
L Penetrating traumatic loss of vision
M Raised intracranial pressure
N Retinal artery occlusion
O Retinal detachment
P Vitreous haemorrhage

The following patients all present complaining of acute visual loss. For each,
please select the most appropriate diagnosis from the above list. The items may
be used once, more than once, or not at all.

Scenario 1

Incorrect
A 65-year-old man presents to the emergency eye department complaining of a sudden loss of
vision in his right eye. On direct questioning you are able to elicit a history of right-sided scalp
tenderness and recent malaise. Fundoscopy reveals haemorrhages on the disc and disc margin on
the right, with cotton wool spots around the disc. His erythrocyte sedimentation rate is 118.

E Your answer

D Correct answer

D – Giant cell (temporal) arteritis

This scenario demonstrates the classical presentation of someone afflicted with giant cell
arteritis. The patient often notices scalp tenderness (often on combing the hair on the affected
side), with concurrent visual loss and malaise. They may also report pain on chewing (jaw
claudication) and shoulder pain. There is an association with polymyalgia rheumatica. An
erythrocyte sedimentation rate (ESR) greater than 40 is highly suggestive of the disease (and
there are very few other diagnoses with an ESR > 100). Be aware that a temporal artery biopsy
may miss the affected section of artery as the disease can skip regions of vascular endothelium.
A strong history should prompt the commencement of oral or intravenous high-dose steroid
therapy (even prior to biopsy and its results). Steroids will not restore visual loss but will prevent
loss of sight in the other eye.

Scenario 2

Incorrect
A 70-year-old woman attends her general practitioner’s surgery with a history of a ‘curtain’
coming down rapidly in her left eye. She had a prior history of flashing lights and ‘spots’ floating
in her vision. She has recently had surgery for a left-sided cataract.

L Your answer

O Correct answer

O – Retinal detachment

Retinal detachment can occur in 1 : 10, 000 of the normal population. The probability is
increased in people who are short-sighted (myopes); have undergone cataract surgery, as in this
specific case, (particularly if this was complicated by vitreous loss); have suffered from a
detached retina in the other eye; or who have been subjected to recent severe eye trauma.
Symptoms of posterior vitreous detachment, including ‘floaters’ (pigment or blood in the
vitreous) and flashing lights (retinal traction), may precede the onset of retinal detachment itself.
As the condition progresses, the patient notices the development of a visual field defect, often
likened to a ‘shadow’ or ‘curtain’ coming down. If a superior detachment occurs this field defect
can evolve rapidly. If the macula becomes detached there is a marked fall in visual acuity.

Scenario 3
 Incorrect
A 60-year-old woman presents to The Emergency Department with a recurrent history of fleeting
loss of vision in her left eye, often lasting up to 10 min. She tells you that she has just had
another episode an hour earlier. On fundoscopy the acutely affected retina is swollen and white,
and the fovea appears very red. You also notice that she has a bruit over her left carotid artery
and the carotid pulse appears slightly diminished.

N Correct answer

N – Retinal artery occlusion

Retinal artery occlusion is usually embolic in nature. The three main forms of emboli are: fibrin-
platelet emboli (from diseased carotids, as in this case); cholesterol emboli (from diseased
carotids) and calcific emboli (from diseased heart valves). The presentation can vary but often
the patient complains of sudden painless loss of all or part of the vision. In this scenario the
fleeting loss of vision experienced by the patient is caused by the fibrin–platelet emboli
obstructing, and then passing through, the retinal circulation (amaurosis fugax). Symptoms,
therefore, persist for a few minutes then dissipate. Cholesterol and calcific emboli (which are less
pliant) may result in permanent obstruction of the retinal vessel, with no visual recovery. On
fundoscopic examination the acutely affected retina is oedematous (swollen, pale), while the
fovea remains red (cherry red spot) as it has no supply from the retinal circulation. Acute
management of the condition is aimed at dilating the arteriole to encourage passage of the
embolus. Results are often disappointing (although better if the patient is seen within 24 h of the
onset of obstruction). Intravenous acetazolamide (reducing intra-ocular pressure), ocular
massage (to exert pressure on vessels in an attempt to dislodge the embolus), anterior chamber
paracentesis (to release aqueous and rapidly lower intra-ocular pressure) and carbon dioxide re-
breathing (vasodilatory effects) are therapeutic techniques that can be employed. The patient
should be thoroughly investigated for systemic vascular disease.

Theme: Abdominal trauma

A   Laparotomy
B   Trial of conservative management
C   Computed tomography (CT) scan of abdomen
D   Laparoscopy
E   Diagnostic peritoneal lavage

For each of the scenarios below select the most appropriate next action. Each
option may be used once, more than once, or not at all.
 

Scenario 1

Incorrect
A 45-year-old car driver is seen by the surgical team in the Accident and Emergency
Department, following a high-speed road-traffic accident. He was tender in the right upper
quadrant and a CT scan has shown a small, isolated tear in the right lobe of his liver with some
free fluid in the peritoneal cavity. A secondary survey reveals no other significant injury. He has
a pulse of 80 and a blood pressure (BP) of 140/90.

C Your answer

B Correct answer

As long as patient 1 remains haemodynamically stable, a liver injury such as this can be
managed conservatively. However in the event of haemodynamic instability he would require a
laparotomy. Continued liver bleeding may present as a fall in haemoglobin and increase in fluid
requirements rather than sudden cardiovascular collapse so it is vital that haemoglobin levels are
checked regularly.

Scenario 2

Incorrect
A 19-year-old man is brought into the Accident and Emergency Department after been stabbed
in the epigastrium. Despite adequate fluid resuscitation he remains hypotensive (BP 90/45) and
tachycardic (pulse 120). A primary survey suggest he has no other injuries.

C Your answer

A Correct answer

There is some role for laparoscopy in the assessment of penetrating trauma but patient 2 is
unstable and requires definitive management in the form of a laparotomy. A stab wound in this
region may have breached the diaphragm and the presence of an associated intra thoracic injury
must be considered in such a patient.

Scenario 3

Incorrect
A 17-year-old motorcyclist is seen in the resuscitation room following a high-speed road-traffic
accident. Radiology in the resuscitation room has shown a haemopneumothorax (for which a
chest drain has been inserted) and a fractured right femur. He was hypotensive on arrival but he
has responded to fluid resuscitation. He has some bruising over his lower abdomen but no
peritoneal signs.

C Correct answer

There is no absolute indication for a laparotomy in patient 3 but the possibility of a significant
abdominal injury must be considered. Diagnostic peritoneal lavage is generally considered to be
an obsolete technique. Assuming patient 3 remains stable he should be investigated by an
abdominal computed tomography (CT) scan. This is a sensitive means of evaluating the
peritoneal cavity and retroperitoneum following trauma. Obviously if his condition were to
deteriorate he may then require a laparotomy.

Theme: Chest injury

 
A Aortic injury
B Flail segment
C Pericardial injury
D Pneumothorax
E Pulmonary contusions
 

For each of the scenarios below, select the most likely chest injury from the list of
options above. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A young man with a penetrating chest injury is clinically well on admission, and has a normal
chest film. However, he deteriorates while on the ward and has a tachycardia, hypotension and
dyspnoea when reviewed. His pulse is weak and JVP is raised.

