Common techniques and Approachs

Question 1

What are the indications and contraindications for halo application

Answer 1

Indications

definitive treatment of cervical spine trauma including:

C1 burst (Jefferson) fracture
type II and III odontoid fractures in young patients (not elderly)
type II and IIA hangman’s fractures

preoperative reduction in the patient with spinal deformity (facet dislocation)
adjunctive postoperative stabilization following cervical spine surgery

Contraindications

absolute

cranial fracture
infection
severe soft-tissue injury at the proposed pin sites

relative

severe chest trauma
obesity, advanced age

recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)

barrel-shaped chest

Question 2

What are the important techniques when applying halo?

Answer 2

• Movement Restriction
  
  • ​More motion below C2
  • Controversial - most motion at C2/3 and least at C7/T1
  • Some say allows 70% of flexion
• Contraindications
  
  • absolute
    
    • cranial fracture
    • infection
    • severe soft-tissue injury at the proposed pin sites
  • relative
    
    • severe chest trauma
    • obesity, advanced age
    • recent evidence demonstrates an unacceptably high mortality rate in patients aged 79 years and older (21%)
    • barrel-shaped chest
• Indications for CT
  
  • possible fracture
  • child <10 for thin bone
• Adults
  
  • total of 4 pins
    
    • 2 posterior pins
      
      • 1 cm above the pinna
    • 2 anterior pins
      
      • lateral 1/3 of the eyebrow
      • this is anterior/medial to temporalis fossa
      • this is lateral to supraorbital nerve
  • tighten to 4-8 inch-pounds of torque
    
    • ​(not foot pounds..)
  • have patient return on day 2 to tighten again
• Pediatrics
  
  • more pins, less torque
  • total of 6-8 pins
  • lower torque (2-4 in-lbs or “finger-tight”)
  • < 2 yrs. can’t use halo and must use Minerva cast

Question 3

What are the common compliations of halo

Answer 3

• Loosening (36%)
  
  • pins placed more cranial = more loosening
    
    • just above pinna at equator of head
    • 0.5cm above brow
  • ring should be closer to head
  • pins should engage at 90 deg angle
  • metal rings better than graphite ring
• Infection (20%)
  
  • especially with anterior pin in temporalis fossa because
  • treat infection with oral antibiotics if pin not loose
  • if infection with loose pin then remove pin
• Discomfort (18%)
  
  • treat by loosening skin around pin
• Dural puncture (1%)
• Crainal nerve VI palsy

Question 4

What are the indications for a CT prior to halo applications

Answer 4

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clinical suspicion for cranial fracture
children younger than 10 to determine thickness of bone

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Question 5

Deltopectoral Appraoch

Answer 5

• Beachchair at 45 deg
• Prep both anterior and posterior
• 12cm incision from coracoid to the deltoid insertion
• find the cephalic vein and retract laterally
• incise the clavipectoral fascia and retract the deltoid laterally
• Identify the pec major inferiorly, and the conjoint tendon superiorly, be aware of the musculocutaneus nerve
• Identify the superior and inferior margins of the subscap, be aware of the axillary nerve along the inferior margin
• Release the subscap leaving some tendon to sew back to

Question 6

Two incision compartment release

Answer 6

• approach
  
  • two 15-18cm vertical incisions separated by _8cm skin bridg_e
• anterolateral incision
  
  • identify and protect the superficial peroneal nerve
  • fasciotomy of anterior compartment performed 1cm in front of intermuscular septum
  • fasciotomy of lateral compartment performed 1cm behind intermuscular septum
• posteromedial incision
  
  • protect saphenous vein and nerve
  • incise superficial posterior compartment
  • detach soleal bridge from back of tibia to adequately decompress deep posterior compartment
• post-operative
  
  • dressing changes followed by delayed primary closure or skin grafting at 3-7 days post decompression
• pros
  
  • easy to perform
  • excellent exposure
• cons
  
  • requires two incisions

Question 7

Nancy Nailing

Answer 7

• Supine on a radiolucent table with c-arm
• fixation of one bone often sufficient stability
• Radial pin
  
  • Usually do this first, because passage of the first nail is easier
  • The ulna is easiest to access if you need to open to pass the nail
  • Small incision over first compartment
    
    • Protect the superficial radial nerve, retract the tendons
  • Use an awl to get your start point with flouro
  • Precontour the nail, feel it hit the cortex and scrape as it is advanced, don’t use a power tool
  • Reduce the fracture and rotate the nail to pass it
  • If you are malreduced and having trouble might need to switch to a smaller nail
• Ulnar pin
  
  • Start on the lateral subcutaneous border of the ulna
    
    • Avoids the olecranon physis
  • Get your point with an awl, make a small hole and then advance the nail
• Assess the whole construct, ensure reduction, cut the pins
• Post-op care
  
  • Splint that allows and and elbow motion
  • See at 4-6 weeks to assess
  • Pins are removed at 6 moths

Question 8

Kocher Approach/EDC Split

Answer 8

• supine with sterile tourniqutte
• Arm is kept pronated to protect the PIN
• 6cm extending obliquely over the lateral epicondyl and radial head
• Facial stripe between ECU and anconeus is idenfitied and split (or the ECU muscle is split)
  
  • the interval is developed, the capsule and the LUCL are identified, then annulus is incised in a z-fashion for later repair
• ECU is split in line from the lateral epiconyle to listers tubercle
• if distal extension is required the supinator can be elevated, but is limited by the PIN 2.6cm distal from the joint

Question 9

Proximal Row Carpectomy

Answer 9

• Indications
  
  • SNAC, SLAC
  • Stage IIIB, IV keinbochs
  • Chronic perilunate dislocation
  • Scaphoid AVN (Preser’s)
  • Wrist contracture
• Contraindications
  
