Justo entre las Naciones

Technique

Method

Features

Complications

Primary acromiocla- vicular joint fixation

K-wires, hook plate K-wires no longer used; requires plate removal

Pin migration into tho- rax; infection, plate/ screw failure Primary coracoclavicu-

lar ligament fixation indicated for acute injury

Coracoclavicular screw, suture loop

Requires screw remov- al, passed via drill holes in clavicle around coracoids or fixed with suture anchor

Screw pullout; suture cutout through clavicle or base of coracoid Coracoclavicular liga-

ment reconstruction indicated for acute and chronic injury

Modified Weaver-Dunn Free tendon graft

Transfer of coracoacro- mial ligament to distal clavicle after distal clavicle resection with or without suture loop coracoclavicular aug- mentation; autogenous hamstring vs anterior tibialis allograft

Possible tunnel expan- sion, hardware failure Few long-term follow- up studies

Vignette 48: Nagging Groin Pain in a Young Athlete

A 25-year-old male who regularly performs martial arts presents with a 6-month history of nagging right hip pain. The pain is felt in the groin area, and he describes it as a muscle pull that has not gotten better. The patient reports significant pain with kicking maneuvers and prolonged sitting. He denies trauma or prior history of hip or knee pain. On physical examination, the pain is worse with flexion, adduction, and internal rotation, with 10 degrees of loss of internal rotation compared with the unaffected hip. X-rays taken in the office are shown in Figures 48-1 and 48-2.

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Vignette 48: Answer

The history, clinical examination, and imaging studies are consistent with combined-type femoroacetab- ular impingement (FAI). FAI is essentially a process in which abnormal morphology of the proximal femur and/or acetabulum leads to pathological contact between the 2 during terminal hip ROM.161 _{This often leads}

to cartilaginous injuries and labral lesions. Most patients present with an insidious onset of groin pain that is worse with hip flexion and rotational maneuvers. The impingement test is positive when the patient has pain with flexion, adduction, and internal rotation. Cam lesions impinge with different provocative motions depending on the relative location (medial occurs with flexion, lateral with abduction, and centromedial with flexion to 90 degrees with internal rotation).162 _{Patients with FAI may also have internal rotation asym-}

metry compared with the opposite hip. Cam-type impingement (common in young active patients) results from an aspherical femoral head with an increased radius, while pincer-type (common in athletic middle- aged women) is secondary to acetabular overcoverage (acetabular retroversion, coxa profunda, protrusion acetabuli). Most commonly, patients have a combination of the 2 types. Additional conditions in the dif- ferential diagnosis for cause of impingement symptoms include prior femoral neck fracture, periacetabular osteotomy, prior slipped capital femoral epiphysis, and residual Legg-Calvé-Perthes disease.161 _{In addition,}

patients with an extensive hip ROM are prone to FAI symptoms.

Plain x-rays (AP pelvis, false profile, and lateral hip views) are the initial diagnostic imaging study to evaluation hip morphology. As seen in our patient, one should look for a crossover sign, which is visualized when the anterior wall of the acetabulum is more lateral than the posterior wall of the acetabulum. The alpha angle is the radiographic parameter that coincides with a loss of femoral head sphericity. An alpha angle greater than 55 degrees is consistent with cam impingement.163 _{Currently, the most sensitive view to detect}

cam lesions is the Dunn lateral view taken at 45 degrees of hip flexion and 20 degrees of abduction, with the beam centered between the pubic symphysis and the anterior superior iliac spine.164 _{MRA has been used by}

most orthopedic surgeons and has been shown to be most effective in detecting labral tears and chondral lesions.161

Nonoperative management consists of NSAIDs, restricted activity, and stretching exercises to maintain ROM. Early surgical intervention is suggested to prevent progression and further destruction of the hip joint. Surgical treatment was initially described with open dislocation of the hip with preservation of the blood supply to the femoral head (don’t forget that the medial femoral circumflex artery is the critical blood source of the femoral head). The technique involves a trochanteric osteotomy with preservation of the medial femoral circumflex artery by an intact obturator externus muscle.161 _{A femoral osteoplasty is performed, and}

the acetabulum is also inspected. Recently, however, hip arthroscopy for FAI has been used to address labral lesions and abnormal osseous morphology. The factor that has most commonly been associated with a poor outcome is joint space narrowing less than 2 mm or advanced joint degeneration. Arthroscopic treatment can include osteochondroplasty for the cam lesion, rim trimming of the pincer lesions, labral repair when possible, or resection if necessary. When appropriately indicated, results can reach 90% good to excellent at 5 years. Complications specific to hip arthroscopy include pudendal nerve palsy secondary to traction, femoral neck fracture (limit resection to > 30% of the diameter of the femoral neck), avascular necrosis of the femoral head, fluid extravasation into the retroperitoneal space, and postoperative instability.

