2. Trauma MCQs

This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture.

There are relative advantages to both types of these external fixators. A frame based on the iliac crest is oftentimes easier to place rapidly because it is less dependent on fluoroscopy. This is also advantageous in this clinical scenario because the patient may not be on a radiolucent table. A frame with pins in the anterior inferior iliac spines may be advantageous in that the pin sites will be away from any future needed incisions if an ilioinguinal approach is needed. There is, however, a higher risk of lateral femoral cutaneous nerve injury or intra-articular pin placement at the hip joint with this frame configuration. This technique is generally more dependent on fluoroscopy for pin placement. Some biomechanic studies have shown advantages to AIIS-based frames but this does not give a definite clinical advantage because neither frame alone is adequate to definitively treat an unstable associated posterior pelvic ring injury. There is no known difference in pin site infection rates between these frame types.

The patient appears to have some indications of a compartment syndrome: increasing pain and signs of nerve compression. Tibia fractures also should heighten the suspicion for a compartment syndrome. Two basic mechanisms of compartment syndrome are that an increase in volume occurs in an enclosed space or there is a decrease in size of the space. In this situation, both are likely occurring; post-fracture swelling is occurring within a closed space and if a cast is in place that may constrict the space even more. One way to increase the available space for swelling would be to bivalve and spread the cast. If the extremity has been casted, then it is vitally important that the cast is bivalved and the surrounding soft dressings under the cast be removed so that all external compression of the compartment has been eliminated. In the face of compartment syndrome, elevation of the limb, masking the pain with morphine, application of ice, or observation alone are all inappropriate.(SBQ12TR.88) When evaluating a fracture dislocation of the elbow, a varus and posteromedial rotation mechanism of injury typically results in what injury pattern?A fracture of the radial head requiring ORIFA highly comminuted radial head fracture requiring radial head arthroplasty or resectionAn MCL injury requiring repairA type I avulsion fracture of the coronoidAn anteromedial coronoid fractureA varus and posteromedial rotation mechanism of injury typically results in a fracture of the anteromedial facet of the coronoid which frequently requires reduction and fixation to restore stability.A varus and posteromedial mechanism of injury about the elbow presents with an injury pattern distinctly different from other injury patterns. A key part of treating this injury pattern is recognizing a fracture of the anteromedial facet of the coronoid, which often requires reduction and fixation to restore stability about the elbow. It is important to recognize this during preoperative planning since this injury typically requires a medial approach.Steinman presents a review article describing coronoid fracture patterns and their mechanisms of injury.Doornberg and Ring present a level 4 review showing that coronoid fracture patterns and their required treatments are predictable based on mechanism of injury. Varus and posteromedial mechanisms were found to reliably create a fracture of the anteromedial facet of the coronoid, and were associated with sparing of the MCL and radial head.Doornberg and Ring also presented a Level 3 review of anteromedial facet cornoid fractures. They found that they could not be adequately visualized and treated from a lateral approach, and that they typically required reduction and fixation to restore adequate stability to the elbow. This stresses the importance of recognizing this injury pattern during preoperative planning.Illustrations A and B are AP and lateral radiographs of an elbow following a varus/posteromedial injury with an anteromedial coronoid facet fracture. Illustration C is a diagram demonstrating fracture lines that create an anteromedial facet fracture fragment. This fracture can be subclassified into three subtypes [anteromedial rim (a), rim plus tip (b), and rim and tip plus the sublime tubercle (c)]Incorrect answers:(SBQ12TR.78) A 67-year-old female patient presents with increasing right hip/thigh pain over the past three months, which is now recalcitrant to anti-inflammatories. There is no history of trauma or constitutional symptoms. Her past medical history consists of hypertension, coronary artery disease, osteoporosis and gastric reflux. Physical examination reveals mild pain at the extremes of range of motion of the hip and a painful right sided limp. A radiograph of the right hip is seen in Figure A. What would be the most appropriate treatment for this patient at this time?ReviewTopicObservation onlyReferral to physiotherapyMRI spine and hipTotal hip arthroplastyIntramedullary femoral nailThis osteoporotic female patient is presenting with subtrochanteric lateral cortical thickening and hip pain. This is consistent with an insufficiency fracture of the femur secondary to use of bisphosphonate medication for treatment of osteoporosis. The most appropriate treatment would be intramedullary femoral nail fixation.Bisphosphonate medications have been shown to be associated with atypical (subtrochanteric) femur fractures. These patients often have prodromal hip pain and lateral cortical thickening on radiographs prior to fracture. In addition, there has shown to be a significantly increased risk of fracture in the presence of the “dreaded black line” that occurs at the site of thickening.Lenart et al. examined a case series of patients using bisphosphonates for the treatment of osteoporosis. They identified 15 postmenopausal women who had been receiving alendronate for a mean (±SD) of 5.4±2.7 years and who presented with atypical low-energy fractures. Cortical thickening was present in the contralateral femur in all the patients with this pattern.Goh et al. retrospectively reviewed patients who had presented with a low-energy subtrochanteric fractures. They identified 13 women of whom nine were on long-term alendronate therapy. Five of these nine patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.Figure A shows a right hip radiograph with subtrochanteric lateral cortical thickening. There is mild arthritic changes in the hip. Illustration A shows a bone scan and radiographs of subtrochanteric lateral cortical thickening that resulted in fracture.Incorrect Answers

The CT scans show a burst fracture that results from an axial load injury. The radiographic hallmark of a burst fracture is compression of the posterior cortex of the vertebral body with retropulsion of bone into the spinal canal. AP radiographs often show widening of the interpedicular distance with a fracture of the lamina.

