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Orthopedic and Hand Trauma

Brett D. Crist, MD and Gregory J. Della Rocca, MD, PhD

Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA

A 30‐year‐old woman fell 6 feet off a ladder at home. She sustained a Gustilo and Anderson type IIIA open tibia fracture. Which of the following has been associated with the lowest risk of infection?
1. Operative debridement within 18 hours of injury
2. Operative debridement within 6 hours of injury
3. Oral antibiotic administration within 24 hours of injury
4. Intravenous antibiotic administration within 3 hours of injury
5. Intramedullary nailing of the tibia within 12 hours
Several factors have been evaluated to look at risk of infection after open fractures. Of the factors listed, early antibiotic administration is the most appropriate answer. Antibiotic administration within 3 hours of injury significantly reduced the rate of infection in a series of 1104 open fractures compared to patients receiving antibiotics greater than 3 hours from injury or no antibiotics at all. Patients should receive intravenous antibiotics within 3 hours from injury and within 1 hour from hospital admission. Timing of surgical debridement as long as it is within 24 hours from injury has not been associated with a significant difference in infection rates of open fractures.

Answer: D

Pollak AN, Jones AL, Castillo RC, et al. The relationship between time to surgical debridement and incidence of infection after open high‐energy lower extremity trauma. J Bone Joint Surg Am (2010); 92(1):7–15.
The same 30‐year‐old woman received cefazolin for her type IIIA open tibia fracture upon arrival to the emergency room. She goes to the operating room within 6 hours for formal debridement, definitive fixation with an intramedullary nail of her tibia, and closure of her open fracture wound. How long should intravenous cefazolin be continued postoperatively?
1. 16 hours
2. 48 hours
3. 72 hours
4. 24 hours
5. 6 hours
Based on the best available data, most open fractures should receive intravenous antibiotics for 24 hours after each operative debridement and then 24 hours after definitive soft tissue management (closure for this patient). Exceptions could be those with significant gross contamination like a type IIIB tibia fracture where 72 hours may be indicated.

Answer: D

Halawi MJ, Morwood MP. Acute management of open fractures: an evidence‐based review. Orthopedics (2015); 38(11):e1025–e1033.

Hoff WS, Bonadies JA, Cachecho R, Dorlac WC. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011; 70(3):751–754.
A 27‐year‐old man sustains a tibia fracture and develops compartment syndrome after intramedullary nailing of his tibia. The attending orthopedic surgeon is eventually sued because the patient undergoes a below‐knee amputation 1 week after the initial surgery. The factor most likely associated with the surgeon losing the lawsuit is a/an:
1. Tibia fracture
2. Open fracture
3. Eventual amputation
4. Delay in fasciotomy
5. Associated vascular injury
Compartment syndrome can have devastating complications that can be avoided with early diagnosis and fasciotomy. Bhattacharyya et al. reviewed medical malpractice claims and identified these risk factors associated with unsuccessful defense and increased liability:
1. Physician documentation of abnormal findings on neurological exam but no action taken
2. Poor physician communication
3. Increased number of cardinal signs (pain, pallor, pulselessness, paralysis, pain with passive stretch)
4. Increased time to fasciotomy
Answer: D

Bhattacharyya T, Vrahas MS The medical‐legal aspects of compartment syndrome. J Bone Joint Surg Am. 2004; 86‐A(4):864–868.
A 53‐year‐old woman was involved in a motorcycle accident. She sustained the Anterior‐Posterior Compression (APC) type 3 pelvic fracture seen below. When she arrives in the trauma bay, her blood pressure is 90/50 mm Hg, and her heart rate is 140 beats/min. A pelvic binder is applied. She is found to have a splenic injury on her abdominal computed tomography (CT) and goes to the operating room. The pelvic binder is positioned over the greater trochanters during surgery to close down her pelvic volume. However, she remains hemodynamically unstable intraoperatively after splenectomy; 3 units of packed red blood cells (PRBC) and 3 units of fresh frozen plasma (FFP) are given. There are no other known sources of uncontrolled bleeding. The next step in resuscitating this patient should include:
1. Repeat head CT.
2. Transfer to angiography for pelvic arterial embolization.
3. Transfuse 3 more units PRBC and 3 FFP and reassess.
4. Repeat her chest‐abdomen‐pelvis CT.
5. Perform retroperitoneal packing.
The most common causes of bleeding associated with pelvic fractures are injury to the posterior venous plexus and cancellous fracture surfaces (85–90%). Approximately 10–15% of bleeding is associated with injures to branches of the internal iliac system (superior gluteal or pudendal arteries). Although decreasing the pelvic volume is an important first step, patients that are in the operating room and continue to be hemodynamically unstable after all other known sources of bleeding are addressed should undergo retroperitoneal packing to address the venous and bony bleeding that occurs. Hemodynamically unstable patients should not be transferred to the CT scanner. The patient has already received adequate fluid resuscitation; another source of bleeding must be identified and addressed. Since the patient is already in the operating room and the most likely cause of pelvic bleeding is venous or fracture surfaces, pre‐ or retroperitoneal packing should be performed prior to going to angiography. If the patient remains hypotensive after retroperitoneal packing and external fixation, then angiography should be performed to address the probable arterial injury. Following this protocol, only 16.7% of hemodynamically unstable patients required subsequent embolization, and there were no mortalities.

