2. Trauma MCQs

The classic posteromedial approach to the tibial plateau utilizes the interval between the medial head of the gastrocnemius (retracted laterally with the neurovascular bundle) and the pes anserinus tendons (retracted medially).

The optimal starting point for a retrograde femoral nail is perfectly centered in the intercondylar notch in the coronal plane, and just anterior to the origin of the posterior cruciate ligament (PCL) in the sagittal plane.

The normal anatomic insertion of the conoid ligament on the clavicle is approximately 45 mm medial to the distal clavicular articular margin. The trapezoid ligament inserts more laterally, approximately 25 mm medial to the joint.

The anterior bundle is the primary restraint to valgus stress at the elbow. It originates on the anterior undersurface of the medial epicondyle and inserts on the sublime tubercle of the proximal medial ulna.

In the Bado classification of Monteggia fractures, Type I (most common) involves an anterior dislocation of the radial head with an apex anterior fracture of the ulnar diaphysis. Type II is posterior, and Type III is lateral.

The quadratus femoris (along with the obturator externus) is left intact during the Kocher-Langenbeck approach to protect the main terminal branch of the medial femoral circumflex artery and preserve the blood supply to the femoral head.

Lahti and associates reported that the most common dental injury in a study of 479 injured ice hockey players was a noncomplicated crown fracture, which accounted for 43.5% of all maxillofacial/dental injuries. The most common cause of injury was a blow from an ice hockey stick. As a cause of injury, the stick was approximately three times as common in games as in training, and only 10% of injured players wore some sort of protective guard. A tooth avulsion is a partial or complete displacement of the tooth from alveolar support. A crown fracture is an incomplete loss or fracture of the tooth enamel without loss of the tooth. The other injuries (mandible fracture, lip laceration, tooth avulsion, and temporomandibular contusion) occur but are not nearly as common.

Fractures of the proximal metadiaphysis of the tibia can be treated successfully with intramedullary nails, but previous studies showed rates of malalignment of up to 84%. The typical deformity is valgus and procurvatum. An ideal starting point is mandatory and should be slightly lateral to the medial border of the lateral tibial eminence on a true AP view and very proximal and anterior on a true lateral view with appropriate coronal and sagittal trajectory of the entry reamer. A medial start point will exacerbate valgus deformity and should be avoided. A reduction should be obtained and maintained during reaming, implant insertion, and interlocking. This can be facilitated via a variety of techniques including intraoperative external fixation, percutaneous reduction clamps or joysticks, semi-extended positioning, blocking screws that are typically inserted posterior and lateral to the nail, and ancillary plate fixation.

Whereas pain and functional disturbance may persist with nonsurgical management, the lack of articular surface contact prevents arthritic symptoms from developing. Cartilage injury caused by trauma and any persistent joint incongruity following repair would contribute to posttraumatic arthritis. Pinning across the acromioclavicular joint has a high incidence of hardware migration and potential catastrophic consequences. Most cases of lost fixation of coracoclavicular screws are at the level of the thread purchase in the coracoid. Routine hardware removal at 8 to 12 weeks is recommended to avoid screw breakage because of natural movement between the clavicle and scapula. The axillary nerve passes around the inferior edge of the subscapularis and is anatomically distant to the coracoid. The musculocutaneous nerve would have the closest anatomic position to the coracoid.

External fixation has been shown not to provide rigid fixation of the pelvis because a long moment arm from the fixator clamps to the posterior pelvis. Even with elaborate constructs, the fixator alone is inferior to internal fixation of the posterior ring. The main purpose of acute external fixation is to stabilize the initial clot forming about the injured pelvic plexus. This initial clot contains innate clotting factors, making it more stable, if not dislodged. If this clot is dislodged after hemorrhage and factor poor resuscitation, the ensuing hemorrhage will not have the same ability to form a stable clot around the injured vessels. The fixator does not stabilize any visceral structures. It interferes with the ability to sit depending on its application and is no more or less comfortable than skeletal traction.