A relatively large percentage of patients sustaining intra-articular fractures develop posttraumatic arthritis despite surgical restoration of joint incongruity and alignment. Fracture-related chondrocyte death (apoptosis) concentrated along matrix cracks in the superficial layer of cartilage has been linked to the pathogenesis of posttraumatic osteoarthritis. Apoptosis is accentuated by a series of aspartate-specific cysteine proteases. Inhibition of this cascade is a target of emerging pharmacological treatment options.

DISCUSSION: Immediate spica casting is ideal for younger children with uncomplicated femoral fractures that are the result of relatively low-energy injury. Surgical stabilization of pediatric femoral fractures is most commonly performed in children who are older than age 6 years or in children with other factors associated with their femoral fracture, such as concomitant head injury, open fracture, floating knee, severe comminution, or vascular injury.

Ankle fractures in diabetics with neuropathy should be treated with enhanced fixation comprising stiff plates with syndesmotic screws, even in the absence of syndesmotic injury. Weightbearing should be delayed for 8 to 12 weeks after surgery, rather than 4-8 weeks (as for normal patients).Diabetics with ankle fractures are prone to complications. Nonoperatively treated cases have up to a 50% incidence of skin breakdown in a cast. Surgically treated patients have up to 40% complication rate. Supplemental fixation can include include multiple syndesmotic screws, spanning external fixation, tibio-talar Steinmann pins, more rigid fibular plates, supplemental intramedulary fibular pinning. Weightbearing after surgery should be delayed (8-12weeks).McCormack and Leith reviewed the complications in 26 diabetic ankle fractures. 19 patients had surgery. The incidence of complications was 42%. Two required amputation and died. None of the non-diabetic control group had complications. They concluded that in the older, diabetic patient with lower demands, especially if insulin-dependent, it may be preferable to accept a loss of reduction and malunion rather than risk the potentially devastating complications associated with operative intervention. If surgery is necessary, the results of this study provides a more accurate prognosis and allows for better discussion of surgical risks with the patient.Roseunbaum et al polled AOFAS members on the treatment of diabetic ankle fractures. (1) For nondisplaced bimalleolar fracture with diabetic neuropathy, respondents preferred casting and nonweightbearing (NWB) for 8-12 weeks. (2) For Weber B fracture dislocation without neuropathy, without syndesmotic injury,respondents preferred either 1/3 tubular or small fragment locking plates with syndesmotic screws and NWB for 8-12 weeks. (3) For bimalleolar fracture dislocation with neuropathy, without syndesmotic injury, respondents preferred small fragment locking plates with syndesmotic screws and NWB for 8-12 weeks.Wukich and Kline reviewed the management of ankle fractures in diabetics. They found that neuropathy is more prevalent in patients with ankle fractures than without. They stress that 1% reduction in HbA1C results in 30% reduction in complication rate. Fracture healing is slower, callus is smaller, with less stiffness, tensile strength and collagen content. Amputation rate is up to 5% for patients treated operatively or nonoperatively. Complications are higher in patients with vasculopathy, neuropathy, or Charcot arthropathy.Incorrect Answers:

