2. Trauma MCQs

DISCUSSION: Pollak and associates found that the average SF-36 score for patients who sustained a pilon fracture was significantly lower than patients with diabetes mellitus, AIDS, hypertension, asthma, migraines, pelvic fracture, polytrauma, and AMI. Moreover, patients having undergone pilon fixation scored lower on all but three of the SF-36 scales (vitality, mental health, and emotional health). REFERENCE: Pollak AN, McCarthy ML, Bess RS, et al: Outcomes after treatment of high-energy tibial plafond fractures. J Bone Joint Surg Am 2003;85:1893-1900.

Anterior-inferior plate fixation of midshaft clavicular fractures has evolved to be an alternative plate location compared to superior plating. The advantages of anterior-interior plating are reduced prominence of the hardware compared to the subcutaneous superior plates; the potential for placement of longer screws as the clavicle is wider front to back than top to bottom, especially laterally; and a potential for decreased risk to the subclavian structures. A relative disadvantage of anterior-inferior plating is a need to detach a small portion of the deltoid origin. Union rates for anterior-inferior plating are similar to those with superior plating.

Pelvic external fixation can be used for the acute resuscitation of patients with pelvic fractures and for definitive treatment of certain injury patterns. Typically frames are constructed with anterosuperior half-pin placement within the iliac crest. Intracortical placement of these pins may be difficult and erroneous placement may render purchase inadequate. Recently, external fixation of the pelvic ring with half-pin placement into the dense supra-acetabular bone in the region of the anterior inferior iliac spine has gained popularity. Kim and associates, in a biomechanical model, demonstrated that anterior-inferior pin placement was biomechanically superior to conventional anterior-superior pin placement in rotationally and vertically unstable fracture patterns. Haidukewych and associates performed a cadaveric study that demonstrated the lateral femoral cutaneous nerve is at risk within a mean distance of 10 mm from the inferior half-pin site but the femoral nerve and femoral artery are not at risk. The average superior extent of the hip capsule was 16 mm above the joint. They suggested that these pins be inserted at least 2 cm above the hip to avoid potential hip capsule penetration. Poelstra and Kahler described a case during which the lower pins were inserted without the benefit of imaging using only palpable landmarks. However, this technique is better reserved for nonresusitative purposes permitting the use of multiplanar fluoroscopic imaging. Image guidance better ensures proper pin placement within the pelvic cortices, minimizing penetration of the hip joint and sciatic notch. No anterior external fixator, regardless of design or region of application, offers sufficient posterior stability to serve as definitive treatment for vertically unstable pelvic fracture variants.

DISCUSSION: Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems. REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: End point of resuscitation. J Trauma 2004;57:898-912. Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89. Englehart MS, Schreiber MA: Measurement of acid-base resuscitation end points: Lactate, base deficit, bicarbonate or what? Curr Opin Crit Care 2006;12:569-574.

DISCUSSION: The patient has a severe high-energy injury from axial loading to the left ankle and distal tibia. This is a closed injury, but the soft tissues are injured and severely swollen. Initial treatment should focus on skeletal stabilization, and incisions directly over the fracture area should be avoided until soft-tissue stabilization has occurred. Immediate spanning external fixation with plans for a delayed reconstruction as needed for the joint surface is the treatment of choice. Closed reduction and application of a constrictive long leg cast may lead to increased risk of tissue necrosis. Immediate open procedures to internally fix the fracture add the risks of soft-tissue necrosis and are to be avoided. Percutaneous plating may be one of the delayed fixation options but should not be used immediately. Primary ankle arthrodesis is not indicated. REFERENCES: Thordarson DB: Complications after treatment of tibial pilon fractures: Prevention and management strategies. J Am Acad Orthop Surg 2000;8:253-265. Marsh JL, Bonar S, Nepola JV, DeCoster TA, Hurwitz SR: Use of an articulated external fixator for fractures of the tibial plafond. J Bone Joint Surg Am 1995;77:1498-1509. Wyrsch B, McFerran MA, McAndrew M, et al: Operative treatment of fractures of the tibial plafond: A randomized, prospective study. J Bone Joint Surg Am 1996;78:1646-1657.