B Your answer

C Correct answer

C – Pericardial injury
Scenario 1 is likely to be the result of a cardiac tamponade. Signs indicating this include a weak
pulse, raised JVP, hypotension and tachycardia. The only other condition that may cause similar
signs is a tension pneumothorax. However, the patient has a normal chest film which makes this
unlikely.

Scenario 2

Incorrect
A cricketer is hit by a ball in the chest. He initially carries on with the game but then collapses,
and is ‘blue-lighted’ to the Emergency Department. He is dyspnoeic, drowsy and has barely
audible breath sounds.

B Your answer

D Correct answer

D – Pneumothorax

The patient in scenario 2 is likely to have a pneumothorax as he has absent breath sounds, is
dyspnoeic and drowsy as a result of hypoxia.

Theme: Dyspnoea
A Cardiac tamponade
B Left haemothorax
C Left tension pneumothorax
D Pulmonary embolus

For each of the descriptions listed below, select the most likely diagnosis from the above list. Each
option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A patient has distended neck veins, having been stabbed lateral to the trachea. Examination
reveals decreased breath sounds, hyperresonant lung fields and tracheal deviation.
C Correct answer

C – Left tension pneumothorax

The patient here has signs of a tension pneumothorax. No tracheal deviation is seen in cardiac
tamponade.

Scenario 2

Incorrect
A patient presents with ECG changes in lead III, Q wave with inverted T and changes in lead I.

D Correct answer

D – Pulmonary embolus

Here, the characteristic ECG changes seen in pulmonary embolus are: S1, Q3, T3.

Scenario 3

Incorrect
A patient has dullness to percussion of the left chest.

B Correct answer

B – Left haemothorax

Dullness to percussion is indicative of fluid in the pleural space, hence the most appropriate
answer here is a haemothorax.

Theme: Chest and thoracic wall injuries

A Cardiac tamponade
B Diaphragmatic rupture
C Flail chest
D Fracture of the sternum
E Myocardial contusion
F Perforated oesophagus
G Pulmonary contusion
H Ruptured thoracic aorta
I Tension pneumothorax
J Traumatic haemothorax

For each of the following situations, select the most appropriate cause for the
chest condition from the above list. Each option may be used once, more than
once, or not at all.

Scenario 1

Incorrect
A 38-year-old man presents with respiratory distress, tachycardia and distended neck veins
following a penetrating injury to the right side of his chest. The patient’s BP is 100/60 mmHg
and respiratory rate is 20/min.

I Correct answer

I – Tension pneumothorax

Tension pneumothorax occurs following penetrating injuries to the chest. This is a surgical
emergency as it may result in cardiorespiratory arrest if the tension is not relieved immediately.
With each inspiration air is drawn into the pleural space and has no route to escape (acting as a
one-way valve). Patients present with respiratory distress, distended neck veins and deviation of
the trachea to the opposite side. There is a shift of the mediastinum to the contralateral
hemithorax. The immediate management is insertion of a large bore needle (cannula) into the
second intercostals space in the mid-clavicular line on the affected side. Following this an
intercostal chest drain must be inserted and connected to an underwater seal.

Scenario 2

Incorrect
A 47-year-old taxi driver involved in a RTA presents with lacerations over his chest and
abdomen. On examination, bowel sounds are heard in the chest. X-ray reveals bowel gas
shadows in his left lung fields.

B Correct answer

B – Diaphragmatic rupture
Diaphragmatic rupture occurs in high-speed blunt abdominal trauma against a closed glottis.
Diaphragmatic rupture is more common on the left as the liver acts as a protective buffer on the
right side. Bowel sounds may be heard in the chest. An X-ray may reveal bowel gas in the lung
fields as the colon and stomach may herniate into the thorax. The surgical approach (trans-
thoracic or trans-abdominal) depends on the stage of recognition and the presence of associated
injuries. If detected early and with associated intra-abdominal injuries, a trans-abdominal
approach is acceptable.

Scenario 3

Incorrect
A 78-year-old gentleman who is a known alcoholic presents with severe chest pain following an
episode of vomiting blood. Chest X-ray reveals gas in the mediastinum and in the subcutaneous
tissues.

F Correct answer

F – Perforated oesophagus

Spontaneous perforation of the oesophagus (Boerhaave’s syndrome) is a result of severe

barotrauma. The pressure in the oesophagus rapidly increases and the oesophagus perforates
(tears) at its weakest point (lower third). The usually history is that of a patient experiencing
severe chest or upper abdominal pain following a heavy meal or a bout of drinking (usually
bingeing). Haematemesis may or may not be present. This condition may be misdiagnosed as a
myocardial infarction or perforated peptic ulcer. Severe upper abdominal rigidity may be seen,
even in the absence of peritoneal contamination.

Scenario 4

Incorrect
A 38-year-old motorcyclist is brought to the Emergency Department following a major RTA. On
examination, he has a raised JVP and muffled heart sounds. The patient’s blood pressure is
100/84 mmHg and his pulses fade on inspiration.

A Correct answer

A – Cardiac tamponade

Cardiac tamponade occurs following trauma, lung or breast carcinoma, pericarditis and
myocardical infarction. The signs include: raised JVP, falling BP and muffled heart sounds
(Beck’s triad). In addition, with inspiration the JVP rises (Kussmaul’s sign) with a fall in systolic
blood pressure of more than 10 mmHg (pulsus paradoxus). Chest X-ray reveals a globular heart;
the left heart border is convex or straight and the right cardiophrenic angle is < 90°.
THEME: Head injury

A   Base-of-skull fracture

B   Extradural haemorrhage
C   Le Fort fracture type I
D   Le Fort fracture type II
E   Subarachnoid haemorrhage
F   Subdural haemorrhage

For each of the following scenarios choose from the above list the most likely
diagnosis. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 69-year-old man, in sheltered accommodation, tripped over the edge of his coffee table 1 week
ago. He didn’t lose consciousness. The warden says the patient has become increasingly
confused over the last 3 weeks. On examination the patient smells strongly of alcohol and his
body is covered with small bruises which seem to be the result of previous falls.

B Your answer

F Correct answer

Subdural bleeds often present a week or more after the initial injury, which may be relatively
innocuous. Chronic alcoholics are at increased risk of having a subdural bleed; they are prone to
recurrent falls, may have signs of chronic liver disease (spider naevi, bruising) and may have
abnormal clotting factors that predisposes them to a higher risk of haemorrhage.

Scenario 2

Incorrect
A 23-year-old man presents to the casualty department after being punched in the face a few
hours ago. There had been no loss of consciousness. He complains he cannot hear well out of his
left ear. On examination, there appears to be blood behind the left tympanic membrane.
A Correct answer

A base-of-skull fracture should always be suspected if the patient has any of the following signs:
bruising around the eyes (‘racoon eyes’), haemotympanum, CSF leak from the nose or ears,
bruising behind the ear (Battle’s sign).

Scenario 3

Incorrect
A cricketer is hit by the ball on his left temporal region. He lost consciousness for a minute.
Despite a small bruise just in front of his left ear tragus, he decides not to go to hospital because
he says he feels fine. After one day, he develops a progressive headache and begins to vomit.

