Theme: Thoracic trauma

Scenario 1

A 26-year-old soldier is hit by shrapnel, resulting in a large defect to the left side of his chest. He is
brought to Casualty, the paramedics having securely occluded the defect on all sides with a sterile
dressing. On examination he is severely dyspnoeic, tachycardic and hypotensive. His trachea is displaced
to the right. Percussion reveals the left side of the chest to be hyper-resonant, with decreased air entry on
auscultation.

L Correct answer

L – Tension pneumothorax

Initially the patient suffers an open pneumothorax (‘sucking chest wound’), whereby the equilibrium
between intrathoracic pressure and atmospheric pressure is immediate; if the defect is approximately two-
thirds the tracheal width then the air follows the path of least resistance, through the defect, impairing
ventilation. The paramedics were correct to close the defect; however, the dressing should only have been
securely taped on three sides so as to create a flutter-type valve effect; this ensures the dressing is sucked
over the defect on inspiration preventing air entering, while the open end allows air to escape on
exhalation. By securing the dressing on all sides, air progressively accumulates in the thoracic cavity,
collapsing the lung on the affected side. The mediastinum is displaced to the opposite side, decreasing
venous return and compressing the opposite lung. The most common cause of tension pneumothorax is
mechanical (positive-pressure) ventilation in the patient with a visceral pleural injury. Rapid
decompression is required to prevent death.

Scenario 2

A 50-year-old builder presents to The Emergency Department having been hit by falling scaffolding. He
did not initially attend The Emergency Department; however, over the past few hours he has become
increasingly dyspnoeic. On examination he has a respiratory rate of 30 breaths/min and a SaO 2 of 89%.
He has equal air entry bilaterally and normal percussion. Chest X-ray reveals fractures of ribs 2 to 6 on
the left side.

J Correct answer

J – Pulmonary contusion

Pulmonary contusion is the most common potentially lethal chest injury, commonly occurring secondary
to multiple rib fractures or flail chest, as a result of blunt trauma. Respiratory failure may be subtle and
develop over time as a result of underlying lung injury, rather than occur instantaneously. Patients with
significant hypoxia (ie pA(02) < 8.0 kPa on room air, Sa0 2 < 90%) and/or chronic lung disease will require
intubation and ventilation.

Theme: Chest trauma management

Scenario 3
A 27-year-old man is brought to The Emergency Department following a stab wound to the left side of
the chest. On examination his respiratory rate is 24 breaths/min, pulse rate is 115/min, and blood pressure
is 90/50 mmHg. There is a dull percussion note and decreased air entry on the affected side.
F Correct answer
F – Insertion of chest drain

This patient probably has a haemothorax. The primary cause is either lung laceration or laceration of the
intercostal/internal thoracic vessels. It is first treated with a large calibre chest drain [then intravenous
access etc, following the ABC (Airways, Breathing, Circulation) protocol]. This not only evacuates the
blood and reduces the risk of a clotted haemothorax, but also allows continuous monitoring of blood loss.
Bleeding is usually selflimiting; however, if it continues, a thoracotomy may be required.

Scenario 4
An 18-year-old woman is brought to The Emergency Department after being hit by a car travelling at
approximately 50 miles/h. She has a suspected fractured pelvis and a Glasgow Coma Score of 13/15. On
arrival, she has a respiratory rate of 36 breaths/min; pulse rate of 120/min and blood pressure is 90/60
mmHg. Examination reveals engorged neck veins, and a hyper-resonant percussion note on the left side
of the chest. The background noise in the department renders auscultation of either breath or heart sounds
difficult to assess.
E Correct answer
E – Immediate needle decompression

This lady has a tension pneumothorax, which develops when a ‘one-way valve’ air leak occurs either
from the lung or through the chest wall. Air is forced into the thoracic cavity without means of escape,
collapsing the affected lung. It is a clinical diagnosis and life-saving treatment, large-bore needle
decompression into the second intercostal space in the midclavicular line of the affected hemithorax,
should not be delayed by waiting for radiological confirmation. Clinical signs of tachypnoea, tachycardia,
hypotension and neck vein distension may initially confuse diagnosis with cardiac tamponade. However,
differentiation may be made by a hyperresonant percussion note and/or the absence of breath sounds over
the affected hemithorax.

