2. Trauma MCQs

Displaced clavicular fractures lateral to the coracoid process (Neer type II and III) are best managed nonsurgically with sling immobilization and physical therapy, starting with pendulum exercises and progressing to active-assisted exercises when comfortable. Supervised therapy should be performed for 3 months or until full painless motion is achieved. In one study by Robinson and Cairns, this form of treatment provided patients with an 86% chance of avoiding a secondary reconstructive procedure.

The advantage of an unreamed intramedullary nail is a loose-fitting intramedullary rod. Placed in the medullary canal, it allows the endosteal circulation to regenerate rapidly and completely where space has been left between the nail and the endosteal surface. The endosteal blood vessels are destroyed during introduction of reamed intramedullary nail.

The radiographic image is an obturator oblique view of the left acetabulum and demonstrates a "spur" sign. It represents a spike of bone from the intact hemipelvis and no articular surface remains with the hemipelvis, which defines the associated both column fracture. The weight-bearing surface of the acetabulum is displaced with the femoral head. In all other patterns, at least part of the articular surface remains with the intact hemipelvis.(SBQ12TR.58) A 35-year-old male was involved in a high speed motorcycle accident. He has a closed head injury, bilateral pulmonary contusions and splenic rupture. His orthopaedic injuries are shown in Figure A. He has a blood pressure of 90/50 mm Hg and a heart rate of 115, despite aggressive resuscitation. An arterial blood gas reveals that his blood lactate is 3.5 and base deficit is -6 mmol/L. Following successful closed reduction of the right hip in the operating room with a percutaneous inserted Schantz pin, what is the next most appropriate treatment for his orthopaedic injuries?ReviewTopicBilateral open reduction and internal fixationOpen reduction internal fixation on the right, reamed intramedullary nailing on the leftTemporizing external fixation on the right, open reduction and internal fixation on the leftBilateral reamed intramedullary nailingBilateral temporizing external fixationThis patient presents with features of hemodynamic instability and a high injury severity score. The next most appropriate treatment would be temporizing external fixation bilaterally. This patient meets the criteria for damage control orthopaedics.Damage control orthopaedics is an approach that contains and stabilizes orthopaedic injuries so that the patient's overall physiology does not undergo further inflammatory insult. As a result, external fixation of femoral shaft fracture and pelvic stabilization is an effective treatment under this strategy. Other indications include vascular injury and severe open fracture.Pallister et al. reviewed the effects of surgical fracture fixation on the systemic inflammatory response to major trauma. They show that early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure. However, early fracture surgery increases the post-traumatic inflammatory response, which carries a higher complication rate compared to temporary fixation.Tisherman et al. created clinical guidelines for the endpoints of resuscitation. Level I data found that standard hemodynamic parameters do not adequately quantify the degree of physiologic derangement in trauma patients. The initial base deficit, lactate level, or gastric pH should be used to stratify patients with regard to the need for ongoing fluid resuscitation.Pape et al. retrospectively reviewed the impact of early total care vs. damage control orthopaedics in the treatment of femoral shaft fractures in polytrauma patients. They found a significantly higher incidence of acute respiratory distress syndrome (ARDS) with intramedullary nailing (15.1%) compared to external fixation (9.1%) when DCO subgroups were compared.Figure A is a pelvic AP radiograph showing a right hip fracture-dislocation with an ipsilateral femoral shaft fracture. On the left side there is a displaced pertrochanteric hip fracture.Incorrect Answers:

DISCUSSION: The subtrochanteric femur has been identified as an anatomic site that is particularly prone to pathologic fracture. An avulsion fracture of the lesser trochanter is a sign of impending femoral fracture. While the other anatomic locations are also frequently involved in metastatic bone disease, pathologic fractures occur less commonly. REFERENCES: Simon MA, Springfield DS, et al: Surgery for Bone and Soft Tissue Tumors. Philadelphia, PA, Lippincott Raven, 1998, p 683. Harrington KD, Sim FH, Enis JE, Johnston JO, Diok HM, Gristina AG: Methylmethacrylate as an adjunct in internal fixation of pathological fractures: Experience with three hundred and seventy-five cases. J Bone Joint Surg Am 1976;58:1047-1055.

DISCUSSION: If the neck is immobilized in excessive extension, it can be difficult for the patient to swallow. If the patient had injured the recurrent or superior laryngeal nerve at the time of the accident, it is likely to have manifested itself earlier on. Esophageal trauma or retropharyngeal edema or hematoma from the fracture also should have manifested itself earlier. Because the fracture was completely reduced, it is unlikely that moving the small fragment posteriorly would have injured the esophagus. REFERENCES: Garfin SR, Botte MJ, Waters RL, Nickel VL: Complications in the use of halo fixation device. J Bone Joint Surg Am 1986;68:320-325. Glaser JA, Whitehill R, Stamp WG, Jane JA: Complications associated with the halo-vest: A review of 245 cases. J Neurosurg 1986;65:762-769.

