2. Trauma MCQs

Hertel et al. described the geometric predictors of humeral head ischemia. The combination of an intact medial hinge (>2 mm displacement indicates disruption) and a short metaphyseal head extension (calcar length <8 mm) attached to the articular segment are the most powerful predictors of ischemia, carrying a positive predictive value of 97% for AVN.

The coracoclavicular (CC) ligaments consist of the conoid and trapezoid. The conoid ligament is located medial and posterior (inserting on the conoid tubercle of the clavicle), and it acts as the primary restraint to superior/inferior translation. The trapezoid ligament is lateral and anterior (inserting on the trapezoid line), acting as the primary restraint to axial compression.

Bryan and Morrey Classification of capitellar fractures: Type I (Hahn-Steinthal) involves a large osseous component. Type II (Kocher-Lorenz) is a shear fracture involving articular cartilage with minimal attached subchondral bone (the 'uncapped' appearance). Type III (Broberg-Morrey) is highly comminuted. Type IV (McKee) extends medially to include the lateral trochlear ridge.

Anteromedial facet fractures of the coronoid provide critical varus and posteromedial rotatory stability to the elbow. They must be rigidly fixed (e.g., suture lasso, screws, or plate) to restore joint congruity and stability.

When elbow extension remains limited after anterior capsular release, the next step is to address the posterior impingement. This involves excising the posterior capsule and frequently resecting the tip of the olecranon.

The conoid ligament inserts more medially (approximately 45 mm from the distal clavicle), whereas the trapezoid inserts more laterally (approximately 25 mm from the distal clavicle). Restoring this footprint optimizes the biomechanics of the AC joint.

DISCUSSIONMany factors can lead to delayed union or nonunion after medial opening-wedge high tibial osteotomy; the factor most associated with delayed union or nonunion is smoking. Other factors include obesity and unstable lateral hinge fractures, but to a lesser extent. An accelerated weight-bearing protocol has no effect on union. The use of locking screws should increase construct stability and is not associated with osteotomy delayed union or nonunion.

DISCUSSION: Measurements of compartment pressures in patients with tibial fractures and compartment syndrome reveal that the highest tissue pressures are recorded at the level of the fracture or within 5 cm of the fracture. Tissue pressures show a statistically significant decrease when they are recorded at increasing distances proximal and distal to the site of the highest pressure recorded. To reliably determine the location of the highest tissue pressure in patients with tibial fractures, measurements should be obtained, at a minimum, in both the anterior and deep posterior compartments at the level of the fracture, as well as at locations proximal and distal. The highest tissue pressure recorded should serve as a basis for determining the need for fasciotomy.

DISCUSSION: The tibia has grown into valgus secondary to the proximal fracture. This occurs in about one half of these injuries, and maximal deformity occurs at 18 months postinjury. The deformity gradually improves over several years, with minimal residual deformity. Therefore, treatment at this age is unnecessary as there is a high rate of recurrence and complications regardless of technique. The valgus deformity is not a result of physeal injury or growth arrest. Medial proximal tibial hemiepiphysiodesis is an excellent method of correcting the residual deformity but is best reserved until close to the end of growth.

DISCUSSION: Usage of a starting point that is too anterior leads to creation of significant hoop stresses in the proximal segment, potentially leading to iatrogenic fracture of the proximal segment. The referenced study by Johnson et al reviews the topic of femoral bursting and notes that even shifting 6 mm too far anteriorly can lead to proximal femoral fracture creation.

