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2. Trauma MCQs

Practice Set 184 of 640

This practice set contains high-yield board review questions covering key concepts in 2. Trauma. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 3661

Topic: 2. Trauma

A 59-year-old woman with a history of osteoporosis is involved in a high-speed motor vehicle accident, resulting in left hip pain and deformity. The initial radiograph from the trauma bay is shown in Figure 1. Postreduction CT is shown in Figures 2 through 4. What is the most appropriate definitive surgical treatment?

. Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty
. ORIF of the acetabular fracture and ORIF of the femoral head fracture fragments
. ORIF of the acetabular fracture and hemiarthroplasty
. Skeletal traction with delayed total hip arthroplasty after the acetabular fracture has healed

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) of the acetabular fracture with concomitant acute total hip arthroplasty

Explanation

DISCUSSION:The radiograph shows a posterior wall acetabular fracture-dislocation. Post reduction CT indicates a large comminuted posterior wall fracture with marginal impaction of the articular surface. A comminuted femoral head fracture also is seen extending to the superior weight-bearing surface. Given the marginalimpaction of the acetabulum and the considerable comminution of the femoral head (which is likely unreconstructible), this injury would have a high risk of causing posttraumatic arthritis if treated with ORIF of the fractures alone. Considering this fact and the patient’s age, ORIF of the posterior wall and acute total hip arthroplasty would likely have the best functional result and the lowest risk of reoperation. Hemiarthroplasty is inappropriate for this injury considering the acetabular fracture. Skeletal traction currently plays a limited role in the definitive treatment of acetabular fractures.

Question 3662

Topic: 2. Trauma

Figure 61 shows the current radiograph of a 69-year-old woman who fell getting out of bed 10 months ago. At the time of injury she was diagnosed with a nondisplaced humeral surgical neck fracture. After 2 weeks of sling immobilization, physical therapy was started for range of motion. She continues to have pain and is unable to elevate her arm. What is the most likely diagnosis?

. Rotator cuff tear
. Posttraumatic glenohumeral arthritis
. Proximal humerus fracture nonunion
. Shoulder infection
. Post fracture stiffness

Correct Answer & Explanation

. Rotator cuff tear

Explanation

The patient has a nonunion at the fracture site. The humeral head fragment has the rotator cuff musculature attached but the head is not united to the humeral shaft. There is no evidence of glenohumeral arthritis or a rotator cuff tear. Given the history, she has no evidence of a shoulder infection at this time. In review of the radiographs, there is an established nonunion; therefore, examination for post fracture stiffness is not possible because the motion is occurring at the nonunion site.(SBQ12TR.96) Interleukin-6 levels have been shown to be a reliable measure of which of the following?OsteoporosisSeverity of injurySarcomatous tumor burdenBone turnoverHyperparathyroidismInterleukin-6 (IL-6) is a proinflammatory cytokine that is increased according to the level of injury sustained and acts to activate the host immune system. In addition, new literature exists to indicate its high sensitivity and specificity for detecting infection in total joint arthroplasty.Overactivation of the immune system and cytokines can lead to systemic inflammatory response syndrome (SIRS), which results in end-organ damage, including small-vessel vascular damage; this would lead to parenchymal cell death from hypoxic insult.Keel et al. report that immediate and early trauma deaths are determined by brain injuries or significant blood loss, while late mortality is caused by secondary brain injuries and host defense failure. The secondary effects are characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators.Pape et al. investigated the effect of surgeries as a "second-hit" phenomenon. They found that surgery on days 2-4 was associated with a greater amount of postoperative organ dysfunction than if the secondary surgery was done on days 5-8. They also found a significant association between IL-6 values above 500pg/dL at the time of surgery and development of multiple organ failure.Sears et al. review the effect of the inflammatory response to trauma and the development of complications (death, multiple organ failure). They report that IL-6 and the HLA-DR2 molecules currently appear to have the most potential for use in predicting outcomes in trauma patients.Illustration A is a diagram that shows some of the effects of IL-6 production. Incorrect Answers:1,3-5: IL-6 levels are not known to be reliably altered by these factors.

Question 3663

Topic: 2. Trauma

A 36-year-old woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with open reduction and internal fixation. What is the most common complication?

