9. Trauma Flashcards
What should be done FIRST when assessing a patient with trauma?
Primary survey (ABCDE)
- Airway
- Breathing
- Circulation with hemorrhage control
- Disability – assess neurologic status
- Exposure of patient and environmental control
Secondary survey
- Full history – medical and drug
- Thorough examination
- Evaluate tenderness and stability as well as neurovascular status of each limb
- Is there injury to joint above or below?
- X-rays and/or CT of all suspected fractures
What are the components of a PRIMARY trauma surgery?
(ABCDE)
- Airway
- Breathing
- Circulation with hemorrhage control
- Disability – assess neurologic status
- Exposure of patient and environmental control
What should always be asked with a break in the skin?
Tetanus status
what is a clinical test for a fracture?
point tenderness over fracture site
what are common fracture patterns?
- transverse
- greenstick
- torus
- oblique (spiral)
- comminuted
which fracture pattern is the most stable?
transverse
transverse fracture pattern is the most stable
what is the weakest region of the physis?
zone of cartilage maturation
what is the Vassal principle?
initial fixation of the PRIMARY fracture will assist stabilization of the secondary fracture
name possible complications of fractures
- delayed union
- non-union
- pseudoarthrodesis
- osteoarthritis
- avascular necrosis
what is the timeframe is considered a delayed union?
what about a non-union?
- delayed union: 4-6 months
- non-union: minimum of 9 month old fracture, with at least 3 months of no progress
define: delayed union
- considered a delayed union at 4-6 months
- healing has not advanced at the average rate for the location and type of fracture/osteotomy
treatment: delayed union
can often be healed by strict immobilization alone
define: non-union
- minimum of 9-month-old fracture with no improvement for 3 months
- fracture or osteotomy that does not show improvement during the above timeframe
treatment: non-union
- intervention might include:
- bone stimulator
- operative means
- atrophic nonunions often require a bone graft
define: pseudoarthrosis
- end-stage of a non-union;
- a fibrocartilaginous surface site and a joint space develops that may contain synovial fluid
treatment: pseudoarthrosis
operative intervention is the only reliable method of forming a union involving a pseudoarthrosis
define: malunion
a fracture that heals in an anatomically incorrect position
most common cause:
non-healing for a bone fracture
improper mobilization
name 5 LOCAL factors of
non-healing of bone fractures
- improper immobilization (MC)
- infection
- poor fixation
- distracted fracture
- vascular status
- severity of injury (comminution, local tissue damage)
name 5 GENERAL/SYSTEMIC factors of
non-healing of bone fractures
- smoking
- diabetes
-
endocrinopathies
- thyroid, parathyroid, testosterone deficiency, vit D deficiency
- malnutrition
-
medications
- steroids, chemo, bisphosphonates
- bone quality
who was Lisfranc?
he was a field surgeon in Napoleon’s army
are dorsal or plantar Lisfranc dislocations more common?
DORSAL dislocations are more common
because the plantar ligaments are stronger than dorsal ligaments
what are the Ottowa Ankle Rules?
- A series of ankle X-ray films is required only if there is any pain in the malleolar zone and any of the following findings:
- Bone tenderness at posterior edge or distal 6 cm of lateral malleolus
- Bone tenderness at posterior edge or distal 6 cm of medial malleolus
- Inability to bear weight both immediately and in ED
- A series of foot X-ray films is required only if there is any pain in midfoot zone and any of the following findings:
- Bone tenderness at base of 5th metatarsal
- Bone tenderness at navicular
- Inability to bear weight both immediately and in ED
what is the classification for:
talar dome lesions
Berndt & Hardy
which stages of Berndt & Hardy classification are often associated with:
lateral ankle ligament ruptures
stages 2, 3, & 4
what are the common:
- locations of talar dome lesions,
- their mechanisms of injury
(DIAL a PIMP)
- Dorsiflexion Inversion – Anterior Lateral (unstable, shallow, wafer-shaped lesion)
- Plantarflexion Inversion – Medial Posterior (deep, cup-shaped lesion)
define: Hawkins sign
- presence of subchondral talar dome osteopenia seen 6-8 weeks after the talar fracture signifying intact vascularity
- absence of sign implies avascular necrosis
On x-ray, look for radiolucent line below the subchondral bone; MC seen on medial side in mortise view
what is the Sneppen classification
Talar BODY fractures
percentage of talar fractures involving the calcaneus
60%
60% of talar fractures involve the calcaneus
of the 60% of talar fractures that involve the calcaneus,
what percentage involves the joint?
