2. Trauma MCQs

TEA has been described for posttraumatic arthritis of the elbow and typically involves a young patient population with multiple previous operations on the affected elbow. Morrey and Schneeberger found aseptic component loosening to be uncommon (<10% of patients) and usually occurring >10 years after surgery. Prosthetic fracture, usually of the ulnar component, is also a late-term finding. Infection is the most common mode of early failure but usually occurs within the first 5 years and has an overall rate of approximately 5%. Bushing wear has been reported as the most common cause of mechanical TEA failure in this population at intermediate-term follow-up.

This man had a mid-diaphyseal tibial fracture that has gone into nonunion. Reamed exchange nailing is indicated. Tibial delayed union can be defined as lack of union from 20-26 weeks post-injury, while nonunion is defined as lack of healing at >9 months post-injury, or absence of progressive signs of healing on radiographs for 3 consecutive months. Persistent pain is a symptom of nonunion. ESR and CRP are performed to rule out infection. Bhandari et al. performed a blinded, multicenter trial on 622 reamed tibial nails and 604 unreamed tibial nails. In closed fractures, patients in the unreamed nail group were at greater risk of primary events than the reamed nail group. There was no difference in groups for open fractures. Primary events were defined as bone-grafting, implant exchange/removal, dynamization, and debridement. Hak reviewed aseptic tibial nonunion. They discuss exchanged reamed nailing for diaphyseal nonunion, adjunctive plate fixation for metaphyseal nonunion, and nail removal and plating for metadiaphyseal nonunion, external fixation for infected nonunion, and distraction osteogenesis of defects.

The treatment of choice for closed diaphyseal femoral fractures in adults is reamed intramedullary nailing with static interlocking. Reaming allows placement of a larger, stronger implant and offers better healing rates than unreamed nailing. Static interlocking ensures that there is no loss of reduction because of underappreciated fracture lines or comminution.

Stable fractures and minimally displaced fractures in children can and should be treated by closed methods. Because loss of reduction is common, alignment of tibia fractures must be monitored closely for the first 3 weeks after cast application. This is most easily handled in a cooperative patient by cast wedging. Some children require application of a second cast under general anesthesia 2 to 3 weeks after injury, particularly if the subsidence of swelling has caused the cast to loosen. Surgical indications include the presence of soft-tissue injuries, unstable fracture patterns, fractures associated with compartment syndrome, and the child with multiple injuries. Surgical options in children include percutaneous pins, external fixation, plates and screws, and intramedullary nails.

Vascular injuries occur in approximately 20% to 35% of knee dislocations, of which one third are posterior. Recognition of the vascular injury is essential. Normal pulses or normal capillary refill do not preclude an arterial injury, and arteriography should be considered in all knee dislocations. If the leg is ischemic, the arteriogram should be circumvented and the patient taken directly to the operating room. The risk of muscle fibrosis, contracture, or vascular insufficiency, and the need for amputation increase significantly when ischemia exceeds 6 hours. This patient has ischemia and is considered a vascular emergency. As such, delays for a thorough examination of the ligament, MRI scans, and even an arteriogram are unwarranted. Concurrent ligamentous repair and reconstruction should be deferred until vascular stability has been achieved.

The answer to this question is controversial. All of the standard textbooks state that development of a radial nerve palsy during initial fracture management may represent a laceration or injury of the nerve by bone fragments at the time of manipulation; therefore, surgery should be considered. However, it appears that there is no scientific basis for this decision. A review of the available literature shows that the results were the same for patients who were observed as for those who underwent radial nerve exploration. The indications for surgical exploration include palsies associated with open fractures, irreducible closed fractures, and vascular injuries. The only other relative indication for surgical exploration is following manipulation of a Holstein-Lewis fracture (a distal third fracture of the humerus with a lateral spike). In this type of fracture, exploration may be necessary if a closed reduction leads to radial nerve palsy because the spike may lacerate or compress the nerve. Observation for return of nerve function may be appropriate for 3 months or longer prior to considering late exploration.

