A 27 year old motorcyclist sustains an isolated injury to his left wrist in a motor vehicle accident.Question
a. Describe and interpret his X-ray
b. List the acute complications of this injury
AnswerAnswer and Interpretation
Facem Vaq Exam 2008.1 – Question 7← X-ray showing a dislocated lunate and a
fractured radial styloid process.← The overall pass rate for this question
was 49/62 (75.8%).← This was a basic question done very
poorly by a number of candidates.← Satisfactory answers required the
diagnosis of the dislocation and fracture plus identification in Part b) of the common complications of this injury.
Poor answers missed the radial fracture, misdiagnosed perilunate dislocation and/or did not mention median nerve injury as a potential complication.
A 45 year old man is brought to your emergency department with severe pain in his right hip after a fall from his bicycle an hour earlier. He has no other obvious injuries.His observations are:
Question
a. Describe and interpret his X-ray (50%)
b. Outline the analgesia options (50%)
AnswerAnswer and Interpretation
Facem Vaq Exam 2008.2 – Question 2← X-ray of complex orthopaedic injury
showing comminuted mid shaft femoral fracture, hip dislocation, acetabular fracture and fracture into the pubic symphysis. Air splint in place.
← The overall pass rate for this question was 62/81 (76.5%).
← Good answers demonstrated a systematic approach to x-ray interpretation and recognized the high likelihood of significant blood loss and significant analgesia issues.
← Poor answer missed one or more injuries and/or failed to take into account the haemodynamic instability in suggesting analgesic options.
Many candidates failed to answer the question as set.
A 54 year old male motorcyclist presents having crashed into the side of a stationary car at 80Kph. His observations are:
HR 140 /minBP 130/90 mmHg supineRR 24 /minSpO2 98 %
a. Describe and interpret his Xray (30%)b. Outline your management options (70%)
Trauma Pelvis X-Ray
VAQ 3
A 54 year old man presents after a fall with his only injury being a painful right ankle.
An Xray is performed.
a. Describe and interpret his Xray 50%
b. Outline your treatment 50%
2003.1 VAQ 4
This 19 year old man presents with an extremely painful knee after a tackle at soccer. He is unable to weight bear. A photograph of the knee is shown.
Questiona. Describe the findings on the photograph. (50%)b. List the possible complications. (50%)
FACEM VAQ Exam 2003.1 – Question 4
Overall pass rate for this question was 64 / 83 (77.1%)
They expected a comprehensive description and an awareness of the neurovascular complications of knee dislocation.
Failures were due to misdiagnosis as a patella dislocation or a lack of knowledge of the neurovascular complications.
2003.2 VAQ 8
An 40 year old man has sustained a crush injury to his left foot at work.
Questiona. Describe the X-ray. (40%)b. How would you manage him? (60%)
FACEM VAQ Exam 2003.2 – Question 8
Overall pass rate for this question was 55 / 82 (67.1%%).
An X-ray showing tarsometatarsal disruption is shown.
This question generated remarks from invigilators about image quality but was not seen as an issue by the examiners who expected that the description would demonstrate the obvious fracture dislocations.
It was expected that there would be an appreciation of the potential for vascular compromise, compartment syndrome and long term disability.
Management should have included early referral for definitive orthopaedic repair.
This 45 year old man presented following a fall from a ladder. He has suffered an injury to his right arm.Question
a. Describe and interpret the X-ray.
b. What are the potential complications of the injury?
AnswerAnswer and Interpretation
Facem Vaq Exam 2004.1 – Question 7← Overall pass rate for this question was
66 / 69 (95.7%).← An X-ray of an elbow dislocation is
shown.← Examiners expected an accurate
description of the xray, which in the single view demonstrated a posterior dislocation of the elbow with a likely lateral component.
← In terms of potential complications it was mandatory that acute neurovascular compromise was mentioned but also it was expected that medium/long term complications such as ongoing instability/stiffness and socioeconomic effects would be mentioned.
