2. Trauma MCQs

The medial sural arteries vascularize the gastrocnemius, plantaris, and soleus muscles proximally. They arise from the popliteal artery. If not adequately mobilized, a gastrocnemius-soleus flap can be devascularized.

The posterior interosseous nerve is located adjacent to the radial neck, placing it at risk for a traction injury with a dislocation of the proximal radius. The typical neurapraxia that results can be expected to resolve with observation within the first 6 to 12 weeks. If recovery is not clinically evident by 3 months, neurophysiologic studies are indicated.

Tibial tubercle avulsion is an injury of the adolescent knee that most often occurs just before the end of growth. The fracture usually occurs with jumping, either at push-off or landing. This patient has a type III injury. In type III injuries, the articular surface is disrupted, and meniscal injury and compartment syndrome can occur. Open reduction is the treatment of choice, and anterior fasciotomy should be considered prophylactically at the time of surgery.

Lower Extremity Assessment Project data suggest that long-term functional outcomes and patient satisfaction at 7 years are equivalent between those who undergo limb-salvage and primary amputations. Return to work is essentially the same between the 2 groups. The projected lifetime healthcare cost for patients treated with amputation is nearly 3 times higher than costs for those who are treated with limb-salvage procedures.

DISCUSSION: The radiograph shows tuberosity malposition. The effect of improper prosthetic placement has also been associated with poor outcomes. However, the malposition of the tuberosity seen on the radiograph clearly explains loss of motion in this patient. It has been demonstrated that the functional results after hemiarthroplasty for three- and four-part proximal humeral fractures appear to be directly associated with tuberosity osteosynthesis. The most significant factor associated with poor and unsatisfactory postoperative functional results was malposition and/or migration of the tuberosities. Factors associated with a failure of tuberosity osteosynthesis in a recent study were poor initial position of the prosthesis, poor position of the greater tuberosity, and women older than age 75 years (most likely with osteopenic bone). Greater tuberosity displacement has been identified by Tanner and Cofield as being the most common complication after prosthetic arthroplasty for proximal humeral fractures. Furthermore, Bigliani and associates examined the causes of failure after prosthetic replacement for proximal humeral fractures and found that although almost all failed cases had multiple causes, the most common single identifiable reason was greater tuberosity displacement. REFERENCES: Bigliani LU, Flatow EL, McCluskey G, et al: Failed prosthetic replacement for displaced proximal humeral fractures. Orthop Trans 1991;15:747-748. Boileau P, Krishnan SG, Tinsi L, et al: Tuberosity malposition and migration: Reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elbow Surg 2002;11:401-412. Tanner MW, Cofield RH: Prosthetic arthroplasty for fractures and fracture-dislocations of the proximal humerus. Clin Orthop Relat Res 1983;179:116-128.

DISCUSSION: The child has a type III tibial spine avulsion fracture. When the avulsed fragment is completely displaced, the preferred treatment is open or arthroscopic reduction of the fragment and internal fixation with sutures or screws. Type I fractures are nondisplaced and can be treated with a long leg cast; type II fractures are hinged and can be treated in a long leg cast if closed reduction is successful. Many patients have some objective anterior cruciate ligament laxity after a tibial spine avulsion fracture; however, with adequate treatment most patients do not have symptomatic laxity. REFERENCES: Mah JY, Adili A, Otsuka NY, et al: Follow-up study of arthroscopic reduction and fixation of type III tibial-eminence fractures. J Pediatr Orthop 1998; 18:475-477. McLennen JG: Lessons learned after second-look arthroscopy in type III fractures of the tibial spine. J Pediatr Orthop 1995;15:59-62. Meyers MH, McKeever FM: Fracture of the intercondylar eminence of the tibia. J Bone Joint Surg Am 1970;52:1677-1684.