DISCUSSION: The patient will most likely exhibit ipsilateral weakness of the tibialis anterior. Gaenslen’s test is designed to detect sacroiliac inflammation as a source of low back pain. Beevor’s sign tests the innervation of the rectus abdominis and paraspinal musculature (L1 innervation). The extensor hallucis longus is predominantly innervated by L5. The peroneals are predominantly innervated by S1. REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Appleton, WI, Century-Crofts, 1976. Hollinshead WH (ed): Anatomy for Surgeons: The Back and the Limbs, ed 3. Philadelphia, PA, Harper & Rowe, 1982.

DISCUSSION: Iliosacral screws have gained popularity for posterior stabilization of pelvic ring disruptions, but complications attributed to incorrect placement are a clinical problem. The L5 nerve root is at greatest risk and is in closest proximity to a malpositioned screw (exiting the sacrum). The L4 root is more anterior at this level. The S1 root is still intraosseous at this level and is at risk but not from the screw exiting anteriorly at this level. The arteries are at risk but are more anterior and are at less risk than the L5 nerve root. REFERENCE: Ebraheim NA, Haman SP, Xu R, Stanescu S, Yeasting RA: The lumbosacral nerves in relation to dorsal SI screw placement and their locations on plain radiographs. Orthopedics 2000;23:245-247.

DISCUSSION: One study found only 8% of organisms grown on pre-debridement cultures eventually caused infection; 7% of cases with negative pre-debridement cultures became infected. Of cases that did become infected, pre-debridement cultures grew the infecting organism only 22% of the time. Post-debridement cultures were more accurate in predicting infection. However, of cases that became infected, the infecting organism was present on post-debridement cultures only 42% of the time. It is concluded that pre-debridement and post-debridement bacterial cultures from open fracture wounds are of essentially no value. It is recommended that they not be done. In another study, before any interventions were performed, initial aerobic and anaerobic cultures of the wounds of 117 consecutive open extremity fractures grades I through III were obtained. The results of these cultures were correlated with the development of a wound infection. If an infection occurred, the organism grown from the infected wound was compared with any organism grown from the primary wound cultures. Of the initial cultures, 76% (89/117) did not demonstrate any growth, while the other 24% (28/117) only grew skin flora. There were only 7 (6%) wound infections, and 71% (5/7) initially did not grow any organisms. Of the isolates that grew from the initial cultures, none were the organisms that eventually led to infection.

A reported indication to perform fasciotomy includes an ICP measurement that is elevated to 30 mm Hg below the diastolic blood pressure. This would be the case if this patient's blood pressure was consistently around 115/55 mmHg (dBp=55; ICP=30; delta p = dBp-ICP = 25 mmHg).Given the poor outcomes associated with missed compartment syndromes, it is important to obtain both clinical and objective data when determining if a patient needs fasciotomies. A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam - especially with intubated patients. An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy.McQueen et al. prospectively reviewed 116 patients with tibia fractures that had continuous monitoring of their anterior compartment for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of30 mmHg is a more reliable indicator of compartment syndrome.Olson et al. provide a review of compartment syndrome for the lower extremity. They discuss a variety of injuries and medical conditions that may initiate acute compartment syndrome, including fractures, bleeding disorders, and other trauma. Although the diagnosis is primarily a clinical one, they also recommend supplementation with compartment pressure measurements in equivocal cases.Figure A shows a closed comminuted tibial shaft fracture. Incorrect Answers:

The development of femoral head ischemic necrosis is the iatrogenically created complication in this skeletally immature patient. Placement of a rigid, antegrade intramedullary nail through the piriformis fossa is likely to damage the vascular supply to the femoral head as the vessels ascend the femoral neck on the way to the femoral head. The MRI scan reveals ischemic necrosis with early collapse of the femoral head. The joint space is preserved on the MRI scan, ruling out chondrolysis.

