2. Trauma MCQs

Based on Godina's classic principles, early soft tissue coverage of severe open tibia fractures, ideally within 72 hours, significantly decreases the rates of deep infection, flap failure, and nonunion compared to delayed coverage.

Sanders Type IV calcaneus fractures (highly comminuted articular surface) have extremely poor outcomes with ORIF, especially in heavy smokers who are at high risk for wound complications. Primary subtalar arthrodesis provides faster recovery and avoids secondary salvage fusions.

A pelvic binder must be centered over the greater trochanters to effectively close the pelvic ring and reduce the retroperitoneal volume. Placing it too high (e.g., over the iliac crests) is less effective and may inadvertently cause outward flaring of the lower pelvis.

In a borderline or unstable polytrauma patient with severe chest injury (pulmonary contusion) and elevated lactate, Damage Control Orthopedics is indicated. Temporary external fixation prevents the 'second hit' phenomenon (e.g., ARDS from marrow embolization during reaming) associated with early definitive nailing.

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.

DISCUSSIONThis clinical scenario describes a patient with EICS, marked by a nonphysiologic rise in muscle compartment pressure during exercise. Pressure testing is the best currently accepted method of diagnosis. Most physicians use the following criteria for diagnosis: resting pressure higher than 15 mm Hg, 1-minute postexercise pressure higher than 30 mm Hg, or 5-minute postexercise pressure higher than 20 mm Hg. Only 1-minute postexercise anterior compartment pressure of 42 mm Hg meets these criteria. Neurologic symptoms in the plantar foot would imply involvement of the posterior compartments and would not support the diagnosis of anterior compartment involvement.

Type B & C lateral condyle fxs in children are potentially unstable. Mintzer and associates recommended pinning of these fractures in the articular surface is not disrupted. To determine the status of the articular surface, they recommended arthrography. If the articular surface is intact, percpinning may be performed. If the articular surface shows that the fx line has extended into the joint and the articular surface is separated, open reduction and pinning are necessary. Once the fx is stabilized, the elbow is immobilized for 4 wks. The pins are then removed & motion is begun.back to this question next question

Lateral 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 ofpostraumatic 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:

DISCUSSION: The patient has a significantly displaced medial epicondyle fracture. The only absolute indication for surgical treatment is irreducible incarceration in the joint. Nonsurgical management usually results in a painless nonunion with good elbow function and little elbow instability. Prolonged immobilization should be avoided to prevent stiffness. Tardy ulnar nerve palsy and cubitus varus are not complications of medial epicondyle fractures. REFERENCES: Chamber HG, Wilkins KE: Part IV: Apophyseal injuries of the distal humerus, in Rockwood CA Jr, Wilkins KE, Beaty JH (eds): Fractures in Children, ed 4. Philadelphia, PA, Lippincott-Raven, 1996, vol 3, pp 801-812. Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.

This patient has atrophic non-union (NU) and varus collapse following cephalomedullary nailing of a subtrochanteric fracture. The ideal treatment involves nail removal, correction of alignment, fracture fixation, and bone grafting. Fixation can be achieved with a nail or plate.Subtrochanteric fractures can be treated with cephalomedullary nailing or fixed angle plates. Nailing of these fractures is technically challenging because the fracture must be reduced prior to nail passage. Failure to do so leads to varus and procurvatum malreduction.Bellabarba et al. reviewed plating of femoral nonunions after intramedullary nailing. Of 23 nonunions, 21 healed at an average of 12 weeks. The remaining 2 cases required repeat plating (at 2 and 8 weeks) for hardware breakage because of noncompliance with weightbearing restrictions. They advocate plating because it allows for correction of malalignment and provides a biomechanically superior tension band construct.Incorrect Answers:(SBQ12TR.48) A 28-year-old male college student sustains a severe foot injury from gunshot-related violence, and subsequently undergoes a lower-extremity amputationas shown in Figure A. At long-term follow-up, which of the following is the strongest predictor of patient satisfaction as related to his injury?Age less than 30Marijuana useUse of negative pressure wound therapyMale genderAbility to return to workThe strongest factor to predict patient-reported outcomes after trauma-related lower extremity amputations is the patient's ability to return to work. This is likely due to the effect of the return to work on the physical, emotional, and financial aspects of the patient's life.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.O'Toole et al reviewed 463 patients treated for limb-threatening lower-extremity injuries and identified factors associated with patient reported outcomes two years after surgery. They found that return to work was the most associated with outcomes, but that physical functioning, walking speed, pain levels, and presence of depression were also associated to a lesser extent with outcomes.Bosse et al performed a multicenter, prospective study to assess outcomes of 569 patients with severe lower extremity limb injuries that resulted in either amputation orlimb salvage procedures. They found that at two years postoperatively, no significant differences were seen between groups in patient-reported outcome. Worse outcomes were associated with rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), and involvement in disability-compensation litigation.Figure A shows a clinical photograph of a Pirigoff amputation at early follow-up. This amputation is an end-bearing amputation that utilizes the plantar heel pad for weightbearing, and relies on a tibiocalcaneal arthrodesis.Incorrect Answers:1-4: These options are not as strong of a factor of patient satisfaction in long-term follow up after trauma-induced lower extremity amputation.

DISCUSSION: Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not. REFERENCES: Copeland CE, Bosse MJ, McCarthy ML et al: Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma 1997;11:73-81. Wright JL, Nathans AB, Rivara FP, et al: Specific fracture configurations predict sexual and excretory dysfunction in men and women 1 year after pelvic fracture. J Urol 2006;176:1540-1545.

DISCUSSION: After an osteoporotic vertebral compression fracture, the risk of subsequent fractures at adjacent levels increases. This is felt to be the result of a shifting of the sagittal alignment more anteriorly, putting more stress on the osteopenic vertebral bodies and their anterior cortices. Pain generally resolves with rest, but this may take weeks or months. It has been demonstrated experimentally that osteoporotic vertebral bodies are actually less stiff and weaker after a compression fracture; therefore, deformity predisposes to further deformity. The extensor musculature often fatigues over time and usually does not hypertrophy. Frontal plane deformity is a rare development. REFERENCES: Heaney RP: The natural history of vertebral osteoporosis: Is low bone mass an epiphenomenon? Bone 1992;13:S23-S26. Tohmeh AG, Mathias JM, Fenton DC, et al: Biomechanical efficacy of unipedicular versus bipedicular vertebroplasty for the management of osteoporotic compression fractures. Spine 1999;24:1772-1776.

Explanation: Scaphoid nonunions are difficult to diagnose on plain radiographs, which offer poor reliability when attempting to determine if there is bridging trabeculae crossing the fracture site. CT scans are more useful for diagnosing scaphoid nonunion. When scanned using conventional axial cuts, the slices may skip through the fracture nonunion site, thereby missing the defect, even with reformats. MR imaging is useful in diagnosing acute scaphoid fractures and has a high sensitivity and diagnostic value for excluding scaphoid fractures as well. Contrast does not enhance the utility of MR imaging in fracture diagnosis.

For a patient with an unstable pelvic ring injury and hemodyamic instability, the most appropriate initial treatment method is a pelvic sheet or binder. Symphyseal plating and iliosacral screw fixation require surgical intervention and may be appropriate following initial stabilization. External fixation and the pelvic C-clamp can be applied in the emergency setting, but usually are reserved for patients who do not respond to simpler less invasive methods initially.

All five factors have been found to be associated with nonunion for type II odontoid fractures. Of these, initial fracture displacement of greater than 6 mm has the greatest association with the development of fracture nonunion.

Traumatic brain injury is considered to be either primary or secondary. Primary injury is direct or impact damage to the brain, and secondary injury can have intracranial or systemic causes. While treatment has little impact on primary brain injury, secondary brain injury can be avoided. There are many causes of systemic secondary brain injury, but none has a greater impact on outcome than hypotension or hypoxia. In fact, the occurrence of hypotension postinjury causes a 10- to 15-fold increase in mortality.

A child with a traumatic brain injury generally achieves significant neurologic recovery and has a more favorable prognosis than an adult. Early stabilization of fractures facilitates transportation of the child for diagnostic tests and decreases the incidence of shortening and malunion. Surgical treatment of the fracture is indicated when cerebral perfusion pressure has stabilized. The transverse femoral fracture in this patient is ideally suited for stabilization with flexible intramedullary nails.

Open clavicular fractures are rare and result from high-energy trauma. In a series of 20 patients with open clavicular fractures, 13 (65%) sustained a closed head injury. Fifteen (75%) had associated pulmonary injuries and 35% had a cervical or thoracic spine fracture. Screening for pulmonary and closed head injuries should be considered in the setting of traumatic open clavicular fractures.

The radiograph reveals a four-part fracture-dislocation of the proximal humerus. Humeral hemiarthroplasty and tuberosity repair is the treatment of choice because the risk of osteonecrosis is high after attempted repair of this injury. Glenoid resurfacing is reserved for acute fractures in which there is significant preexisting glenoid arthrosis, such as in patients with rheumatoid arthritis.

The radiograph shows an atrophic nonunion of the humeral shaft. The management of humeral nonunions has been studied with compression plates and bone graft, as well as intramedullary nailing and bone graft. Compression plating with bone graft results in the highest rate of union. Compression plating by itself is not adequate, given the bone loss and lack of callus in this nonunion. Pulsed electromagnetic fields is a viable option for hypertrophic nonunions where there is inherent stability. Intramedullary nailing does not provide as much compression and stability as that achieved with compression plating.