2. Trauma MCQs

DISCUSSION: The patient has a well-established nonunion in a very porotic bone. Electrical stimulation has been found effective in treating tibial nonunions, but there is very little data on humeral nonunions, especially chronic well-established ones. Ultrasound stimulation is effective in accelerating fracture healing, but there is little data concerning the treatment of nonunions. Intramedullary nailing with bone graft is an option, but it may be difficult to obtain a rigid construct in a very porotic bone. An Ilizarov-type external fixator would be an alternative, but there is little clinical data for the humerus and it may be poorly tolerated. A plate and screw construct with bone graft combines rigidity with the biologic advantage of the bone graft. A recent series reported on the use of a plate combined with onlay allograft for recalcitrant nonunions.

Stemless shoulder arthroplasty prostheses have recently been suggested as an alternative to traditional stemmed replacement. Advantages of the stemless surgical technique would includeA.   better glenoid exposure than with stemmed prostheses.B.   reliable use in four-part proximal humerus fracture reconstruction.C.   use in proximal humeral malunion without the need for an osteotomy. D.   improved long-term survivorship profile.

Persistent Horner’s sign (ptosis, miosis, and anhidrosis) is a sign of proximal injury, usually avulsion of the roots from the cord which disrupts the sympathetic chain. Root rupture or avulsion proximal to the myelin sheath has less chance of healing. Two-month-old infants with persistent weakness in the other areas described may still have a good prognosis for recovery. Concurrent clavicle fracture has been shown to have no prognostic value.

The MR images show a tear through a discoid lateral meniscus. A discoid meniscus is caused by a failure of apoptosis during development in utero and is considered a congenital abnormality. Discoid menisci are prone to tearing and can be caused by minimal trauma. There is no known genetic cause for this condition. Radiographic findings that may be present in the setting of a discoid meniscus include lateral joint space widening, squaring of the lateral femoral condyle, and cupping of the lateral tibial plateau. Contralateral discoid menisci are noted in 20% of patients. There are no other known associated conditions. Treatmentof a symptomatic discoid meniscus should include partial meniscectomy and saucerization or repair.

An APC type I involves slight widening of pubic symphysis and/or anterior sacroiliac (SI) joint. An APC II is a continuation of this force, and additionally involves a disrupted anterior SI joint, as well as sacrotuberous and sacrospinous ligaments. An APC III also involves disrupted posterior SI ligaments, causing complete SI joint disruption with potential translational and rotational displacement. An APC-II pelvic ring injury involves injury to all of these structures except the posterior sacroiliac ligaments.

DISCUSSION: Several studies have shown that only patient age and pre-injury functional independence measure scores were independent predictors of functional outcome after hip fracture. The other choices are less predictive than pre-injury functional status. The Soderqvist et al study showed that a Short Portable Mental Status Questionnaire score of <3 and male gender were associated with an increased mortality rate during the first twelve months. Moreover, patients with a score of <3 had a significantly worse outcome with regard to the ability to walk and to perform the activities of daily living.

DISCUSSION: The patient has a flexion-type olecranon fracture, and the integrity of the extensor mechanism is disrupted. With this degree of displacement, closed reduction and extension casting would not be adequate. The strongest construct is an oblique screw across the fracture site, with a tension band. Healing is rapid in this age group; therefore one of the heavy absorbable sutures can be used as the tension band. Two parallel pins with the stainless steel tension band wire (AO technique) can be used but requires wire dissection for removal. Once the fracture is healed, the single screw can be removed easily with only a small incision.

DISCUSSION: Necrotizing fasciitis is a rapidly progressive soft-tissue infection with the potential to threaten both life and limb. Patients who are immunocompromised (HIV infection, diabetes mellitus, alcohol abuse) are at increased risk. However, any patient in the immediate postoperative phase is susceptible to wound infection. Early detection is the key. Necrotizing fasciitis is primarily a surgical problem that requires urgent debridement and broad-spectrum IV antibiotics. Rapid diagnosis and prompt treatment help to reduce mortality, which may approach 30%.

