AAOS Orthopedic Trauma MCQs (Set 3): Lower & Upper Extremity Fractures | Board Review

The oblique radiograph of the wrist reveals a displaced fracture of the pisiform that usually occurs following a direct blow or sudden contraction of the flexor carpi ulnaris tendon. Persistent pain secondary to pisotriquetral incongruity and degenerative arthritis warrants pisiform excision, which does not compromise wrist flexion strength. Pisiform fractures are usually missed on routine radiographic views. An oblique or carpal tunnel view can be helpful in visualizing the pisotriquetral joint.

The patient has a significantly angulated proximal humerus fracture with a high degree of varus angulation, and rotational malalignment is likely. Failure to correct the varus angulation will result in permanent loss of shoulder abduction because the patient's age limits bony remodeling. These fractures are inherently unstable due to the inability to control the proximal fracture alignment. Shoulder spica casts have a high rate of redisplacement after treatment. Adequate open or closed reduction and pin fixation in the operating room optimizes alignment and all but eliminates the chance of redisplacement. Dobbs MB, Luhmann SJ, Gordon JE, et al: Severely displaced proximal humerus epiphyseal fractures. J Pediatr Orthop 2003;23:208-215. Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, p 701.

Iliosacral screws cannot always be placed safely due to variations in pelvic anatomy. Transiliac bars are an alternative method for fixation but are placed using an open technique. A screw can be placed percutaneously through both iliac wings posterior to the posterior border of the sacrum. The starting point is visualized using a lateral C arm shot and is located on the posterior iliac crest at about the level of the S1 body where the crest has its largest area posterior to the sacrum. This area is labeled A in the figure, B represents the sacral canal, C is S1, D is the area cephalad to the iliocortical density, and E is the anterior border of the sacrum. The radiograph demonstrates a well-placed sacroiliac screw. Moed BR, Fissel BA, Jasey G: Percutaneous transiliac pelvic fracture fixation: Cadaver feasibility study and preliminary clinical results. J Trauma 2007;62:357-364.

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a "Velpeau" axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.

Ninety percent of injuries to the proximal radius in children are radial neck fractures, and 50% of these fractures are through the metaphyseal bone. The remaining 50% are Salter-Harris type I or II fractures. These radiographs show a fracture of the radial head and subluxation of the radius anteriorly. Most congenital radial head dislocations are posterior lateral. Nonsurgical treatment modalities are unlikely to be successful due to the wide displacement of the fracture fragments, as well as dislocation of the radial head. Leung AG, Peterson HA: Fractures of the proximal radial head and neck in children with emphasis on those that involve the articular cartilage. J Pediatr Orthop 2000;20:7-14. Hashemi-Nejad A, Goddard NJ: Radial head fractures. Br J Hosp Med 1994;51:223-226.

The patient has a neglected PIP joint fracture-dislocation with comminution involving more than 40% of the volar articular surface of the middle phalanx. Volar plate arthroplasty has been advocated for the treatment of acute unstable and chronic dorsal fracture-dislocations. The volar plate is incised laterally and released from the collateral ligaments. The volar fragments of the middle phalanx are removed and a trough is created for advancement of the volar plate, which is secured with sutures secured on the dorsum of the middle phalanx beneath the extensor mechanism. Dionysian E, Eaton RG: The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint. J Hand Surg Am 2000;25:429-437. Eaton RG, Malerich MM: Volar plate arthroplasty of the proximal interphalangeal joint: A review of ten years' experience. J Hand Surg Am 1980;5:260-268.

Displaced fractures of the scaphoid are best treated with compression screw fixation. Proximal third fractures (as in this patient) are optimally approached via a dorsal approach to ensure proper reduction and compression. Fractures of the scaphoid waist can be approached either by a volar or a dorsal approach. Kirschner wire fixation is limited to proximal pole fractures that are too small to accommodate the trailing head of a compression screw. Retting ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole fractures. J Hand Surg Am 1999;24:1206-1210.

The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment. Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.

An isotropic material is one that has similar mechanical properties regardless of the orientation of the material. Examples of isotropic materials include metals, plastics, and methacrylate. Most biologic tissues are anisotropic, meaning their mechanical properties alter depending on the materials' orientation to the applied stress.

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. 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.

A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures. Buckley R, Tough S, McCormack R, et al: Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 2002;84:1733-1744. Sanders R: Displaced intraarticular fractures of the calcaneus. J Bone Joint Surg Am 2000;82:225-250.

The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region. Ring D, Quintero J, Jupiter JB: Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg Am 2002;84:1811-1815. Ring D, Jupiter JB, Zilberfarb J: Posterior dislocation of the elbow with fractures of the radial head and coronoid. J Bone Joint Surg Am 2002;84:547-551.

The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome. Shafi S, Elliot AC, Gentilello L: Is hypothermia simply a marker of shock and injury severity or an independent risk factor for mortality in trauma patients? Analysis of a large national trauma registry. J Trauma 2005;59:1081-1085. Pape HC, Hildebrand F, Pertschy S, et al: Changes in the management of femoral shaft fractures in polytrauma patients: From early total care to damage control orthopedic surgery. J Trauma 2002;53:452-461.

The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.

