• The major muscles that are divided during resuscitative thoracotomy include the pectoralis major, the pectoralis minor, and the serratus anterior muscles.

  • Pectoralis major muscle: It originates from the anterior surface of the medial half of the clavicle, the anterior surface of the sternum, and the cartilages of all of the true ribs (the first seven ribs which are directly attached to the sternum). The 5-cm wide tendon inserts into the upper humerus.

  • Pectoralis minor muscle: It arises from the third, fourth, and fifth ribs, near their cartilages, and inserts into the coracoid process of the scapula.

  • Serratus anterior muscle: It originates from the first eight or nine ribs and inserts into the medial part of the scapula.

• The left phrenic nerve descends on the lateral surface of the pericardium.

• The lower thoracic aorta is situated to the left of the vertebral column. The esophagus descends on the right side of the aorta to the level of the diaphragm, where it moves anterior and to the left of the aorta. The aorta is the first structure felt while sliding your fingers along the left posterior wall anterior to the spine.

• The trachea is 10–12 cm long and 2–2.5 cm wide, extending from C6 to T5.

• The trachea is composed of 16–20 incomplete rings with a flattened posterior wall of muscle and fibrous tissue.

• The anatomic borders of the trachea include the isthmus of the thyroid and paired strap muscles anteriorly. The common carotid arteries, thyroid lobes, and recurrent laryngeal nerves form the lateral borders.

• The paired strap muscles are in front of the trachea and larynx. These include the sternohyoid muscles and the underlying sternothyroid and thyrohyoid muscles.

• The thyroid cartilage is suspended from the hyoid bone by the thyrohyoid membrane. The cricothyroid ligament connects the inferior portion of the thyroid cartilage to the cricoid cartilage. Inferior to this is the first tracheal ring.

• The larynx is composed of three paired (arytenoid, corniculate, and cuneiform), and three unpaired (cricoid, thyroid, and epiglottic) cartilages.

• The cartilaginous and bony structures of the larynx include the hyoid bone as well as the thyroid and cricoid cartilages. The trachea begins below the cricoid cartilage.

• The hyoid bone, thyroid cartilage, and tracheal cartilages are incomplete rings, with posterior membranous walls. In contrast, the cricoid cartilage is a complete ring, forming an important structural attachment for muscles and ligaments of the larynx. The cricoid cartilage ensures airway patency by stenting the larynx open.

• The cricothyroid membrane is situated between the thyroid and cricoid cartilages in the midline anteriorly. It is located directly beneath the skin, providing direct and easy access to the airway. This membrane is bordered superiorly by the thyroid cartilage, inferiorly by the cricoid cartilage, and laterally by the paired cricothyroid muscles. In adults, it is approximately 1 cm tall and 2–3 cm wide.

• The vocal cords are enclosed within the thyroid cartilage, approximately 1 cm from the upper border of the cricothyroid membrane.

• The cricothyroid membrane is about four fingerbreadths from the suprasternal notch.

• The spleen lies under the ninth to eleventh ribs, under the diaphragm. It is lateral to the stomach and anterosuperior to the left kidney. The tail of the pancreas is in close anatomical proximity to the splenic hilum and amenable to injury during splenectomy or hilar clamping.

• The spleen is held in place by four ligaments, which include the splenophrenic and splenorenal ligaments posterolaterally, the splenogastric ligament medially, and the splenocolic ligament inferiorly. The splenorenal ligament begins at the anterior surface of Gerota’s fascia of the left kidney and extends to the splenic hilum, as a two-layered fold that invests the tail of the pancreas and splenic vessels. The splenophrenic ligament connects the posteromedial part of the spleen to the diaphragm, and the splenocolic ligament connects the inferior pole of the spleen to the splenic flexure of the colon. The splenogastric ligament is the only vascular ligament and contains five to seven short gastric vessels that originate from the distal splenic artery and enter the greater curvature of the stomach. Excessive retraction of the splenic flexure or the gastrosplenic ligaments can easily tear the splenic capsule and cause troublesome bleeding.

• The mobility of the spleen depends on the architecture of these ligaments. In patients with short and well-developed ligaments, mobilization is more difficult and requires careful dissection in order to avoid further splenic damage.

• The splenic hilum contains the splenic artery and vein and is often intimately associated with the tail of the pancreas. The extent of the space between the tail of the pancreas and the splenic hilum varies from person to person.

• The splenic artery is a branch of the celiac axis that courses superior to the pancreas towards the splenic hilum where it divides into upper and lower pole arteries. There is significant variability in where this branching occurs. Most people, approximately 70%, have a distributed or medusa like branching that occurs 5–10 cm from the spleen. Simple branching occurs in approximately 30%, 1–2 cm from the spleen.

• The splenic vein courses posterior and inferior to the splenic artery, receives the inferior mesenteric vein, and joins the superior mesenteric vein to form the portal vein.

