AAOS & ABOS Trauma MCQs (Set 2): Cervical Spine, Pilon & Forearm Fractures | Board Prep

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. Kreig JC, Mohr M, Ellis TJ, et al: Emergent stabilization of pelvic ring injuries by controlled circumferential compression: A clinical trial. J Trauma 2005;59:659-664. Croce MA, Magnotti LJ, Savage SA, et al: Emergent pelvic fixation in patients with exsanguinating pelvic fractures. J Am Coll Surg 2007;204:935-942.

The child has isolated ipsilateral femoral shaft and tibial shaft fractures. Spica cast immobilization is unlikely to accommodate for shortening and alignment in this child with multiple levels of injury. In this instance, efforts should be made to mobilize a least one level of the limb; therefore, treatment should include flexible nailing of the femur and tibia. Rigid reamed nails are not indicated in this young patient secondary to risk of a growth arrest and osteonecrosis of the proximal femur. Poolman RW, Kocher MS, Bhandari M: Pediatric femoral fractures: A systematic review of 2422 cases. J Orthop Trauma 2006;20:648-654. Anglen JO, Choi L: Treatment options in pediatric femoral shaft fractures. J Orthop Trauma 2005;19:724-733.

The AMA report identified communication breakdown as the most common cause of errors that harm patients. It is extremely important to learn to communicate effectively with your patients. Understanding cultural and language differences helps avoid communication errors. Jimenez R, Lewis VO (eds): Culturally Competent Care Guidebook. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2007. American Medical Association ethical force program report: "Improving communication - Improving care", 2006

Although the end points of resuscitation are still unclear, what is known is that normalization of the standard hemodynamic parameters (blood pressure, heart rate, and urine output) is not adequate. Up to 85% of patients with normal hemodynamic parameters can still have inadequate tissue oxygenation or uncompensated shock. The initial base deficit, lactate level, or gastric pHi can be used to stratify patients for resuscitation needs, risks of death, and multiple organ failure (level 1 evidence). The time it takes to normalize the base deficit, the lactate level, or gastric pHi, can predict survival (level 2 evidence). Patients who have been in uncompensated shock (abnormal vital signs) should have their resuscitation monitored using data other than vital signs. Tisherman SA, Barie P, Bokhari F, et al: Clinical practice guideline: Endpoints of resuscitation. J Trauma 2004;57:898-912. Moore FA, McKinley BA, Moore EE, et al: Inflammation and the Host Response to Injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care. III. Guidelines for shock resuscitation. J Trauma 2006;61:82-89.

Fortunately, surgical treatment of sub-acute pelvic ring injuries is relatively uncommon as acute management has become more common. Delayed reconstruction of pelvic ring malunion and impending malunion is rare. Nonsurgical management may have a role as long as the hemipelvis does not flex, shorten, and/or externally rotate. The AP pelvic radiograph suggests that all three motions are happening in this patient. These are just a few of the indications to repair the pelvic ring and this is best done with anterior and posterior fixation. Anterior symphyseal plating will help correct most of the deformity. Posterior fixation can and should be added to lessen the forces on the anterior ring reconstruction when repair is performed in a sub-acute or delayed fashion. Posterior fixation can help obtain a more anatomic reduction and helps decrease the risk of anterior hardware failure. Mears DC: Management of pelvic pseudarthroses and pelvic malunion. Orthopade 1996;25:441-448. Matta JM, Dickson KF, Markovich GD: Surgical treatment of pelvic nonunions and malunions. Clin Orthop Relat Res 1996;329:199-206.

Mortality following trauma that requires surgical intervention for head, chest, and abdominal injury exceeds 90%. The type of pelvic fracture is a predictor of associated injury, blood requirements, and overall mortality. AP III pelvic fractures require the most blood, and are associated with significant abdominal trauma and shock. Lateral compression pelvic fractures are more associated with head, chest, and occasionally abdominal trauma, and mortality often occurs from associated injuries. Dalal SA, Burgess AR, Siegel JH, et al: Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. J Trauma 1989;29:981-1000. Eastridge BJ, Burgess AR: Pedestrian pelvic fractures: 5-year experience of a major urban trauma center. J Trauma 1997;42:695-700.

The radiographs reveal a bony avulsion of the flexor profundus insertion (Jersey finger). The large bony fragment classifies this as a Leddy type III injury. The bony fragment has retracted to the level of the annular pulley (A4). Leddy JP, Packer JW: Avulsion of the insertion of the profundus tendon insertion in athletes. J Hand Surg 1977;2:66-69.