Scenario 5
A 65-year-old man is the driver in a high-speed road traffic accident. He is brought to The Emergency
Department complaining of severe chest pain and difficulty breathing. Examination reveals a shallow
respiratory rate of 34 breaths/min and a Sa02 of 92% on 60% oxygen. He has contusions to both sides of
the chest and there is reduced air entry bilaterally. Palpation of the chest wall reveals crepitus and
asymmetrical movement of the right chest wall.
H Correct answer
H – Intubation and ventilation

This gentleman has a flail chest, which occurs when a segment of the chest wall loses bony continuity
with the rest of the thoracic cage. It usually results from blunt trauma associated with multiple rib
fractures. It is the underlying significant pulmonary contusion that is problematic. The definitive
treatment is to re-expand the lung and ensure adequate oxygenation; in a hypoxic patient a short period of
intubation and ventilation may be necessary until the diagnosis of the entire injury pattern is complete.

Theme: Infection
Haemolytic streptococci cause cellulitis and ascending lymphangitis. Prolonged antibiotic usage leads to
the development of membranous colitis due to Clostridium difficile. Proteus or another gut commensal is
the most likely infection following bowel surgery. Gram-negative rods and pseudomonas especially
contaminate hospital equipment.

Scenario 6
Bloody diarrhoea following prolonged treatment with antibiotics
D Correct answer
Gram-positive rods

Scenario 7
A perineal wound infection following abdominoperineal resection
B Correct answer
Facultative anaerobic Gram-negative bacilli

Scenario 8
A pathogen that causes colonisation of humidifiers and ventilators and opened sterile solutions
C Correct answer
Aerobic Gram-negative rods

THEME: UPPER-LIMB NERVE INJURIES

Scenario 9
A 25-year-old motorcyclist is brought to the Accident and Emergency Department following a road
traffic accident (RTA). He complains of pain in the root of his neck. On examination, his right arm is
adducted, internally rotated and extended at the elbow. He has loss of sensation along the outer aspects of
the arm and the forearm.
B Correct answer

Upper brachial plexus or supraclavicular plexus lesion (C5, C6) occurs due to excessive depression of the
shoulder or displacement of the head that opens out the angle between the shoulder and the neck (Erb-
Duchenne paralysis). In neonates, it may occur following traction on the shoulder girdle during difficult
labour or in breech delivery. In adults, it may occur due to a fall exerting weight on the shoulder or to an
RTA in which the head has been forcibly moved away from the shoulder. There is loss of shoulder
abduction, elbow flexion and forearm supination. Consequently, the affected limb is internally rotated,
extended at the elbow and pronated (porter’s tip position). There is sensory loss over the outer aspect of
the arm and the outer aspect of the forearm.

Scenario 10
A 65-year-old man is brought to the Accident and Emergency Department with a wrist drop and sensory
loss over a small patch at the base of the thumb. X-rays shows a mid-humerus fracture.
F Correct answer

F Radial nerve

The radial nerve (C5–T1) is damaged at the mid-humerus level by fractures or pressure (eg prolonged
tourniquet). Radial nerve damage is also seen in patients who fall asleep with an arm dangling over the
back of a chair (Saturday night palsy). Radial nerve injury causes paralysis of the brachioradialis, the
wrist extensors and the extensor digitorum, leading to wrist drop; there may be a small patch of sensory
loss over the dorsum of the thumb and the first web space. With more proximal lesions, sensation is also
lost over the dorsum of the forearm.

Scenario 11
A 30-year-old man presents to the Accident and Emergency Department with a deep laceration to his
right wrist after he was involved in a fight in his local pub. On examination, he is unable to pinch and has
loss of sensation over his little and ring fingers.
I Correct answer

Ulnar nerve
The ulnar nerve (C8, T1) is an important motor nerve of the hand. Pressure (eg from a deep ganglion) or
laceration at the wrist may cause distal lesions. Injury to this nerve at the level of the wrist produces
hypothenar wasting and clawing of the hand due to unopposed action of the long flexors; there is loss of
sensation over the little and ring fingers. Finger abduction is weak and the loss of thumb adduction makes
pinching difficult. This is due to paralysis of the adductor pollicis and the first palmar interosseous muscle
causing flexion of the thumb (due to the flexor pollicis longus) when the patient is asked to grasp a card
between their thumb and index finger (Froment’s paper sign).

Theme: Chest pain

The cardiac causes of chest pain should always be eliminated with the history, examination and
investigations. A difference in blood pressures should alert you to the possibility of a ruptured aorta.
Boerhaave’s syndrome describes the spontaneous rupture of the oesophagus following vomiting, and can
be associated with surgical emphysema. In any post-operative patient, always consider a pulmonary
embolus, as well as a myocardial infarction depending on history. Spontaneous pneumothoraces usually
occur in tall young athletic people and if small can be treated with simple needle aspiration and follow-up
chest X-ray.

