The 2027 Trauma & Orthopaedics ST3 Interview Revision Platform: Question Bank, Live Practice and Mocks with Other Candidates

This is a lateral radiograph of the left elbow in a skeletally immature child, showing a Gartland type 3, extension-type supracondylar fracture. Assuming this is an isolated injury with no concerns of non-accidental injury, and that he's been resuscitated according to ATLS, my biggest concern is neurovascular injury, and I'd manage him per BOAST guidelines.

For assessment, I'd document nerve function: the median nerve with an OK sign, the radial nerve with a thumbs up, and the ulnar nerve by crossing the middle finger over the index. I'd check capillary refill and the radial pulse, and look for a pucker sign, which suggests the proximal fragment has pierced brachialis. For initial management, I'd splint the arm in a position of comfort, recheck the neurovascular status, look for signs of compartment syndrome, and request a check X-ray.

Type 1 is undisplaced, type 2 is angulated with an intact posterior cortex, and type 3 is completely displaced.

The BOAST guidelines. In summary: the neurovascular status should be assessed and documented with the motor and sensory function of each nerve (radial, median, anterior interosseous and ulnar). Night-time operating is indicated for an absent radial pulse, impaired perfusion, open injuries or threatened skin viability. Fixation is with two 2mm K-wires in a crossed or divergent configuration, and if a medial wire is used, steps should be taken to protect the ulnar nerve, such as inserting it with the arm in extension through a small medial incision to visualise the nerve. If there's no clinical ischaemia after reduction, routine brachial artery exploration isn't required, but if ischaemia is suspected, exploration is needed to relieve vessel entrapment, and this is an emergency, so the vascular team should be notified immediately.

In an appropriately marked and consented patient, after a WHO checklist, I'd position him supine. I'd apply traction to the limb, correct any rotation with pronation or supination, and confirm reduction with the image intensifier. I'd then hyperflex the elbow with my thumb over the olecranon to reduce the fracture, and in that position place two divergent wires laterally, confirming satisfactory positioning again under X-ray. I'd apply a backslab and ensure the neurovascular status was monitored overnight.

First I'd examine him, checking both motor and sensory function, and look for external causes, loosening any tight bandages, casts or splints that could be compressing the nerve, while monitoring for compartment syndrome. If that doesn't resolve it, I'd promptly alert the operating surgeon. I have a duty of candour, so I'd inform the parents of the complication. I'd consider imaging with MRI or nerve conduction studies and arrange follow-up in hand clinic, and if the deficit continues, I'd involve the local peripheral nerve injury unit and consider surgical exploration.

This is cubitus varus, a complication of supracondylar fractures, which can lead to a tardy ulnar nerve palsy. It usually results from anterior subluxation of the nerve, or the nerve becoming trapped in the fibres of flexor carpi ulnaris and scar tissue. Cubitus varus can be avoided by achieving a Baumann angle similar to the contralateral arm.