• The upper mediastinum contains the aortic arch with the origins of its major branches. These include the innominate (brachiocephalic) artery, proximal left common carotid artery, and proximal left subclavian artery. The left and right innominate (brachiocephalic) veins join to become the superior vena cava (SVC).

• The thymic remnant and surrounding mediastinal fat are the first tissues encountered when entering the upper mediastinum. These tissues lie over the left innominate vein and the aortic arch.

• The left innominate vein is approximately 6–7 cm long and it transverses the upper mediastinum under the manubrium sterni and over the superior border of the aortic arch. It joins the right innominate vein just to the right of the sternum at the level of the first to second intercostal space to form the SVC.

• The right innominate vein is approximately 3 cm in length and it courses vertically downward and joins the left innominate vein at a 90° angle to form the SVC.

• The SVC is approximately 6–7 cm in length and is located lateral and parallel to the ascending aorta. A small segment is enclosed within the pericardium.

• The ascending aorta is contained within the pericardium. The aortic arch begins at the superior attachment of the pericardium. The first branch of the aortic arch is the innominate artery, which then branches into the right subclavian and right common carotid arteries. The next branch of the arch is the left common carotid artery, followed by the left subclavian artery. The innominate artery and the left common carotid artery originate relatively anteriorly, while the left subclavian artery originates more posteriorly. Anatomical variants include a common origin for the left common carotid artery and innominate artery, as well as a common origin for the left subclavian and left common carotid artery.

• The left vagus nerve travels between the left common carotid and subclavian arteries just anterior to the arch and branches off into the recurrent laryngeal nerve, which loops around and behind the aortic arch, ascending along the tracheoesophageal groove.

• The right vagus nerve crosses over the right subclavian artery, immediately gives off the recurrent laryngeal nerve, which loops behind the subclavian artery and ascends behind the common carotid artery along the tracheoesophageal groove.

• The thoracic or descending aorta begins at the fourth thoracic vertebra on the left side of the vertebral column. Below the root of the lung, it courses to a position anterior to the vertebral column as it passes into the abdominal cavity through the aortic hiatus in the diaphragm at the twelfth thoracic vertebra.

• The esophagus lies on the right side of the aorta proximally. Distally, as it enters the diaphragm, it courses in front of the aorta.

• The aorta has nine pairs of aortic intercostal arteries that arise from the posterior aspect of the aorta and travel to the associated intercostal spaces. The bronchial and esophageal arteries are additional branches of the aorta as it descends in the thorax.

• For vascular trauma purposes the abdomen is divided into four retroperitoneal anatomical areas:

  • Zone 1: The midline retroperitoneum from the aortic hiatus to the sacral promontory is broken into supramesocolic and inframesocolic areas. The supramesocolic area contains the suprarenal aorta and its major branches (celiac artery, superior mesenteric artery, and renal arteries), the supramesocolic segment of the inferior vena cava with its major branches, and the superior mesenteric vein. The inframesocolic area contains the infrarenal aorta and infrarenal inferior vena cava.

  • Zone 2 (left and right): This is the paired right and left region lateral of Zone 1 containing the kidneys and renal vessels.

  • Zone 3: The pelvic retroperitoneum, which contains the iliac vessels.

• The abdominal aorta originates between the two crura of the diaphragm at the level of T12–L1 and bifurcates into the common iliac arteries at the level of L4–5. The umbilicus is an approximate external landmark for the aortic bifurcation. The first large branch is the celiac trunk, followed by the superior mesenteric artery 1–2 cm inferiorly, and both course anteriorly and inferiorly. The renal arteries originate 1–2 cm below the origin of the superior mesenteric artery at the level of L2 and course laterally. Finally, the inferior mesenteric artery originates 2–5 cm above the aortic bifurcation on the left anterior aspect of the aorta.

  • Celiac artery: The main trunk originates on the anterior surface of the aorta at the level of T12–L1. It is 1–2 cm long and divides into three branches at the upper border of the pancreas—the common hepatic, left gastric, and splenic arteries. The celiac is encased in extensive fibrous, ganglionic, and lymphatic tissues, which makes surgical dissection of the celiac artery difficult. In 10–20% of patients, the left gastric artery gives off a replaced left hepatic artery that courses through the gastrohepatic omentum and can be injured while mobilizing the left lobe of the liver or lesser curve of the stomach.

  • Superior mesenteric artery (SMA): The SMA originates from the anterior surface of the aorta at the level of L1, 1–2 cm below the celiac artery. It courses posterior to the neck of the pancreas and anterior to the third part of the duodenum, beyond which it enters the root of the mesentery. SMA branches include the inferior pancreaticoduodenal artery, the middle colic artery, an arterial arcade with 12–18 intestinal branches, the right colic artery, and the ileocolic artery. In 10–20% of patients, the SMA gives off a replaced right hepatic artery, which courses posterior to the head of the pancreas and runs posteriorly and to the right of the portal vein.