Low velocity gunshot wounds (GSW) to the hip are most commonly associated with bowel perforation. Consultation with general surgery (or in some facilities, trauma surgery) is necessary to exclude this.The incidence of GSW is increasing and it is the 2nd leading cause of death in young males in the US after motor vehicle accidents. The incidence of a GSW to the buttock is approximately 8% of all GSW to the extremities. Potential complications of pelvic and acetabular GSW include septic arthritis, enterocutaneous, enteroacetabular, and vesicoacetabular fistulas, infected nonunion, malunion, and injuries to the iliac vessels. The presence or absence of intra-abdominal injuries affects treatment and outcome.Bartkiw et al. reviewed 2808 GSW and found 1235 associated fractures including 42 fractures of the hip and pelvis. Ten orthopaedic operative procedures were performed in 7 patients. Associated nonorthopaedic injuries included 15 small/large bowel perforations (36%), 7 vessel lacerations (17%), and 2 urogenital injuries (5%) that required surgery.Najibi et al. reviewed 39 GSW to acetabulum. They found 32 simple and 7 associated fracture patterns. The most common simple and associated patterns were anterior column and both column, respectively. Bowel injuries were the most common associated injures (42%). Predictors of poor outcome include high-velocity missile, involvement of acetabular dome, abdominal injury, nerve injury, vascular injury, and male gender. Deep infection was associated with primary anastomosis of bowel injury and an associated fracture pattern.Figure A shows a GSW to the right hip with acetabular fracture and visible bullet fragment.Incorrect Answers:

The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) to improve the healing of open tibial shaft fractures has been the focus of two prospective clinical studies. Swiontkowski et al showed when compared to the control group (intramedullary nail fixation and routine soft-tissue management), the group receiving the rhBMP-2 required fewer bone-grafting procedures, fewer invasive secondary interventions, and there was a lower rate of infection. A shorter-term study by Govender et al showed significantly more patients treated with rhBMP-2 had healing of the fracture at the postoperative visits from ten weeks through twelve months. Govender et al found similar results in regards to a decreased need of secondary procedures, improvement in time to union, improved wound healing, and decreased infection rate in those who received BMP-2. Hospital stay duration was not significantly different.

The examination findings do not correlate with an acute injury (full range of cervical motion and the absence of pain). Radiographically, the fracture appears old based on the smooth contour of the fracture fragments and the absence of soft-tissue swelling. Flexion-extension radiographs can be obtained to determine potential instability; if present, stabilization and fusion should be considered.

Great toe fractures through the physis should be considered open fractures if there is bleeding at the nail fold. Treatment should include irrigation and debridement and appropriate antibiotics. Immobilization with a cast is usually sufficient for treatment of the fracture.

