2. Trauma MCQs

The patient’s chronic symptoms are associated with a fracture of the base of the hook of the hamate; therefore, the treatment of choice is simple excision of the fracture fragment, with reasonable expectations of functional return. Acute fractures may be difficult to treat because of the high incidence of nonunion, but once nonunion is discovered, nonsurgical management usually is unsuccessful. Bone grafting may be a surgical alternative, but successful outcomes with percutaneous fixation or trephination of the fibrous union have not been reported.

The most frequent complication is posttraumatic arthritis. With talar neck fractures, osteonecrosis is relatively common, occurring in up to 50% of patients. Fracture nonunion occurs in 10% to 12% of patients. Varus malunion can occur with medial comminution. Wound dehiscence and deep infection are much less frequently encountered.(SBQ12TR.14) Elevated interleukin 6 (IL-6) is most closely associated to which of the following clinical outcomes in orthopedic trauma patients?Decreased mortality ratesIncreased mortality ratesDecreased osteomyelitis infection ratesIncreased rhabdomyolysis ratesIncreased compartmental syndrome ratesElevated levels of Interleukin 6 (IL-6) is most closely associated with higher injury severity scores and increased mortality rates in polytrauma orthopaedic patients.Hyperstimulation of the inflammatory system by major trauma is considered to be the key element in the pathogenesis of severe inflammatory response syndrome and multi-organ dysfunction syndrome. IL-6 is a complex acute-reactant cytokinase that is expressed by cells in response to tissue injury. IL-6 levels are associated with injury severity, complications, and mortality. Patients with the most severe injuries have the highest IL-6 serum levels.Sears et al. reviewed the markers of inflammation in major trauma. They suggest that interleukin-6 and human leukocyte antigen-DR class II molecules appear to have the greatest potential for use in predicting the clinical course and outcome in trauma patients. Early identification of traumatic patients, based on inflammatory markers and genomic predisposition, could help to guide intervention and treatment.Pape et al measured the perioperative concentrations of interleukin-6 in sixty-eight blunt trauma patients with non-life threatening pelvic fractures. Release of proinflammatory cytokines were higher in patients undergoing surgical procedures that cause increased blood loss. The release of markers seems to be related to the type and magnitude of surgery, rather than to the duration of the procedure.Illustration A shows a diagram of the acute inflammatory response after major trauma Incorrect Answers:

DISCUSSION: Sagittal malalignment is commonly seen after nailing proximal tibia fractures. The start point as well as the direction of the nail can lead to sagittal deformity. Lang found that a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. It is logical that a fracture that is reamed and then nailed in the posterior direction will lead to a gap anteriorly, and that posterior comminution will lead to anterior angulation as the fracture hinges on the intact cortex anteriorly. An anterior starting hole will tend to lead to more of a posterior nail direction. Tornetta found that using only 15 degrees knee flexion (semi-extended) eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site; therefore, interlocking in flexion leads to anterior angulation. Krettek found that a posteriorly placed blocking screw is meant to prevent posterior placement of the nail and therefore encourages decreased anterior angulation of the fracture.

DISCUSSION: This patient has a comminuted distal femur fracture. A fixed-angle device such as a locking plate is preferred to confer angular stability to the construct and prevent varus collapse. The strategy to promote union of the fracture is to provide a low-strain environment to allow bone healing. Strain is determined by the amount of motion over the length of a fracture. In the case of a noncomminuted fracture, the fracture surfaces can be compressed and rigid fixation applied to abolish strain and promote primary bone healing without callus. In the case of a comminuted fracture, the preferred fixation strategy focuses on distributing motion along the length of the fracture to provide a low-strain environment that will promote secondary bone healing and callus formation.

Early stabilization of femur fractures in patients with concomitant head injuries has been found to have no increased risk of worsening neurologic outcomes. Recent data suggests that intramedullary nails done acutely leads to decreased pulmonary complications, decreased thromboembolic events, improved rehabilitation, decreased length of stay, and cost of hospitalization.

The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization.

Discussion: Three cases of anterior distal femoral cortex penetration during intramedullary nailing for subtrochanteric fractures were documented by Ostrum and Levy in a 2005 study. It appears that the difference in femoral anteroposterior bow between the bone and the implant is a contributing factor to distal femoral anterior cortex penetration in intramedullary nailing of subtrochanteric fractures. There is no evidence of osteoarthrosis on the radiographs. Although nonunion is possible, based on the radiographic findings it is more likely that this patient's pain is attributable to the curvature of the nail. The lateral image of the hip reveals an appropriate starting point for the device.

Humeral shaft fractures in infants and young children heal rapidly and have excellent remodeling potential. Appropriate treatment in this age group is immobilization with a coaptation splint and bandaging the arm to the thorax for comfort. Internal fixation is appropriate in multiple trauma, and external fixation may be useful when soft-tissue injury is extensive.

External fixation is a temporizing treatment that allows the soft tissues to return to normal while maintaining your overall alignment. A fibular plate can help keep the length. Final treatment involves restoration of the tibial plafond articular surface which can only be done with ORIF +/- bone grafting. There is no role for primary arthrodesis in this young patient.OrthoCash 2020

An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. Trauma CT scans should be reviewed for non-displaced or minimally displaced femoral neck fractures during the initial workup. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization are associated with the fewest complications. Due to the potentially devastating complications of the femoral neck fracture in young patients (avascular necrosis, nonunion, and malunion), the neck fracture should be treated first, followed by the shaft. Current recommendations involve treating the neck with a sliding hip screw or cannulated screws, followed by intramedullary nailing of the femoral shaft.

Avascular necrosis (AVN) is more common among physiologically young patients after femoral neck fractures. The higher energy of injury is a likely contributor. Closed reduction has not been shown to increase the risk for AVN when an anatomic reduction is obtained. A surgical delay of 24 hours does not cause AVN. Patients with associated femoral shaft fractures are not at increased risk for AVN; in fact, some studies have shown a relatively lower rate of AVN when a femoral neck fracture is associated with a femoral shaft fracture.

This patient has Mason II radial head fracture. ORIF will give the best results.Non-/minimally displaced radial head fractures without a block to rotation can be managed nonoperatively. Complete articular fractures with >=3 fragments do better with radial head replacement. Indications for ORIF include large articular surface fragments, > 2 mm of displacement, mechanical block to forearm rotation, or associated fractures or ligament injuries requiring surgery.Pike et al. retrospectively compared patients undergoing ORIF for isolated radial head fractures with radial fractures associated with other fractures/dislocations. They found no differences in pain/disability and complications or secondary capsular release between groups.Yoon et al. retrospectively compared isolated partial articular displaced (2-5mm) radial head fractures treated nonoperatively vs ORIF. They found no clinical benefit with ORIF compared to non-operative management. The ORIF group had more complications. Younger patient age and larger fracture displacement favored operative intervention. Younger patients fared worse.Figures A and B are radiographs and 3D reformatted CT images showing a displaced partial articular radial head fracture.Incorrect Answers:>= 3 fragments.

The soft-tissue defect is in a difficult position—the distal tibia. The defect is too distal for a gastrocnemius flap, and the exposed bone precludes an immediate skin graft. Vacuum-assisted closure (VAC) is very effective in soft-tissue defects such as this one. Healthy granulation tissues form quickly. VAC can be the definitive treatment, or it can be used before skin grafting. Wet-to-dry dressings could promote granulation, but the process is hastened substantially by VAC.

Regardless of the social situation, the orthopaedic surgeon's primary role is to proceed and offer expeditious and appropriate care for the patient's injuries. The statement put forth by the AAOS implores the orthopaedic surgeon to be aware of the integral components to identify, document, and care for minors, elders, and/or partners who are victims of domestic abuse. Care should not be delayed while waiting for a social situation to be evaluated.

DISCUSSION: Although intramedullary nails or plates with screws, either of which may be combined with cement, may be used as internal fixation for a displaced humeral diaphyseal pathologic fracture, torsional performance is best biomechanically when the canal is filled with cement and fixed with a plate. In the largest comparative biomechanical study to date, 40 artificial humeri were divided into 5 different constructs and tested in torsion. The construct that resisted the largest load to failure was the construct at which the canal and tumor defect were filled with bone cement and the screws were inserted into dry cement. That being said, the weaknesses of the plate and cement technique include the potential for poor quality bone adjacent to and extending away from the fracture site and difficulty in protecting the entire bone from progression of local disease. Numerous factors beyond just the biomechanics, including the patient’s disease load and comorbidities, the underlying primary disease and responsiveness to radiotherapy and other adjuvant treatments, and the location and local extent of disease, must be considered when determining the best operative technique to employ in each patient with a pathologic fracture.

Following any closed fracture, the most important determinant for the timing of surgery is the condition of the soft tissues and especially the skin. The best determinant of appropriate soft-tissue condition is the presence of wrinkling of the skin (wrinkle sign) at the site of the incision. A wrinkle sign is present when all the interstitial edema has left the skin; this may take up to 14 to 21 days of elevation. Any abrasion must be epithelialized so that there are no bacteria left at the site. To date, no other method of soft-tissue viability measurement has been shown to be of any clinical benefit.

Most textbooks and early publications list the incidence of complications of nonsurgical treatment of clavicle fractures as very low. However, recent studies on this topic have found an entirely different picture. The studies show that patients reported shoulder weakness and fatigability, upper extremity dysesthesia, and shoulder asymmetry with an incidence of 31%. Indications for surgery in the past have included open fractures, associated neurovascular injury, and widely displaced fractures tenting the skin. Fractures with more than 2 cm of shortening and comminuted fractures with significant displacement have been associated with poor outcomes. Nonunion after nonsurgical management was found to be more common in the study by Robinson and associates in displaced comminuted fractures, in patients with advanced age and female gender.

The patient has an acute peroneal tendon dislocation. The evaluation for syndesmotic injury and lateral ankle instability is negative. The cortical avulsion off the distal tip of the lateral malleolus, a rim fracture, is characteristic of peroneal tendon dislocations. The sensation of apprehension or frank subluxation of the peroneal tendons with active dorsiflexion of the foot while the foot is held in plantar flexion confirms the diagnosis. Based on these findings, initial management should consist of cast immobilization and protected weight bearing. If a recurrent or chronic condition develops, surgery is the most reliable treatment option.

DISCUSSION: The figures show an open tibial fracture, a femoral shaft fracture, and femoral head dislocation. The most urgent treatment is reduction of the femoral head, as timing to reduction has been correlated with preventing osteonecrosis. After reduction of the femoral head, the next priority is wound management, followed by stabilization of the femoral and tibial fractures with either splinting, traction, or external fixation. REFERENCES: Sahin V, Karakas ES, Aksu S, et al: Traumatic dislocation and fracture-dislocation of the hip: A long-term follow-up study. J Trauma 2003;54:520-529. Moed BR, Willson-Carr SE, Watson JT: Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am 2002;84:752-758.

Figures 1 and 2 are the radiographs of a 17-year-old boy who injured his wrist 6 months ago. He is experiencing pain and limited motion. What is the most effective treatment option?