When compared to compression plating, anterograde intramedullary nailing results show increased risk for shoulder impingement.Options for operative management of humeral shaft fractures mainly consist of intramedullary nail or plate and screw constructs. The main advantage to intramedullary nailing is when the soft tissue envelope makes a large incision undesireable or the fracture pattern dictates a relative stability construct - such as segmental or massively comminuted injuries. The disadvantages include trauma to the rotator cuff, post operative shoulder pain, indirect reduction leading to increased risk of malrotation, and increased reoperation for implant removal.Li et al. performed a randomized controlled trial with 45 patients that investigated the difference in post operative malrotation and functional outcomes when comparing intramedullary nails versus open reduction and internal fixation. They concluded thatwhen comparing the two operative options, patients who underwent intramedullary nailing had a greater degree of malrotation, which was associated with decreased range of motion. Additionally, they found lower functional scores with patients who underwent intramedullary nailing.Kurup et al. performed a systematic review comparing outcomes between compression plating and intrameduallary nailing for operative treatment of humeral shaft fractures. With a total of 260 patients, they found no difference with blood loss, fracture union, iatrogenic radial nerve palsy, iatrogenic fracture comminution, elbow impingement, return to pre-injury occupation, and functional shoulder scores. They did show a statistically significant increase in shoulder impingement and reduction of range of motion when using an intramedullary nail.Figure A is a AP radiograph of a comminuted humeral shaft fracture. Illustration A is a radiograph of a humerus fixed with an intramedullary nail. Illustration B is a radiograph of a humerus fixed with a compression plate.Incorrect Answers:

With the examination demonstrating reduced visual acuity and visual field changes, emergent CT is needed to look for traumatic optic neuropathy from direct or indirect trauma. The most common mechanism is blunt facial trauma (78%), but penetrating trauma is also common (22%). The most common etiologies are sports and motor vehicle accidents. Fluorescein eye stain would only be useful for corneal abrasion or corneal foreign body. CT scans are often helpful for an orbital fracture, optic nerve sheath hemorrhage, optical canal fractures, skull fractures, foreign bodies, nonorbital facial fractures, or associated brain injuries. The presence of a fracture of the optic canal on a CT scan was a poor prognostic sign in a recent series by Goldenberg and associates. The treatment is controversial. Although treatment options include high-dose corticosteroids, retrobulbar steroid injection, optic canal decompression, and optic sheath fenestration, there is no consensus as to the optimum treatment. It has been reported that treatment does not alter the prognosis in children and adolescents. Only 29% to 44% of children and adolescent patients had significant improvement in visual acuity. Hyphema is a collection of free blood in the anterior chamber of the eye. It is the most common intraocular eye injury associated with sports as reported by Denyi and associates, and occurs in 24% of injured eye cases. At the time of injury, it occurs as a haze in the anterior chamber. An eye patch and ophthalmology evaluation in 2 days is inappropriate because timely evaluation in this scenario is important. High-dose steroids are often used for this injury but not before a full evaluation including a CT scan. Observation is not appropriate because the injury needs an urgent evaluation.

The radiographs show a lateral compression pelvic ring injury with a displaced superior ramus fracture, or tilt fracture. Tilt fractures are most commonly caused by a lateral compression mechanism. These injuries are often seen in female patients and careful examination, including vaginal examination, is required to rule out open fractures. Lateral compression results in internal rotation, not external rotation, of the pelvic ring. Tilt fractures are not commonly seen with anterior-posterior compression injuries or vertical shear injuries. Sagittal translation is not a term used to describe pelvic ring injuries.

DISCUSSION: Tip-apex distance (TAD) as it relates to a lag screw in the femoral head is the summation of the distance between the end of the screw and the apex of the femoral head on AP and lateral radiographs. TAD is a useful intraoperative indicator of deep and central placement of the lag screw in the femoral head, regardless of whether a nail or a plate is chosen to fix a fracture. A TAD of <25mm has been shown to minimize the risk of fixation cut-out in stable and unstable intertrochanteric hip fractures.

DISCUSSION: The most serious, acute complication of severe maxillofacial trauma is airway obstruction that can result in early death. It is most likely to be associated with multiple mandibular fractures or combined maxillary, mandibular, and nasal fractures. The mandible suspends the tongue anteriorly. When the mandible is fractured and the patient is supine, the tongue falls posteriorly and obstructs the airway. Soft-tissue swelling around the injured oronasal structures can also result in a loss of airway patency. Endotracheal or nasotracheal intubation is often impossible and a surgical airway may often have to be created to prevent death by asphyxiation. Other injuries that may require immediate attention include head or cervical spine injury and hemorrhage. A cerebrovascular accident is also less common but is associated with injury to the common carotid artery or its branches. Periodontal disease is generally a long-term complication from dental injuries. Hearing loss is not a common complication of dental and facial trauma.

DISCUSSION: Arthroscopic versus open distal clavicle excision has the advantage of allowing evaluation of the glenohumeral joint arthroscopically prior to moving into the subclavicular and subacromial space to perform the distal clavicle excision. This can be of value in both confirming the diagnosis as well as avoiding diagnostic errors. Berg and Ciullo showed that in 20 patients who underwent open distal clavicle excision that resulted in failure, 15 of those patients had a superior labral anterior posterior (SLAP) lesion. Of these 15 patients who had the lesion treated surgically, 9 went on to a good to excellent result after the surgery was performed arthroscopically. Fewer complications, lower infection rate, and decreased surgical time have not been documented in the literature. Arthroscopic technique sacrifices the inferior acromioclavicular ligament and preserves the superior acromioclavicular ligament.

