Purpose

Troponin T levels are routinely checked in trauma patients after experiencing a ground-level fall to identify potential cardiac causes of syncope. An elevated initial troponin prompts serial testing until the level peaks. However, the high sensitivity of the test may lead to repeat testing that is of little clinical value. Here, we examine the role of serial troponins in predicting the need for further cardiac workup in trauma patients after sustaining a fall.

Methods

Retrospective review of all adult trauma activations for ground-level fall from January 1, 2021 to December 31, 2021 in patients who were hemodynamically and neurologically normal at presentation. Outcomes evaluated included need for cardiology consult, admission to cardiology service, outpatient cardiology follow-up, cardiology intervention and in-hospital mortality.

Results

There were 1555 trauma activations for ground-level fall in the study period. The cohort included 560 patients evaluated for a possible syncopal fall, hemodynamically stable, Glasgow Coma Scale score of 15, and with a troponin drawn at presentation. The initial median troponin was 20 ng/L (13-37). Second troponin values were drawn on 58% (median 33 ng/L (22-52)), with 42% of patients having an increase from first to second test. 29% of patients had a third troponin drawn (median 42 ng/L (26-67)). The initial troponin value was significantly associated with undergoing a subsequent echo (p=0.01), cardiology consult (p<0.01), admission for cardiac evaluation (p<0.01), cardiology follow-up (p<0.01), and in-hospital mortality (p=0.01); the initial troponin was not associated with cardiac intervention (p=0.91). An increase from the first to second troponin was not associated with any of outcomes of interest. Analysis was done with cut-off values of 30 ng/L, 50 ng/L, 70 ng/L, and 90 ng/L; a troponin T threshold of 19 ng/L was significant for cardiology consult (p=0.01) and cardiology follow-up (p=0.04). When the threshold was increased to 50 ng/L, it was also significant for admission for cardiac issue (p<0.01). When the threshold was increased to 90 ng/L, it was significant for the same three outcomes and in-hospital mortality (p=0.04).

Conclusion

The initial serum troponin has clinical value in identifying underlying cardiac disease in patients who present after ground-level fall; however, that serial testing is likely of little value. Further, using a cut-off of >50 ng/L as a threshold for further clinical evaluation would improve the utility of the test and likely reduce unnecessary hospital stays and costs for otherwise healthy patients.

Level of evidence

Level III.

Intramedullary nailing is considered the gold-standard treatment for tibial shaft fractures. The goals of treatment for these fractures are correction of axial and rotational alignment and adequate mechanical stability, allowing for optimal healing. The nail is secured in place using screws or other fasteners that are placed through the bone and into the nail itself.2  Another benefit is the ability to preserve the soft tissue around the fracture to safeguard the extraosseous blood supply and minimize soft tissue damage.3 In reference to tibial intramedullary nailing, a start point is the location where a hole is drilled in the tibia to insert the intramedullary nail. The ideal starting point for guide wire placement for the average tibia is described as 2 mm medial to the lateral tibial eminence on AP imaging and just anterior to articular surface and parallel to the anterior tibia cortex on lateral imaging.6,7 It is a critical part of the procedure because it determines the trajectory and positioning of the nail within the medullary canal.7 Having a good, ideal starting point can prevent valgus angulation and translation at the fracture site. If the start point is too far off center or at the wrong angle, the nail may be inserted incorrectly and not provide the necessary support for the bone to heal, leading to malalignment or nonunion.  It is believed that different approaches to tibial intramedullary nailing may have differing abilities to achieve an optimal start point due to associated anatomical visualization and access. These approaches include suprapatellar, parapatellar, and infrapatellar nailing. The suprapatellar approach involves making an incision above the patella and placing instruments across the patellofemoral joint, potentially damaging the joint surface. However, the nail can be inserted at the start point with the knee extended, which leads to better alignment and stability of the fractured bone. Most importantly, the main advantage of the suprapatellar approach is that it reduces anterior angulation by eliminating the extension force of the quadriceps and aids fracture reduction by preventing proximal fragment migration.4,5 The parapatellar approach, proven to be effective and reliable, involves making a smaller incision below the patella with the knee in hyperflexion. This approach is less invasive than the suprapatellar approach regarding the patellofemoral joint, but the patellar tendon needs to be circumnavigated leading to potential for higher incidence of anterior knee pain.6 Also, it can be more difficult to achieve proper alignment and increases the risk of apex anterior deformities.4 The infrapatellar approach is split into transtendinous approach and paratendinous approach where the starting point is established by splitting the patellar tendon or making an incision on either side of the knee, respectively.6 This approach provides good visualization, but it can increase the risk of damage to the patellar tendon and other soft tissue structures around the knee.