. Posttraumatic arthritis
. Infection
. Fixation failure
. Malunion
. Nonunion

Correct Answer & Explanation

. Posttraumatic arthritis

Explanation

DISCUSSION: The most common complication associated with tarsometatarsal joint injury is posttraumatic arthritis.  In one series, symptomatic arthritis developed in 25% of the patients and half of those went on to fusion.  In another series, 26% had painful arthritis.  Initial treatment should consist of shoe modification, inserts, and anti-inflammatory drugs.  Fusion is reserved for failure of nonsurgical management.  Hardware failure may occur, but it is clinically unimportant.REFERENCES: Kuo RS, Tejwani NC, DiGiovanni CW, et al: Outcome after open reduction and internal fixation of Lisfranc joint injuries.  J Bone Joint Surg Am 2000;82:1609-1618.Arntz CT, Veith RG, Hansen ST Jr: Fractures and fracture-dislocations of the tarsometatarsal joint.  J Bone Joint Surg Am 1988;70:173-181.Thompson MC, Mormino MA: Injury to the tarsometatarsal joint complex.  J Am Acad Orthop Surg 2003;11:260-267.

Question 3664

Topic: 2. Trauma

03

. lateral process fracture
. anterior process fracture
. tongue type
. comminuted posterior facet
. back to this question next question
. joint depression type 18.03

Correct Answer & Explanation

. tongue type

Explanation

The Essex-Lopresti reduction technique is a useful method for the treatment of tongue type calcaneal fractures. With this technique, a steinman pin is inserted percutaneously into the posterior facet fragment. This pin is then used to disimpact the fragment and reduce the fracture.

Question 3665

Topic: 2. Trauma

During total shoulder replacement for rheumatoid arthritis, fracture of the humeral shaft occurs. An intraoperative radiograph shows a displaced short oblique fracture at the tip of the prosthesis. At this point, the surgeon should

. insert a standard humeral prosthesis with cerclage wires at the fracture site and autologous cancellous bone graft.
. insert a standard humeral component and apply a humeral orthosis postoperatively.
. cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.
. remove all instrumentation, perform an open reduction and internal fixation of the fracture, and delay completion of replacement surgery until the fracture has healed.
. discontinue the procedure and return for completion of total shoulder replacement when the fracture has healed.

Correct Answer & Explanation

. cement a long-stemmed humeral component to bypass the fracture site and supplement with cerclage wires.

Explanation

DISCUSSION: The risk of intraoperative fracture in osteopenic rheumatoid bone is significant.  Fractures may occur with dislocation of the head and canal reaming, especially while extending and externally rotating the shoulder.  If the fracture occurs at the distal tip of the prosthesis, the use of a long-stemmed prosthesis to bypass the fracture site and supplementation with wire cables has been reported with good results.REFERENCES: Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty.  J Bone Joint Surg Am 1995;77:1340-1346.Boyd AD Jr, Thornhill TS, Barnes CL: Fractures adjacent to humeral protheses. J Bone Joint Surg Am 1992;74:1498-1504.Petersen SA, Hawkins RJ: Revision of failed total shoulder arthroplasty. Orthop Clin North Am 1998;29:519-533.

Question 3666

Topic: 2. Trauma

In an effort to reduce costs, a limited MRI sequence is planned to detect a possible occult hip fracture. What is the anticipated fracture signal?

. Bright on T 1 and T 2
. Dark on T 1 and T 2
. Dark on T 1 , bright on T 2
. Bright on T 1 , dark on T 2
. Enhancement by gadolinium

Correct Answer & Explanation

. Bright on T 1 and T 2

Explanation

DISCUSSION: At present, radiologists perform multiple MRI images to rule out all possible diagnoses.  The ability to specify the anticipated changes on MRI should become more important as a means of reducing costs.  MRI is sensitive to changes in free water (or hemorrhage) and thus this will appear dark on T1and bright on T2.REFERENCES: Miller MD: Review of Orthopaedics, ed 3.  Philadelphia PA, WB Saunders, 2000, p 116.Guanche CA, Kozin SH, Levy AS, et al: The use of MRI in the diagnosis of occult hip fractures in the elderly: A preliminary review.  Orthopedics 1994;17:327-330.

Question 3667

Topic: 2. Trauma

Treatment of this fracture should consist of

. closed reduction, limited immobilization (1-2 weeks), and early functional rehabilitation.
. limited immobilization in a long-arm cast (4 weeks) and early functional rehabilitation.
. open reduction and internal fixation.
. open reduction, capsular repair, and suture fixation of the bony fragment and ligament.

Correct Answer & Explanation

. closed reduction, limited immobilization (1-2 weeks), and early functional rehabilitation.

