Organizaciones Solidarias

Anterior column Anterior wall

T-type Posterior column

Posterior wall

Transverse + posterior wall Posterior column + posterior wall Transverse Anterior + posterior hemitransverse

have a better long-term outcome and a lower incidence of arthritis compared with those with greater than 1 mm of residual displacement.36

Injury of the sciatic nerve associated with acetabular fracture occurs most often when the femoral head is dislocated posteriorly. Iatrogenic nerve palsy, however, is caused almost exclusively by prolonged retraction of the sciatic nerve. This most often occurs through a Kocher-Langenbeck approach and primarily affects the peroneal division. To reduce the risk for such injury, tension to the sciatic nerve is minimized by flexing the knee at least 60 degrees and maintaining the hip in an extended position. Traumatic and iatrogenic nerve injuries to the sciatic nerve are most often a form of axonotmesis. If a nerve palsy develops, an ankle-foot orthosis (AFO) is used because some nerve function recovery is expected in the first year.

Heterotopic ossification (HO) is another complication related to the degree of soft tissue disruption from the injury or the surgical approach utilized. Prophylactic treatments for HO include indomethacin for 6 weeks, low-dose external radiotherapy (single dose, 700 to 800 cgy, can be given pre- or postoperatively), or a combination of both. Finally, ON of the femoral head may occur following fracture-dislocation. Immediate reduction of the hip decreases the rate of ON.

Why Might This Be Tested? Numerous aspects of an acetabular fracture may be tested, including fracture

pattern identification based on x-rays, an axial CT section of the acetabulum, surgical approach used to com- plete ORIF, and complications related to injury and surgical intervention.

Acetabular fractures are high-energy injuries diagnosed with x-rays. High suspicion should be held for associated injuries, including soft tissue, neurologic, and bony injuries. Correctly characterizing the fracture pattern allows for the correct surgical approach to allow for anatomic reduction. Posttraumatic arthritis is the most common complication.

Vignette 12: Pedestrian Struck and Sustains an Open Leg Fracture

A 27-year-old female pedestrian is struck by a motor vehicle. Comprehensive trauma evaluation reveals an isolated injury to the right lower leg. AP and lateral x-rays show a proximal third metadiaphyseal frac- ture of the tibia with comminuted fibula fracture at the same level. There is 20-degree apex anterior and 30-degree apex medial angulation with 2 cm of shortening. She is comfortable and neurovascularly intact with palpable pulses and has no pain with passive stretch of her toes. There is a 3-cm open wound over the tibial crest with an exposed tibia.

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The patient is taken to the operating room for definitive management.

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Irrigation and debridement with definitive closure and IM nailing of the tibia are performed without complication.

Vignette 12: Answer

The first sign of compartment syndrome is pain out of proportion to the injury. Decreased sensation and pain with passive stretch of muscles in the affected compartment are the best early signs of compartment syndrome. Other common exam findings include paresthesia/hypoesthesia, paralysis, palpable swelling, and absent pulses. Diagnosis is clinical, while a measured ΔP (ΔP = diastolic pressure – intracompartmental pres- sure) less than 30 mm Hg may serve as a diagnostic adjunct in equivocal cases or in cases in which clinical exam is impossible or unreliable. Treatment is emergent for compartment fasciotomy.37

This is a type II Gustilo-Anderson open fracture. See Table 12-1 for complete classification.38 _(Wound

size is not really that important in defining the type of open fracture; it’s really more about energy, perios- teum, and overall soft tissues, not the wound length.) All patients with open fractures should receive tetanus prophylaxis, intravenous (IV) antibiotics, and irrigation and debridement of the open fracture. Historic recommendations for specific antibiotic use and timing of irrigation and debridement have recently been challenged. The previous standard was for a first-generation cephalosporin, adding an aminoglycoside for higher grade and a clostridial species–specific antibiotic for farmyard injuries. The timing of irrigation and debridement for type I injuries may be delayed until the following morning because evidence does not man- date emergent management. Most surgeons feel that type II or III or any grossly contaminated wound should be treated with urgent surgical irrigation and debridement.

Primary closure of open wounds may be performed at the surgeon’s discretion. Minimal to noncontami- nated wounds may be closed at the index procedure, whereas grossly contaminated wounds require serial debridement with or without local antibiotic delivery and/or negative pressure wound therapy. When the open wound is unable to be closed primarily, adjunctive procedures, such as skin grafting with or without rotational muscle flap coverage, fasciocutaneous flap, or free tissue transfer, must be considered. The timing of coverage is largely dictated by the wound and fracture stability. Every attempt should be made to pro- vide definitive fracture stability prior to soft tissue coverage to allow for uninterrupted soft tissue healing. Definitive coverage should be performed as soon as possible but ideally within 7 to 10 days because infection rates and flap failures increase with increasing coverage time.

Coronal plane deformity less than 5 degrees, sagittal plane deformity less than 10 degrees, malrotation less than 5 degrees, and shortening less than 1 cm allow for nonoperative treatment of a tibial shaft fracture, whether through cast treatment or functional bracing.

IM nail, plate, and external fixation have all been used successfully for tibia fractures. External fixa- tion may be used in the setting of a narrow canal diameter (< 8 mm), excessive contamination, severe open fractures, open physes, and complex periarticular injury. Plate fixation may be preferred in proximal or distal metadiaphyseal fractures, especially with articular extension or when access to the IM canal may be compromised. Nail fixation is preferred in diaphyseal fractures to prevent soft tissue and periosteal strip- ping, blood supply disruption, and wound breakdown/infection. When external fixation is chosen as initial management, conversion to a definitive IM nail should be performed within 28 days to reduce the chance of secondary infection from contaminated pin tracts.

Table 12-1.