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MONDAY, 29 APRIL, 2002

SECOND PAPER - 2 hours

ALL questions must be answered - Question 3 (50%) & Questions 4 & 5 (25% each)

Question Three - 1Hour

A male motorcyclist thought to be in his mid twenties is brought into your emergency department unconscious after having been found on the country roadside by a passing cyclist No witnesses are available and no identification has been found on him.

His Glasgow Coma Scale is ten and he has been clinically stable since his discovery. thirty minutes earlier. His blood pressure is 100/70 mm Hg, his pulse is 100 beats per minute and his temperature is 35.5 degrees Celsius. His respiratory rate is 25 per minute.

He has an obvious deformity at his left knee with a cold pale pulseless leg below it and his right thigh is deformed and swollen. There is a 5 cm wound over the right mid tibia associated with swelling and deformity of the leg. The circulation in the right leg is intact. There is deformity of the right distal radius and several old scars are noted on the volar aspect of the left wrist He has multiple skin tattoos.

You are the only doctor available for the first half-hour.

1. Outline your priorities in the assessment, investigation and initial management of this patient. (40 marks)
2. Your trauma colleagues subsequently stabilise, and are no longer concerned about his non orthopaedic injuries.
• Discuss the management of his musculoskeletal injuries. (40marks)
3. Assume the non-orthopaedic injuries resolve fully.
   • Discuss the rehabilitation of this patient. (20 marks)

Question Four - 1½ hour

A 58 year old physically active woman in excellent health presents complaining of pain around the medial aspect of the ankle and hindfoot. Symptoms have become persistent, slowly worsening and are significantly limiting her activities. There is no past history of any injury or joint problem. Clinical examination demonstrates swelling & tenderness about the medial ankle-hind foot.

1. Give your differential diagnosis outlining the key clinical features and investigations for the six most likely diagnoses. (30 marks)
2. Three months later, the symptoms have progressed and the medial longitudinal arch has some flattening.
   • Outline the natural history of the most likely diagnosis and discuss its management. (20 marks)
     

Question Five - ½ hour

You are called to assess a seven year old boy in the Emergency Department with a supracondylar fracture of the right humerus sustained four hours previously. Examination reveals a closed fracture with tenting of the soft tissues over the anterior aspect of the elbow. The radial pulse is absent but the forearm and hand are well perfused. X-rays show a markedly displaced fracture

1. Outline your assessment of this child's injury. (l0 marks)
2. Discuss in detail your management of this fracture. Include the possible situation of failed closed reduction. (30marks)
3. Twelve hours after reducing the fracture you discover the child is unable to flex the right thumb and index finger. How would you further assess and manage this apparent complication. (l0 marks)

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