A 25-year-old male runs into a tree while going 45 mph on his motorcycle. He presents to your level 1 trauma hospital with the injuries shown in figures A through C. After closed reduction, which of the following is true with respect to treatment for this patient?Heterotopic ossification is uncommonMinifragment screws are sufficient for fracture fixationKocher-Langenbeck is the optimal surgical approach for this injuryFragment excision leads to improved outcomes compared to open reduction and internal fixationA 2 mm fragment step-off is considered the cut-off for non-surgical managementThis patient has sustained a Pipkin II femoral head fracture with associated anterior hip dislocation. An open reduction with internal fixation of the femoral head fragments with direct visualization is indicated to restore stability and congruity of the hip joint. These fractures can be treated with mini-fragment screws with excellent reduction and purchase without risks of extensive chondral injury or screw prominence.Femoral head fractures are uncommon injuries usually associated with hip dislocations. They are classified using the Pipkin Classification (Illustration B). While resection of small femoral head fracture fragments can be considered (Pipkin I) as sufficient and satisfactory treatment, this fragment is large and displaced and thus should be treated with ORIF for optimal results. Regarding the surgical approach, advocates for the direct anterior approach state direct access to the anterior portion of the femoral head with decreased overall complication rates. Other approaches, including surgical hip dislocation and Kocher-Langenbeck, are also useful depending on associated injuries (acetabulum fractures, etc.) and location of the head fragment. ORIF of these fractures can be performed with the use of countersunk mini-fragment screws, headless screws and even bioabsorbable pins to avoid prominence or extensive chondral injury.Marecek et al. authored a review article on femoral head fractures. They described these injuries as being generally associated with hip dislocations and require prompt reduction. They noted that the surgical fixation of the femoral head is generally done through the direct anterior approach or via a surgical hip dislocation depending on associated injuries. The authors also discussed the importance of using mini-frag screws to avoid hardware prominence. They also noted that while heterotopic ossification is a common finding after the anterior approach for these injuries, it is rarely proven to be symptomatic.Giannoudis et al. reviewed femoral head fractures focusing on management, complications and clinical results. They reported on 453 femoral head fractures in 450 patients. Regarding Pipkin Is, they noted that fragment excision gave better results compared to ORIF (p=0.07), while Pipkin IIs showed improved outcomes with ORIF. Regarding complications, they noted the following rates: wound infection (3%), sciatic nerve palsy (4%), AVN (11.9%), post-traumatic OA (20%) and HO (16.8%). They also noted the anterior approach was associated with promising long-term functional results and a lower incidence of major complication rates.Figure A is an AP pelvis radiograph revealing a left hip dislocation with a large femoral head fracture extending into the weight-bearing zone of hip joint(Pipkin II). Figures B and C are CT scan images revealing an anteriorly dislocated hip with a large femoral head fracture without associated acetabulum fractures. Illustration A is the post-op fluoroscopy showing ORIF of femoral head with multiple 2.7 cortical screws. Illustration B demonstrates the Pipkin classification for femoral head fractures.Incorrect Answers:Which of the following describes the most common organism cultured from septic olecranon bursitis?Gram positive cocci in chainsGram positive bacilli in branchesGram positive cocci in pairs and clustersGram negative diplococciGram negative bacilli with thin rodsCorrect answer: 3The most common cultured organism in the setting of septic olecranon bursitis is Staphylococcus aureus (S. aureus), appearing as gram positive cocci in pairs and clusters.S. aureus is responsible organism in approximately 80% of cases of septic olecranon and prepatellar bursitis. Mixed flora is also common. Patient demographics in both conditions are similar, more commonly involving middle-aged males. Direct inoculation is presumed to be the primary culprit as opposed to hematogenous seeding, as blood supply to the bursal tissue is poor. Differentiating infectious from non-infectious bursitis can be challenging.Aaron et al. provide a review article on the four most common types of bursitis: olecranon, prepatellar, trochanteric, and retrocalcaneal. They note that olecranon bursitis is the most common superficial bursitis, and that a careful history and physical exam can help differentiate infectious from noninfectious olecranon bursitis. The authors discuss one series of 46 patients demonstrating that a skin temperature overlying the affected bursa ≥2.2°C than the contralateral, unaffected bursa had a 100% sensitivity and 94% specificity in diagnosing a septic process.Illustration A shows a patient with olecranon bursitis. Illustration B shows the classic gram stain for S. aureus (gram positive cocci in pairs and clusters).Incorrect Answers:During a trauma conference, a hand surgeon presents a case of a 25-year-old male who injured his elbow while roller skating. While describing the patient's radiographs, he reports that this injury is associated with valgus posterolateral rotatory instability. Which of the following images is most likely the patient's radiograph?Posterolateral rotatory instability (PLRI) can result from a "terrible triad" fracture-dislocation pattern (seen in Figure E), classically involving a radial head fracture, coronoid tip or base fracture, and an elbow dislocation.Terrible triad injuries typically occur with axial loading, supination, and a valgus directed force through the elbow. In comparison to PLRI which results from a terrible triad injury, posteromedial rotatory instability (PMRI) commonly results from an anteromedial coronoid facet fracture following a varus-directed force. These injuries also very frequently also have a lateral collateral ligament complex injury but often have no radial head fracture. PLRI is far more common than PMRI. Generally with a PLRI pattern, the lateral collateral ligament complex fails first, followed by injury to the anterior capsule or coronoid, and lastly the medial collateral ligament complex is affected. Nonoperative management is possible, but only indicated in small, non-displaced radial head fractures with small coronoid tip fractures. Typically, terrible triad injuries are addressed surgically with radial head fixation or arthroplasty, lateral collateral ligament repair, and, less commonly, coronoid fracture fixation or anterior capsule repair.Ring et al. reviewed 56 patients who had been treated with an ORIF of the radial head at 48 months after injury. They found unsatisfactory outcomes for patients who had an ORIF of radial head fractures with greater than 