  • Renal arteries: The right renal artery emerges at a slightly higher level and is longer than the left and courses posteriorly to the inferior vena cava. Approximately 30% of patients have more than one renal artery, usually an accessory artery supplying the lower pole of the kidney. Both renal veins lie anteriorly of their accompanying renal arteries. The left renal vein is significantly longer than the right and courses anteriorly to the aorta. The left renal vein drains the left gonadal vein inferiorly, the left adrenal vein superiorly, and the renolumbar vein posteriorly. The right gonadal vein drains directly into the IVC.

  • Inferior mesenteric artery (IMA): The IMA provides blood supply to the left colon, sigmoid, and the rectum. It communicates with the SMA through the marginal artery of Drummond and arc of Riolan.

• Trauma laparotomy set

• Fixed abdominal retractor, e.g., Bookwalter

• Adequate lighting including a headlamp

• Temporary abdominal closure devices should be available, if needed

• Deep partial or full thickness skin wounds, with an underlying vascularized bed, may be closed by autologous skin grafting, especially if healing by contracture would lead to prolonged healing time or functional or aesthetic deformity. Split thickness skin grafts (STSGs) are used most often for large wounds. Thin (0.06–0.010 in.), intermediate (0.010–0.013 in.), and thick (>0.014 in.) split thickness grafts can be harvested. Thinner grafts survive more reliably on a less vascular bed and have faster donor site healing; however, thinner grafts contract more than thicker grafts and the esthetic results are inferior. Most STSGs are of intermediate thickness, 0.012 in. Thinner grafts (0.010) should be considered in children and the elderly due to their thinner dermis.

• STSG donor sites heal by re-epithelialization with proper wound care. The lateral thigh or back are the most common donor sites, although STSGs may be harvested from nearly any uninjured anatomic area, including buttocks, abdomen, scrotum, and scalp.

• Meshed STSGs can be expanded and require less donor site than sheet grafts, but contract more and the esthetic results are not as good. Sheet grafts are used in children or in areas where contracture is unacceptable.

• Full thickness skin grafts have little role in acute wound closure. These are reserved for delayed reconstruction of critical areas, such as the hands and face.

• Meticulous technique is important for graft success, and includes hemostasis, placement of dressings, and adequate postoperative immobilization.

Pain may be asked as part of a viva topic or candidates may be lucky or unlucky enough to have a full 5-minute viva devoted to the topic. It is an important part of orthopaedic practice which is often neglected, but more important now with the push towards day-case surgery and even day-case arthroplasty. Pain is well known to appear as questions in the Part I MCQ/SBA exam.

This viva can be awkward, as bits and pieces such as pain assessment can appear fluffy to orthopods and in real life is best left to the anaesthetists.

Section 2 of the basic science (Tr & Orth) syllabus is a large topic, difficult to grasp at face value as it appears quite removed from the average orthopaedic surgeon’s practice. However, it pervades many aspects of clinical practice and therefore must be understood.

It contains large sections of A-list topics that just need to be learnt as well as possible, otherwise marks will be thrown away.

A recent shift in emphasis with basic science from the ICB is to try and link a topic into a clinical problem to make the subject more clinically relevant and less dry. A classic example is the clinical photograph of an explanted worn PE cup leading on to a discussion of wear.

A good understanding of tribological properties helps the orthopaedic surgeon to choose the most suitable bearing solution for each individual patient.

Wear is an A-list topic with similar competency questions in the first part of a viva but unexpected or esoteric higher-order thinking questions in the second part. This is a method to keep the topic fresh with each diet of exams.

Alexander Suvorov would have done well in the trauma viva section of the FRCS Tr & Orth. Two citations attributed to him underpin the approach to the exam: Train hard, fight easy and He who is afraid is half beaten. Approach and strategy is everything and this comes from a combination of practice and knowledge acquisition. It is a time-dependent chess match where every move will be undertaken in a specified time, but in a sequence that is out of your control. Keep this analogy as you attempt different clinical scenarios. It is not only knowing the subject that is important, but also imparting it in an appropriate fashion, flexibly so that you can tell the examiners what they want to hear.

It is important to spend time learning surgical approaches and anatomy. At least two questions in the exam will be drawn from these areas in either the trauma and/or basic science vivas. Anatomy is fairly straightforward for the FRCS(Tr & Orth), either it’s learnt and known well for the exam, allowing candidates to score easy marks, or it hasn’t been learnt and the viva quickly unfolds, losing scoring opportunities for the candidate. The skill is anticipating which questions are more likely to appear in the exam than others and adjusting your revision time accordingly to take this into account.

These are posteroanterior (PA) and lateral radiographs of the wrist that show an extra-articular distal radius fracture. On the PA view, the radial height and inclination are maintained. On the lateral view, there is dorsal comminution with dorsal angulation of the distal radius. The radiographs also showed thumb carpometacarpal arthritis.