Failures were due to candidates not accurately describethe xray (merely interpreting it) and an inadequate list of complications.
A 38 year old woman presents with severe pain in her right foot after a fall from her motorcycle 2hours earlier. She has no other injuries.Question
a. Describe and interpret her X-rays
b. Outline your management
Lateral
AnswerAnswer and Interpretation
Facem Vaq Exam 2009.2 – Question 4← The overall pass rate for this question
was 43/67 (64.2%).← AP and lateral X-rays showing Lisfranc
fracture / dislocation of right foot.← Pass criteria: Part a)
Injury of Lisfranc or tarso-metatarsal joint of right foot.Fracture dislocation (avulsion fracture 2nd MT).Lateral translation of at least 2nd and 3rd metatarsals.No dorsal malalignment visible
← Pass criteria: Part b)
Severe injury requiring relatively urgent orthopaedic managementAnalgesia; appropriate doses of narcoticsPlaster backslab and elevationUrgent orthopaedic referralKeep fasted and investigations as indicated for theatre.
← Fail criteria: Features in answers that were unsuccessful included:
Absence of pass criteriaDischarge of patientExcessive delay
A 65 year old woman has been brought to your emergency department after being struck by a car at a pedestrian crossing. She has a painful right leg. Her AP and Lateral X-rays are shownQuestion
a. Describe and interpret her X-rays (50%)
b. Outline potential complications (50%)
Images
AnswerAnswer and Interpretation
FACEM VAQ Exam 2011.1 – Question 2← The overall pass rate for this question
was 65/82 (79.3%)← Pass Criteria
Tib/Fib fracture2 out of 4 other findingsInterpretation regarding mechanism
Common peroneal nerve injuryPopliteal artery-injuryat least 3 other complications
← Features of unsuccessful answersIncorrect xray reading no interpretationMissing important complications
particularly neuro/vascular
A 23 year old man has been brought to your emergency department after a fall onto his outstretched right hand from a height of three metres.Question
a. Describe and interpret his X-rays (100%)
Xr
AnswerAnswer and Interpretation
FACEM VAQ Exam 2011.2 – Question 5← The overall pass rate for this question
was 48/81 (59.3%)← Pass Criteria
Accurate description of complex fracture dislocation of wrist.Including dislocated carpal bones and dislocated lunateMust mention neurovascular riskGood answers also included- additional comments regarding complications, prognosis
← Features of unsuccessful answersNo mention of neurovascular statusInaccurate description of injuryFailure to recognise lunateNo mention of open injury; choosing urgent
reduction in ED (without rationale)2004.1 VAQ 7
This 45 year old man presented following a fall from a ladder. He has suffered an injury to his right arm.
Questiona. Describe and interpret the X-ray. (30%)b. What are the potential complications of the injury? (70%)
FACEM VAQ Exam 2004.1 – Question 7
An X-ray of a dislocated elbow is shown.
Overall pass rate for this question was 66 / 69 (95.7%).
Examiners expected an accurate description of the xray, which in the single view demonstrated a posterior dislocation of the elbow with a likely lateral component.
In terms of potential complications it was mandatory that acute neurovascular compromise was mentioned but also it was expected that medium/long term complications such as ongoing instability/stiffness and socioeconomic effects would be mentioned.
Failures were due to candidates not accurately describe the xray (merely interpreting it) and an inadequate list of complications.
Median & ulna nerve. Brachial artery.
2004.2 VAQ 5An 82 year old man presents following a fall in the shower. He is complaining of a painful right shoulder. An X-ray has been taken.
Questiona. Describe and interpret the X-ray. (50%)b. What are the potential complications of this injury? (50%)
FACEM VAQ Exam 2004.2 – Question 5
The overall pass rate for this question was 57 / 64 (89.1%).
The X-ray reproduced shows a dislocated shoulder.
The expectation was that candidates would comment on the view and identify this as an oblique view which clearly demonstrated an anterior dislocation.