A displaced femoral neck fracture in a young patient is considered a surgical urgency and prompt anatomic reduction and internal fixation is recommended. There are a few studies that have specifically looked at the rate of osteonecrosis in this patient population. A review of femoral neck fractures in patients ages 15 to 50 years revealed that the incidence of osteonecrosis in displaced fractures was 27% compared with 14% in nondisplaced fractures. The quality of the reduction also influenced the rate of osteonecrosis. Time to reduction, type of implant, presence or absence of capsulotomy, and location of the fracture are not associated with osteonecrosis risk.(SBQ12TR.90) A 40-year-old male sustained the injury seen in Figure A, and subsequently underwent the procedure shown in Figure B. One hour post-operatively he starts to complain of pain in the operative leg, and the pain is unchanged with active or passive stretch. The external dressing is released with little resolution of symptoms. His blood pressure is 115/78 mm Hg with compartment pressures in the leg measuring 31 to 35 mm Hg. His ABI index is 1.1 in the leg. What would be the next step in management?ReviewTopicMRI angiography of legFour-compartment fasciotomyFollow-up examination the following dayContinued monitoring and serial examinationsEMG studyThe patient is at risk for developing compartment syndrome of the leg. The next most appropriate step would be to support his systemic blood pressure and monitor compartment pressures.A clinical assessment is the diagnostic cornerstone of acute compartment syndrome. However, the intracompartmental pressure measurement has been advocated to help confirm the diagnosis in patients where there remains uncertainty after clinical exam.An absolute compartment pressure >30 mm Hg or a difference in diastolic pressure and compartments pressure (delta p) <30 mm Hg may help to confirm the necessity for fasciotomy. However, the treatment of early compartment syndrome should be to initially improve the limbs perfusion pressure gradient. This can be done by treating underlying factors such as hypotension, coagulopathy, or vascular compromise due to either a true vascular injury or artificially by external compression. Frequent reassessment is then critical to effectively manage these patients. If clinical diagnosis persists despite these efforts, urgent fasciotomy would be considered.McQueen looked at 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.White et al. looked at 101 patients with tibial fractures with satisfactory Delta P measurements. THey found that patients with elevated intramuscular pressures >30 mm Hg after tibial fracture do not have a greater incidence of complications than those with low pressures, so long that Delta P <30 mm Hg.Figure A shows a Shatzker V tibial plateau fracture. Figure B shows fixation of fracture seen in Figure A.Incorrect Answers:30 mm Hg or persistently elevated absolute compartment pressures.. Answer 3: It would not be appropriate to leave this patient with impending compartment syndrome.(SBQ12TR.57) A 56-year-old right hand dominant attorney falls from standing and sustains the closed injury shown in Figure A. The treating surgeon elects to fix her fracture using a plate and screw construct. Based on the available imaging, which of the following fracture characteristics best justifies this fixation choice?Fracture displacementIntra-articular fracture extensionThe fracture extends distal to the coronoidOblique fracture lineFracture comminutionThis patient has a displaced, intra-articular, comminuted olecranon fracture. Comminution is an indication for plate fixation.Most displaced olecranon fractures are treated operatively. Options include tension band constructs, intramedullary screws, plate and screw fixation or fragment excision with triceps advancement. Any construct relying on inter-fragmentary compression (tension band, intramedullary screws) requires a non-comminuted fracture pattern. Plate fixation is indicated in the setting of comminution, extension past the coronoid, or in the setting of associated instability.Bailey et al. retrospectively reviewed 25 patients who underwent plate fixation of displaced olecranon fractures. Twenty-two of 25 patients had good or excellent outcomes. Five of 25 patients (20%) of patients required plate removal for symptomatic hardware. The authors concluded that plate fixation was an effective treatment for displaced olecranon fractures, with good functional outcomes.Figure A shows a displaced, comminuted olecranon fracture without evidence of propagation past the coronoid.Incorrect answers:congruity but does not dictate implant selection. Answer 3. Extension distal to the coronoid is an indication for plate fixation but there is no evidence of such extension on the radiograph shown Answer 4. This fracture is comminuted, without a distinct fracture line.

High-energy tibial pilon fractures involve disruption of the soft-tissue envelope with significant lower extremity edema. Definitive reconstruction of the comminuted distal tibia should be delayed for at least 7 days to allow edema to dissipate, lowering the risk of skin necrosis. An external fixator is the best method to keep the ankle at anatomic length while preventing skin necrosis. Ligamentotaxis will hold the fragments reduced to allow the edema to dissipate. CT may be obtained in traction to localize the individual fragments and plan surgical incisions and subsequent fixation.

The patient has an uninfected symptomatic nonunion of the femur after reamed antegrade nailing with an appropriately sized implant. The fracture is well aligned and has some callus response indicating reasonable vascularity. Auto-dynamization has occurred via fatigue failure of the distal interlocking screws but the patient remains symptomatic and the fracture line is evident, consistent with nonunion. Reamed exchange nailing is preferred because it allows for improved mechanics via a larger diameter nail and repeat interlock and improved biologics via reaming which is felt to elicit an inflammatory reaction and generate bone graft in situ. Unfortunately, the results of exchange nailing are not as good in patients who smoke and smoking cessation should be counseled and encouraged. The data on external bone stimulation on unhealed fractures of the femur with an intramedullary nail present are lacking. In light of a benign clinical examination and history and normal blood work parameters with reference to infection, open biopsy of the nonunion prior to definitive surgical treatment is unwarranted. The patient has mechanical instability and bone grafting in situ will not address this issue in terms of promoting progression to union or allowing for improved function and less pain.

This child has a tibial tuberosity avulsion fracture with intraarticular extension. There is a risk for anterior compartment syndrome of the leg because of rupture of the anterior tibial recurrent artery located around the lateral border of the tibial tubercle. The vessels retract under the fascia, leading to bleeding into the anterior compartment.

DISCUSSION: The radiographs show a distal third humerus fracture that is angulated, rotated, and not rigidly fixed. Rigid fixation is needed because mobilization is highly desirable to improve pulmonary function. The acetabular fracture is through the weight-bearing dome but is nondisplaced. Nonsurgical management of the acetabular fracture requires at least 6 weeks of touchdown weight bearing to minimize the forces across the hip joint. Open reduction and plate fixation would achieve anatomic reduction and immediate mobilization. A single posterolateral 4.5-mm plate or two 3.5-mm plates at 90 degrees are possible alternatives. Immediate weight bearing on a plated humerus fracture with the use of crutches or a walker has been shown to be safe and would allow touchdown weight bearing, protecting the hip. None of the other options would achieve this goal for this distal fracture. REFERENCE: Tingstad EM, Wolinsky PR, Shyr Y, Johnson KD: Effect of immediate weightbearing on plated fractures of the humeral shaft. J Trauma 2000;49:278-280.

DISCUSSION: CT scanning is indicated in acetabular fractures for determination of surgical approach and techniques, evaluation of marginal impaction and presence of intra-articular loose bodies (especially after hip dislocation), and evaluation of fracture piece sizes and relative positions. Kellam et al reviewed their initial experience with CT scanning and acetabular fractures, and noted a 25% change in surgical planning when CT was utilized versus plain radiographs; they also noted the ability to detect marginal impaction and fracture size/position was improved with CT.

