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Difficulty: HardOrthopedic Surgery

Match each clinical vignette describing an orthopedic injury with the most appropriate definitive management step.

  • A 32-year-old man with a closed tibial fracture develops excruciating leg pain and paresthesias; his intracompartmental pressure is 45 mmHg and his diastolic blood pressure is 70 mmHg.Immediate four-compartment fasciotomy
  • A 72-year-old woman with a history of severe, symptomatic left hip osteoarthritis sustains a displaced, completely intracapsular left femoral neck fracture following a mechanical fall.Total hip arthroplasty (THA)
  • A 21-year-old male sustains a completely displaced mid-shaft clavicle fracture with 3 cm of shortening and severe skin tenting causing marked blanching of the overlying soft tissue.Urgent open reduction and internal fixation (ORIF)
  • A 28-year-old man presents with persistent anatomic snuffbox tenderness 8 months after a wrist injury; MRI demonstrates a scaphoid waist nonunion with avascular necrosis of the proximal pole.Vascularized bone grafting and internal fixation

Answer

The tibial fracture patient with elevated compartment pressure matches with immediate four-compartment fasciotomy. The elderly patient with a femoral neck fracture and baseline severe osteoarthritis matches with total hip arthroplasty. The clavicle fracture with skin blanching matches with urgent open reduction and internal fixation. The scaphoid nonunion with avascular necrosis matches with vascularized bone grafting and internal fixation.
Each pairing relies on identifying absolute indications that deviate from standard or less invasive management. The tibial fracture patient has acute compartment syndrome (delta pressure < 30 mmHg) requiring fasciotomy. The older patient with a femoral neck fracture and baseline osteoarthritis requires a total hip arthroplasty rather than a hemiarthroplasty to address the arthritic acetabulum. The clavicle fracture patient has impending skin necrosis, an absolute indication for ORIF. Finally, scaphoid nonunion with proximal pole AVN requires a vascularized bone graft due to the compromised retrograde blood supply.

Step-by-Step Solution

1
Calculate the delta pressure for the patient with the closed tibial fracture.
The delta pressure is 25 mmHg (70−45=2570 - 45 = 25).
A delta pressure of less than 30 mmHg is the diagnostic threshold for acute compartment syndrome, which dictates the need for emergent surgical decompression.
2
Analyze the optimal surgical approach for the 72-year-old with a displaced femoral neck fracture.
Identify that total hip arthroplasty (THA) is required over hemiarthroplasty.
While hemiarthroplasty is standard for many elderly patients with this specific fracture, the presence of severe pre-existing osteoarthritis dictates THA to address both the fracture and the diseased native acetabulum.
3
Identify the complication risk in the patient with the displaced clavicle fracture and skin blanching.
Recognize an impending open fracture.
Severe skin tenting with blanching indicates ischemia of the overlying skin; if left untreated, the skin will necrose, converting a closed fracture into an open one, making urgent ORIF necessary.
4
Determine the graft requirement for a scaphoid nonunion with proximal pole avascular necrosis (AVN).
Select vascularized bone grafting and internal fixation.
The proximal pole of the scaphoid has a tenuous retrograde blood supply. Once AVN occurs, a standard non-vascularized bone graft will fail to integrate, requiring a vascularized graft to restore local perfusion and promote osseous union.

Key Concept

Absolute surgical indications and advanced orthopedic management strategies for specific trauma complications and fracture patterns.
Estimated Time:2m 0s
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Orthopedic Surgery

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