2. Trauma MCQs

DISCUSSION: The examination and radiographs are consistent with a sleeve fracture of the patella, which is an avulsion fracture of the distal pole of the patella with a disruption of the extensor mechanism. Treatment is open reduction and internal fixation of the patella, and repair of the extensor mechanism.The distal fragment can be much larger than it appears on the radiographs because it consists largely of cartilage.REFERENCES: Wu CD, Huang SC, Liu TK: Sleeve fracture of the patella in children: A report of five cases. Am J Sports Med 1991;19:525-528.Grogan DP, Carey TP, Leffers D, et al: Avulsion fractures of the patella. J Pediatr Orthop 1990; 10:721 - 730. Question 37When addressing a proximal intertrochanteric or subtrochanteric fracture in a juvenile with open growth plates, the arterial supply from what artery at the neck must be preserved?Lateral femoral circumflexMedial femoral circumflexSuperior glutealInferior glutealObturatorDISCUSSION: The medial femoral circumflex artery supplies blood to the femoral head. Its position along the posterior-superior femoral neck places this structure at risk with intramedullary nailing of the femur. Therefore, lateral entry through the greater trochanter is preferred when intramedullary fixation is performed.REFERENCES: Gordon JE, Swenning TA, Burd TA, et al: Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295- 1301.Green NE, Swiontkowski MF: Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 419-424.

DISCUSSION: Fractures with a posterior wall fragment that makes up less than one third of the surface generally are stable. Conversely, fractures with a fragment making up more than 50% of the surface are unstable. Patients with an intermediate fracture fragment should undergo a fluoroscopic examination under sedation or anesthesia to determine if the fragment is truly stable. If so, the patient can be treated nonoperatively and safely mobilized. REFERENCES: Tornetta P III: Non-operative management of acetabular fractures: The use of dynamic stress views. J Bone Joint Surg Br 1999;81:67-70. Keith JE Jr, Brashear HR Jr, Guilford WB: Stability of posterior fracture-dislocations of the hip: Quantitative assessment using computed tomography. J Bone Joint Surg Am 1988;70:711-714.

At 9 months, observation is no longer an option, as the fracture is not healing and is adjacent to an arthrofibrotic joint. Plate osteosynthesis has been shown to be an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and/or immobilization in a cast. Wiss et al reported a series of fifty tibial nonunions with a similar clinical scenario. He reported that, with compression plating, 92% of the nonunions healed without further intervention. In their study, 39/50 patients had autogenous bone grafting in addition to compression plating.

DISCUSSION: The patient had an open fracture that was initially treated with what appears to be appropriate irrigation and debridement and intramedullary nail placement. The post-operative infection and need for rotational flap is worrisome, but she has not had any issues since the flap. She has abundant callus formation but the fracture line is still visible and unchanged on 2 sets of radiographs. The patient has persistent pain. The best initial evaluation is to ensure that there is no underlying infection with laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Nuclear medicine studies have questionable utility, but may be helpful if the inflammatory markers from laboratory studies come back elevated. A CT scan is not warranted because the sequential radiographs show persistent fracture lines and no changes. The patient has a hypertrophic nonunion. Originally, she had appropriate treatment and has shown the ability to make callus, thus her biologic capacity appears to be intact and bone grafting is not needed. The hypertrophic nature of her fracture nonunion indicates that she needs more stability. The best treatment for a hypertrophic nonunion of the tibia is exchange nailing. Based on successive radiographs and the lack of healing, observation is probably just delaying the inevitable. Plating with retention of the nail can be useful in recalcitrant long bone non-unions, especially in the femur.

DISCUSSION: The humerus was treated with an intramedullary nail. Findings from two prospective randomized studies of intramedullary nailing or compression plating of acute humeral fractures have shown approximately a 30% incidence of shoulder pain with antegrade humeral nailing. This is the most common complication in both of these series. Nonunions are present in approximately 5% to 10% of humeral fractures treated with an intramedullary nail. Infection has an incidence of approximately 1%. Elbow injury is unlikely unless the nail is excessively long. Rarely, injury to the radial nerve is possible if it is trapped in the intramedullary canal. REFERENCES: Chapman JR, Henley MB, Agel J, et al: Randomized prospective study of humeral shaft fracture fixation: Intramedullary nails versus plates. J Orthop Trauma 2000;14:162-166. McCormack RG, Brien D, Buckley RE, et al: Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective, randomised trial. J Bone Joint Surg Br 2000;82:336-339.

