2. Trauma MCQs

DISCUSSION: This fracture is displaced, and there is dislocation of the subtalar joint. The tibiotalar and talonavicular joints remain reduced. In the classification originally created by Hawkins and modified by Canale and Kelly, this would be a Hawkins type II, carrying a 20% to 50% risk of osteonecrosis.

DISCUSSION: Both the medial collateral ligament and the olecranon contribute to valgus stability of the elbow. Excessive olecranon resection increases the demand placed on the medial collateral ligament in resisting valgus forces during throwing. Bone removal from the olecranon should be limited to osteophytes.

This is a Bado type 2 (posterior) Monteggia lesion, which is associated with higher rates of complications than other types of Monteggia lesions. The injury is associated with indirect high-energy trauma and less often pathologic causes. Of the four types of Monteggia lesions, the type 2 or posterior type is associated with the worst prognosis. These injuries are best treated surgically with dorsal plating of the ulna and reduction with fixation or arthroplasty of the radial head. The major complications seen with this injury pattern are nonunion and plate failure. Almost all patients have some loss of elbow range of motion. Satisfactory results based on functional scores for this injury are not universal. Neurologic injury and ulnohumeral instability are unusual with this type of injury. Full functional recovery is not expected with nonsurgical management.(SBQ12TR.101) An otherwise healthy young adult male sustains a transverse radial shaft and ulna fracture. He undergoes definitive surgical fixation with two nonlocking compression plates (LCPs) as shown in Figure A. What is the principle of this fixation technique on bone healing?Absolute stability with direct healing by callus formationRelative stability with indirect healing by callus formationAbsolute stability with direct healing by internal remodelingRelative stability with indirect healing by internal remodelingAbsolute stability with endochondral bone formationDefinitive surgical fixation for a simple transverse both bone forearm fracture would include open reduction and internal fixation with absolute stability with direct healing by internal remodelling (i.e., primary bone healing). The radius is fixed with a 7-hole

DISCUSSION: Displaced greater tuberosity fractures often will block abduction and/or external rotation by impinging on the underside of the acromion or posterior glenoid. The indications for open reduction and internal fixation are 1 cm of displacement or 45 degrees of rotation of the tuberosity fracture. Surgical treatment has recently been recommended for 0.5 cm of tuberosity displacement. REFERENCES: Neer CS II: Displaced proximal humeral fractures: II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090-1103. Flatow EL, Cuomo F, Maday MG, et al: Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus. J Bone Joint Surg Am 1991;73:1213-1218.

DISCUSSION: This patient is unstable and is not a good candidate for Early Total Care (ETC) and therefore should be managed by the tenets of Damage Control Orthopaedics (DCO). Débridement and external fixation is preferable for this patient. Intramedullary nails would be a component of ETC. Calcaneal traction is not considered ideal because it does not allow the patient to travel as easily. The S.P.R.I.N.T. study concluded that while reamed nails may offer benefit in closed fractures, there was no difference between reamed or unreamed nails in the treatment of open fractures of the tibia. Uniplanar external fixation and tibial plating are not considered the best options for open tibia fractures. Additional findings of the S.P.R.I.N.T. study conclude that delaying surgical intervention for at least 6 months after injury may reduce the need for reoperation.

DISCUSSION: Delayed wound healing and wound dehiscence is the most common complication of surgical management of calcaneal fractures through an extensile lateral approach, occurring in up to 25% of patients. Most wounds ultimately heal with local treatment; the deep infection rate is approximately 1% to 4% in closed fractures. Posttraumatic arthritis may develop despite open reduction and internal fixation, but the percentages remain low. Peroneal tendinitis may occur from adhesions within the tendon sheath or from prominent hardware but is relatively uncommon. Nonunion of a calcaneal fracture is rare. REFERENCES: Sanders RW, Clare MP: Fractures of the calcaneus, in Coughlin MJ, Mann RA, Saltzman CL (eds): Surgery of the Foot and Ankle, ed 8. Philadelphia, PA, Mosby-Elsevier, 2007, vol 2, pp 2017-2073. Sanders RW, Clare MP: Fractures of the calcaneus, in Bucholz RW, Heckman JD, Court-Brown C (eds): Rockwood and Green’s Fractures in Adults, ed 6. Philadelphia, PA, Lippincott Williams & Wilkins, 2006, vol 2, pp 2293-2336.