C Your answer

B Correct answer

This scenario is typical of someone with a possible extradural bleed. It is caused by a fracture of
the temporal or parietal bone causing laceration of the middle meningeal artery. These patients
may or may not suffer loss of consciousness at the time of the initial injury and appear fine
(‘lucid interval’). They may deteriorate rapidly after a few hours/days complaining of symptoms
associated with a rise in intracranial pressure (headache, vomiting, decrease in the level of
consciousness).

Scenario 4

Correct
A 19-year-old is brought to A&E after being repeatedly punched in the face. On examination, his
face is grossly swollen and there is a palpable step in his maxilla. There appears to be an
intermittent discharge of clear fluid from his nose.

D Correct answer

Le Fort fractures lie between the frontal bone, base of the skull and mandible. They are classified
as Le Fort I, II and III depending upon the severity of injury. Le Fort I involves only the tooth-
bearing portion of the maxilla. Le Fort II involves the maxilla, nasal bones and medial aspects of
the orbits. Le Fort III involves the maxilla, zygoma, nasal bones, ethmoid and the small bones of
the base of the skull. Classically there is a ‘palpable step’ in the maxilla and there may be CSF
rhinorrhoea, diplopia and conjuctival haematoma.
Theme: ASA (American Society of Anesthesiologists) physical status classification

A    ASA 1
B    ASA 2
C    ASA 2E
D    ASA 3
E    ASA 4

For each of the following case histories, select the most likely answer from the
above list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 20-year-old man, with no past medical history, admitted electively for an inguinal hernia
repair.

B Your answer

A Correct answer

This patient is young and presents with no comorbidity, therefore ASA 1 is the correct
answer.

Scenario 2

Incorrect
A 72-year-old woman, with unstable angina, poorly controlled hypertension and COPD,
admitted electively for a right radical nephrectomy.

D Your answer

E Correct answer

This woman is an ASA 4 as she has unstable angina, which is viewed as a constant threat to
her life. An ASA 3 would suggest functional limitation only.

Scenario 3
 Incorrect
A 50-year-old man, with diet-controlled diabetes, admitted electively for a circumcision.

B Correct answer

He has mild systemic disease with no other significant past history, therefore is an ASA 2.

Scenario 4

Incorrect
A 42-year-old man, with well-controlled, non-insulin-dependent diabetes, admitted as an
emergency with appendicitis.

C Correct answer

He is an ASA 2 as although he has diabetes it is well controlled; the E denotes an

emergency case.

Theme: Head injuries - Glasgow Coma Scale (GCS)

A    GCS 14
B    GCS 11
C    GCS 15
D    GCS 7
E    GCS 6

For each of the following case histories, select the most likely answer from the
above list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 25-year-old man brought to A&E after being knocked off his mountain bike by a car. His eyes
open to pain and he localises to pain but seems disorientated.
B Correct answer

This patient scores 2 for having eyes that open to pain, 5 for localising to pain and 4 for being
disorientated. GCS 11

Scenario 2

Incorrect
A 32-year-old man brought into A&E with a dislocated right shoulder is complaining of and
pointing to an area of severe pain in his right shoulder. He appears orientated and has his eyes
open.

C Correct answer

With eyes that are open spontaneously (4), being orientated (5) and having an appropriate motor
response (6), this patient has a GCS of 15.

Scenario 3

Incorrect
A 44-year-old man involved in an RTA brought into A&E with decorticate posturing, incoherent
mumbling and eyes that open to a painful stimulus.

D Correct answer

A patient whose eyes only open to pain (2), mumbles incoherently (2) and has abnormal flexion
(decorticate) (3) has a GCS of 7.

Scenario 4

Incorrect
A 40-year-old man jumped off a bridge. He has been brought into A&E with decerebrate
posturing, eyes that open to a painful stimulus and is making incomprehensible sounds.

E Correct answer

A patient whose eyes only open to pain (2), mumbles incoherently (2) and has abnormal
extension (decerebrate posturing) (2) has a GCS of 6.
Theme: Interpretation of pupil size

A    Oculomotor nerve compression

B    Horner's syndrome
C    Drugs
D    Pontine lesion
E    Optic nerve injury
F    Metabolic encephalopathy
G    None of the above

For each of the operative scenarios listed below, select the most likely cause of
the pupillary findings. Each option may be used once, more than once, or not at
all.

Scenario 1

Incorrect
A 75-year-old male smoker is admitted short of breath and complaining of right-sided chest pain.
He has a mass in the apex of his right lung. He is given intravenous morphine for pain relief. On
examination you note that he has mild right-sided ptosis and miosis.

B Correct answer

Horner’s syndrome is unilateral miosis, partial ptosis and anhydrosis. It is caused by

disruption of the cervical sympathetics, in this case by an apical lung tumour.

Scenario 2

Incorrect
An 18-year-old female is brought in to the emergency department. She has been found collapsed
at the back of a nightclub. There is no evidence of a head injury. She has a reduced Glasgow
Coma Scale. Both pupils are constricted and it is difficult to assess whether they are responsive
to light.

G Your answer

C Correct answer
Causes of bilaterally small pupils include drugs (opiates), a destructive lesion of the pons
and a metabolic encephalopathy. In this case the most likely cause is illicit drug use.

Scenario 3

Incorrect
During the secondary survey of a severely head-injured patient, you find mild bilateral dilatation
and a sluggish pupillary response to light.

E Your answer

A Correct answer

An early sign of temporal lobe herniation is mild pupillary dilatation and a sluggish
response to light. This is caused by mild compression of the oculomotor nerve (cranial
nerve III). As herniation worsens there is further dilatation, ptosis and paralysis of the
ocular muscles innervated by CN III.

CN III contains parasympathetic fibers which normally causes constriction.

Scenario 4

Incorrect
A workman is injured in an explosion on a building site. He has shrapnel wounds to his head and
chest. His pupils seem to be equal. However, the right pupil does not react directly to light but
does react to light in the opposite eye.

E Correct answer

This patient has sustained a penetrating injury to his right optic nerve. This leads to a pupil
that is cross reactive (Marcus–Gunn pupil) and may be dilated or normal in size.

Theme: Glasgow Coma Scale

A    14
B    13
C    12
D    5
E    4
F    3
G    0

For each of the clinical scenarios listed below, select the correct Glasgow Coma
Score for the patient. Each option may be used once, more than once, or not at
all.

Scenario 1

Incorrect
A 66-year-old gentleman is brought in by ambulance. He was found collapsed having fallen off a
ladder. On arrival the paramedics are performing cardiopulmonary resuscitation.

F Correct answer

Eye opening: none – 1, best motor response: none – 1, verbal response: none – 1

Scenario 2

Incorrect
You see a 16-year-old girl in the emergency department. She seems to be sleeping and smells of
alcohol. She opens her eyes when you ask her to and tries to knock your hand away when you
rub on her sternum. When she opens her eyes you have a brief conversation, which doesn’t quite
make sense.

