2. Trauma MCQs

Figure A show a classic SAD (supination adduction) fracture according to the Lauge-Hansen Classfication. This is evident by the vertical medial malleolar fracture and supinated position of the foot. The vertical medial malleolar fracture is best treated by screw fixation parallel to the joint (perpendicular to the fracture line). Careful attention must be paid to the presence of any medial plafond impaction from the talar displacement; if this is present, disimpaction and stabilization must be performed in order to optimize outcomes.The referenced review article by Michelson covers rotational ankle fractures, with a review of the diagnosis, treatment options, and patient outcomes. He notes that unstable fractures (bimalleolar, bimalleolar equivalent, etc.) usually are managed with open reduction and internal fixation for optimal outcomes.Incorrect answers:Figure B shows a Weber C (high fibular) ankle fracture, PER, without any evidence of a medial malleolar fracture.Figures C (SER IV), D (PER IV), and E (isloated medial malleolar fracture) all show fractures not suitable for screw fixation of the medial malleolus parallel to the joint since their fracture lines are not vertical.OrthoCash 2020Which of the following is an advantage of using blocking screws for tibial nailing?Decrease risk of nail breakageEliminate use of interlocking screwsAllow for larger nail useEnhance construct stiffnessDecrease torsional rigidityCorrent answer: 4Blocking screws can be used to help obtain and maintain reductions, increase construct stiffness, and neutralize translational forces. There are no studies as of yet that find a blocking screw to decrease nail failure.Krettek found that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability by decreasing mechanically measured deformation.In a later clinical study, Krettek found that after using blocking screws, tibial healing was evident radiologically at a mean of 5.4 months with a decreasedrate of malunions.Ricci also found that blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.OrthoCash 2020Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?6 weeks after initiation of weight bearing4 weeks postoperatively8 weeks from the date of injuryOnce full range of motion of the ankle and knee existAt the time of bony unionCorrent answer: 1According to the first referenced study by Egol et al, appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries.The second reference by Egol studied only operatively treated ankle fractures and found that time to appropriate braking returns at 9 weeks postoperatively. Interestingly, no significant association was found between the functional scores and normalization of total braking time.OrthoCash 2020A 42-year-old male sustains the injury seen in figure A. What negative sequelae would occur with displacement of this fracture in the characteristic fashion?Post-traumatic subtalar arthrosisStress fracture of the fibulaReflex sympathetic dystrophyAchilles tendon rupturePosterior skin necrosisCorrent answer: 5The radiograph shows a tongue-type calcaneus fracture, with major displacement of the posterior calcaneal body/tuberosity. The Achilles tendon insertion here causes characteristic proximal and posterior displacement, and with increasing displacement, posterior skin necrosis can be caused in a short period. Per the references, this should be treated urgently to prevent this sequelae. Lag screw fixation is appropriate for this fracture pattern, placed perpendicular to the fracture.OrthoCash 2020A 34-year-old male falls 10 feet from a balcony and is brought to the emergency room with the deformity seen in Figure A. Radiographs shown are shown in Figure B and C. Which of the following structures can block closed reduction of this injury pattern?Flexor hallucis longus tendonExtensor digitorum brevis musclePosterior tibial tendonTibialis anterior tendonPlantar fasciaFigures A through C show a medial subtalar dislocation. Irreducible dislocations are typically the result of either inadequate sedation or interposed soft tissue structures.In medial dislocations, the extensor digitorum brevis, the deep peroneal neurovascular bundle, or the joint capsule may block a closed reduction. In lateral dislocations, the most common structure implicated as a block to reduction is the posterior tibial tendon, although the flexor digitorum longs, posterior tibial neurovascular bundle or flexor hallucis may also block reduction.Bibbo et al found that subtalar dislocations were irreducible 32% of the time and that 88% had ipsilateral foot and ankle injuries. At follow up, 89% of patients demonstrated radiographic changes of the subtalar joint, and had worse function on the side of the subtalar dislocation as demonstrated by lowerAOFAS scores.Incorrect Answers:OrthoCash 2020Spontaneous rupture of the extensor pollicis longus tendon is most frequently associated with which of the following scenarios?Non-displaced distal radius fractureNon-displaced Rolando fractureSecond metacarpal base fractureBoxer's fractureNon-displaced radial styloid fractureCorrent answer: 1Rupture of the extensor pollicis longus (EPL) tendon after non operative treatment for a distal radius fracture occurs with a 0.3-5% incidence. The causes of EPL rupture include mechanical irritation, attrition, and vascular impairment leading to delayed rupture. Synovitis of the extensor carpi radialis due to repetitive use may invade the EPL tendon and lead to rupture.Recommended treatment in the pre-rupture setting includes a third dorsal compartment release with or without an extensor retinacular patch graft. Palmaris longus graft or a transfer from the extensor indicis proprius to the EPL tendon are reasonable treatment options. Results of all treatments seem to be clinically satisfactory.The referenced article by Gelb is a review of the etiology and treatment of this injury. He reviews the above discussion and findings.OrthoCash 2020A 79-year-old cyclist is involved in an accident and sustains a displaced femoral neck fracture as seen in Figure A. What is theoptimal treatment?Open reduction internal fixationBipolar hemiarthroplastyUnipolar hemiarthroplastyTotal hip arthoplastyNonoperative treatmentAn AP pelvis radiographs with a displaced femoral neck fracture is seen in Figure A. It important to note that degenerative changes are seen on this image. Both references suggest that elderly active individuals should be treated with a primary total hip after displaced femoral neck fractures.In the first study by Blomfeldt et al, the group reviewed a series of patients who underwent either an acute primary total hip arthroplasty for a femoral neck fracture or a delayed primary hip after an attempt at ORIF. They found that the group treated with an acute primary total hip arthroplasty had better Harris hip and quality of life scores.The second reference from Blomfeldt et al, studies a population of active elderly patients randomized to either a total hip arthroplasty or bipolar for femoral neck fractures. The group found no mortality or dislocation difference between the groups, but higher Harris hip scores at 1 year in patients treated with a total hiparthroplasty.OrthoCash 2020A 53-year-old man sustains the injury seen in figure A and later undergoes open reduction and internal fixation. What variable willmost significantly increase his rate of degenerative arthritis in the long-term?Postoperative joint stepoffAlteration of limb mechanical axisFracture typeMale sexAge greater than 50Maintenance of mechanical axis correlates most with a satisfactory clinical outcome when managing an intra-articular fracture of the proximal tibia.According to the study of plateau fractures with up to 27 year follow-up by Rademakers et al, malalignment of the limb by greater than 5 degrees tripled the rate of degenerative osteoarthritis (27% v. 9%). Age at time of injury had no effect on outcome; 31% had joint space narrowing but 64% of those knees were well tolerated.Weigel and Marsh's study looked at high energy plateau fractures treated with staged external fixation followed by internal fixation, and noted a low rate of severe arthrosis even with mild to moderate joint incongruity.Stevens et al noted a worse outcome with increasing age at presentation with these injuries; fracture type had a small influence and adequacy of reduction had no significant influence on outcome.Figure A is a coronal CT image showing a lateral tibial plateau fracture with significant joint depression.OrthoCash 2020A 69-year-old male sustained a proximal humerus fracture that underwent open reduction and internal fixation nine months ago. He complains of constant pain and weakness; repeat radiographs are shown in Figures A and B. What is the most appropriate surgical treatment at this time?Revision open reduction and internal fixationValgus corrective osteotomy of proximal humerusShoulder arthroplastyShoulder arthrodesisHumeral head resectionCorrent answer: 3Figures A and B show loss of fixation of a proximal humerus fracture. The most appropriate treatment for this scenario is a humeral arthroplasty, as the tenuous blood supply of the proximal humerus is likely chronically disrupted, leading to osteonecrosis and poor healing potential of the proximal humerus.Traditionally, hemiarthroplasty was performed for these presentations, but reverse total shoulder arthroplasty has emerged as a potentially bettertreatment method, especially if the rotator cuff function/status is unknown or poor.According to the referenced article by Norris et al, delayed shoulder hemiarthroplasty decreased shoulder pain in 95% of patients but warned of technical difficulties and limited postoperative range of motion. A total shoulder arthroplasty is needed if glenoid erosion from the screw(s) or bone occurs.OrthoCash 2020During the ilioinguinal approach to the pelvis, the corona mortis artery must be identified and ligated if present. The corona mortis artery joins the external illiac artery with which other major artery?PudendalDeep illiac circumflexHypogastricObturatorTesticularThe "corona mortis" (translated as “crown of death”) artery is a vascular variant that joins the external illiac and the obturator artery as it crosses the superior pubic ramus. Tornetta et al did a study where "fifty cadaver halves were dissected to determine the occurrence and location of the corona mortis. Anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both. The distance from the symphysis to the anastomotic vessels averaged 6.2 cm (range, 3-9 cm)." The corona mortis can be injured in superior ramus fractures and iatrogenically while plating pelvic ring injuries using the ilioinguinal approach.OrthoCash 2020A 26-year-old male sustains a femoral shaft fracture treated with the implant shown in Figure A. Postoperatively, what muscular deficits can be expected at medium and long-term follow-up?Weakness with hip abduction and knee flexionWeakness with hip abduction and knee extensionWeakness with knee flexion and knee extensionWeakness with hip external rotation and hip abductionWeakness with hip external rotation and hip flexionCorrent answer: 2Figure A shows a femoral shaft fracture treated with an antegrade femoral nail. Long term deficits are weakness with knee extension (quadriceps) and hip abduction (glutei muscles).The referenced study by Kapp et al noted long term quadriceps weakness as well as decreased bone mineral density in the femur (femoral neck by 9%, the lateral cortex by 20% and the medial cortex by 13%). It is unclear whether this is due to the injury, treatment, or a combination of both.The second referenced study by Archdeacon et al also noted weakness in hip abduction, which showed time dependent improvement. He reports that increased early ipsilateral trunk lean is associated with worse recovery of abduction strength.OrthoCash 2020A 33-year-old male sustains the injury seen in Figure A as a result of a high-speed motor vehicle collision. Based on this image, what is the most likely acetabular fracture pattern?Both columnAnterior columnAnterior column posterior hemitransverseTransverseT-typeThe radiograph in Figure A shows a transverse acetabulum fracture. The iliopectineal (anterior column) and ilioischial lines (posterior column) are interrupted, revealing bicolumnar involvement; however, this is different than the both column fracture, as a transverse pattern has articular surface still in continuity with the axial skeleton via the sacroiliac joint.The referenced article by Patel et al showed a wide variation of inter and intra-observer agreement in interpreting radiographs of acetabular fractures, with high agreement for basic radiographic classification and only slight to moderate agreement for other radiologic variables such as impaction.The other referenced article by Letournel is a great review article regarding the initial classification of these fractures as well as a quick summary of his outcomes.OrthoCash 2020A 56-year-old carpenter sustains the closed injury seen in Figures A, B, and C. After temporary spanning external fixation is performed and soft tissue conditions improve, what strategy provides the optimal fixation for this fracture pattern?Anatomic lateral locking platePosteromedial and lateral platesAnatomic medial locking plateConversion of the spanning external fixator to a hinged external fixatorPosterior buttress plateCorrent answer: 2Figures A and B show a bicondylar tibial plateau fracture, with a typical appearing lateral fracture line and a posteromedial fracture line. The posteromedial sheared fracture piece is difficult, and/or sometimes impossible, to achieve appropriate stable fixation with a single lateral locking plate, as there will be limited screw purchase and fixation into the posteromedial fragment.The referenced article by Georgiadis notes that a dual incision approach is safe and is associated with improved outcomes over their historical comparisons.They describe the dual incisions and approaches in length, and review risks/issues with each approach.The other referenced study by Bhattacharyya et al notes that these fractures have a typical appearance of the posteromedial fracture piece and that articular reduction quality is correlated with short-term results. They recommended buttress-type fixation of these fracture pieces.OrthoCash 2020A 31-year-old male sustains an irreducible ankle fracture-dislocation with the foot maintained in an externally rotated position. An AP and lateral radiograph are shown in figures A and B respectively. The attempted post reduction AP and lateral are shown in C and D. What structure is most likely preventing reduction?Anterior-inferior tibiofibular ligamentPosterior-inferior tibiofibular ligamentPeroneus brevis tendonPosterolateral ridge of the tibiaFlexor hallucis longus tendonCorrent answer: 4As described by Hoblitzell et al, the so-called "Bosworth fracture-dislocation" is a rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible. It can cause compartment syndrome, as reported by Beekman and Watson.Hoblitzell et al stress the importance and difficulty of recognizing these injuries. Standard