OrthoCash 2020Figures 1 and 2 are the radiographs of a 41-year-old diabetic male presenting with right lower extremity pain after cutting his leg it on a piece of rusty metal yesterday. Serial physical exam demonstrates rapid progression of the overlying erythema and worsening pain. In the emergency department, labs are significant for a C-reactive protein (CRP) of 180 mg/L, white blood cell (WBC) count of 19,000/mm3, glucose of 11 mmol/L, creatinine of 150 umol/L, and sodium of 120 mmol/L. He has a temperature of 102°F and a heart rate of 110 bpm. What additional laboratory value is needed to calculate this patient’s LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score?ESRHemoglobinPotassiumBicarbonateCalciumThe LRINEC score is based on the patient's serum CRP, WBC count, hemoglobin, sodium, creatinine, and glucose.The LRINEC score is a clinical tool designed to help distinguish between necrotizing fasciitis and other soft tissue infections using these 6 key laboratory values. The most important of these is CRP, as a value >150 mg/Lcontributes 4 of a possible 13 points. Illustration A demonstrates the scoring system for each laboratory value used in the calculation of the LRINEC score. A score >6 has been shown to have a PPV of 92% for having necrotizing fasciitis. The patient in this vignette already has a score of 10 without knowledge of the hemoglobin level, which is very concerning for necrotizing fasciitis. As a result, emergent surgical debridement is indicated.Stoneback et al. reviews the presentation and management of necrotizing fasciitis. The authors note that the incidence of necrotizing fasciitis is between 500 and 1500 cases per year in the United States, and that the mortality rate averages 21.9%. They emphasize that necrotizing fasciitis may be difficult to distinguish from more common skin infections such as cellulitis or soft tissue abscess in its early stages but will often rapidly deteriorate, as illustrated in this vignette.Wong et al. developed the LRINEC scoring system. In a retrospective review of 145 patients with necrotizing fasciitis and 309 patients with severe cellulitis or abscesses, they used their scoring system to demonstrate that a LRINEC score of 6 points or greater had a PPV of 92.0% and an NPV of 96.0%.Tsai et al. challenged the utility of the LRINEC score in aiding in the diagnosis of Vibrio Necrotizing Fasciitis. In their retrospective review of 70 patients with Vibrio Necrotizing Fasciitis, they showed that only 11% of patients had a LRINEC score >6. The authors concluded that the LRINEC scoring system is of more limited utility for this subset of the disease and propose that severe hypoalbuminemia, thrombocytopenia, and increased banded forms of leukocytes may have greater utility.Figures A and B are AP and lateral radiographs of the lower leg demonstrating diffuse subcutaneous gas. This is concerning for necrotizing fasciitis.Illustration A is a table showing the LRINEC scoring breakdown. A maximum total score of 13 could be achieved.Incorrect Answers:OrthoCash 2020A 35-year-old male presents to the emergency department following a motorcycle accident. On initial examination in the emergency department, he is found to have a left flail arm and multiple other injuries. There is a concern for a brachial plexus injury. What examination findings would support a diagnosis of a pre-ganglionic injury?Abnormal histamine responseFlail armIntact sensory nerve action potentials (SNAPs)Lateral scapular wingingNormal cervical paraspinal signal on EMG/NCVCorrent answer: 3Brachial plexus injuries are classified as either pre-ganglionic or post-ganglionic. A pre-ganglionic injury would be supported by intact sensory nerve action potentials (SNAPs).Diagnosing brachial plexus injuries as either pre- or post-ganglionic is multi-faceted and begins with a thorough physical examination. Findings suggestive of a pre-ganglionic injury would include Horner Syndrome (due to disruption of the sympathetic chain), MEDIAL scapular winging resulting from rhomboid and serratus anterior paralysis, cervical paraspinal muscle weakness, absent sensation, and hemidiaphragmatic paralysis. CT myelography may demonstrate pseudomeningocele, and NCS/EMG would show intact sensory nerve action potentials (SNAPs) with denervation of the cervical paraspinal musculature. Finally, a histamine test would show a triple response, with redness, wheal, AND flare. Conversely, a post-ganglionic injury would besupported by BOTH motor and sensory deficits of the flail arm, maintained innervation to cervical paraspinal muscles, and an abnormal histamine response test (redness and wheal with NO flare).Limthongthang et al. reviews the common clinical findings associated with pre-and post-ganglionic injuries. The authors discuss the diagnostic algorithm, including a thorough history, physical examination, electrodiagnostic studies, and CT myelogram or MRI. They emphasize that an angiogram should additionally be considered given that 20% of brachial plexus injuries have associated major vascular injuries. The authors conclude with appropriate surgical timing and suggest potential treatments depending on injury location.Giuffree et al. reviews management of brachial plexus injuries. The authors discuss appropriate timing of treatment based on the injury mechanism. They emphasize the priorities of functional restoration, beginning with elbow flexion, followed by a stable shoulder, and lastly intrinsic hand function. The authors present various surgical options to attain these goals and discuss their outcomes.O'Shea et al. discusses the utilization of advanced imaging and electrodiagnostic testing for evaluation of brachial plexus injuries. The authors note the utility of CT myelogram toward identifying root avulsions. They also suggest that electrodiagnostic studies be obtained no sooner than 4 weeks following injury and subsequently at 6-week intervals to monitor progression. They note that SNAPs are the most important criteria in distinguishing between pre- and post-ganglionic injuries, and conclude that electromyographic studies are crucial in determining not only the level of injury but also donor nerves for transfers.Incorrect Answer:indicative of a pre-ganglionic injury due to involvement of the dorsal scapular nerve (branching from the C5 root) and the long thoracic nerve (branching from the C5-7 roots).OrthoCash 2020A 47-year-old male diabetic has developed a calcaneal ulcer, as shown in figure A, that has been managed with wound care and a total contact cast. He presents to the emergency department with worsening erythema progressing up his leg with new draining wounds. On admission, despite antibiotics and intravenous fluids, he develops worsening pain and new bullae shown in Figure B. His laboratory studies indicate CRP >200, WBC 25k, Sodium 127, glucose 233, and hemoglobin 12. What is the best next step in the management of his condition?Emergent vascular explorationUpgrade level of care ICU with antibiotic escalationMRI foot for osteomyelitis evaluationEmergent surgical debridement including possible amputationCT with contrast of lower extremityCorrent answer: 4This patient meets the clinical criteria for the diagnosis of necrotizing fascitis, therefore the next step in management is surgical debridement with possible amputation.Necrotizing fasciitis is an aggressive infection with rapid spread along fascial planes. Initial presentation may be consistent with cellulitis; however, rapid progression along fascial planes may result in skin necrosis, muscular invasion, and subsequent myonecrosis. The rapidity of diagnosis and emergent surgical debridement is essential. Risk factors including intravenous drug abuse, alcohol abuse, and diabetes should be assessed, and if necrotizing fascitis is on the differential, the LRINEC score may be employed for diagnosis in equivocal cases. This scoring system can be found on our associated Orthobullets page.Wong et. al. developed