3 articular fragments. The authors recommended ORIF of radial head fractures with 3 or few fragments.Steinmann performed a review of coronoid process fractures. The author reports that with an anteromedial coronoid fracture, the anteroposterior (AP) radiograph of the elbow will demonstrate progressive narrowing of the joint space from lateral to medial. Dr. Steinmann concludes that an important determinant of stability is the involvement of the sublime tubercle (insertion point of the MCL), and that medial instability is likely with involvement of the sublime tubercle.Mathew et al. review the anatomic, biomechanical, and operative principles of terrible triad injuries. The authors discuss that the primary goal of fixation is to stabilize the elbow and allow early range of motion. They underscore technical improvements and implant developments which have improved outcomes.Figure A demonstrates a capitellum fracture. Figure B demonstrates an olecranon fracture.Figure C demonstrates a displaced radial head fracture.Figure D demonstrates an anteromedial facet coronoid fracture.Figure E demonstrates a terrible triad injury with a radial head fracture,coronoid tip fracture, and elbow subluxation.Incorrect Answers:A 32-year-old soccer player presents with severe right ankle pain and inability to bear weight after sustaining a slide-tackle injury during a game. Radiographs are shown in Figures A and B. Given the nature of his injury, he is taken for surgical reduction and fixation. Following medial malleolar fixation, the syndesmosis is addressed. All of the following are true regarding the most appropriate intraoperative technique for anatomic syndesmotic reduction EXCEPT:The axis of the reduction clamp should parallel the anatomic trans-syndesmotic angleThe lateral tine of the clamp should be seated just posterior to the lateral malleolar ridgeThe medial tine should be placed on the anterior third of the tibia on a true lateral fluoroscopic view of the ankleThe reduction clamp should be placed 1-2cm proximal to the tibial plafondThe surgeon should apply judicious compression under fluoroscopic visualization to avoid over-compression of the syndesmosisWhen placing a clamp across the syndesmosis to facilitate reduction, the lateral tine should be placed directly on the lateral malleolar ridge. Placing the lateral tine either more anteriorly or posteriorly has been shown to result in sagittal malreduction from fibular translation.Syndesmotic reduction has proven to be technically challenging, with reportedly greater than 50% of cases resulting in malreduction. Provisional reduction is most often attained via a pointed reduction clamp. Placement of the lateral tine is outlined above. The medial tine should be placed at the anatomic midportion of the medial tibia, which can be confirmedfluoroscopically as the anterior third of the tibia on a true lateral view of the ankle. It is important to maintain the axis of the clamp parallel to the joint line and to the anatomic syndesmotic angle. The clamp should furthermore be maintained 1-2cm proximal to the mortise, at the level of the incisura, to avoid deformation or undue translation of the fibula. Lastly, over-compression of the syndesmosis has been demonstrated, though the clinical implications remain controversial.Putnam et al. performed a radiographic analysis of the ideal orientation for placement of a syndesmotic reduction clamp. Based on the CT scans of uninjured adult ankles, the authors showed that the trans-syndesmotic axis could be most reliably paralleled by a reduction clamp by placing the lateral tine on the lateral malleolar ridge and the medial tine radiographically within the anterior third of the tibia, anatomically half-way between the anterior and posterior cortices. They further specified that the ideal location was within the central one-third of the distance from the anterior tibial cortex to the anterior fibular cortex.Cosgrove et al. prospectively evaluated the effect of medial clamp tine positioning on the incidence of syndesmotic malreduction. The authors found that malreduction most often resulted from deviation of the clamp axis from the syndesmotic axis. With the clamp at 1-2cm proximal to the mortise and the lateral tine on the lateral malleolar ridge, the ideal position of the medial tine was within the anterior third of the tibia. The rate of sagittal malreduction increased substantially with increasingly posterior placement of the medial tine. The medial clamp position did not affect coronal plane malreduction.Gardner et al. review the technical considerations in reduction and fixation of syndesmotic injuries. The authors stress careful positioning of the reduction clamp, advocating that the clamp should be placed from the lateral malleolar ridge to the center of the anteroposterior width of the medial tibia.Additionally, they note that placement too proximal or distal results in coronal plane deformity of the fibula, and that over-compression of the syndesmosis is certainly possible.Figure A is the AP radiograph of the left ankle demonstrating a displaced medial malleolar fracture and syndesmotic widening. Figure B is the lateral radiograph of the ipsilateral knee showing an associated proximal fibular fracture.Illustration A shows the syndesmotic angle and anatomic trans-syndesmotic axis as compared to the AP and lateral fluoroscopic axes. Illustration B shows the ideal positioning of the medial tine within the anterior third of the tibia on a true lateral view of the ankle.Incorrect answers:A 45-year-old male injures his wrist during Live Action Role Play in Chicago two weeks ago. He underwent operative fixation by and presents to your clinic for his 2 week follow-up visit. You review his operative note in which the surgeon reports having to apply a volarlocking plate in a distal position to secure the difficult intra-articular fracture. The patient shows you the lateral film in Figure A. You remove his splint, he has no difficulty moving any fingers, very minimal pain, and is not taking any narcotic medication. How do you counsel him about his post-operative period?The plate may need to removed once the fracture is healed to reduce the chance of flexor pollicis longus injuryThe plate may need to removed once the fracture is healed to reduce the chance of flexor carpi radialis injuryThe plate may need to removed once the fracture is healed to reduce the chance of flexor digitorum superficialis – index finger injuryThe patient should undergo revision fixation as soon as possibleThe plate is in appropriate position and will likely never need to be removedCorrect answer: 1This patient’s volar locking plate (VLP) is distal to the "watershed line", extending volarly beyond the most volar aspect of the distal radius. He is at greatest risk for an attritional rupture of the FPL.A VLP placed this distal and volar is more likely to cause flexor tendon injury.Up to 12% of all patients undergoing volar plate fixation will experience flexor tendon injury, and the FPL is the most common tendon associated with the VLP (57% of total flexor tendon ruptures). The average time from fixation to