DISCUSSION: Ipsilateral femoral neck and shaft fractures occur in up to 6% of femur fractures. A femoral neck fracture is often vertical and nondisplaced. A high degree of suspicion is necessary to avoid "missed" femoral neck fractures in patients with this condition. Although an examination and dedicated hip radiographs help to avoid missed injuries, a significant decrease in missed injuries has been described with the use of thin-cut pelvic CT images. In patients who undergo trauma, a pelvic CT scan is often performed to assess for associated injuries and is easily reviewed to examine the femoral neck. Although MRI is advocated to identify isolated occult femoral neck fractures, CT has been described as the method of choice with which to identify ipsilateral femoral neck and shaft fractures in the trauma population. Currently, no literature supports the use of MRI in this population. RECOMMENDED READINGS: Tornetta P 3rd, Kain MS, Creevy WR. Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol. J Bone Joint Surg Am. 2007 Jan;89(1):39-43. PubMed PMID: 17200308. Kuhn KM, Agarwal A. Femoral fractures. In: Cannada LK, ed. Orthopaedic Knowledge Update.

If both teams are present, a single timeout is sufficient for the entire procedure. If one team is absent, a second timeout needs to be completed prior to start of the second part of the procedure. The WHO pre-surgical safety checklist involves assessment at three points during an operative procedure: before induction of anesthesia, before skin incision, and before the patient leaves the operating room. Some components of the checklist include confirming IV access and allergies, administration of antibiotic prophylaxis, and surgical site verification. The surgeon has been shown to be the most effective team member at reducing complications when using the checklist. Haynes et al. evaluated the effects of the WHO pre-surgical checklist on perioperative complication rates at eight international sites. They found a significant reduction in rates of complications and death in patients over the age of 16 undergoing noncardiac procedures after implementation of the checklist. Illustration A shows the WHO pre-surgical checklist. Incorrect Answers: Answer 1: The intern does not need to be present for the timeout. Answer 2: The implant representative is not necessary for the timeout. Answer 4: The attending surgeon needs to be present in the same OR for the timeout. Answer 5: The timeout has been shown to decrease rates of complication and death.

DISCUSSION: The Chaput fragment, highlighted by the arrow in Illustration A, is the anterolateral fragment of the distal tibia. This section of bone attaches to the anterior inferior tibiofibular ligament and is often hinged off this structure due to the fracture. A pilon fracture is often split into three main fragments at the joint level (Illustration B): Chaput fragment (anterolateral), Volkmann fragment (posterolateral), and a medial fragment. The Volkmann fragment is the attachment site of the posterior inferior tibiofibular ligament. The Wagstaff fragment is the fibular corollary to the Chaput fragment, and serves as the other attachment of the anterior inferior tibiofibular ligament.

Closed treatment of humeral shaft fractures with functional bracing is indicated in the vast majority of isolated injuries. An ipsilateral brachial plexus injury, however, is a contraindication to nonoperative management in a functional brace.Indications for operative management of humeral shaft fractures are limited given the high rates of union and ability of adjacent joints to compensate for deformity. Intact muscular tone is necessary to effect bony apposition in closed treatment with a functional brace. The absence of neurologic and muscle function in patients with a flail extremity leads to increased rates of nonunion and malunion.Rutgers and Ring conducted a retrospective review of patients managed with functional bracing of humeral shaft fractures at a single institution. The authors found a 90% overall union rate, with maintenance of shoulder and elbow motion. They caution though, that 29% of their proximal third fractures went on to nonunion.Figure A demonstrates an AP radiograph of a comminuted humeral shaft fracture with varus alignment.Incorrect Answers:

DISCUSSION: Patients who sustain grade III open fractures that are related to a farm environment require ampicillin or penicillin for Clostridium coverage. REFERENCES: Holton PD, Mader J, Nelson CL, Osmon DR, Patzakis MJ: Antibiotics for the practicing orthopaedic surgeon. Instr Course Lect 2000;341:36-42. Wilkins J, Patzakis M: Choice and duration of antibiotics in open fractures. Orthop Clin North Am 1991;22:433-437.

DISCUSSION: Exchange nailing is indicated for nonunions of diaphyseal femoral and tibia fractures in the absence of infection, comminution, or segmental bone loss. Hypertrophic nonunions need better stability (increased nail diameter) to achieve union. Whereas atrophic nonunions often need better biology (bone graft, flap coverage, etc.). The referenced article by Brinker et al reviews the indications for exchange nailing. They argue, on the basis of the available literature, that exchange nailing is an excellent choice for aseptic nonunions of noncomminuted diaphyseal femoral and tibia fractures. Zelle et al. demonstrated 95% success with reamed exchange nailing for the treatment of aseptic tibial shaft nonunions that were initially treated with nonreamed intramedullary nailing.

DISCUSSION: A recent randomized trial of surgical versus nonsurgical management of calcaneal fractures showed that patients who were on workers’ compensation did poorly with surgical care. These patients had less favorable outcomes regardless of their initial management. Factors such as age, smoking, and vasculopathies compromise skin healing, leading to greater surgical risks. The best results were obtained in patients who are younger than age 40 years, have unilateral injuries and are injured during noncompensable activities. Women tend to do better with surgery than men. REFERENCES: Howard JL, Buckley R, McCormack R, et al: Complications following management of displaced intra-articular calcaneal fractures: A prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma 2003;17:241-249. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744.