Better answers identified the associated Hill Sachs deformity.
Failing answers did not address these issues or would not commit to the anterior dislocation without a second view.Some misinterpreted the coracoid as a glenoid fracture.
The expectation was that potential complications would include both early and late and consider not only direct fracture complications but also iatrogenic and social.
Failing candidates did not adequately cover these issues or listed a whole series of orthopedic complications many of which were unlikely or unheard of with this particular injury.
2004.2 VAQ 6A previously well 3 year old boy is brought to the emergency department by his parents following a fall from play equipment at home. He has injured her left leg. An X-ray has been taken.
a. Describe and interpret the X-ray. (30%)b. Outline your management. (70%)
FACEM VAQ Exam 2004.2 – Question 6
Overall pass rate for this question was 60 / 64 (93.8%).
The Xray shown is of a mid shaft fracture of the femur.
Examiners sought a high standard for what was considered a straight forward question. It was expected that the description would be comprehensive giving a clear description of all aspects of the deformity and given the force required at least raise a suspicion of NAI.
Although the focus of the management section needed to be the fracture itself general issues such as basic resuscitation, maintaining temperature, parental involvement/engagement and dealing with NAI should have been covered.
The fracture specific issues included monitoring/treating for neurovascular compromise, pain relief including femoral nerve block and traction/splinting.
2005.1 VAQ 4A 24 year old man presents to your emergency department following a fall. He is complaining of a painful right wrist.
Questiona. Describe and interpret his X-rays. (50%)b. List your management priorities for this man. (50%)
FACEM VAQ Exam 2005.1 – Question 4
Overall pass rate for this question was 38 / 44 (86.4%)
The X-ray shown is of a trans-scaphoid, perilunate dislocation of the wrist and spiral fracture of the ring finger metacarpal
It was essential in the examiners view that an answer correctly identified both the scaphoid fracture and the dislocation.
It was expected that management would include supportive treatment such as splinting and elevation, emergent reduction if neurovascular compromise was present and plans otherwise for urgent reduction.
The examiners were prepared to accept initial reduction in the emergency department but only as part of a coordinated plan developed in consultation with orthopaedic service who would then take on definitive care.
2005.2 VAQ 5
An 8 year old boy is brought to your emergency department after injuring his right arm in a fall from his bicycle. This is an isolated injury.
Questiona. Describe and interpret his X-ray. (50%)b. Outline your management of this boy. (50%)
FACEM VAQ Exam 2005.2 – Question 5
The overall pass rate for this question was 44/56 (78.6%).
The X-ray shows a displaced supracondylar fracture
This was considered a straight forward question that most well prepared candidates would easily pass. The description/interpretation needed to include not only the grossly displaced fracture but also specifically mention that this is associated with the risk of neurovascular injury.
Failing answers incorrectly described the film as a dislocation, did not emphasise the need for urgent reduction if there was vascular compromise and did not mention the paediatric specific issues of parental involvement (ie they only managed the fracture and not the child).
2006.2 VAQ 4
A 30 year old man has had his left leg run over by a car. Resulting in isolated right lower limb injuries. He is in considerable pain. There are open wounds at his right ankle and his right foot is pale.
Questiona. Describe and interpret the X-ray (50%)b. List your management priorities. (50%)
FACEM VAQ Exam 2006.2 – Question 4
Overall pass rate for this question was 48/57 (84.2%)
X-ray of complex fracture dislocation of ankle.
The examiners felt this was a good question.
Pass/fail resolved around a detailed descriptive of the fractures, plus management of vascular insufficiency of the open wounds, and analgesic/antibiotic issues.
2007.2 VAQ 4
A 25 year old man sustains an injury to his right ankle in a fall from a ladder. He sustained no other injuries.
Questiona. Describe and interpret his photograph (30%)b. Outline your management (70%)
FACEM VAQ Exam 2007.2 – Question 4
Overall pass rate for this question was 67/77 (87.0%)
This question was felt to be very straight forward requiring a basic answer only to pass.