The technique of intramedullary nailing with titanium elastic nails is based on the concept of balanced forces across the fracture site with two equally sized nails. Implantation of the largest sized nails possible, with two equally sized nails, maximizes the stiffness at the fracture site, thereby optimizing fracture alignment and stability. Impacting the nails into the medullary canal can impact the fixation by minimizing distal purchase of the nail at the cortical insertion site. Closed reduction commonly permits bony reduction and passage of the nails; open reduction is reserved for inability to align the fracture. Luhmann SJ, Schootman M, Schoenecker PL, et al: Complications of titanium elastic nails for pediatric femur fractures. J Pediatr Orthop 2003;23:443-447. Lascombes P, Haumont T, Journeau P: Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop 2006;26:827-834.

The risk of infection in a 3B open tibia fracture is most directly related to the timing of the soft-tissue coverage and less related to the size or location of the wound. The wound VAC does not lower or raise the risk of infection in open fractures. It does appear to increase the window of time to obtain coverage without increasing the risk of infection. Additionally, the wound VAC may decrease the probability of needing free tissue coverage. Intramedullary nailing has not been shown to lower the risk of infection in 3B fractures. Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-292. Dedmond BT, Kortesis B, Punger K, et al: The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibia shaft fractures. J Orthop Trauma 2007;21:11-17.

The radiograph reveals a distal clavicle fracture. In children, a periosteal sleeve will remain attached to the intact coracoclavicular ligament, and as such, remodeling can be expected. Therefore, nonsurgical management with a sling is preferred. Surgical treatment is not necessary, and a shoulder spica cast offers no advantage over a simple sling.

The mainstay of early treatment of open fractures includes irrigation and debridement. Prior to the development of antibiotics, this was traditionally accomplished with some form of detergent irrigation. Antibiotic irrigation has been in favor more recently but has mixed scientific results related to its use. Results of at least one major study show the use of a nonsterile liquid soap additive (castile soap) is at least as effective as the use of bacitracin with regards to the rate of postoperative infection and fracture healing, and shows a significant decrease in problems with soft-tissue healing.

Symphyseal widening of greater than 2.5 cm and less than 5 cm denotes an AP II injury and a rotationally unstable pelvis. An AP II pelvic ring injury is best treated with anterior open reduction and internal fixation. Nonsurgical management is reserved for AP I injuries. Pelvic binders are used only acutely and should not be used for definitive management. Iliosacral screws usually are not necessary in the acute management of AP II injuries. Matta JM: Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996;329:88-96. Templeman DC, Schmidt AH, Sems AS, et al: Diastasis of the symphysis pubis: Open reduction internal fixation, in Wiss D (ed): Masters Techniques in Orthopaedic Surgery-Fractures, ed 2. Philadelphia, PA, Lippincott Williams and Wilkins, 2006, pp 639-648.

The superior gluteal artery is a branch of the posterior division of the internal iliac artery and exits the pelvis through the greater sciatic notch. It can be injured as a result of a pelvic ring fracture or acetabular fracture that has a fracture of the posterior column. Agur AM, Dalley AF (eds): Grant's Atlas of Anatomy, ed 12. Philadelphia, PA, Lippincott Williams and Wilkins, 2008.

The patient sustained a growth plate fracture of the distal radius and ulna. Although treated with closed reduction and casting, the follow-up radiographs demonstrate shortening of the radius in comparison to the ulna, and the MRI scan confirms thinning of the distal radius growth plate and bony bars consistent with a growth arrest. At this time, the discrepancy in length is too minor to consider lengthening of the radius; in addition, excision of a physeal bar with minimal growth potential is not likely to restore the gross discrepancy. Ulnar styloid fractures are rarely symptomatic and do not require treatment in the asymptomatic patient. Closure of the distal ulna growth plate will prevent further discrepancy between the radius and ulna. Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.

The development of femoral head ischemic necrosis is the iatrogenically created complication in this skeletally immature patient. Placement of a rigid, antegrade intramedullary nail through the piriformis fossa is likely to damage the vascular supply to the femoral head as the vessels ascend the femoral neck on the way to the femoral head. The MRI scan reveals ischemic necrosis with early collapse of the femoral head. The joint space is preserved on the MRI scan, ruling out chondrolysis. Letts M, Jarvis J, Lawton L, et al: Complications of rigid intramedullary rodding of femoral shaft fractures in children. J Trauma 2002;52:504-516. Buckley SL: Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop Relat Res 1997;338:60-73.

The radiograph reveals a "bony mallet injury." As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate. Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.

The patient has spinal shock. Steroid administration and MRI are appropriate therapeutic and diagnostic procedures. Myelography with CT is of little value unless there is an unusual skeletal variant. Spinal cord-evoked potentials have no value. The best method to determine the patient's neurologic recovery is repeated physical examinations over the first 48 to 72 hours. Spivak JM, Connolly PF (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 183-184.

The patient has a zone 1 base of the fifth metatarsal fracture (Pseudojones) that represents a less serious injury compared to zone 2 and 3 fractures with regard to healing potential. Treatment is symptomatic and casting is not necessary. These fractures are well treated with a hard-soled shoe for comfort and weight bearing as tolerated. Surgical intervention is not warranted. Vorlat P, Achtergael W, Haentjens P: Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop 2007;31:5-10. Wiener BD, Linder JF, Giattini JF: Treatment of fractures of the fifth metatarsal: A prospective study. Foot Ankle Int 1997;18:267-269.