2. Trauma MCQs

DISCUSSION: Lateral compression type II fractures (as described by the Young-Burgess Classification System) are associated with a crescent fracture of the iliac wing located on the side of impact. A representative CT scan image and illustration of this injury are shown in Illustration A and B respectively. A table describing each pelvic injury and their associated complications is shown in Illustration C. Illustration D shows each Young-Burgess pelvic injury type.Burgess et al discuss the effectiveness of a treatment protocol as determined by their pelvic injury classification and hemodynamic status. The injury classification system was based on lateral compression, anteroposterior compression, vertical shear, and combined mechanical injury types. They found that their classification-based treatment protocols reduce the morbidity and mortality related to pelvic ring disruption.Tile discusses acute pelvic trauma and his classification system for pelvic injuries (ie. Types A, B, and C). He states that any classification system must be seen only as a general guide to treatment, and that the management of each patient requires careful, individualized decision making.Incorrect2:ThisdescribesanAPC-IIinjury3:ThisdescribesanAPC-IIIinjury4:ThisdescribesandLC-Iinjury

DISCUSSION: The most common deformity after antegrade nailing of a subtrochanteric femur fracture is varus and procurvatum (or flexion). This is caused by the hip abductors and iliopsoas pulling the proximal fragment into abduction and flexion, while the distal fragment is pulled into adduction from the adductors.The reference by French et al is a review on 45 patients with subtrochanteric fractures treated with cephalomedullary interlocked nailing. Based on femoral neck-shaft angle, 61% of the fractures were reduced in at least 5º varus. The authors attributed this malalignment to failure to counteract muscle forces acting on the proximal fragment, combined with the adducted position of the distal femur during portal creation.The reference by Ricci et al is a report of 403 femoral shaft fractures treated with intramedullary nailing. Patients with proximal femoral shaft fractures were found to have the highest incidence of malalignment. The most common deformity in this group was varus, followed by procurvatum (or flexion).

DISCUSSION:The cross-table lateral radiograph shows that the patient has decreased acetabular anteversion. She is likely impinging on her cup in flexion and levering the femoral component posteriorly. Given a well-fixed and well-aligned femoral component and a negative infection work-up, the preferred treatment is to revise the acetabulum with a goal of increasing acetabular anteversion to avoid prosthetic impingement. Conversion to a constrained or elevated rim liner is suboptimal in this setting, because the problem is impingement. Indications for a constrained liner are neuromuscular compromise, abductor deficiency, or instability despite well-fixed and well-placed components. Given her 5 of 5 abductor strength, gluteus medius repair is not indicated.

