2. Trauma MCQs

Hypoxia and hypotension are associated with lower GCS scores in polytrauma patients with major head injuries, but whether early fracture fixation adversely affect CNS outcomes has been controversial. New studies, however, have found no association between early surgery and decreased discharge GCS scores. The referenced study by Scalea et al reviewed 171 patients with pelvic or lower extremity fractures and head injuries; they showed no difference in CNS outcomes or mortality in patients who underwent early fixation. The second reference by Brundage et al showed improved outcomes (including high GCS scores at time of discharge) in those who had early fixation of femoral shaft fractures in the head-injured patient. The last referenced study by Jaicks et al found a lower discharge GCS in the early fracture fixation group compared with the late group. However, they also found that early fracture fixation was associated with hypoxemia and hypotension, as well as greater fluid administration.

DISCUSSION: Historically, normal blood pressure, heart rate, and urine output have been endpoints to signal complete resuscitation in the polytrauma patient. The review article by Porter et al states that there is a high incidence of patients (as much as 85%) in "compensated" shock despite normal vital signs and urine output parameters. Compensated shock is secondary to a maldistribution of blood flow and tissue oxygenation as splanchnic organs have less distribution of the cardiac output compared to the heart and the brain. The article by Elliott is also a review, and it states that serum lactate is the best indicator of peripheral organ perfusion and tissue oxygenation. It also states that base deficit and gastric mucosal pH are appropriate end points to determine the complete resuscitation of trauma patients.

This patient has had an unconstrained total elbow arthroplasty (TEA). Unconstrained TEA is least preferred for late-stage rheumatoid arthritis where there is significant capsuloligamentous instability and bony erosion.Unconstrained (unlinked or resurfacing prosthesis) TEA depend on intact bony and ligamentous constraints for stability. These are appropriate for humeroulnar conditions with intact collateral ligaments and radiocapitellar articulation e.g. osteoarthritis, post-traumatic arthritis, intra-articular distal humerus fracture, and malunion of the distal humerus. Conditions with increased risk of instability (ligamentous injury, rheumatoid arthritis) will benefit from a linked or semiconstrained prosthesis.Mansat et al. reviewed the Coonrad-Morrey linked (semi-constrained) TEA implant in 70 patients after 5 years. They found that patients with inflammatory arthritis had higher function than those with traumatic conditions (fractures, nonunions and posttraumatic arthritis). Survival rate was 98% and 91% at 5 and 10 years, respectively. They concluded that this implant provided satisfactory treatment for different indications although radiolucent lines and bushing wear were a concern.Hildebrand et al. reviewed the functional outcome of the Coonrad-Moorey prosthesis in 51 elbows after 50 months. The inflammatory arthritis group had higher performance scores than the traumatic/post-traumatic conditions group. Isometric extensor torque was found to be less than the nonoperated side. Radiolucency was noted in 11 elbows.Figures A and B show an unconstrained TEA with radial head replacement. Illustration A shows more examples of unconstrained TEA. Illustration B shows a semiconstrained TEA. The arrow points to the anterior flange. Illustration C shows radiolucent lines around the stems. Illustration D shows severe bushing wear leading to locking mechanism failure. Illustration E is a table comparing linked and unlinked implants.Incorrect Answers:

The patient has a symptomatic painful atrophic midclavicular nonunion, and the treatment of choice is rigid internal fixation with a dynamic compression plate and autogenous bone grafting. A tension band effect is desired and achieved by placing the plate superiorly. Excellent success rates of 90% to 100% have been reported using this technique. Intramedullary screw fixation without bone grafting has a decreased success rate. Partial claviculectomy is not a preferred option.

The patient has an intertrochanteric fracture malunion with protrusion of the hardware and penetration into the acetabulum. To restore leg length and relieve pain, total hip arthroplasty is necessary. Valgus osteotomy is appropriate for fracture nonunion with an intact femoral head with no signs of osteonecrosis. Bipolar hemiarthroplasty with acetabular erosion will most likely lead to pain as will removal of the hardware with or without physical therapy.

