Updated Orthopedic Review | Dr Hutaif General Orthopedi -...

and repair of the lateral ulnar collateral ligament and medial collateral as needed
The results of elbow dislocations with associated radial head and coronoid fractures are often poor because of recurrent instability and/or stiffness from prolonged immobilization. Therefore radial head replacement and open reduction internal fixation of the coronoid is the most appropriate treatment.
Pugh et al reported their experiences with this difficult population. Their protocol consisted of ORIF or replacement of the radial head, ORIF of the coronoid fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged external fixation. Of the 36 cases, the outcome was graded as 28 excellent to good, 7 fair, and 1 poor. 8 cases required re-operation. The authors concluded that their surgical protocol restored sufficient elbow stability to allow early motion post-op, thereby enhancing the functional outcome. In fracture dislocation of the elbow with radial head and coronoid fracture, the radial head must be fixed or replaced to restore stability. The ORIF of coronoid fracture and radial head restores some valgus stability therefore MCL repair may not be needed. However, the varus stability must be restored by LCL repair.

The clinical scenario and radiographs are consistent with a Gustilo and Anderson type 3A open tibia fracture.
Melvin et al review the evidenced-based literature and make recommendations for the initial evaluation and management of open tibial shaft fractures. The time elapsed before antibiotic administration and adequate surgical debridement of all contamination are the only factors definitively shown to reduce infection and improve outcome. Traditional recommendations have suggested surgical debridement of open fractures occur within 6 hours of injury. However, there is no literature to support this time window. Certainly, open fractures should be addressed with urgency, but there is no evidence reporting a definitive time window. There is insufficient data to recommend gram negative coverage with gentamicin for all open fractures although this is a common practice. The addition of antibiotics to the irrigation solution has been shown to decrease bacterial load, but it has also demonstrated host tissue necrosis and delayed wound healing. There is not sufficient data to support its use over a castile soap solution or normal saline. Similarly, high pressure pulsatile lavage decreases bacterial load, but also seeds bacteria deeper within the soft tissues and harms host tissues. There is no evidence to support pulsatile lavage over gravity flow.

5/. Fragment excision and advancement of the triceps tendon
The radiograph shows an olecranon fracture with articular comminution and depression of a large intra-articular fragment. This pattern is best treated with plate fixation to support the articular reduction.
Bailey et al reviewed 25 cases of olecranon fractures (simple and comminuted fracture patterns) treated with plate fixation. All 25 went on to union. There were no major complications reported. Twenty percent of patients underwent hardware removal at a later date for prominence.
Hak et al review the treatment options available for olecranon fractures. Simple intra-articular fractures without comminution are suitable for tension band fixation. Comminution of the articular surface is an indication for plate fixation and may benefit from bone graft to support depressed articular segments. Osteoporotic patients or fractures with severe comminution may do better with fragment excision and advancement of the triceps.

4/. Total elbow arthroplasty
5/. Casting for 4 weeks then ROM
Total elbow arthroplasty (TEA) is ideal for treating comminuted osteoporotic fractures of the distal humerus in low demand elderly patients. Outcomes are good to excellent with quick return of stability and functional motion but with carrying weight restriction of 5 lbs. ORIF would be the best choice for younger individuals with better bone quality.
Cobb described the outcomes of 21 total elbow arthroplasties in elderly patients all of which had good or excellent results without evidence of component loosening. The mean motion was 25 to 130 degrees. Complications included fracture of the ulnar component in one patient after another fall, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one.
McKee et al. performed a randomized controlled study of TEA versus fixation and found that TEA for the treatment of comminuted intra-articular distal humeral fractures resulted in more predictable and improved 2-year functional outcomes compared with ORIF. They also found that although elderly patients with this injury have an increased baseline DASH score, they appear to accommodate to objective limitations in function with time.
Frankle et al. retrospectively compared TEA to plate fixation for distal humerus fractures in the elderly and found a significant improvement in outcomes and revision rates with TEA as compared to plate fixation. The differences were seen most in women with associated comorbidities, such as rheumatoid arthritis, osteoporosis, and conditions requiring the use of systemic steroids.

5/. Symphysiotomy
The clinical presentation and radiograph is consistent with an open-book type parturition-induced pelvic dislocation.
The case series by Kharrazi et al reports four patients treated with open-book type parturition-induced pelvic dislocations. The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a postpartum symphyseal diastasis less than 4.0 cm. All four patients had significant symptoms and radiographic widening (anterior splaying) of the sacroiliac joints. The three patients who had presented acutely were treated with closed reduction and application of a pelvic binder, while two had closed reduction of their pelvic dislocation while anesthetized with a general anesthetic. At latest follow-up the diastasis at the pubic symphysis reduced to an average of 1.7 cm (range: 1.5-2.0) The authors advocate nonoperative treatment with bedrest and a properly positioned pelvic binder in the acute setting for patients with a symphyseal diastasis of 4.0 cm of less and operative treatment for diastasis greater than 4cm.
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3/. Broad-spectrum oral antibiotics for 3-5 days
4/. Broad-spectrum intravenous antibiotics for 7-14 days
5/. IV methylprednisolone at 5.4mg/kg/h for 48 hours
The patient in the scenario has a GSW to the lumbar spine with neurologic deficits but without a retained missile in the spinal canal. In patients with visceral injury, the treatment is broad-spectrum antibiotic coverage for 7 days.
Kumar et al reviewed 33 patients with GSW to the spine and associated visceral injuries. They concluded that 7 days of antibiotic treatment targeted at colonic flora is the treatment of choice.
Roffi et al reviewed 51 low-velocity GSW that perforated the viscus prior to the spine. They concluded that broad spectrum antibiotics combined with bedrest significantly reduced the risk of spinal or paraspinal infections. Furthermore, bullet removal had no effect on infection rates.
Velmahos et al followed 153 GSW to the spine for 28 months. While rates of sepsis were higher in the lumbar spine than cervical and thoracic spine, they concluded that retained bullets do not increase the likelihood of septic complications.
Incorrect Answers:
Answer 1 & 2: Indications for surgery with a GSW to the lumbar spine include 1) spinal instability 2) a neurologic deficit is present that correlates with radiographic findings of neurologic compression by the missile. 3) Lead missile is in contact with the cerebrospinal fluid (CSF). This patient does not have any of these criteria.
Answer 5: GSWs are a contraindication for spinal dose steroids.