C Correct answer

Eye opening: to speech – 3, best motor response: localises pain – 5, verbal response:
confused conversation – 4

GCS 12

Scenario 3

Incorrect
A 30-year-old woman is brought in by ambulance. She was ejected from her car during a road
traffic collision. She is tolerating an oropharygeal airway, is tachyopnoeic, tachycardic and has a
systolic blood pressure of 90/30 mmHg. She is not opening her eyes and abnormally flexes to
pain. She was making some sounds when she first came in but is now silent.

D Correct answer

Eye opening: none – 1, best motor response: abnormal flexion – 3, verbal response: none –
1

Scenario 4

Incorrect
A 28-year-old is brought in from a nightclub. He has fallen from a balcony and sustained a head
injury. He has been drinking and taking illicit drugs. He is being aggressive and tried to punch
your house officer but missed. He is now shouting abuse although it doesn’t seem to make sense.

A Correct answer

Eye opening: spontaneous – 4, best motor response: obeys commands – 6, verbal response:
confused conversation – 4

THEME: INJURIES TO THE UPPER ARM AND SHOULDER REGION

A    Fracture of the coracoid process

B    Anterior dislocation of the shoulder
C    Fracture of the greater tuberosity
D    Fracture of the acromion process
E    Posterior dislocation of the shoulder
F    Fracture of the head of humerus
G    Fracture of the neck of scapula
H    Fracture of the neck of humerus
I     Acromioclavicular joint subluxation
J    Ruptured coracoacromial ligament

Please select the most appropriate diagnosis from the above list. Each option may
be used once, more than once, or not at all.

 
Scenario 1

Correct
A 39-year-old motorcyclist is brought to the Accident and Emergency Department after being
involved in a high-speed road-traffic accident. He sustained severe trauma to his right upper back
when he fell onto the road. There is bruising and tenderness over this region. He has drooping of
the right shoulder with lengthening of the arm. Movement of the shoulder is severely restricted
and the arm is held in adduction.

G Correct answer

Scapular neck fractures are usually caused by direct trauma to the upper back, as in a fall from
height or by high-speed road-traffic accidents. It can also result from an anterior or posterior
force applied to the shoulder region. Patients present with bruising and tenderness over the
scapular region on the affected side; maximal tenderness is over the lateral humeral head. There
is also drooping of the affected shoulder with apparent lengthening of the arm, particularly with
fracture of the neck of the scapula. Patients with scapular neck fractures resist all shoulder
movements and will hold the limb in adduction. Fractures of the scapula, first or second ribs or
the sternum, suggest a magnitude of injury so severe that associated injuries to the head, neck,
spinal cord, lungs and the great vessels should be ruled out. Most scapular neck fractures can be
treated conservatively. Internal fixation is indicated for some articular fractures of the glenoid
cavity.

Scenario 2

Incorrect
An 18-year-old man is brought to the Accident and Emergency Department with a painful
shoulder, after falling awkwardly during a rugby tackle. On examination, there is a swelling in
the deltopectoral groove with lowering of the anterior axillary fold and a prominent acromion
process. The arm is slightly abducted and externally rotated.

B Correct answer

Anterior (subcoracoid) dislocation is the commonest type of dislocation of the shoulder. The
usual mechanism of injury is a fall onto the outstretched arm with the arm abducted and
externally rotated. It can also result from various sporting injuries, commonly basketball and
rugby. Pain is severe and the patient is unwilling to attempt movements of the shoulder. A
swelling may be noticed in the deltopectoral groove (displaced head) with an undue prominence
of the acromion process. The arm is held in slight abduction and external rotation (( looks like
patient wants to shake hand with you )). There may be flattening and loss of contour of the
shoulder just below the acromion process and lowering of the anterior axillary fold. If the
axillary nerve is damaged, patients may present with loss of sensation over the upper, outer
aspect of the arm (regimental badge area).
Scenario 3

Incorrect
An 80-year-old woman presents to the Accident and Emergency Department with extensive
bruising and pain over her right upper/mid arm. She tripped while in toilet and banged her right
arm against the edge of the bathtub 2 days ago. She is unable to move her right shoulder. She
suffers from osteoporosis.

H Correct answer

Fracture of the neck of the humerus is common in middle-aged and elderly patients. The fracture
could result from direct trauma to the upper arm. In elderly patients, particularly women, the
bone is frequently osteoporotic; the possibility of a pathological fracture secondary to
malignancy should also be borne in mind. The patient may present with extensive bruising and
pain over the upper- and mid-parts of the arm. Sometimes the presentation is delayed since the
patient may be able to use the arm to some extent without much pain. This is particularly true for
impacted fractures. The modern Neer’s classification for fractures of the proximal end of
humerus is based on the involvement of the four parts: a) articular segment of the head, b) the
greater tuberosity, c) the lesser tuberosity and d) the surgical neck. Depending on the number of
parts displaced they are called as two-part, three-part or four-part fractures.

THEME: INJURIES TO THE FOREARM AND HAND

A    Pulled elbow

B    Fracture of the olecranon process
C    Monteggia's fracture
D    Fracture of the coronoid process
E    Fracture of the radial head
F    Smith's fracture
G    Colles' fracture
H    Scaphoid fracture
I     Galeazzi's fracture
J    Dislocated elbow

Please select the most appropriate diagnosis from the above list. Each option may
be used once, more than once, or not at all.

 
Scenario 1

Incorrect
A 35-year-old man presents to the Accident and Emergency Department with a painful upper
forearm after being involved in a fight in his local pub. There is pain and tenderness over the
elbow region and upper forearm. Plain radiography reveals an angulated fracture at the junction
of the proximal and middle third of the ulna and the head of the radius is dislocated anteriorly.

C Correct answer

Monteggia’s fractures, comprising less than 5% of forearm fractures, are primarily associated
with falls on an outstretched hand with forced pronation. The mechanism of injury is that of
transmission of force through the hand and forearm with the elbow partially flexed. It can also
result from direct trauma to the forearm. Monteggia’s fracture is characterised by angulation at
the junction of the proximal and middle third of ulna accompanied by anterior dislocation of the
radial head. Following injury, patients may present with elbow pain. Depending on the type of
fracture and severity, they may also have elbow swelling, deformity, crepitus and paraesthesia.
Elbow flexion and forearm rotation are limited and painful. Radial head dislocation may lead to
radial nerve injury. The posterior interosseous branch of the radial nerve, which courses around
the neck of the radius, is especially at risk, especially in Bado’s type II injuries.

Scenario 2

Incorrect
A 38-year-old woman presents to the Accident and Emergency Department with a painful right
wrist after having fallen on her outstretched hand. On examination, there is mild swelling over
the wrist and the movements are restricted. The pain is maximal over the distal end of radius in
the snuffbox region, which is worsened on longitudinal compression of the thumb.

G Your answer

H Correct answer

The scaphoid is the most commonly fractured carpal bone. The mechanism of injury is usually a
fall on the outstretched hand with the wrist extended and radially deviated. This causes extreme
dorsiflexion at the wrist and compression to the radial side of the hand leading to fracture of the
scaphoid. The patient usually complains of a deep, dull pain in the radial wrist, which is
worsened by gripping or squeezing. It is also exacerbated by active extension and adduction of
the thumb. Tenderness in the anatomic snuffbox and pain on longitudinal compression of the
thumb (scaphoid compression test) are the most accurate signs of scaphoid fracture, although the
former is more commonly performed. There may be mild wrist swelling or bruising and,
possibly, fullness in the anatomic snuffbox, suggesting a wrist effusion. Early accurate diagnosis
and management of scaphoid fractures is vital: a delay can lead to a variety of adverse outcomes
including persistent pain, nonunion, delayed union, decreased grip strength, decreased range of
wrist motion and osteoarthritis of the radiocarpal joint. The differential diagnosis for suspected
scaphoid injuries include distal radius fracture, fractures of other metacarpal bones, scapholunate
dissociation, tenosynovitis or strains.