radiographs are difficult to interpret due to the often severe external rotation of the foot. Prompt treatment, though can lead to good results in patients. The posterolateral ridge of the distal tibia hinders reduction and reduction often requires an open techniqueMayer and Evarts stated AP and mortise radiographs can be hard to interpret due to the external rotation posture of the foot. In their series a closed reduction consisting of traction and medial rotation applied to the foot while the fibular shaft is pushed laterally was successful in 3/4 patients.OrthoCash 2020A 37-year-old female sustains the injury seen in Figures A and B. At long-term follow up, degeneration of which of the following joints has been shown to have the highest rate of patient symptoms?Tibiotalar jointTalonavicular jointCalcaneocuboid jointLisfranc jointSubtalar jointFigures A and B show a medial subtalar dislocation, which is more common than a lateral dislocation (65% vs. 35%).The referenced article by Bibbo et al looked at long-term follow up of these patients, and noted that radiographic degeneration of the ankle and subtalar joints were 89%, although 31% of ankle joints were symptomatic and 68% of subtalar joints were symptomatic. Midfoot degeneration was seen radiographically in 72% (15% symptomatic).OrthoCash 2020In treating a lateral split-depression type tibial plateau fracture, which of the following adjuncts has been shown to have the least articular surface subsidence when used to fill the bony void?Crushed cancellous allograftHydroxyapatiteCalcium phosphate cementAutogenous iliac crestBisected diaphyseal humeral allograftCorrent answer: 3In treating tibial plateau fractures, calcium phosphate has been shown to have the least amount of articular subsidence on follow-up examinations.The referenced study by Russell et al noted a significantly increased rate of subsidence at 12 months with autograft as compared to calcium phosphate cement (in types I-VI).The other referenced study by Lobenhoffer et al noted improved radiographic outcomes and earlier weightbearing with usage of calcium phosphate cement.OrthoCash 2020The pelvic spur sign on plain radiography is indicative of the following injuries?Transtectal transverse acetabular fractureVertical shear pelvic ring injuryDisplaced H-type sacral fractureBoth column acetabular fractureAnterior-posterior type III pelvic ring injuryCorrent answer: 4The pelvic spur sign is indicative of a both column acetabular fracture. It is best seen on an AP or obturator oblique x-ray. The spur is the intact portion of the ilium, still attached to the axial skeleton and seen posterosuperior to the displaced acetabulum (typically medially displaced).Illustration A shows the spur sign (arrows) on a CT image, while illustration B shows an obturator oblique of the pelvis and the spur sign is shown with the long tailed arrow (on the left of the image).OrthoCash 2020A 33-year-old male sustains a distal humerus fracture and is treated with open reduction and internal fixation of the distal humerus with olecranon osteotomy. A postoperative radiograph is shown in Figure A. A new deficit of the anterior interosseous nerve is now noted in the recovery room. What physical exam finding would be expected with this nerve injury?Inability to flex radiocarpal jointLoss of sensation over palmar aspect of thumbLoss of sensation over dorsal hand first webspaceInability to abduct index fingerInability to flex thumb interphalangeal jointCorrent answer: 5A deficit in the anterior interosseous nerve (AIN) would result in an inability to flex the interphalangeal joint (IPJ) of the thumb.Injury to the AIN can be seen with K-wires that penetrate through the anterior cortex of the proximal ulna, such as mentioned above. The AIN is a branch of the median nerve that provides motor function to forearm/hand. It branches off from the median nerve 4 cm distal to the medial epicondyle, passes between the 2 heads of the pronator teres, travels through the forearm anterior to the interosseous membrane between the flexor pollicis longs (FPL) and flexor digitorum profundus (FDP), and then terminates in the pronator quadratus (PQ). The nerve gives of branches to the FDP, FPL, and PQ enabling for flexion of the distal phalangeal joint of the index and middle fingers, flexion of the IPJ of the thumb, and aids with pronation of the forearm, respectively.Injury to the nerve will result in weakness in motor function to these muscles.Mekail et al. reviewed the anterior approach to the proximal radius in order to describe and identify important neurovascular and musculoskeletal structures in the area. They were specifically aiming to determine the safest anatomic orientation for plate and screw fixation in regards to the posterior interosseous nerve. The authors, however, did discuss that medial plating was especially dangerous to the AIN, and significantly increased the risk of iatrogenic injury to the branch sent to the FPL.Parker et al. reported a case report in a patient who experienced an AIN deficit postoperatively after tension banding of an olecranon fracture.Intraoperatively, there were multiple passes of the K-wires in an attempt to find purchase in the anterior cortex of the ulna. The authors believed that during these passes, the nerve was injured and concluded that placing K-wires should not occur without radiologic visualization.Figure A is a postoperative lateral radiograph after tension banding of the olecranon. Perforation of the anterior ulnar cortex can be seen by the K-wire which can cause damage to the AIN nerve. Illustration A is a schematic of the path of the AIN, its branches, and its function.Incorrect Answers:OrthoCash 2020A computed tomography (CT) scan has been shown to be indicated for evaluation of all of the following aspects of acetabular fractures, EXCEPT:Determination of surgical planningIntra-articular loose bodiesMarginal impactionFracture piece size and positionDetermination of pre-existing degenerative changesCorrent answer: 5CT 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.OrthoCash 2020A 69-year-old woman falls while getting out of her car and lands on her right shoulder sustaining a 4-part proximal humerus fracture. She subsequently undergoes surgery to treat the fracture, with immediate postoperative radiographs shown in Figure A. Six months following surgery, she denies shoulder pain, but she is unable to actively raise her hand above her shoulder. Which of the following is the most likely cause of this limitation?Joint infectionRetroversion of the prosthesisGlenoid arthritisAxillary nerve injuryGreater tuberosity malunionCorrent answer: 5The radiograph demonstrates a humeral hemiarthroplasty. Malunion of the greater tuberosity is a known complication of this procedure, and the most likely cause for loss of shoulder elevation.Frankle et al in 2004 reported a 25% rate of greater tuberosity malunion. They discuss surgical techniques to improve fixation of the tuberosities following hemiarthroplasty for proximal humerus fractures.Frankle et al in 2002 evaluated 5 different techniques to reattach the tuberosities following shoulder hemiarthroplasty in human cadavers. Findings suggested that a circumferential medial cerclage should be placed around the tuberosities to enhance the stability of the tuberosity repair.Bosch et al reviewed 39 consecutive 3 or 4 part proximal humerus fractures that were treated with either primary hemiarthroplasty or secondary hemiarthroplasty following a primary ORIF. Patients who underwent primaryhemiarthroplasty reported better clinical outcomes. The authors concluded that elderly patients with 3 or 4 part humerus fractures are best treated with early arthroplasty.OrthoCash 2020An acetabular fracture with all segments of the articular surface detached from the intact posterior ilium is defined as what fracture pattern?TransverseBoth columnAnterior column posterior hemitransversePosterior column with posterior wallAnterior column with anterior wallCorrent answer: 2A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other radiographic findings consistent with a both column acetabular fracture can be seen in Illustration A (AP), Illustration B (obturator oblique), and Illustration C (iliac oblique).OrthoCash 2020A large posteromedial tibial plateau fracture pattern, as seen with the bicondylar tibial plateau fracture shown in Figures A and B, is important to recognize because of which of the following factors?Association with posteromedial corner of the knee injuryAssociation with anterior tibial artery injuryPossible need for dual plate fixationPossible need for single extensile anterior approach to the kneeIncreased risk of deep venous thrombosisCorrent answer: 3Figures A and B show a bicondylar tibial plateau fracture with a large posteromedial fracture piece. This has clinical importance, as currently available plate/screw constructs often have poor fixation of this fracture segment, and this pattern often requires a second, posteromedial, approach and placement of a second plate/screw construct.The referenced article by Barei et al notes a prevalence of posteromedial fracture pieces of nearly 33% of all bicondylar tibial plateau fractures. They also recommend supplementary or alternative fixation techniques when this pattern is recognized.The referenced article by Higgins et al notes a 59% incidence of this fracture pattern (consisting of nearly 25% of the total joint surface) in bicondylar tibial plateau fractures, and recommends appropriate fixation to combat the vertical shear instability through a separate approach.The last referenced study by Higgings et al notes a significantly increased rate of late fracture displacement in a biomechanical model with a single lateral locking plate as compared to a dual plate construct.OrthoCash 2020At the elbow, the anterior bundle of the medial collateral ligament inserts at which site?Radial tuberosity3mm distal to the tip of the coronoidAnteromedial process of the coronoidMedial border of the olecranon fossaRadial side of ulna at origin of annular ligamentCorrent answer: 3The anterior bundle of the medial collateral ligament of the elbow inserts at the anteromedial process of the coronoid, also known as the sublime tubercle.Fractures at this site have been shown to have worse results with nonoperativetreatment, due to increased rates of instability and post-traumatic arthrosis.The referenced articles by Ring and Steinmann are great reviews of the topic of coronoid fractures. They review the diagnosis, treatment options, rehabilitation, and outcomes of these injuries. They focus on the importance of the coronoid in elbow stability, especially with base fractures, or ones that involve the sublime tubercle.Illustration A depicts the anterior bundle of the MCL inserting at the sublime tubercle.OrthoCash 2020In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?Transverse fracture below the level of the syndesmosisShort oblique fracture running from anteroinferior to posteriosuperiorShort oblique fracture running from posteroinferior to anteriosuperiorComminuted fracture at or above the level of the syndesmosisWagstaff fractureIn the Lauge-Hansen classification, the characteristic fibular fracture pattern in a pronation-abduction injury is a comminuted fibular fracture above the level of the syndesmosis. In the first stage of this injury pattern, the deltoid fails in tension, or an avulsion fracture of the medial malleolus occurs. In the second stage, the anterior inferior tibiofibular ligament ruptures, or a small bony avulsion of this ligament's insertion/origin occurs. The final stage includes the creation of a comminuted fibular fracture above the level of the syndesmosis.The referenced article by Siegel et al noted that extraperiosteal bridge plating of these ankle injuries was safe and had excellent radiographic and clinical outcomes at final follow-up.OrthoCash 2020A 38-year-old male sustains the closed injury shown in Figures A and B. When treating this injury with an intramedullary nail, addition of blocking screws into which of the following positions can prevent the characteristic malunion deformity?Anterior to the nail in the proximal segment; medial to the nail in the proximal segmentAnterior to the nail in the proximal segment; lateral to the nail in the proximal segmentPosterior to the nail in the proximal segment; lateral to the nail in the proximal segmentAnterior to the nail in the distal segment; lateral to the nail in the distal segmentPosterior to the nail in the distal segment; medial to the nail in the proximal segmentFigures A and B show a proximal tibia fracture, which is prone to malreduction/malunion into a characteristic valgus and procurvatum (apex anterior) deformity. Placement of screws in this instance posterior to the nail (medial to lateral) and lateral to the nail (anterior to posterior) in the proximal segment will prevent iatrogenic malalignment.Intramedullary nails will not effect a reduction in metaphyseal proximal tibia fractures. Valgus and apex anterior deformities in these injuries may be caused by deforming muscular forces, limb positioning in hyper flexion, as well as iatrogenic deformity created by improper nail insertion technique. Blocking (Poller) screws are utilized to redirect intramedullary nails by creating an artificial cortex to guide the nail into appropriate position.The referenced biomechanical study by Krettek et al noted that addition of blocking screws added increased stability to metaphyseal fractures.Ricci et al noted no malalignment intraoperatively or at final follow-up of proximal tibia fractures treated with intramedullary nails if blocking screws were used.OrthoCash 2020In an uninjured proximal tibia which statement best describes the shape and position of the medial tibial plateau relative to the lateral tibial plateau?More concave and more proximalMore convex and more proximalMore concave and more distalMore convex and more distalSymetric in conture and more distalThe medial tibial plateau is more concave and more distal relative to the lateral tibial plateau.Watson et al report "the medial tibial plateau has a more concave shape and is larger in both length and width than the lateral tibial plateau, which has a slightly convex shape. The lateral tibial plateau lies proximal to the medial plateau. The convexity of the lateral plateau helps differentiate it from the medial plateau on a lateral radiograph of the proximal tibia."Illustration A shows the relative concavity of the medial and lateral proximal tibia.OrthoCash 2020On average, the radial nerve travels from the posterior compartment of the arm and enters the anterior compartment at which of the following sites?Spiral groove of the humerusAt the arcuate ligament of Osborne10 cm distal to the lateral acromion10 cm proximal to radiocapitellar jointAt the origin of the deep head of the tricepsCorrent answer: 4The radial nerve enters the anterior compartment through the intercompartmental fascia on average 10 cm proximal to the radiocapitellar joint. It has never been found to remain in the posterior compartment within