flexor tendon rupture has been cited at 9 months. To judge if a plate is volar to the watershed line, a plum line can be made in the proximal direction from the most volar edge of the distal radius. If a plate is volar to this (Soong) line, the patient is thought to be at a higher risk for flexor tendon injury. As a result, this patient should be followed closely and if pain with thumb flexion is present after 3 months, the surgeon should consider plate removal so long as the fracture is healed to reduce the chance of FPL rupture. Ruptured tendons require repair, grafting, or transfer with hardware removal.Griffin and Chhabra comprehensively reviewed the risk factors and adverse events following VLP fixation of distal radius fractures, including flexor tendonitis and rupture. They found that risk factors for flexor tendon rupture following VLP fixation included plate placement distal to the watershed line and that PQ repair does not seem to affect flexor tendonitis.Agnew et al. analyzed wrist MRIs to determine the relationship between the flexor tendons and the watershed line. They found that at 3mm proximal to the watershed line, the FPL and FDP to the index finger were 2.6 and 2.2mm anterior to the volar rim of the distal radius. The authors suggested that distally placed plates are incredibly close to the flexor tendons.Chilelli et al. described 24 of 48 wrists which had VLP following distal radius fracture and went on to experiences loss of FPL flexion post-operatively. They found that FPL ROM generally returned after 52 days, however with an associated average loss of 11° in thumb IPJ ROM. The authors attribute this to stripping of FPL from the bone during the volar approach.Soong et al. divided patients who underwent VLP fixation for distal radius fractures into three groups according to position of plate relative to a plum line extending proximally from the most volar and distal aspect of the distal radius: those with a VLP dorsal to the Soong line (grade 0), those with the VLP volar to the Soong line but proximal to the rim (grade 1), and those with a VLP volar to the Soong line and at or distal to rim (grade 2). Of the 73 cases reviewed, the authors reported three flexor tendon ruptures, two of which were grade 2 position. The authors concluded that both position of plate and type of plate were contributors to flexor tendon injury following VLP fixation.Figure A is a lateral radiograph of the wrist demonstrating appropriate reduction and fixation but with the VLP volar to the "watershed" or Soong line.Illustration A is a lateral radiograph with Soong's line drawn to show that this plate is too volar.Incorrect Answers:A 42-year-old construction worker sustains a crush injury to the hand at a job site. He has immediate pain and significant swelling, and is taken to the local emergency department for evaluation. Radiographs do not demonstrate any fracture or dislocation. On exam,he experiences severe pain with passive motion at the metacarpal phalangeal joints and when the wrist is flexed and extended.Otherwise he has intact sensation and appropriate capillary refill. What is the next best step in diagnosis or treatment?Advanced imagingArterial DopplerAdmission for overnight observationSurgical interventionPain controlThis patient presents with compartment syndrome of the hand. A history and clinical exam are the best tools to identify the diagnosis, and the treatment consists of emergent fasciotomies.Compartment syndrome of the hand may be secondary to trauma, burn, IV drug use, extravasation of IV fluids, or major limb revascularization. The diagnosis is usually made with pain out of proportion to exam, particularly with passive stretch of the digits. It is possible to have compartment syndrome without neurovascular changes (paresthesia, pallor, pulselessness), particularly earlier in the presentation. Compartment measurements may be obtained and are considered diagnostic with an absolute value greater than 30mmHg or when the compartment pressure is within 30mmHg of the patient's diastolic blood pressure. However pressure testing is not necessary in most cases, but may be particularly important in the patient who is obtunded, intubated, or who had a block, as the physical exam will be confounded. There are ten hand compartments: hypothenar, thenar, adductor pollicis, four dorsal interosseous, and three palmar interosseous; and emergent surgical release of all ten compartments is indicated.Codding et al. comprehensively reviewed hand compartment syndrome. The authors identify the history and physical exam as the most critical aspect of the diagnosis. More specifically, they noted that pain with passive stretch of the MCPJ is the most sensitive clinical sign on physical exam. The authors conclude the short comings of the research on hand compartment syndrome, but note the potential morbidity of a missed diagnosis is so great that the threshold for surgical intervention should be very low.Lipschitz et al. reviewed the measurement of compartment pressures in the hand. The authors discussed technical pearls including leveling the monitor at the level of the heart, using local analgesia on the skin only, inserting the needle perpendicular to the skin, and measuring all 10 hand compartments.They noted that any measurement greater than 30mmHg or within 30mmHg of the diastolic blood pressure may be considered diagnostic.Illustration A shows the standard incisions utilized to release all ten hand compartments. Incisions are generally placed directly overlaying the thenar musculature, hypothenar musculature, the carpal tunnel, and dorsally over the metacarpals. The radial and ulnar border of each metacarpal are incised through the dorsal incisions to release the interossei compartments.Incorrect Answers:A 60-year-old woman with a history of well-controlled diabetes and hypertension sustained a fall into a ditch yesterday and presents with persistent left ankle pain and deformity. The injury is closed, and the patient is neurovascularly intact. Injury films are shown in Figures A and B. An unsuccessful attempt at reduction in the emergency department with sedation was made. What is the cause of failure of closed reduction?Subacute nature of fractureIncarceration of the deltoid ligamentIncarceration of the fibula behind the posterolateral ridge of tibiaEntrapment of the flexor hallucis longus (FHL) tendonEntrapment of the extensor digitorum brevis (EDB)Correct answer: 3The patient has sustained a Bosworth fracture-dislocation, which is a fixed dislocation of the fractured fibula behind the posterolateral tibial ridge. These fractures are generally irreducible via a closed means and require open reduction.The initial radiographs in this vignette reveal posterior subluxation of the talus and fibula without significant coronal plane deformity. This deformity should raise the suspicion of a Bosworth fracture-dislocation, especially if closed reduction is unsuccessful. Bosworth fracture-dislocations can often be associated with posterior malleolar fractures, specifically of the posterolateral rim of the distal tibia. These injuries often fail closed