Scenario 12
A man with pain in the central chest radiating to the back that started an hour ago. Widened mediastinum
was noticed on his chest X-ray and his blood pressure was 180/110 mmHg in the right arm and 110/70
mmHg in the left arm.
A Correct answer
Scenario 13
A young man with chest pain that started Sunday morning, he has been vomiting the night before. On
examination subcutaneous crepitations were found over the chest and shoulder.
C Correct answer

Theme: Consent for surgery

Scenario 14
A 33-year-old glamour model with severe endometriosis underwent an abdominal
hysterectomy/adhesiolysis for chronic pelvic pain. At the time of laparotomy, the uterus was found to be
densely adherent to the rectum. The surgeon proceeded with the operation, resulting in a rectal perforation
requiring repair and formation of a colostomy. Legal action is taken by the patient against the
gynaecologist.
B Correct answer
B – Battery

This lady has undergone a procedure without her consent and to which, had the procedure been
abandoned, she would probably not have consented. Battery in principle is a violation of the civil law to
touch another person without their consent. The harm resulting from battery does not necessarily have to
be physical in nature. In the situation of informed consent harm may be construed as the moral violation
of the patient’s right to exercise a rational choice.

Scenario 15
A 63-year-old man underwent a laparoscopic cholecystectomy for symptomatic gallstone disease having
previously had surgery for a perforated duodenal ulcer many years previously. Following a difficult
procedure requiring laparoscopic adhesiolysis, the patient developed signs of an acute abdomen on the
second post-operative day requiring laparotomy and small bowel resection for two perforations which had
led to peritonitis. He had a stormy postoperative course on the Intensive Care Unit and eventually was left
with a troublesome enterocutaneous fistula requiring further surgery. It is alleged subsequently that
during consent, no mention was made of the risk of inadvertent injury to other structures such as bowel.
G Correct answer
G – Negligence

Battery is not the only legal action that surgeons risk for inadequately respecting their patient’s right to
informed consent. Although the patient had given his general consent to the surgery in question, he had
not been properly advised of its potential hazards (in this case inadvertent damage to other structures by
trocar insertion/dissection/diathermy). In such situations, the legal claim is that had the patient known the
risks in question, they would not have proceeded with the surgery. NB Surgeons are not protected from
accusations of negligence by a signed consent form.
Note: in this case, the surgeon might also be deemed negligent for choosing a laparoscopic approach to
this surgery in the first place.

Scenario 16
A 40-year-old woman attends the colorectal outpatient clinic with rectal bleeding. Following history-
taking and abdominal examination, the attending coloproctologist performed a rectal examination and
proctosigmoidoscopy, the latter of which proved uncomfortable for the patient. The surgeon is surprised
to find himself some time later responding to a complaint that the patient said she had not consented to
the examination.
E Correct answer
E – Implied consent

In many situations it is neither necessary nor practicable to give informed (especially written) consent. It
is deemed in such situations that the patient’s willingness to present themselves for investigation or
treatment implies their consent (such as in this case).

Scenario 17
A 23-year-old student suffering from a bipolar disorder attempts suicide by jumping in front of a train. He
suffers bilateral pneumothoraces and a flail chest. On the ward, he attempts to remove his chest drains and
essential oxygen therapy. He is currently under a section 2.
C Correct answer
C – Treatment in best interests under common law

In English law, no one is able to give consent for treatment of another adult against his or her will. The
only exception to this rule is treatment of the mental disorder itself in patients sectioned under the 1983
Mental Health Act (answer I). This is not, however, true for treatment of other physical conditions in
patients with mental illness. However, essential, especially life-saving, treatment may be given to such
patients in the patients’ best interests under Common Law when they are deemed incapable for any
reason to give informed consent.
(Resources for this subject may be obtained from www.doh.gov.uk and the chapter by Len Doyal in the
Clinical Surgery in General RCS Course manual.)

Theme: Trauma procedures in the resuscitation room

Scenario 18
A patient with a systolic blood pressure of 60 mmHg following stab wound to chest, distended neck
veins, reasonable bilateral air entry, central trachea.
A Correct answer
Pericardiocentesis

A cardiac tamponade must be aspirated by pericardiocentesis with a large needle through a sub-xiphoid
approach.