Scenario 3

Incorrect
A 55–year-old woman presents to the Accident and Emergency Department with a painful
swelling over her left distal forearm following a road-traffic accident. On examination, there is
tenderness, swelling and deformity over this region. Plain radiography reveals a fracture at the
middle and distal thirds of the radius with the fragment of the radius tilted towards the ulna.
There is disruption of the distal radioulnar joint.

I Correct answer

Galeazzi’s fracture is a fracture of the junction of the distal third and middle third of the radius
with associated subluxation or dislocation of the distal radioulnar joint. They usually occur after
a fall on the hand with a rotational force superimposed on it (axial load placed on a
hyperpronated forearm). It can also occur following direct blow to the middle/distal forearm as
in road-traffic accidents. Patients present with pain and soft-tissue swelling at the distal third
radius fracture site and at the wrist joint. On examination, there is bruising, swelling and
tenderness over the lower end of the forearm. Deformity may be present. Plain radiography
reveals the displaced fracture of the radius and the fragments of the radius are usually tilted
medially towards the ulna. The ulnar head is prominent due to dislocation of the inferior
radioulnar joint. Galeazzi’s fractures in adults should be treated by open reduction and internal
fixation. Surgical reduction of both the radius and distal radioulnar joint provides the best
opportunity for healing.

THEME: BRACHIAL PLEXUS INJURIES

A    Median nerve

B    Axillary nerve
C    Ulnar nerve
D    Radial nerve
E    Musculocutaneous nerve
F    Medial pectoral nerve
G   Suprascapular nerve
H   Long thoracic nerve
I    Lateral pectoral nerve
J   Nerve to rhomboid

Please select the most appropriate diagnosis from the above list. Each option may
be used once, more than once, or not at all.

Scenario 1

Incorrect
A 55-year-old woman presents to the Accident and Emergency Department with pain over her
right upper arm after sustaining an injury to the region following a fall. On examination, there is
bruising and tenderness over the mid-arm region. Neurological examination reveals sensory loss
over the lateral side of the back of the hand and she is unable to extend her wrist.

D Correct answer

Radial nerve compression or injury may occur at any point along the anatomical course of the
nerve. It may be associated with fracture of the humerus, especially in the middle third or at the
junction of the middle and distal thirds; the radial nerve lies in the spiral grove in this region. The
presentation may be at the time of the injury or secondary to fracture manipulation; delayed
presentation may be seen from a healing callus. The other important site of compression of the
radial nerve is in the proximal forearm in the area of the supinator muscle and involves the
posterior interosseous branch. Such injuries cause wrist drop (paralysis of the extensor muscles
of the wrist, finger and thumb) and also paralysis of the brachioradialis and the supinator
muscles. Very proximal lesions may affect the triceps muscle. There is sensory loss over the
dorsoradial aspect of the hand and the dorsal aspect of the radial 3 1/2 digits.

Scenario 2

Incorrect
A 32-year-old man presents to the Orthopaedic Clinic with inability to raise his right arm. He
had a deep intramuscular injection to his deltoid region 2 days ago. On examination, there is a
small area of anaesthesia over the insertion of deltoid and loss of shoulder abduction beyond 10–
15.

B Correct answer

The axillary (circumflex) nerve can be injured or damaged after fracture dislocation of the upper
humerus, shoulder dislocation, pressure from casts or splints, improper use of crutches or deep
intramuscular injections. There may be wasting and weakness of the deltoid resulting in the loss
of shoulder abduction. The patient is unable to initiate abduction of the shoulder because the
supraspinatus and the deltoid help the early phase of abduction; supraspinatus causes the first
10–15 of abduction followed by deltoid, which helps in further 90–100 of abduction. There
may be a small area of sensory loss over the insertion of deltoid (upper outer aspect of the deltoid
region; also called the ‘regimental badge area’). Relevant investigations in patients with
suspected axillary nerve injuries secondary to intramuscular injection include electromyography,
nerve biopsy and magnetic resonance imaging.

Scenario 3

Incorrect
A 68-year-old woman presents to the Orthopaedic Clinic complaining of a ‘prominent scapula’.
She had recently undergone mastectomy for breast cancer. On examination, the scapula becomes
prominent (standing out) over the vertebral border and the inferior angle when she is asked to
push her arms against the wall.

H Correct answer

The long thoracic nerve (nerve of Bell), comprising C5, 6, 7 nerve roots, supplies the serratus
anterior muscle, which helps to stabilise the scapula. This nerve may be injured following
injuries to the brachial plexus or could be damaged during surgeries to the chest wall, breast
(including mastectomy and breast augmentation) or the axillary region. Other causes include
radiotherapy, trauma, anaesthetic nerve block and transaxillary incision. Paralysis of the serratus
anterior muscle causes winging of the scapula particularly when the patient is asked to push
his/her arms against resistance.

THEME: INJURIES TO THE CHEST AND THORACIC CAVITY

A    Oesophageal rupture

B    Diaphragmatic rupture
C    Myocardial contusion
D    Fracture of the sternum
E    Traumatic haemothorax
F    Ruptured thoracic aorta
G   Tension pneumothorax
H   Cardiac tamponade
I    Flail chest
J   Hiatus hernia
Please select the most appropriate diagnosis from the above list. Each option may
be used once, more than once, or not at all.

Scenario 1

Incorrect
A 35-year-old man is brought to the Accident and Emergency Department with a penetrating
injury to the right side of his chest sustained during a brawl in his local pub. He is in respiratory
distress, has distended neck veins and breath sounds are absent on the right side of chest. His
pulse is 118/min, blood pressure is 96/60 mmHg and his respiratory rate is 22/min.

F Your answer

G Correct answer

Tension pneumothorax occurs following penetrating chest injuries. This is a surgical emergency
as it may result in cardio-respiratory arrest if the tension is not relieved immediately. With each
inspiration air is drawn into the pleural space and has no route to escape (acts as a one-way
valve). Patients present with chest pain, respiratory distress (air hunger), tachypnoea,
tachycardia, hypotension, distended neck veins and unilateral absence of breath sounds. The
chest wall on the affected side is hyper-resonant on percussion and the trachea may be deviated
to the opposite side. The mediastinum may also be shifted to the contra-lateral hemi-thorax.
Immediate management consists of insertion of a large bore needle (cannula) into the second
intercostal space in the mid-clavicular line on the affected side. Definitive management includes
an intercostal chest drain and connecting it to an underwater seal.

Scenario 2

Correct
A 47-year-old taxi-driver is brought to the Accident and Emergency Department after being
involved in a road-traffic accident. He has deep lacerations over his left chest and upper
abdomen. On examination, bowel sounds are heard in the chest. Plain radiography after naso-
gastric tube insertion reveals the tube to be in the thoracic cavity.