reduction, given the engagement of the fibula behind the posterolateral tibial ridge, and frequently require open reduction. In this situation, the most effective method to reduce the fracture is through a posterolateral approach. This is the same approach that can then be utilized for the fixation of the posterolateral fragment and fibula.Delasotta et al. discussed a case presentation of a 24-year-old male with a Bosworth fracture-dislocation in which the anterior compartment musculature was interposed within the fracture site, impairing both closed and eventual open reduction of the injury. The authors go on to discuss how 3D CT reconstruction of the bone and soft tissues can aid in both the diagnosis and preoperative planning of such injuries. They also note that these injuries should be admitted for compartment and neurovascular checks and undergo urgent surgical treatment.Gardner et al. performed a cadaveric study directly comparing fixation of posterior malleolar fractures to syndesmotic stabilization in a simulated stage IV pronation-external rotation injury. Compared with the intact specimens, the authors found that fixation of the posterior malleolus restored 70% of the native stiffness, but syndesmosis stabilization only restored 40%. The authors concluded that given the likely integrity of the posterior inferior tibiofibular ligament in the setting of posterior malleolar fractures, anatomic reduction and fixation may be more appropriate than syndesmotic stabilization and better suited to restore stability.Switaj et al. retrospectively evaluated the incidence of posterior malleolar fractures and posterior pilon variants in a 270 patients with operatively treated ankle fractures. The authors noted a relative frequency of posterior malleolar fractures of 50% and that of the posterior pilon variants of 20% within the entire cohort. While they found no significant difference in frequency of posterior malleolar or posterior pilon variants with regard to either AO/OTA or Lauge-Hansen classification, patients with posterior pilon variants were significantly older.Figure A and B show the AP and lateral views of an ankle revealing a lateral malleolar fracture with tibiotalar subluxation and posterior dislocation of the fibula with respect to the posterolateral ridge of the tibia, consistent with aBosworth fracture-dislocation.Incorrect answers:A 42-year-old male who works as a professional clown presents with severe ankle pain and gross deformity after tripping and falling over his props at a children’s birthday party. His radiograph is shown in Figure A. Following fixation of the medial and lateral malleolar fractures, the syndesmosis is assessed and is found to be persistently unstable. All of the following are true regarding posterior malleolar fixation EXCEPT:Fixation of the posterior malleolus obviates the need for syndesmotic fixation in most casesFixation of the posterior malleolus remains biomechanically inferior to trans-articular syndesmotic fixationFunctional and radiographic outcomes following posterior malleolar fixation are at least equivalent if not superior to those following syndesmotic fixationNon-anatomic fixation of the posterior malleolus will compromise syndesmotic fixationThe syndesmosis is often incompletely injured in the setting of a posterior malleolar fractureFixation of the posterior malleolus has been shown to be biomechanically superior to single-screw trans-articular syndesmotic fixation. Anatomic reduction and fixation will most often obviate the need for syndesmotic fixation, as the posterior inferior tibiofibular ligament (PITFL) is typically intact and attached to the fragment.Posterior malleolar integrity is essential to ankle function and stability. The posterior malleolus not only contains the talus posteriorly but adds to articular congruity for tibiotalar load transfer and contributes to rotatory ankle stability through the PITFL. As a result, posterior malleolar fractures compromise these critical functions. Operative management is therefore aimed at containment ofthe talus, restoration of articular congruity, reduction of the incisura, and restoring integrity to the syndesmosis. Functional and radiographic outcomes following posterior malleolar fixation have been shown to be at least equivalent to those following syndesmotic fixation.Miller et al. compared the need for syndesmotic fixation in bi- and tri-malleolar ankle fractures following anatomic reduction and fixation in the prone position versus initial conservative management in the supine position. The authors found that fixation of the posterior malleolus obviated the need for syndesmotic fixation in 97.9% of cases, while nearly 25% of patients with no initial fixation required stabilization. They concluded that prone positioning and anatomic fixation of the posterior malleolus should be performed as this adequately restored syndesmotic stability in almost all cases.Gardner et al. performed a radiographic evaluation of syndesmotic integrity in the setting of pronation-external rotation stage 4 ankle fractures with associated posterior malleolar fractures. Based on radiographs and MRI, no complete tears of the posterior-inferior tibiofibular ligament were evident. The fracture pattern was then simulated in cadavers, and posterior malleolar fixation restored 70% of the native stability while syndesmotic fixation alone restored only 40% of the native stability. The authors advocated for posterior malleolar fixation over syndesmotic stabilization.Miller et al. prospectively compared the outcomes following posterior malleolar and syndesmotic fixation for unstable ankle fractures with partial syndesmotic injury. At a minimum one-year follow-up, the authors found that patients who had undergone open reduction with fixation of posterior malleolar fractures had no difference in outcomes as compared to those who underwent syndesmotic fixation. They concluded that not only was syndesmotic reduction maintained at final follow-up following posterior malleolar fixation, but that functional outcomes were at least equivalent to syndesmotic fixation.Fitzpatrick et al. evaluated the impact of posterior malleolar fixation toward restoring syndesmotic stability in a cadaveric supination-external rotation stage 4 fracture model. The authors found that failure to fix or anatomically reduce posterior malleolar fragments resulted in non-anatomic translation of the fibula and ultimately in syndesmotic malreduction. They advocated for anatomic reduction and fixation of larger posterior malleolar fractures.Figure A is an AP radiograph of the right ankle demonstrating a displaced trimalleolar ankle fracture with maintained relationship between the distal fibula and posterior malleolar fragment.Incorrect Answers:A 35-year-old morbidly obese female presents with global right ankle pain and significant swelling after a misstep over one of her cats on the stairs. She is unable to bear weight, but the skin is intact. Injury films are shown in Figures A through D. What is the internervous plane through which direct anatomic reduction and fixation of both fractures could best be achieved?