Scenario 19
A patient with a systolic blood pressure of 60 mmHg following blunt chest trauma, distended neck veins,
no air entry on the right side, tracheal deviation to the left.
C Correct answer
Needle thoracocentesis
A tension pneumothorax is a clinical diagnosis and is treated initially by needle aspiration through the
second intercostal space in the mid-clavicular line. Formal chest drainage is performed later towards the
end of the primary survey.

Theme: Shock

Scenario 20
A motorcyclist was admitted to the emergency department having been thrown a distance of 30 feet. He
was wearing a helmet and had recovered consciousness at the scene. He remained confused. Pulse 40
bpm, respiratory rate 30/min, blood pressure (BP) 75/60 mmHg, on catheterization there was no urine
output. Lateral cervical spine X-rays were suggestive of a fracture of C6.
C Correct answer
Neurogenic shock

Neurogenic shock is due to the loss of sympathetic tone and combines the symptoms characteristic of
hypovolaemic shock with a profound bradycardia.

Scenario 21
A 25-year-old marathon runner was involved in a road traffic accident while out training. She was
admitted to the emergency department with a pulse of 100 bpm, BP 75/60 mmHg, respiratory rate 30/min.
Her abdomen was generally tender, peritoneal lavage was positive. There was no urine output.
F Correct answer

Theme: Head injury (types)

Scenario 22
A 26-year-old man is assaulted with a baseball bat. On examination, he has multiple lacerations and
bruises on his face. There is blood in the left external auditory meatus and bilateral black eyes with a left
subconjunctival haematoma. Glasgow Coma Scale (GCS) is 15.
A Correct answer
A – Basal skull fracture

Skull fractures may be of the vault or base. Basal skull fractures usually require computed tomography
(CT) scanning (bone windows) for identification. The clinical signs include, however, ‘racoon’ or ‘panda’
eyes (as in this case), retroauricular eccymosis (ie mastoid bruising = Battle’s sign), subconjunctival
haemorrhage and blood in the external auditory meatus. Such fractures rarely require intervention but
may be associated with cerebrospinal fluid leaks from ear or nose, or with cranial nerve palsies (as well as
neurological injury). All should have 24-h neurological observation. Antibiotics are not now
administered.

Scenario 23
A 31-year-old falls from a height sustaining multiple injuries, including blunt injury to the head. She is
deeply unconscious on arrival at The Emergency Department (GCS 3) with normal pupils. A CT scan
demonstrates no focal abnormality but there is poor grey–white differentiation and loss of sulcal pattern
with effacement of both lateral ventricles. The neurosurgeons place a monitoring bolt which demonstrates
an intracranial pressure of 50 mmHG.
C Correct answer
C – Diffuse axonal injury

This is the most severe type of diffuse brain injury (less severe are defined as mild concussion and classic
cerebral concussion). There is no focal injury requiring emergency evacuation. The appearances are those
of cerebral oedema and raised intracranial pressure. Treatment should be aimed at medically reducing
intracranial pressure (< 25 mmHg) and increasing cerebral perfusion pressure and oxygenation. The
prognosis is very poor.

Scenario 24
A 29-year-old woman with a history of epilepsy has a witnessed fit and fall with a blunt injury to the left
side of her head with laceration. She recovers rapidly from the fit to a GCS of 15 by the time of her
arrival in The Emergency Department and is awaiting a skull X-ray when she starts to become drowsy
and confused. She is moved to the resuscitation area where her GCS declines rapidly to 7, requiring
intubation.
D Correct answer
D – Extradural haematoma

These are located outside the dura but within the skull. They are most commonly located in and
associated with injuries of the temporal or temporoparietal region and often result from tearing of the
middle meningeal artery by a fracture. Because they are commonly not associated with primary brain
injury, there is classically a ‘lucid interval’ before a rapid decline in neurological status as a result of
cerebral compression from arterial bleeding. The so-called ‘talk and die’ scenario.

Theme: Surgical incisions

Scenario 25
A 72-year-old woman presents to The Emergency Department with a 1-day history of a painful lump in
the left groin and vomiting. On examination she has a hard, tender, irreducible mass just below the
inguinal ligament.
M Correct answer
M – Transverse ‘unilateral’ Pfannenstiel

This patient has a strangulated femoral hernia that requires urgent surgical repair. The McEvedy (high)
approach was classically based on a vertical incision made over the femoral canal and continued upwards
above the inguinal ligament; however this frequently resulted in an unsightly scar. This has now been
replaced with a transverse ‘unilateral’ Pfannenstiel incision, which can be extended to form a complete
Pfannenstiel incision if a formal laparotomy is required. Alternative approaches include the Lockwood
(low), Lothiessen (transinguinal) and laparoscopic approaches. NB Hans Hermann Johannes Pfannenstiel,
German gynaecologist (1862–1909).