The radiographs reveal a gap between the scaphoid and lunate bones, indicative of disruption of the scapholunate ligament complex. The three components of the complex are the dorsal scapholunate ligament, the volar (or palmar) scapholunate ligament, and the proximal fibrocartilaginous membrane, listed in decreasing yield strength. Disruption of the stout dorsal interosseous ligament is required for scapholunate dissociation to occur. Berger RA: The ligaments of the wrist: A current overview of anatomy with considerations of their potential functions. Hand Clin 1997;13:63-82.

Safe placement of a sacroiliac screw depends on excellent imaging of and understanding of pelvic anatomy. There are variations in the anatomy of the upper sacrum. Patients with dysplasia of the sacrum can have "in-out-in" screws placed that exit the ilium, pass anterior to the sacral ala, and injure the L5 nerve root. To make sure that this does not occur, a lateral image of the sacrum is used to ensure that the starting point is in the "safe zone." The starting point needs to be below the iliac cortical density (ICD) which parallels the sacral alar slope. This will prevent placing screws into the recessed ala of patients with a dysplastic sacrum. The triangular area anterior to the ICD is labeled A in the figure, B represents the sacral canal, C is S2, D is the anterior border of the sacrum, and E represents the greater sciatic notches. Routt ML Jr, Simonian PT, Agnew SG, et al: Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: A cadaveric and clinical study. J Orthop Trauma 1996;10:171-177.

The intraoperative radiograph reveals a scapholunate ligament disruption. Repair of the stout dorsal scapholunate interosseous ligaments is required. Interestingly, the results of scapholunate ligament injuries associated with distal radius fractures appear to be superior to those of isolated ligament injuries. Smith DW, Henry MK: Comprehensive management of soft-tissue injuries associated with distal radius fractures. J ASSH 2002;3:153-164.

A recent review of 200 consecutive distal radius fractures noted that the overall incidence of extensor pollicis longus rupture was 3%. The causes are believed to be mechanical irritation, attrition, and vascular impairment. The fracture is usually nondisplaced and the patient notes weeks to months after injury the sudden, painless inability to extend the thumb. Treatment involves extensor indicis proprius tendon transfer or free palmaris longus tendon grafting. Skoff HD: Postfracture extensor pollicis longus tenosynovitis and tendon rupture: A scientific study and personal series. Am J Orthop 2003;32:245-247. Bonatz E, Kramer TD, Masear VR: Rupture of the extensor pollicis longus tendon. Am J Orthop 1996;25:118-122.

According to the published outcomes analyses from the Lower Extremity Assessment Project (LEAP) study group of patients prospectively followed for 2 to 7 years, definitive fixation with an intramedullary nail has shown improved outcomes when compared to definitive external fixation. The findings showed that the timing of wound debridement (within 6 hours from injury as compared to within 6 to 24 hours), the timing of soft-tissue coverage (3 days or less from injury as compared to more than 3 days), and the timing of bone grafting after injury (within or after 3 months) did not impact the infection or union rates and had no effect on functional outcome. 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.

Definitive treatment decisions for displaced distal radius fractures in the elderly are based on a number of factors related to the fracture pattern and patient demographics. The first step in any treatment algorithm is a closed reduction and splinting with reassessment of alignment parameters. This is an extra-articular fracture with dorsal angulation. Low-demand elderly patients can be treated well with accepted minor malreduction. Handoll HH, Madhok R: Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;2:CD000314.

Marsh and associates retrospectively reviewed 56 tibial plafond fractures and found that the patients perceived improvement in their function and pain for an average of 2.4 years. They demonstrated some limitations in recreational activities but not marked limitations. Patients were unlikely to need a late arthrodesis (13%), and their outcomes did not correlate well with assessments of reduction or arthritis scores.

The CT cut shows a fracture through the posterior portion of the iliac wing or a crescent fracture. This occurs after a laterally directed force is applied to the anterior part of the involved iliac wing.

A spectrum of perilunate injury patterns exists, with the dorsal trans-scaphoid perilunate fracture-dislocation being the most common. Perilunate injuries are highly unstable complex carpal disruptions that are not amenable to closed treatment. Open reduction and internal fixation is necessary to accurately restore carpal alignment via fracture reduction and fixation and intercarpal ligament repair. Controversy exists regarding the need for dorsal or combined dorsal and volar approaches. Based on the radiographic findings of a volar dislocation of the lunate and the associated median nerve injury, the patient requires open reduction and internal fixation via combined dorsal and volar approaches with a concomitant carpal tunnel release. Herzberg G, Forissier D: Acute dorsal trans-scaphoid perilunate fracture-dislocations: Medium-term results. J Hand Surg Br 2002;27:498-502. Melone CP Jr, Murphy MS, Raskin KB: Perilunate injuries: Repair by dual dorsal and volar approaches. Hand Clin 2000;16:439-448.