Posterior partial articular tibial plateau fractures are rare. Prone positioning is preferred for definitive fixation. Surgical approaches vary, but typically incorporate a posteromedial interval deep to the popliteus and soleus to provide buttress plating to the posterior column of the tibia.

DISCUSSION: Femoral neck fracture nonunion is a challenging problem for orthopaedic surgeons. Vertical fractures are more prone to nonunion due to shear stress rather than compressive forces across the fracture site. Several authors have suggested these fractures are more common in young adults due to injury type and bone composition. It is widely regarded that an effort should be made to salvage the femoral head if vascularity remains. The most common method to treat this complication is valgus intertrochanteric osteotomy of the femur. This functionally makes a vertical fracture more horizontal, converting shear into compressive forces. It also helps correct the varus position of the fracture nonunion. REFERENCES: Hartford JM, Patel A, Powell J: Intertrochanteric osteotomy using a dynamic hip screw for femoral neck nonunion. J Orthop Trauma 2005;19:329-333. Mathews V, Cabanela ME: Femoral neck nonunion treatment. Clin Orthop Relat Res 2004;419:57-64.

In adults, minimally displaced fractures of the ulna may be treated non-operatively.Even in the setting of minimal displacement, fractures involving the radial diaphysis, or both bones of the forearm, are at high risk of displacing further and progressing to malunion or nonunion. Given the potential for a resulting loss of forearm rotation, open reduction internal fixation is indicated for almost all adult diaphyseal radius and both bone fractures.Schulte et al. review the management of both bone forearm fractures in adults. They review biomechanics, fixation techniques, outcomes and complications. They note that the goals of fixation in simple patterns are 'cortical opposition, compression, and restoration of forearm geometry.'Anderson et al. treated 330 acute diaphyseal forearm fractures with compression plating from 1960 to 1970. At 4 months to 9 years follow up, they achieved a 97.9%union rate for the radius and 96.3% union rate for the ulna.Illustration A shows measurement of radial bow. A dotted line perpendicular to the line drawn from the radial tuberosity to the ulnar aspect of the distal radius can be used to measure radial bow when drawn at the point of maximum distance to the ulnar edge of the radius.Incorrect answers:

Pelvic ring injuries are associated with a high incidence of mortality mainly due to retroperitoneal hemorrhage. Early stabilization is an integral part of hemorrhage control. Temporary stabilization can be provided by a pelvic sheet, sling, or an inflatable garment. While the other choices are urgent as well, hypotension caused by pelvic widening demands the most immediate attention.