Scenario 26
A 38-year-old woman has been taking regular diclofenac for relief of chronic backache. She is referred to
The Emergency Department with sudden onset of upper abdominal pain. On examination she is pyrexial
and tachycardic, abdominal examination reveals severe epigastric tenderness. There is a
pneumoperitoneum evident on an erect chest X-ray.
N Correct answer
N – Upper midline
The most likely diagnosis in this patient is a perforated peptic ulcer. In those patients suitable for surgery,
access is most commonly by upper midline incision. The historical alternative of a right paramedian
incision is now rarely used, providing little additional exposure and potentially rendering part of the
abdominal wall anaesthetic and ischaemic with poor wound healing and increased risk of hernias.

Theme: Management options in a patient with head injury

The primary aim of clinical and radiological assessment of patients with head injury is to identify those
patients with clinically important brain injury and, most crucially, those with an intracranial haematoma
requiring urgent neurosurgical management. The vast majority of head injuries are classified as ‘mild’
with a low-risk of intracranial haematoma. Previously, skull X-ray has been heavily relied upon to triage
patients with mild head injury but the sensitivity of this investigation may be as low as 38%. Therefore, it
is currently only justified if computed tomography (CT) is not available, or when non-accidental injury in
children is suspected. By contrast, CT scanning has a sensitivity and specificity approaching 100%, and
so the Royal College of Surgeons Guidelines state that 24-h CT is required in all centres receiving head-
injured patients.

Scenario 27
A 70-year-old woman attends The Emergency Department having fallen at home. She is unclear of the
events surrounding the fall, and as she lives alone, no collateral history is available. She has vomited three
times since arrival in the department. Her Glasgow Coma Scale (GCS) is currently 15. All other
observations are normal. There is no evidence of focal neurological deficit.
C Correct answer
C – CT scan

Despite the apparently trivial mechanism of injury and the normal Glasgow Coma Scale (GCS), this lady
has two clinical features that indicate risk of a clinically significant brain injury (age > 64 years and more
than one episode of vomiting). The Canadian Head CT Rule was derived from a cohort of more than 3000
patients using multivariate analysis of several risk factors, and has identified the following clinical
features that indicate that there is a clinically significant brain injury requiring neurosurgical intervention:
• GCS < 13 at any point since injury
• GCS 13 or 14 with failure to regain GCS 15 within 2 h
• suspected open or depressed skull fracture
• any sign of basal skull fracture (Battle’s sign, haemotympanum etc)
• more than one episode of vomiting
• age > 64 years
• post-traumatic seizure
• coagulopathy (including anti-coagulant therapy)
• focal neurological deficit.
CT scan should be performed within 1 h in all such patients. Two further features in the absence of the
above indicate a risk of clinically significant brain injury that does not require neurosurgical intervention:
retrograde amnesia of > 30 min and dangerous mechanism of injury (pedestrian hit by vehicle, fall from a
height etc). CT scan in such patients may be delayed for up to 8 h.

Scenario 28
A 38-year-old gentleman has been involved in a road traffic accident and brought to The Emergency
Department as a ‘trauma call’. The ambulance staff inform you that he was a pedestrian hit by a car
travelling at approximately 40 mph. He has sustained a significant head injury but the paramedic crew
report that he was alert at the scene and that his pupils were equal and reactive. Having completed the
primary survey, your examination reveals a GCS of 8, and a fixed dilated left pupil. There is no evidence
of hemiparesis. No other significant injuries are apparent, and the patient is stable, and has a pulse rate of
50/min and a blood pressure of 160/80 mmHg. You request an urgent CT scan, but are informed that this
will not be possible in your unit as the scanner is undergoing repair.
I Correct answer
I – Endotracheal intubation

This patient has several risk factors for significant brain injury requiring urgent neurosurgical
intervention. Clearly, he requires a CT scan, but this is currently unavailable in the receiving Unit. A skull
X-ray is unlikely to provide sufficient information relating to the degree of brain injury sustained, and
therefore this patient should be transferred to a Neurosurgical Unit where clinical and radiological
assessment may be performed. In addition, there is a clear indication to administer an intravenous bolus
of mannitol (1 g /kg) in this case, because there is a history of deterioration in consciousness level and
pupil changes, secondary to rising intracranial pressure. The creation of an emergency burr hole
performed by a general surgeon is not generally recommended or supported, and can only be justified in
patients with rapidly expanding intracranial haematomas that are imminently life-threatening, and when
definitive neurosurgical care is unavailable. Neither criteria are met, as the diagnosis is not yet clear, and
neurosurgical care is available. However, before mannitol and transfer (which you might have been
tempted to choose), he will require intubation, ‘A’ being before ‘D’

Theme: Laparoscopic complications

The above are all descriptions of complications that may arise as a result of laparoscopic surgery. For
each clinical scenario please select the most appropriate answer from the above list. The items may be
used once, more than once, or not at all.