The patient has a nonunion of the lateral condyle of the left humerus. Observation or cast treatment at this stage is not likely to lead to healing of the fracture. MRI will not add any additional information. Open reduction, with minimal posterior soft-tissue stripping, is recommended to establish union of the fracture. Local or other bone graft may also be required. There are no studies that indicate that the displaced fracture will heal with late percutaneous fixation.(SBQ13PE.40) Immediate spica casting is most appropriate for which of the following?:Review Topic2-month-old girl with a displaced spiral mid-diaphyseal femur fractureA 26-month-old boy with a displaced spiral mid-diaphyseal femur fracture with <2 centimeters of shortening3-day-old with teratologic right hip dislocation9-year-old boy with a displaced spiral mid-diaphyseal femur fracture12-year-old girl weighing 90 pounds with a displaced spiral mid-diaphyseal femur fractureChildren older than 6 months and up to 6 years with diaphyseal femur fractures may be treated with spica casting.Children younger than 6 months may only require a Pavlik harness. Immediate spica casting is indicated in children 6 months to 6 years with less than 2 cm of shortening. Each additional cm of shortening at presentation doubles the risk of loss of reduction (1 cm: 12%, 2 cm: 24%, 3 cm; 50%).Kocher et al. provide the AAOS Clinical Practice Guideline for the treatment of pediatric diaphyseal femur fractures. Their recommendation for diaphyseal femur fractures with <2 cm shortening in children 6 months to 5 years is Grade B, based on Level II evidence (two level II and one level I study). They recommend early spica or traction with delayed spica. They suggest early spica, as this is more convenient than traction.In an earlier article, Flynn et al. review the management of pediatric femoral shaft fractures. They recommend early spica casting for the child between 1 and 6 years inlow-energy femoral fractures with up to 2 cm shortening. Illustration A shows several styles of lower extremity spica casts.Incorrect answers:

Discussion: Unstable pelvic fractures can be devastating injuries often resulting in significant morbidity and even death. According to the referenced study by Smith et al, fracture pattern and angiography/embolization were not predictive of mortality in patients with unstable pelvic injuries. The three factors they found to be predictive were: increased blood transfusions in the first 24 hours, age >60 years, and increased ISS or RTS scores. Deaths were most commonly from exsanguination (<24 hours) or multiorgan failure (>24 hours). Incorrect Answers: Choices 1-4 are not as predictive of mortality as choice 5.

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of

Discussion: Pelvic bleeding occurs predominantly from disruption of the posterior venous plexus and bleeding from the fractured bone. Occasionally arterial bleeding is seen, with injury to the superior gluteal artery most common. Anterior pelvic bleeding occurs from injury to the obturator artery (commonly from a pubic bone fracture laceration) and less frequently from the pudendal artery near the symphysis. The location of the bleeding on CT and angiography images does not correspond to the superior gluteal, external iliac, or femoral arteries.

Popliteal artery injury during total knee arthroplasty is relatively rare. Knee flexion, the position that occurs during most of the arthroplasty procedure, allows the popliteal vessels to fall posteriorly, further away from harm. Anatomically, the popliteal artery lies anterior to the popliteal vein and 9 mm posterior to the posterior aspect of the tibial plateau in 90 degrees of flexion.

A concern in the multiply injured patient who has a pulmonary contusion is the potential for further pulmonary compromise because of embolization of marrow, blood clot, or fat during manipulation of the medullary canal. Because damage control in the multiply injured patient requires a technique that can be performed rapidly and consistently, the treatment of choice is application of an external fixator. By placing two pins above and below the fracture and with longitudinal traction, the fracture is quickly realigned and stabilized.

DISCUSSION: The dial or spherical osteotomy leaves the medial wall or teardrop in its original position and, as a result, is intra-articular. The other pelvic osteotomies (except Chiari) redirect the acetabulum, including the medial wall. The Chiari osteotomy improves coverage without redirecting the acetabulum within the pelvis, and it leaves the teardrop in the same place.