The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.

DISCUSSION: An anterior approach to the sacroiliac joint is indicated with the presence of a symphysis dislocation, which can be reduced through the same approach. The other choices are all relative contraindications to this approach. A sacroiliac dislocation or malalignment can lead to gait abnormalities, pelvic obliquity, back or buttock pain, as well as neurological changes.

OrthoCash 2020A patient presents with the injury shown in figures A and B. What has been associated with the technique depicted in figures C and D?Longer operative timesIncreased deep surgical infection ratesUnacceptably high malunion/nonunion ratesSlower early return to functionLonger hospital staysCorrent answer: 3Treatment of Shatzker V and VI tibial plateau fractures with hybrid external fixation is associated with increased malunion and nonunion rates.Hybrid external fixation for treating tibial plateau fractures involves the use of an external fixator to achieve reduction through ligamentotaxis. Additional fracture reduction is achieved through limited open incisions with fixation augmented through percutaneous cannulated screws. Definitive treatment with this technique avoids soft tissue complications that have been associated with traditional open reduction and internal fixation with bicondylar plating.However, studies have reported high malunion and nonunion rates due to a lack of rigid fixation.Bertrand et al. performed a prospective cohort study of patients undergoing either open reduction and internal fixation versus hybrid external fixation for Schatzker V and VI tibial plateau fractures. Hybrid external fixation was associated with significantly shorter operative times but insignificantly increased complication rates. They concluded that there were limited statistically differences between these techniques, but further studies are required before advising hybrid external fixation for higher Schatzker tibial plateau fractures.Gross et al. performed a retrospective study of patients treated with hybrid external fixation for Shatzker V and VI tibial plateau fractures. The authors found there was an 80% union rate, a 70% satisfactory reduction rate, and a 52% rate of malunion. The development of osteoarthritis was associated with plateau widening, articular comminution, articular step-off, and incorrect mechanical alignment. The authors concluded that hybrid external fixation is an effective means for the treatment of tibial plateau fractures that minimizes tissue dissection, with decreased blood loss, and shorter operative times, but associated with a very high malunion rate.Hall et al. performed a multicenter randomized controlled trial comparing the treatment of Schatzker V and VI fractures with open reduction and internal fixation with hybrid external fixation. Patients with hybrid external fixation had less intraoperative blood loss, fewer unanticipated secondary procedures, slightly faster return to pre-injury activity at 6 months and 1 year, and shorterhospital stay. They concluded that both hybrid external fixation and open reduction and internal fixation provide effective means for fracture treatment, but hybrid external fixation avoids soft tissue complications with deleterious consequences.Figure A is an AP radiograph of the right knee with a Schatzker VI tibial plateau fracture. Figure B is an axial CT slice of the articular surface of the tibia with extensive comminution. Figures C and D are the AP and lateral radiographs of the knee with a hybrid external fixation construct for a tibial plateau fractureIncorrect answers:OrthoCash 2020An 89-year-old female sustained the injury shown in Figure A and underwent a hemiarthroplasty. Which of the following has been associated with increased rates of post-operative dislocation?Posterior approachAnterior approachAnterolateral approachUse of a bipolar implantUse of a monopolar implantThe incidence of dislocation after hemiarthroplasty is highest when using a posterior approach.Elderly femoral neck fractures are one of the most common fractures encountered by orthopaedists and will only become more common as the population continues to age. The displacement of the femoral head is associated with delayed union or nonunion, an increased risk of femoral head necrosis due to disrupted blood flow at the femoral neck, and failure of internal fixation devices. For this reason, displaced femoral neck fractures in older patients are often treated with hemiarthroplasty. Three approaches to hemiarthroplasty have been described: a lateral approach, a posterior approach, and an anterior approach. The posterior approach has been used more historically; however, its use has been called into question as it has been associated with increased dislocation rates.Parker performed a trial on all patients with intracapsular femoral neck fractures being treated with hemiarthroplasty. Patients were randomized to surgery using either a lateral or posterior approach. They found that there were no statistically significant differences observed for any of the outcome measures including mortality, degree of residual pain and regain of walking ability. They concluded that both surgical approaches appear to produce comparable functional outcomes.van der Sijp et al. performed a meta-analysis to compare the outcomes based on approaches for hemiarthroplasty in the treatment of proximal femur fractures. They found 21 studies and found that the posterior approach poses an increased risk of dislocation and reoperation compared to the lateral approach and anterior approaches. They conclude that there are no evident advantages of the posterior approach and its routine use for fracture-related hemiarthroplasty should be questioned.Figure A is an AP pelvis radiograph demonstrating a displaced right femoral neck fracture.Incorrect Answers:OrthoCash 2020A 50-year-old male sustained a humeral shaft fracture treated operatively 6 months ago. He denies medical problems but smokes 10 cigarettes per day. His current radiograph is shown in Figure A. He continues to have pain in his arm that is affecting his quality of life. On physical examination, there is motion at the fracture site. C-reactive protein and erythrocyte sedimentation rate are within normal limits. Which is the most appropriate definitive treatment for this fracture?Exchange humeral nailingAugmentative platingNail removal with open reduction compression platingSmoking cessation and medical optimizationNail removal with open reduction and compression plating with bone graftingThis patient has sustained an atrophic nonunion of a humeral shaft fracture treated with an intramedullary nail. The most appropriate definitive treatment is nail removal with open reduction and compression plating with bone grafting.Most diaphyseal humeral fractures can be managed non-operatively with functional bracing. Operative treatment is indicated under a number of circumstances including open fractures, associated neurovascular injury, proximal and distal articular extension of the fracture, and in patients with other multiple injuries. Surgical stabilization can be accomplished with different implants and techniques. The two most common are plate and screw fixation and intramedullary nailing. Plate fixation has the advantages of potential absolute stability and sparing the rotator cuff from an incision. Intramedullary nailing has to be inserted proximally with potential damage to the rotator cuff. It, however, can be inserted with small incisions. If a nonunion develops after intramedullary nailing, nail removal and compression plating is the preferred treatment choice.Heineman et al. performed a metanalysis on plate fixation or intramedullary nailing of humeral shaft fractures. They performed a literature search from 1967-2007 comparing nails and plates in patients with humeral shaft fractures that reported complications due to surgery. They found that the risk of a complication is lower when plating a fracture of the humeral shaft than when using an intramedullary nail.Gerwin et al. performed an anatomical study to define the course of the radial nerve in the posterior aspect of the arm, with particular reference to its relationship to operative exposures of the posterior aspect of the humeral diaphysis. They found that the radial nerve crosses the posterior aspect of the humerus from an average of 20.7 +/- 1.2 centimeters proximal to the medial epicondyle to 14.2 +/- 0.6 centimeters proximal to the lateral epicondyle. They found the approach to permit the most visualization was the triceps reflecting approach.Figure A is a lateral radiograph of an atrophic nonunion of a humeral shaft being stabilized with an intramedullary nail.Incorrect Answers:OrthoCash 2020A 45-year-old man is struck while crossing a major highway and sustains the injury depicted in Figure A. Which of the following statements comparing the techniques in Figure B and C is most accurate?Technique depicted in Figure B is associated with an increased risk of septic arthritisTechnique depicted in Figure B is associated with increased rate of anterior knee painTechnique depicted in Figure B is associated with improved postoperative fracture alignmentTechnique depicted in Figure C is associated with an increased risk of septic arthritisTechnique depicted in Figure C is associated with improved postoperative fracture alignmentCompared to infrapatellar tibial nailing, suprapatellar tibial nailing is associated with improved postoperative fracture alignment.While antegrade tibial nailing results in postoperative anterior knee pain in approximately 20% of patients, there is no significant difference in the incidence of anterior knee pain when the conventional infrapatellar approach is compared to suprapatellar approaches. In open tibial shaft fractures, no difference has been observed in the incidence of knee sepsis with either approach. However, several studies have demonstrated that intramedullary nail fixation through a suprapatellar approach is associated with a more accurate entry position and a more accurate fracture reduction when compared with an infrapatellar technique, particularly in more proximal and distal shaftfractures, without evidence of a functional impact on the patellofemoral joint. Lastly, intraoperative radiography is generally less cumbersome with suprapatellar nailing.Marecek et al. performed a multicenter comparison study of suprapatellar and infrapatellar approaches and the risk of knee sepsis after treatment of open tibia fractures. They reported no differences in the rates of infection, deep infection, or reoperation between suprapatellar and infrapatellar nailing groups. They concluded that the risk of knee sepsis after suprapatellar nailing of open fractures is low.Avilucea et al. performed a retrospective cohort study comparing postoperative alignment after suprapatellar versus infrapatellar nailing for distal tibial shaft fractures. They reported a significantly increased rate of primary angular malalignment of greater than 5 degrees in the infrapatellar compared to the suprapatellar nailing cohort. They concluded that in the treatment of distal tibial fractures, suprapatellar nailing results in a significantly lower rate of malalignment compared with the infrapatellar nailing.Jones et al. performed a study comparing the radiologic outcome and patient-reported function after suprapatellar and infrapatellar intramedullary nailing. They reported no difference in anterior knee pain, however, found a more accurate fracture reduction, both in terms of angulation and translation in the coronal plane, with the use of the suprapatellar technique. They concluded that when compared with infrapatellar nailing, the suprapatellar technique was not associated with more anterior knee pain, yet more accurate nail insertion and fracture reduction.Figure A depicts a displaced distal third tibial shaft fracture. Figure B depicts the infrapatellar tibial nailing technique. Figure C depicts the suprapatellar tibial nailing technique.Incorrect Answers:OrthoCash 2020A 56-year-old woman sustains the closed injury depicted in Figures A-B. On examination, her wrist is mildly swollen and she is unable to actively oppose her thumb. She also complains of some paresthesias in her thumb and index finger. The patient undergoes closed reduction and splinting; however, her paresthesias worsen significantly in the next 12 hours. What is the likely mechanism of her paresthesias and