Scenario 29
A 45-year-old obese man is undergoing a laparoscopic cholecystectomy. The abdomen has been rapidly
insufflated with carbon dioxide. The anaesthetist alerts you to a sudden and rapid drop in blood pressure
with a concomitant tachycardia. There is no evidence of intra-abdominal bleeding on inspection with the
scope.
I Correct answer
I – Reduced venous return

Insufflation of the abdomen to create a pneumoperitoneum is important to allow adequate visibility and
instrumental access for the surgeon. However, it is not without potential complications. The pressure
exerted by the pneumoperitoneum can lead to a reduction in cardiac venous return, resulting in
hypotension and a reflex tachycardia. It can also compromise diaphragmatic movement, which is
important in patients with restrictive lung disease.

Scenario 30
A 51-year-old woman undergoes a difficult laparoscopic cholecystectomy. In the ensuing 48 h she
develops jaundice. Liver function tests are: AP 250 mmol/litre, bilirubin 147 mmol/litre. An urgent
endoscopic cholangiogram does not delineate the intrahepatic biliary tree.
K Correct answer
K – Visceral injury: obstruction

The patient has obstructive jaundice. This can occur either as a result of inadvertently clipping the
common hepatic or common bile duct (rather than the cystic duct) or because of the presence of a retained
stone. Patients with an obstructing gallstone tend to present in the later post-operative course, following
resolution of the discomfort associated with surgery.

Theme: Peripheral nerve injury

Scenario 31
A 28-year-old man sustains a varus injury to his left knee while skiing. He notes loss of sensation over
front and anterior half of the leg and dorsum of the foot.
B Correct answer
Common peroneal nerve

Deep peroneal nerve injury may give rise to an anterior compartment syndrome and loss of sensation in
the first web space between the first and second toes. The common peroneal nerve is often damaged at the
level of the fibular neck by severe traction when the knee is forced into varus (eg lateral ligament injuries
and fractures around the knee) or from pressure from a splint or plaster cast. The patient has foot drop and
loss of sensation over the front and outer half of the leg and dorsum of the foot.

Scenario 32
A 32-year-old motorcyclist is involved in a road traffic accident and sustains a severe laceration 6 cm
above the ankle on the lateral aspect of his leg. He is unable to evert his foot and has noted some
numbness over the dorsum of foot and medial four toes.
D Correct answer
Superficial peroneal nerve
The superficial peroneal nerve innervates the peroneal muscles and emerges through the deep fascia 5-10
cm above the ankle to supply the skin over the dorsum of the foot and medial four toes.

Theme: Multiple trauma

Scenario 33
A 57-year-old man is brought into the emergency department following a road traffic accident. He is
conscious with an adequate airway. The Glasgow Coma Score (GCS) is 15. He is tachypnoeic (30 rpm).
His pulse is 150 bpm and reduced in volume. The distal pulses are present. His blood pressure (BP) is
85/45 mm Hg. The chest X-ray shows multiple rib fractures on the left side (ribs 7, 8 and 9) and a small
pneumothorax. A left chest drain is inserted and bubbles in the waterseal bottle. Pelvic X-ray is normal.
Analysis of the diagnostic peritoneal lavage fluid reveals a white cell count (WCC) of 1000/mm3 and an
amylase of 400 units. He remains hypotensive (BP 90/55 mm Hg) despite 2 l of fluid resuscitation.
F Correct answer
Ruptured spleen

Hypotension, tachycardia and low CVP suggest hypovolaemia. Multiple rib fractures on the left side and
positive DPL support the diagnosis of splenic rupture.