The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare. Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120. Cannata G, De Maio F, Mancini F, et al: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179. Ray TD, Tessler RH, Dell PC: Traumatic ulnar physeal arrest after distal forearm fractures in children. J Pediatr Orthop 1996;16:195-200.

The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally. Jebson PL, Louis DS: Amputations, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 1947.

There is a high incidence of partial or complete laceration of the radial nerve with high-energy open fractures of the humeral shaft. The recommended treatment is irrigation and debridement of the fracture followed by open reduction and internal fixation and exploration of the radial nerve. If the nerve is completely lacerated, primary repair may be performed but poor outcomes have been reported. If a large zone of nerve injury is identified, delayed nerve grafting is advocated. Ring D, Chin K, Jupiter JB: Radial nerve palsy associated with high energy humeral shaft fractures. J Hand Surg 2004;29:144-147. Foster RJ, Swiontkowski MR, Bach AW, et al: Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am 1993;18:121-124.

Implant-related fractures following hip fracture surgery were reported by Robinson and associates and showed that the risk of an ipsilateral femoral fracture is significantly increased with the use of short cephalomedullary nails as compared to a compression hip screw. The use of short cephalomedullary nails has not been shown to increase the risk of deep venous thrombosis or nonunion. Cephalomedullary nails overall have decreased surgical blood loss when compared to use of sliding-compression hip-screw devices. Robinson CM, Adams CI, Craid M, et al: Implant-related fractures of the femur following hip fracture surgery. J Bone Joint Surg Am 2002;84:1116-1122.

Incarcerated fragments and nonconcentric reductions are best treated with urgent open reduction, retrieval of the fragments, and internal fixation. Delayed treatment increases the damage to the articular surface, even if traction is applied. There is no role for nonsurgical management with entrapped fragments and nonconcentric reduction of the hip. Epstein HC, Wiss DA, Cozen L: Posterior fracture dislocation of the hip with fractures of the femoral head. Clin Orthop Relat Res 1985;201:9-17.

The sheath of the psoas muscle or the iliopectineal fascia separates the more lateral iliopsoas muscle and the femoral nerve from the more medially located iliac vessels. This fascia has to be taken down to enter the true pelvis. Masquelet AC, McCullough CJ, Tubiana R: An Atlas of Surgical Exposures of the Lower Extremity. Philadelphia, PA, JB Lippincott, 1993. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.

Isolated Lauge-Hansen supination-external rotation-type ankle fractures comprise 20% to 40% of ankle fractures and nonsurgical management is effective for managing SER-2 ankle fractures. Tornetta and associates recently showed that medial ankle tenderness, ecchymosis, and swelling are not reliable findings when trying to determine deltoid competence. Stress radiographs showing a medial clear space of greater than 4 mm or one that is also 1 mm greater than the superior joint space, or any lateral talar subluxation are indicative of deltoid incompetence and indicative of a SER-4 ankle fracture. McConnell T, Creevy W, Tornetta P III: Stress examination of supination external rotation-type fibular fractures. J Bone Joint Surg Am 2004:86;2171-2178. Kristensen KD, Hansen T: Closed treatment of ankle fractures: Stage II supination-eversion fractures followed for 20 years. Acta Orthop Scand 1985;56:107-109.

Salter type I fractures of the distal femur are quite unstable; therefore, closed reduction and cast immobilization can be expected to result in high rates of redisplacement. Optimal treatment consists of open or closed reduction and smooth pin fixation, and supplemental casting is required to ensure fracture stability. Screw fixation may increase rates of growth plate injury. Blade plate or flexible nail fixation will be challenging to apply and is not necessary. Flynn JM, Skaggs DL, Sponseller PD, et al: The surgical management of pediatric fractures of the lower extremity. Instr Course Lect 2003;52:647-659. Thomson JD, Stricker SJ, Williams MM: Fractures of the distal femoral epiphyseal plate. J Pediatr Orthop 1995;15:474-478.

The clinical photographs indicate that the tenodesis effect of digit flexion with passive wrist extension and digit extension with passive wrist flexion is intact, indicating no discontinuity of the extensor or flexor tendons. The most likely injury is a laceration of the posterior interosseous nerve.