B Correct answer

Diaphragmatic rupture occurs in high-speed blunt abdominal traumas when the patient has got a
closed glottis. It is more commonly diagnosed on the left as the liver obliterates the defect or acts
as a protection on the right side. Blunt trauma produces large radial tears in the diaphragm that
lead to herniation of the bowel contents into the thoracic cavity. Bowel sounds may be heard in
the chest. X-ray may reveal bowel gas in the lung fields as the colon and stomach may herniate
into the thorax. Diaphragmatic ruptures may be missed initially if the chest film is misinterpreted
as showing an elevated diaphragm, acute gastric dilatation, subpulmonary haematoma or a
loculated pnuemohaemothorax. If a laceration of the diaphragm is suspected, a gastric tube
should be inserted. When the gastric tube appears in the thoracic cavity on the chest film, the
need for special contrast studies is eliminated. Magnetic resonance imaging is accurate in
visualising the anatomy of the diaphragm (and diaphragmatic injuries) and so the investigation of
choice. The surgical approach (trans-thoracic or trans-abdominal) depends on the stage of
recognition and the presence of associated injuries. If detected early in a patient with other intra-
abdominal injuries, a transabdominal approach is acceptable.

Scenario 3

Incorrect
A 28-year-old man is brought to the Accident and Emergency Department with severe chest and
epigastric pain. He was repeatedly punched on his chest and upper abdomen when he was
involved in a fight in a nightclub. Plain radiography reveals gas in the mediastinum,
subcutaneous emphysema and a left-sided haemothorax. His pulse is 124/min and blood pressure
is 100/70 mmHg.

C Your answer

A Correct answer

Oesophageal perforation caused by closed chest injuries or direct trauma to the oesophagus is
rare and accounts for about 10% of all oesophageal ruptures. However, if unrecognised, it could
be life threatening. The clinical picture could be identical to that of post-emetic oesophageal
rupture (Boerhaave’s syndrome). The perforation secondary to closed chest injuries is usually in
the upper third of the oesophagus while Boerhaave’s syndrome is more common in the lower
third. Oesophageal perforation causes leakage of oesophageal/gastric contents into the
mediastinum. The patient presents with epigastric pain or shock out of proportion to the apparent
injury. Presence of mediastinal air in plain radiography and subcutaneous emphysema suggests
the diagnosis, which can be confirmed by contrast studies and/or oesophagoscopy. The resulting
mediastinitis and immediate or delayed rupture into the pleural space could lead to empyema.
Oesophageal injury should be considered in any patient who: (i) has a left pneumothorax or
haemothorax without a rib fracture; (ii) has received a severe blow to the lower sternum or
epigastrium and is in pain or shock out of proportion to the apparent injury or; (iii) has
particulate matter in the chest tube after the blood begins to clear. Wide drainage of the pleural
space and mediastinum with direct repair of the injury via a thoracotomy is the most appropriate
treatment. The prognosis is good if the repair is performed early (within a few hours of injury).
THEME: LOWER LIMB NERVE INJURIES

A    Pudendal nerve

B    Tibial nerve
C    Lateral cutaneous nerve of thigh
D    Saphenous nerve
E    Sciatic nerve
F    Common peroneal nerve
G    Medial plantar nerve
H    Femoral nerve
I     Sural nerve
J    Lateral plantar nerve

Please select the most appropriate nerve injury from the above list. Each option
may be used once, more than once, or not at all.

Scenario 1

Correct
A 25-year-old man presents to the Orthopaedic Clinic with a painful right knee and difficulty
walking. He was hit over the lateral side of his knee with a hockey stick 2 days ago. On
examination, he is unable to dorsiflex and evert his left foot. He has reduced sensation over the
lateral aspect of his lower leg and the dorsum of this foot and toes. X-ray shows a fracture of the
fibular neck.

F Correct answer

Common peroneal nerve (lateral popliteal nerve; L4–S2) injury is common following fibular
neck fractures since the nerve winds down the neck and is relatively superficial at this point.
Isolated fractures of the proximal fibula or fibular shaft are however uncommon and are usually
due to a direct blow producing transverse or comminuted fractures. The fibula can also be
injured by indirect forces, with the proximal fibula most commonly fractured by external rotation
forces and the distal fibula by internal rotation forces. The common peroneal nerve can also be
injured following a trauma or injury to the knee, use of tight plaster casts and pressure to the
fibular neck region from positions during deep sleep or coma. Common peroneal nerve gives
motor supply to the dorsiflexor and evertor muscles of the ankle and toes. Its sensory braches
supply the anterior and lateral aspect of the leg and whole of the dorsum of the foot and toes
except the lateral aspect of the foot (supplied by the sural nerve). Injury to this nerve results in
foot drop and the patient is unable to dorsiflex and evert the foot. The sensory loss is over the
anterior and lateral aspect of the leg and dorsum of the foot and the toes.

Scenario 2
 Incorrect
A 25-year-old man is brought to the Accident and Emergency Department following a deep stab-
wound injury to his upper left thigh. On examination, he has numbness over the anterior thigh
and medial aspect of his leg. He is unable to extend his knee and the knee jerk is diminished.

G Your answer

H Correct answer

Femoral nerve (L2–4) reaches the front of the leg by penetrating the psoas muscle before it exits
the pelvis by passing beneath the medial inguinal ligament to enter the femoral triangle. In the
femoral triangle, it lies just lateral to the femoral artery and vein. It may be injured by direct
penetrating wounds, gunshot wounds, traction during surgery, injuries to the femoral triangle, by
massive haematoma within the thigh, psoas abscess, fractured pelvis or by hip dislocation. It
innervates the iliopsoas (a hip flexor) and the quadriceps (a knee extensor). The motor branch to
the iliopsoas originates in the pelvis proximal to the inguinal ligament and injury at or above this
level leads to loss of hip flexion. The sensory branch of the femoral nerve, the saphenous nerve,
innervates skin of the medial thigh and the anterior and medial aspects of the calf. Damage to
this femoral nerve causes weakness of the quadriceps muscle and decreased patellar reflex. The
patient finds that the knee gives way on walking and has difficulty climbing stairs. There is
numbness over the anterior thigh and medial aspect of the leg.

Scenario 3

Incorrect
A 37-year-old man is brought to the Accident and Emergency Department after a high-speed
road-traffic accident. He hit his flexed knee against the dashboard of his car. On examination,
there is loss of sensation over the sole of the foot. He is unable to flex his toes. Ankle jerk is lost.
Plain radiography reveals posterior dislocation of the knee.

F Your answer

B Correct answer

The tibial nerve (S1–S2) may be damaged by posterior dislocation of the knee, posteriorly
displaced fractures of the tibia, sports injuries and severe fractures around the knee joint. It may
also be compressed behind the medial malleolus by the posterior tarsal tunnel. Tibial nerve
supplies the flexor compartment giving muscular branches to the deep surface of soleus, flexor
digitorum longus and hallucis longus and tibialis posterior. It divides into medial and lateral
plantar branches to supply the intrinsic muscles of the foot and provides sensation to the plantar
surface of the foot. It also provides cutaneous and articular branches to the medial side of the
ankle and foot. Injury to the tibial nerve results in loss of toe flexion and inability to invert the
ankle. Ankle jerk is lost. There is complete sensory loss over the plantar surface of the foot.
Theme: Chest pain

A    Oral analgesia

B    Oral analgesia and admission
C    Chest drain and analgesia

For each of the scenarios below select the most appropriate treatment. Each
option may be used once, more than once, or not at all.