what is the most appropriate treatment?Nerve compression; open reduction internal fixation with open carpal tunnel releaseNerve laceration; open reduction internal fixation with primary nerve repair or graftingDecreased arterial inflow; fasciotomy with open reduction internal fixationReflex sympathetic dystrophy; vitamin CNerve compression; repeat closed reductionCorrent answer: 1This patient is presenting with signs of acute carpal tunnel syndrome (CTS) in the setting of a displaced distal radial fracture. The pathogenesis of acute CTS is nerve compression, requiring urgent open carpal release with open reduction internal fixation (ORIF).Acute CTS is a well-recognized phenomenon after distal radial fractures. Risk factors include ipsilateral upper extremity fractures, translation of the fracture fragments, and articular distal radius fractures (DRFs). Acute CTS can manifest with paresthesias in the median nerve distribution and opponens pollicis weakness. Acute CTS is an indication for urgent surgical decompression of the median nerve.Odumala et al. performed a study to evaluate the role of carpal tunnel decompression in the prevention of median nerve dysfunction after buttress plating of DRFs. They reported that prophylactic decompression of the carpal tunnel results in twice the relative odds of developing median nerve dysfunction, which routinely self-resolved. They concluded that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may actually increase postoperative morbidity.Medici et al. performed a case-control study to investigate whether carpal tunnel release (CTR) during fixation DRFs improves outcomes. They reported no statistically significant difference between the groups in VAS and Mayo Wrist Scores, however, an increased risk of subsequent CTR in the group who underwent ORIF with no CTR at the index procedure. They concluded that the release of the transverse carpal ligament during ORIF may reduce the incidence of postoperative median nerve dysfunction.Niver et al. reviewed CTS after DRFs. They reported that acute CTS noted at the time of DRF warrants urgent surgical release of the carpal tunnel and fracture fixation, and that delayed CTS presenting after a distal radius fracture has healed may be managed in the standard fashion for CTR. They concluded that there is no role for prophylactic CTR at the time of distal radius fixation in a patient who is asymptomatic.Figures A and B depict a displaced apex volar DRF and a mildly displaced ulnar styloid fracture.Incorrect Answers:OrthoCash 2020Figures A and B depict the closed injury radiograph of a 79-year-old right-hand-dominant woman who fell on her left wrist. According to meta-analysis and systematic reviews, which of the following statements is most accurate regarding her injury?Improved functional outcomes with open reduction internal fixation (ORIF) through FCR approach vs. closed treatmentNo difference in radiographic outcomes after ORIF vs. closed treatmentNo difference in functional outcomes after ORIF vs. closed treatmentImproved functional outcomes with closed treatment vs. ORIFImproved functional outcomes with external fixation and K wire fixation vs. ORIFThis elderly patient has sustained a closed intra-articular and shortened distal radial fracture (DRF). Many studies have reported no difference in functional outcomes when patients aged 60 and over are treated in a closed manner versus operatively for unstable fractures.The treatment of DRFs in the elderly population is controversial. A variety of nonoperative and operative treatments are available, including closed reduction and splinting/casting, K wire stabilization, external fixation, and ORIF. While conservative management of DRFs in the elderly is common,recent systematic reviews and meta-analyses have demonstrated that despite worse radiographic outcomes after closed treatment of unstable fractures, functional outcomes were no different between patients treated closed versus surgically in patients over the age of 60 years.Ju et al. published a systematic review and meta-analysis comparing treatment outcomes between nonsurgical and surgical treatment of unstable DRFs in the elderly. They reported no significant differences in DASH score, VAS pain score, grip strength, wrist extension, pronation, supination, and ulnar deviation between the groups. They concluded that operative and nonoperative treatments result in similar outcomes in the treatment of unstable DRFs in the elderly, with no impact on subjective function outcome and quality of life with closed treatment.Diaz-Garcia et al. published a systematic review of the outcomes and complications after treating unstable DRFs in the elderly, comparing various treatment techniques. They reported significant differences in wrist motion, grip strength, DASH score, although these findings may not be clinically meaningful. They concluded that although the operatively treated group had improved radiographic outcomes, functional outcomes were no different when compared to the group treated in a closed manner.Figure A depicts an unstable intra-articular and shortened DRF. Incorrect Answers:no difference in functional outcomes between operative and closed treatment modalities for DRF.OrthoCash 2020An active 60-year-old woman falls from her attic and presents with the injury in Figure A. She undergoes successful closed reduction and sling immobilization. At follow up, she is unable to move her shoulder. New radiographs are depicted in Figures B and C. What is the next best step?Continued sling immobilizationClosed reduction percutaneous pinningOpen reduction internal fixationHemiarthroplastyReverse total shoulder arthroplastyCorrent answer: 3This active patient presents with a greater tuberosity fracture dislocation. Open reduction internal fixation (ORIF) is indicated, particularly when the greater tuberosity fragment is displaced greater than 5mm.Many proximal humerus fractures are minimally displaced and respond acceptably to nonoperative management. Isolated greater tuberosity fractures or rotator cuff injuries are associated with shoulder dislocations in the elderly population. The greater tuberosity fragment undergoes deforming forces by the supraspinatus and infraspinatus muscles. In active patients, it is well-accepted that greater tuberosity fracture displacement greater than 5mm is an indication for ORIF to restore their ability to perform overhead activities and prevent impingement.Schumaier et al. published a review article on the treatment of proximal humerus fractures in the elderly. They highlighted that while bone density was a predictor of reduction quality, social independence was a better predictor of outcome. They concluded that although the majority of minimally displaced fractures can be treated successfully with early physical therapy, treatment for displaced fractures should consider the patient's level of independence, bone quality, and surgical risk factors. They emphasized that there was no clear evidence-based treatment of choice, and the surgeon should consider their comfort level during their decision-making.George et al. published a review article on greater tuberosity humerus fractures. They reported that these fractures may occur in the setting of anterior shoulder dislocations or impaction injuries against the acromion or superior glenoid, with surgical fixation recommended for fractures with greater than 5 mm of displacement in the general population or greater than 3 mm of displacement in active patients involved in frequent overhead activity. They recommended close followup and supervised rehabilitation to increase successful outcomes.Figure A depicts a greater tuberosity fracture dislocation of the left shoulder. Figures B and C depict reduction of the glenohumeral joint with residual displacement of the greater tuberosity. Illustrations A and B depict radiographs after ORIF.Incorrect Answers:OrthoCash 2020A 21-year-old football player is tackled as he falls onto an outstretched arm. He sustains the injury shown in Figure A. He undergoes successful operative treatment of his injury. In which order did his injury occur?MCL > LCL > anterior capsuleMCL > anterior capsule > LCLanterior capsule > MCL > LCLLCL > anterior capsule > MCLLCL > MCL > anterior capsuleCorrent answer: 4The patient sustained a terrible triad injury of the elbow, which progresses from the LCL to the anterior capsule and then the MCL.Terrible triad injuries of the elbow are traumatic injuries that occur after a fall on an extended arm that results in a combination of valgus, axial, and posterolateral rotatory forces. The key features of a terrible triad injury include a radial head fracture, a coronoid fracture, and an elbow dislocation. Disruption of the structures in the elbow characteristically occurs from lateral to medial, affecting the LCL first, followed by the anterior capsule and MCL. Outcomes following terrible triad injuries have historically been poor; however, more recent literature has shown that good outcomes can be achieved with surgical stabilization of the elbow followed by an early rehabilitation protocol. Some authors use temporary immobilization, but range-of-motion exercises are typically initiated by 48 hours postoperatively. Active range of motion is particularly important, as it recruits muscles that act as dynamic stabilizers of the elbow. Depending on the injury, method of fixation, and stability that is achieved, the range of motion may be limited to 30° of extension during the early postoperative period but should allow full flexion.Giannicola et al. (2013) performed a study to determine the critical time period for recovery of functional range of motion after surgical treatment of complex elbow instability (CEI). They found that the first 6 months after surgery represent the critical rehabilitation period to obtain a functional elbow and that elbow flexion recovered at a rate slower than that of the other elbow movements. They recommend that, following CEI surgical treatment, a rehabilitation program should be started promptly and should be continued for at least 6 months because a significant improvement of ROM occurs in this period.Giannicola et al. (2015) performed a study analyzing the predictability of outcomes of terrible triad injuries (TTI) treated according to current diagnostic and surgical protocols. They found that the current diagnostic and therapeutic protocols allow for satisfactory clinical outcomes in a majority of cases but a high number of major and minor unpredictable complications still persist. Low compliance, obesity, and extensive soft elbow tissue damage caused by high-energy trauma represented negative prognostic factors unrelated to surgery.McKee et al. performed a review on their standard surgical protocol for the treatment of elbow dislocations with radial head and coronoid fractures. Their surgical protocol included fixation or replacement of the radial head; fixation of the coronoid fracture, if possible; repair of associated capsular and lateral ligamentous injuries; and, in selected cases, repair of the medial collateral ligament and/or adjuvant-hinged external fixation. They found that their surgical protocol restored sufficient elbow stability to allow early motion postoperatively, enhancing the functional outcome. They recommend early operative repair with a standard protocol for these injuries.Figure A is a lateral radiograph of the elbow demonstrating a terrible triad injury with a comminuted radial head/neck fracture, displaced coronoid fracture, and posterior elbow dislocation. Illustration A is a rendered image of the radiograph shown in Figure A with the components labeled.Incorrect Answers:OrthoCash 2020An 82-year-old female sustains the fracture shown in Figure A as the result of a ground level fall. Which of the following has been shown to be a reliable predictor of postoperative lateral wall fracture for this injury after treatment with a sliding hip screw?Reverse obliquity fracture patternLateral wall thicknessPrevious contralateral hip fractureDEXA T-score <-2.0Calcar comminutionLateral wall thickness has been shown to be a predictor of postoperative lateral wall fracture. As the lateral wall thickness decreases, there is an increased chance of fracture.Lateral wall fracture creates an unstable fracture pattern and increased screw sliding/collapse. This shortens the neck and abductors, leading to worse patient outcomes (radiographic and clinical). Recognition of a thin wall