Why Might This Be Tested? The number of hip arthroscopies and the diagnoses of FAI have been rapidly

growing over the past 5 to 6 years. There has been significant interest in understanding the etiology, natural progression, diagnostic modalities, and clinical outcomes.

FAI is a popular recent clinical diagnosis. Appropriate radiographic studies to confirm the diagnosis include a true AP pelvis view, Dunn lateral view, false profile view, MRA, and CT scan with 3D reconstructions. Be aware of hip morphology that is amenable to hip arthroscopy and those that require open hip dislocation or pelvic or femoral osteotomies.

Vignette 49: Look Out for That Hay Swather!

A 61-year-old White male has been transferred to the emergency room from another institution one state away. He sustained multiple injuries after he was run over by a hay swather, a farm implement that cuts hay and forms it into a windrow. At initial evalution, he is alert and oriented with normal vital signs; however, his condition deteriorates during transfer to your hospital. Upon initial assessment in the trauma bay, he is intubated for a GCS of 7 (E1 V1 M5) and inability to maintain a patent airway. Breath sounds are equal bilat- erally and labored. Radial and dorsalis pedis pulses are 2+, and his extremities are warm and well perfused. Vital signs are as follows: blood pressure, 84/62; heart rate, 125; respiratory rate, 20; temperature, 35.5°C. A secondary survey reveals facial lacerations and swelling as well as a soft abdomen; FAST ultrasound is nega- tive. Both a C-collar and a pelvic binder are in place. Following brief removal of the binder, visual inspection reveals no skin lacerations near the pelvis. Output through the Foley catheter shows gross hematuria. No gross deformities are present throughout the extremities; however, ecchymosis is noted at the right lateral ankle and above the left clavicle. Following log roll, no step-off or deformity is palpable throughout the posterior column of the spine. Rectal examination reveals no presence of blood; however, tone is decreased. Medical and surgical history is unknown.

Pertinent lab values are as follows: hemoglobin and hematocrit, 10.9 gm/dL and 31.7%, respectively; plate- lets, 95 k/uL; pH, 7.29; pCO₂, 45.1 mm Hg; HCO₃, 21.2 mEq/L; lactate, 1.8 mmol/L. He received 3 units of blood in the trauma bay. An AP x-ray of the pelvis and a single axial CT scan cut are shown in Figure 49-1.

The patient has also sustained the following injuries diagnosed via imaging: rib fractures, pulmonary con- tusion, grade 1 liver laceration, ruptured bladder, and fractures of his left clavicle and right lateral malleolus.

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Figure 49-1. (A) AP pelvis x-ray and (B) CT scan cut of the pelvis on initial

presentation.

Vignette 49: Answer

The diagnosis is a right posterior iliac fracture with symphyseal diastasis in excess of 2 cm and contralat- eral sacral diastasis. This injury pattern is most consistent with AP compression; without quantification of pelvic instability, the radiographs alone narrow the injury to either APC-II or APC-III predicated upon the degree of symphyseal diastasis. This patient’s pelvis is both rotationally and laterally unstable and should be considered an APC-III “open book” injury fracture-variant. He was intubated on arrival per Advanced Trauma Life Support (ATLS) protocol due to difficulty protecting his airway in the setting of reduced mental status. In addition, he demonstrated labored breathing secondary to numerous rib fractures (possible flail chest), findings that present concern for inability to autoventilate. The hemodynamic instability, character- ized by decreased blood pressure and tachycardia, was treated with rapid infusion of packed red blood cells in the trauma bay and further volume resuscitation with crystalloid solution.

The timing of definitive pelvic fixation to address the APC-III injury depends on the patient’s physiologic state, which may be classified as borderline per guidelines described by Pape et al165 _{(Table 49-1). Therefore, with}

hemodynamic stabilization, this patient may receive pelvic fixation acutely.

Trauma epidemiologic research identifies three distinct peaks in death rates as a function of time from injury. The first peak occurs within the first hours and is usually caused by massive hemorrhage or neuro- logical injury. The second peak occurs over the next few hours and is characterized by airway, breathing, or cardiovascular insults. The final peak in mortality is delayed days or weeks and is often due to multi-organ system failure and sepsis. Patients who sustain traumatic injuries should undergo initial evaluation and man- agement guided by the ATLS protocol to identify and treat conditions contributing to mortality in the second peak. The utility of fracture stabilization in polytrauma patients is not different than in patients with isolated fractures; proper treatment results in reduced pain, minimized incidence of fat embolization, and early

Table 49-1.