the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score to assist in early diagnosis of necrotizing soft tissue infections. The authors used logistic regression to identify significant predictors of necrotizing fasciitis. The score utilizes a total white cell count, hemoglobin, sodium, glucose, serum creatinine, and CRP. A LRINEC score of 6 points or higher has a positive predictive value of 92%, and below 6 points a negative predictive value of 96%. Importantly, ESR is not a component in the scoring system as it correlated poorly with risk. The patient presented already has two positive serum findings with an LRINEC score of 6.Stoneback et al. review the diagnosis and management of necrotizing fasciitis. They note that Group A streptococcus is one of the most prevalent organisms, but infections are typically polymicrobial. Because of the need for prompt initiation of treatment, adjunctive diagnostic tests should not impede the timing of surgical exploration and debridement. Necrotizing fasciitis is a clinical diagnosis where only emergent surgical debridement and appropriate antibiotic treatment can prevent progression and death.Tsai et al. retrospectively reviewed 70 patients with 71 episodes of Vibrio necrotizing fasciitis and sepsis. Of the 70 patients, 68 had a history of contact with seawater or raw seafood; 66 had underlying chronic diseases. They noted that severe hypoalbuminemia, severe thrombocytopenia, and increased banded forms of leukocytes are laboratory risk indicators of necrotizing fasciitisthat aid in pointing toward the initiation of early surgery and predict a higher risk of death.Figure A is a clinical photograph of a calcaneal ulcer. Figure B shows ascending erythema and bullae consistent with a necrotizing skin infection. Illustration A demonstrates the LRINEC scoring system. The scoring system is not largely utilized as a screening tool due to its poor sensitivity in studies that attempted to validate it.Incorrect answers:OrthoCash 2020A 36-year-old man with HIV, chronic kidney failure, and chronic IV drug use presents with worsening fevers, chills, and purulent drainage from his leg. His infection progresses rapidly and he becomes acutely septic. He is therefore taken urgently to the OR for radical debridement of the fascia and surrounding tissues, with a plan for delayed closure. His CRP is 90 mg/dL and he is hyponatremic. Intraoperative cultures are obtained. To cover the most common organism(s) associated with this condition, what antibiotic would you initially recommend?Intravenous vancomycinIntravenous vancomycin and gentamicinIntravenous gentamicinIntravenous linezolid and meropenemIntravenous micafunginThis patient with lower extremity necrotizing fasciitis underwent a radical debridement of fascia and surrounding tissues. The most common culture isolate from necrotizing fasciitis is polymicrobial, which should be the target of initial antibiotic treatment. Of the above options, intravenous Linezolid and Meropenem would be an acceptable empiric therapy as Linezolid would cover MRSA and invasive group A Streptococcus while Meropenem would cover gram-positive/negative anaerobic coverage and enteric organisms.Necrotizing fasciitis is an aggressive infection with rapid spread along fascial planes. While the initial presentation may suggest cellulitis, rapid progression along fascial planes may result in skin necrosis and subsequent myofascial necrosis. The time from admission to debridement has been shown to be a significant predictor of outcomes. Immediate empiric antibiotics coveringpolymicrobial species including aerobic, anaerobic, gram-positive and gram-negative bacteria are of equal importance.Stoneback et al. reviewed the diagnosis and management of necrotizing fasciitis. They reported that while most necrotizing fasciitis infections are polymicrobial, group A Streptococcus remains one of the more prevalent organisms in isolation. They recommended surgical debridement as the utmost importance in necrotizing fasciitis management and emphasized appropriate antibiotic selection in treating sepsis and halting the further bacterial spread.Wong et al. developed the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, a novel diagnostic scoring system for distinguishing necrotizing fasciitis from other soft tissue infections based on laboratory tests routinely performed for the evaluation of severe soft tissue infections. This score allocated 1 point each to the following labs: total white cell count, hemoglobin, sodium, glucose, serum creatinine, and C-reactive protein. They reported that a cutoff value of 6 points had a positive predictive value of 92.0% and a negative predictive value of 96.0%, and concluded that the LRINEC score is a powerful score that can detect even clinically early cases of necrotizing fasciitis.Tsai et al. investigated whether clinical indicators predict laboratory findings during the initial stages of necrotizing fasciitis and the relationship between the LRINEC score and the diagnosis of vibrio infection. They reported that a systolic blood pressure of 90mmHg or less at the time of admission predicted mortality and that patients with a LRINEC score of >6 had an 11% chance of surviving vibro-specific necrotizing fasciitis.Figure A is a clinical image depicting necrotizing fasciitis of the lower extremity, with characteristic ischemic patches, cutaneous gangrene, dermal induration, bullae formation. Illustration A is a table from Wong's study that demonstrates the components, clinical values, and scoring system for the LRINEC score.Scores of 6 or greater are highly concerning. They concluded that severe hypoalbuminemia, severe thrombocytopenia, and increased leukocytosis were reliable markers.Incorrect Answers:OrthoCash 2020A 27-year-old male is involved in a motor vehicle collision and presents to the ER with the right lower extremity injury shown in Figures A and B. He undergoes immediate closed reduction and the post-reduction CT is shown in Figures C and D. The patient undergoes percutaneous surgical screw fixation of the injury. At 2 years followup, he presents with a supination deformity with decreased eversion of the foot at rest. Radiographs reveal no evidence of talus subchondral sclerosis or collapse. Which of the following is the most likely cause of the finding in this patient?Avascular necrosisSubtalar arthritisTibiotalar arthritisVarus malunionPlanovalgusThe patient has sustained a displaced talar neck fracture with medial comminution which requires open reduction and internal fixation to restore anatomic alignment. The patient has likely sustained varus malunion which is a common deformity noted with non-anatomical reduction leading to hindfoot supination and decreased eversion.Talar neck fractures, while uncommon, can lead to significant morbidity in the ambulatory patient. Treatment of these injuries requires prompt reduction due to the tenuous blood supply to the talus. The most common complications noted after a talar neck fracture are avascular necrosis, subtalar arthritis, tibiotalar arthritis, and varus malunion. A talus varus malunion generally occurs due to medial talar neck comminution and/or non-anatomic reduction of the injury. This deformity can lead to decreased eversion and a supination deformity causing patients to ambulate on the lateral aspect of the foot. These malunions are generally treated with a medial opening wedge osteotomy.Fortin and Balazsy review the pathology and treatment of traumatic talus fractures. They cite that injuries to the head, neck, or body of the talus can result in permanent pain, loss of motion, and deformity. They note that failure to recognize fracture displacement (even when minimal) can lead to undertreatment and poor outcomes. They conclude that unrecognized medial talar neck comminution can lead to varus malunion and a supination deformity with a decreased range of motion of the subtalar joint.Lindvall et al. performed a retrospective review to evaluate