Orthopedic Trauma Review | Dr Hutaif Trauma & Fractures -...

Knee dislocations are known to have a high risk for vascular injury. Although the specific treatment of various combinations of ligamentous injuries is controversial, the need for emergent revascularization is not. In this particular patient, after vascular repair, the most important initial concern is protection of the vascular repair. A spanning external fixator, especially in this patient with gross instability, will allow for easier assessment of vascular status, evaluation of fasciotomy wounds,
and temporary stability of the knee. A cylinder cast can stabilize the knee but will not allow wound assessment or room for inevitable post-injury/postoperative swelling. Diagnostic knee arthroscopy is not necessary, and ligamentous repair/reconstruction should be delayed until the vascular repair is stable. PREFERRED RESPONSE: 1

The patient is relatively hemodynamically stable and is a candidate for early surgical stabilization of his injuries. The femoral shaft fracture is best managed acutely with definitive intramedullary nailing. The rotationally unstable pelvic ring injury should be addressed at the time of femoral fracture fixation. In this patient, it is best managed acutely by anterior external fixation. Distal femoral traction would not be optimal for either injury.

_**RESPONSES FOR QUESTIONS 101 THROUGH 104**_
1. Open reduction and internal fixation with absolute stability
2. Open reduction and internal fixation with relative stability
3. Closed reduction with casting
4. Reamed locked intramedullary nailing
5. External fixation
_For each of the following fractures choose the best method for definitive fixation._

FOR QUESTIONS 105 THROUGH 107:_
This scenario is a common one for the presentation of a displaced intracapsular hip fracture. Injured elderly patients not found for an extended period of time prior to hospital admission are at greater risk for the development of a venous thromboembolism and should have a screening Doppler. Whereas a tractioninternal rotation radiograph is valuable in further delineating the fracture pattern, it is not necessary in making the diagnosis. The frog lateral radiograph should be avoided in hip fracture management because it causes unneeded pain and risks displacement if none exists. An MRI scan is not indicated in a displaced fracture, but may be useful in diagnosing nondisplaced fractures. A CT scan is not warranted in the absence of clinical signs of intra-abdominal trauma or a high-energy mechanism. Surgical treatment is warranted in this ambulatory, independent patient. Whereas many studies have looked at optimal timing of surgery, no definitive time frame has been elucidated. Most authors agree that surgery is urgent and should follow optimization of all comorbid medical conditions. Technical aspects of the surgery are not dependent on time from injury. Given that this is a displaced femoral neck fracture in an elderly patient,the options of fracture repair, which include intramedullary nailing, closed reduction and pinning, and open reduction and internal fixation, are associated with high rates of complications and revision surgery.
Of the two arthroplasty choices, total hip arthroplasty has been shown to yield the best clinical and functional results with a lower rate of reoperation. Hemiarthroplasty is reserved for low functioning or minimally ambulatory patients.
_CLINICAL SITUATION FOR QUESTIONS 108 THROUGH 110**_
A 23-year-old man was injured in a high-speed motorcycle accident. He sustained bilateral pulmonary contusions, a closed left femoral fracture, an open, comminuted, contaminated, diaphyseal left tibia fracture without bone loss, and a small subdural bleed. His blood pressure in the trauma bay was 85/50 mm Hg and did not respond to initial volume resuscitation. He has a heart rate of 122/min and a core temperature of 34.7°C.

FOR QUESTIONS 108 THROUGH 110:**_
This patient is unstable and is not a good candidate for Early Total Care (ETC) and therefore should be managed by the tenets of Damage Control Orthopaedics (DCO). Débridement and external fixation is preferable for this patient. Intramedullary nails would be a component of ETC. Calcaneal traction is not considered ideal because it does not allow the patient to travel as easily. The S.P.R.I.N.T. study concluded that while reamed nails may offer benefit in closed fractures, there was no difference between reamed or unreamed nails in the treatment of open fractures of the tibia. Uniplanar external fixation and tibial plating are not considered the best options for open tibia fractures. Additional findings of the S.P.R.I.N.T. study conclude that delaying surgical intervention for at least 6 months after injury may reduce the need for reoperation.