DISCUSSION: Locked plating is becoming more common. Some biomechanical data comparing locked plating to standard plating have been reported for osteoporotic distal femoral fractures and humeral shaft fractures. Significant differences were seen mainly for osteoporotic fractures without cortical contact. Not all osteoporotic fractures and all comminuted fractures have been shown to demonstrate significant mechanical improvement with locked plating compared to standard plating. Spiral fractures often can be repaired with a lag screw, obtaining adequate cortical contact. Osteoporotic fractures with a torsion mode of failure failed earlier with locked plating systems than with standard plating systems. REFERENCES: Zlowodzki M, Williamson S, Cole PA, et al: Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures. J Orthop Trauma 2004;18:494-502. Comparison of the AO Locking Plate with the Standard Limited-Contact Dynamic Compression Plate (LC-DCP) for Fixation of Osteoporotic Humeral Shaft Fractures. David J. Hak, MD, MBA; Scott J. Hazelwood, PhD. OTA Book of Abstracts 2003.

DISCUSSION: Tibial tuberosity fractures are uncommon avulsion injuries. Most are sports-related and occur in older adolescents. Type I fractures represent an avulsion of a small fragment of the tuberosity. Type II fractures involve the entire anterior tuberosity with extension proximally to the level of the horizontal portion of the proximal tibial physis. Type III injuries involve the entire tuberosity with extension proximally into the articular surface, a Salter-Harris type III fracture. Patients present with pain, swelling, and tenderness over the tuberosity. Patella alta may be present. Surgical treatment of type I fractures is needed if patella alta (compared to the normal uninjured side) and a significant bony prominence are present. Displaced types II and III fractures are treated with open reduction and internal fixation. A cancellous interfragmentary screw may be placed through the tuberosity into the metaphysis. Because this injury occurs in patients near skeletal maturity, growth arrest with secondary genu recurvatum is rare. The mechanism is typically a violent contraction of the quadriceps while the knee is flexed or axially loaded.

DISCUSSION: Osteonecrosis of the femoral head is a known complication from the use of rigid intramedullary nails for femoral fractures in adolescents. When the nails are placed through the piriformis fossa, the lateral ascending vessels of the femoral neck may be injured, resulting in osteonecrosis of the femoral head in 1% to 2% of patients. Rigid reamed nails placed into the piriformis fossa are contraindicated in children with open growth plates because the physis is a barrier to blood supply and the ligamentum teres does not provide sufficient vascularity. Alternative fixation methods for femoral fractures in adolescents include external fixation and open reduction and internal fixation. Nailing through the tip of the trochanter may decrease the incidence of this serious complication.

DISCUSSION: A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.

DISCUSSION: Functional bracing has been demonstrated to have a very high rate of healing without any functional limitations in a large series of patients. Surgery is reserved for “floating elbows,” open injuries, neurovascular injuries, and those fractures that go on to nonunion. REFERENCES: Sarmiento A, Zagorski JB, Zych GA, et al: Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am 2000;82:478-486. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, p 267.

Tension band wiring may not provide adequate stability to prevent displacement in a comminuted fracture. Plate fixation is most commonly recommended for comminuted fractures of the olecranon. Additionally, plate fixation is used for oblique fractures distal to the midpoint of the trochlear notch, fractures that involve the coronoid process, and those associated with Monteggia fracture-dislocations. Tension band wiring is best indicated for simple transverse fractures through the midpoint of the trochlear notch.

As stated, the radiograph shows a multiple-part fracture dislocation of theproximal humerus, with what appears to be a head-splitting component. Answer 1(rotator cuff repair) is certainly not indicated yet – maybe as a secondary procedureonce the bone is healed, or as a subsequent procedure while dealing with the fracture.Similar to question #109, there is no need to resurface the glenoid unless we haveevidence of significant degenerative changes, which we don’t. ORIF of head-splittingfractures hasn’t had any promising results, and AVN is always an issue here. Botharticles referenced discuss the outcomes of acute hemiarthroplasty in thetreatment of 3- and 4-part proximal humerus fractures versus late replacement forfailed non-operative treatment, and the benefits of early management in regardsto difficulty of procedure, post-operative pain, and functional ROM/strength outcomes. Arthrodesis is a viable option, but not with the good results of hemiarthroplasty as evidenced here.Goldman RT, Koval KJ, Cumom F, Gallagher MA, Zuckerman JD: Functional outcome after humeral head replacement for acute three- and four-part proximal humeral fractures. J Shoulder Elbow Surg 1995;4:81-86.Norris TR, Green A, McGuigan FX: Late prosthetic shoulder arthroplasty for displaced proximal humerus fracture. J Shoulder Elbow Surg 1995;4:271-280.back to this question next question

DISCUSSION: The prognosis for a young patient with a head injury is more favorable compared to that for adults. Full neurologic recovery generally occurs. Spasticity may occur within a few days after injury, which can lead to fracture displacement if immediate spica casting or traction is used. Early surgical stabilization will reduce problems with shortening and malunion and will facilitate transportation of the child for diagnostic tests. Surgery may be performed when it is best for the patient, either on the day of injury or later if time is needed for stabilization. In this patient, the fracture is ideally suited to stabilization using flexible intramedullary nails. Heinrich and associates’ report of 78 diaphyseal femur fractures stabilized with flexible intramedullary nails included 14 patients with an associated closed head injury. All fractures healed, and there were no major complications. REFERENCES: Tolo VT: Management of the multiply injured child, in Rockwood CA, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, pp 83-95. Heinrich SD, Drvaric DM, Darr K, MacEwen GD: The operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: A prospective analysis. J Pediatr Orthop 1994;14:501-507.

DISCUSSION: 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 2.4 years. They demonstrated some limitations in recreational activities but not marked limitations. Patients were unlikely to need a late arthrodesis (13%), and their outcomes did not correlate well with assessments of reduction or arthritis scores. REFERENCE: Marsh JL, Weigel DP, Dirschl DR: Tibial plafond fractures: How do these ankles function over time? J Bone Joint Surg Am 2003;85:287-295.

The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.

Results show that patients who underwent humeral head replacement for fracture almost routinely report pain relief, but functional reports vary. The most commonly reported difficulty is the use of weight in the overhead position with wide variation in active elevation. Factors found to affect active elevation include age, humeral offset, greater tuberosity positioning, and four-part (as compared with three-part) fractures.

The complications of femoral neck fractures in children include osteonecrosis, malunion, nonunion, and premature physeal closure. It is presumed that the risk of osteonecrosis is directly related to the amount of displacement at the time of injury and is not affected by the type of treatment. The risk of the other complications can be decreased depending on the type of treatment. Anatomic reduction by either closed or open methods can reduce the risk of malunion. The addition of internal fixation allows for maintenance of the reduction. In young children who cannot comply with a partial or non-weight-bearing status, the addition of a spica cast gives added protection.

Tibial fractures are classified on the basis of their anatomical location and the status of the prosthesis fixation. Type I fractures involve the tibial plateau, type II fractures occur adjacent to the stem of the tibial component, type III fractures are distal to the tibial stem, and type IV fractures involve the tibial tubercle. Subclassifications include A with a well-fixed implant; B with a loose implant; and C, which occur intraoperatively. Treatment of periprosthetic tibial fractures is based on the location of the fracture and the status of the component fixation. Types II or III fractures associated with prosthetic loosening or instability are best managed with revision arthroplasty, usually with a diaphyseal-engaging intramedullary tibial stem. Supplemental internal fixation may be necessary. Type III fractures with well-fixed and stable implants are treated using the standard principles of tibial fracture management.

The most common complications associated with open reduction and internal fixation of distal humerus fractures are those associated with repair of an associated olecranon osteotomy. Complications associated with olecranon osteotomy fixation include failure of fixation (5%) and the need for secondary removal of painful hardware (70%). Nonunion of a distal humerus fracture treated with 90/90 plating is uncommon and results from inadequate fixation, excessive soft-tissue stripping, or use of inadequate plate fixation such as one third tubular plates. Heterotopic ossification is seen in approximately 4% of cases, infection 4%, and ulnar nerve palsy 7%. Although a relatively minor complication, the need for removal of painful hardware from the olecranon osteotomy is by far the most common complication seen in these cases.