the long-term results (average of 74-month followup) of surgical treatment of isolated, displaced talar neck and/or body fractures with stable internal fixation in 25 patients. They noted an overall union rate of 88% regardless of surgical timing. The authors noted posttraumatic subtalar arthritis in all patients (100%) and talus osteonecrosis in 13/26 (50%) of patients. The authors concluded that a delay in surgical fixation does not appear to affect the outcome, union, or prevalence of osteonecrosis and that posttraumatic arthritis is a more common complication than osteonecrosis following operative treatment.Figures A and B are the Lateral and AP radiographs of a displaced talar neck fracture with tibiotalar dislocation. Figures C and D are the post-reduction sagittal foot CT cuts that reveal a displaced talar neck fracture with medialcomminution.Incorrect Answers:OrthoCash 2020Figures A-C are a 32-year-old female who presents to the trauma bay after falling off a roof. Paramedics state that she was initially complaining of back pain, but she now appears irritable and lethargic. She has received 2 liters of crystalloid since arriving in the trauma bay. Her blood pressure is now 76/42. A Foley catheter is placed, and her urine output is 12 ml/hour. What additional finding would suggest hemorrhagic shock over neurogenic shock?TachycardiaBradycardiaDecreased cardiac outputVasodilationWarm dry skinCorrent answer: 1This patient sustained a multi-traumatic injury and is suffering from hemorrhagic shock. The presence of tachycardia would favor the diagnosis of hemorrhagic shock over neurogenic shock.In initial hypovolemic shock (stage I, <15% blood loss), heart rate, blood pressure, urine output, pH, and mental status are largely unaffected, as the body can typically compensate for this amount of volume loss. With increasing blood loss, tachycardia, hypotension, low urine output, decreased pH, hemoconcentration, cool clammy skin, and altered mental status can be observed. This patient sustained a splenic injury and T12 and L3 vertebral injuries. Both hemorrhagic and neurogenic shock may result in a decrease in cardiac output and hypotension; however, neurogenic shock may also present with warm dry skin, vasodilation, loss of sympathetic tone, and paradoxical bradycardia.Schouten et al. review the initial management of the spinal column and spinal cord injury (SCI) in the emergency room. The authors discuss that acutely, deep tendon reflexes are absent and paralysis is flaccid, but that this transitions to hyper-reflexia and spasticity with time. They conclude that spinal shock is a temporary physiologic state of the acutely traumatized spinal cord, evident by the transient absence of reflexive function caudal to the spinal cord injury followed by gradual return of reflex activity. Additionally, the diagnosis of a "complete" spinal cord injury cannot be made until the neural "shock" resolves.Spector et al. review cauda equina syndrome. They report on the characteristic findings such as varying patterns of low back pain, sciatica, lower extremity sensorimotor loss, and bowel and bladder dysfunction. Classical findings include urinary retention, saddle anesthesia of the perineum, bilateral lower extremity pain, numbness, and weakness. The authors conclude that there should be a high index of suspicion in the postoperative spine patient with back and/or leg pain refractory to analgesia, especially in the setting of urinary retention.Hadley et al. review the presentation of acute SCI. The authors report that hypotension has been associated with an increased risk of mortality followingspinal cord injuries. They conclude that hypotension (systolic blood pressure<90 mm Hg) should be avoided after acute SCI, with the maintenance of mean arterial blood pressure at 85 to 90 mm Hg for the first 7 days after acute spinal cord injury in order to improve spinal cord perfusion.Sekhon et al. review the epidemiology, demographics, and pathophysiology of SCI. They discuss primary and secondary injury, with the mediators of secondary injury including vascular mechanisms, excitatory amino acids, calcium, sodium, free radicals, inflammation, and apoptosis.Figures A is a sagittal CT image demonstrating T12 and L3 vertebral fractures. Figure B is an axial CT image demonstrating a splenic injury with hematoma. Figure C is a clinical photograph demonstrating left abdominal flank injury.Illustration A shows the classification of hemorrhagic shock.Incorrect Answers:OrthoCash 2020A 32-year-old inebriated male falls from a mechanical bull at a bar and sustains a closed displaced intra-articular distal radius fracture. He presents to your clinic and given his age and the fracture characteristics, he is taken for open reduction with volar locking platefixation. After completing instrumentation, radiocarpal screw penetration is best assessed on which fluoroscopic view?Extended wrist tangential viewFlexed wrist tangential viewPA anatomic tilt viewRadial inclination viewStandard lateral viewCorrent answer: 4While no single radiographic view can completely rule out intra-articular screw penetration, radial inclination views (most commonly a 22-degree anatomic tilt lateral view) best demonstrates screw penetration of the radiocarpal joint.Intra-articular screw penetration is a potential complication of distal radius fracture fixation. Due to the complex native geometry, standard PA and lateral fluoroscopic views are not effective in evaluation of the joint reduction, screw length or screw position. For this reason, various supplemental views have been described to facilitate identification of articular incongruity as well as dorsal or intra-articular penetration of screws, either into the radiocarpal or distal radioulnar joint.Tweet et al. reviewed the most commonly used imaging techniques and views for the evaluation of intra-articular screw penetration during volar plate fixation of distal radius fractures. Of nearly 700 ASSH members surveyed, 87% relied exclusively on fluoroscopy, three-quarters (74%) of which implemented tilt views or rotational fluoroscopy. Cadaveric analysis supported use of a 22-degree lateral projection and rotational fluoroscopy as adjuncts for the detection of intra-articular screw penetration. They concluded that no combination of imaging effectively allowed the detection of all intra-articular screws.Patel et al. evaluated the utility of supplemental radiography in assessing screw placement in distal radius fracture fixation using volar locking plates. The authors found that supplementation of the standard AP and lateral views with lateral tilt views significantly increased accuracy and confidence.Specifically, more acute angles (15 and 23-degree views) provided better visualization of ulnar screws while larger angles (30 degrees) allowed assessment of more radial-sided distal plate screws.Illustration A is an example of an extended wrist tangential view showing clear visualization of the sigmoid notch and distal radioulnar joint (DRUJ), with intraarticular penetration of the DRUJ shown on the left and extra-articular screwsfree of the DRUJ.Illustration B is an example of a flexed wrist tangential view, or “skyline” view, demonstrating no dorsal penetration of the screws, which can be obscured on a true lateral due to Lister’s tubercle.Illustration C shows an example of a standard PA view (left) and 11-degree anatomic tilt PA view, allowing better visualization of the articular surface. Illustration D shows a standard true lateral view (left) and 22-degree radial inclination lateral view (right), allowing better visualization of screw relationship to the radiocarpal joint.Incorrect Answers:OrthoCash 2020A 40-year-old slips on the ice on a wintery Michigan day and sustains a comminuted intra-articular distal radius fracture. Which of the regions on the patient's injury AP radiograph in Figure A, if not addressed properly during surgery, represents a risk for radiocarpal instability?