Explanation

DISCUSSIONVarus posteromedial rotatory instability is a complex injury pattern that starts with varus stress resulting in a fracture of the anteromedial coronoid. The anterior MCL attaches to the sublime tubercle, which is part of the anteromedial coronoid facet. The posterior MCL attaches to the posterior medial aspect of the ulna. The radial collateral and lateral ulnar collateral attach to the ulna at the crista supinatoris. The bony landmark is the sublime tubercle; as noted above, the crista supinatoris is lateral on the ulna. The radial notch is also lateral and is the articulation between the proximal ulna and proximal radius. The anteromedial coronoid facet is part of the coronoid, which extends more lateral and anterior than the anteromedial facet. The anteromedial facet represents the critical weight-bearing portion of the ulnohumeral joint. Damage to this structure causes posteromedial subluxation that often results in severe progressive arthritis. The coronoid is the larger structure of which the anteromedial coronoid facet is a portion. The posteromedial coronoid facet does not appear to be critical in weight bearing. The radial notch is not associated with increased stress with weight bearing. The treatment of displaced fractures of this structure is open reduction and internal fixation utilizing buttress plating. Closed treatment is acceptable only for nondisplaced fractures with appropriate radiographic follow-up. Suture fixation is not advocated because of inadequate strength.RECOMMENDED READINGSPollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. J Bone Joint Surg Am. 2009 Jun;91(6):1448-58. doi: 10.2106/JBJS.H.00222.Sanchez-Sotelo J, O'Driscoll SW, Morrey BF. Anteromedial fracture of the coronoid process of the ulna. J Shoulder Elbow Surg. 2006 Sep-Oct;15(5):e5-8. Epub 2006 Jul 26. Erratum in: J Shoulder Elbow Surg. 2007 Jan-Feb;16(1):127. PubMed PMID: 16979044.

Question 3668

Topic: 2. Trauma

Staged open reduction and internal fixation with free flap soft tissue reconstruction is the most appropriate definitive treatment method for which of the following tibial injuries?

. Type IIIB intra-articular distal tibia fracture
. Type IIIB segmental midshaft tibia fracture
. Type IIIB transverse midshaft tibia fracture
. Type IIIB Schatzker I proximal tibia fracture
. Type IIIB Schatzker IV proximal tibia fracture

Correct Answer & Explanation

. Type IIIB intra-articular distal tibia fracture

Explanation

DISCUSSION: By definition, with Type IIIB injuries, there is exposed bone after debridement which will require a local or a free flap for coverage. Distal third IIIB tibial shaft fracture are unique in that they usually require a free flap or reverse sural rotational flap to obtain adequate coverage. As stated in Skeletal Trauma, "As local donor muscles in the distal third of the tibia are almost non-existent, closure of an open plafond fracture, or any extensive Type IIIB injury in this area will usually require free tissue transfer. The primary options are latissimus dorsi or rectus abdominus for large defects, and gracilis for smaller wounds." In addition to the flaps mentioned here, others, including fasciocutaneous flaps and radial forearm flaps, are also utilized with success in this area.Typically, treatment of Type IIIB tibial shaft fractures should be staged. Initially tetanus prophylaxis, antibiotics with gram negative and positive coverage, and application of an external fixator with repeat I&D’s are employed for immediate fracture care. Plating is usually required in the presence of significant intra-articular fracture involvement.Incorrect Answers: Typically, proximal third tibia fractures requiring soft tissue coverage can be treated with a gastrocnemius rotation flap and middle third tibia fractures with soft tissue defects can be reliably covered with a soleus rotation flap. Therefore, a free flap is rarely indicated in the proximal and middle tibia.

Question 3669

Topic: 2. Trauma

What is the most common donor site complication following a free vascularized fibular graft for osteonecrosis of the femoral head?

. Sensory deficit
. Motor deficit
. Flexor hallucis longus contracture
. Deep venous thrombosis
. Fibular fracture

Correct Answer & Explanation

. Sensory deficit

Explanation

DISCUSSION: Urbaniak and Harvey reported donor site morbidity following free vascularized fibular graft in 198 consecutive patients.  At a 5-year follow-up, they reported overall complications in 24% of the patients.  The most common complication was a sensory deficit (11.8%), followed by motor weakness (2.7%), flexor hallucis longus contracture (2%), and deep venous thrombosis (less than 1%).REFERENCE: Urbaniak J, Harvey E: Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg 1998;6:44-54.

Question 3670

Topic: 2. Trauma

A 45-year-old man who is a smoker has a significant hemothorax and bilateral closed femoral fractures. On insertion of a chest tube, 1,100 mL of blood was returned. He has had 75 mL of chest tube output over the last 2 hours while being resuscitated in the ICU. His base deficit is now 2 and his urine output has been 3 mL/kg over the last hour. What is the next most appropriate step in management?

. Continued skin traction
. Skeletal traction of both femurs
. External fixation of both femurs
. Intramedullary nailing of one femur and external fixation and delayed nailing for the other femur
. Intramedullary nailing of both femurs

Correct Answer & Explanation

. Continued skin traction

Explanation

DISCUSSION: Although this patient had a hemothorax, the bleeding has stopped and he has been resuscitated to a euvolemic status with a small base deficit and good urine output.  External fixation of both femurs is an option but an unnecessary step in the treatment algorithm.REFERENCES: Nork SE, Agel J, Russell GV, et al: Mortality after reamed intramedullary nailing of bilateral femur fractures.  Clin Orthop Relat Res 2003;415:272-278.Pape HC, Zelle BA, Hildebrand F, et al: Reamed femoral nailing in sheep: Does irrigation and aspiration of intramedullary contents alter the systemic response?  J Bone Joint Surg Am 2005;87:2515-2522.

Question 3671

Topic: 2. Trauma

A 60-year-old woman with a history of osteoporosis fell from a standing height and sustained a supracondylar distal humerus fracture with an intercondylar extension. Which of the following plate constructs yields the highest stiffness for fixation of the fracture?

. Single posterior Y plate
. Single medial plate with bicortical locking screws
. Dual plating with medial and posterolateral LC-DCP
. Dual plating with medial and posterolateral one third tubular plates
. Dual plating with medial and lateral LC-DCP

Correct Answer & Explanation

. Single posterior Y plate

Explanation

Optimal treatment of distal humeral fractures relies on reestablishment of a congruent articular surface with a fixation construct that is stable enough to allow for early range of motion. Several biomechanical studies have been performed to evaluate the biomechanical strength of various plating configurations. These studies have shown that dual plate configurations are more stable than single plates, regardless of the type of plate used. One third tubular plates have been shown to be significantly weaker than LC-DCP or reconstruction plates, resulting in weaker constructs, and clinically higher rates of hardware failure and nonunion. Whereas traditional teaching has suggested plating in perpendicular planes, recent biomechanical studies have demonstrated that parallel medial and lateral plates confer a greater rigidity to the construct than perpendicular plating schemes.

Question 3672

Topic: 2. Trauma

A 5-year-old boy has a deformity of his right arm after falling from a jungle gym. A radiograph is shown in Figure 37. Management should consist of

. closed reduction of the ulna and transcapitellar pinning of the radial head.
. closed reduction of the ulna and radial head dislocation.
. closed reduction of the ulna and annular ligament repair.
. open reduction of the radius and plating of the ulna.
. open reduction of the ulna and immobilization in an extension cast.

Correct Answer & Explanation

. closed reduction of the ulna and transcapitellar pinning of the radial head.

Explanation

DISCUSSION: Monteggia fractures in children must be recognized.  Early appropriate treatment is much easier than delayed reconstruction for a missed radial head dislocation.  In younger children, attempts should be made to reduce the ulna fracture and radial head dislocation with traction and manual manipulation.  Anterior Monteggia fractures are the most common, and in this variety the radius is much better stabilized in elbow flexion.  Posterior Monteggia fractures are less common and may be managed in elbow extension.  Closed reduction is much more successful in younger children; ulnar fixation with a rod or plate may be needed in older patients with unstable fractures.  Annular ligament repair is rarely needed in the acute fracture.REFERENCES: Wilkins KE: Changes in the management of Monteggia fractures.  J Pediatr Orthop 2002;22:548-554.Kay RM, Skaggs DL: The pediatric Monteggia fracture.  Am J Orthop 1998;27:606-609.Ring D, Jupiter JB, Waters PM: Monteggia fractures in children and adults.  J Am Acad Orthop Surg 1998;6:215-224.

Question 3673

Topic: 2. Trauma

A 39-year-old female presents with the following motor vehicle crash with the injury seen in Figure A (immobilized in a pelvic binder). The iatrogenic neurologic injury most commonly caused by placement of the anterior construct for this injury, as shown in Figure B, would cause which of the following?