This patient has atrophic non-union (NU) and varus collapse following cephalomedullary nailing of a subtrochanteric fracture. The ideal treatment involves nail removal, correction of alignment, fracture fixation, and bone grafting. Fixation can be achieved with a nail or plate.Subtrochanteric fractures can be treated with cephalomedullary nailing or fixed angle plates. Nailing of these fractures is technically challenging because the fracture must be reduced prior to nail passage. Failure to do so leads to varus and procurvatum malreduction.Bellabarba et al. reviewed plating of femoral nonunions after intramedullary nailing. Of 23 nonunions, 21 healed at an average of 12 weeks. The remaining 2 cases required repeat plating (at 2 and 8 weeks) for hardware breakage because of noncompliance with weightbearing restrictions. They advocate plating because it allows for correction of malalignment and provides a biomechanically superior tension band construct.Incorrect Answers:OrthoCash 2020A 38-year-old male was struck by a truck and sustained the injury seen in figure A. Treating this injury with an intramedullary nail with a larger radius of curvature can lead to what complication?Posterior perforation of the distal femurVarus malreductionComminution of the fracture siteIatrogenic femoral neck fractureAnterior perforation of the distal femurCorrent answer: 5According to the study by Egol et al, the average femoral anterior radius of curvature was 120 cm (+/- 36 cm), and currently available femoral nails have a greater radius of curvature (i.e. more straight). This mismatch has been shown to lead to an increased risk of perforation of the anterior distal femur as the nail is impacted into the canal.The referenced study by Tencer et al noted an increased risk of iatrogenic femoral fracture with anterior starting point >6mm from the anatomic axis.They recommend starting in line with the femoral axis, or just a few millimeters anterior in order to minimize this risk.Illustration A depicts anterior femoral cortex penetration secondary to nail/femur radius of curvature mismatch.OrthoCash 2020A 60-year-old woman is undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. What structure is at greatest risk for injury from the pin marked by the red arrow in Figure A?Anterior branch of the axillary nervePosterior humeral circumflex arteryLong head of the biceps tendonCephalic veinMusculocutaneous nerveCertain anatomic structures are at risk with percutaneous pinning of proximal humerus fractures. The red arrow in Figure A marks a proximal lateral pin that would place the anterior branch of the axillary nerve at risk.Rowles and McGrory performed an anatomic study of the structures at risk with closed reduction and percuatneous pinning of the proximal humerus and found that proximal lateral pins were a mean of 3mm from the anterior branch of the axillary nerve. Pins placed through the anterior cortex and directed into the humeral head fragment were a mean of 2mm from the long head of the biceps tendon and greater tuberosity pins were found to be 8mm from the posterior humeral circumflex and 10mm from the main trunk of the axillary nerve as they penetrated the medial cortex of the humerus.Jaberg et al retrospectively reviewed the clinical and radiographic results of 48 patients at an average of 3 years after undergoing closed reduction and percutaneous pinning of a proximal humerus fracture. 70% good to excellent results with their described technique, and the authors caution that radiographic malunion did not correlate with patient function.Incorrect AnswersOrthoCash 2020A 42-year-old female sustains the injury seen in the computed tomography images seen in Figures A and B. According to the Letournel classification, what is the injury pattern shown?Posterior wallTransverseAnterior wallPosterior columnBoth columnThe axial CT cut and Judet radiographic view shown reveals a transverse fracture pattern according to the Letournel classification system. This can be determined by the fact that the articular surface of the acetabulum is attached to the intact portion of the ilium, which is connected to the axial skeleton posteriorly through the sacroiliac joint. This differs from a both-column fracture, in which the articular surface of the acetabulum has no attachments to the axial skeleton due to fracture line(s). The axial CT scan also shows a vertical fracture line which is typical of a transverse fracture pattern.Durkee et al review the classification schemes for these injuries, as well as comment on the importance of quality images (Judet views, CT, etc).Figures A and B show a transverse acetabular fracture with mild displacement.OrthoCash 2020Which of the following is true regarding plating of humeral shaft fractures compared to intramedullary nailing?worse functional resultshigher need for subsequent surgerieshigher incidence of radial nerve injurylower complication ratesdecreased nonunion ratesCorrent answer: 4Controversy exists regarding nailing compared with plating of humeral shaft fractures, but the most recent and highest level evidence indicates decreased complication rates with open reduction and internal fixation of these injuries.Lin et al found less blood loss with intramedullary nailing than plating, but nailing was also associated with increased shoulder surgery, likely 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, however more recent studies have challenged these findings.Heineman et al. (2012) have recently conducted an update on their meta-analysis to include more recent randomized studies. With the inclusion of newer studies the author found a statistically significant increase in total complication rate with the use of IM nailing compared with ORIF. The authors found no significant difference between the two treatment modalities for the secondary outcomes (nonunion, infection, nerve palsy, re-operation)Incorrect Answers:OrthoCash 2020A 35-year-old male sustains the fracture seen in Figures A and B. Which of the following substances has been shown to result in the least radiographic subsidence when combined with open reduction and internal fixation?Cancellous allograft bone chipsAutograft iliac crestFemoral intramedullary reamingsCalcium phosphate cementCalcium sulfate cementCorrent answer: 4Figures A and B show a plateau fracture with a lateral split and depression of the articular surface. In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations due to its high compressive strength.The study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement. Welch and Zhang reproduced tibial plateau fractures in goats and compared cancellous autograft to calcium phosphate cement augmentation. At 24 hours, four of five specimens treated with autograft had subsidence of the fragment. Only two specimens from limbs treated with cement showed minimal subsidence; the remaining were congruent.Yetkinler’s study compared cement to no cement treatment in a model of depressed plateau fractures. Calcium phosphate cement of high compressivestrength provided equivalent or better stability than conventional open reductionand internal fixation with either auto/allograft bone which had both a lower compressive strength and reduced mechanical stability.OrthoCash 2020The modified Judet approach to the posterior