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.OrthoCash 2020Which of the following findings best describes the acetabular fracture shown in Figure 38?Posterior column with articular impaction and a free fragmentAnterior column with articular impactionPosterior wall with an intra-articular fragmentPosterior wall with articular impaction and a free intra-articular fragmentPosterior wall with articular impactionCorrent answer: 4The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment.OrthoCash 2020A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence ofnormal sexual function and normal vaginal childbirth.sexual dysfunction (dyspareunia) and normal vaginal childbirth.normal sexual function and caesarean section childbirth.sexual dysfunction (dyspareunia) and caesarean section childbirth.normal sexual function and caesarean section childbirth until hardware removal.Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth isalmost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.OrthoCash 2020A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?Closed treatment and castingOpen reduction and internal fixationPrimary subtalar arthrodesisPercutaneous fixationExternal fixationA Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.OrthoCash 2020A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repairRadial head resection and lateral collateral ligament repairRadial head arthroplasty aloneRadial head arthroplasty and lateral collateral ligament repairRadial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repairThe combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region.OrthoCash 2020A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C).What is the most appropriate management for the femoral shaft fracture at this point?Reamed intramedullary nailingTractionExternal fixationOpen platingMast suitThe patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.OrthoCash 2020A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?MRI scanPhysical examinationWorkers’ compensation statusSurgeon availabilityPatient ageThe most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.OrthoCash 2020A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?Consult the ethics committee before giving blood.Use cell saver blood.Ask the patient’s family for consent to give blood.Use plasma expanders.Give the patient blood.Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open wound is not recommended nor would there likely be enough from an open pelvic fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.OrthoCash 2020Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, andtalectomy.reimplantation of the talus.reimplantation of the talus with acute triple arthrodesis.Syme amputation.transtibial amputation.The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.OrthoCash 2020Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?SpiralObliqueTransverseSegmentalComminutedA pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism.OrthoCash 2020A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?Kocher-LangenbeckIliofemoralIlioinguinalExtended iliofemoralTriradiate approachThe fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiateapproaches although useful for this fracture, have a higher rate of complications.OrthoCash 2020An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includesplating of the radial shaft fracture then open repair of the triangular fibrocartilage complex.open reduction and internal fixation of the radius and ulna.plating of the radius then closed reduction and evaluation of the distal radioulnar joint (DRUJ).closed reduction of the radius and DRUJ.plating of the radius then pinning of the DRUJ in pronation.This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.OrthoCash 2020A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?Chronic osteomyelitisPlanovalgus hindfootPlantar nerve entrapmentWound dehiscencePainful hardwareThe patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.OrthoCash 2020Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?A primed immune system with an increased risk of a systemic inflammatory responseNothing since they are no longer in uncompensated shock and their vital signs have normalizedHigher nonunion rates after fracture fixationHigher infection rates after definitive fracture fixationHigher complication rates after temporizing external fixation of long bone fracturesPatients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a “primed” immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered.OrthoCash 2020A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination isintact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?Emergent four compartment fasciotomiesEmergent four compartment fasciotomies and open reduction and internal fixation of the fractureElevation of the limb overnight and four compartment fasciotomies in the morningElevation of the limb overnight and a recheck of compartment pressures in the morningEmergent MRI of the knee and legCorrent answer: 2The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.OrthoCash 2020Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?The mean arterial blood pressure is above 90 mm Hg.The pulse pressure has normalized.Urine output is greater than 0.5 to 1 mL/kg/h.Oxygen delivery has been maximized.Aerobic metabolism has been restored in all tissue beds.Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.OrthoCash 2020A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?InfectionMalunionLoss of forearm rotationRefractureDelayed union/nonunionHealing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.OrthoCash 2020The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?Anterior superior iliac spineSciatic buttressA column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)The most superior portion of the roof of the acetabulumIliopectineal lineThe teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.OrthoCash 2020A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure

Severely displaced acromioclavicular injuries disrupt the deltotrapezial fascia and muscular origin in addition to the ligaments (acromioclavicular and coracoclavicular or trapezoid and conoid). When the deltoid is still attached to the clavicle, an isometric shoulder shrug will tend to reduce the displacement. When the deltoid is detached but the trapezius is attached, this maneuver will increase the deformity and surgery may be indicated.

The patient has a projected limb-length discrepancy of 7 cm. This includes the 4 cm she already has, plus 3 cm expected growth of the uninvolved distal femur during the 3 years of growth she has remaining. She also has moderate limb deformity. Femoral lengthening is considered the treatment of choice because it can address both the limb-length discrepancy and the deformity. Epiphyseodesis will not result in limb-length equality at maturity, with only approximately 1.8 cm of equalization expected from this procedure. Use of closed femoral shortening of 7 cm runs the risk of weakening the quadriceps on the normal side and will leave the patient with a remaining residual valgus deformity. Tibial lengthening will leave the knees at different levels. A shoe lift can be prescribed as a temporary measure but is not a good long-term solution.

Surgical treatment is favored for young, active patients with displaced proximal humerus fractures. Nonsurgical treatment is favored to treat fractures with minimal displacement among low-demand elderly patients. When ORIF is used, a number of strategies are employed to prevent failure, including restoration of medial cortical support (medial calcar), incorporation of the rotator cuff into the construct, and placement of screws of adequate length to gain purchase in the subchondral bone of the humeral head. Intramedullary allograft is not routinely required but is useful when dealing with osteoporotic bone. Cancellous allograft has not been shown to prevent failure. Varus collapse and failure of fixation are more prevalent in patients with osteoporotic bone, and, in these cases, strategies for supplemental fixation are advisable. In cases of severe osteoporosis, comminution, or poor bone quality, shoulder arthroplasty may be a better choice. Without a functioning rotator cuff, as would happen with a tuberosity nonunion, outcomes after shoulder hemiarthroplasty and TSA are poor.

Wound closure is one of the most critical factors in ensuring a functional result following a crush injury. Skin coverage reduces edema, protein lead, and risk for infection, and minimizes healing with fibrosis and subsequent loss of joint motion. Wound closure should be performed as soon as all nonviable tissue has been debrided. Split-thickness skin grafts, however, do not provide optimal coverage over exposed tendons, bones, or joint spaces. In a study presented in The Journal of Trauma, once the wounds became covered by granulation tissue, split-thickness skin grafts were placed as an initial measure to provide a further barrier to infection and protein leak. The patients showed good functional results despite not utilizing flap coverage for their extensive injuries.

DISCUSSION: The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize at least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur. REFERENCES: Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures: A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654. Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733. Beaty JH: Operative treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 2005;434:114-122.

DISCUSSION: Though no gold standard exists, a reduction of concordant pain by at least 75 to 80% following an intra-articular, image-guided anesthetic injection is considered to be the most reliable method of identifying the SI joint as the cause of a patient's pain. Although provocation tests including the Gaenslen test, the compression test, thigh thrust, and Yeoman test are commonly used and can be helpful in diagnosing non-specific SI joint pain, individually they are not as reliable as the response to a diagnostic, anesthetic injection. Of note, the combination of all 4 maneuvers has proven to be more useful than any one individual test. An MRI of the SI joint showing bony erosion and bone marrow edema suggests inflammatory arthritis and may not necessarily be associated with pain.

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.

DISCUSSION: The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.

The patient is a thin man with an isolated left humerus fracture. The fracture has bony apposition and should be amenable to closed treatment; therefore the most appropriate treatment is coaptation splinting with conversion to a fracture brace. A hanging arm cast is not recommended for a transverse fracture because of the propensity to distract the fragments, especially if left in place for a long period of time. A shoulder immobilizer is not an appropriate treatment for a humeral shaft fracture. A transverse fracture line is sometimes considered a relative indication for surgical treatment if the fragments are distracted, but in this patient, immediate surgical fixation is not warranted in the absence of other indications for surgical treatment.