DISCUSSION: The radiographs reveal a severely comminuted distal humerus fracture. A long arm cast, functional bracing, and closed reduction and percutaneous pin fixation all have a poor outcome and could result in a nonunion that will be very difficult to treat. Open reduction and internal fixation is indicated in most supracondylar humerus fractures, but total elbow arthroplasty is a good alternative in elderly patients who have multiple medical problems and when the fracture pattern may preclude stable enough internal fixation to allow postoperative motion. REFERENCES: Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients. J Bone Joint Surg Am 1997;79:826-832. Morrey BF: Fractures of the distal humerus: Role of elbow replacement. Orthop Clin North Am 2001;31:145-155.

DISCUSSION: As reviewed in the referenced article by Starr et al, when placing a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best determine the anteroposterior placement of the screw in the pubic ramus. To ensure placement outside of the joint, the outlet obturator oblique is best, but all other views should be incorporated into determination of the position of fixation, as the corridor for this screw placement is quite narrow.

DISCUSSION: The fracture has occurred around the stem, representing a Vancouver type B fracture, and the stem is clearly loose, making it a type B2 fracture. The appropriate treatment is removal of the loose in situ stem; ORIF of the femur using cerclage wires, cables, or a plate; and insertion of a longer revision stem such as a tapered fluted modular titanium or fully porous coated cylindrical stem to bypass the fracture. All of the other options are incorrect, because they represent inappropriate treatment options for a Vancouver type B2 fracture.

DISCUSSION: The risk of femoral nonunion after intramedullary nailing is significantly increased when NSAIDs are administered post-operatively. Giannoudis et al assessed factors which could affect union in 32 patients with nonunion of a fracture of the diaphysis of the femur and 67 matched patients whose fracture had united. They found that there was no relationship between the rate of union and the type of implant, mode of locking, reaming, distraction or smoking. They also concluded that there was a marked association between nonunion and the use of NSAIDs after injury and delayed healing was noted in patients who took NSAIDs and whose fractures had united. Burd et al performed a study to determine if patients with an acetabular fracture, who received indomethacin for prophylaxis against HO, were at risk of delayed healing or nonunion of any associated fractures of long bones. The study group consisted of 112 patients who had sustained at least one concomitant fracture of a long bone; of which 36 needed no prophylaxis, 38 received focal radiation and 38 received indomethacin. When comparing patients who received indomethacin with those who did not, a significant difference was noted in the rate of long bone nonunion (26% vs 7%).

DISCUSSION: Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction. REFERENCES: Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314. Young CF, Nanu AM, Checketts RG: Seven-year outcome following Colles’ type distal radial fracture: A comparison of two treatment methods. J Hand Surg Br 2003;28:422-426.

DISCUSSION: The radiographs show a minimally displaced fracture of the tibial eminence, which is classified as a McKeever type II injury. In a number of studies, it has been found that most of these fractures will reduce with extension of the knee. This is often made easier with evacuation of the hemarthrosis. The position of knee immobilization is controversial, with some authors preferring full extension and others preferring 20 degrees of flexion. Flexion to 90 degrees will further displace the fragment. If the fragment does not reduce or if the patient has a McKeever type III or IV injury, reduction and internal fixation are required. This can be done with either an open or an arthroscopic procedure. Excision of the fragment is not indicated. REFERENCES: Meyers MH, McKeever FM: Fractures of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684. Wiley JJ, Baxter MP: Tibial spine fractures in children. Clin Orthop 1990;255:54-60. Janarv PM, Westblad P, Johansson C, Hirsch G: Long-term follow-up of anterior tibial spine fractures in children. J Pediatr Orthop 1995;15:63-68. Kuhn JE, Sailer MJ, Sterett WI, Hawkins RJ: Arthroscopic technique for the treatment of tibial spine fractures in the skeletally immature patient. J Ortho Tech 1995;3:7-12.

DISCUSSION: The 1,2 intercompartmental supraretinacular artery is a branch of the radial artery. The vessel provides a reliable source of vascularized bone graft with an adequate pedicle length for use in scaphoid nonunions. REFERENCES: Sheetz KK, Bishop AT, Berger RA: The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20:902-914. Steinmann SP, Bishop AT, Berger RA: Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg 2002;27:391-401.

According to the first referenced study by Egol et al, appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries. The second reference by Egol studied only operatively treated ankle fractures and found that time to appropriate braking returns at 9 weeks postoperatively. Interestingly, no significant association was found between the functional scores and normalization of total braking time.