Good answers identified the compound nature of the injury and the need for early reduction in the ED and early OR washout and definitive repair.
2008.1 VAQ 4
An intoxicated 34 year old man sustains an isolated knee injury after a fall.
Questiona. Describe and interpret this man’s photograph (30%)b. List the major issues to be addressed in the next four hours (70%)
FACEM VAQ Exam 2008.1 – Question 4
Clinical photograph showing major knee dislocation.
The overall pass rate for this question was 31/62 (50.0%).
The examiners commented that this was a good quality clinical photograph which raised many consultant level issues.
It was highly discriminative with marks ranging from 2 to 8. Most candidates described the photo adequately.
High quality answers to Part b) addressed immediate reduction of the knee, appropriate methods of sedation/analgesia including RSI and suggested appropriate assessment for possible accompanying vascular and neurological injury.
Poor answers failed to address the above areas or described assessment for injuries to other regions of the body despite this having been defined in the question as “an isolated knee injury”
2008.1 VAQ 7
A 27 year old motorcyclist sustains an isolated injury to his left wrist in a motor vehicle accident.
Questiona. Describe and interpret his X-ray (50%)b. List the acute complications of this injury (50%)
FACEM VAQ Exam 2008.1 – Question 7
X-ray showing a dislocated lunate and a fractured radial styloid process.
The overall pass rate for this question was 49/62 (75.8%).
This was a basic question done very poorly by a number of candidates.
Satisfactory answers required the diagnosis of the dislocation and fracture plus identification in Part b) of the common complications of this injury.
Poor answers missed the radial fracture, misdiagnosed perilunate dislocation and/or did not mention median nerve injury as a potential complication.
2008.2 VAQ 2
A 45 year old man is brought to your emergency department with severe pain in his right hip after a fall from his bicycle an hour earlier. He has no other obvious injuries.
Questiona. Describe and interpret his X-ray (50%)b. Outline the analgesia options (50%)
FACEM VAQ Exam 2008.2 – Question 2
X-ray of complex orthopaedic injury showing comminuted mid shaft femoral fracture, hip dislocation, acetabular fracture and fracture into the pubic symphysis. Air splint in place.
The overall pass rate for this question was 62/81 (76.5%).
Good answers demonstrated a systematic approach to x-ray interpretation and recognized the high likelihood of significant blood loss and significant analgesia issues.
Poor answer missed one or more injuries and/or failed to take into account the haemodynamic instability in suggesting analgesic options.
Many candidates failed to answer the question as set.
Question 6
A 25 year old man is brought to your Emergency Department after a motorcycle accident. His only complaint is severe right arm pain.
a. Describe and interpret his X-ray (30%)b. Outline your management (70%)
FACEM VAQ Exam 2009.1 – Question 6
The overall pass rate for this question was 50/81 (61.7%)
X-ray showing a comminuted, displaced, angulated fracture of radius with dislocation of the distal radio-ulnar joint.
Pass criteria were an accurate description of all the injuries plus a management plan addressing analgesia, potential neurovascular complications and early operative intervention.
Question 1
An 82 year old lady returns to your department 3 days after a fall, complaining of ongoing shoulder pain and bruising. She was seen in your ED soon after the fall by a junior resident, who diagnosed a soft tissue injury after viewing this X-ray, and gave her a broad-arm sling.
a) Describe this X-ray.
b) Outline your management.
a.) R shoulder x-ray single view A-P2 part SNOH fracture with impaction, 50% medial displacement and approx 30 degrees lateral angulation Soft tissue swellingNo obvious dislocation on single view (needs 2nd to exclude posterior).
b.) Management issues
Patient care and safe disposition Harm minimisation including potential complaint Resident education and supervision Assess x-ray R/V process – missed fracture not
detected Documentation.