Scenario 34
A 30-year-old man is brought into the emergency department following a road traffic accident. He is
conscious. He has tachypnoea (46rpm), tachycardia (135 bpm) and distended neck veins. His systemic BP
is 90/45 mmHg. His heart sounds are greatly diminished. A chest X-ray shows three fractured ribs (ribs 5,
6 and 7) on the left side and a small pneumothorax. A left chest drain drains air and no blood, the BP is
95/50 mmHg after 2 l of crystalloid infusion. The electrocardiogram (ECG) shows reduced voltage in
QRS complexes.
A Correct answer
Cardiac tamponade

The presence of distended neck veins, and failure to respond to fluid resuscitation strongly suggest the
diagnosis of cardiac tamponade and exclude rupture of the aorta and the spleen as the possible cause of
hypotension. Diminished heart sounds and reduced voltage of QRS complexes are recognized features of
cardiac tamponade.

Theme: Knee injuries

Scenario 35
A young footballer injures his right knee in a tackle and develops swelling of the knee a few days later.
He presents to casualty with an area of tenderness 2–3 cm above the joint line on medial aspect. He has
increased valgus deformity on examination.
C Correct answer
Medial collateral ligament
The history in the young footballer is most suggestive of a medial collateral ligament injury as there is a
valgus deformity and tenderness above the joint line. Tenderness over the joint line is suggestive of
meniscal injury.

Scenario 36
A 60-year-old develops a painful left knee following a fall. On examination in the orthopaedic clinic a
few days later, swelling on the left knee is seen. Flexion views of both knees show that the left tibia
plateau lies more anteriorly than on the right.
F Correct answer
Anterior cruciate ligament

The anterior cruciate ligament prevents backward displacement of the femur on the tibial plateau and
limits extension of the lateral condyle of the femur.

Scenario 37
A patient involved in a road traffic accident hits his knee on the dashboard, producing an immediate
haemarthrosis. X-ray shows no bony injury, but he later experiences difficulty walking down stairs.
G Correct answer
Posterior cruciate ligament

The posterior cruciate ligament prevents the femur from sliding forwards off the tibial plateau. In the
weight bearing flexed knee it is the only stabilizing factor for the femur and its attached quadriceps. In
walking down stairs, the upper knee is flexed and weight bearing, while the lower knee is straight.
Immediate haemarthrosis is indicative of cruciate ligament rupture or fracture.

Theme: Peripheral nerve injury

Scenario 38
On examination you notice a patient has clawing of their right hand. There is hyperextension of the
metacarpophalangeal joints and mild flexion at the interphalangeal joints of the ring and little finger.
There is some loss of muscle bulk in the medial border of the forearm and flattening of the hypothenar
eminence. They are unable to adduct and abduct the fingers, and flexion of the wrist results in abduction.
There is altered sensation in the little finger and ulnar border of the hand. There is normal sensation in the
arm.
F Correct answer

These findings are consistent with a proximal ulnar nerve lesion around the elbow. Injuries at the wrist
lead to more obvious clawing ‘ulnar paradox’ as the flexor digitorum profundus muscle is not paralysed.
This results in marked flexion of the interphalangeal joints.

Scenario 39
A 40-year-old woman is seen in outpatients complaining of progressively worsening numbness in her
right index finger and thumb. She has also noticed she has become clumsier with her right hand. At night
she gets tingling in the same digits; dangling her arm out of the bed seems to improve the symptoms.
C Correct answer

The symptoms she reports are consistent with carpal tunnel syndrome. There should be normal sensation
over the thenar eminence as the sensory branch supplying this region branches before the carpal tunnel.

Theme: Treatment options for renal/ureteric calculi

Scenario 40
A 32-year-old man has a 24-hour history of right ureteric colic. He is apyrexial and pain controlled with
simple analgesia, and imaging reveals a 3-mm distal right ureteric calculus with no hydronephrosis.
B Correct answer

More than 95% of ureteric calculi of 5 mm or less will pass through without intervention. Indications for
intervention in patients with ureteric calculi include: severe pain; sepsis (an obstructed infected system);
or a large calculus that is very unlikely to pass. Intervention is also indicated for patients with a single
kidney.

Scenario 41
A 72-year-old woman has a history of recurrent urinary tract infections (UTIs). Imaging demonstrates a
large staghorn calculus in her right kidney with a normal-looking left kidney. A renogram demonstrates
35% function on the right side.
A Correct answer

Large staghorn calculi are best treated with a percutaneous nephrolithotomy. This offers the best chance
of stone clearance in patients with large stone burdens. The recurrent UTIs are most likely to be due to the
large staghorn calculus.

Scenario 42
A 40-year-old woman has a 3-day history of left ureteric colic. She is pyrexial and tachycardic with an
increased white cell count. Imaging reveals a 9-mm mid-ureteric calculus on the left with severe left-
sided hydronephrosis.
C Correct answer
This patient clinically and radiologically has an obstructed infected system that requires intervention. In
the acute phase, the objective is to drain the kidney – the insertion of a ureteric stent would be an
appropriate course of action.

