JPOSNA Feb 2022: Fracture Quiz

This trauma quiz represents an interactive session where POSNA members are able to work through nine clinical scenarios to challenge how they would address these problems. Associated with each scenario is an OITE-style question and multiple-choice options that seek the most preferred answer from the clinician. In addition to the answer and follow-up radiographs, we have enlisted the opinions of some POSNA experts in trauma to provide an evidenced-based approach to thinking through each trauma problem.

Quiz Authors:

Ryan Muchow, MD
Associate Professor of Orthopaedic Surgery, Residency Director, University of Kentucky School of Medicine, Lexington KY

Megan Young, MD
Affiliate Faculty Georgetown University; Limb lengthening, Deformity, and Trauma specialist, Children’s National Hospital, Washington DC

Stephanie Holmes, MD
Associate Professor of Orthopaedic Surgery, University of Utah. Hip and Trauma Specialist, Primary Children’s Medical Center., Salt Lake City, UT

Expert Panel:

Benton Heyworth, MD
Associate Professor of Orthopedic Surgery, Harvard Medical School; Associate Program Director, Orthopedic Surgery Medicine Fellowship, Boston Children’s Hospital, Boston, MA

Mark Sinclair, MD
Associate Professor of Orthopedic Surgery, University of Missouri-Kansas City; Children’s Mercy, Kansas City, MO

Caroline Tougas, MD
Assistant Professor, University of Missouri-Kansas City; Children’s Mercy, Kansas City, MO

Kenneth David Illingworth, MD
Pediatric Spine/Orthopaedics, Director of Pediatric Orthopaedic Trauma, Assistant Professor of Orthopaedics, Pediatrics and Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA

Quiz Authors:

Ryan Muchow, MD
Associate Professor of Orthopaedic Surgery, Residency Director, University of Kentucky School of Medicine, Lexington KY

Megan Young, MD
Affiliate Faculty Georgetown University; Limb lengthening, Deformity, and Trauma specialist, Children’s National Hospital, Washington DC

Stephanie Holmes, MD
Associate Professor of Orthopaedic Surgery, University of Utah. Hip and Trauma Specialist, Primary Children’s Medical Center., Salt Lake City, UT

Expert Panel:

Benton Heyworth, MD
Associate Professor of Orthopedic Surgery, Harvard Medical School; Associate Program Director, Orthopedic Surgery Medicine Fellowship, Boston Children’s Hospital, Boston, MA

Mark Sinclair, MD
Associate Professor of Orthopedic Surgery, University of Missouri-Kansas City; Children’s Mercy, Kansas City, MO

Caroline Tougas, MD
Assistant Professor, University of Missouri-Kansas City; Children’s Mercy, Kansas City, MO

3-year-old male fell onto outstretched left upper extremity at the park sustaining an isolated elbow injury shown in Figures 1A, B, and C. Initial management by an outside orthopedic surgeon included cast immobilization for 6 weeks. He now presents 3 months post-injury with the images shown in Figures 2A, B and C. Elbow pain has resolved and motion has been restored to within 5 degrees of the contralateral elbow. What is the next best step in management?

Figure 1

Figure 2

Observation

Repeat cast immobilization

Repeat cast with pulsed electronic magnetic field stimulation

Percutaneous screw fixation

Osteotomy, internal fixation and bone grafting

A 10-year-old male, was tackled playing football and sustained an isolated injury to his left shoulder. He was neurovascularly intact on presentation and without complaints of shortness of breath or dysphagia. Initial injury films are shown in Figures 1A and B. A CT scan shown in Figure 2 confirms the injury. What is the most appropriate treatment option?

Figure 1a

Figure 2b

Figure 2c

Sling immobilization

Closed reduction and Figure of 8 bracing

Open reduction and suture fixation

Open reduction and plate fixation

Open reduction and fixation with allograft tendon

11-year-old male tripped and fell while walking the dog sustaining isolated left upper extremity injury. Initial injury films are shown in Figures 1A and B. On presentation the patient had a PIN palsy and palpable radial pulse. What is the best method of definitive treatment?

