2. Trauma MCQs

DISCUSSION: In a report of more than 70 hips treated by surgical dislocation, iatrogenic osteonecrosis failed to develop in any of the hips. REFERENCE: Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U: Surgical dislocation of the adult hip: A technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119-1124.

The Mason classification differentiates the degree of displacement, angulation, and mechanical block to motion. Most nondisplaced radial head fractures (Mason I) in which there is no block to motion can be treated nonsurgically. Mason type III injuries are severely comminuted radial head fractures. Fragment excision can be considered in unreconstructable fractures in which the interosseous membrane is intact. However, if the interosseous membrane has been disrupted, fragment excision can lead to proximal migration of the radius with associated wrist problems. In this case, radial head arthroplasty is indicated. Radial head arthroplasty may also be required when the radial head fracture is associated with other ligamentous injuries as seen following an elbow dislocation, or with an associated unstable coronoid fracture.

DISCUSSION: The major criteria for the diagnosis of fat embolism syndrome include hypoxemia (PaO2 of less than 60 mm Hg), central nervous system depression, and a petechial rash that is most often located in the axillae, conjunctivae, and palate. The rash is often transient. Tachycardia, pyrexia, anemia, thrombocytopenia, and the presence of fat in the urine are all considered minor criteria. To establish the diagnosis of fat embolism syndrome, one major and four minor signs should be present. Pulmonary embolism, which is the major differential diagnosis, usually is not associated with conjunctival petechia or thrombocytopenia. REFERENCE: Buckwalter JA, Einhorn TA, Simon SR (eds): Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System, ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000, pp 308-316.

OrthoCash 2020A 26-year-old male sustains a fall from a ladder onto his outstretched right hand. He is evaluated in the emergency room and is found to have a closed injury to his elbow without evidence of neurovascular compromise. Plain radiographs are obtained and are shown in Figures A and B. During surgery a sequential approach is used to treat each element of this injury. Which part of the procedure is felt to add the most to rotatory stability?Radial head replacementRadial head ORIFCapsular plicationLateral collateral ligament complex repair or reconstructionMedial collateral ligament complex reconstructionCorrent answer: 4The essential lesion that results in the most instability in a terrible triad injury of the elbow is rupture of the lateral collateral ligament. Repair of this lesionresults in the greatest increase in elbow rotatory stability.The key components of a terrible triad injury are a radial head fracture, coronoid fracture, dislocation of the ulnohumeral joint and disruption of the lateral collateral ligament complex. While restoration of the bony anatomy is important for static stability, the key primary stabilizer that needs to be addressed is the lateral collateral ligament complex. In acute injuries LCL repair may be possible. In chronic injury, LCL reconstruction would need to be considered.Forthman et al. reviewed 34 patients with an elbow dislocation, 22 of 34 of which were terrible triad injuries. Open reduction internal fixation or radial head replacement (as appropriate) along with LCL repair was completed; the MCL was not surgically addressed. Seventeen of 22 had good or excellent results, indicating that MCL repair is not necessary.Pugh et al. discuss their surgical protocol for addressing terrible triad injuries with 28/36 of their patients obtaining good or excellent results. Their inside out protocol is described as follows: 1) coronoid fracture ORIF (capsular repair), 2) radial head fracture ORIF or replacement 3) LCL complex repair (isometric point is center of capitellum), 4) reevaluation of stability; MCL repair or hinged fixator applicationJensen et.al in cadaveric studies have demonstrated that radial head replacement alone decreases varus laxity and external rotatory laxity to 14.6 &

DISCUSSION: Despite the negative radiographic findings, the child’s age and presentation are most consistent with a toddler’s fracture. There is often not a witnessed injury. The differential diagnosis of infection is unlikely given that the child is afebrile and shows no signs of illness. Immobilization will make the child more comfortable and will often allow weight bearing. Repeat radiographs at the end of treatment will show a healing fracture and confirm the diagnosis. Aspiration of the tibial metaphysis would be indicated to obtain material for culture. The bone scan and MRI would show abnormalities, but these studies are nonspecific, costly, and time-consuming. Occasionally, oblique radiographs will show the fracture. REFERENCES: Halsey MF, Finzel KC, Carrion WV, Haralabatos SS, et al: Toddler’s fracture: Presumptive diagnosis and treatment. J Pediatr Orthop 2001;21:152-156. Oudjihane K, Newman B, Oh KS, et al: Occult fractures in preschool children. Trauma 1988;28:858-860.

The radiographs show an ulnar shaft fracture with a radial head dislocation (Monteggia fracture). The ulnar shaft fracture requires reduction, either closed or open. Once the ulnar fracture has been reduced, usually the radiocapitallar joint will relocate with closed manipulation. In patients for whom the radiocapitallar joint does not relocate after ulnar reduction, or in patients with missed Monteggia injury, reduction of the radiocapitellar joint usually requires opening of the elbow capsule and reconstruction of the annular ligament.

DISCUSSION: The CT scan reveals a completely displaced physeal fracture of the medial clavicle with marked posterior displacement of the distal fragment. This fracture pattern is associated with potential injury to the vascular structures of the mediastinum. Reduction should be performed for this fracture and generally can be done closed with shoulder retraction and upward pull on the clavicle with a towel clip. Once reduced, the fracture is relatively stable and typically will heal in good position. Reduction should be performed in the operating room in the event that a vascular injury is detected once compression is removed from the clavicle. Open reduction may be necessary if closed reduction is not possible; however, pinning or ligament reconstruction usually is not necessary. REFERENCES: Rockwood CA, Matsen FA (eds): The Shoulder, ed 2. Philadelphia, PA, WB Saunders, 1998, p 581. Wirth MA, Rockwood CA Jr: Acute and chronic traumatic injuries of the sternoclavicular joint. J Am Acad Orthop Surg 1996;4:268-278.

Locking screw fixation is a relatively new option in the armamentarium of orthopaedic surgeons treating fractures. The understanding of the biomechanics, implications to healing, and optimal indications and surgical techniques is still in evolution. A periprosthetic proximal femur fracture with a stable prosthesis is best treated with open reduction and internal fixation with locking proximal fixation with or without cerclage cables. Diaphyseal fractures treated with compression plating or bridge plating can be treated well with conventional implants unless osteoporosis is severe. An AO/OTA B-type partial articular fracture is also better suited to standard buttress plating with periarticular rafting lag screws. Locking fixation is not always required for a transverse displaced midshaft clavicle fracture.

DISCUSSION: The 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. REFERENCE: Lansinger O, Bergman B, Korner L, et al: Tibial condylar fractures: A twenty-year follow-up. J Bone Joint Surg Am 1986;68:13-19.

Using a systematic approach to review the radiograph, the fracture of the left proximal humerus is readily recognized. Linear air soft-tissue density at the lung periphery would suggest a pneumothorax, but this finding is not shown on the radiograph. The upper thoracic spine is well aligned. The sternoclavicular and distal clavicles are normal.

An anatomical study demonstrated that in 97% of clavicles, 2 to 3 branches of the supraclavicular nerve were crossing the clavicle with wide location variability in the zone in which most clavicle fractures occur and surgery would take place. The subclavian vein and artery and brachial plexus are rarely injured, although there are case reports of injury to all, either by the displaced fracture fragments or errant hardware.

According to the published outcomes analyses from the Lower Extremity Assessment Project (LEAP) study group, definitive fixation with an intramedullary nail has shown improved outcomes when compared to definitive external fixation. The LEAP study has shown at 7-year follow-up that patients who are definitively treated with external fixation have a significantly longer time to union, poorer functional outcomes, longer time to achieve full weight bearing, and more time in the hospital.

In a retrospective study based on 21 patellar fractures, non-operative treatment was selected in 12 of the cases with only one unsatisfactory result. Patellar fractures are classified as nondisplaced or displaced (greater than 2mm), with or without displacement of the polyethylene component from the bone bed, and with or without loss of the integrity of the extensor mechanism. In the cases of displaced fractures it appears that these patients do well with nonoperative therapy. Nonoperative treatment was uniformly satisfactory with no adverse effect noted on extensor lag, quadriceps strength, or knee score. The initial treatment of a nondisplaced patellar fracture after total knee arthroplasty should always be nonoperative regardless of physical findings.

OrthoCash 2020A 36-year-old woman presents with a grade 3 open midshaft femoral shaft fracture as the result of a high-speed motor vehicle collision. Concomitant injuries include a high-grade splenic laceration requiring splenectomy as well as a subdural hematoma that requires monitoring and maintenance of cerebral perfusion pressure. After irrigation and debridement of the open fracture, which of the following is the most appropriate management of the femoral shaft fracture at this time?Placement of antibiotic beads, wound closure and immobilizationReamed antegrade intramedullary nailingUnreamed antegrade intramedullary nailingWound closure and Hare traction splint placementPlacement of an external fixatorCorrent answer: 5The clinical scenario is consistent with a femoral shaft fracture in a patient that is not stable from a neurosurgical perspective. Therefore, the most appropriate treatment at this time is placement of an external fixator.When evaluating polytrauma patients with long bone fractures, timing of surgery must be approached considering all clinical conditions. One factor most likely to adversely affect long term outcome in polytrauma patients with severe brain injury is intra-operative hypotension; therefore, whenever a patient has a subdural hematoma that requires close observation, definitive surgery of long bone fractures should be delayed.Flierl et al. review the immunopathophysiology of traumatic brain injury and the role of the orthopaedic surgeon in avoiding a "second hit" injury to the brain by appropriately timing the fixation of femoral shaft fractures. They recommend a multidisciplinary approach, taking individual patient-specific factors into consideration and in general, DCO principles for severe head-injured patients (GCS 3-13) and "early total care" principles for patients with mild head injury (GCS 14-15).Illustration A is a visual representation of the treatment algorithm recommended in the article.Incorrect Answers:OrthoCash 2020A 23-year-old healthy male was involved in a motor vehicle collision and sustained the injury seen in Figure A. Physical examination after ORIF of the plateau fracture revealed a Grade 3 Lachman, varus laxity at both 0 and 30 degrees of knee flexion, and 15 degrees of external rotation asymmetry at 30 degrees of knee flexion. Which of the following structures (indicated with asterisk*) must be surgically repaired to restore stability to the knee?This patient sustained a high-energy injury to the left knee, including a tibial plateau fracture as well as both anterior cruciate ligament (ACL) and posterolateral corner (PLC) injuries as indicated on the physical examination findings. In addition to ORIF of the plateau fracture, the surgical plan should include ACL reconstruction as well as posterolateral corner (PLC) reconstruction, specifically with lateral meniscal repair and allograft reconstruction of the lateral collateral ligament (LCL,asterisk in Figure C) and popliteofibular ligaments.The PLC consists of static (LCL, popliteus tendon, popliteofibular ligament, lateral capsule) and dynamic (biceps femoris, popliteus muscle, IT band, lateral head of the gastrocnemius) structures. Failure to identify a PLC injury associated with an ACL injury often leads to failure of ACL repair.Stannard et al. reported on the clinical outcomes of 22 patients with PLC injuries (7 isolated) who underwent modified 2-tailed reconstruction of the popliteofibular ligament and LCL utilizing transtibial and transfibular bone tunnels. At an average 29.5 months post-operatively, the authors noted excellent results with restoration of range of motion and stability in both the isolated and multiligamentous injured groups.Stannard et al. reported on a separate cohort of 56 patients with PLC injuries either undergoing direct repair or modified 2-tailed reconstruction. The authors noted significantly inferior results in the repair group (37% failures) compared to the reconstruction group (9%) failures, and concluded that reconstruction is the procedure of choice for the majority of patients who sustain high-energy PLC injuries.Levy et al. reported on 28 patients with multiligament knee injuries undergoing either direct PLC repair with staged cruciate ligament reconstruction or delayed single-stage multiligament reconstruction. The authors noted a significantly higher rate of failure in the repair/staged group compared to the delayed reconstruction group, and deemed reconstruction to be a more reliable option than repair alone in the multiligamentously injured knee.Figure A includes AP and lateral radiographs of the left tibia demonstrating acomminuted lateral tibia plateau fracture. Figure C demonstrates a gross dissection of the posterolateral corner (left knee), with the asterisk on the lateral collateral ligament (LCL)Incorrect answers:OrthoCash 2020A 25-year-old, training for a marathon, presents with persistent heel pain over the past several weeks. He has difficulty with ambulation and has an antalgic gait. A squeeze test of the heel is positive. A lateral foot radiograph is shown Figure A. Of the options listed below, what is the most appropriate next step in management?EMG/NCV studyHeel pad cortisone injectionPhysical therapy with Graston techniques to plantar fasciaMRI of the footNon-weight bearing cast for 4-6 monthsCorrent answer: 4Based on the clinical findings and imaging shown, one should be suspicious for a calcaneal stress fracture. This can be confirmed by obtaining an MRI.Calcaneal stress fractures are often associated with increases in training intensity. They may be seen in patients with the female athletic triad. An MRI is used to help delineate the diagnosis when it is not clear from the history and physical exam.Neufeld et al. review the diagnosis and management of plantar fasciitis. They note that there are many causes of inferior heel pain, including nerve compression, FHL tendinitis and calcaneal stress fractures. The latter commonly presents with diffuse swelling and pain with medial to lateral compression of the heel.Figure A shows a lateral radiograph of the foot with no obvious osseous abnormality of the calcaneus.Illustration A shows a T1 weighted sagittal reconstruction of an MRI that is demonstrative of a dark line; this is consistent with a stress fracture.Incorrect AnswersOrthoCash 2020A 28 year-old-male presents with the injury pattern seen in Figure A. Which of the following is a risk factor for wound complications following operative treatment?Open injuryWorkers' Compensation involvementAdjunct use of allograftContralateral calcaneus fractureMale sexAccording to the referenced study by Folk et al, the risk of early wound complications is highest in open injuries, diabetics, and smokers.No significant differences were seen in complication rates in terms of: age, sex, other pre-existing medical conditions, social history, mechanism of injury, time from injury to surgical stabilization, the type of incision used, use of preoperative antibiotics, or type of wound closure.Notably, 25% of the patients had some sort of early wound complication, and 21% of the patients required surgical treatment due to their wound complication.Their conclusion: "Smoking, diabetes, and open fractures all increase the risk of wound complication after surgical stabilization of calcaneus fractures.Cumulative risk factors increase the likelihood of wound complications."OrthoCash 2020A 86-year-old man slips on the ice and falls sustaining the injury shown in Figure A. He has Type 2 diabetes mellitus, atrial fibrillation, coronary artery disease, end-stage renal disease on dialysis and chronic obstructive lung disease. All of the following variables are associated with increased mortality at one year after injury EXCEPT?Intertrochanteric fractureTwo or more pre-existing medical conditionsAge of eighty-five years or moreMale genderOperative fixation within 48 hoursOperative fixation within 48 hours is not associated with increased mortality. However, operative delay of 3 or more days results in increased mortality.Medical optimization and surgery for hip fractures in elderly patients should be performed as soon as possible following admission to hospital. Surgical intervention in elderly hip fracture patients reduces morbidity and mortality.Postoperatively, weightbearing as tolerated decreases the risk for poor outcomes and decreases complications e.g. muscle atrophy, pressure sores, pneumonia, urinary retention.Zuckerman et al. reviewed mortality associated with operative delay in older patients with hip fractures. They found that operative delay of 3 or more calendar days results in greater 1-year mortality. Other predictors of mortality include age >85yrs, male sex, presence of 2 or more pre-existing medical conditions, ASA grade III or IV, and inter-trochanteric fracture.Switzer et al. reviewed perioperative considerations in the geriatric patient. They showed that hip fracture repair after 2 days results in decrease in independent living, pressure sores and longer hospital stay. They found with early surgery, pain, length of hospital stay and 1-month mortality was reduced.Figure A shows unstable intertrochanteric fracture. Incorrect Answers:mortality.OrthoCash 2020Which of the following processes relies on an exopolysaccharide glycocalyx?Osteoclast differentiationBiofilm creationMetastatic bone diseaseEndochondral bone formationIntramembranous bone formationCorrent answer: 2Exopolysaccharide glycocalyx allows bacteria to adhere to orthopaedic implants and elude antimicrobial therapies through the creation of biofilms.Biofilms are defined as a structured community of bacterial cells enclosed in a self-produced polymeric matrix and adherent to an inert or living surface.Biofilm production usually occurs within 4 weeks, and is extraordinarily hard to eradicate with antibiotic therapy alone. In the setting of a chronic infection of an orthopaedic implant (>4 weeks), explantation of the implant followed by antimicrobial therapy is the most reliable method of curing the infection.Nguyen et al. reviewed 21 patients who underwent revision arthroplasty with negative intraoperative cultures. After standard cultures were obtained (all negative), the implants underwent an ultrasound protocol to theoretically disrupt the biofilm. 1 of the 21 implants grew coag-negative Staph after the bath.Fux et al. reviewed biofilms with respect to orthopaedic and non-orthopaedic conditions. They discussed how aspirations are often falsely negative possibly because the microorganisms persist only within a biofilm on the synovia but not in planktonic form.Illustration A and the video provided show the process of biofilm formation. Incorrect Answers:pathway.OrthoCash 2020A ballistics expert examines the effects of bullets on tissues. He defines a "penetrating missile" as one that delivers an entrance wound but no exit wound, and a "perforating missile" as one that possesses both entrance and exit wounds. He also defines bullet "yaw" as the tumble of a bullet or its tendency to turn sideways in flight. A diagram of bullet yaw is seen in Figure A. Which of the following scenarios leads to the greatest transfer of kinetic energy to tissues?Penetrating missile with mass "2m", velocity "v", yaw of 90 degrees at the point of impactPerforating missile with mass "m", velocity "2v", yaw of 0 degrees at the point of impactPenetrating missile with mass "m", velocity "2v", yaw of 90 degrees at the point of impactPerforating missile with mass "m", velocity "2v", yaw of 90 degrees at the point of impactPenetrating missile with mass "2m", velocity "v", yaw of 0 degrees at the point of impactA penetrating (but not perforating) missile with highest velocity (2v) and largest yaw (90 degrees, or sideways travel) leads to greatest transfer ofkinetic energy.The kinetic energy (E) of a bullet is proportional to its mass (m), and velocity(v) squared. A bullet of mass m traveling at 2v will have greater E than one of mass 2m traveling at v. Maximum energy transfer is achieved with yaw of 90 degrees (sideways). Yaw is decreased with longer distances of bullet travel, allowing a bullet to strike its target nose-on. Penetrating (non-exiting) missiles deliver all their contained kinetic energy, while perforating (exiting) missiles transfer significantly less energy to tissuesBartlett et al. reviewed ballistics and gunshot injuries. They state that energy transfer depends on 6 factors including: (1) amount of kinetic energy at impact, (2) stability and entrance profile (yaw), (3) caliber, construction and configuration of the bullet, (4) distance and path traveled within the body (penetrating vs perforating), (5) biological characteristics of tissues impacted, and (6) mechanism of tissue disruption (stretching, tearing, crushing).Figure A illustrates the concept of bullet yaw. Illustration A shows blocks of gelatin perforated by similar caliber missiles at different velocities (A, 1,000fps; B, 2,800 fps), with arrows indicating missile tracks.Incorrect Answers:OrthoCash 2020A 35-year-old man is thrown from his vehicle and sustains a left proximal femoral shaft fracture and right distal femoral shaft fracture. The surgeon elects to treat both fractures with reamed intramedullary nailing. Which of the following is true regarding the risk of malrotation?The left femur (proximal fracture) is at increased risk of internal malrotation and the right femur (distal fracture) is at increased risk of external malrotation.The left femur (proximal fracture) is at increased risk of external malrotation and the right femur (distal fracture) is at increased risk of internal malrotation.Malrotation does not depend on fracture location, but whether the nail is placed antegrade or retrograde.Both femora are at increased risk of internal malrotation.Malrotation does not depend on fracture location, but whether the nail uses a piriformis entry point or a trochanteric entry point.In proximal femoral fractures, the distal fragment (femoral shaft) will be relatively internally rotated. In distal femoral fractures, the distal fragment will be relatively externally rotated.The direction of femoral malrotation depends on the pull of attached muscles. In PROXIMAL fractures, the proximal fragment is externally rotated by the iliopsoas, short external rotators and abductors. This leads to relative internal rotation of the distal fragment (femoral shaft), leading to INTERNAL malrotation. In DISTAL fractures, the proximal fragment (femoral shaft) is pulled medially by the adductors, while the distal fragment is pulled into external rotation by the lateral gastrocnemius and plantaris, leading to EXTERNAL malrotation.Lindsey et al. reviewed malrotation following femoral shaft nailing and found that malrotation was present in up to 27.6% of all femoral shaft fractures managed this way. Risk was highest with pure transverse fractures (OTA 32-A3), and Winquist III and IV fractures (OTA 32-C). Using a fracture table increases risk of internal malrotation, and supine positioning with a bump (without fracture table) increases risk of external malrotation.Ricci et al. reviewed nailing of femoral shaft fractures. They recommend the following to obtain correct rotation: (1) using alignment of the anterior superior iliac spine, patella and second toe, (2) fluoroscopic evaluation of cortical widths, key fragments or femoral anteversion, (3) checking both legs for symmetry before leaving the operating room. They also state that "The direction of femoral malrotation is based on which attached muscles areinvolved. For example, proximal femur fractures tend toward net internal rotation of the femoral shaft secondary to the pull of the iliopsoas muscle, short external rotators, and glutei on the proximal femur. The relative external rotation of the proximal femur results in internal rotation of the distal segment. Conversely, external malrotation can occur in distal femoral fractures secondary to the pull of the adductor muscles on the proximal fragment and the pull of the plantaris and lateral gastrocnemius muscles on the distal fragment."Illustration A shows how muscle attachments affect fracture deformity and predispose to malrotation.Incorrect AnswersOrthoCash 2020A 30-year-old man is brought to your level 1 trauma center with a closed left diaphyseal humerus fracture, a closed left midshaft femur fracture, right sided rib fractures, and multiple facial fractures following a motorcycle accident. He is neurovascularly intact in his left arm and leg. Figure A shows a radiograph of his left humerus. What would be the most appropriate definitive treatment?Non-operative management of the humerus and plating of the femurPlating of the humerus and intramedullary nailing of the femurNon-operative management of the humerus and intramedullary nailing of the femurPlating of both the humerus and femurIntramedullary nailing of the humerus and plating of the femurCorrent answer: 2The clinical scenario involves a polytrauma patient with ipsilateral humerus and femur fractures. The humerus should be plated to facilitate early weight bearing, allowing for mobilization with crutches.Humeral shaft fractures account for 3-5% of all fractures and follow a bimodal distribution. Most humerus fractures can be treated non-operatively with a coaptation splint, followed by functional bracing. However, a strong relative indication for surgical management is a polytrauma patient. Plating of humerus fractures has high union rates and facilitates early weight bearing, which is necessary for rehabilitation with a concomitant lower extremity injury.Bell et al. retrospectively reviewed the outcomes of polytrauma patients treated with plate fixation for humeral shaft fractures. All but one of the fractures united, and patients had excellent function following surgery, allowing early weight-bearing through the injured extremity.Heineman et al. recently updated their systematic review of randomized controlled trials comparing plating with intramedullary nailing for humeral shaft fractures. They conclude that current literature supports a reduction in complication rates when plating humeral shaft fractures compared to intramedullary nailing.Tingstad et al. performed a retrospective study evaluating immediate weightbearing with plated humeral shaft fractures. They demonstrated that ORIF of humeral shaft fractures followed by early weight-bearing was safe and efficacious.Figure A is an AP x-ray of a left humeral shaft fracture. Illustration A shows the diaphyseal humerus fracture from Figure A following ORIF with a plate.Incorrect Answers:OrthoCash 2020Risk of postoperative fixation failure for a complete sacral fracture has been associated with what variable?Anterior pelvic ring fixation methodVertical nature of sacral fractureIliosacral screw lengthNumber of iliosacral screwsAge > 50Illustration A, a coronal CT image, shows a vertical sacral fracture, which creates a vertically unstable pelvic ring. Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.According to the referenced study by Griffin et al, fixation failure of iliosacral screws was significantly associated with vertical sacral fractures and not with any of the other answers listed above. All cases of hardware failure occured within the first 3 weeks; a lesser relationship between hardware failure and sacroiliac joint injury was noted.OrthoCash 2020Which muscle shown in Figure A-E derives its innervation from the posterior cord of the brachial plexus?Figure D shows the subscapularis. It is innervated by the upper and lower subscapular nerves derived from the posterior cord of the brachial plexus.While the subscapularis is innervated by the upper and lower subscapular nerves, it may also be innervated by a middle subscapular nerve. The upper subscapular nerve consistently originates from the posterior cord (C5-C6) and usually innervates the bulk of the muscle, but the lower subscapular nerve often shows variation. The most common variation of the lower subscapular nerve is as a branch of the axillary nerve, yet this has not been shown to place the nerve at greater risk during surgery.Lyons et al. review subscapularis tears, including diagnosis and management. While they recommend repair of acute tears, they state that repair of chronic tears is often impossible and may require tendon or muscle transfers.Kasper et al. dissected 20 cadavers to detail the innervation of the subscapularis muscle. They found a highly variable pattern of innervation, with 25% of cadavers having a lower subscapular nerve arising from the axillary nerve.Illustration A shows a picture of the brachial plexus. Incorrect Answers:musculocutaneous nerve derived from the lateral cord.lateral pectoral nerves derived from the medial and lateral cords, respectively. Answer 3: Image shows the rhomboid major, innervated by the dorsal scapular nerve derived from the C5 nerve root.OrthoCash 2020A 19-year-old male sustains the injury shown in Figure A while skiing. Injury to what structure should be evaluated intraoperatively during fixation of the fibula?Deltoid ligamentSyndesmosisProximal fibulaCalcaneofibular ligamentPosterior tibial tendonCorrent answer: 2According to the referenced study by Jenkinson et al, up to 37% of operatively treated ankle fractures can have undetected syndesmotic instability when examined intraoperatively. This is important due to the negative effects of a displaced mortise and the abnormal loading forces seen on the talus with even a 2mm lateral shift. Also, fibular fractures >4.5cm proximal to the mortise are more likely to be associated with syndesmotic instability, especially when deltoid ligament tears are present. When fixing the syndesmosis, Tornetta et al's referenced study has shown that the syndesmotic compression has no negative effects on ankle range of motion.OrthoCash 2020An 19-year-old male presents to the emergency room following an motor vehicle accident as an unrestrained driver. Examination reveals unilateral jugular vein engorgement. Chest and special viewradiographs are seen in Figures A and B respectively. Following CT scan of the chest, the next step in management isNonsurgical management and follow-up CT scan in 6 weeksClosed reduction in the emergency room under sedationClosed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by immobilization for 4 weeksClosed reduction in the operating room under general anesthesia with thoracic surgery on standby, followed by compression platingOpen reduction in the operating room under general anesthesia, followed by transarticular pinning with K-wiresThis patient has a right posterior sternoclavicular (SC) dislocation. Management involves closed reduction and bracing. Closed reduction should be performed with a thoracic surgeon available in the event of mediastinal involvement.The SC joint can dislocate anteriorly or posteriorly. Posterior dislocations are first treated with closed reduction. If closed reduction fails, open reduction is indicated. Early complications of posterior SC dislocation include pneumothorax, laceration/erosion/occlusion of great vessels, esophageal rupture and brachial plexus compression. Late complications include tracheoesophageal fistula, stridor and dysphagia.Groh et al. reviewed traumatic SC injuries. Reduction maneuvers in posterior SC dislocation include: (1) traction on the arm and slowly bringing it into extension, (2) traction with the arm in adduction and posterior pressure applied to the shoulder, and (3) pulling anteriorly on a towel clip encircling the medial clavicle. Chronic instability after posterior SC dislocations can be managed with figure-of-8 semitendinosus graft or medial clavicle resection and reattachment of the clavicle to the first rib with dacron tape.Glass et al. performed a systematic review on SC dislocations. They found mediastinal compression occurred 30% of the time with posterior dislocations.Figures A and B are radiographs demonstrating asymmetry of the SC joints, characteristic of a right posterior SC dislocation (Figure B is not a serendipity view). Illustration A demonstrates how in POSTERIOR dislocation, the clavicle appears INFERIOR, and in ANTERIOR dislocation, the clavicle appears SUPERIOR on a serendipity view radiograph respectively. Illustration B shows the imaging technique for a serendipity view radiograph. Illustration C is a reconstructed CT image of the patient showing left posterior SC dislocation.Incorrect Answers:OrthoCash 2020Figure A shows an isolated left ankle injury in an active 48-year-old recreational hockey player. Past medical history includes insulin dependent diabetes mellitus for 35 years. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. His pedal pulses are palpable. Of the following options, what would be the recommended treatment?Closed reduction and casting for 6 weeksClosed reduction and casting for 12 weeksOpen reduction and internal fixation with restricted weight bearing for 2 weeksOpen reduction and internal fixation with restricted weight bearing for 6weeksOpen reduction and internal fixation with restricted weight bearing for 12 weeksFigure A shows an unstable, ankle fracture-dislocation in a otherwise healthy 48-year-old diabetic patient. The most appropriate management would be open reduction and internal fixation with an extended period of restricted weight-bearing.Surgical treatment of unstable ankle fractures in diabetic patients is associated with a high complication rates. Diabetic patients are inherently poor healers due to the alterations in their microvascular system. Over-fixation of the fracture and extended immobilization has been shown to reduce wound and bone healing complications associated with diabetes. Surgical techniques typically call for multiple syndesmotic screws, stronger plates (vs 1/3 tubular plates) and prolonged periods of immobilization.Jani et al. retrospectively examined a cohort of 15 patients with diabetes mellitus who sustained unstable ankle fractures. The combination of transarticular fixation (Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins or screws) and prolonged (>12 weeks), protected weightbearing provided 13 of 15 patients with a stable ankle for weight bearing.Wukich et al. compared the complication rates of ankle fracture fixation in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes. They found that patients with complicated diabetes had 3.4 times increased risk of a non-infectious complications (eg. malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis.Figure A shows AP and lat radiographs of SER4 ankle fracture-dislocation. Incorrect Answers:fractures. Again, these need to be treated with an extended period of immobilization.OrthoCash 2020Fixed-angle implants are often used for fixation of distal femur fractures. Three commonly used implants (Implants A, B and C) are shown in Figures A, B and C respectively. Which of the following statements is true reagarding these implants?Implant B is better able to control fractures with a small distal segment than Implants A and C.Implant C is better able to control coronal plane fractures than Implants A and B.During insertion, Implant C results in removal of a larger amount of bone, compared with Implants A and B.Implant A demonstrates less subsidence and greater load to failure compared with Implant C.Implant A demonstrates lower fixation strength in torsional loading compared with Implant CImplant C (locking compression plate, LCP) affords better control of coronal plane fractures than Implant A (95-degree angled blade plate, ABP) and Implant B (dynamic condylar screw, DCS).The LCP allows for better control of coronal plane and multi-fragmented fractures because the multiple locking screws at the distal end secure the plate at multiple points and allow capture of fracture fragments in different planes.Newer polyaxial locking plates have even greater versatility in screw positioning.Vallier et al. reviewed their experience with the ABP and LCP in distal femur fixation. They note that complications and secondary procedures (treatment of infection, nonunion, malunion, prominent implant removal) were more frequent in LCP than ABP patients.Gwathmey et al. reviewed the fixation of distal femoral fractures. They state that the LCP is biomechanically superior to the ABP in cyclic loading and ultimate strength. However, the LCP has less fixation strength in torsional loading.Figure A shows a 95-degree angled blade plate. Figure B shows a dynamic condylar screw. Figure C shows a locking compression plate. Illustration A shows a coronal plane fracture (Hoffa fracture, OTA 33-B3).Incorrect Answers:OrthoCash 2020A 34-year-old man is involved in a motor vehicle accident and sustains an open tibia fracture and is treated with intramedullary nailing. For the next 4 years, he continues to have pain and persistent discharge from a sinus over his shin. He ambulates with crutches and refrains from putting weight on the extremity. The clinical appearance and radiographs are seen in Figures A and B. Wound culture reveals methicillin-resistant Staphylococcus aureus (MRSA). What is the next step in treatment?Retention of tibial nail, lifelong intravenous antibiotic suppressionDebridement and lavage, exchange nailing using a larger diameter nail, intravenous antibiotics for 6 weeks.Debridement and lavage, excision of sinus tract, implant removal, intravenous antibiotics for 6 weeks.Debridement and lavage, addition of ring fixator, intravenous antibiotics for 6 weeks.Debridement and lavage, excision of sinus tract, exchange nailing using antibiotic impregnated-cement nail, intravenous antibiotics for 6 weeks.The patient has chronic osteomyelitis and an infected nonunion complicating previous IM nailing of an open tibia fracture. Successful treatment requires debridement, removal of the existing tibial nail, placement of an antibiotic-impregnated rod and IV antibiotics. Sinus tract excision and biopsy is important to exclude malignant transformation (Marjolin's ulcer).Intramedullary infection is a recognized complication of IM nailing, especially in the setting of an open fracture. When the fracture fails to unite prior to deep infection treatment options include: nail removal and antibiotic exchange nailing, nail removal, intramedullary debridement and uniplanar externalfixation, or nail removal and resection of the infected segment with circular frame application and bone transport.Paley et al. first described the treatment of intramedullary infection with antibiotic-impregnated cement nails in 6 femora, 2 tibiae and 1 humerus. There was no recurrence of infection. The antibiotic-impregnated cement nail fills the canal dead space while locally eluting high concentrations of antibiotics (for up to 36 wk), and is easy to remove.Qiang et al. described antibiotic-cement rod placement in 19 patients (5 femora, 14 tibiae). There was no recurrence of infection. 11 cases went on to union, 6 cases achieved partial union, 1 case had nonunion and 1 went on to amputation.Riel et al. described the method of creating a PMMA-coated nail. They advocate this method because it provides limited axial and bending stability (but no rotational stability).McGrory et al. described 53 patients with malignancy complicating chronic osteomyelitis. 50 patients had squamous cell carcinoma. Most had mixed infections, predominantly Staph and Strep.Figure A shows a poor soft tissue envelope with a draining sinus consistent with chronic osteomyelitis. Figure B is an AP radiograph showing fluffy callus formation, lack of bony bridging and interlocking screw back out. Combined with the clinical picture this would be consistent with deep infection.Illustration A shows the steps of making an antibiotic-impregnated cement rod using a 3 mm guidewire, chest tube and cement gun. Illustration B is a lateral radiograph of a cement rod in the tibia.Incorrect Answers:OrthoCash 2020A 45-year-old construction worker sustains a fall and presents with an isolated injury to his upper extremity. Radiographs of the affected wrist are shown in Figure A. After soft tissue swelling subsides, open reduction and internal fixation of the distal radius is performed. Following fixation, a "shuck" test is performed and shows persistent instability of the distal radioulnar joint. Incompetence of which of the following anatomic structures is the most likely etiology of this finding?Radioulnar ligaments of the TFCCUlnar collateral ligamentFracture fixationUlnolunate ligament of the TFCCUlnotriquetral ligament of the TFCCCorrent answer: 1The patient has sustained a distal radius fracture and concomitant ulnar styloid fracture. The shuck test is performed after fixation of the distal radius to assess the status of the DRUJ, namely the radioulnar ligaments.Injuries to the DRUJ often occur with distal radius fractures. The presence of an ulnar styloid fracture may signify injury to the DRUJ. After the distal radius has been fixed, the shuck test is performed. This test is completed with the elbow at 90 degrees of flexion, the forearm in neutral rotation, followed by pronation and supination. The examiner attempts to translate the ulnar in the sagittal plane. Excessive sagittal plane ulnar translation signifies DRUJ injury.Kim et al. review the effect of ulnar styloid nonunion on functional outcome after distal radius ORIF. Of the 91 patients treated with distal radius ORIF, 22% were found to have a nonunion of the ulnar styloid. There was nodifference in wrist functional outcomes, ulnar sided wrist pain, or DRUJ stability.Sammer et al. reviewed 144 patients undergoing ORIF of the distal radius. The DRUJ was stable in all patients after internal fixation. An ulnar styloid fracture was found in 88 patients. Functional outcome scores were not affected by the presence of an ulnar styloid fracture. Additionally, the size of the fracture, extent of displacement, or healing status did not affect the outcome.Figure A shows a PA radiograph of the wrist demonstrating a comminuted distal radius fracture with a concomitant ulnar styloid fracture. Illustration A shows an example of the shuck test used to test the DRUJ.Incorrect Answers:OrthoCash 2020Which of the following deformities is most common after the amputation shown in Figure A?Pes cavusPes planusHindfoot valgusEquinovarusCalcaneovalgusThe most common deformity after a midfoot amputation as shown in Figure A is an equinuovarus deformity due to the pull of the Achilles and plantarflexors in face of loss of the common extensors and distal insertion of the tibialis anterior.Ng et al. review foot and ankle amputations, and review the issues inherent with each amputation level, including prosthesis fitting and use. They also mention that careful repair of all released or transected tendons is needed to maintain a plantigrade foot.Early reviews the importance of soft tissue balancing with midfoot amputations. They note that the attachment of the resected tendons into the more proximal retained bones is critical for success in restoration of foot position and ambulation capabilities.Figure A shows a midfoot amputation as the result of trauma. Illustration A shows the lateral view of the amputation, with an obvious equinus deformity.Incorrect Answers:OrthoCash 2020A 68-year-old patient undergoes total knee arthroplasty for end-stage degenerative joint disease. Two years later, she trips and falls at home and sustains a fracture seen in Figures A and B. Before her fall, she was a community ambulator and had no knee pain. The component is determined to be stable and the surgeon decides to treat this fracture with closed reduction and retrograde intramedullary fixation with a supracondylar nail. Which of the following statements is true?The starting point tends to be more posterior than usual, resulting in hyperextension at the fracture site.An arthrotomy is not necessaryA high-speed carbide burr is usually necessary to enlarge the box for nail entry.The backup plan should include devices that allow multiple points of fixation in the distal segment, such as dynamic condylar screw and fixed angle blade plate.The backup plan should include devices that resist varus collapse, such as condylar buttress plates.The patient has a cruciate-retaining (CR) prosthesis. The starting point for nail entry is more posterior than normal because of the femoral component. This leads to hyperextension at the fracture site.Periprosthetic femur fractures above total knee implants occur in 2% of patients. It is important to note: (1) pre-injury function, to determine if the prosthesis was loose, (2) the type of implant (CR vs posterior stabilized, PS) as a PS implant with a closed box would make retrograde intramedullary nailing more difficult (the surgeon has to consider the size of the box vs size of thenail, and if the box is smaller than the nail, must be prepared to enlarge the box with a metal-cutting burr, which has inherent problems of introducing wear debris into the joint), (3) pre-fracture radiographs help determine the position of the implants (flexion-extension, varus-valgus). These fractures can be treated with non-locking condylar buttress plates (not recommended today), fixed angle devices and intramedullary nailing.McLaren et al. describe 7 osteopenic patients (mean age, 61yrs, range 47-84yrs) treated with retrograde supracondylar nailing. They suggest not reaming, and placing 2-3 screws in the distal fragment. This may require leaving the nail protruding by 1cm. They then suggest removing the protruding segment with a burr at the end of the procedure.Haidukewych et al. debate plating vs nailing in a 80yr old osteopenic patient. It may be difficult to introduce retrograde intramedullary nails through the same incision if dense scar tissue is present. On the other hand, most plates require extensive dissection and do not respect the soft tissues and fracture biology, except for LISS plates and nails.Figures A and B show a displaced Lewis and Rorabeck type II periprosthetic fracture. Illustration A shows the technique of retrograde supracondylar nailing. With the knee flexed, the fracture is reduced and the entry point is in the intercondylar notch. Illustration B shows a comparison between PS and CR implants. Note the "box" in the PS implant. This is absent in the CR implant.Illustration C shows the Lewis and Rorabeck classification.Incorrect Answers:OrthoCash 2020A 34-year-old female is involved in a high-speed motor vehicle collision and sustains a traumatic proximal forearm amputation. She successfully undergoes debridement and closure, and six weeks later, is fitted with her temporary prosthesis. In order to optimize heroutcomes upon returning to work as a secretary, which of the following is recommended?Obtaining formal functional capacity testingWaiting for final prosthesis fitting prior to full releaseMinimize use of her prosthetic while at workAllowing return to work when full elbow range of motion is seenOffer outpatient psychological counselingCorrent answer: 5Upper extremity trauma has serious, acute psychological effects that can linger long after the physical injury. These effects may negatively affect patient-reported outcomes, and may also be associated with worsening pain complaints. Coping and stress management techniques can be reviewed with formal psychological counseling, and should be offered to all patients who have underwent an amputation.Richards et al surveyed 34 patients who had emergency upper extremity surgery and found high levels of psychological distress in patients, including 29% with high levels of both depression and post-traumatic stress disorder (PTSD). They also found that disability was strongly related to pain, depression, and PTSD symptoms.Mallette et al assessed the attitudes of hand surgery patients and hand surgeons regarding psychologic influences on illness and compared their attitudes with those of the general population. They found that surgeons underestimated the openness of patients to discuss psychological issues and that patients believed in the strong effect of psychologic factors on healing and pain.Illustration A shows a myoelectric prosthesis in a military veteran. Incorrect Answers:Workers' Compensation is involved or formal disability proceedings occur. Answer 2: Final prosthetic fitting is not necessary for full release.OrthoCash 2020A 40-year-old male patient sustains a bimalleolar ankle fracture and undergoes open reduction and internal fixation. Four months later, he returns for follow-up with mild ankle discomfort, and a radiograph is shown in Figure A. What is the most appropriate next step in treatment?Syndesmosis sagittal plane reduction and fixationSyndesmosis coronal plane reduction and fixationOsteotomy and revision of the fibula and syndesmosisRetrieval of osteochondral fragmentRevision plating of the fibula and syndesmosis reduction and fixation.This patient has undergone ORIF of the lateral malleolus with shortening of the lateral malleolus and lateral tibiotalar tilt. Revision surgery would entail bone grafting and re-plating of the fibula.Malunion of the fibula component of ankle fractures lead to tibiotalar instability and post-traumatic ankle arthritis. The distal fragment is usually shortened and externally rotated. The osteotomy can restore length and correct rotation.Markers for potential instability include: (1) asymmetry of the medial-lateral clear spaces, (2) talar tilt >2mm, (3) talar subluxation, (4) abnormal talocrural angle (normal, 75-86deg).Chu et al. opined that reconstruction for distal fibula malunions should include:(1) osteotomy, (2) +/- syndesmotic fixation and (3) autologous bone graft. They recommend: (1) low oblique osteotomy for fractures below thesyndesmosis, (2) transverse osteotomy above the syndesmosis for high fractures (PER4) and low fractures with tibiofibular instability, (3) inspection of the tibiofibular joint through an anterolateral window to ensure anatomic reduction.Weber et al. described a method of corrective lengthening osteotomy of the fibula in 23 cases. They described 3 criteria for assessing normal fibular length. Seventeen patients had good-excellent results, and 6 had fair-poor results (1 of these 6 needed ankle fusion).Figure A is an AP radiograph of a distal fibula fracture fixed in a shortened position with lateral talar tilt and degenerative changes at the anterolateral tibiotalar joint. Illustration A is an anteroposterior radiograph after fibular osteotomy and correction with medial distal tibial autograft to correct talar tilt and restore anatomic fibular length. Illustration B shows the normal talocrural angle. Illustration C shows the Weber-Simpson method of fibula lengthening used in Illustration A.Incorrect Answers:OrthoCash 2020A 38-year-old concert violinist presents after falling onto a pronated, outstretched hand this morning. She complains of lateral elbow pain. Examination reveals lateral elbow tenderness, and an 80 degree arc of flexion-extension and 60 degree arc of prono-supination, with extremes of motion limited by pain. There is no bony block to motion. Radiographs of her injury are seen in Figures A through D. The most appropriate treatment plan that would allow her to return to her occupation would beSling immobilization for 2 days, followed by active mobilization.Long-arm cast immobilization for 1 week, followed by active mobilization.Long-arm cast immobilization for 1 week, followed by passive mobilization.Long-arm cast immobilization for 2 weeksOpen reduction and internal fixationCorrent answer: 1This patient has a Mason Type I radial head fracture (minimally displaced, no mechanical block, intra-articular displacement <2mm). Non-operative treatment is recommended. Sling immobilization for 2 days followed by active mobilization is recommended.Radial head fractures occur after axial loading/fall onto a pronated, outstretched hand as the most force is transmitted from the wrist to the radial head in this position. For Type II and III fractures, open reduction and internal fixation is indicated. For Type III fractures with more than 3 fragments, radial head replacement is advocated. Radial head excision in the acute setting is generally not recommended to prevent late proximal radial migration and ulnocarpal impingement, as an easily missed Essex-Lopresti injury is possible; any patient with a painful DRUJ or mid forearm in the face of a radial head fracture should not undergo excision.Paschos et al. compared (1) immediate active mobilization vs (2) sling immobilization for 2 days, followed by active mobilization vs (3) immobilization in a cast for 7 days followed by active mobilization. Early mobilization (Groups 1 and 2) had better ROM and less pain at 4 wks. Group 2 had better pain relief than Group 1 in the first 3 days, and the best functional scores at 12wks. They recommend early mobilization after a delay of 48 hours.Tejwani et al. reviewed current management of radial head and neck fractures. Most fractures can be managed nonoperatively with early motion if there is no instability or block to elbow motion. Complex fractures require ORIF or arthroplasty (fragment >1/3 of the radial head, ORIF not possible).Figures A through D are radiographs showing an undisplaced simple (AO/OTA 21-B2.1) radial head fracture.Incorrect Answers:OrthoCash 2020What is the primary advantage of two incisions compared to one for open reduction internal fixation of a both bones forearm fracture?lower risk of synostosislower risk of wound complicationslower rate of radial neuritisless pronator teres denervationlower malunion rateCorrent answer: 1Post-osteosynthetic synostosis is a known complication in both bone forearm fractures. The risk is increased in fractures of the proximal 1/3 of the ulna and radius. Other risk factors include severity of injury, head trauma, polytrauma. Vince et al found synostosis was often associated with bone fragments or hardware in the interosseous space. Bauer et al found 1/65 cases treated utilizing the two-incision approach developed synostosis, while 5/12 cases in which the fractures were stabilized using a single incision developed synostoses. They recommended a two incision approach to both bones ORIF.OrthoCash 2020A 25-year-old female presents to the emergency room for the fourth time in the last week. She has vague complaints of extremity pain. Physical examination by a male ER resident has been limited each visit because she is terrified of the pain that the clinician may cause. On physical examination, she is withdrawn and frightened.Regions of ecchymosis are noted throughout chest and abdomen. She has requested multiple radiographs, MRI and CT scans. Today's imaging (radiographs, MRI, CT scan) has been unrevealing. What is the most likely diagnosis?MalingeringComplex regional pain syndromeAnxiety disorderIntimate partner violenceFibromyalgiaBased on the history and clinical presentation, the most likely diagnosis is intimate partner violence.Domestic violence or intimate partner violence can be in the form of mental or physical abuse, neglect or abandonment. Close to 25% of women will experience domestic violence. Risk factors include young age (19-29 years of age), females, pregnancy and lower socioeconomic status. Affected patients will have repeated visits to the emergency room, find reasons to stay in a treatment facility for an extended period of time and constantly seek approvalof their partner.Shields et al. reviewed factors influence outcome in treatment of patients affected by domestic violence. They found that positive outcomes were associated with interdisciplinary approaches to management. This included better history assessment, providing written documentation regarding intervention and better access to information on community resources.Illustration A is a chart documenting the frequency of female domestic violence throughout the world as of 2012.Incorrect AnswersOrthoCash 2020Which of the following injuries is most likely associated with the fracture seen in Figure A?Medial meniscal tearLateral meniscal tearLateral collateral ligament ruptureMedial collateral ligament rupturePosterior cruciate ligament ruptureCorrent answer: 2Lateral meniscal tears are most commonly associated with Schatzker II tibial plateau fractures (split/depressed).Soft tissue pathology is common in tibial plateau fractures. In general, fractures that are largely displaced and/or a result of high energy trauma are more likely to have associated soft tissue pathology. A majority of meniscal injuries that occur in the setting of tibial plateau fractures are meniscocapsular detachments. This has important implications for healing (more reliable healing in the vascular zone). Additionally, the meniscus usually remains in close contact with the femoral condyle, while the tibial plateau widens around it. It is generally agreed upon that meniscal tears should be repaired, if possible, at the time of internal fixation to decrease the likelihood of postraumatic arthritis.Gardner et al. review 62 patients with Schatzker II tibial plateau fractures that had an MRI preoperatively. For displaced fractures, the incidence of lateral meniscal tears was 83%, while the incidence of lateral collateral and posterior cruciate ligament injuries was 30%.Ringus et al. attempted to determine if the degree of lateral tibial plateau fracture depression on computed tomography (CT) images predicted the presence of lateral meniscus tears. Fractures with > 9mm depression had an eight-fold increase in lateral meniscal tears, and those younger than 48 years-old had a four-fold increase in lateral meniscal tears.Illustration A shows an MRI of a Schatzker II tibial plateau fracture with a lateral meniscal detachment and a medial meniscal tear. Illustration B shows the Schatzker Classification, I-VI.Incorrect Answers:OrthoCash 2020A 26-year-old male sustains a traction injury to his left arm after a motorcycle crash with resulting weakness in this left upper extremity. An electromyography (EMG) done shows normal cervical paraspinal muscle activity. Which of the following statements is true regarding this injury?The injury has likely resulted in the avulsion of several nerve rootsPhysical exam would likely reveal drooping of his left eyelid and anhidrosisIntact paraspinal musculature on EMG is suggestive of a post-ganglionic lesionImmediate surgical intervention with neurotization would eliminate weakness and restore functionThe patient would show a normal histamine testCorrent answer: 3Normal cervical paraspinal muscle activity on EMG is characteristic of a postganglionic injury.Determining whether a brachial plexus injury is pre- or post-ganglionic has important treatment and prognostic implications. Findings that suggest a preganglionic lesion include Horner syndrome (ptosis, miosis, anhidrosis), a medially winged scapula, loss of paraspinal musculature activity on EMG, and a normal histamine test. These injuries tend to have a worse prognosis than post-ganglionic lesions, which show an abnormal histamine test and intact cervical paraspinal activity on EMG.Moran et al. review brachial plexus injuries. They recommend a baseline EMG for non-operative injuries at 3-4 weeks time after Wallerian degeneration has occurred.Shin et al. also review brachial plexus injuries. While an MRI can visualize much of the brachial plexus and may be able to demonstrate neuromas, a CT myelogram still remains the primary mode of radiographic evaluation for nerve root avulsion in the acute setting.Illustration A shows the difference between a pre- and post-ganglionic lesion. Illustration B shows the brachial plexus for reference.Incorrect Answers:OrthoCash 2020A 25-year-old male pedestrian sustained a Type II open tibia fracture after being struck by a car at 10:00PM. He was transported to a Level I trauma hospital where he was given intravenous antibioticsand tetanus at 10:45PM. He underwent irrigation and debridement of the wound with 9L of saline solution and was treated with reamed intramedullary nail fixation at 11:45PM. A vacuum assisted dressing was placed over a 5x3cm skin deficit. What part of his overall treatment has shown to reduce the risk of infection THE MOST at the site of injury?Early tetanus administrationEarly intravenous antibiotic administrationReamed intramedullary nail fixationIrrigation and debridement of the open fracture with 9L of solutionVacuum assisted dressings over skin deficitCorrent answer: 2The most important factor shown to reduce the risk of infection at the site of an open fracture is early intravenous antibiotic administration.Infection risk after Gustilo Type II open fractures ranges from 10-20% in large studies. Antibiotic treatment initiated within 3 hours from the time of injury has shown to significantly reduce the rate of infection. Antibiotic coverage for Type II open fractures should cover gram positive bacteria. Soil-contaminated wounds should include anaerobic coverage. The dose of antibiotic given must be within a therapeutic range and titrated to the patient's weight (e.g. Ancef 2 g IV for >70 kg). Duration of antibiotic therapy has been suggested to be between 1 and 3 days, although there is no agreement on a firm end point.Pollak et al. reviewed a large cohort of open fractures treated at Level I trauma centers. They demonstrated a significant decrease in infection rate with either early direct admission (<2 hours) or transfer (<11 hours) for ONLY type III open tibia fractures. They did not not discuss timing of antibiotic treatment because this was not prospectively collected. Although they did not collect data on antibiotic treatment, the authors theorize that early transfer potentially resulted in earlier administration of antibiotics.Patzakis et al. examined a series of 1104 open fractures to determine the factors contributing to infection. They showed the most important factor in reducing the infection rate was the early administration of antibiotics.Illustration A is table showing the Gustilo classification of open fractures. Incorrect Answersin open fractures, however, the most important factor has been shown to beearly antibiotic therapy.OrthoCash 2020A 65-year-old female sustained the injury seen in Figure A after a slip and fall getting out of the shower. She is an avid golfer and walks the course on most days. Her past medical history includes borderline hypertension and migraine headaches. Which treatment option has shown to have the lowest re-operation rate and best clinical outcomes scores in this patient population?Closed reduction with cannulated screw fixationOpen reduction with cannulated screw fixationClosed reduction and short intramedullary nail fixationHemiarthroplastyTotal hip arthroplastyFigure A shows a displaced right femoral neck fracture in an active, healthy elderly patient. Treatment of her hip fracture with total hip arthroplasty (THA) has shown to have the lowest re-operation rates and best functional outcome scores when compared to internal fixation devices and hemiarthroplasty.Large studies have shown the incidence of femoral head AVN to be approximately 30-45% with displaced femoral neck fractures (Garden III-IV). For this reason, treatment of these injuries in elderly patients have supported arthroplasty over ORIF. Treatment of patients with THA vs. hemiarthroplasty have also been investigated. Studies have shown that THA has lower reoperation rates and improved functional outcome scores in younger, active elderly patients compared to hemiarthroplasty.Avery et al. prospectively followed a cohort of 81 patients treated with THA vs. hemiarthroplasty in high functioning elderly patients with displaced femoral neck fractures. They showed a lower mortality rate (p = 0.013) and trend towards superior function in patients treated with THA. Advantages with THA vs hemiarthroplasty must be traded off against a slightly higher risk of dislocations.Hedbeck et al. performed a randomized controlled trial involving 120 elderly patients with acutely displaced femoral neck fractures that were treated with either bipolar hemiarthroplasty or THA. They showed Harris hip scores and EQ-5D scores in favour of THA. They suggested treatment with THA in elderly, lucid patients with displaced femoral neck fractures.Figure A is a AP pelvic radiograph. The most obvious finding is a displaced femoral neck fracture.Incorrect Answers:OrthoCash 2020A 30-year-old man is the front seat passenger in a motor vehicle accident. He presents with deformity in his knee seen in Figures A andB. Radiographs are seen in Figures C and D. Examination reveals weak foot pulses. After unsuccessful attempts at closed reduction, it is noted that the pulses are no longer palpable and the foot is cool. What is the next step in treatment?Open reduction through an anteromedial approach, spanning external fixation. If pulses do not return, perform popliteal artery exploration.Closed reduction in the operating room using a femoral distractor. If pulses do not return, perform on-table angiogram.Manual in-line skeletal traction using a calcaneal pin in the emergency room, provisional long-leg splinting. If pulses do not return, perform computed tomography angiography in the radiology suite.Manual in-line skeletal traction using a proximal tibial pin in the emergency room, provisional long-leg splinting. If pulses do not return, perform standard angiography in the angiography suite.Open reduction through a posterior approach, spanning external fixation. If pulses do not return, perform popliteal artery exploration.This patient has a posterolateral knee dislocation with a avascular limb. Urgent surgical intervention is warranted. The medial femoral condyle (MFC) has button-holed through the medial capsuloligamentous structures, leaving skin and medial subcutaneous tissues entrapped between the MFC and the joint cavity producing a ‘pucker sign’. An anteromedial approach is necessary.Stabilization is then best achieved with an external fixator. Persistent ischemia (absence of pulses after reduction) is an indication for popliteal artery exploration.Posterolateral dislocations are caused by a posterior-directed and rotational force, and are often irreducible. Vascular injury arises because of proximal tethering (fibrous adductor hiatus tunnel) and distal tethering (fibrous soleus hiatus tunnel) at the popliteal fossa.Rihn et al. outlined the treatment algorithm for acutely dislocated knees. If pulses return after reduction, radiographs and evaluation of ABI are indicated. If ABI<0.9, CT angiography or formal angiography is indicated. If ABI >0.9, a period of in-hospital observation is indicated. If pulses remain absent and the limb remains ischemic following reduction, emergent surgical exploration and revascularization in the operating room is necessary. The spanning external fixator supplies enough rigidity to maintain reduction and allows access for serial neurovascular examinations.Patterson et al. examined knee dislocations with vascular injury in the Lower Extremity Assessment Project (LEAP) study. Of the 18 patients in this group, all required popliteal arterial repair. Overall, 14 patients were treated with limb salvage and 4 patients were treated with an amputation. Patients with salvaged limbs had moderate to high level of disability 2 years after injury.Figures A and B show the clinical appearance of posterolateral knee dislocation with a ‘pucker sign’. Figures C and D are radiographs showing posterolateral knee dislocation. These radiographs classically show 1 view of the tibia, but another view of the femur. Thus, the AP XR shows an AP of the tibia, but an oblique of the femur. Similarly, the lateral XR shows a lateral of the tibia, and an oblique of the femur. This is because XR technologist determines the AP/lateral projection based on the position of the foot (which follows the tibia).Incorrect Answers:OrthoCash 2020An ankle-brachial index is most commonly indicated after sustaining which of the following fracture patterns, seen in Figures A-E?Figure C shows a Schatzker IV tibial plateau fracture, or medial fracture-dislocation of the knee. Of the fracture patterns shown, Schatzker IV tibial plateau fractures have the highest incidence of vascular injury and most often require measurement of an ankle-brachial index (ABI) to rule-out associated vascular injury.Schatzker IV tibial plateau fractures (fracture of the medial plateau) are rare and are most commonly associated with high-energy trauma after a varus/axial load. At the time of initial injury, the fracture pattern produces a temporary dislocation of the knee, placing tension on the peroneal nerve and popliteal artery. Because of the likelihood of associated popliteal artery injury, ankle-brachial indices, frequent neurovascular checks, and arteriography are commonly performed following injury.Berkson et al. review high-energy tibial plateau fractures. They state that Schatzker IV fractures are usually the result of high-energy trauma, and have a high incidence of popliteal artery and peroneal nerve injury. In contrast, Schatzker V and VI are more commonly associated with compartment syndrome.Gardner et al. review 103 tibial plateau fractures. 77% of fractures had an associated rupture of either cruciate or collateral ligaments. 86% of Schatzker IV fractures had an associated medial meniscus tear.Illustration A is a worksheet for calculating the ankle brachial index. An ABI less than 0.90 has been shown to have a sensitivity exceeding 87% and a specificity exceeding 97% for identifying lower-extremity arterial injury.Incorrect Answers:OrthoCash 2020A 34-old-male was involved in a high speed MVC. He sustained an injury to his right leg as seen in Figures A and B. He was treated initially with external fixation for 11 days before his soft-tissues would permit definitive open internal fixation. After removing the external fixator and plating the fibula, what would be next step in the operative plan for reduction and fixation of this injury?Application of an anterolateral pre-contoured plate with distal locking screws to the tibiaAnatomical reduction and stabilization of the tibial articular surfaceApplication of a medial pre-contoured plate with distal non-locking screws to the tibiaAnatomical reduction and stabilization of the tibial metaphyseal segmentProximal screw insertion with non-locking screws to distract the metaphyseal fracture comminutionFigures A and B show an AO/OTA Type C Pilon fracture with metaphyseal comminution and intra-articular involvement of the tibia. There is an associated fibula fracture. The next step in the operative treatment of this injury, after removal of external fixation, would be anatomical reduction and stabilization of the articular surface.The first step in the treatment of pilon fractures involves anatomical reduction and stabilization of the articular surface. This can be accomplished with pointed reduction clamps, K-wires, lag screws, or any combination of these. Plate fixation and reduction of the metaphyseal comminution should occur after the joint surface has been re-established. Simple fibular fractures can be plated before fixation of the tibia. Comminuted fibular fractures are usually better reconstructed after the tibia has been repaired, so that the tibia and talus can be used as a guide for positioning of the lateral malleolus.Sirkin et al. reviewed the protocol for treatment of complex pilon fractures. They showed that the severity of soft-tissue injury will dictate the timing of fixation and choice of implant. To avoid wound healing problems, it is generally accepted that two or more stages of repair should be used.Figure A, B and C show a high energy fracture to the distal tibia. Incorrect Answers:reduction and stabilization of the articular fracture fragments. The use of medial and anterolateral locking plates are appropriate for fixation of this fracture. Longer implants improve load distribution and stability.securing the proximal end of the plate to the tibial shaft. A kick-stand screw can be placed in the most proximal hole to increase the working length of the plate. This can be placed percutaneously if desired.OrthoCash 2020Which of the following ankle fractures seen in Figures A-E most likely occurred as a result of abduction of the foot relative to the tibia?

This patient has sustained a femoral shaft fracture. The next best step in management would be to CT scan the hip to assess for an associated femoral neck fracture.Femoral neck fractures are seen less than 10% of the time with femoral shaft fractures, but they are frequently missed on initial evaluation. The neck fracture line is almost vertical and nondisplaced, or minimally displaced. Therefore fine (2-mm) cut CT scan through the femoral neck should be ordered in the preoperative workup of these patients.Tornetta et al. reported that they reduced the delay in diagnosis of concomitant femoral neck fractures by 91% by instituting a protocol that included: dedicated AP internal rotation plain radiograph, a fine (2-mm) cut CT scan through the femoral neck, an intraoperative fluoroscopic lateral radiograph prior to fixation, as well as postoperative AP and lateral radiographs of the hip in the operating room prior to awakening the patient.Figure A shows a trauma view lower extremity radiograph with an isolated left midshaft femur fracture.Incorrect Answers:setting of fracture. Answer 5: The age, injury and fracture pattern are not consistent with a pathologic femur fracture.

It is recommended that If ligament injury is documented in the presence or absence of fracture, open reduction and internal fixation should be performed. According to gossans and De Stoop, who studied 20 patients with Lisfranc injuries, 5 of 7 had a poor outcome with plaster immobilization, 1 out of 2 had a poor outcome with reduction and plaster, and 7 out of I 1 had a good result with ORIF. 2 of these had a poor result, and 2 had injuries severe enough to result in amputation due to Clostridium infection secondary to open fractures.

In a normal AP pelvis radiograph, the anterior rim of the acetabulum runs medially and distally, diverging from the posterior rim which runs much more vertically. In excessive acetabular retroversion, the anterior rim (bold line in Figure 33b) and posterior rim start laterally, and as these lines progress medially and distally, the anterior line crosses the posterior line. This predisposes to femoral acetabular impingement.

Healing 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.

Type V acromioclavicular dislocations are characterized by elevation of the clavicle of 100% to 300% and involve extensive soft-tissue stripping. The treatment of choice is surgical reduction of the acromioclavicular joint and some type of stabilization. Treatment of type III injuries is controversial.

The radiographs show a fracture-dislocation with translation in both the coronal and sagittal planes, evidence of significant instability requiring surgical stabilization. Anterior instrumentation is not as effective as posterior instrumentation in restoring stability, and because there is little bony destruction, the anterior column can be successfully reconstructed with simple realignment. The treatment of choice is multisegment posterior fusion with instrumentation.