. Weakness of hip flexion
. Weakness of ankle dorsiflexion
. Numbness of the medial thigh
. Numbness of the lateral thigh
. Numbness of the perineum

Correct Answer & Explanation

. Weakness of hip flexion

Explanation

This patient was treated with posterior stabilization, and an anterior subcutaneous internal fixator (ASIF). The most common neurologic injury seen following placement of the ASIF construct is irritation of the lateral femoral cutaneous nerve (LFCN), causing numbness and/or pain of the lateral thigh.Unstable pelvic fractures can be treated in a multitude of ways. The ASIF construct is typically created by placing long pelvic screws or polyaxial pedicle screws in the supraacetabular region, similar to the supraacetabular pins for an anterior external fixator. Then a curved bar is placed subcutaneously and connected to the supraacetabular screws. They are typically removed after 3-4 months when fracture healing is complete.Vaidya et al. present a retrospective review of the use of ASIF as definitive treatment of unstable pelvic fractures. All patients in the study tolerated the construct well. LFCN irritation was seen in 30% of patients, and resolved in all but one patient.Müller et al. present a retrospective review of the use of posterior stabilization and ASIF. They report an acceptably low complication rate, and good to excellent outcomes in 64.5% of patients.Figure A is a radiograph demonstrating a right APC3 and left APC2 pelvic injury, imaged in a pelvic binder. Figure B is a postoperative radiograph following posterior stabilization and ASIF.Incorrect answers:

Question 3674

Topic: 2. Trauma

Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing?

. worse functional results
. higher need for subsequent surgeries
. less blood loss
. higher union rates
. increased postoperative shoulder stiffness

Correct Answer & Explanation

. worse functional results

Explanation

DISCUSSION: Lin et al found less blood loss with intramedullary nailing than plating, but nailing was also associated with increased shoulder surgery due to disruption of the rotator cuff tendon during insertion. Meekers et al found a higher union rate, better functional results and a lower reoperation rate after plate and screw fixation versus nailing. They concluded that plating was superior in most cases of humeral shaft fracture, except for pathological fractures, very obese patients, and open fractures.

Question 3675

Topic: 2. Trauma

Which of the following factors has been shown to increase mortality in poly-trauma patients with severe head injuries?

. Delayed fixation of fractures
. Decreased intracranial pressure
. Intra-abdominal injury
. Intra-operative hypotension
. Decreased platelet count

Correct Answer & Explanation

. Delayed fixation of fractures

Explanation

DISCUSSION: The factor most likely to adversely affect long term outcome in poly-trauma patients with severe brain injury is intraoperative hypotension.Chesnut et al demonstrated that hypotension (SBP <90mmHg) was profoundly detrimental, occurring in 35% of these patients and associated with 150% increase in mortality.Pietropaoli et al reviewed 53 patients with severe head injuries and required early surgical intervention (surgery within 72 hours of injury). All patients were initially normotensive on arrival. There were 17 patients (32%) who developed intra-operative hypotension and 36 (68%) who remained normotensive throughout surgery. The mortality rate was 82% in the IH group and 25% in the normotensive group.

Question 3676

Topic: 2. Trauma

-The World Health Organization Fracture Risk Assessment Tool (FRAX) calculates which fracture risk?

. year risk for hip fracture
. year risk for distal radius fracture
. year risk for any fragility fracture
. year risk for hip fracture
. year risk for distal radius fracture

Correct Answer & Explanation

. year risk for hip fracture

Explanation

Question 3677

Topic: 2. Trauma

A 25-year-old woman has lower leg pain during exercise without numbness, tingling, or weakness. The symptoms resolve by the following day. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19a (Table 1). She undergoes anterior compartment fasciotomy with complete resolution of symptoms. Two years later, she has recurrent pain and tightness with exercise. Radiographs, a technetium bone scan, and noninvasive vascular study findings are normal. Compartment pressure measurements obtained 1 minute after exercise are shown in Figure 19b (Table 2). What is the most likely etiology for her recurrent symptoms?

. Misdiagnosis
. Hematoma formation
. Postsurgical fibrosis
. Failure to recognize involvement of other compartments

Correct Answer & Explanation

. Misdiagnosis

Explanation

DISCUSSIONExertional compartment syndrome involves an increase in compartment pressure caused by exercise or sports activity that restricts blood flow in the compartment, resulting in pain with continued activity. Compartment pressures of at least 15 mm Hg measured at rest, at least 30 mm Hg measured 1 minute after exercise, and at least 20 mm Hg measured 5 minutes after exercise are diagnostic. Surgical fasciotomy for exertional compartment syndrome is successful for the majority of patients, but recurrence rates as high as 20% have been reported. Scar formation within the fascial defect can result in recurrent symptoms and/or nerve entrapment, and recurrence is typically observed after an initial symptom-free period. In a series of 18 patients, recurrent symptoms occurred at a mean of 23.5 months after the index procedure. Other potential causes of recurrence include inadequate fascial release, failure to recognize involvement of other compartments, nerve compression, and misdiagnosis. Surgical complications after fasciotomy include hemorrhage leading to excessive fibrosis, neurovascular injury, and hematoma or seroma formation.