The radiographs reveal a medial ankle injury with a widened medial clear space. No fibula fracture is visualized on this view; therefore, full-length radiographs looking for a proximal fibula fracture are required to determine treatment. The presence or absence of medial tenderness has been shown to not be a good predictor of unstable injuries. A history of previous injuries or ankle instability is typically lateral instability, which would not present with this radiographic appearance. An MRI scan can be used to evaluate subtle syndesmotic injuries, but there is a clear widening of the medial clear space in this case. The inability to bear weight is not helpful in determining the treatment options.(SBQ12TR.24) In each of the following scenarios, atrophic fracture nonunion occurred after initial treatment with intramedullary nail fixation. Which scenario has shown to have the highest rate of osseous union if treated with exchange intramedullary nailing?Oligotrophic nonunion of a comminuted humeral shaft fractureOligotrophic nonunion of a transverse humeral shaft fractureOligotrophic nonunion of an oblique distal femur fractureOligotrophic nonunion of a comminuted tibial shaft fractureOligotrophic nonunion of an oblique tibial shaft fractureReamed exchange nailing is recommended for the management of aseptic nonunions of noncomminuted tibial shaft fractures. Union rates have been reported between 76-96% in large studies.Tibial exchange nailing promotes osseous bone healing of non-unions by providing biological and mechanical support. The biological support is provided by reaming the medullary canal. This increases periosteal blood flow and stimulates periosteal new-bone formation. The mechanical support is provided by a larger-diameter intramedullary nail, which increases the rigidity and strength of the nail.Brinker et al. reviewed the concept of exchange nailing of nonunited long bone fractures. They showed that exchange nailing is the most successful in the treatment of nonunions following closed or open fractures without substantial bone loss. Aseptic, noncomminuted diaphyseal femoral and tibial shaft fractures showed the highest rates of union with exchange nailing, which were found to be 76-100% and 72-96%, respectively.Illustration A shows a heterotrophic non-union of the tibia after intramedullary nailing. The patient was treated with exchange nailing with a larger nail. On the right shows a 4 month post-op radiograph after exchange nailing showing osseous union at the fracture site.Incorrect Answers:(SBQ12TR.79) A right-hand dominant female sustains a right proximal humerus fracture. The patient is provided a sling, and is recommended pendulum exercises with elbow range of motion to begin in 1 to 2 weeks. Which of the following would be an indication for surgical management?Age greater than 70 years.Fracture pattern in Figure ASignificant medical comorbidities.Fracture pattern in Figure BFracture pattern in Figure CThe patient has been treated with non-operative management for her proximal humerus fracture. Operative management should be considered in patients with head splitting proximal humerus fractures and in those with dislocations that cannot be reduced.Head splitting proximal humerus fractures should be treated with operative management. Open reduction internal fixation versus hemiarthroplasty are used to treat this type of fracture. Surgical management is also considered in proximal humerus fractures in young patients, in fractures where the greater tuberosity isdisplaced >5 mm, and in proximal humerus fractures associated with humeral shaft fractures.Koval et al. studied 104 patients with one-part proximal humerus fractures treated non-operatively, and found 80% with good or excellent results. They also found that 90% of patients treated non-operatively had either no or mild pain about the shoulder at follow-up.Lefevre-Colau et al. performed a randomized prospective study on 74 patients with an impacted proximal humerus fracture. One group was treated with early mobilization of the shoulder (within 3 days after the fracture) while the other group was immobilized for 3 weeks followed by physiotherapy. They concluded that early mobilization was safe and allowed for quicker return to functional use of the affected limb.Figure A shows an AP radiograph of a right minimally displaced greater tuberosity proximal humerus fracture. Figure B shows AP and axillary radiographs of a right head split proximal humerus fracture that is posteriorly dislocated. Figure C shows an AP radiograph of a right minimally displaced Salter Harris II proximal humerus fracture. Illustration A shows an AP radiograph of a left valgus impacted proximal humerus fracture with a greater tuberosity fragment displaced >5mm treated with ORIF.Incorrect Answers:

DISCUSSION: The referenced article by Schildhauer et al is a cadaveric study that examined the biomechanical properties of different fixation constructs under cyclic loading and demonstrates that triangular osteosythesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in-vitro cyclical loading. The illustration below shows the radiographic appearance of triangular osteosynthesis.

DISCUSSION: An important hemodynamic consideration in the pregnant trauma patient is the potential hypotensive effect of supine positioning. This effect, which is caused by aortocaval compression by the enlarged uterus, may decrease cardiac output by 25%. Use of a right hip wedge, manual displacement of the uterus, or lateral tilt positioning of the patient may help avoid this situation. Patient positioning must be determined with a focus on the well-being of the fetus. To avoid compression of the inferior vena cava in the patient who is in her second or third trimester, the left lateral decubitus position (left side down) should be used. The referenced review article by Flik et alreviews the appropriate physiological changes of pregnancy and covers the treatment of orthopedic trauma in the face of pregnancy.

DISCUSSION: Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate.  Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock.  The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence).  The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence).  Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs.REFERENCES: Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation.  J Trauma 2004;57:898-912.Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury,a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation.  J Trauma 2006;61:82-89.Englehart MS, Schreiber MA: Measurement of acid-base resuscitation endpoints: Lactate, base deficit, bicarbonate or what?  Curr Opin Crit Care 2006;12:569-574.

DISCUSSION: Caucasian race has not been found to be a predictor for transfer to a Level 1 trauma center. The retrospective case-control study by Koval et al found that African-American race, presence of medical comorbidity, medicaid insurance, and male gender are predictors for transfer of patients to a trauma center that have ISS scores less than 9. The article by Nathens et al found that lack of insurance was an independent predictor for transfer to a trauma center after adjusting for differences in injury severity. An injury severity score of 36 represents a patient that has sustained life-threatening polytrauma and should be transferred to a Level 1 trauma center.