A limbus or apophyseal fracture caused by heavy lifting or twisting is commonly seen in older children and adolescents. Nonsurgical management is rarely successful. A wide laminectomy with surgical excision of the limbus fragment is recommended if neurologic symptoms are present.

The AP, obturator oblique, and iliac oblique views of the pelvis reveal a fracture that disrupts the iliopectineal and ilioischial lines, indicating a fracture that involves both anterior and posterior columns. A displaced posterior wall fracture is also present, best seen on the obturator oblique view. The anterior to posterior directed fracture line on the CT scan indicates a transverse fracture; therefore, the patient has a transverse with posterior wall fracture pattern.

The patient has a periprosthetic fracture below the femoral stem. The component is porous coated and well fixed. Open reduction and internal fixation, leaving the stem in place, can be performed when bone quality is good. Plating with or without allograft struts and supplemental cerclage fixation generally is acceptable.

Successful treatment of a pilon fractures requires a complete understanding of the fracture configuration. This information is not available using radiographs alone; therefore, CT is used to define the fracture anatomy but only after stabilization and distraction of the fracture via external fixation. MRI does not adequately show the detail of the bone fragments. Immediate ORIF is contraindicated because of the high rate of soft-tissue complications with this treatment regimen, whereas closed treatment has a high rate of poor outcomes because of arthritis. Delayed ORIF is the recommended treatment, but this occurs after temporary stabilization and CT scanning.