The fracture shown represents a both column fracture described by Letournel and Judet. The fracture is a combination of a posterior column fracture and an anterior column fracture. T-type, transverse and hemitransverse all have a transverse element to them. The fracture shown involves more than just the anterior column.Note the classic “Spur Sign” seen in these radiographs. This is pathognomonic of a both-column fracture of the acetabulum.The other defining feature of the both column fx (as evident by these films) is that there is no intact acetabulum connected to the bone fragment which is connected to the ipsilateral SI joint.

The patient initially has a distal third femoral fracture and a pulseless limb. The first step is to reduce the fracture and reassess the vascular status. Although the pulse returns, it feels different than the quality of the pulse in the contralateral uninjured extremity. There is a risk of a vascular injury with this fracture pattern due to tethering of the femoral vessels at the adductor hiatus; therefore, the vascular status needs further assessment since the pulses are not symmetrical. A physical examination is not very accurate in assessing whether a vascular injury is present; therefore, serial examinations are not appropriate. Angiography is very sensitive and specific but is time consuming and can cause complications secondary to the dye and the arterial puncture required to perform it. Duplex ultrasound is effective but is very operator-dependent and may not be available 24 hours a day. The ABI is easily performed and has been shown to be sensitive and specific. If the value is greater than 0.9, the negative predictive value is 99% and when the value is less than 0.9, it is 95% sensitive and 97% specific for a major arterial injury. It has been shown to be useful for blunt lower extremity injuries as well as knee dislocations.

Numerous reports have documented serious complications including death from migration of intact or broken Kirschner wires or Steinmann pins into hilar structures such as the heart, pulmonary artery, and the aorta.

The displaced talar neck fracture should be treated with open reduction and internal fixation using screws. Closed reduction and casting will not maintain position, and percutaneous pinning is not able to maintain reduction to allow union. External fixation and amputation are not necessary for this injury unless there is severe soft-tissue loss.

Pediatric distal clavicle fractures are typically treated non-operatively because of the great osteogenic capacity of the intact inferior periosteum. The coracoclavicular ligaments remain attached to the periosteum and new bone fills any remaining bony gaps within the periosteal sleeve. Recent articles by Nenopoulos et al recommend sling immobilization for the majority of fractures (84%) and only attempt surgical fixation for children >8 years old with severely displaced fractures (>2 cortical diameters). They found excellent function with conservative treatment and union in all fractures. Surgical care resulted in improved cosmetic appearance.

Discussion: Suprapatellar nailing has been very useful in the management of proximal tibia fractures, allowing a better reduction. Both arthroscopy and MRI have been utilized after suprapatellar nailing to evaluate for changes in the patellofemoral joints, and no significant changes can be attributed to this technique. In a comparative study between suprapatellar nailing and standard (infrapatellar) nailing, both techniques showed excellent range of motion and no significant differences between the methods. In a separate study, it was noted that patients who underwent suprapatellar nailing did not complain of anterior knee pain that is often seen with standard nailing.

The posterior portal created 3 cm proximal to the tip of the olecranon and the posterior lateral portal created 3 cm proximal from the tip of the olecranon and just lateral to the triceps are the "workhorse" portals of the posterior compartment and although relatively safe, risks exist. The radial nerve proximity averages 4.8 mm (3 to 8 mm) from the posterolateral portal. The central posterior portal is close to 20 mm from the ulnar nerve.

DISCUSSION: Although the Holstein-Lewis fracture, described as an oblique distal one third fracture, is best known for its association with neurologic injury, radial nerve palsy is most commonly associated with middle one third humeral fractures. Most nerve injuries are neurapraxias or axonotmeses, with up to 90% resolving in 3 to 4 months.

EXPLANATION: Compartment syndrome of the hand can result from a variety of factors, including a traumatic event such as crush injury, fracture, vascular insult, a high-pressure injection injury, or an insect or spider bite. The treatment involves decompressive fasciotomy of the involved compartments. The diagnosis of hand compartment syndrome is determined by history, examination, and objective testing. Patients experience pain out of proportion to the injury, along with swelling and tense skin. Pain may occur with passive motion of the metacarpophalangeal joints as the intrinsic muscles are stretched. Invasive intracompartmental pressures can be measured in the compartments of the hand but not in the fingers. Arterial Doppler studies assess arterial blood flow, and an abnormality would be a late finding. MRI would show edema of the hand and fingers, but the decision to perform surgical release is less likely made from the findings. The most appropriate method of determining the need for finger fasciotomy is the history and physical examination.