Proximal tibial fractures develop an apex anterior (procurvatum) and valgus malalignment. Blocking (poller) screws should be placed in the concavity of the deformity, thus posterior and lateral to the nail. The Herzog curve should be proximal to the fracture site.Up to 58% of proximal tibial fractures are malaligned. Malalignment arises because the nail fits loosely in the wide metaphyses and cannot control alignment. Without close fit of the nail at the fracture site, the nail will not align the fracture independent of a stable reduction and careful nail path. Blocking screws serve to reduce the size of the proximal metaphyseal canal and guide final nail passage.Stinner et al. discuss strategies in proximal tibial fracture nailing. They describe an accurate starting point (using the twin peaks AP view or fibular bisector AP view, and flat plateau lateral view). They emphasize fracture reduction prior to reaming and implant placement.Hiesterman reviewed nailing of extra-articular proximal tibial fractures. Techniques described include blocking screws, unicortical plating, using a universal distractor, nailing in flexion/locking in extension, semiextended nailing (including percutaneous suprapatellar quads-splitting approaches), multiple proximal interlocking screws (>=3).Illustration A shows placement of a coronal blocking screw. Illustration B shows placement of a sagittal blocking screw. Illustration C shows the effect of the Herzog curve. A more distal Herzog curve leads to a "wedge" effect and fracture displacement whereas a proximal Herzog curve contains the fracture. The "wedge" effect occurs as the nail is seated and impinges on the posterior cortex of the distal segment accentuating an apex anterior deformity because of the effective widening of the nail above the bend and posterior force on the distal segment to match the nail shape.Incorrect Answers:

DISCUSSION: The patient has a displaced four-part proximal humerus fracture. Given her age and the presence of osteopenia, a cemented hemiarthroplasty is the treatment of choice. The glenoid is uninjured so a total shoulder arthroplasty is not indicated. Percutaneous pinning in younger individuals with good bone quality may be indicated but not in an 82-year-old woman with osteopenia. Sling immobilization and immediate pendulum exercises will lead to a nonunion. Sling immobilization for 6 weeks followed by active range of motion will result in a nonunion or malunion with unacceptable functional results. REFERENCES: Neer CS II: Displaced proximal humeral fractures: I. Classification and evaluation. J Bone Joint Surg Am 1970;52:1077-1089. Bigliani LU, Flatow EL, Pollock RG: Fractures of the proximal humerus, in Rockwood CA Jr, Matsen FA III (eds): Rockwood and Matsen The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, pp 352-354.

DISCUSSION: The radiographs and CT scans show a displaced intra-articular calcaneal fracture, with loss of calcaneal height and length. Recent multicenter, randomized, prospective studies suggest that surgical treatment of displaced intra-articular calcaneal fractures is associated with an almost six-fold decrease in the risk of posttraumatic subtalar arthritis (necessitating subtalar arthrodesis) compared to nonsurgical treatment. Despite ongoing controversy, surgical treatment has not been shown to be advantageous with respect to activity, time to return to work, or subtalar joint range of motion. A nonunion of a calcaneal fracture is exceedingly rare regardless of the treatment method.

Cephalomedullary implants for treatment of proximal femur fractures have gained in popularity over the last decade. Although these implants have improved outcomes for certain fracture types, multiple complications are associated with this implant. Failure may occur secondary to implant design (for example, mismatch of curvature of the nail to the femur, which can result in distal anterior cortical perforation).

There are four ways in which a plate acts: compression, tension band, bridge or spanning, and buttress. Since there is no cortical contact with the large span of comminution, this plate is acting as a bridge plate. A bridge plate is defined as when the plate is used as an extramedullary splint attached to the two main fragments, leaving the comminution untouched.

Salter-Harris III and IV fractures of the medial malleolus often contain a large cartilaginous portion, larger than the apparent ossified fragment seen on radiographs. Consequently, articular incongruity is common. As such, open reduction and internal fixation is often required. Growth disturbance and angular deformity are also common complications of Salter-Harris III and IV fractures of the distal tibia.

The patient has an open fracture of the physis of the distal phalanx with a portion of the nail bed interposed in the physis. Seymour initially described this injury in the distal phalanges of fingers. Optimal treatment consists of removing the interposed tissue, irrigating the fracture, and a short course of antibiotics. The nail should be preserved to provide stability.

DISCUSSION: Atrophic nonunions of the radius and ulna are fairly rare with modern techniques of fixation; the few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions. The referenced study by Ring et al noted a 100% healing rate and improved patient reported outcomes with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting for atrophic forearm nonunions.

The radiographs reveal a distal femoral fracture that is often associated with a neurovascular injury at the level of the fracture. Initial treatment should be to reduce the fracture, stabilize it, and then reevaluate the extremity for neurovascular function. A CT scan, arteriogram, or MRI scan would not help and would delay treatment. A cast would not be appropriate because access to the extremity is necessary and it would not provide stabilization for vascular repair if it is required.

DISCUSSION: The referenced study by Buckley et al is a prospective study of intra-articular calcaneus fractures at several trauma centers. They found that overall, the outcomes after nonoperative treatment were not different from those after operative treatment. However, when stratifying groups, women who were managed operatively scored significantly higher on the SF-36 than did women who were managed nonoperatively. Also, patients who were less than twenty-nine years old, had a Böhler angle of 0 degrees to 14 degrees, a comminuted fracture, or a light workload did better after surgery compared with those who were treated nonoperatively.