should lead toward the use of an intramedullary device or adjunct use of a trochanteric stabilizing plate with a sliding hip screw device.Baumgaertner et al. reported that the failure of peritrochanteric fractures that have been treated with a fixed-angle sliding hip-screw device is frequently related to the position of the lag screw in the femoral head. They established the tip-apex distance as the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this distance on a lateral radiograph, after controlling for magnification. Upon reviewing their series, none of the 120 screws with a tip-apex distance of twenty-five millimeters or less cut out, but there was a very strong statistical relationship between an increasing tip-apex distance and the rate of cutout, regardless of all other variables related to the fracture.Socci et al. performed a literature review of relevant papers and appropriate clinical databases and concluded that fixation of AO 31A1 fractures was best achieved with a sliding hip screw device and that all other types of intertrochanteric hip fractures be fixed with an intramedullary device.Utrilla et al. reported no difference in outcome in stable fractures, but better mobility at one year following intramedullary fixation of unstable fractures.Hsu et al. measured the thickness of the lateral wall of patients with AO/OTA 31-A1 and 31-A2 type intertrochanteric hip fractures. They found that the lateral wall thickness was a reliable predictor of postoperative lateral wall fracture for unstable AO Type A2 fractures and concluded that the lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.Figure A shows a standard obliquity intertrochanteric hip fracture.Illustration A from the Hsu article demonstrates the measurement of the lateral wall thickness. The distance is measured along a 135-degree angle, between a point 3cm distal to the innominate tubercle of the greater trochanter and the fracture line (midway between the two cortical lines).Incorrect Answers:OrthoCash 2020A 78-year-old patient presents with right hip pain and inability to bear weight after an unwitnessed fall at a nursing home. Figures A and B are the radiographs of the hip and pelvis. Which statement is true regarding the treatment of these injuries?Smaller lateral wall thickness favors sliding hip screw constructsUnstable fractures are best treated with sliding hip screw constructsAvoiding distal locking screws in intramedullary implants protects against refractureStable fractures have no differences in outcomes between sliding hip screws and intramedullary implantsImplant stability has a greater impact on outcomes rather than reduction qualityStudies have shown that in stable intertrochanteric femur fractures there are no differences in outcomes between sliding hip screws and intramedullary implants.Intertrochanteric femur fractures are one of the most common fractures in the geriatric population. Implant selection has been a great topic of research with most studies reporting minimal to no differences in outcomes between intramedullary and sliding hip screw constructs in stable fracture patterns.Unstable fractures, however, are reportedly better treated with a distally locked intramedullary implant. The quality of fracture reduction has a greater impact on the overall outcome than implant selection.Hsu et al. performed a retrospective study of risk factors for postoperative lateral wall fractures in patients treated with sliding hip screws for intertrochanteric femur fractures. They found that fracture classification and lateral wall thickness, which is measured from 3 cm distal from innominate tubercle and angled 135 degrees to the fracture line, were associated with postoperative lateral wall fracture. They recommended not treating intertrochanteric femur fractures with sliding hip screws if the lateral wall thickness is less than 20.5 mm.Socci et al. reviewed the literature regarding the treatment of intertrochanteric femur fractures. Based on the literature, they recommend treatment of AO/OTA type 31A1 fractures with sliding hip screws, type 31A2 fractures with short intramedullary implants, and 31A3 fractures with long intramedullary implants. Simple basicervical fractures of the femoral neck can be treated with sliding hip constructs whereas comminuted fractures treated with intramedullary devices due to the inherent instability of the pattern. The most import aspect in fracture healing is the quality of the reduction rather than the choice of implant.Lindvall et al. performed a retrospective study of refracture rates in patients treated with either long or short cephalomedullary nails. The authors found a 97% union rate with both implant types and refracture not associated with either long or short implants. Rather, refracture was associated with the lack of a distal locking screw. The authors recommended locking intramedullary implants to avoid refracture.Utrilla et al. performed a randomized control trial of elderly patients treatedwith compression hip screw or Trochanteric Gamma Nail for intertrochanteric femur fractures. They reported the only differences between the two implants were quicker operating time, less fluoroscopy use, and better walking with unstable fractures treated with intramedullary implants. The authors recommended either construct for stable fractures, but intramedullary implants for unstable fractures.Figures A and B are the AP and lateral radiographs of the right hip radiographs demonstrating a simple and minimally displaced intertrochanteric femur fracture, classified as an AO/OTA 31A1 fracture. Illustration A depicts the AO/OTA classification system for proximal femur fractures.Incorrect answers:OrthoCash 2020A 28-year-old male that sustained a closed left femoral shaft fracture 12 months ago and underwent intramedullary nailing presents with persistent pain in the right thigh. The patient walks with an antalgic gait. He denies any fevers or chills. His surgical sites are well healed and there are no signs of drainage. Serum ESR and CRP are 12 mm/hr (reference <20 mm/hr) and 0.9 mg/L (reference <2.5 mg/L), respectively. Figures A and B are the AP and lateral radiographs of the left femur. Which treatment option offers the highest chance of union and enables immediate weight-bearing?Nail removal with compression plating and open bone graftingClosed reamed exchange nailingNail dynamizationNail retention with plate augmentation and bone graftingElectrical bone stimulatorCorrent answer: 4The patient is presenting with a hypertrophic nonunion of the femur below the isthmus, which studies have shown to have a higher union rate when treated with plate augmentation. Retention of the nail allows for full weight-bearing postop.Hypertrophic nonunion of the femur is the result of fracture site hypermobility with sufficient biology for healing. This is demonstrated with abundant callus formation without bridging trabeculae. Traditionally, this is treated with closed reamed exchange nailing which increased construct stiffness with a larger diameter nail, improved isthmic fit, and extrusion of reaming contents to the nonunion site. However, studies have demonstrated a higher union rate with open plate augmentation, bone grafting, and nail retention. This is due to the ability to correct nonunion site deformity, provide added compression at the nonunion site, and increase fracture site biology with bone graft.Lynch et al. reviewed the literature regarding the treatment options for femoral nonunions. The literature suggests high union rates when hypertrophic nonunions are treated with exchanged reamed nailing. However, the use of augmentative plate fixation allows for further deformity correction. The proposed mechanism by which exchange reamed nailing is increased construct stiffness with a large diameter nail, usually by 1-2 mm, increased isthmic fit, and autogenous bone graft extrusion into the nonunion site.Somford et al. performed a systematic review of the surgical treatment of femoral nonunions. Results demonstrate that exchange nailing provides a 73% union rate compared to plate augmentation of 96%. They speculated that there were increased indications for exchange nailing for oligotrophic nonunions in many of the included studies, which may have reduced the union rate. Further, plate augmentation does allow for deformity correction, which can further improve the union rate.Figures A and B are the AP and lateral radiographs of the femur with hypertrophic nonunion as suggested with the abundant callus formation and broken distal interlock screws. Illustration A and B are the AP and lateral radiographs of the distal femur subsequent plate augmentation and fracture healing.Incorrect Answers:OrthoCash 2020A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment?External fixation with serial doppler examinationsIntramedullary nailingOpen reduction internal fixation using plates and screwsImmediate 2-compartment fasciotomies and external fixationImmediate 4-compartment fasciotomies and external fixationCorrent answer: 5This patient has clinical symptoms and signs of leg compartment syndrome and should undergo immediate fasciotomies of all 4 leg compartments, followed by external fixation for fracture stabilization.Tibial fractures are among the most common reasons for compartment syndromes of the leg. A clinical assessment is key in the diagnosis of acute compartment syndrome. If there is uncertainty, intracompartmental pressure measurement has been advocated to help confirm the diagnosis. An absolutecompartment pressure >30 mm Hg or a difference in diastolic pressure and compartment pressure (delta p) <30 mmHg may help to confirm the necessity for fasciotomy.McQueen et al. published a report of 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. They reported significant differences in any sequelae of acute compartment syndrome between patients who underwent compartment pressure monitoring and those who had not. They recommended that all patients with tibial fractures should have continuous compartment monitoring to minimize the incidence of acute compartment syndrome.Mawhinney et al. reported on three cases of tibial compartment syndrome after closed intramedullary nailing of the tibia. They reported that the only predisposing factors for the development of compartment syndrome were the surgery and the fracture itself. They concluded that tibial compartment syndrome is a relatively rare but significant complication of tibial nailing.Figure A is an AP and lateral radiograph of the leg with displaced, comminuted middle third tibia and fibula fractures.Incorrect Answers:OrthoCash 2020A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated?Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspaceDecreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toesDecreased arterial inflow; inability to dorsiflex his ankleDecreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspaceDecreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toesCompartment syndrome initially results from a decrease in venous outflow relative to arterial inflow. This patient has elevated pressures in the lateral compartment of the leg, which is where the superficial peroneal nerve runs to supply sensation to the dorsum of the foot including the hallux and 3rd and 4th toes.Compartment syndrome results from compromised venous outflow from the leg relative to the arterial inflow. This venous congestion leads to elevated compartment pressures that ultimately lead to compromised arterial inflow without compartment release. There are 4 compartments in the leg: anterior, lateral, superficial posterior, and deep posterior. The anterior compartment contains the deep peroneal nerve, the lateral compartment of the leg contains the superficial peroneal nerve, and the deep posterior compartment contains the tibial nerve.McQueen et al. performed a study to determine risk factors for acute compartment syndrome. They found that young patients, especially men, were most at risk of acute compartment syndrome after injury. They recommend that, when treating such injured patients, the diagnosis should be made early, utilizing measurements of tissue pressure.Olson et al. published a review on acute compartment syndrome in lower extremity musculoskeletal trauma. They reported that acute compartment syndrome is a potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia, and death. They report that recognizing compartment syndromes requires having and maintaining a high index of suspicion, performing serial examinations in patients at risk, and carefully documenting changes over time.Illustration A is a diagram depicting the compartments of the leg and its contents.Incorrect Answers:OrthoCash 2020Which of the following amputations results in an approximate 40% increase in energy expenditure for ambulation?SymeTraumatic transtibialVascular transtibialTraumatic transfemoralVascular transfemoralThe energy expenditure of a vascular transtibial amputation is approximately 40% greater.The energy expenditure for ambulation increases with lower extremity amputation. Diabetics and vasculopathic patients who undergo amputationhave significantly increased energy requirements compared with nondiabetic patients undergoing amputations for trauma. The metabolic cost for a vascular transtibial amputation is 40% compared to a 25% increase in normal patients who sustain a traumatic amputation.Huang et al. used a mobile instrument system to measure energy consumption by indirect calorimetry at rest and during ambulation in 25 unimpaired subjects, 6 unilateral below-knee (BK) amputee patients, 6 unilateral above-knee (AK) amputee patients and 4 bilateral AK amputee patients. They found that in comparison to unimpaired subjects, the mean oxygen consumption was 9% higher in unilateral BK amputee patients, 49% higher in unilateral AK amputee patients and 280% higher in bilateral AK amputee patients.Pinzur et al. performed a study to measure cardiac function and oxygen consumption in 25 patients who underwent amputation for peripheral vascular disease (PVD), and in five similarly aged control patients without PVD. They found Normal walking speed and cadence decreased and oxygen consumption per meter walked increased with more proximal amputation. They conclude that peripheral vascular insufficiency amputees function at a level approaching their maximum functional capacity and more proximal amputation levels, the capacity to walk short or long distances is greatly impaired.Incorrect Answers:OrthoCash 2020A 25-year-old man sustains the injury shown in Figures A-C. What is the primary advantage of using a trochanteric flip osteotomy (TFO) in treating this injury?It may be performed in a minimally invasive mannerIt involves minimal soft tissue strippingIt leads to higher union ratesIt allows the surgeon to address all sites of injury through one approachThis patient has sustained a right hip fracture-dislocation with fractures of the femoral head and posterior wall. The TFO allows the surgeon to address all sites of injury through a single approach.Femoral head fracture-dislocations are a result of high-energy trauma. Treatment ranges from closed reduction and conservative management to total hip arthroplasty. Intermediate options include open reduction and internal fixation or excision of fracture fragments. Complications of this injury include post-traumatic hip arthritis, avascular necrosis, and heterotopic ossification.The injury is further complicated when a fracture of the acetabulum is concomitantly present. There has been no consensus treatment on this injury constellation as it presents quite rarely. The TFO is one approach that allows the surgeon to treat and stabilize both injuries concurrently. It should be noted that a surgical hip dislocation is performed in conjunction with the TFO to allow access to the femoral head.Solberg et al. performed a retrospective study of patients sustaining Pipkin IV fracture/dislocations with a TFO. They had 12 patients over a 6 month period. They found that all patients healed radiologically and one patient developed osteonecrosis. 10 out of 12 patients had good to excellent outcomes. They concluded that using a surgical protocol with TFO rendered clinical resultscomparable to previously reported outcomes in a series of isolated femoral head fractures.Giannoudis et al. performed a systematic review to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. They reported that fracture-dislocations were managed with emergent closed reduction, followed by definite treatment, aiming at an anatomic restoration of both fracture and joint incongruity. They concluded that neither the TFO nor an anterior approach seems to endanger femoral head blood supply compared to the posterior one, with the TFO possibly providing better long-term functional results and lower incidence of major complication rates.Henle et al. reported on the result of 12 patients of femoral head fractures with associated posterior wall fractures treated with a TFO. They found good to excellent results in 10 patients. The two patients with poor outcome developed avascular necrosis of the femoral head and underwent total hip arthroplasty.Heterotopic ossification was seen in five patients. They concluded that the TFO may lead to favorable outcomes in this injury constellation.Figure A is an AP radiograph of the right hip demonstrating a femoral head fracture-dislocation. Figure B is an axial CT image demonstrating a posterior wall fracture. Figure C is an axial CT image demonstrating a femoral head fragment within the acetabulum. Illustration A is the Pipkin classification of femoral head fractures: Type I is below the fovea, Type II is above the fovea, Type III is associated with a femoral neck fracture, and Type IV is associated with an acetabular fracture.Incorrect Answers:OrthoCash 2020A 30-year-old male is brought to your emergency department following a motor vehicle collision at high speed. He is intubated in the field for airway protection but is hemodynamically stable. Subsequent workup shows a displaced acetabular fracture, in addition to an intracranial bleed and liver laceration which do not require surgery. When placing an antegrade anterior column screw, what radiographic view should be used to avoid intra-pelvic screw penetration?Iliac oblique view with hip and knee flexedIliac oblique inlet viewObturator oblique view with hip and knee flexedObturator oblique outlet viewObturator oblique inlet viewCorrent answer: 2The iliac oblique inlet view will best show the the anterior-posterior placement of an anterior column ramus screw.Percutaneous and limited-open acetabular fixation is becoming increasingly common as it avoids the morbidity of extensile pelvic dissection and allows early mobilization. However, it relies heavily on a mastery of radiographic landmarks and ability to interpret these images to reduce fracture fragments without direct visualization. Slight deviations of the fluoroscopy beam and/or fracture displacement will distort the radiographic image. Without a facile ability to interpret these and make appropriate adjustments, percutaneous fixation will be extremely onerous.Starr et al. described their early techniques for percutaneous and limited-open acetabular fixation. They first implemented this for minimally displaced fracture patterns but have expanded these to a wider range of pathology. They cite the benefit of earlier mobilization in the poly-traumatized patient as great use for this technique.Mauffrey et al. reviewed radiograph utilization during acetabular fracture care. Though CT has added tremendously to demonstrating subtleties of acetabular fractures, they state the use of AP and orthogonal iliac and obturator oblique Judet views cannot be overlooked. Interpreting these radiographs allows the surgeon to recreate 2-dimensional images into a 3-dimensional fracture pattern and better understand the character of the injury.Illustrations A and B demonstrate the iliac oblique inlet view and obturator oblique outlet views, respectively.Illustration C demonstrates the relationship of the critical structures at risk of injury during anterior column screw placement. Illustrations D and E show the starting point with screw trajectory, and position of the hip during posterior column screw.Incorrect Answers:OrthoCash 2020A 34-year-old male sustains the injury shown in Figures A and B. Which factor has been found to be elevated in the synovial fluid and contributes to post-traumatic arthritis?TGF-BetaRANKLIL-2IL-6cAMPThe patient has sustained a tibial plafond or pilon fracture as depicted in Figures A and B. IL-6 is one of many inflammatory molecules that has been found to be elevated in the synovial fluid following an intra-articular ankle fracture.Post-traumatic arthritis following intra-articular fractures is a known complication. It commonly appears 1-2 years following injury and is related to chondrocyte death at the margins. There has not been shown to be any association between prolonged non-weight bearing, poor patient compliance with weight-bearing restrictions, and hardware reactions with the development of post-traumatic arthritis. However, literature has shown that the inflammatory molecules present in the synovial fluid can have a significant effect on the development of posttraumatic arthritis. Important inflammatory factors that have been found to be elevated include IL-6, IL-8, MMP-1, MMP-2, MMP-3, MMP-9 and MMP-10.Adams et al. looked at the synovial fluid of 21 patients with an intra-articular ankle fracture and used the un-injured ankle as a control. They found the inflammatory molecules of GM-CSF, IL-10, IL-1 beta, IL-6, IL-8, IL-10, IL-12p70, TNF-alpha, MMP-1, MMP-2, MMP-3, MMP-9, MMP-10 were all elevated. They concluded that these inflammatory molecules may play a role in posttraumatic arthritis development.Adams et al. looked at the synovial fluid of 7 patients from his previous 21 patients that had intra-articular ankle fractures. They found that IL-6, IL-8, MMP-1, MMP-2, and MMP-3 were significantly elevated in comparison to the uninjured ankle. They concluded that the sustained elevated intra-articular inflammatory environment is a potential contributor to post-traumatic arthritis.Figures A and B are sagittal and axial CT slices, respectively, that depict a tibial plafond or pilon fracture.Incorrect Answers:immune system.OrthoCash 2020A 29-year-old female presents to the trauma bay from the scene of a high-speed motor vehicle accident. She is found to have a closed intraarticular distal radius fracture with a concomitant ulnar styloid base fracture. She subsequently undergoes ORIF of the distal radius fracture with a volar locking plate. The ulnar styloid fracture is not addressed. Which of the following, if present, is least likely to affect functional outcomes?Ulnar styloid nonunionDRUJ instabilityArticular step-off >3mmRadial shorteningWorkers compensation claimCorrent answer: 1Ulnar styloid non-unions do not affect the overall outcome of hand or wrist function following ORIF of distal radius fractures.Ulnar styloid base fractures can be associated with DRUJ disruption and TFCC rupture. The DRUJ should be independently evaluated following ORIF of the distal radius. Without instability, unlar styloid fractures do not need to be addressed. If instability exists, the DRUJ should be treated as a separate entity, typically cross-pinned using k-wires. The result of ulnar styloid nonunions are inconsequential to the overall outcome of patients undergoing distal radius ORIF.Daneshvar et al review the effects of ulnar styloid fractures on patients sustaining distal radius fractures. They report that patients with a concomitant ulnar styloid fracture had a slower recovery of wrist flexion and grip strength compared to those with an isolated distal radius fracture. They conclude, however, that even the presence of an ulnar styloid nonunion did not significantly affect outcomes.Buijze et al review the clinical impact of united versus non-united fractures of the proximal half of the ulnar styloid following volar plate fixation of the distal radius. They report no difference in motion, strength or outcome scoresbetween the united and non-united groups at 6 months follow up. They conclude that nonunion of the ulnar styloid does not have an effect on the overall outcome of hand or wrist function.Incorrect Answers:OrthoCash 2020Which of the following proximal humerus fractures has the highest likelihood of developing humeral head ischemia?Posteromedial calcar length of the humeral head less than 8 mm and a loss of medial hinge are among the most reliable predictors of ischemia in the surgical management of humeral head fractures.Proximal humerus fractures are classified based on the Neer classification, in which 4 parts are described: greater tuberosity, lesser tuberosity, articular surface, and the shaft. A fragment is considered a part if it is greater than 45 degrees angulated or