Fragility or osteoporotic fractures are common in postmenopausal women and older men and include fractures of the proximal humerus and distal radius and hip and vertebral compression fractures. The most reliable predictor of a fragility fracture is a past fragility fracture. Use of bisphosphonates for treatment of osteoporosis results in atypical femur fractures and a decrease in risk for fragility fractures (including hip fractures). There also are reports of osteonecrosis of the mandible with prolonged use of these drugs. Current medical literature suggests stopping these drugs after 3 to 5 years to allow bone remodeling.

How many compartments exist in the foot:

On the basis of the delayed diagnosis of these injuries, a best-practice protocol was developed by the attending trauma surgeons for the evaluation of the femoral neck in patients with a femoral shaft fracture. This protocol includes a preoperative AP internal rotation radiograph of the hip, a fine-cut (2-mm) CT scan through the femoral neck (as a part of the initial trauma scan), and an intraoperative fluoroscopic lateral evaluation of the hip just prior to fixation of the femoral shaft. They found that fine-cut CT (2 mm was the best screening tool in this group of patients) identified 12 of the 13 fractures.

In the US, about 1.5 million fractures occur annually. Each year, 250,000 new vertebral compression fractures are diagnosed, and more than 80% of these are related to weakened vertebral bodies secondary to osteoporosis. Patients with vertebralfractures are more likely to fall and are five times more likely to sustain subsequent fractures than individuals without such a fracture. Analysis of data from Medicare patients with a vertebral fracture had an overall mortality rate that was approximately twice that of the matched controls. The survival rates following a fracture diagnosis, as estimated with the Kaplan-Meier method, were 53.9%, 30.9%, and 10.5% at 3, 5, and 7 years, respectively which were significantly lower than the rates for the controls. The mortality risk following a fracture was greater for men than for women. The mortality risk was greater when the fracture occurred at a younger age. The adjusted hazard ratio was 1.8 compared to the non-fracture group

After HTO, particularly in patients who have been immobilized after a closing-wedge osteotomy, patella baja is a common finding. This can precipitate anterior knee pain or patellofemoral pain syndrome. Recurrence of medial joint overload is incorrect because the patient has no medial joint complaints. Nonunion is less likely with a closing-wedge osteotomy and likely will not result in anterior knee pain.

Rib fractures are the most commonly observed fractures associated with scapular fractures.Scapular fractures are associated with high-energy trauma, with motor vehicle collisions being a common mechanism of injury. These fractures are also associated with increased Injury Severity Scores and therefore clinicians need to be cognizant of concomitant injuries. In addition to associated orthopaedic injuries, pulmonary injuries (contusions, hemothorax, and pneumothorax) and head injuries are associated with scapular fractures. A CT chest should be considered in patients with scapulafractures, to best visualize associated rib fractures and pulmonary injuries.Baldwin et al. conducted a retrospective case control analysis using the US National Trauma Database that included 9,453 scapular fractures. In their study, the most commonly associated fractures were rib fractures (52.9%), followed by fractures of the spine (29.2%), clavicle (25.2%), and pelvis (15.3%). Lung and head injuries occurred in 47.1% and 39.1% of the cases, respectively.Incorrect Answers:(SBQ12TR.107) An 87-year-old female sustains the injury shown in Figure A after a fall from standing. At baseline, she ambulates with a walker in her home and lives with a 24-hour home health aide. She has a past medical history of stroke and mild dementia. Following medical optimization, what is the most appropriate treatment modality?Intramedullary nailHemiarthroplastyClosed reduction percutaneous pinningTotal hip arthroplastySliding hip screwAt baseline, with minimal ambulatory status and dependence on a 24-hour home health aide, the best treatment choice is hemiarthroplasty.Arthroplasty is the gold standard for displaced femoral neck fractures in the elderly. In community ambulators with relative independent lives, total hip arthroplasty (THA) is recommended. For minimal ambulator, hemiarthroplasty is recommended.van den Bekerom et al. randomized 252 patients over 70-years-old to either THA or hemiarthroplasty for displaced femoral neck fractures. With increased blood loss, operative time and dislocation risk, they did not recommend THA unless there was good preoperative ambulatory status, and/or pre-existing osteoarthritis or rheumatoid arthritis.Figure A exhibits a displaced femoral neck fracture Incorrect answers: