2. Trauma MCQs

Multiple attempts at closed reduction, delayed surgery for proximal humeral fractures, and associated closed head injury all have been associated with a higher incidence of heterotopic ossification.

Jehovah's witnesses beliefs regarding blood products stems from direct interpretation of passages from the bible. The use of crystalloid, starch products such as Hetastarch and colloids are accepted. Typically Jehovah's witnesses will accept most medical treatment but refrain from the use of blood products including whole blood, packed red cells, platelets, white cells, or plasma. Any autologous transfusion, whether from the patient themself or donor directed, is forbidden. The use of cell-saver type processes is a matter of individual choice by the patient. The use of hemoglobin-based oxygen carriers are now accepted by many patients but it is important to respect the wishes of each individual patient. It is very important to discuss preoperatively with the patient and family their wishes and thoughts on what is acceptable to use. Many facilities have adopted bloodless-surgery protocols and committees that definitively outline the measures that can be used and take into consideration the many ethical issues involved in taking care of these patients.

DISCUSSION: The perifibular approach is carried out through a straight lateral incision beginning just posterior and parallel to the fibula from the fibular head to the tip of the lateral malleolus. At the proximal end of the incision, the common peroneal nerve must be identified and protected. Elevation of the soleus off the posterior fibula ensures proper deep compartment release. The anterior edge of the incision is then retracted to expose the anterior and lateral compartments, and at this point, care must be taken to avoid the superficial peroneal nerve as it exits the fascia of the lateral compartment and runs anterior in the distal third of the leg. The referenced article by Whitesides is a review of compartment syndrome pathology, diagnosis, and treatment.

DISCUSSION: A both column acetabular fracture is defined as an acetabular fracture with no articular surface in continuity with the remaining posterior ilium (and therefore, axial skeleton). The spur sign is a radiological sign seen with these fractures, and is the posterio-inferior aspect of the intact posterior ilium. The spur sign and other radiographic findings consistent with a both column acetabular fracture can be seen in Illustration A (AP), Illustration B (obturator oblique), and Illustration C (iliac oblique).

DISCUSSION: The most important aspect in the decision for surgery in an acetabular fracture is the ability of the femoral head to remain concentrically reduced under the dome in AP and Judet oblique views of the pelvis. If this parameter is present, then the need for surgery is determined by other aspects such as fragmentation, age, incongruity, and displacement. If the head remains stable under the dome without traction, there is sufficient acetabular dome to provide stability, and nonsurgical treatment may be appropriate. REFERENCES: Tile M: Assessment and management of acetabular fractures, in Tile M (ed): Pelvic and Acetabular Fractures, ed 2. Baltimore, MD, Williams and Wilkins, 1995, pp 305-354. Letournel E: Acetabular fractures: Classification and management. Clin Orthop 1980;151:81-106. Letournel E, Judet R: Fractures of the Acetabular, ed 2. Berlin, Springer-Verlag, 1993, pp 29-49.

Terrible triad injuries of the elbow are common, and the management of type I coronoid tip fractures remains controversial. Type I coronoid fractures result in only small changes in elbow kinematics that have been shown to be uncorrected with suture repair. A type I coronoid tip fracture is not amenable to buttress plate fixation. The radial collateral ligament is a component of the lateral collateral ligament complex and has already been repaired. The persistent medial laxity and posteromedial joint subluxation noted is indicative of ongoing instability. The next step would be repair or reconstruction of the medial collateral ligament, which willnormally correct the medial instability. Articulated versus static external fixation can be considered ifrestoration of the ligamentous constraint of the medial side of the elbow cannot be accomplished surgically.

DISCUSSION: Nondisplaced distal radial fractures have a higher rate of spontaneous rupture of the extensor pollicis longus tendon. The extensor mechanism is felt to impinge on the tendon following a nondisplaced fracture and causes either a mechanical attrition of the tendon or a local area of ischemia in the tendon. REFERENCES: Helal B, Chen SC, Iwegbu G: Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand 1982;14:41-47. Hirasawa Y, Katsumi Y, Akiyoshi T, et al: Clinical and microangiographic studies on the rupture of the EPL tendon after distal radial fractures. J Hand Surg Br 1990;15:51-57.

DISCUSSION: Plain radiographic imaging of a patient with an acetabular injury begins with 5 standard views of the pelvis. The obturator oblique view shows the anterior column and posterior wall. The iliac oblique view shows the posterior column and the anterior wall. Judet and Letournel have a classification system for acetabular fractures. For this patient, a small fracture of the posterior wall is visualized on the AP view (Figure 15a).

DISCUSSION: The patient has a volar displaced two-part intra-articular distal radial fracture-dislocation of the wrist. Although a closed reduction is usually easily obtained, it is very difficult to maintain the reduction without internal fixation. The approach is determined by the direction of the dislocation, in this case volar. Stabilization with a buttress plate neutralizes the axial loading forces on the fractured fragment. REFERENCE: Cohen M, McMurtry RY, Jupiter JB: Fractures and dislocations of the carpus, in Browner BD (ed): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, pp 1328-1335.

The outlet view best guides superior-inferior screw orientation during percutaneous S1 screw placement. This is due to the relative forward flexion of the sacrum and pelvis due to pelvic incidence. A lateral sacral view and an inlet pelvis view would best guide anterior-posterior screw orientation. Routt et al. reviewed percutaneous techniques of pelvic surgery. Although anterior pelvic external fixation remains the most common form of percutaneous pelvic fixation, iliosacral screws have the advantage of stabilizing pelvic disruptions directly while diminishing operative blood loss and operative time. They stress the importance of a thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations for surgical success.

In an ipsilateral unstable pelvic ring and acetabular fracture, the pelvic ring injury must be initially stabilized in order to reduce the acetabular fracture to a stable base. The referenced article by Matta reviewed 259 patients with acetabular fractures treated within 21 days of injury and found that the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved.

The radiographs show a lateral condyle fracture with 2 mm of displacement. As opposed to other pediatric elbow fractures, lateral condyle fractures have a higher incidence of nonunion. This may be due to minimal metaphyseal bone on the distal fragment, the intra-articular nature of the fracture, or from further displacement when treated nonsurgically. These fractures with 2 mm and greater of displacement should be treated with reduction and stabilization. Osteonecrosis and fishtail deformity may be seen in very rare cases of lateral condyle fractures. The incidence is certainly less than the rates of nonunion seen in nonsurgically treated fractures with 2 mm and greater of displacement. Varus malunion from overgrowth and elbow stiffness are more likely seen in fractures treated surgically.

The LEAP study is a multicenter prospective study evaluating multiple aspects of reconstruction versus amputation in the treatment of mangled extremity injuries. With regard to patient satisfaction, treatment variables such as decision for reconstruction versus amputation, or initial presence or absence of plantar sensation have little impact. In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction. Instead, the most important predictors of patient satisfaction at 2 years after injury include the ability to return to work, absence of depression, faster walking speed, and decreased pain.

This hypotensive patient has an obvious open book injury of the pelvic ring on the AP pelvis radiograph and further radiographs are not needed prior to the initiation of treatment. Although angiography may be indicated if he does not respond to stabilization of his pelvis and fluid/blood administration, temporary stabilization of the pelvis with a sheet or binder should be performed first because it is simple, quick, and has been shown to be effective. This patient does not need a laparotomy at this point since the FAST examination did not show any free intra-abdominal fluid and his chest radiograph was unremarkable, leaving the most likely source of bleeding the pelvic fracture. Open reduction with internal fixation of a pelvic injury is not indicated in an acutely ill patient.

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

The patient is in hemorrhagic shock, and timely hemostasis in the operating room should be the highest priority. Further imaging and insertion of central lines carry the risk of further delays in arresting the source of the patient’s bleeding. Albumin (colloid) solutions have questionable indications, are expensive, and have been associated with increased mortality. Crystalloid solutions such as normal saline or lactated Ringer’s solution are the initial resuscitative fluid of choice until blood becomes available. Pneumatic antishock garments have been associated with higher mortality rates, particularly in patients with cardiac and thoracic vascular injuries.

The patient has a subperiosteal abscess. Because aspiration revealed 10 mL of purulent fluid, the treatment of choice is surgical incision and drainage of the abscess, followed by immobilization to reduce the risk of pathologic fracture. With an adequate response to IV antibiotics and a susceptible bacteria, the patient may then be switched to oral antibiotics.

DISCUSSION: Chronic anterior knee pain at the insertion site is the most frequently reported complication of closed nailing of a tibial shaft fracture. A high incidence of knee pain has been associated with IM nailing. The etiology of anterior knee pain remains unclear. It had been previously thought that the incidence of pain is higher when the nail was inserted by a patellar tendon-splitting approach versus a paratendon approach. According to the Keating paper, insertion of the nail through the patellar tendon was associated with a higher incidence of knee pain compared to the paratendon site of nail insertion (77% and 50% respectively). Toivanen et al. investigated this question when the group randomized fifty patients with a tibial shaft fracture requiring intramedullary nailing equally to treatment with paratendinous or transtendinous nailing. Fourteen (67%) of the twenty-one patients treated with transtendinous nailing reported anterior knee pain at the final evaluation. Of these fourteen patients, thirteen were mildly to severely impaired by the pain. Fifteen (71%) of the twenty-one patients treated with paratendinous nailing reported anterior knee pain, and ten of the fifteen were impaired by the pain. The Lysholm, Tegner, and Iowa knee scoring systems; muscle-strength measurements; and functional tests showed no significant differences between the two groups. Compared with a transpatellar tendon approach, a paratendinous approach for nail insertion does not reduce the prevalence of chronic anterior knee pain or functional impairment by a clinically relevant amount after intramedullary nailing of a tibial shaft fracture.

Humerus fractures account for 11% of all fractures among snowboarders and are the second-most-common upper-extremity fracture after radius fractures (48%). Surgical fixation is recommended for fractures with residual displacement >5 mm, or >3 mm in active patients involved in frequent overhead activity. Malunion can result in a mechanical block to shoulder abduction or external rotation and altered rotator cuff mechanics, causing weakness. A rich arterial network provides a favorable healing environment for greater tuberosity fractures. Consequently, nonunion and osteonecrosis are uncommon.

DISCUSSION: The radiograph shows a displaced type II distal clavicle fracture with nonunion. Because the patient’s symptoms are minimal, the injury can be treated like a grade III acromioclavicular separation. Present management should consist of ice, anti-inflammatory drugs, activity modification, and perhaps physical therapy. If nonsurgical management fails to provide relief, the surgical options are varied with no uniformity in the literature regarding surgical treatment of this injury. REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286. Craig EV: Fractures of the clavicle, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1998, vol 1, pp 428-482.