DISCUSSION: In open fractures, the hematoma that forms beneath the periosteum and around the ends of the fracture site is lost from the open wound. In addition, the irrigation process washes out the hematoma that contains growth factors and cytokines from the platelets. While loss of blood supply at the fracture site and soft-tissue coverage are important factors, the most important is loss of the factors that initiate the inflammatory phase of fracture healing. Infection may also delay healing, but is less common in this population.REFERENCES: Buckwalter JA, Einhom TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 377-381.Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1-14.2010 Pediatric Orthopaedic Examination Answer Book • 57

There is no clear treatment of these fractures the reference literature reviewed shows that soft-tissue tracks of low-velocity gunshot wounds are not rendered sterile by the bullet force. Despite this information, the majority of studies that have followed the healing of fractures secondary to gunshot wounds reveal a surprising low infection rate.

DISCUSSION: The most common complication is anterior knee pain (57%).  The knee pain is activity related (92%) and exacerbated by kneeling (83%).   Although knee pain is the most common complication, most patients rate it as mild to moderate and only 10% are unable to return to previous employment.  Some authors report less knee pain with a peritendinous approach when compared to a tendon-splitting approach.  In one study, nail removal resolved pain in 27%, improved it in 70%, and made it worse in 3%.  The incidence of the other complications was: infection 0% to 3%, nonunion 0% to 6%, and malunion 2% to 13%.  Compartment syndrome is rare after nailing.REFERENCES: Court-Brown CM: Reamed intramedullary tibial nailing: An overview and analysis of 1106 cases.  J Orthop Trauma 2004;18:96-101.McQueen MM, Gaston P, Court-Brown CM: Acute compartment syndrome: Who is at risk?J Bone Joint Surg Br 2000;82:200-203.Keating JF, Orfaly R, O’Brien PJ: Knee pain after tibial nailing.  J Orthop Trauma1997;11:10-13.

DISCUSSION: Negative outcome factors have been shown to include: increasing patient age, time from injury to surgery (>3 weeks), intraoperative complications, femoral head bone or cartilage injury, and fracture reduction > 1-2mm from anatomic. Choice of surgical approach has not been shown to affect patient outcomes.The referenced study by Matta evaluated outcomes of displaced acetabular fractures. The overall clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.

The more severe the trauma, the higher the rate of subsequent clavicular nonunion. Neither duration nor type of immobilization has been clearly demonstrated to be a causative factor in the development of nonunion. Similarly, closed reduction has not been found to alter the healing course in midshaft clavicular fractures.

DISCUSSION: In most series, elbow stiffness is the most common complication and can be overcome by achieving stable fixation and initiating early motion after surgery.  All of the other complications are seen but to a lesser degree than elbow stiffness.REFERENCES: Sanders RA, Raney EM, Pipkin S: Operative treatment of bicondylar intra-articular fractures of the distal humerus.  Orthopedics 1992;15:159-163.Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 397-404.

Debridement of wound and immediate reamed nailing performed on 67 patients with open fractures of femoral diaphysis including 36% grade 1, 45% grade II. All fractures healed within four months after injury.

This is simple A, B, Cs and doctoring. History and Physical exam come first. Noninvasive assessement includes visual inspection, clinical examination (feel pulses, check capillary refill, feel temperature of skin), and ABIs. X-ray, CT, and MRI would be good secondary studies to identify bony or soft tissue injuries—after initial reduction and splinting/stabilizatoin. Angiography would be indicated if there were asymmetric pulses or an ABI < 0.9, or if there was any other indication that a vessel injury may have occurred.OKU Truama 2 says “the use of ABI with the blood pressure cuff and Doppler evaluation of the distal circulation has been proposed as effective in determining any occult vascular injury. A ratio > 0.9indicates a normal study.”[1]The referenced article confirms this. “Confirmation of the safety and accuracy of physical exam in the evaluation of knee dislocation for injury of the popliteal artery.” J. Trauma2002; 52: 247-252back to this question next question[1]OKU Trauma 2 pg 151-153

DISCUSSION: The most common variation of a Hoffa fracture is a coronal fracture of the lateral femoral condyle. The most appropriate screw placement of the above answer choices in the treatment of the most common Hoffa fracture variant would be anterior to posterior screws across the lateral condyle for fixation.Hoffa fractures are coronally oriented fractures of the femoral condyles, with most occurring in the lateral condyle. They are commonly associated with high-energy fractures of the distal femur and can often be overlooked during the assessment and treatment of distal femur fractures. Hoffa fractures are best evaluated using CT scans.Nork et al. studied the association of supracondylar-intercondylar distal femoral fractures and coronal plane fractures. Of 202 supracondylar-intercondylar distal femoral fractures, they found coronal plane fractures were diagnosed in 38%. A coronal fracture of the lateral femoral condyle was involved more frequently than the medial condyle. Eighty-five percent of these coronal fractures involved a single lateral femoral condyle.Holmes et al. looked at five cases of coronal fractures of the femoral condyle. All cases received open reduction and internal fixation with lag screws through a formal parapatellar approach. They reported good results with all fractures healing within 12 weeks without complications with final range of motion at least 0 degrees to 115 degrees.