4/. Lag screw fixation followed by retrograde femoral nail
5/. Proximal femoral locking plate
An ipsilateral femoral neck fracture occurs in approximately 6% to 9% of all femoral shaft fractures. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. As a result, trauma CT scans should be reviewed for non to minimally displaced femoral neck fractures during the
initial work up.
Watson et al did a retrospective review of 13 patients who had healing complications develop after their index surgical procedure for ipsilateral femoral shaft and neck fractures. Six of the eight (75%) femoral neck nonunions occurred after the use of a second generation, reconstruction-type intramedullary nail. Factors contributing to nonunion of the femoral shaft were the presence of an open fracture, use of an unreamed, small diameter intramedullary nail, and prolonged delay to weightbearing. Lag screw fixation of the femoral neck fracture and reamed intramedullary nailing for shaft fracture stabilization were associated with the fewest complications.
Peljovich et al discuss that several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of neck/shaft fractures. Due to the the potentially devastating complications of the femoral neck fracture in young patients (avascular necrosis, nonunion, and malunion), the neck fracture should be treated first followed by the shaft. Current recommendations involve treating the neck with a sliding hip screw versus cannulated screws followed by intramedullary nailing of the femoral shaft.

5/. pelvic external fixation followed by sacroiliac screws
This patient sustained an open-book pelvic fracture with a pubic symphysis diastasis of less than 2.5cm. From the Young and Burgess classification, he has anteroposterior compression (AP) type 1 injury. Treatment of this is protected weight-bearing and symptomatic treatment. Stress examination can be utilized in order to ensure that the injury is, in fact, a APC-1 injury, and not a more severe posterior injury that would require operative intervention.

1/. Gustilo 3A with spanning external fixation and delayed definitive fixation with soft tissue coverage
2/. Gustilo 3A with immediate medial and lateral plating followed by delayed soft tissue coverage
3/. Gustilo 3B with spanning external fixation and delayed definitive fixation with soft tissue coverage
4/. Gustilo 3B with immediate medial and lateral plating followed by delayed soft tissue coverage
5/. Gustilo 3C with spanning external fixation and delayed definitive fixation with soft tissue coverage
The injury described above is a Type IIIB injury as per the Gustilo and Anderson classification. Type I injuries are low energy and have small soft tissue wounds (usually <1 cm in length) with minimal contamination. Type II injures have a wound >1 cm in length, but do not have extensive soft-tissue
damage, flaps, or avulsions. Type IIIA injuries are associated with soft-tissue damage secondary to high-energy trauma but have adequate soft-tissue coverage. Type IIIB injures exhibit severe periosteal stripping and bone exposure, often associated with massive contamination. These often require treatment with soft-tissue coverage procedures. Type IIIC fractures require vascular repair. The risk for infection in this scenario is as high as 44%, so placing definitive plate fixation is contraindicated when future debridement and soft tissue coverage procedures will be needed. External fixation provides excellent stability, provisional skeletal alignment, and minimal additional soft tissue injury.

Moed et al performed a study to determine the clinical outcome in patients in whom a displaced fracture of the posterior wall of the acetabulum had been treated by open reduction and internal fixation. They were able to show good to excellent clinical results for patients who underwent anatomic reduction and internal fixation of posterior wall acetabulum fractures as assessed using radiographs. Fractures in elderly patients and patients who sustained extensive comminution were more likely to have worse clinical result.
In a separate study, Moed et al. evaluated the results of 67 patients who underwent ORIF of a posterior wall fractures by assessing the accuracy of postoperative AP pelvis, obturator oblique films, iliac oblique films, and CT scans. They found that postoperative pelvic CT scan was the most accurate way to judge final fracture reduction and was able to pick up residual fracture displacements that were not seen on postoperative plain radiographs. They concluded that the accuracy of reduction as assessed on postoperative CT scan was the most reliable indicator of clinical outcomes.

3/. Immediate surgical exploration
4/. Shoulder MRI
5/. CT scan of the humerus
The clinical presentation is consistent for a residual radial nerve palsy 4 months after a humeral shaft fracture. An EMG is indicated at this time to evaluate the status of the nerve recovery.
A radial nerve injury which occurs during a humeral shaft fracture or after bracing is not an indication for immediate exploration. Most often, the nerve function returns without surgical intervention. An EMG should be performed at 3-5 months to evaluate the status of the nerve recovery. If fasciculations are present, then this represents recovery, and observation should be continued. If fibrillations are present, this represents denervation, and surgical exploration should be considered.
Pollock et al followed 24 humeral-shaft fractures with associated radial-nerve injuries, 2 of which required open exploration and all recovered. They recommend careful observation for return of nerve function and exploration at 3.5-4 months after injury if there is still no clinical or EMG evidence of recovery.
Bostman et al reviewed 59 immediate and 16 secondary radial nerve palsies and no support emerged for routine early exploration in either group.
Figures A and B show an oblique fracture at the junction of the middle and distal 1/3 of the humeral shaft.
Illustration A shows the relative close position of the radial nerve to the humerus at the midlevel of humerus, and why it is at risk with a humerus shaft fracture.
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