Rib fractures may be extremely painful. The importance of treating rib fractures is in
the management of the underlying lung and the prevention of pulmonary
complications such as pneumonia and collapse. Atelectasis will occur if the lung is not
aerated fully, which would occur if there is poor chest expansion due to pain. Young
patients can tolerate a rib fracture more easily than elderly patients. With good
physiotherapy and analgesia, these young patients may be managed conservatively at
home. However, elderly patients would not tolerate rib fractures so well and
necessitate admission with regular analgesia, physiotherapy and probably prophylactic
antibiotics. In a polytrauma patient, it would be wise to insert a chest drain for both
the treatment of the pneumothorax and to prevent the development of a recurrent or
tension pneumothorax when the patient is ventilated.

Scenario 1

Incorrect
Young footballer with fracture of the fourth rib, normal chest X-ray.

A Correct answer

Scenario 2

Incorrect
Elderly man with fracture of the fourth rib and normal chest X-ray.

B Correct answer

Scenario 3
 Incorrect
Polytrauma – fracture of the fourth rib and femur, and pneumothorax.

C Correct answer

THEME: TRAUMA MANAGEMENT

A    Chest X-ray (CXR) erect

B    Plain abdominal X-ray
C    X-ray pelvis
D    Laparotomy
E    Abdominal ultrasound

For each of the patients described below, select the single most appropriate
action from the options listed above. Each option may be used once, more than
once, or not at all.

Scenario 1

Incorrect
A young woman presents having fallen off her horse, landing on the left side of the abdomen.
There has been no loss of consciousness or head injury. A fall in blood pressure was noted and
was resuscitated with two units of Haemaccel. Hb in A&E was 9.8 g/dl.

C Your answer

E Correct answer

The patient is now haemodynamically stable and therefore one can investigate her. The best
imaging technique from the choice above is ultrasound, but if given the choice computed
tomography (CT) would be better.

Scenario 2

Incorrect
A young man has been stabbed in the mid line, just above the umbilicus. Four to six hours after
being admitted to hospital and observed, he develops signs of peritonitis.

C Your answer

D Correct answer

The patient is unstable and an emergency laparotomy is indicated.

THEME: CHEST INJURY

A    Aortic injury

B    Pericardial injury
C    Pneumothorax
D    Flail segment
E    Pulmonary contusions

For each of the patients described below, select the single most likely diagnosis
from the options listed above. Each option may be used once, more than once, or
not at all.

Scenario 1

Incorrect
A young man with penetrating chest injury is clinically well on admission and has a normal chest
film. However, he deteriorates on the ward and has a tachycardia, hypotension, and dyspnoea
when you are asked to see him. His pulse is weak and his jugular venous pressure (JVP) is
raised, and breath sounds are present.

B Correct answer

The clinical scenario here is likely to be due to pericardial effusion. Signs indicating this
include weak pulse, raised JVP, hypertension and tachycardia. The only other condition
which may cause these symptoms is a tension pneumothorax. However, he has a normal
chest film and breath sounds which makes this unlikely.

Scenario 2
 Incorrect
A cricketer is hit by a ball in the chest. He initially carries on with the game but then collapses
and is rushed to A&E. He is dyspnoeic, drowsy and has barely audible breath sounds.

C Correct answer

This patient is likely to have a pneumothorax as he has absent breath sounds, is dyspnoeic and
drowsy due to hypoxia.

Theme: Radial nerve injury

A    Compression at the level of the elbow

B    Fracture at the level of the mid-humerus
C    Compression at the level of the axilla
D    Laceration at the level of the wrist

Describe the level of injury for the following patients. Each option may be used
once, more than once, or not at all.

In low radial nerve lesions, ie those due to fractures or dislocations at the elbow,
the posterior interosseus nerve may be injured and the patient is unable to
extend the fingers; there is also weakness of thumb abduction and extension. In
high lesions such as in fractures of the humerus or due to prolonged tourniquet
pressure, there is weakness of the radial extensors of the wrist and numbness
over the anatomical snuff box. In very high lesions, the radial nerve may be
compressed in the axilla, eg, crutch palsy, which leads to paralysis of the triceps
and absent triceps reflex.

Scenario 1

Incorrect
A 25-year-old man presenting with weakness of wrist and hand with paralysis of the triceps and
absent triceps reflex.
C Correct answer

Scenario 2

Incorrect
A 19-year-old man presenting with a wrist drop with inability to extend the metacarpophalangeal
joints of the hand, together with altered sensation over the region of the anatomical snuff box.
The triceps reflex is present.

B Correct answer

Scenario 3

Incorrect
A 30-year-old man presenting with inability to extend the metacarpophalangeal joints of the
hand with weakness of thumb abduction and interphalangeal extension.

A Correct answer

Theme: Making good use of available imaging resources

A    Plain radiographs

B    CT pulmonary angiography
C    Lung perfusion scan
D    Percutaneous (conventional) angiography
E    None of the above

For each of the following situations, select the most likely answer from the above
list. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A previously well 52-year-old man has become hypotensive, tachycardic and oliguric 2 h after a
somewhat ‘tricky’ embolisation procedure to treat a right hepatic artery aneurysm.

C Your answer

D Correct answer

This may well be the fastest way of both finding and dealing with the site of blood loss which
must be presumed to have originated from the previous catheterization procedure.

Scenario 2

Incorrect
A 21-year-old man attends a local district general hospital following a road traffic accident. He is
responsive but has a widening of his mediastinum seen on posterior–anterior(PA) chest X-ray.
He is currently haemodynamically stable. The nearest cardiothoracic surgeon is in a tertiary
referral centre 1 h away and asks for further investigation.

C Your answer

B Correct answer

In a stable patient, as in this case, the ‘gold standard’ is to perform angiography to look at the
great vessels; however, this is only recommended if the patient is within a cardiothoracic centre
with surgeons available. In this case, a CT scan is fast, and images can often be sent to the
cardiothoracic surgeons electronically. If the patient is stable this should not delay transfer
significantly if requested promptly.

Scenario 3

Incorrect
Day 10 post-operative, a 65-year-old lady suffers pleuritic chest pain and collapse whilst at the
toilet. She cannot seem to get her breath, and arterial saturations are measured at 87%. She
gradually improves but shows some abnormalities on chest X-ray. The consultant would like
further investigation as to the cause.

A Your answer

B Correct answer

As a general rule ventilation-perfusion scans are very accurate at detecting acute PE, especially
in cases where there is a normal chest X-ray. This is because most false positives arise in patients
with underlying chest disease such as chronic obstructive pulmonary disease (COPD). Thus in
patients with an abnormal chest X-ray, most centres currently advocate CT scanning to avoid
such confusion. Small filling defects can be very accurately detected by this method.