DISCUSSION: Egol et. al. studied locked and conventional plates. They concluded that locked plates may be increasingly indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates remain the fixation method of choice for periarticular fractures that demand perfect anatomical reduction, and certain types of non-unions that require increased stability for union.

DISCUSSION: This issue has been debated since Inman published his classic study on clavicular rotation in 1944.  Subsequently, it has been shown by several authors that the clinical evaluation of patients with either coracoclavicular screws in place or with arthrodesis of the coracoclavicular reveals little to no loss of shoulder motion.  This is most likely the result of synchronous motion of the scapula and clavicle in shoulder movements.REFERENCES: Flatow EL: The biomechanics of the acromioclavicular, sternoclavicular, and scapulothoracic joints. Instr Course Lect 1993;42:237-245.Kenedy JC, Cameron H: Complete dislocation of the acromioclavicular joint.  J Bone Joint Surg Br 1954;36:202-208.Rockwood CA Jr, Williams GR, Young CD: Disorders of the acromioclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 483-553.Inman VT, Saunders JB, Abbott LC: Observations of the function of the shoulder joint.  Clin Orthop 1996;330:3-12.

DISCUSSION: Anterior dislocation is the most common type of sternoclavicular dislocation.  The medial end of the clavicle is displaced anterior or anterosuperior to the anterior margin of the sternum.  In a study by Omer, 31% of athletic injuries have been known to cause a dislocation of the sternoclavicular joint.  The serendipity view can show this dislocation, as will CT of the chest.  This view requires the x-ray beam to be aimed at the manubrium with 40 degrees of cephalic tilt.  An anterior sternoclavicular joint dislocation will appear superiorly displaced, while a posterior sternoclavicular joint dislocation is inferiorly displaced on the serendipity view.REFERENCES: Rockwood CA Jr, Matsen FA III (eds): The Shoulder.  Philadelphia, PA, WB Saunders, 1998, vol 1, pp 566-572.Omer GE Jr: Osteotomy of the clavicle in surgical reduction of anterior sternoclavicular dislocation.  J Trauma 1967;7:584-590.

DISCUSSION: Proximal humeral fractures in children are classified as metaphyseal or Salter-Harris type I or II fractures, and most of these fractures are treated with closed methods.  Eighty percent of the growth of the humerus comes from the proximal physis; therefore, tremendous remodeling potential is present.  Indications for open reduction include open fractures or severely displaced fractures in adolescents with minimal growth remaining.  Acceptable limits of reduction in adolescent proximal humeral fractures include bayonet apposition and angulation of less than 35°.  Common blocks to reduction in adolescents include the biceps tendon and periosteum.  For this fracture, use of a shoulder sling without reduction will lead to healing and an excellent result as the proximal humerus remodels.REFERENCES: Kohler R, Trillaud JM: Fracture and fracture separation of the proximal humerus in children: Report of 136 cases.  J Pediatr Orthop 1983;3:326-332.Beaty JH: Fractures of the proximal humerus and shaft in children.  Instr Course Lect 1992;41:369-372.DobbsMB, Luhmann SL, Gordon JE, et al: Severely displaced proximal humeral epiphyseal fractures.  J Pediatr Orthop 2003;23:208-215.BeringerDC, Weiner DS, Noble JS, et al: Severely displaced proximal humeral epiphyseal fractures: A follow-up study.  J Pediatr Orthop 1998;18:31-37.Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus.  J Pediatr Orthop B 1997;6:219-222.