  • Inflammatory OA
  • Capitate OA
  • Ulnar carpal translocation
  • Controversial
    
    • Heavy labourer
    • <35 yo
• Approach
  
  • Dorsal longitudinal incision in line with 4th extensor compartment
  • Incise retinaculum in line with incision, protect the dorsal radial artery
  • Excise the PIN in the capsule
  • Examine the capitate - if arthritis perform an arthrodesis
  • Protect the radioscapholunate ligament, avoid iatrogenic cartilage injury
• Place osteomte parallel to FCR, excise the proximal scaphoid
• Remove the lunate, scaphoid, triquetrum and pisiform whole,
• Seat the capitate in the lunate fossa and assess for impingement on the trapesium
  
  • do a radial styloid excision if necessary
• Maintenance of the volar ligaments is important to prevent subluxation
• Close capsule and retinaculum seperately

Question 10

First MTP Arthrodesis

Answer 10

• dorsal plate with compression screw is biomechanically strongest construct
• preferred surgical alignment
  
  • 10 to 15 degrees of valgus in relation to the metatarsal shaft
  • 15 degrees of dorsiflexion in relation to the floor
• Malalignment
  
  • fusion in excesssive dorsiflexion causes pain at tip of the toe, over the IP joint, and under the 1st metatarsal with excessive dorsiflexion
  • fusion in excessive plantar flexion causes increased pressure at the tip of the toe
  • fusion in excessive valgus increases the risk of IP joint degeneration
• Complications
  
  • Nonunion
  • metatarsaligia

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Question 11

Direct SL repair for acute injury

Answer 11

• Approach
  
  • small incision is made just distal to the radial styloid
  • care to avoid cutting the radial sensory nerve branches
• technique
  
  • place two k-wires in parallel into the scaphoid bone
  • reduce the SL joint by levering the scaphoid into extension, supination and ulnar deviation and lunate into flexion and radial deviation
  • pass the k wires into the lunate
  • confirm reduction of the SL joint under fluroscopy
• place patient in short arm cast
• post-operative care
  
  • remove k-wires in 8-10 weeks
  • no heavy labour for 4-6 months

Question 12

Hip Arthroscopy

Answer 12

• Position
  
  • may be done supine or in lateral decubitus position
  • Should be done with traction, be careful as this is a common complication
• Joint distension
  
  • can load joint with saline to distend joint - usully done with flouro
  • requires traction in line with the femoral neck
  • well padded perineal post
    
    • ~50 pounds of traction
• Scope insertion
  
  • anterolateral scope placed first with flouro guidance
  • arthroscope insertion over guidewire in joint above the GT
  • anterior portal placed second
    
    • 2cm anterior to anterolateral
    • then placed under fluoroscopic guidance with the hip flexed and in internal rotation
  • posterior portal placed last
    
    • 2cm posterior to GT
    • zona orbicularis provides landmark for iliopsoas
• Immediate post-operative period
  
  • NWB or PWB for ~ one week
  • with gradual progression to full weight bearing
• Rehabilitation
  
  • strengthening is started after full ROM is achieved
  • Return to full activity at ~ 3 months
• May prevent traction injuries with
  
  • intermittent release of traction
  • adequate anesthesia

Question 13

Cavus Foot reconstruction

Answer 13

• Supine, tourniquette
• Calcaneal slide and longus to brevis
  
  • lateral incision along the peroneal tendons, protect the sural nerve
  • open the sheath, preserve the retinaculum unless combining procedure with modified bronstrum
  • transfer longus to brevis with nonabsorbable suture and a baried note
  • subperiosteal disection to calcaneus, homen superior and anterior to achilles
  • ossilating saw to perform the osteotomy being careful of medial structures
  • lateral slide 8-10mm, secure with percutaneous k-wires and 6.5mm canulated lag screws
  • rasp the prominent bone
• First ray dorsiflexion osteotomy
  
  • incision over first ray, medial to extensor tendons, retract them laterally to protect NV structures and perform subperioteal disection, protect soft tissues with homens
  • dorsal closing wedge ostotomy 1cm from the joint. Start the cut with saggital saw 2-3mm from first cut angled proximally and complete with osteotome
  • Secure with 3.5mm lag screw; don’t enter the TN joint
• Plantar fascia release
  
  • ​plantar/medial incision with release of fascia 1cm from calcaneal tuberosity
  • stay away from the weight bearing surface and protect the nerves
• Jone procedure with IP fusion
  
  • ​small dorsal incision over the IP, incise EHL and perform capsulotomy
  • denude the cartilage and secure with retrograde to antegrade K-wire in the center of the IP; secure with a retrograde screw that is not in the 1st MTP joint
  • Make a more proximal incision over the 1st MT, identify the EHL, drill a medial and lateral hole to loop the tendon back on itself; secrue with non-absorbable suture

Question 14

What is the injury instability severity score

Answer 14

• Age at Surgery (yrs)
  
  • ≤ 20: 2
  • > 20: 0
• Degree of sport participation (pre-operative)
  
  • Competitive: 2
  • Recreational or none: 0
• Type of Sport (pre-operative)
  
  • Contact or forced overhead: 1
  • Other: 0
• Shoulder Hyperlaxity*
  
  • Hyperlaxity (anterior/inferior): 1
  • Normal: 0
• Hill-Sachs lesion on AP radiograph
  
  • Visible on external rotation: 2
  • Not visible on external rotation: 0
• Glenoid loss of contour on AP radiograph
  
  • Loss of contour: 2
  • No lesion: 0
• Total (points)
  
  • 10

Question 15

What is the glenoid tract

Answer 15

glenoid tract is 85% of the glenoid at the widest interval

if the hillsachs is larger than this the lesion will engage and you address it posteirorly