Scenario 4

Incorrect
A 23-year-old man becomes acutely dyspnoeic, cyanosed and distressed shortly after having an
internal jugular line inserted for chemotherapy. He is tachycardic with distended neck veins and
a deviated trachea.

B Your answer

E Correct answer

The patient has a life threatening tension pneumothorax. This is a clinical diagnosis that has
already been made. Feel free to get a plain radiograph after you have decompressed the patient’s
chest and saved his life.

Theme: Abdominal Injury

A Abdominal ultrasound or computed tomography (CT) scans

B Cystourethrography
C Immediate surgery
D Closed observation
E Fluid resuscitation

For each of the scenarios below, choose the most appropriate action from the list
shown above. Each option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 25-year-old man was kicked and punched at his left flank. On arrival at the Accident and
Emergency Department, his clinical observations were GCS 15/15, heart rate (HR) 105/min,
blood pressure (BP) 120/70 mmHg, respiratory rate (RR) 20/min and SpO2 on air was 96%.
Primary survey was completed and was uneventful. There was bruising and tenderness over his
left flank. What will be the most appropriate next step of management?
A Correct answer

Abdominal ultrasound or computed tomography (CT) scans

In view of the nature of his injury, it is crucial to rule out splenic and/or renal injury. An
abdominal ultrasound or CT scan will be of great help in establishing this.

Scenario 2

Incorrect
A 38-year-old male driver wearing a seat belt was involved in a road traffic accident. There was
no head injury, thoracic injury, limb injury or obvious external blood loss. He has extensive
bruising on his left hypochondriac region of his abdomen. Despite adequate fluid resuscitation,
his observations are anxious, HR 136/min, blood pressure (BP) 70/50 mmHg, RR 22/min and
SpO2 100% on high flow oxygen. What is the most appropriate management?

C Correct answer

Immediate surgery

It is obvious that this man did not respond to fluid resuscitation due to continuous intra-
abdominal haemorrhage, in this case, splenic injury is high on the list (left renal injury
involving the vascular pedicle is also likely). Such patient will need immediate laparotomy.

Scenario 3

Incorrect
A 21-year-old soldier was shot at his abdomen. His clinical observations are: GCS 15/15, HR
120/min, blood pressure (BP) 75/50 mmHg after intravenous fluid resuscitation, RR 24/min,
SpO2 98% on high flow oxygen. There was an entry wound of the bullet at his umbilical region,
exit wound at his right flank. What is his next management?

C Correct answer

Immediate surgery

All high-velocity penetrating gun shot wounds (GSW) or low-velocity penetrating (stab)
abdominal injury with hypotension or shock are indications for immediate laparotomy.

Scenario 4

Incorrect
A 5-year-old girl fell and landed onto her abdomen sustaining marked bruising ecchymosis of
her epigastric region on her anterior abdominal wall. She was tender over this region but there
were no peritonitic signs. She remains haemodynamically normal. Her abdominal ultrasound
scan is unremarkable. Her blood tests including serum amylase were within the normal limits.
What will be the appropriate management for this girl?

D Correct answer

Closed observation

This patient’s injury is very likely to be superficial knowing that her general condition
remained stable and abdominal ultrasound scan/blood test were unremarkable. She will
benefit from in-patient closed observation and analgesia.

THEME: DIAGNOSIS OF SURGICAL EMERGENCIES

A   Acute cholecystitis
B   Acute Appendicitis
C   Ectopic pregnancy
D   Perforated peptic ulcer
E   Acute pancreatitis

For each of the scenarios below, choose one diagnosis from the list above. Each
option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A 36-year-old woman presented with acute onset of abdominal pain, associated with nausea and
vomiting. The pain, which has been present for the past 2 hours, is colicky, right upper quadrant,
localised, and with no aggravating or relieving factors. She has a BMI of 35.

D Your answer

A Correct answer
Acute cholecystis secondary to gallstones is common in women in their forties, with increased
BMI, and of reproductive age. In most cases the gallstones are asymptomatic and remain
unnoticed for many years; but when they cause irritation of the gall bladder, this results in
colicky, right hypochondrial pain. Touching the gall bladder area with the thumb while the
patient takes a deep breath will cause the patient to stop her breath because of pain caused by
contact between the inflamed gall bladder and the abdominal wall (Murphy’s sign).

Scenario 2

Incorrect
A 16-year-old boy presented in A&E with acute onset of lower abdominal pain, associated with
fever and vomiting. The pain is colicky around the umbilicus, shifts to the right iliac fossa, and
has no aggravating or relieving factors. On examination he has rebound tenderness.

A Your answer

B Correct answer

These are the classic signs of acute appendicitis. It occurs when the appendix is obstructed by a
faecolith or foreign body in the lumen, by a fibrous stricture in its wall from a previous
inflammation, or by enlargement of lymphoid follicles in its wall secondary to a catarrhal
inflammation of its mucosa. Occasionally it is associated with a carcinoid tumour. As the
appendix of the infant is wide-mouthed and well drained, and as the lumen of the appendix is
almost obliterated in old age, appendicitis at the two extremes of life is relatively rare.

Scenario 3

Incorrect
A 70-year-old man on analgesics for rheumatoid arthritis presented with acute onset of severe
abdominal pain radiating towards the right shoulder, aggravated by movement and relieved by
sitting still. He is also feeling nauseated.

C Your answer

D Correct answer

Perforated peptic ulcer is common in older patients taking NSAIDs or steroids for systemic
diseases. A previous history of peptic ulceration is obtained in most cases, although patients in
agony may forget this. In a delayed case, after 12 hours or more, the features of generalized
peritonitis with paralytic ileus become manifest – there is abdominal distension and effortless
vomiting, and the patient is extremely toxic and in oligaemic shock.
Theme: Wound infections

A    Orf virus

B    Brucella
C    Pseudomonas
D    Klebsiella
E    Coxsackievirus
F    Streptococcus pyogenes

For each of the scenarios below choose the most likely cause of infection. Each
option may be used once, more than once, or not at all.

Scenario 1

Incorrect
A women sustains a burn from an oven grill. She works as a nurse in the Urology Unit. Eight
days later she noticed green pus in wound.

C Correct answer

Pseudomonas inhabits human and animal gastrointestinal tract, water and soil. The organism
survives in moist environments in hospital and may also survive in aqueous antiseptic and other
fluids. It affects patients with an underlying condition eg. Burns and malignancy or as a result of
therapeutic interventions eg urinary catheterisation.

Scenario 2

Incorrect
A 35-year-old butcher cut himself. Later that night he noticed some red lines radiating from the
wound.

F Correct answer

Streptococcus pyogenes can cause the following

· tonsillitis and pharyngitis

· peritonsillar abscess

· otitis media

· mastoiditis

· wound infections with cellulites and lymphangitis

· erysipelas

necrotising fascitis.

Scenario 3

Incorrect
A 60-year-old gentleman pricked his index finger on a rose bush thorn. A few days later he
noticed some redness and swelling near nail of index finger.

D Correct answer

Klebsiella spp inhabit the human intestine. Some strains are saprophytic in soil, water and
vegetation. They are responsible for wound infections, urinary tract infections (UTIs),
septicaemia, endocarditis and, rarely, pneumonia.