scapula exploits the internervous interval between what two muscles?Supraspinatus and infraspinatusSupraspinatus and subscapularisInfraspinatus and teres minorTeres minor and teres majorTeres major and lattisimusCorrent answer: 3The posterior or modified Judet approach to the scapula is typically used for internal fixation of scapular fractures. This approach utilizes a transverse incision over the scapular spine with detachment of the posterior deltoid. The interval between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is identified and used to gain access to the posterior aspect of the scapula and glenoid.The reference by Obremskey et al argues the approach "combines several important goals including: 1) exposure of all bony elements of the scapula which have adequate bone stock for internal fixation; 2) minimal trauma to the rotator cuff musculature; and 3) protection of the major neurologic structures (suprascapular nerve superiorly and axillary nerve laterally)." They believe "the main advantage of the exposure is limiting muscular dissection, which can potentially improve rehabilitation and limit morbidity of the operation."OrthoCash 2020An 82-year-old female sustains an intertrochanteric hip fracture and is treated with a sliding hip screw. What is the most appropriate definitive step in treating the failure seen in figure A?Non-weight bearingValgus proximal femoral osteotomyTotal hip arthroplastyRevision open reduction and internal fixationProximal femoral resectionCorrent answer: 3Figure A shows superior cutout of the lag screw from the sliding hip screw as well as the superior cannulated screw used for an "antirotation" device.In the referenced review article by Haidukewych and Berry, salvage of failed treatment of hip fractures in the elderly is limited by bone quality and comorbidities. They recommend total hip arthroplasty in this instance to restore function, decrease pain, and limit periods of immobilization. They mention that the major challenges for arthroplasty are: assessing the need for acetabular resurfacing, selecting the femoral implant, and managing the greater trochanter.OrthoCash 2020A 13-year-old boy falls out of a tree and sustains the injury seen in Figures A and B. He is taken to the OR for fixation of his fracture.The next morning, the patient’s blood pressure is 185/105 mm Hg and pulse rate is 130. He complains of pain that is not improved with opiates. On physical exam, the foot is firm. The decision is made to obtain compartment pressures to rule out compartment syndrome of the foot. Which of the following paths in Figure C marks theappropriate location to measure the central compartment, and what would be considered abnormal values?Path A, absolute value of 30-45 mmHg or delta p > 30mmHgPath B, absolute value of 30-45 mmHg or delta p > 30mmHgPath B, absolute value of 30-45 mmHg or delta p < 30mmHgPath C, absolute value of 30-45 mmHg or delta p > 30mmHgPath C, absolute value of 30-45 mmHg or delta p < 30mmHgCorrent answer: 3The correct approach to measure pressures in the central compartment of the foot is by directing the needle lateral and plantar through the abductor hallicus, just under the base of the first metatarsal. Abnormal values indicating the need for decompression are an absolute value of 30-45 mmHg or a Δp < 30mmHg (the difference between the patient's diastolic blood pressure and compartment pressures).The most common symptom of compartment syndrome in the extremities is intense pain. However, 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. Additionally, in compartment syndrome of the foot, pain on passive extension of the toes may or may not be present, and 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. Thus, for patients with equivocal findings on physical exam, foot compartment pressures should be measured in order to confirm the diagnosis. There are 8 compartments in the foot: lateral, medial, central, and 4 interosseous. The lateral compartmentcontains the abductor digiti minimi and flexor digiti minimi brevis, and is measured by directing the needle 1cm medial and plantar under the midshaft of the 5th metatarsal. The medial compartment contains the abductor hallicus and flexor hallicus brevis, and is measured by directing the needle lateral and plantar under the base of the first metatarsal. The central compartment contains the oblique head of the adductor hallucis, and is measured through the same approach as the medial compartment after advancing the needle more deeply. The 4 interosseous compartments entail the 2nd, 3rd, and 4th web spaces, and can be measured by directing the needle plantar into each respective dorsal webspace.Ojika et al. performed a systematic review on foot compartment syndrome. They found that the most common cause of foot compartment syndrome was crush injury to the foot, and that diagnosis was mostly made through a combination of clinical findings and compartment pressure measurements.Badhe et al. reported 4 cases where competent sensate patients developed compartment syndromes without any significant pain. They found that pain is not a reliable clinical indicator for underlying compartment syndrome, so in a competent sensate patient, the absence of pain does not exclude compartment syndrome. They concluded that a high index of clinical suspicion must prevail in association with either continuous compartment pressure monitoring or frequent repeated documented clinical examination with a low threshold for pressure measurement.Flynn et al. looked at the diagnosis and outcome of acute traumatic compartment syndrome of the leg in children. They found that a delay in diagnosis may occur because acute traumatic compartment syndrome manifests itself more slowly in children or because the diagnosis is harder to establish in this age group. They state that the results of the present study should raise awareness of late presentation and the importance of vigilance for developing compartment syndrome in the early days after injury.Figures A and B are lateral and Harris radiographs of the foot demonstrating a calcaneus fracture. Figure C is a cross-sectional image of the foot. Illustration A is an image depicting the compartments of the foot.Incorrect Answers:compartment. Additionally, a Δp < 30mmHg (not > 30mmHg) is considered abnormal.OrthoCash 2020A 35-year-old female presents to the emergency room after a motor vehicle collision where her leg was pinned under the car for over 30 minutes. A clinical photo and radiographs are shown. Which of the following is the most accurate way to diagnose compartment syndrome?surgeon's palpation of the leg compartmentsparesthesias in her footdiastolic blood pressure minus intra-compartmental pressure is less than 30 mmHgdiastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHgintra-compartmental pressure measurement of 25 mmHgCorrent answer: 3The clinical picture is consistent with compartment syndrome. The most accurate way to make the diagnosis is to measure the difference between the diastolic blood pressure and intracompartmental pressure (delta p).In a prospective study of 116 patients with tibial diaphyseal fractures, McQueen et al found that the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. They recommended that a fasciotomy should be performed if the