Deformities that are seen simultaneously on the AP and lateral roentgenograms of the same bone are actually shadows of the true deformity. If, for example, angulation is seen at the site of a fracture on both of the standard roentgenograms, then the true plane of angulation is somewhere between the coronal and sagittal planes, and the actual amount of angulation is greater than that visualized on either roentgenogram. Because the standard roentgenograms are orthogonal (at right angles) to each other, it is possible to calculate the actual plane and angle of deformity on the basis of dimensions measured from the roentgenograms.

In the article by Gallagher, et al, they note a 12% incidence of pathologic fractures associated with acute leukemic lesions. The fracture should be treated using standard methods. Thus, the treatment of displaced fracture through an osteolytic lesion in the metaphysis of the distal femur in a 4-year-old girl would be closed reduction and immobilization in a cast.

All the factors listed, with the exception of an ipsilateral femoral fracture, are representative of a low-energy stable tibial shaft fracture that will do well with closed reduction and immobilization in a long leg cast, followed by weight bearing as tolerated and then a functional brace or patellar tendon bearing cast until union is achieved. Shortening will not increase from that seen on these initial radiographs. The spiral fracture provides a broad surface for healing, and the fibular fracture at another level indicates a stable soft-tissue envelope which, with the immobilization device, will stabilize the fracture reduction. An ipsilateral femoral fracture is a strong indication to surgically stabilize both fractures.

Vertical fractures have a higher rate of displacement and nonunion because of shearing forces across the fracture. Biomechanical and clinical studies indicate that for the vertically oriented fracture of the femoral neck, the most stable fixation construct is a sliding hip screw and side plate.