The most common symptom of compartment syndrome in the extremities is intense pain. Compartment syndrome can be difficult to diagnose in children and patients who are comatose, nonverbal, and/or mentally compromised because they may not be able to properly express their level of pain. In compartment syndrome of the leg, pain on passive extension of the toes is the most frequent clinical diagnostic finding. However, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present. Swelling and absence of the dorsalis pedis pulse may be expected findings with extensive trauma to the foot, making the clinical diagnosis even more difficult. Repositioning the ankle will add to further swelling. The clinician must be alerted regarding elevations in blood pressure and pulse because such elevations may be the only manifestation of the deeper problem. The transient blood pressure elevation does not require cardiac screening with electrocardiogram or echocardiogram as in chronic hypertension. Kidney function testing is not necessary because the blood pressure elevation is not renal in origin. Compartment pressures should be measured immediately in the foot and will require anesthesia in the pediatric age group.(SBQ13PE.91) An 12-year-old girl presents with right hip pain. Bilateral frog laterals are shown in Figure A. Laboratory work-up reveals TSH 11 mIU/L (Ref range: 0.4-4.0 mIU/L) and Free T4 is 0.5 ng/dL (Ref range: 0.7-1.9 ng/dL). What is the most appropriate treatment recommendation?Review TopicIn situ pinning of right hipProtected weight bearing and MRI of right hipImmediate endocrine referral and treatmentOpen biopsy right hipIn situ pinning bilateral hips PREFERRED RESPONSE 5In patients with slipped capital femoral epiphysis (SCFE) and concomitant endocrinopathy, bilateral pinning is the recommended treatment.This patient's laboratory values reveal hypothyroidism, which increases the risk of bilateral involvement. Thus, the most appropriate treatment recommendation is surgical fixation of both hips.Wells et al. analyzed 131 SCFEs over a 30-year period. The authors noted that 100% of patients with associated endocrinopathy went onto contralateral slip and recommended not only prophylactic pinning, but in those with open triradiate cartilage, recommended preventative screening with TSH/Free T4 laboratory studies.Riad et al. followed 90 patients and analyzed impact of age, gender and race on contralateral slip development. Girls under the age of 10 and boys under the age of 12 had a significantly increased risk of contralateral involvement. Therefore, the authors recommended contralateral pinning for girls and boys that met those age criteria, respectively.Figure A exhibits a right SCFE on bilateral frog lateral views. Incorrect Answers:

DISCUSSION: Serum lactate levels can be used to evaluate the effectiveness of the resuscitation of patients who have multiple injuries.  Even after resuscitation, patients may have occult hypoperfusion as defined by a serum lactate level of greater than 2.5 mmol/L.  The studies referenced indicate that these patients are at increased risk of perioperative complications such as organ failure or adult respiratory distress syndrome if definitive surgical fixation of the orthopaedic injuries is pursued prior to correction of the occult hypoperfusion.  The other markers may be an indication of current physiology but have not been correlated with perioperative risks.REFERENCES: Blow O, Magliore L, Claridge JA, et al: The golden hour and silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcomes from major trauma.  J Trauma 1999;47:964-977.Crowl A, Young JS, Kahler DM, et al: Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation.  J Trauma 2000;48:260-267.Shulman AM: Prediction of patients who will develop prolonged occult hypoperfusion following blunt trauma.   J Trauma 2004;57:725-800.

DISCUSSION: In this age group, bayonet apposition can produce very good results.  Healing occurs rapidly, and remodeling usually is complete in less than 1 year.  All of the other methods have significant risks of complications and are unnecessary for this fracture.REFERENCES: Martin RF: Fractures of the proximal humerus and humeral shaft, in Letts RM (ed): Management of Pediatric Fractures.  New York, NY, Churchill Livingstone, 1994,pp 144-148.Sanders JO, Rockwood CA Jr, Curtis RJ: Fractures and dislocation of the humeral shaft and shoulder, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4.  Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 937-939.