differential pressure level drops to under 30 mmHg.The cited study by Kakar et al found the intraoperative DBP is significantly lower than the preoperative DBP in patient undergoing IM nailing for tibia shaftfractures. Therefore, they emphasize that the surgeon should recognize that intraoperative DeltaP may be lower than DeltaP once the patient is awakened in deciding whether to perform a fasciotomy versus awaken the patient and perform serial examinations and or compartment pressure measurements.An absolute intra-compartmental value greater than 30 to 45mmHg can also be used to make the diagnosis of compartment syndrome, but is more controversial than the delta p according to Kakar and Amendola.OrthoCash 2020What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?ligament avulsion off the humeral originligament avulsion off the ulnar insertionmidsubstance rupturebony avulsion of the humeral origincombined proximal and distal ligament avulsionsCorrent answer: 1The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin.McKee noted that in 62 consecutive operative elbow dislocations and fracture/dislocations, the LUCL was ruptured in all of the patients, proximally in 32, bony avulsion proximally in 5, midsubstance rupture in 18, ulnar detachment in 3, ulnar bony avulsion in only 1, and combined patterns in 3.Pugh et al established a standard protocol to treat elbow fracture dislocations (terrible triad) which includes coronoid repair, radial head repair/replacement, LUCL repair, and MCL and/or external fixation as needed.OrthoCash 2020A 24-year-old male sustains the injury seen in Figure A after being thrown from a motorcycle at a high speed. Which of the following fixation methods has been shown to be the most stable fixation construct for this injury?Posterior bridge plating and anterior ring external fixationPercutaneous iliosacral screw and anterior ring external fixationPercutaneous iliosacral screw and anterior ring internal fixationTransiliac screwTwo percutaneous iliosacral screwsCorrent answer: 3Figure A shows an APC III injury, which is a rotationally and vertically unstable injury, with damage to the anterior ring, pelvic floor, and posterior ligamentous stabilizing structures.The referenced study by Sagi et al found that biomechanically, a percutaneous iliosacral screw and anterior ring internal fixation was the most stable construct. In addition, he found no biomechanical support for addition of a second iliosacral screw.OrthoCash 2020A 33-year-old male patient presents with a comminuted open tibia fracture after involvement in a motor vehicle crash. He has a history of smoking but is otherwise healthy. He is given antibiotics, and taken immediately for irrigation and debridement, followed by an un-reamed stainless steel intramedullary nail. Due to bone loss there is a non-circumferential cortical defect measuring 12 mm at the fracture site. All of the following factors in this patient's history and presentation increase his risk for adverse outcome EXCEPT:High-energy mechanism of injuryUse of un-reamed nailImplant materialFracture gapHistory of smokingCorrent answer: 2Of the factors listed only the use of an un-reamed intramedullary nail for an open tibia fracture has not been shown to increase the risk of adverse outcome or need for reoperation.The treatment of open tibia fractures with intramedullary nailing can be complicated by many factors. High energy mechanism of injury, use of a stainless steel nail, residual fracture gap greater than 1 cm, and a history of smoking have all been shown to increase the risk of adverse outcome. The use of reamed and un-reamed nails for open tibia fractures have been studied, and no significant difference in outcome has been found.Schemitsch et al. present data from a prospective randomized trial of tibia fractures treated with reamed or unreamed intrameduallry nails. They found no difference in risk of adverse outcome between reamed and un-reamed nails in open tibia fractures. They did, however, find an increased risk of adverse outcomes in high-energy mechanisms, use of stainless steel (versus titanium) rods, and a residual fracture gap of greater than 1 cm. They comment that their data did not show a significant increase in risk due to history of smoking, but cite other studies that have demonstrated such a relationship.Bhandari et al. present data from a prospective randomized study of patients with tibia fractures randomized to reamed or un-reamed tibial nails. For closed fractures they found a lower rate of primary events (most commonly need for dynamization) in the reamed group. However, they found no difference in outcomes for either technique in open fractures.Incorrect answers:OrthoCash 2020Following antegrade intramedullary nailing of a femoral shaft fracture, the complication shown in Figure A occurs. Which of the following errors most likely resulted in this complication?Applying external rotation torque on the proximal femur after placing proximal interlocking screwsExcessive interfragmentary compression of the fracture site prior to placing proximal interlocking screwsUsing too anterior a starting point for a piriformis-entry point nailInserting a trochanteric-entry point nail through the piriformis fossaInserting a right femoral nail into the left femurCorrent answer: 3Using a piriformis nail, a starting point that is too anterior will result in iatrogenic fracture ("bursting") of the proximal femur.Antegrade nailing achieves fixation via 3-point fixation. In the sagittal plane, because of anterior sagittal bow, this is achieved at distal anterior cortex, middle posterior cortex (apex of curvature) and proximal anterior cortex. In the coronal plane, because of the lateral bow, this is achieved at the lateral distal femur, middle medial femur (apex of curvature), and proximal lateral femur (greater trochanter). Piriformis nails have a single sagittal bow.Trochanteric nails are bowed in 2 planes, necessitating a twisting motion during insertion to negotiate both bows.Papadakis et al. performed an experimental study on 18 cadaveric femora. Anterior bursting was found in 56% of nails placed too anteriorly. Bursting was not seen in nails placed through a more posterior entry point. They emphasize the location of the entry point when performing antegrade nailing.Johnson et al. reviewed the biomechanical factors affecting fracture stabilityand femoral bursting. They found that position of the starting hole was most important. Anterior displacement by >6mm led to high hoop stresses and bursting of the anterior cortex. This is important as an eccentrically reamed cortex may be difficult to recover from. They recommend either selecting a smaller diameter nail or overreaming by 1-2mm as a solution.Figure A shows a fracture split of the proximal femur (left, without magnification; right, close-up). Illustration A shows anterior cortex pressures exceeding 100kPa for too-anterior entry points.Incorrect Answers:Wrong-side placement of a trochanteric entry nail would lead to varus malalignment at the fracture site, more so than placing a piriformis nail through the greater trochanter.OrthoCash 2020A 30-year-old male sustains a brachial plexus injury as the result of a motor vehicle collision. Palsy of which of the following muscles would not be