This patient has a bisphosphonate-related (BP) fracture. There is increased risk of iatrogenic fracture with IM nailing of this fracture.Subtrochanteric fractures are fractures extending from the lesser trochanter to 5cm distal to it. BP fractures are characterized by (1) focal lateral cortical thickening, (2) transverse fracture orientation, (3) medial spike and (4) lack of comminution. There is increased risk of iatrogenic fracture with IM nailing because BP fractures have thickened, brittle cortices and the mismatch between medullary diameter and increased proximal nail diameter results in iatrogenic fracture.Weil et al. reviewed the outcome of surgically treated bisphosphonate fractures. IM nailing resulted in healing in 54% of bisphosphonate fractures with 98-99% of conventional fractures. In their study, 46% required revision procedures.Prasarn et al. compared plate and nail treated bisphosphonate fractures with conventional fractures. They found that the bisphosphonate group had more major and minor complications (68%) than the conventional group (10%). The most common complications were intraoperative femoral shaft comminution (nail) and hardware failure (plate).Figure A shows diffuse cortical thickening with an antero-lateral cortical ridge. Figure B shows a transverse subtrochanteric fracture extending through the middle of the cortical ridge seen previously. Note also healed fractures of the left superior and inferior rami. Figure C is a post-reduction radiograph showing the transverse fracture through the beak-shaped region of the previous insufficiency fracture. Illustration A shows a typical bisphosphonate-related fracture with transverse fracture orientation,focal lateral cortical thickening (white arrows), medial beak (black arrow), and lack of comminution. Illustration B shows a conventional subtrochanteric fracture. Illustration C shows intraoperative iatrogenic fracture with anterolateral comminution during nailing. Illustration D shows fixation with a proximal femoral hook LCP Plate with late hardware failure at 3 months.Incorrect Answers:

Plate fixation (with bone graft as needed) is the procedure of choice for humeral shaft nonunions.Rubel et al in a combined cadaveric and clinical study comparing one versus two plate constructs for humeral nonunions found that the two plate construct was significantly stiffer, but had no difference in healing rate compared with a single plate construct; 92% of the humeral shaft nonunion patients went onto union with rigid plate fixation.Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. Theyreport 100% union rate with locking plate fixation of these humeral shaft nonunions, with use of autograft in >50% of their cases. Subjective shoulder scores were excellent or good in 22 of 24 patients.Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.OrthoCash 2020

Tension band wire fixation of olecranon fractures is recommended for fracture patterns that are proximal to the coronoid process and are relatively transverse to withstand compressive forces. When comminution is present, a neutralization technique such as plating is preferred over a compressive technique such as tension band wire fixation. Such neutralization plating, if performed correctly, does not have the risk of narrowing the sigmoid notch as tension band wire fixation would. Fractures of the tip of the olecranon, transverse fractures, fractures associated with osteoporosis, and displaced fractures are all relative indications for tension band wire fixation.

The next best step is an MRI of the hip and pelvis to investigate for an occult fracture. Moderate evidence supports MRI as the advanced imaging of choice for the diagnosis of presumed hip fractures not apparent on initial radiographs.

The severity of injuries and the lack of physiologic reserve in this and other elderly patients often result in mortality. Base deficit has shown to be a reliable predictor of mortality even in normotensive elderly blunt trauma patients. Although tachycardia, low systolic blood pressure, and low hemoglobin may all contribute to these patients' mortality, base deficit may be used as a predictor of mortality and a measure of resuscitation.

The patient has a simple fracture pattern that can be reduced anatomically and stabilized with absolute stability by interfragmental compression and protection plating. This will guarantee a 95% to 98% union rate.

Intertrochanteric hip fractures with lateral wall fractures should be treated with an intramedullary device as opposed to a sliding hip screw, as the intact lateral wall provides a buttress for the proximal fragment facilitating fracture impaction as well as rotational and varus stability.Palm et al showed that 22% of patients with a fractured lateral femoral wall underwent reoperation for collapse of fracture compared to 3% with an intact lateral femoral wall. Interestingly, 74% of the lateral proximal femoral wall fractures were iatrogenic during the procedure itself.Gotfried et al reported on 24 patients with postoperative intertrochanteric hip fracture collapse and noted that this complication followed fracture of the lateral wall in every instance and resulted in a protracted period of disability until fracture healing. They recommend care when drilling at the base of the lateral wall intraoperatively.Lindskog et al review the diagnosis, treatment, as well as biomechanical reviews of treatment options for unstable intertrochanteric hip fractures.Incorrect Answers:OrthoCash 2020