All of the aboveCorrent answer: 4The maximum acceptable difference in rotational malreduction between the surgical and contralateral legs for femoral version is 15°. Therefore, answers 1 and 2 are correct.Normal femoral neck anteversion is approximately 11-13°, with a normal range between 5-20°. The variation within the same patients can also be up to 15° difference between limbs. Current literature has shown that this 15° difference is well tolerated by patients, including when this has occured as a result of rotational malreduction following intramedullary nail fixation for a diaphyseal femur fracture.Ayalon et al. aimed to compare the difference in femoral version (DFV) after intramedullary nailing performed by a trauma-trained and non-trauma trained surgeon. The mean post-operative DFV was 8.7° in these patients, compared to 10.7° in those treated by surgeons of other subspecialties. Post-operative version or percentage of DFV >15° did not significantly differ between these two groups.Omar et al. studied the utility of pre-operative 'virtual reduction' of bilateral femoral fractures that were initially stabilized with external fixation. After external fixation, the mean rotational difference between both legs was 15.0°± 10.2°. Following virtual reduction, the mean rotational difference between both legs was 2.1° ± 1.2°, after intramedullary nailing, compared to 6.1° ±

DISCUSSION: The patient sustained a high-angle femoral neck fracture. The follow-up clinical findings and radiograph show that she now has a nonunion with failed internal fixation. The joint appears preserved. In a healthy, young patient, arthroplasty of the femoral head, although possible, is not ideal. Excellent healing and function can be obtained in 70% to 80% of patients with femoral neck nonunion with a valgus intertrochanteric osteotomy.

DISCUSSION: Surgical treatment of sub-acute pelvic ring injuries is relatively uncommon. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are indications to repair the pelvic ring, and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion.

DISCUSSION: Several studies have documented the satisfactory outcomes of total elbow arthroplasty when osteosynthesis is not feasible for fixation of a distal humerus fracture, particularly in the physiologically older patient with low functional demands. Total elbow arthroplasty should be considered when a comminuted intra-articular distal humerus fracture occurs in a woman older than age 65 years, particularly with such associated comorbidities as systemic steroid use, osteoporosis, or rheumatoid arthritis.

The fracture pattern shown in the radiographs is a fracture of the posterior column. The only line interrupted on the AP pelvis is the ilioischial line. The obturator oblique view shows that the iliopectineal line is intact as is the outline of the posterior wall. The iliac oblique view shows an interruption of the ilioischial line and an intact anterior wall. Therefore, this fracture is a fracture of the posterior column.

This patient has an anteroposterior compression pelvic fracture associated with shock. In patients with closed pelvic fractures and hypotension, mortality rises to approximately 1 in 4 (10%-42%) and hemorrhage is the major reversible contributing factor. Initial management of a major pelvic disruption associated with hemorrhage requires hemorrhage control and rapid fluid resuscitation. A pelvic binder should be placed to reduce pelvic volume. The patient has signs and symptoms of class IV hemorrhage, which include marked tachycardia exceeding 140, a significant decrease in BP, and a very narrow pulse pressure. Urinary output is negligible, and mental status is markedly depressed. The skin is cold and pale. The degree of exsanguination with class IV hemorrhage is immediately life-threatening, and rapid transfusion and immediate surgical intervention are necessary. Nonresponse to fluid administration indicates persistent blood loss. Blood preparation should be emergency blood release. Type and cross-match of blood can be used for additional resuscitation in transient responders.

DISCUSSION: In a multivariate analysis, the strongest factor for the development of compartment syndrome is fracture of the proximal third of the forearm. However, compartment syndrome can still occur without a fracture. Therefore, these patients should be followed with a high level of suspicion for the development of compartment syndrome. REFERENCES: Moed BR, Fakhouri AJ: Compartment syndrome after low-velocity gunshot wounds to the forearm. J Orthop Trauma 1991;5:134-137. Hahn M, Strauss E, Yang EC: Gunshot wounds to the forearm. Orthop Clin North Am 1995;26:85-93.