75% of the talar fx + calc fx ALSO involve the joint
define: Mondor sign
Plantar, rearfoot ecchymosis that is pathognomonic for calcaneal fractures
how is the Bohler angle affected by a calcaneal fracture?
Bohler angle DECREASES with intra-articular calcaneal fracture
(Normal: 20-40o)
how is Gissane angle affected by a calcaneal fracture?
INCREASES with intra-articular calcaneal fracture
(Normal: 120-145o)
what fractures are commonly associated with calcaneal fractures?
- vertebral fractures, especially L1
- femoral neck
- tibial plateau
MOI: anterior process fracture
inversion with plantarflexion
*Mechanism of injury for anterior process fracture on calcaneus
clinical tests for ankle ligament pathology
- Anterior drawer test
- Calcaneofibular-stress inversion
- Abduction stress
- Ankle arthrogram
- Peroneal tenography
anterior drawer test: outcomes
- 5-8 mm drawer → rupture of ATF
- 10-15 mm drawer → rupture of ATF + CF
- >15 mm drawer → rupture of ATF + CF + PTF
talar tilt test: outcomes
>10° → rupture of CFL
stress inversion test: outcomes
- 5° inversion → rupture of ATF
- 10-30° inversion → rupture of ATF + CF
Achilles tendon rupture: clinical symptoms
- Pain with history of “pop”
- Weakness or loss of function
- Palpable dell in area of ruptured tendon
- Inability to perform single leg rise
- Increased ankle dorsiflexion
define: Thompson test
A positive test results when squeezing of the calf muscle does not plantarflex the foot
define: Hoffa sign
- Increased dorsiflexion compared to the contralateral side, along with the
- Inability to perform a single-leg rise test
(*indicates an Achilles tendon rupture)
radiographic finding of Achilles Tendon Rupture
Disruption of Kagers triangle
MC common location for Achilles tendon to rupture
Watershed area: 1.5-4 cm proximal to calcaneal insertion
define:
Pott fracture
Bimalleolar fracture
define:
Cotton
Trimalleolar fracture
define:
Tillaux-Chaput
Avulsion fracture of anterior, lateral tibia from AITFL
define:
Wagstaff fracture
Avulsion fracture of anterior, medial fibula from AITFL
define:
Cedell fracture
Fracture of posterior medial process of talus
define:
Shepard fracture
Fracture of posterior lateral process of talus
define:
Foster fracture
Entire posterior process of the talus
define:
Bosworth fracture
Lateral malleolar fracture (fibula) with ankle displacement
*this is a rare fracture-dislocation of the ankle caused by extreme external rotation of a supinated foot
define:
Maisonneuve fracture
Proximal fibular fracture
(*Weber Type C high fibula fracture)
MC MOI:
ankle fracture
SER
supination external rotation
MOI:
transverse lateral malleolar fracture
SAD I
supination adduction
MOI:
short, oblique medial malleolar fracture
SAD II
supination adduction II
MOI:
short, oblique lateral malleolar fracture
PAB III
pronation abduction III
MOI:
spiral, lateral malleolar fracture with a posterior spike
(AP and lateral views)
SER II
supination external rotation II
MOI:
high fibular fracture
PER III
pronation external rotation III
(also called Maisonneuve fracture)
what is a Lauge-Hansen Type V?
PRONATION DORSIFLEXION
- Vertical tibial malleolar tip fracture
- Anterior tibial lip fracture
- Supramalleolar fibular fracture
- Transverse posterior tibia fracture level with proximal aspect of anterior tibial fracture
When should a posterior malleolar fracture be fixated?
ORIF when fragment is greater than 25% of the posterior malleolus
what direction should transsyndesmotic screws be inserted using a lag technique?
Approximately 30° from the sagittal plane
from posterior-lateral to anterior-medial
should transsyndesmotic screws be inserted using a lag technique?
No.
- Fully-threaded cortical screws are placed across both cortices of the fibula and the lateral cortex of the tibia.
- The goal is stabilization rather than compression.
what do you clinically test via Jack Toe Test?
Foster fracture –
a fracture of the entire posterior process
define:
Thurston-Holland sign
Epiphysis is separated from the physis with the fracture extending into the metaphysis resulting
in a triangular fracture fragment (AKA Flag sign)
- *fracture through the epiphysis transversely going through metaphysis (triangle)*
- *MOST COMMON SALTER-HARRIS FRACTURE*