expected with this injury if the injury was postganglionic in nature?Rhomboid majorExtensor carpi radialis longusBiceps brachiiDeltoidBrachioradialisA brachial plexus injury would involve all of the upper extremity muscles as well as most of the periscapular muscles. Complete plexus palsies are rare, and are often associated with scapulothoracic dissociation or other high-energy injuries.Preganglionic injuries often involve the cervical paraspinal musculature as well as a complete plexus injury. EMG evidence of intact signals in the serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) are suggestive of a postganglionic lesion/injury.Tubbs et al. reported on the surgical anatomy of the dorsal scapular nerve in a cadaver study. They found that the nerve came off the C5 nerve root in 95%, ran 2.5cm medial to the spinal accessory nerve as it traveled on the anterior border of the trapezius muscle, and was intertwined with the dorsal scapular artery in all specimens.Balakrishnan et al reported on the comparison of clinical exam and EMG in predicting site of lesions in brachial plexus injuries. The combination of EMG and exam localized the nerve injury in 80%, while the paraspinal EMG was the most sensitive solitary examination method (67%).Illustration A shows a diagram of the brachial plexus. Incorrect Answers:5: These muscles are all innervated by nerves that come from the brachialplexus, and would be affected with a postganglionic injury.OrthoCash 2020A 40-year-old male sustains a fall from a height. He sustains the isolated injury shown in the radiograph and CT images seen in Figures A through C. Surgery is planned. Which of the following constructs is the most appropriate definitive fixation for this injury?Lateral locked platingMedial bridge platingMedial buttress plateMedial lag screw with washersExternal fixationThis patient has a medial tibial plateau fracture. Medial buttress plating (MBP) is indicated.Medial tibial plateau fractures (Schatzker IV, Hohl and Moore II) may represent fracture dislocations of the knee. Neurovascular injuries must be excluded. In these instances, the medial fragment represents the stable fragment, and the rest of the tibia is the fractured fragment, with the entire leg acting as the lever arm.Berkson et al. reviewed high energy tibial plateau fractures. Medial fractures may be treated with a medial plate or external fixation. Open reduction may be necessary because of fracture line obliquity and propensity of the medial plateau to shorten and rotate in the sagittal plane. Meniscal injuries should be repaired and avulsed cruciates fixed early. Collateral ligaments should be reconstructed after obtaining bone healing and range of motion.Ratcliff et al. compared the stability of lateral locked plates and medial buttress plates in a cadaver model. They found that the medial buttress plate had greater fixation strength/failure force (4136N) compared with the lateral locking plate (2895N), although maximum cyclic displacement and residual displacement results were not different. They concluded that for verticallyorientated medial tibial plateau fractures, medial buttress plates were more stable.Figure A is a radiograph showing a medial tibial plateau fracture extending across the tibial eminence. This is also classified as a Hohl and Moore Type II fracture. Figures B and C are coronal and axial CT scan images confirming the medial tibial plateau fracture and excluding a bicondylar fracture. Illustration A shows a medial tibial plateau fracture fixed with a medial buttress plate (cadaveric model with fibula removed). Illustration B shows the Hohl and Moore Type II fracture involving the entire condyle.Incorrect Answers:OrthoCash 2020A 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 flexionWeakness of ankle dorsiflexionNumbness of the medial thighNumbness of the lateral thighNumbness of the perineumCorrent answer: 4This 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 ananterior 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:OrthoCash 2020What would be the most appropriate surgical indication for transferring fascicles of the ulnar nerve to the motor nerve of the biceps and fascicles of the median nerve to the motor nerve of the brachialis?C8 - T1 nerve root avulsion 3 months agoC5 - C6 nerve root avulsion 2 months agoUpper brachial plexus palsy 22 months agoMedial and posterior cord injury from gunshot wound 2 months agoC6 ASIA A spinal cord injuryCorrent answer: 2Transfer of fascicles from (1) ulnar nerve to the nerve to the biceps and (2) median nerve to the motor nerve of the brachialis would be appropriate in thetreatment of an acute (<3-6 months) upper brachial plexus palsy.Upper trunk injury (C5, C6) often results from the avulsion of both the C5 and C6 nerve roots. Injuries of this nature usually result from a downward force on the shoulder with lateral bending of the cervical spine in the opposite direction. This results in what is commonly called an Erb-Duchenne palsy. Patients often present with a flail shoulder and loss of elbow flexion. Other common treatments for C5 and C6 root avulsion include neurotization of the musculocutaneous (MSC) nerve by the spinal accessory (SA) or intercostal nerve, and neurotization of the supra-scapular nerve by the SA.Liverneaux et al. looked at short term results of (1) ulnar nerve fascicle transfer to the nerve to the biceps and (2) fascicle of the median nerve to the motor branch to the brachialis in 15 patients with acute C5 - C6 nerve root avulsion injuries. Grade 4 elbow flexion was restored in each of the 10 patients. There was no secondary deficit in grip strength or sensation.They concluded that this double nerve transfer technique will likely reduce the need for secondary procedures to augment elbow flexion.Teboul et al. reviewed thirty-two patients with an upper nerve-root brachial plexus injury that underwent ulnar nerve fascicle transfer to the nerve of biceps to restore elbow flexion. After the nerve transfer, twenty-four patients achieved grade 3 elbow flexion strength or better. They note that this procedure will spare the C5 nerve root and other nerves for grafting or transfer elsewhere.Illustration A shows harvesting of an ulnar nerve fascicle for transfer. Illustration B shows transfer of the fascicle of the ulnar nerve to the motor nerve of the biceps.Incorrect Answers:sensory quadriplegia. Nerve transfers using the ulnar nerve (C8-T1) would also be redundant as this nerve would be non-functional in this patient.OrthoCash 2020A 31-year-old female presents to the trauma bay following a motorcycle crash. Her blood pressure is 95/70 mmHg, heart rate is 115 bpm. Lactate measured in the trauma bay is 10 mmol/L. She has multiple rib fractures, pulmonary contusions, and a positive FAST exam requiring immediate exploratory laparotomy. After laparotomy her lacate remains unchanged. She has a closed right femur fracture and an open right tibia fracture as seen in Figures A and B. Besides antibiotics and thorough irrigation and debridement, which of the following would be an appropriate step in the immediate management of her fractures?Reamed intramedullary nailing of the tibia and femurUn-reamed intramedullary nailing of the tibia, and reamed intramedullary nailing of the femurReamed intramedullary