This patient has an extraarticular distal tibia fracture and distal fibula fracture. Reamed intramedullary nailing and fibular plating is indicated in this case.In the distal tibial metaphysis, there is no snug endosteal fit for an IM nail. Center-center nail placement in both proximal and distal fragments is necessary to maintain alignment. There is also increased stress on distal locking bolts to maintain fracture alignment. Assuming static medial-lateral distal locking screws, accurate coronal plane and rotational alignment is achieved by fibular plating as a first step. This alsoprevents late loss of alignment because of distal locking screw toggle. Reamed nailing allows a stiffer, larger nail to be placed, and allows redistribution of endosteal osteogenic material to the fracture site. Although there is endosteal vascular compromise, this does not affect fracture healing because of intact periosteal supply.Bhandari et al. conducted a prospective, randomized, blinded comparison of 622 patients who had reamed nailing, and 604 who had unreamed nailing. For closed fractures, a significantly greater number in the unreamed group required bone grafting, implant exchange and dynamization. There was no difference in groups for open fracture nailing.Egol et al. retrospectively reviewed distal metaphyseal tibia-fibula fractures treated with IM nailing with (25 cases) and without (47 cases) adjunctive plating. They found that plating was associated with maintenance of reduction (significant) as was the use of 2 medial-lateral distal locking bolts (not significant). They recommend fibular plating when IM nailing for distal tibia fractures.Figures A and B show an extraarticular distal tibia fracture with distal fibula fracture. Incorrect Answers

DISCUSSIONProximal humerus fractures account for approximately 5% of all fractures, with incidence increasing to reflect an aging population and related osteoporosis. Treatment is dependent upon the mechanism of injury, the patient’s physiologic age and activity level, the fracture pattern, and rotator cuff integrity. Most of these injuries are nondisplaced or minimally displaced and are associated with a good overall prognosis with nonsurgical treatment and temporary impairment. A patient with a nondisplaced surgical neck fracture should be treated without surgery. K-wire stabilization, although technically difficult to achieve, is an option for compliant patients with 2-part, 3-part, and valgus-impacted 4-part fractures who have adequate bone stock. Valgus-impacted 4-part fractures pose reduced risk for osteonecrosis because of the preserved blood supply through the medial hinge, which allows for this technique. For displaced 2-part fractures accompanied bymetaphyseal comminution, K-wire fixation cannot provide adequate stability to initiate a graduated home exercise or outpatient physical therapy program. Formal open reduction with intramedullary or plate fixation in addition to bone grafting (fibular strut allograft) is the best surgical option for the clinical scenario involving a displaced surgical neck fracture with comminution. Osteosynthesis of 3-part fractures may be feasible for physiologically young and active patients without humeral head involvement and osteoporosis.Current indications for primary hemiarthroplasty include most 4-part fractures, 3-part fractures and dislocations in elderly patients with osteoporotic bone, head-splitting articular segment fractures, and chronic anterior or posterior humeral head dislocations with more than 40% of articular surface involvement. Because of the intra-articular nature of this patient’s 4-part injury in this scenario, hemiarthroplasty with anatomic reconstruction of the greater and lesser tuberosities is most appropriate. Relative indications for hemiarthroplasty also include fractures with more than 20 degrees of varus, associated moderate to severe osteopenia, and revision surgery for failed osteosynthesis. Currently accepted indications for rTSA include scenarios in which the fracture pattern, level of comminution, bone quality, and rotator cuff deficiency preclude plate fixation or hemiarthroplasty. Scenarios involving 4-part fractures and associated rotator cuff tears and tuberosity comminution are best served with a reverse shoulder prosthesis. One of the positive attributes of this implant is the ability to achieve functional forward flexion and abduction regardless of tuberosity healing, position, and degree of comminution. Caution is warranted with this surgical technique because complication rates are higher than for hemiarthroplasty reconstruction. Acute, irreducible 2-part fracture-dislocations of the proximal humerus necessitate open reduction and internal fixation of the affected tuberosities (posterior, lesser tuberosity; anterior, greater tuberosity) through screw, anchor, and/or suture fixation. These fracture-dislocations can be managed with this technique because of the integrity of the vascular supply, which is maintained by the soft-tissue attachments to the intact tuberosities. Repeated attempts at a closed reduction in the 37-year-old with the posterior fracture-dislocation could result in neurovascular injury and myositis ossificans and should be avoided. Arthroplasty reconstruction in this scenario should not be the index procedure in light of concerns regarding implant survivorship in patients of this age and their assumed elevated activity levels.RECOMMENDED READINGSHarrison AK, Gruson KI, Zmistowski B, Keener J, Galatz L, Williams G, Parsons BO, Flatow EL. Intermediate outcomes following percutaneous fixation of proximal humeral fractures. J Bone Joint Surg Am. 2012 Jul 3;94(13):1223-8. doi: 10.2106/JBJS.J.01371.View Abstract at PubMedIannotti JP, Ramsey ML, Williams GR Jr, Warner JJ. Nonprosthetic management of proximal humeral fractures. Instr Course Lect. 2004;53:403-16. Review.View Abstract at PubMedMata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013 Dec;22(12):1737-48. doi: 10.1016/j.jse.2013.08.021. Review.View Abstract at PubMedJobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190. Epub 2015 Jan 28. Review.View Abstract at PubMedBae JH, Oh JK, Chon CS, Oh CW, Hwang JH, Yoon YC. The biomechanical performance of locking plate fixation with intramedullary fibular strut graft augmentation in the treatment of unstable fractures of the proximal humerus. J Bone Joint Surg Br. 2011 Jul;93(7):937-41.View Abstract at PubMedKontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008 Nov;90(11):1407-13. doi: 10.1302/0301-620X.90B11.21070. Review. PubMed PMID: 18978256.View Abstract at PubMedHertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 Jul-Aug;13(4):427-33. PubMed PMID: 15220884.View Abstract at PubMedCLINICAL SITUATION FOR QUESTIONS 67 THROUGH 70Figure 67 is the radiograph of a right-hand-dominant 70-year-old woman who arrives at the emergency department with acute left shoulder pain following a fall down a flight of stairs. She expresses acute diffuse left shoulder pain and swelling. Prior to her injury, she had full active painless shoulder range of motion.