DISCUSSION: Multiple authors have shown similar infection rates for grade 1 and 2 open medial fractures and closed fractures that have been treated with an extensile lateral approach and open reduction and internal fixation. Patients only need IV antibiotics for 2 to 3 days after surgery. Formal open reduction and internal fixation is not recommended for grade 3 medial wounds and most lateral wounds.

DISCUSSION: Denis divided the sacrum into three zones: zone 1 represents the lateral ala, zone 2 represents the foramina, and zone 3 represents the central canal. A fracture is classified according to its most medial extension. Those in zone 3 are typically bursting-type fractures or fracture-dislocations and are most prone to neurologic sequelae.

Supervised exercise therapy with static or dynamic progressive elbow splinting over a 6 month period has shown to have the greatest improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness.The goal of treatment in post-traumatic stiffness is to restore a functional range of elbow motion (30° to 130°). Non-operative modalities are considered the first-line of treatment. Aggressive physical therapy has traditionally been advocated. However, the use of static or dynamic progressive elbow splinting with a turnbuckle has shown to provide better functional outcomes. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.Gelinas et al. treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 +/- 1.8 months. The mean range of motion improved from 32 - 108, to 26 - 127 degrees (p = 0.0001). Their results suggest that static progressive splinting is an effective modality for postoperative elbow stiffness.Lindenhovius et al. randomized sixty-six patients with post-traumatic elbow stiffness into static progressive elbow splint therapy or dynamic elbow splinting over a 12month period. There was no significant difference in outcomes between treatment modalities. ROM increased by 40° vs. 39° at six months, respectively. DASH scores improved from 50 vs 45 at enrollment to 32 vs. 25 at six months, respectively.Illustration A shows an image of a static progressive elbow splint. Incorrect Answers:(SBQ12TR.94) A 60-year-old otherwise healthy female sustains the fracture in FigureA. Immediate surgical treatment would most likely prevent which of the following complications?Malunion.Regional osteopenia.Skin necrosis.Posttraumatic arthritis.Refracture.The patient has a calcaneal tuberosity fracture. The Achilles tendon is attached to the displaced fragment, which can cause soft tissue compromise and skin necrosis if not treated promptly.Displaced calcaneal tuberosity and tongue-type calcaneus fractures have a high incidence of wound complications if not treated urgently. Recommended management includes surgical fixation often performed percutaneously. Lag screws are typically directed from the posterior superior tuberosity inferiorly and distal. In cases of skin sloughing and skin necrosis, flaps may be needed.Gardner et al. reviewed 139 tongue-type calcaneus fractures, and found that 21% had some degree of posterior skin compromise. Additionally, there was a statistically significant increase in posterior skin compromise with delayed presentations.Hess et al. reviewed 3 cases of calcaneal tuberosity avulsion fractures that let to skin necrosis because of a delay in treatment.Tornetta reviewed the indications for percutenaous treatment of calcaneus fractures, and found it was successful and most useful in tongue-type calcaneus fractures.Figure A shows a lateral radiograph of a R ankle showing a calcaneal tuberosity fracture. Illustration A shows an AP radiograph of a R ankle following percutaneous reduction and internal fixation of the calcaneus fracture with two cannulated screws. Illustration B shows a lateral radiograph of a R ankle showing interval reduction and fixation of the calcaneus fracture. Illustration C shows a clinical photograph of posterior skin compromise associated with a calcaneal tuberosity fracture.Incorrect Answers:Malunion, regional osteopenia, posttraumatic arthritis, and refracture risk would not be significantly altered with immediate surgical intervention as opposed to operative management within a reasonable time frame.