displaced >1cm. The posterior humeral circumflex artery is the main blood supply to the humeral head. Following ORIF, humeral head ischemia may occur and is associated with the initial fracture pattern. Several factors including <8mm of calcar length attached to the articular segment, disruption of the medial hinge, displacement >10mm and angulation >45 degrees have been associated with a disruption of the vascular supply to the humeral head.Campochiaro et al review Hertel’s criteria of calcar length and medial hinge integrity and its reliability in predicting humeral head necrosis. They reported a 3.7% incidence of ischemia across all 267 fractures evaluated. In those patients that developed AVN, 30% had all of the predictors described by Hertel, however, in the non-AVN group, only 4.7% had these same findings.They concluded that while Hertel’s criteria are helpful, they may not be sufficient and the authors recommended 3-dimensional evaluation of any fracture involving the calcar.Xu et al reviewed avascular necrosis in patients with proximal humerus fractures who were treated surgically. They reported on 291 patients throughout 7 studies in which there was no difference in the incidence of AVN for those treated surgically or nonoperatively. However, they concluded through subgroup analysis looking at different fixation constructs that, plate fixation specifically was associated with a higher risk of AVN than conservative management of proximal humerus fractures.Figure A demonstrates a proximal humerus fracture with a medial calcar length of >8mm attached to the articular segment. Figure B is a proximal humerus fracture with a displaced greater tuberosity fragment. Figure C demonstrates a proximal humerus fracture with a medial calcar length of <8mm attached to the articular segment. Figure D is a displaced metadiaphyseal proximal humerus fracture in a skeletally immature patient. Figure E is a radiograph of a metadiaphyseal proximal humerus fracture in a skeletally mature patient with a medial calcar length >8mm.Incorrect Answers:OrthoCash 2020A 34-year-old man presents with the closed injury depicted in Figure A after a high energy twisting injury. Which of the other injuries below is most commonly associated with his known injury?Nondisplaced medial malleolus vertical shear fractureNondisplaced Volkmann's fragmentNondisplaced Chaput's fragmentNondisplaced lateral wall talar fracturePosterior inferior tibiofibular ligament disruptionCorrent answer: 2This patient has sustained a distal third tibial shaft spiral fracture, which is commonly associated with nondisplaced posterior tibial plafond fractures, with the classic Volkmann's fragment.Prior to operative management, distal third spiral tibial shaft fractures should always be evaluated for intra-articular extension. As this commonly associated injury can be missed on plain radiographs, an ankle CT is often recommended. This is especially important when intramedullary fixation is used for definitive management of the tibial shaft fracture, as nail insertion can displace apreviously nondisplaced intraarticular fracture. Anterior to posterior lag screw fixation prior to nailing may be useful in these cases.Sobol et al. investigated the incidence of concomitant posterior malleolar fractures (PMFs) in operative distal third spiral tibial shaft fractures. They reported that spiral distal third tibial shaft fractures were identified with an ipsilateral posterior malleolus fracture in 92.3% of cases. They recommended a preoperative ankle CT in all cases with this specific fracture morphology to properly diagnose this commonly associated injury.Hou et al. investigated the posterior malleolar fracture association with spiral tibial shaft fractures. They reported that plain radiography (both preoperative and intraoperative) resulted in rare identification of these associated injuries, which resulted in missed injuries. They concluded that a CT or MRI ankle may be a higher yield method to detect these injuries.Figure A demonstrates a distal third spiral tibial shaft fracture. Illustration A is a schematic demonstrating the Volkmann, Chaput, and medial malleoli intraarticular fragments of the distal tibia.Incorrect Answers:OrthoCash 2020An 18-year-old male is admitted for a diaphyseal, open, tibial shaft fracture after falling off a motorcycle. He has a past medical history of nicotine dependence and obesity. He undergoes provisional splinting by the resident on call and is noted to be "neurovascularly intact" following splint placement. Throughout the evening, however, the patient has an increasing narcotic requirement and develops pain with passive stretch of his toes. What factor listed below is most associated with his progressive symptoms overnight?Age < 20Male genderBody mass index >/ 30 kg/m^2Open fractureNicotine useThe highest prevalence of compartment syndrome is found in patients aged 12-19 years, followed by 20-29 years.One theory for the higher prevalence of compartment syndrome in younger patients is increased muscle mass in this cohort. If there is more muscle in a compartment, there is less room for swelling. On the flip side, elderly or deconditioned patients who have less muscle or fatty atrophy may be better able to accommodate muscle swelling. Additionally, a diaphyseal fracture location is associated with a higher risk of compartment syndrome. Again, this may be due to the fact that there is more muscle than tendon, and thus more swelling, in the proximal leg.Shadgan et al. retrospectively reviewed 1,125 patients with diaphyseal tibia fractures to look for risk factors associated with the development of compartment syndrome. Compartment syndrome occurred in approximately 8% of patients with this injury. They concluded that younger patients were at a higher risk of developing compartment syndrome and that male gender, open fracture, and intramedullary nailing were not risk factors.Beebe et al. set out to determine the correlation between the OTA/AO classification of tibia fractures and the development of compartment syndrome. they conducted a retrospective review of a prospectively collected database comprising 2,885 fractures. They concluded that age, sex, and the OTA/AO classification were highly predictive for the development of compartment syndrome in this cohort.McQueen et al. similarly looked at predictors of compartment syndrome after tibial fractures in a retrospective cohort study. There were 1,388 patients in their study with ages ranging from 12-98; identical to the Shadgan study, 69% of patients were male. They concluded the strongest risk factor was age, with the highest prevalence in 12 to 19-year-olds.Park et al. additionally analyzed 414 patients with tibia fractures in a retrospective cohort study. The main outcome measure of this study was the rate of clinically determined compartment syndromes requiring fasciotomy by anatomic region. The found that diaphyseal fractures were more frequently associated with the development of compartment syndrome than proximal (next most common site) and distal tibia fractures, specifically in younger patients.Incorrect Answers:OrthoCash 2020Figure A is the radiograph of a 79-year-old female with elbow pain following a fall. Compared with a total elbow artrhoplasty, open reduction and internal fixation would most likely result in?Greater Mayo Elbow Performance ScoreGreater Disabilities of the Arm, Shoulder and Hand ScoreIncreased flexion-extension arcIncreased reoperation rateDecreased complication rateCorrent answer: 4This patient sustained a comminuted distal humerus fracture. Open reduction and internal fixation (ORIF) is found to have higher repoeration rates compared with total elbow arthroplasty (TEA) in the elderly: 27% versus 12%, respectively.Distal humerus fractures account for approximately 30% of elbow fractures. There is often a low energy mechanism of injury in the elderly patient. While ORIF and TEA may be utilized in bicolumnar distal humerus fractures in the elderly patient, recent literature has demonstrated favorable outcomes with TEA in this aged cohort. TEA is indicated in the low demand osteoporotic patients with bicolumnar distal humerus fractures that are not amendable to ORIF. Utilization of TEA has demonstrated greater functional outcome scores, greater motion, less complications, and a lower revision rate.Mckee et al. conducted a prospective, randomized, controlled trial comparing functional outcomes, complications, and reoperation rates in elderly patients with displaced intra-articular, distal humeral fractures treated with ORIF or primary semiconstrained TEA. They reports that patients who underwent TEA had significantly better motion, performance and outcome scores, lower reoperation rates compared with the ORIF group. They concluded that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF and that TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation.Githens et al. performed a systematic review and meta-analysis to analyze outcomes and complication rates in elderly patients with intra-articular distal humerus fractures being treated with either TEA or ORIF with locking plates. They report that TEA and ORIF for the treatment of geriatric distal humerus fractures produced similar functional outcome scores and range of motion.However, they found a non-statistical trend toward a higher rate of major complications and reoperation after ORIF. They conclude that the quality of study methodology was generally weak and ongoing research including prospective trials and cost analysis is indicated.Figure A is the AP radiograph of a comminuted bicolumnar distal humerusfracture. Illustration A are the radiographs of a comminuted distal humerus fracture in an elderly patient treated with a TEA. Illustration B is the postoperative radiographs of a comminuted distal humerus fracture treated with ORIF.Incorrect Answers:OrthoCash 2020Figure A is the postoperative radiograph of an 82-year-old female who was treated with a cephalomedually nail for a left intertrochanteric hip fracture. Which of the following is the most common complication following use of this device?Anterior perforation of distal femurBreakage of the screwImplant cutoutMalunionNonunionIntertrochanteric hip fractures are most commonly treated with a cephalomedullary nail. The most common complication following utilization of a cephalomedullary nail is implant failure and cutout.Intertrochanteric hip fractures are extra-capsular injuries that are common in the elderly osteoporotic patient. These injuries carrry a 20-30% mortality rate in the first year following fracture. Femoral cephalomedullary nails are often used to treat these injuries. Often a helical blade or screw may be used to provide fixation within the femoral neck. Overall, the most common complication following use of this device is implant failure and cutout, which occurs most commonly within 3 months following surgery. A known risk factor of this complication is an increased tip-apex distance, with a 60% failure rate reported with a distance exceeding 45mm.Gardner et al. reviewed the use of a helical blade device to stabilizeintertrochanteric hip fractures. They reported a mean telescoping in unstable and stable fractures of 4.3 mm and 2.6 mm, respectively. They also found that blade migration within the femoral head averaged 2.2 mm overall, with no difference between stable and unstable fractures. They concluded that position changes occurred within the first 6 weeks postoperatively, with no subsequent detectable migration or telescoping.Haidukewych et al. reviewed patients with failed internal fixation of a hip fracture. They report that salvage options are dependent on the anatomic site of the nonunion, the quality of the remaining bone and articular surface, and patient factors such as age and activity level. They conclude that in younger patients with either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. Conversely, in older patients with poor remaining proximal bone stock or a badly damaged hip joint, conversion to hip arthroplasty is recommended.Figure A is the AP radiograph of the right hip treated with a cephalomedullary nail. Illustration A demonstrates screw cutout.Incorrect Answers:OrthoCash 2020Figure A is the radiograph of a 42-year-old female who presents to the trauma bay following a motor vehicle collision. She subsequently undergoes ORIF through a posterior approach. Iatrogenic injury to which nerve in Figure B is most likely with this approach?

may be performed.OrthoCash 2020

Touch weight bearing (10 to 15 kg) regimens have shown to minimize joint reaction forces across the hip. This weight bearing restriction should be considered in patients who have undergone open reduction internal fixation of transtectal transverse posterior wall fractures.The definition of touch weight bearing (also known as touch-down weight bearing) is ill-defined in the literature. Published data suggest touch weight bearing to be 10 to 15 kg of load applied to ground by the affected limb or less than 20% of body weight. In contrast, partial weight bearing is reported as 20 to 25 kg or 30% to 50% of body weight. Joint reaction forces across the hip have been shown to be lowest with touch weight-bearing. In this scenario, the foot should be flat against the ground so the flexor and extensor musculature that cross the hip are relaxed. With non-weight bearing restrictions, the musculature across the hip will be contracted, which increases contact pressures and joint reaction forces.Rubin et al. looked at the validity of touch weight-bearing and partial weight bearing regimens. They found that most patients overload the limb up to 50% more than the target weight prescribed.Lewis et al. showed that maintaining non-weight-bearing position of the involved leg produces increased compressive forces across the hip joint due to activation of the hip flexors compared to restricted weight-bearing.Incorrect Answers:

DISCUSSION: In patients with flexion-distraction injuries of the thoracolumbar spine, 50% have associated, potentially life-threatening, visceral injuries that occasionally are diagnosed hours or even days after admission. Based on these findings, consultation with a general surgeon is recommended. Blunt and penetrating injuries to the cardiopulmonary system or aorta sometimes can be seen with this type of injury, but they are no more common than with other types of thoracolumbar fractures because of the relatively mild bony injury anteriorly. Neurologic trauma with this type of fracture is also somewhat rare. REFERENCES: Levine AM (ed): Orthopaedic Knowledge Update: Trauma. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1996, pp 351-360. Inaba K, Kirkpatrick AW, Finkelstein J, et al: Blunt abdominal aortic trauma in association with thoracolumbar spine fractures. Injury 2001;32:201-207.

DISCUSSION: The pectoralis major tendon inserts lateral to the biceps tendon, which runs in the bicipital groove. The primary vascular supply of the articular surface of the humeral head is derived from the anterior circumflex humeral artery, which continues into the arcuate artery once it enters the bone. The entry point is on the anterolateral aspect of the humerus just medial to the greater tuberosity within the bicipital groove. To avoid compromising circulation, the blade plate should be placed lateral to the bicipital groove and pectoralis major tendon insertion.

Increased immobilization and delayed weight bearing are indicated in the neuropathic population after treating an ankle fracture. Patients with diabetes mellitus and peripheral neuropathy have higher complication rates following ankle fractures treated surgically or nonsurgically. The elevated HgbA1c and neuropathy both predict a higher complication rate with this fracture. Outcomes after nonsurgical management of this fracture are poorer than after surgical treatment. Early bone grafting is not recommended in closed fractures, but the use of supplemental internal fixation is recommended because of the high risk of nonunion. More substantial constructs with supplemental fixation, locking fixation, fixation through the calcaneus and talus into the tibia, or external fixation are necessary. Primary arthrodesis is not recommended in this fracture pattern or in a relatively active patient.

The anatomic lesion in this patient is not exactly defined, but she has most likely sustained an injury about the knee. A Salter-Harris type I proximal tibial physeal fracture is likely. The normal radiograph reading can be misleading because these injuries may displace and spontaneously reduce. The child is at risk of compartment syndrome although she is currently not displaying signs of it. Thus, even though this injury may seem trivial by radiographic findings, it should be treated like a knee dislocation with a risk of late developing compartment syndrome. MRI or CT may be necessary to define the injury. She does not require emergent treatment, but merits close observation for possible compartment syndrome. Any of the possible injuries about the knee can be unstable and require internal fixation after reduction.

This is a Vancouver B2 periprosthetic fracture (fracture around the stem, loose implant, adequate bone stock). The standard of care for a B2 fracture is revision of the femoral component to a long extensively porous-coated or modular fluted tapered uncemented stem. The new stem must bypass the most distal aspect of the fracture by at least two cortical diameters. ORIF alone is contraindicated when the stem is loose (Vancouver B1 vs B2).

This is a Vancouver B3 fracture (fracture around the stem, loose stem, severe proximal bone loss). In elderly, low-demand patients with inadequate proximal bone stock to support or heal a new stem, a proximal femoral replacement (tumor prosthesis) is the treatment of choice, allowing for immediate stability and early weight-bearing.

Medializing the acetabulum brings the center of rotation of the hip closer to the body's center of gravity. This decreases the moment arm of the body weight. Consequently, less abductor muscle force is required to maintain a level pelvis, leading to an overall decrease in the hip joint reaction force.

Pelvic discontinuity occurs when there is a complete separation of the superior hemipelvis (ilium) from the inferior hemipelvis (ischium and pubis). Radiographically, this is best identified on an AP pelvis by a visible fracture line or gap that disrupts both the anterior column (iliopectineal line) and the posterior column (ilioischial line), often with medial translation of the inferior hemipelvis.

DISCUSSION: The pelvic injury is a severe anterior-posterior compression III or Tile C injury. The vessel most likely injured is the superior gluteal artery, but several arterial bleeding sources are likely. Vertical shear injuries can also injure this vessel, but it is much less common. When arterial injury follows a lateral compression injury, it is usually related to injury of a more anterior vessel like the obturator artery or a branch of the external iliac artery.

A metabolic parameter such as the base deficit or lactate level has been shown to better reflect the resuscitation status and survival after trauma. Normalization of hemodynamic parameters does not accurately reflect the resuscitation status and a patient can be in compensated shock (occult tissue hypoperfusion) despite normalization of the heart rate and blood pressure. The use of temporizing measures with delayed definitive fracture treatment has been shown to decrease systemic complications in these patients with occult hypoperfusion.

Lipohemarthrosis is formed when an intraarticular fracture occurs and can be detected with arthrocentesis or imaging such as X-ray, MRI, ultrasound, or CT. It is most commonly seen with occult tibial plateau fractures but can be associated with any intra-articular fractures. Up to three layers are visible on an MRI (fat/serum/cellular parts of blood), and this separation may take up to 3 hours to appear after injury. Detection of lipohemarthrosis on an MRI is very sensitive and specific for intraarticular fracture.

This patient has a periprosthetic femoral fracture with a loose femoral stem and normal femoral bone stock, representing a Vancouver type B2 fracture. The most appropriate treatment is fixation of the fracture, along with revision of the stem. Considering his age, bone quality, and activity level, a longer uncemented stem is most predictable. Although a cylindrical stem may also be used, the fluted stem option is the only uncemented choice listed and is the most appropriate option. A cemented stem is a poorer choice because it is difficult to keep the cement out of the fracture site, which would pose a risk for nonunion at the fracture. Also, overall poorer results have been associated with long cemented stems in healthy, active people. Surgery does not need to be delayed to allow the ecchymosis to resolve, and simple open reduction and fixation does not address the loose stem.

This is a typical patellar sleeve fracture. The patellar tendon avulses a portion of the distal bony patella, along with the retinaculum and articular cartilage from the inferior pole of the patella. It is common in children between ages 8 and 10 years. Anatomic reduction and repair of the extensor mechanism are mandatory to reestablish full knee extension.

Fixation of patella fractures with tension band constructs leads to a need to remove implants in over 50% of cases in multiple studies.Tension band constructs result in absolute stability when performed correctly. This technique works by converting tension from muscle pull into compressive force on the articular side of the fracture. Tension band constructs require a fracture pattern or bone that is able to withstand compression, an intact cortical buttress opposite to the tension band, and fixation that withstands tensile forces.LeBrun et al. and associates evaluated functional outcomes of surgically isolated patella fractures. They reported that 52% of patients underwent surgery for hardware removal, and 38% of patients who retained their hardware reported pain at some time. They also found that nearly 20% had extensor lag, and almost 38% had restricted flexion. Extension power on testing showed significant mean deficits when compared to the contralateral side.Bayar et al. evaluated 20 patients with patella fractures and found that articular incongruity of >1mm was the largest risk factor for quadriceps weakness at a mean of 30 months postoperatively. No significant differences were seen with sex, fracture pattern, or time from injury to surgery.Illustration A shows patella fixation with plate/screw construct. Incorrect Answers:OrthoCash 2020