Question 3678

Topic: Pelvic & Acetabular Trauma

The primary purpose of obtaining the radiograph shown in Figure 9 is to assess

. the anterior column of the acetabulum.
. the acetabular rim.
. the os acetabulae.
. anterior coverage of the femoral head.
. femoral anteversion.

Correct Answer & Explanation

. the anterior column of the acetabulum.

Explanation

DISCUSSION: The radiograph shows a faux profil view of the hip.  The primary purpose of this view is to evaluate anterior coverage of the femoral head.REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.Ganz R, Klaue K, Vinh TS, Mast JW: A new periacetabular osteotomy for the treatment of hip dysplasias: Technique and preliminary results.  Clin Orthop 1988;232:26-36.Lequesne M, deSez S: Le faux profil du bassin: Nouvelle incidence radiographique pour l’etude de la hance.  Son utilite dans les dysplasies et les differentes coxopathies.  Rev Rhum Mal Osteoartic 1961;28:643.

Question 3679

Topic: 2. Trauma

The implant shown in Figures 47a and 47b is introduced submuscularly employing a minimally invasive technique. A percutaneous method of screw insertion is used distally. What nerve is most at risk?

. Sural
. Saphenous
. Superficial peroneal
. Deep peroneal
. Posterior tibial

Correct Answer & Explanation

. Sural

Explanation

Minimally invasive methods used for stabilizing complex periarticular fractures continue to evolve. Encouraging results suggest a diminished threat to the soft tissues and enhanced preservation of osseous blood supply. Contemporary locking implants combined with indirect reduction lead to desirable biomechanical and biologic environments for osseous and soft-tissue healing. Deangelis and associates, in a cadaveric tibial study, demonstrated the superficial peroneal nerve to be at significant risk during percutaneous screw placement in very distal targeted holes (within laterally applied tibial locking plates). Use of a larger incision and cautious dissection to the plate in this region were encouraged to minimize risk to this structure.

Question 3680

Topic: 2. Trauma

A 26-year-old man is brought to the emergency department unresponsive and intubated after being found lying on the side of the road. He has a Glasgow Coma Scale score of 6. A chest tube has been inserted on the right side of the chest for a pneumothorax. An abdominal CT scan reveals a small liver laceration and minimal intraperitoneal hematoma. A pneumatic antishock garment (PASG) is on but not inflated. He has bilateral tibia fractures. A pelvic CT scan shows an anterior minimally displaced left sacral ala fracture and left superior and inferior rami fractures. He has received 2 L of saline solution and 4 units of blood but remains hemodynamically unstable. What is the next most appropriate step in management?

. Inflation of the abdominal portion of the PASG
. Application of a pelvic clamp
. Application of a pelvic external fixator
. Rapid infusion of 4 more units of blood
. Angiography and embolization

Correct Answer & Explanation

. Inflation of the abdominal portion of the PASG

Explanation

DISCUSSION: There is no identifiable thoracic, abdominal, or long bone source of ongoing bleeding.  The patient has a lateral compression Burgess-Young type I pelvic ring injury.  This injury does not increase the pelvic volume because it is not unstable in external rotation.  Application of a PASG, a pelvic clamp, or an external fixator may be helpful if the patient has a pelvic injury that is unstable in external rotation or translation but would be of little use in this injury pattern.  Persistent hemodynamic instability after administration of 4 units of blood is the decision point where most authors would recommend angiography and embolization.  If the pelvis is unstable in external rotation or translation, inflation of the PASG trousers or application of an external fixator is recommended before angiography.  Attributing the hemodynamic instability to the head injury before ruling out the pelvis as a source is not indicated.REFERENCES: Burgess AR, Eastridge BJ, Young JW, et al: Pelvic ring disruptions: Effective classification system and treatment protocols.  J Trauma 1990;30:848-856.Evers BM, Cryer HM, Miller FB: Pelvic fracture hemorrhage: Priorities in management.  Arch Surg 1989;124:422-424.Flint L, Babikian G, Anders M, Rodriguez J, Steinberg S: Definitive control of mortality from severe pelvic fracture.  Ann Surg 1990;211:703-707.

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