DISCUSSION: Medial plateau fracture dislocations are rare. Failure to recognize this pattern can lead to poor patient outcomes secondary to poor surgical decision making. Pathognomonic findings on the anteroposterior radiograph include an intact lateral column (lateral articular surface still in continuity with tibial shaft), centrolateral articular impaction, shortening, and condylar widening. The medial femoral condyle stays with the fractured medial tibial plateau segment. Initial management of axially unstable tibial plateau fractures with soft tissue swelling should consist of spanning external fixation and closed manipulative realignment. This allows for soft tissue recovery with the knee joint provisionally stabilized in reduced station. It also provides time for pre-operative planning, which is typically empowered via a CT scan with reconstructions. If the pattern was initially misdiagnosed as a more typically bicondylar tibial plateau fracture, the CT scan will clarify the misconception and allow for better surgical decision making. Supine positioning is preferred for definitive fixation, but surgical approaches vary. Attempting to stabilize a medial partial articular pattern in the supine position from a lateral utility approach is fraught with difficulties. Lateral locked plating is not designed for this indication. The lateral utility approach allows for visualization of the centrolateral impaction and lateral meniscal peripheral capsular avulsion repair, but when used alone leads to biomechanically unsound implant placement. The primary plate should be on the medial side of the tibia rather than the intact lateral column.

DISCUSSION: There are 5 simple and 5 associated fracture types according to the classification system created by Judet and Letournel. The key feature which distinguishes both column fractures from other associated types is that all articular segments are detached from the intact portion of the ilium, which remains attached to the sacrum through the SI joint. Although the transverse plus posterior wall, T-shaped, and anterior plus posterior hemi-transverse fractures all show involvement of the anterior and posterior columns, they are not “both columns” because a portion of the articular surface remains in its normal position, attached to intact ilium. The intact ilium is responsible for the "spur sign" noted most prominently on the obturator oblique radiograph.

Recent studies comparing surgical treatment with nonsurgical management in displaced clavicle fractures have revealed a decreased rate of malunion and nonunion with surgery. In addition, significant malunions can lead to functional deficits at the shoulder. Thus, with open reduction and internal fixation and anatomic or near-anatomic reduction, there should be a higher likelihood of normal shoulder strength and function. Infection and local sensory deficits would not be expected with nonsurgical management, whereas surgical treatment has a small risk of infection and a high likelihood of sensory deficits from iatrogenic damage to the supraclavicular nerves.

The radiograph reveals a reverse obliquity subtrochanteric/intertrochanteric fracture. Open reduction and internal fixation should be accomplished with a 95° fixed angle device. An intramedullary nail with screw fixation into the head is another possible technique. Either method should correct the varus deformity. Exchange of a high-angled screw and plate device to a longer side plate and bone grafting does not afford any improvement in the mechanical stability. Hardware removal and retrograde intramedullary nailing is not indicated for this level of a proximal femoral injury. Placement of an implantable bone stimulator may change local biologic factors but would not enhance mechanical stability. The patient’s femoral head is intact without signs of collapse; therefore, hardware removal, proximal femoral resection, and total hip arthroplasty are not warranted.

Pauwels type III femoral neck fractures have a highly vertical orientation, making them subjected to significant vertical shear forces rather than compressive forces. Multiple biomechanical studies have shown that a fixed-angle device, such as a sliding hip screw (SHS), provides superior resistance to vertical shear compared to multiple parallel cancellous screws. Adding a derotational screw to the SHS construct further increases rotational stability and load to failure.

The posteromedial approach to the tibial plateau utilizes the interval between the medial head of the gastrocnemius (which is retracted laterally and posteriorly to protect the neurovascular bundle) and the pes anserinus tendons (which are retracted medially and anteriorly). This provides direct, safe access to the posteromedial shear fragment for buttress plating.

Hoffa fractures are coronal shear fractures of the femoral condyle. Biomechanical studies have consistently shown that posterior-to-anterior (PA) directed lag screws provide significantly higher stability, compression, and load to failure compared to anterior-to-posterior (AP) screws. This is due to the thicker, denser subchondral bone posteriorly allowing for superior screw purchase, despite the technical challenge of an intra-articular start point.

The Hawkins sign is a subchondral radiolucent band seen in the dome of the talus, typically appearing 6 to 8 weeks after injury. It represents subchondral osteopenia (bone resorption) which can only occur in the presence of an intact blood supply causing localized hyperemia. Therefore, a positive Hawkins sign is a highly reliable indicator that the talar body remains vascularized, predicting a very low risk of avascular necrosis (AVN).