Patient care
Full reassessment including 2 view re-xray, extent of bruising.Analgesia. Paracetamol/codeine or morphine titrate to responseCollar and cuffu-slab for additional traction
patient/relative education reassurance and apology (“miss” will not affect prognosis, broad arm sling appropriate)
Discharge home only if safe:
“Non-pathological” cause of fall (eg. No syncope)Pain controlled on oral medicationAble to cope at home with likely dominant arm in slingSupport including additional organised through ED (multidisciplinary)Patient/relatives happy for dischargeFollow-up home visit/GP and fracture clinic 1/52.Falls/geriatric clinic as appropriate
Otherwise admit ortho/aged care team.
Missed fracture
Educate (sensitively) resident and assess need for further ortho/radiology education for individual and groupAssess supervision levels and address staffing levels and skill-mix as appropriateClinical indicator: add to audit.Assess reporting and recall procedures (as 3/7 and patient self-presented) with aid of radiologists. Institute changes and reassess as quality improvement programFull documentation, including of apologies, to anticipate potential complaint/medico-legal.
Description
#SNOH (1)other description (1)
Management
Patient care analgesia (1) reassessment (1) collar and cuff or sling (1) explanation, apology and reassurance (1) disposition (2)
Error prevention individual and group training reporting and recall (2)
Question four - Xray
A twenty year old hotel bouncer presents following an injury at work.
a) Describe and interpret his Xray. (30%) b) Outline your management. (70%)
a) Xray left hand AP view
AP Xray hand Incomplete view – 2-5th metacarpals visualised, but not 1st or digits or carpus
Fractured neck of 5th metacarpal Appears displaced – degree of angulation towards palm needs to be determined from lateral
xray Marked soft tissue swelling in keeping with fracture +/- soft tissue injury Consider possibility of compound injury (including compound MCP joint injury given
mechanism) Summary; fractured neck of 5th metacarpal right hand (Boxers fracture) needing further
radiological evaluation and clinical evaluation for rotational deformity /
b) Management of fractured neck of 5th metacarpal
Analgesiao Titrated IV narcotic / IM narcotic or oral combination analgesiao Ulnar nerve block may also be of value if severe pain (not usual)
First aid o Elevationo Ice o Splint
Manage complicationso Rotational deformity – as determined by examination (flexed fingers should align
and all point towards the scaphoid) is an indication for correction to avoid functional impairment
o Angulation – up to 30-40o of angulation may be tolerated and accepted without functional impairment (in contrast to 2nd and 3rd MC)
o Compound injury – wound care / IV antibiotics broad spectrum / consultation plasticso Compound joint injury – wound care / broad spectrum AB’s / consultations plastics /
likely joint wash out in OT / time critical / consider body fluid exposure (eg tooth injury)
o Concomitant tendon or ligament injury possibleo Neurovascular complication unlikely
Immobilisation o Ulna gutter splinto Flexion to 90 degrees at MCP joint, wrist extension to 20 degreeso Sling
Consultation – plastic surgeon Disposition
o admission if significant complication as stated aboveo otherwise review at 7-10 days o home with appropriate analgesia and fracture care instructions o ? dominant hando work care / medicolegal issues (eg if assault) as needed eg documentation
Question 1
A 35 year-old woman tripped walking down some stairs 1 hour prior to arrival. It is evident she
is intoxicated with alcohol.
A photograph of her ankle is shown. She has no other injuries.
a) Describe and interpret the photograph (50%)
b) Outline your initial treatment (50%)
Question 5A 2 year-old o boy is brought in by his mother. He was playing with his older brother in an
adjoining room before his mother heard a cry. Subsequently, the child has been reluctant
to his use his right arm, which is held straight by his side.
Examination reveals no obvious deformity. The child has no other injuries.
A resident medical officer who assessed this child shows you x-rays he ordered.
Describe and interpret these x-rays (100%).
Question 8A 23 year-old man fell off a ladder, landing on his feet. An x-ray of his painful foot is taken.
a. Describe and interpret the x-ray (50%).
b. Outline the important features in the history of this patient (50%).