Figure 1a

Figure 1b

Closed reduction and cast application

Open reduction and plate fixation of the radius and ulna and cast in hyperflexion to prevent displacement of radial head

Intramedullary fixation of the ulna and radiocapitellar pinning

Intramedullary fixation of the ulna and closed reduction of the radial shaft fracture and Bell Tawse reconstruction with triceps fascia

Intramedullary fixation of the ulna and radial shaft fracture followed by assessment of the radiocapitellar joint and open treatment if unable to achieve a concentric reduction

An 11-year-old boy was “catching some sweet air” while trying out his new snowboard, unfortunately the landing was not as expected and he was seen in the ED with a deformed leg and with the associated radiographs. He was managed with closed reduction and cast immobilization. Which of the following is an unacceptable treatment option?

Figure 1

Conversion to flexible nail fixation with two antegrade nails

Repeat attempt at casting with posterior mold and foot in more equinus

Accept angulation in lateral plane and follow-up in a month for short leg cast. The fracture will remodel.

Conversion to definitive external fixation

Stabilization with a percutaneous plate

A 12-year-old 34 kg male was hiking along a cliff edge with his father and fell ~20 feet. He had splenic and renal lacerations, a mild brain injury, minimally displaced bilateral wrist fractures and a right femur fracture. He was taken emergently to the operating room for an exploratory laparotomy and a splenectomy was performed. His hemodynamic instability resolved by hospital day #2. Figure 1A-B demonstrate his injury. What is the best method of fixation for this patient?

Figure 1

Damage control orthopaedic surgery with external fixation as definitive treatment

Flexible nailing with two retrograde titanium elastic nails

Rigid antegrade nail, with a lateral trochanteric entry nail

Rigid antegrade nail, with a greater trochanteric entry nail

Rigid antegrade nail, with a piriformis-start nail

A 14-year-old boy was thrown from his ATV and is seen in the ED with the following Pelvis Xray. He is hemodynamically stable and after orthopaedic evaluation it appears that this is an isolated skeletal injury. CT scan images of his pelvis are included. The next best step in management is?

Figure 1

Conservative management with gradual mobilization from bed to chair over 6 weeks

Spica cast immobilization

Definitive external fixation of his pelvis and NWB for 6 weeks

Urgent urology evaluation for bladder rupture

Surgical pelvis stabilization

A 13-year-old 69 kg male was skiing and fell onto his left side. He sustained a left femur fracture, left segmental humerus fracture, and left renal artery laceration which resulted in complete necrosis of the left kidney. Figures 1 A-D demonstrate his orthopaedic injuries. What is the next best step in management for this patient?

Figure 1

Flexible nailing of humerus and femur fractures

Plate fixation of the segmental humerus fracture and trochanteric-entry nailing of femur fracture

Flexible nailing of left humerus fracture and trochanteric-entry nailing of left femur fracture

External fixation of left femur fracture and left humerus fracture

Closed treatment of humerus fracture and submuscular plating of femur fracture

13-year old female, right-hand dominant, fell while performing a stunt on her competitive cheerleading team. She sustained a left elbow injury and deformity which was “improved” at an outside hospital and presents to your institution with numbness/tingling in her left small and ring fingers. Radiographs in Figure 1 A-B demonstrate the injury. What would is the next best step in management?

Figure 1

Splint management for 1 week, early motion to prevent stiffness

Order an MRI to determine the status of ulnar nerve

Emergent open reduction of a displaced capitellum fracture

Closed reduction and percutaneous screw fixation

Attempted closed reduction in ED and semi-elective open reduction and internal fixation and early ROM protocol.

A 9-year old female was riding a Go-Cart and it shockingly wrecked, resulting in a right arm injury. The initial ED management involved placement in a coaptation splint with post-reduction radiographs seen in Figure 1 A-B, and there was a documented normal neurovascular exam afterwards. Upon presentation to clinic 3 days later, the girl is complaining that her splint is digging into her armpit. On physical examination she can not extend her fingers at the MCP joints and she cannot extend her IP joint to her thumb. What is the the next best step in the management?

Figure 1

Trim down coaptation splint and order MRI exam of her axilla and upper arm.

Perform retrograde flexible nailing of the humerus fracure

Hanging arm cast with a splint to prevent stiffness until palsy resolves

Sarmiento brace x 6 weeks. If nerve function doesn’t return at 4 weeks, perform an EMG and repair nerve if no activity on EMG

Open reduction, nerve exploration, and plate fixation of the humerus fracture