Theme: Renal calculi

Scenario 43
A 30-year-old pregnant woman (26 weeks) presents with septicaemia and abdominal pain. Investigations
reveal an obstructed right kidney due to a 2 cm calculus. She is commenced on intravenous
antimicrobials.
E Correct answer
Percutaneous nephrostomy

The most appropriate treatment in this patient is to drain the kidney through a percutaneous nephrostomy
and administer antimicrobials.

Scenario 44
A 40-year-old man presents with a left-sided renal colic. Intravenous urogram (IVU) shows a 1 cm
calculus in the upper third of his ureter. There is no complete obstruction. His symptoms fail to resolve on
conservative management.
B Correct answer
Extracorporeal shock wave lithotripsy (ESWL)

ESWL is now used to treat 90% of calculi that do not pass spontaneously.

Theme: Thyroid disease

Scenario 45
A 13-year-old girl presents to the surgical outpatient department with a neck swelling. Clinical
examination shows a 2.8 cm solid lump in the left thyroid lobe, and two enlarged cervical lymph nodes
lateral to the thyroid mass. Ultrasonography confirms the solid nature of the thyroid nodule. FNA biopsy
of the thyroid nodule reveals malignant cells with vesicular appearance of nuclei. The nodule is cold on
radio-isotope scanning.
F Correct answer

The presence of regional lymphadenopathy, the age of the patient and the characteristic vesicular
appearance of the nuclei support the diagnosis of papillary carcinoma. The surgical treatment consists of
total thyroidectomy and removal of enlarged lymph nodes.
F Papillary carcinoma

Scenario 46
A 60-year-old man presents to the outpatients with rapidly enlarged thyroid swelling and hoarseness.
Clinical examination shows a 2.8 cm solid lump in the left thyroid lobe and two enlarged cervical lymph
nodes lateral to the thyroid mass. Ultrasonography confirms the solid nature of the thyroid nodule. FNA
biopsy of the thyroid nodule reveals malignant cells with vesicular appearance of nuclei. The nodule is
cold on radio-isotope scanning.
B Correct answer
B Anaplastic carcinoma

The presence of regional lymphadenopathy, the age of the patient and the characteristic vesicular
appearance of the nuclei support the diagnosis of anaplastic carcinoma. The surgical treatment consists of
total thyroidectomy and removal of enlarged lymph nodes.

THEME: INOTROPES
Scenario 47
A 79-year-old patient is admitted with abdominal pain and a raised serum lactate of 2.0. She has a blood
pressure of 90/60 and a pulse of 95 bpm in A+E. She is resuscitated and taken to theatre, where she
undergoes small-bowel resection with end ileostomy and mucous fistula. Post-operatively, she requires
inotropic support; the surgeon is concerned about the viability of the remaining bowel.

E Correct answer

Dopexamine has limited proven use but is a dopamine receptor agonist which increases splanchnic flow.
This patient has ischaemic bowel which is susceptible to further injury with the necessary inotropes.

Scenario 48

A 56-year-old man with a history of ischaemic heart disease has a myocardial infarction 2 d post-
hemiarthroplasty for a fractured neck of femur. He is clinically shocked, with a blood pressure of 80/45
and a pulse of 50 bpm, he normally takes atenolol. He is transferred to the Coronary Care Unit and started
on inotopic support.

B Correct answer

Adrenaline binds alpha and beta receptors and would increase the cardiac output and the vascular tone.

Scenario 49

A 45-year-old man requires a surgical airway for epiglottitis, this is performed as an emergency in A+E
before initial observations are carried out, the airway is successfully placed, and initial observations are
formed. The patient is peripherally well perfused (temperature 38.2°C and blood pressure unrecordable
with a thready pulse 140 bpm). He requires inotropic support in the Intensive Therapy Unit.

A Correct answer

This is a case of septic shock, and noradrenaline is the ideal drug.

Scenario 50

An obese, diabetic, smoking arteriopath suffers a cardiac event after a difficult femoral popliteal bypass
graft. He develops congestive cardiac failure and is shocked and peripherally poorly perfused. He is
reviewed by the Intensive Therapy Unit team who are confident he is well hydrated and has a low cardiac
output and high systemic vascular resistance.

D Correct answer

Dobutamine binds beta 1 and beta 2 receptors, so increasing cardiac output and reducing SVR, unlike
adrenaline which increases Systemic Vascular Resistance by binding alpha 1 receptors.