Answer: E

Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013; 21(8):448–457.

Cothren CC, Osborn PM, Moore EE, Morgan SJ, Johnson JL, Smith WR. Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift. J Trauma. 2007; 62(4):834–839; discussion 839‐842.
The above 53‐year‐old woman with the APC 3 pelvic ring injury is significantly more likely to complain of which of the following when compared to a man with the same injury:
1. Leg length discrepancy
2. Genitourinary dysfunction
3. Low back pain
4. Posterior pelvic pain
5. Dyspareunia
Although patients that sustain pelvic ring injuries complain of pelvic and low back pain, women are at significant risk for dyspareunia—pain/discomfort with sexual intercourse. Dyspareunia may occur in up to 91% of women and most likely occurs with anteroposterior compression (APC) type fractures. Furthermore, women also have a high incidence of genitourinary complaints (49%). It is critical to ask patients about these complaints during follow‐up, so they may be addressed. Of note, a woman with a pelvic fracture is more than twice as likely to give birth by cesarean section. The rate of low back pain, posterior pelvic pain, and leg length discrepancy is not different from men.

Answer: E

Vallier HA, Cureton BA, Schubeck D. Pelvic ring injury is associated with sexual dysfunction in women. J Orthop Trauma. 2012; 26(5):308–313.

Cannada LK, Barr J. Pelvic fractures in women of childbearing age. Clin Orthop Relat Res. 2010; 468(7):1781–1789.
A 22‐year‐old man falls off of a roof and sustains a Gustilo and Anderson type 1 open tibia and fibula fractures with a 1 cm anteromedial tibial wound. There’s no gross contamination and minimal periosteal stripping. His wound is irrigated with saline, and a saline‐soaked gauze dressing is applied. He is placed in a splint, and there is no neurovascular compromise or concern for compartment syndrome. His Glasgow Coma Scale (GCS) score is 7 and is noted to have a left‐sided intraparenchymal cerebral hemorrhage. Formal operative irrigation and debridement and stabilization of his open tibia fracture should occur:
1. Within 24 hours
2. As soon as the OR is ready
3. Within 6 hours
4. When his head injury allows
5. Within 12 hours
The “6‐hour” rule for debridement of open fractures originated from an 1898 presentation by Paul Leopold Frederich where he contaminated guinea pigs with garden mold and stair dust to illustrate the importance of surgical debridement. In this antiquated animal study, debridement of the contaminated wound was less likely to be effective after 6–8 hours. Several studies have shown no association between timing of debridement and infection when debridement occurs within 24 hours. Others have shown a difference between debridement within 6 hours and less than 24 hours. However, all of these studies either have flawed study designs or too small a sample size to gain statistical significance. Therefore, emergent debridement is not necessarily supported, but neither is elective debridement. Current practice is based upon the current best evidence and includes debridement of open fractures urgently when the life‐threatening emergencies have been addressed, patient’s medical condition is stabilized and when the appropriate surgical resources are available.

Answer: D

Werner CM, Pierpont Y, Pollak AN The urgency of surgical debridement in the management of open fractures. J Am Acad Orthop Surg. 2008; 16(7):369–375.

Halawi MJ, Morwood MP. Acute management of open fractures: an evidence‐based review. Orthopedics. 2015; 38(11):e1025–e1033.
A 32‐year‐old man sustains a distal one third Gustilo and Anderson type IIIB open tibia fracture with an associated segmental fibula fracture from a motorcycle accident. Which finding should you consider performing a below‐knee amputation?
1. 5.5 cm of tibial bone loss after debridement
2. Absent plantar foot sensation
3. Absent dorsalis pedis pulse
4. Transected tibial nerve
5. Inability to actively dorsiflex the ankle
A visibly documented transected tibial nerve is the only answer that should have a patient consider an amputation. Inability to actively dorsiflex the ankle could be related to the fracture and associate pain, or a peroneal nerve palsy. As long as there is an identifiable posterior tibialis pulse, the absence of a dorsalis pedis pulse does not indicate an amputation; 5.5 cm of tibial bone loss can be reconstructed with a variety of bone‐grafting techniques. The lack of plantar foot sensation alone no longer indicates amputation. The Lower Extremity Assessment Project (LEAP) was a multicenter prospective outcome study that involved 601 patients with severe, limb‐threatening lower extremity patients that compared limb salvage versus amputation; 67% of patients in the limb salvage group with lack of plantar sensation upon admission had complete return of plantar sensation within 24‐months. There were no significant outcomes differences found between the insensate salvage, insensate amputation, and the sensate control groups. The presence or absence of plantar sensation should not be used to direct treatment.

Answer: D

Bosse MJ, McCarthy ML, Jones AL, et al

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