nail of the tibia, and un-reamed intramedullary nailof the femurPosterior slab splint of the tibia, and 10 lbs skeletal traction of the femurExternal fixation of the tibia and femurCorrent answer: 5This patient is suffering from multiple injuries and has evidence of chest injury and incomplete resuscitation. The immediate treatment of her fractures should be external fixation for both the tibia and the femur.For polytraumatized patients with multiple injuries including extremity fractures, damage control orthopaedics dictates that long bone fractures should be temporarily stabilized. Either inadequate stabilization, or early total care, such as a reamed or unreamed nails, can exacerbate the patient's condition and increase the risk of a second-hit phenomenon. For this patient with pulmonary contusions and continued elevation of lactate indicating end-organ hypoperfusion her extremities should have staged treatment according to damage control principles.Morshed et al. present a retrospective review of polytraumatized patients with femur fractures and compared outcomes based on the time frame in which their fractures were definitively treated. They found delaying treatment at least 12 hours to allow appropriate resuscitation and treatment of other traumatic injuries led to a decrease in mortality of 50%. Patients with intra-abdominal injuries benefited most from staged treatment of the extremities.Figure A is a radiograph showing a closed right femur fracture. Figure B is a radiograph of an open right tibia fracture.Incorrect answers:OrthoCash 2020A 68-year-old woman undergoes a hemiarthroplasty for a proximal humerus fracture through a deltopectoral approach. Whatrange of motion exercise should not be utilized in the immediate postoperative period due to concerns about lesser tuberosity fixation?PendulumsPassive internal rotation of the shoulder to the plane of the bodyActive forearm supinationPassive external rotation of the shoulder past 30 degreesPassive forward flexin of the shoulder to 90 degreesCorrent answer: 4Frankle et al found that passive external rotation of the shoulder placed the most stress on the lesser tuberosity fixation. The subscapularis tendon inserts on the lesser tuberosity and is the deforming force when placed under tension during external rotation. They also found that non-anatomic tuberosity reduction of 4-part proximal humerus fractures treated with hemiarthroplasty increased torque and impaired external rotation kinematics.OrthoCash 2020A 72-year-old female sustains a displaced intracapsular femoral neck fracture. Which of the following is TRUE regarding the long term differences between possible treatment options for this injury?Patients undergoing total hip arthroplasty are more likely to experience persistent pain than those undergoing internal fixationPatients undergoing total hip arthroplasty are less likely to require reoperation than those undergoing internal fixationThere is no difference in functional outcome scores between internal fixation and total hip arthroplastyPatients undergoing internal fixation perform activities of daily living better than those undergoing total hip arthroplastyMortality rates are higher following total hip arthroplasty than internal fixationElderly patients with femoral neck fractures (FNF) undergoing total hip arthroplasty (THA) are less likely to require reoperation than those undergoing internal fixation.Intracapsular FNF are common in elderly patients after a fall from standing height. Treatment depends on physiological age and displacement (Garden's classification). For displaced fractures, physiologically young patients are treated with internal fixation while physiologically old patients are treated witheither hemiarthroplasty (debilitated, less active patients) or THA (more active patients, those with acetabular disease or preexisting inflammatory arthritis).Chammout et al. retrospectively compared the long term (17 years) results of THA (cemented both component) and ORIF (2 cannulated screws) in elderly patients (>65 years). They found no difference in mortality. But hip scores were higher and pain was better in the THA group, while reoperation rates were higher in the ORIF group. Walking speed was initially faster in the THA group, but later did not differ between groups. They recommend THA for elderly patients with displaced FNF.Rogmark et al. prospectively compared closed reduction and internal fixation (CRIF) with arthroplasty (combining hemiarthroplasty and THA) at 2 years in elderly patients (>70 years). Failure rates were higher, pain was worse, and walking was more impaired after CRIF. They recommend arthroplasty for patients >70 with FNF.Incorrect Answers:OrthoCash 2020A polytrauma patient underwent the following procedures: (1) statically locked intramedullary nailing for a right femoral shaft fracture; (2) open reduction with plate-and-screw fixation [ORIF] for a right simple distal fibula fracture; (3) ORIF right middle third radius and ulna fracture; and (4) ORIF left humeral shaft fracture. What is the appropriate weightbearing status for this patient?Weight bearing as tolerated in all extremitiesEarly protected weight bearing right lower extremity in walking cast, weight bearing as tolerated left upper extremity, non-weight bearing right forearmWeight bearing as tolerated in bilateral lower extremities and right upper extremity, non-weight bearing left upper extremityNon-weight bearing bilateral upper extremities and right lower extremityNon-weight bearing right upper and lower extremities, weight bearing as tolerated left upper and lower extremities without walking castThe standard postoperative weightbearing for locked medullary nailing for femoral shaft fractures and humeral shaft fractures is weight bearing as tolerated (WBAT). Simple ORIF ankle fractures may be managed with early protected weight bearing. ORIF right middle third radius and ulna fracture should be managed with a period of non-weight bearing due to risk of secondary displacement of the fracture.Tingstad et al. examined the effect of immediate weightbearing on plated fractures of the humeral shaft. They reported that immediate weightbearing on humeral shaft fractures, treated with plating and full weightbearing, did not have any negative effect on the union or malunion rates.Brumback et al. evaluated the feasibility, safety and efficacy of immediate weightbearing after treatment of femoral shaft fractures with statically locked IM nail. Using biomechanical and clinical data, they showed that all fractures united with no loss of fixation or hardware failure.Starkweather et al. retrospectively assessed the complications and loss of reduction in patients who bore weight in a short leg cast within 15 days after surgical repair of acute unilateral closed ankle fractures. Of the 81 ankle fracture radiographs, 80 (98.8%) showed no displacement in fracture reduction on the final follow-up examination. These results suggest early protected weightbearing may be safe.Incorrect Answers:OrthoCash 2020A 22-year-old female falls off the back of a motorcycle and sustains the injury in Figure A. She is hemodynamically unstable and massive transfusion protocol is activated. What is the correct ratio of transfusion of packed red blood cells, platelets and plasma?