DISCUSSION: Although pain, pallor, paresthesia, paralysis, and pulselessness are all possible signs and symptoms of compartment syndrome in children with fractures, studies have shown increasing analgesia requirement is more sensitive.Bae et al reviewed thirty-six cases of compartment syndrome in 33 pediatric patients. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. "They found pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, was a more sensitive indicator of compartment syndrome."Whitesides et al summarizes the diagnosis and treatment of acute compartment syndrome. They emphasize the need for early diagnosis, as "muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible." They recommend fasciotomy be performed when tissue pressure rises past 20 mm Hg below diastolic pressure.

DISCUSSION: Avulsion fractures of the tibial spine are rare injuries that result from rapid deceleration or hyperextension of the knee in skeletally immature individuals.  This injury is the equivalent of ruptures of the anterior cruciate ligament in adults.  These fractures are classified as types 1 through 3.  Type 1 is a minimally displaced fracture, type 2 fractures have an intact posterior hinge, and type 3 fractures have complete separation.  The radiograph demonstrates a completely displaced, or type III, tibial spine avulsion.  Surgical reduction is indicated in type 2 fractures that fail to reduce with knee extension and in all type 3 fractures.  Reduction may be arthroscopic or open, with fixation of the bony fragment using a method that maintains physeal integrity and prevents later growth arrest.  Preferred techniques would be with suture or an intra-epiphyseal screwREFERENCES: Wiley JJ, Baxter MP: Tibial spine fractures in children.  Clin Orthop 1990;255:54-60.Mulhall KJ, Dowdall J, Grannell M, et al: Tibial spine fractures: An analysis of outcome in surgically treated type III injuries.  Injury 1999;30:289-292.Owens BD, Crane GK, Plante T, et al: Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes.  Am J Orthop 2003;32:103-105.VockeAK, Vocke AR: Cartilaginous avulsion fracture of the tibial spine.  Orthopedics 2002;25:1293-1294.

Polytraumatized patients can be classified as stable, unstable, borderline, or in extremis. Management of the borderline patient is controversial because it is unclear which patients can safely undergo early definitive surgical stabilization of fractures, and which patients would benefit from temporizing "damage control" stabilization to allow adequate resuscitation and physiologic stabilization prior to definitive treatment. Although the question of damage control versus early total care is unresolved, there are several clinical parameters that have been suggested for use in deciding who should be treated with early damage control. These include Injury Severity Score of greater than 40, Injury Severity Score of greater than 20 with thoracic trauma, multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock, bilateral femoral fractures, pulmonary contusion noted on radiographs, hypothermia of less than 35 degrees C), and a head injury with an Abbreviated Injury Score of 3 or greater. A hemoglobin of 9 g/dL is not included in these suggested parameters.

The decision to perform fasciotomy of the fingers for a hand compartment syndrome is most appropriately made usingA. clinical examination.B. invasive pressure measurement.C. arterial Doppler study.D. MRI.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. 41MRI 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.45- Figures 1 and 2 show the MRI studies of a 35-year-old manual laborer with persistent wrist pain despite immobilization. At the time of surgery, collapse of the capitate and arthritic changes of the midcarpal joint are noted. What is the most appropriate procedure for this condition?A. Local vascularized bone graftB. Proximal row carpectomyC. Midcarpal fusionD. Total wrist arthroplastyThe T1-weighted MRI reveals decreased signal that is consistent with avascular necrosis (AVN) of the capitate. Figure 2 demonstrates increased signal of the capitate consistent with edema. The etiology of AVN of the capitate may be related to trauma, abnormal interosseous vascular supply, and hypermobility. Surgical treatment is considered for patients who have had persistent symptoms despite immobilization. At the time of surgery, collapse of the capitate and arthritic changes would be treated most appropriately with a salvage procedure. A midcarpal fusion is a motion-preserving salvage procedure and is the most appropriate option given to address the pain associated with the midcarpal arthritic changes. The alternative options are not appropriate for this patient. Local vascularized bone grafts are considered for situations in which no evidence of capitate collapse or arthritis is observed.

From the following options, a short working length of the construct is a known risk factor for femoral plate failure.Implant failure is common in distal femur fractures stabilized with plate fixation. Contributors to failure include a short working length of the construct, plate-screw density more than 0.5 and short plate lengths. This will lead to failure as it causes increased strain on the plate over a short segment, anddoes not allow enough motion at the fracture site to form bone for healing by secondary intention.Ricci et al. reviewed 355 cases of distal femur plate fixation. 64 patients (19%) required reoperation to promote union, including 30 that had a planned staged bone grafting. Risk factors for proximal implant failure included open fracture, smoking, increased body mass index, and shorter plate length.Kregor et al. reviewed 119 patients with distal femoral plate fixation. They found that 93% fractures healed without acute bone grafting. Complications included 5 losses of proximal fixation, 2 nonunions, and 3 acute infections.Illustration A is an AP of the distal femur demonstrating a comminuted distal femur fracture which has failed fixation with a laterally based distal femur locking plate. It has undergone varus collapse which is a common mechanism of failure for these injuries. Illustration B is a series of AP radiographs of the distal femur of the same patient that was revised to an intramedullary retrograde nail. Illustration C and D show the concepts of plate length, plate-to-screw density and the working length of the plate.Incorrect Answers:OrthoCash 2020

EXPLANATION:Figures 1 and 2 show a scaphoid nonunion with substantial bone resorption at the nonunion site. Cast immobilization and bracing with bone stimulator use would not be successful treatments at this point because the fracture is 6 months old and there is considerable bone resorption at the fracture site. Scaphoid excision with intercarpal fusion is an option to use only after bone-grafting procedures have failed or arthritis is present. Bone-grafting procedures using both vascularized and nonvascularized graft sources are associated with a high success rate that decreases with avascular necrosis of the proximal pole. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis.