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Fractures and Pimp Questions > Fractures > Flashcards

Fractures Flashcards

1
Q

What is the acronym for indications for Open reduction?

A

NO CAST: Nonunion, Open fx, Compromise of blood supply, Articular surface malalignment, Salter harrris grade III-IV, Trauma pts who need early ambulation

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2
Q

What is the classification for open fx?

A

Gustilo and Anderson. Types I-III. Based on wound size, soft tissue coverage. Final typing made after surgery

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2
Q

What is the classification for open fx?

A

Gustilo and Anderson. Types I-III. Based on wound size, soft tissue coverage. Final typing made after surgery

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3
Q

What are the 5 steps in initial treatment of an open fx?

A
  1. prophylactic abx: cefazolin or cefoxitin/gentamycin. 2. Debride 3. Tetanus shot 4. Lavage w/irrigation within 6hrs 5. ORIF
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4
Q

Describe Type I open Fx?

A

<1cm wound, low contamination, inside-out pattern, minimal soft tissue inj

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6
Q

What is the classification for open fx?

A

Gustilo and Anderson

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7
Q

what is this

A
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8
Q

What are the 4 osseous segments of Neer classification?

A

humeral head, humeral shaft, greater, lesser tuberosity

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9
Q

What are the deforming muscular forces on the osseous segments of Neer?

A

Greater tub: sup and post by supraspinatus and ext rotators (t minor/infrasp)

Lesser Tub: medialy by subscap

Humeral Shaft: medial by pec major

deltoid insertion causes abduction of the proximal fragment

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10
Q

What provides the major blood supply to humeral head?

A

Arcuate artery (ascending branch of the ant circumflex humeral artery) runs in intertubercular groove.

Post circumflex hum artery also provides supply

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11
Q

What type of fx of proximal humerus is at most risk for osteonecrosis? Why?

A

Fracture of anatomical neck because they disrupt humeral head vascular supply

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12
Q

What nerve must be tested in proximal humerus fx?How?

A

Axillary N. Traction injury, especially in ant fx/dislocation. Test for skin sensation over lateral aspect of proximal shoulder. Motor exam usually is not usueful acutely bc of pain.

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13
Q

What defines a “part” in Neer classification of prox hum fx?

A

A part is > 1cm displaced or >45 degrees angulation

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14
Q

What is treatment of one-part minimally displaced prox humerus fx?

A

M/c type (85%). Treat w/sling immobilization with early shoulder motion at 7-10 days. Pendulum exercise with passive ROM. 6 weeks post injury active ROM started

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15
Q

Fx of lesser tuberosity are commonly associated with what?

A

Posterior dislocation (assume post dis until proven otherwise)

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16
Q

How are 2 part anatomic neck fx treated?

A

Associated with high incidence of osteonecrosis. Generally in young pts ORIF. In older pts usually prosthesis like a hemiarthroplasy

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17
Q

What would be a good surgical approach for a greater tuberosity fx?

A

Superior deltoid split

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18
Q

What is a mnemonic to remember the ossification centers around the elbow?

A

CRITOE (CMTOL)

Capitellum: by 2 years

Radial Head: by 4 yrs

Medial (Internal) Epicondyle: by 6 yrs

Trochlea: 8 yrs

Olecranon: 8-10yrs

Lateral (External) Epicondyle: 12 yrs

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19
Q

What is anterior humeral line and its significance in supracondylar fx?

A

When extended distally, this line should intersect the middle third of the capetellum. Often lost in supracondylar fx

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20
Q

3 fat pads near elbow?

A

Anterior, Posterior and Supinator

Anterior may be seen without trauma

Posterior: when present an occult fx is present 70% of time

Supinator: Anterior displacement of this pad is seen in 50% of radial neck fx

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21
Q

What are the 2 types of supracondylar fx?

A

Extension and Flexion Types. Extension is 98% in peds

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22
Q

What classification is used for supracondylar fx?

A

Gartland. 3 types (flexion or ext)

I: Nondisplaced

II: displaced with intact posterior (anterior if flex type) cortex: may be angulated or rotated

III: Complete displacement. Posteromedial or lateral

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23
Q

How do you treat pediatric supracondylar fx? (extension or flexion)

Type I? Type II? Type III?

A

Type I: immbolization in long arm cast or splint w/ forearm in neutral at 60-90 degrees for 3 wk

Type II: Try reduction and splint first. If unstable or not maintaining reduction then percuteneous pin (cross pin)

Type III: Usually need pinning. ORIF if rotational instability or NV damage

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24
Q

What is the MC Neurologic injury with supracondylar fx? How would it present?

A

AIN (branch of median nerve). Inability to pinch thumb and first fingertip together/ can’t hold piece of paper in fingertips. Test by asking them to make OK sign

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25
Q

Most common vascular injury in supracondylar fx?

A

Brachial artery. CHECK pulses before and afer reduction. Especially after elbow flexion is performed

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26
Q

Malreduction in supracondylar fx commonly leads to what angular deformity (10-20%)?

A

Cubitus Varus. Occurence is <3% with pinning

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27
Q
A
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28
Q

What is the terrible triad of the elbow?

A
  1. Posterolateral dislocation
  2. Fx of coronoid
  3. Fx of radial head
    - LCL is usually torn also and needs repair. MCL may be torn.
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29
Q

What classification is used for radial head fx?

A

Mason. types I-IV

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30
Q

Classification? Treatment?

A

Mason Type I. Nondisplaced or less than 2mm displacement.

Treat: Sling for 3 days. Early ROM after. Possible elbow aspiration w/ injection of lidocaine for pain relief

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31
Q

Classification? Treatment?

A

Mason Type II fx of radial head. Single displaced fragment >2mm or fx of neck angulated >30 deg

Treat: ORIF, especially if mechanical block to motion

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32
Q

Classify? Treat?

A

Mason Type II fx of radial neck. >30 deg angulation

Treat: Usually ORIF, especially if block to motion

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33
Q

Classify? Treat?

A

Mason Type III fx of radial head. Comminuted fx involving entire head.

Treat: Attempt ORIF if possible. RH arthroplasy or excision. ORIF works best if 3 or less parts

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34
Q

Classify? Treat?

A

Mason Type IV radial head fx with elbow dislocation

Treat:

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35
Q

Classify? Treat? Associated with?

A

Essex Lopresti: Comminuted radial head fx (and or dislocation) with disruption of DRUJ and interosseous membrane. Proximal migration of radius.

Treat: Requires RH replacement and stabilization of DRUJ. NO radial head excision Will worsen proximal radius migration

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36
Q

What other injuries are readial head fx associated with?

A

Essex Lopresti (tear of interosseous mem and DRUJ), terrible triad of elbow (coronoid fx and elbow dislocation with LCL tear, MCL/LCL tear, elbow dislocation,

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37
Q

Describe Monteggia Fx

A

Fx of proximal ulna with dislocation of radial head. Types I-IV

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38
Q

What is the classification used for Monteggia fx? Describe each.

A

Bado classification. I-IV

I: Anterior dislocation of radial head w/fx of proximal ulna. Most common

II: Posterior dislocation of radial head with fx of proximal ulna

III: Lateral dislocation of radial head with fx of proximal ulna

IV: Ant dislocation of radial head with fx of proximal 1/3 of both radius and ulna

IV:

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39
Q

What is the treatment for a Monteggia fx?

A

Most require ORIF in adults. ORIF of ulna usually reduces radius on its own.

Peds type I and II can usually be non-op with casting in supination

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40
Q

What is the most common nerve injured in a Monteggia Fx?

A

PIN

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41
Q

Describe. Classification? Treat?

A

Monteggia Fx. Bado Type I. Treatment ORIF

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42
Q

What is the classification for these?

A

Monteggia. Bado Types I-IV

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43
Q

What is a nightstick Fx?

A

Fx of the ulna usually right under the part closest to the skin (medial side). Usually occurs as someone uses ulna to protect from trauma

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44
Q

What is it

A

Nightstick fx

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45
Q

What is it?

A

Monteggia Type II (Bado) Fx

Radius dislocate post with fx of ulna

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46
Q

What is a Galeazzi Fx?

A

A fx of the distal 1/3 of radial shaft with shortening forces causing DRUJ dislocation

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47
Q

What is a reverse Glaeazzi?

A

A fx of the distal ulna with associated disruption of the DRUJ

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48
Q

Why is Galeazzi called the “fracture of necessity”?

A

Because it requires ORIF to achieve a good result

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49
Q

What is the tretament for Galeazzi?

A

ALL need ORIF to make sure there is anatomical reduction of the DRUJ and stabilization

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50
Q

What are the 4 major deforming forces contributing to loss of reduction in Galeazzi fx that is treated non op?

A

Weight of hand, brachioradialis, pronator quadratus insertion, thumb extensors and abductors

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51
Q

What is it? Treat?

A

Galeazzi fx. ORIF

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52
Q

Describe

A

Galeazzi

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53
Q

What is it?

A

Galeazzi before and after reduction

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54
Q

What are the different types of acetabular fractures?

A

Elementary and Associated Fractures. 5 of each

Elementary: Posterior wall, posterior column, Anterior wall, anterior column, transverse

Associated: Post column/post wall, transverse/post wall, T-shaped, Ant column/posterior hemi transverse, both columns

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55
Q

What are the 5 types of elementary acetabular fx?

A

Ant wall, ant column, post wall, post column, transverse

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56
Q

What are the 5 types of Associated acetabular fx?

A

Post wall/post column, Transverse/post wall, T-shaped, Ant column/post hemi transverse, both columns

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57
Q

What determines the fracture pattern in acetabular fx?

A

Direction of force and position of femoral head at impact

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58
Q

What is it?

A

Fracture of post wall of acetabulum. MC type of acetabular fx. Associated with Post dislocation. Get Obturator view to see well

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59
Q

What is it?

A

Fracture of post column

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60
Q

What is it?

A

Fracture of anterior wall

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61
Q

What is it?

A

Elementary Fracture of anterior column of acetabulum

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62
Q

What?

A

Transverse acetabulur fx. Elementary

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63
Q

What?

A

Associated acetabular, Post wall/Post column

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64
Q

What?

A

Transverse/Post wall associated acetabular fx

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65
Q

What?

A

T-shaped acetabular associated fx

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66
Q

What?

A

Anterior column/posterior hemi transverse

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67
Q

What?

A

Both Columns acetabular fx

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68
Q

What common nerve injury occurs during acetabular fx? Especially a post wall fx/dislocation?

A

Peroneal division of sciatic nerve

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69
Q

What are common complications of acetabular fx and treatment of the fx?

A

avascular necrosis of head of femur, damage to peroneal division of sciatic n (test dorsiflexion), post traumatic arthritis is mc, Hetorotopic ossification after surgery

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70
Q

What are some important radiographic lines to evaluate when looking at acetabular fx?

A
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71
Q

What portions of the pelvis make up the anterior column?

A

Superior pubic ramus, anterior acetabular wall, anterior iliac wing, pelvic brim

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72
Q

What classification is used for femoral head fx?

A

Pipkin I-IV

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73
Q

What is the mechanism of injury for most femoral head fx?

A

Most associated with posterior hip dislocation from hihg energy trauma

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74
Q

What is immediate treatment for femoral head fx?

A

waiting >6hrs for reduction inc risk of avn

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75
Q

What is the blood supply to the femoral head?

A

Medial circumflex femoral artery provides the majority of the superior weight bearing portion. Lateral circumflex and artery of the ligamentum teres supply the remainder.

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76
Q

Classify and Treat?

A

Pipkin Type I fx of femoral Head. Hip dislocation with fx of femoral head inferior to fovea capitis femoris. Does NOT invovle weight bearing surface

1st step is reduce post dislocation and usually can be managed without sx.

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77
Q

Classify and treat?

A

Pipkin type II femoral head fx. Hip dislcation w/fx of femoral head superior to the fovea capitis. DOES involve weight bearing surface. Inc risk of arthritis.

Reduce hip. Usually requires ORIF. Definitely if step off is >1mm

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78
Q

Classify and Treat

A

Pipkin Type III femoral head fx. This is a type I or II injury along with fx of femoral neck. High incidence of avn

In young individuals emergency ORIF of neck and head. If older pt w/displaced femoral neck, prosthetic replacement is indicated

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79
Q

Classify and treat

A

Pipking type IV femoral head fx. A type I or II injury with associated fx of acetabulum, usually post wall.

ORIF.

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80
Q

What is the classification used for femoral neck fx?

A

Garden classification Types I-IV

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81
Q

Classify

A

Garden I fx of femoral neck. Usually incomplete and may have some valgus impaction

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82
Q

Classify

A

Garden Type II femoral neck fx. Complete and nondisplaced on AP and lateral views. Rarely have a break in the trabeculations

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83
Q

Classify

A

Garden Type III femoral neck fx. Marked angulation and displacement but no proximal translation of shaft. Trabeculations of femoral head not aligned with acetabulum

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84
Q

Classify

A

Garden type IV femoral neck fx. Completely displaced. Trabecular pattern of the head assumes a parallel orientation with acetabulum. Usually proximal migration of femoral shaft.

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85
Q

How would you treat a young pt with a femoral neck fx? Even if it is not displaced

A
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86
Q

How would you treat a displaced femoral neck fx in young pt?

A
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87
Q

How would you treat an older pt with a femoral neck fx who is still very active?

A

DO NOT do screw fixation. High rate of failure

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88
Q

How would you treat an older less active pt with a femoral neck fx

A
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89
Q

What are some complications with femoral neck fx?

A

Osteonecrosi…especially with displaced fx. Nonunion

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90
Q
A

Garden type I

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91
Q
A

Garden Type II

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92
Q
A

Garden Type III

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93
Q
A

Garden type IV

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94
Q

What classification is used for intertrochanteric fx?

A

Evans. It is based on stability of the fx. Based on prea nd posreduction stability meaning can you convert unstable to stable. In a stable fx, the posteromedial cortex remains in contact or minimally displaced. A stable fx means that it can resist medial force postreduction

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95
Q
A

Evans classification for intertrochanteric fx. Based on stability.

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96
Q

What are 2 types of intertrochanteric fx that are inherently unstable?

A

Basicervical and Reverse Obliquity. DON”T use a sliding hip screw for Reverse obliquity, they have tendency to displace medially after placement

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97
Q

What are 2 common ways to treat Evans intertrochanteric fx?

A

All get sx. Can use sliding hip screw, except for reverse obliquity, or intramedullary hip scre nail

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98
Q

What classification used for ankle fx?

A
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99
Q

Which type of fibula fx has higher incidence of syndesmotic disruption? Proximal or distal?

A

The more proximal the fx the higher the risk

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100
Q

What is the mc cause of death in a pelvic ring fx?

A

Hemorrhage

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101
Q

What vascular structures commonly cause lots of bleeding in pelvic ring fx?

A

Venous>Arterial. Internal pudendal art > sup gluteal art

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102
Q

Which pelvic ligaments are most important to pelvic stability?

A

The posterior sacroiliac complex. Strongest ligaments in the body

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103
Q

Which nerves are we most worried about in pelvic ring fx?

A

L5 and S1…lumbosacral plexus

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104
Q

What images do we want in pelvic ring fx?

A

AP pelivs, inlet view, outlet view, CT

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105
Q

What is considered a “stable” pelvic ring injury?

A

One that can withstand normal physiologic forces without abnormal deformation

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106
Q

What are the classifications for pelvic ring fx?

A

APC (anteriorposterior compression I-III)

LC (lateral compression I-III)

Vertical shear

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107
Q

What is the most common type of pelvic ring fx?

A

Lateral compression type I. Anterior oblique ramus fx with sacral compression. Stable and usually no surgery

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108
Q

What classification is used for pelvic fx?

A

Young and Burgess

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109
Q

Classify and Treat

A

APC type I. <2.5cm pubic diastasis. Intact posterior ligaments (may have vertical rami fx)

Treat: usually Non op and protected weight bearing

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110
Q

Classify and Treat

A

APC type II. >2.5 cm pubic diastasis. Open Book Pelvic. Anterior SI joint diastasis from sacrospinous and sacrotuberous rupture but post sacroiliac intact.

Treat: Anterior symphiseal plate or external fixator

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111
Q

Classify and Treat

A

APC III pelvic fx. Complete ant and post disruption. Post SI ligaments torn and anterior SI ligaments torn. Great risk of hemorrhage. Associated w/vascular injury

Treat: Anterior symphiseal plate or external fixator with SI screws

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112
Q

Classify and Treat

A

LP I pelvic fx. Oblique ant ramus fx with ipsilateral sacral compression

Treat: Non op with careful protected weight bearing

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113
Q

Classify and Treat

A

LP type II pelvic fx. Oblique rami fx with ipsilateral ilium fx dislocation causing SI injury.

Treat: ORIF ilium

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114
Q

Classify and Treat

A

LP III pelvic ring fx. Basically and LP2 with contralateral APC 3 (windswept pelvis) (peds v auto or rollover accident)

Treat: Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.

115
Q

Classify and Treat

A

Vertical shear fx. Posterior and superior directed force. Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%

Treat: Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.

116
Q
A

Vertical shear fx

117
Q
A

APC I fx

Symphysis widening < 2.5 cm

Non-operative. Protected weight bearing

118
Q
A

APC II

Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact.

Anterior symphyseal plate or external fixator

119
Q
A

APC III

Disruption of anterior and posterior SI ligaments (SI dislocation).
APCIII associated with vascular injury

Anterior symphyseal plate or external fixator and posterior stabilization with SI screws

120
Q
A

LC I

Oblique ramus fracture and ipsilateral anterior sacral ala compression fracture

Non-operative. Protected weight bearing

121
Q
A

LP II

Ramii fracture and ipsilateral posterior ilium fracture dislocation (Crescent fracture).

Open reduction and internal fixation of ilium

122
Q
A

LC III

Ipsilateral lateral compression and contralateral APC (windswept pelvis).
Common mechanism is rollover vehicle accident or pedestrian vs auto.

Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.

123
Q

What is cancellous bone?

A

Cancellous bone = spongy one = trabecular bone

Has a higher surface area:mass ratio because it is less dense

124
Q

Where do we commonly find cancellous bone?

A

At the end of long bones and interior of vertebrae

125
Q

Which Frykman classifications for distal radius are extra articular?

A

I and V (or II and VI)

126
Q

What is the Frykman classification?

A

It is a type of Colle’s fracture that classifies distal radius based on intra or extra articular and whether or not ulnar styloid is fractured. Odd # is no ulnar styloid. add even # to add ulnar styloid injury

I: extraarticular

III: intrarticular involving distal radiocarpal

V: intraarticular involving DRUJ

VII: intraarticular involving both radiocarpal and DRUJ

127
Q

What?

A

Frykman I (II would be addition of ulnar styloid fx)

128
Q

What?

A

Frykman III (IV would be including ulnar styloid)

Intrarticular fx involving radiocarpal joint

129
Q

What

A

Frykman V (6 is w/ulnar styloid): Fx of distal radius with intraarticular involvement of the DRUJ

130
Q

what?

A

Frykman VII (VIII w/ ulnar styloid). Distal radius fx invovlig intraarticular of both radiocarpal and DRUJ

131
Q

What is normal radial height, inclination and volar tilt?

What are acceptable parameters after fx?

A

Height= 11mm Radial incline = 22degrees Volar tilt= 11 degrees

Acceptable? <5mm height loss, <5 degree change in rad incline, <5 degrees of dorsal angulation or within 20 degrees of contalateral side. Also <2mm intraarticular step off

132
Q

What classification is used for tibial plateau fx?

A

Schatzker types I-VI

I: Lateral plateau split fx

II: Lateral plateau split w/ depressed fx (most common)

III: Lateral plateau depression fx

IV: Medial plateau fx

V: Bicondylar fx

VI: Plateau fx with separation of metaphysis from diaphysis

133
Q

What?

A

Schatzker type I: lateral plateau split fx

134
Q

What

A

Schatzker II: lateral split fx with lateral depression

135
Q

Classify

A

Schatzker III: pure lateral depression fx

136
Q

Classify

A

Schatzker type IV: split fx of medial plateau

137
Q

Classify

A

Schatzker type V Bicondylar plateau fx

138
Q

Classify

A

Schatzker VI: Plateau fx with metadiaphyseal separation

139
Q

When would you consider operative treatment in a tibial plateau fx vs non op?

A

If >3mm intrarticular step off, if >5mm displacement or gapping. If less than that you can consider knee brace or cast of 6-8wk NWB.

140
Q

What are the most common tibial plateau fx?

A

Lateral, especially Schaztker type II (lateral split with depressed fx)

141
Q

What are some major complications from tibial plateau fx?

A

Compartment syndrome, posttraumatic arthritis and popliteal artery injury

142
Q

What major complication should be watched for in tibial shaft fx?

A

Compartment syndrome

143
Q

What is the weber classification for ankle fx?

A

Based on the level of the fx of the fibula.

A= below plafond

B= at plafond

C= above plafond

144
Q

What should the tip to apex distance be for the lag screw in DHS placement in femoral head? How measured? Why important?

A

Measured from sum of distances from tip of lag screw to apex of center of femoral head on ap and lateral radiograph. Should be <25mm to minimize risk of screw cutout.

145
Q

How is a subtroch fx defined?

A

A fx betweenthe lesser trochanter and a point 5 cm distal

146
Q

What are the deforming forces in a sub troch fx?

A

Proximal frag: iliopsoas > flexion, short rotators > ext rot, glut med and min > abduction

Distal portion: Adductors > proximal pull and into varus

147
Q

What is the classification commonly used for subtrochanteric fractures?

A

Russell-Taylor:

Broken up into types I and II based on whether the fx extends into the piriformis fossa or not

148
Q

What are the 2 most common ways to treat subtrochanteric fx?

A

Almost all get sx unless pt has many co-morbidities. Most are treated with cephalomedullary IM nail. Some can also be treated with 95 degree fixed angle device.

DON’T use DHS (sliding hip screw). Poor choice and unstable.

149
Q
A

Type Ia subtroch fx (Russell Taylor).

Fracture that does NOT extend into piriformis foss and LT is still attached to proximal fragment.

150
Q
A

Type Ib subtroch fx. (Russell Taylor) Fx does NOT extend into piriformis but does involve LT

151
Q
A

Type IIa subtroch fx. Extends into piriformis fossa but the lesser troch is intact still. (Russell Taylor)

152
Q
A

Type IIb subtroch fx. Extends into piriformis fossa and LT is also comminuted. (Russel Taylor)

153
Q

Type III garden fx of femoral neck usually falls into what direction?

A

It usually gets partially displaced into Varus

154
Q

Fx of the femoral shaft may commonly be associated with what other injury/fx?

A

Fracture of the ipsilateral femoral neck

155
Q

How is a distal femur fx defined?

A

From the articular surface to 5 cm above metaphyseal flare

156
Q

What are the deforming forces on a distal femur fx?

A

Quads/hamstrings > shortening

Gastroc > post displacement

157
Q

How is varus defined?

A

Varus is when the DISTAL bone heads TOWARD midline

158
Q

How is valgus defined?

A

Valgus is when the DISTAL bone heads AWAY from midline

159
Q

What is the cotton test?

A

Tests integrity of tib-fib syndesmosis. Place clamp around fibula after fixation and pull laterally to test.

160
Q

How much displacement/shortening of a clavicle fx is toelrated before ORIF is indicated?

A

<2cm`

161
Q

What are the 4 signs of osteoarthritis?

A

Joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts

162
Q

What are some of the common causes of AVN?

A

Trauma, corticosteroids, EtOH, inflammatory disorders

163
Q

What muscles are innervated by Radial Nerve?

A

Triceps, Anconeus, lateral ½ of Brachialis, ECRL, Brachioradialis

164
Q

Which muscles are inervated by the PIN?

A

All muscles of 6 dorsal compartments except ECRL. Add supinator

165
Q

Which muscles are innervated by the ulnar nerve?

A

FCU, Ulnar 2 of FDP, Hypothenar compartment (abductor digiti minimi, flexor digit minimi brevis, opponens digit minimi), ulnar 2 lumbricals, dorsal/palmar interossei, adductor pollicis, deep head of flexor pollicis brevis, palmaris brevis

166
Q

Which finger is most commonly involved in jersey finger?

A

Ring finger because it is the most prominent with grip. (75% of cases)

167
Q

What are the flexor zones of the hand?

A
168
Q

Which muscles are innervated by the AIN?

A

Radial 1/2 of the FDP, Pronator quadratus, FPL

169
Q

Which meniscus is more commonly torn in acute injury?

A

Lateral meniscus (medial is more common with chronic injury/degeneration)

170
Q

What is a Barton fracture?

A
171
Q

What is the most commonly injured ligament in the hand?

A

The volar scapholunate ligament…leads to scapholunate dissociation. May see Terry Thomas sign (>3mm distance between scaphoid and lunate on xray with clenched fist)

172
Q

What is gamekeeper thumb? Difference between that and skiers? What is stenor lesion?

A

Game keeper is tear of the UCL of the thumb and MCP junction. Gamekeeper is chronic, skier is acute. Stenor lesion is when the adductor pollicis aponeuosis is wedged underneath the tear so it can’t heal on its own and requires surgery.

173
Q

What muscle is a major deforming force in distal radius fx that causes much of the shortening? Where does it insert?

A

Brachioradialis. It inserts on volar aspect of radial styloid

174
Q

Where is a common place for PIN to be compressed?

A

Arcade of froshe

175
Q

What is the eponym for a distal 1/3 spiral humerus fracture with radial nerve palsy? What physical exam sign would you see?

A

Holstein Lewis Fracture. See Wrist drop

176
Q

Which muscles have dual innervation?

A

Brachialis (musculocutaneous and radial), FDP (ulnar and median), flexor pollicis brevis (ulnar/median), lumbricals (ulnar/median), adductor magnus (sciatic/obturator),

177
Q

What is the classification for periprosthetic fractures?

A

Vancouver A-C (B has parts 1-3)

178
Q

When doing a distal clavicle resection, how much from medial to lateral do you want to take? What happens if you go too medial?

A

Take about 8mm on women and 1cm in males. If you go too medial you run into the coracoclavicular ligaments (trapezoid and conoid). Disruption of those leads to sup/inf clavicle instability

179
Q

What is one of the most important things to determine when looking at an xray of a periprosthetic fx?

A

If the component is stable or loose

180
Q

What are the six radiographic lines to examine when looking at an AP pelvis, especially with pelvic trauma?

A

Acetabular roof notch(or ring), Iliopectineal line (ant column), Ilioischial line (post column), anterior wall, post wall, acetabular teardrop (U shaped figure making up inferomedial portion of acetabulum)

181
Q

What are the six radiographic lines to examine when looking at an AP pelvis, especially with pelvic trauma?

A
182
Q
A

The iliopectineal line is part of the anterior column (large white arrow); ilioischial line is part of the posterior column (black arrow), and teardrop appearance (small white arrow)

183
Q
A

Theiliopectineallineisdisrupted(whitearrow)indicating anterior column fracture. There is also a comminuted fracture through the posterior column and posterior acetabular wall (black arrow).

184
Q
A

The anterior (black arrow) and posterior (white arrow) walls of the acetabulum.

185
Q
A

Impacted fracture of the right femoral neck with valgus angulation.

186
Q
A

Bilateral slipped capital femoral epiphysis

187
Q

What is a common displacement of an intertrochanteric fx? Why? What are the deforming forces?

A

Commonly found in external rotation and varus with leg shortening. Abductors (glut med and min) displace the greater troch laterally, Iliopsoas displaces the lesser troch medial and proximal, quadriceps, hamstring and hip adductors displace distal fragment proximally. Adductors also pull it medially.

188
Q

In an intertrochanteric fx with displaced greater troch, what additional tretment is required?

A

You need a troch plate

189
Q

Why do patients with OA with valgus knees commonly have numbness and tingling in their feet?

A

Due to peroneal nerve irritation/compression

190
Q

A compression fx of the femoral neck is on what side?

A

The inferior (medial) side. They tend to heal well.

191
Q

What makes an intertrochanteric fx unstable?

A

Reverse Obliquity, Subtroch extension, large posteromedial fragment (medial calcar/lesser troch)

192
Q

What nerve do we worry about with humeral shaft fx? Especially distal humerus?

A

Radial nerve

193
Q

When/If you are suspicious of a fx going into a joint, what should you do?

A

Get a CT. Ex: distal humerus, tibial plateau, pilon, etc

194
Q

What does every orthopedic physical exam need to include?

A

Inspection for open injuries, sensory/nerve distribution, vascular/pulse, AROM/PROM, strength

195
Q

What part of the radial head is most likely to fx? Why?

A

The anterolateral portion because it has less subchondral bone

196
Q

If you see a radial head fx, what must you also evluate?

A

DRUJ to make sure there is not an essex-lopresti fx

197
Q

What is the most common direction for elbow dislocation?

A

Posterolateral

198
Q

What makes up the MCL of the elbow?

A

Anterior bundle, Post bundle and Transverse ligament

199
Q

What is the most important restraint to valgus stress at the elbow? Where are its insertions?

A

Ant bundle of the MCL of the elbow. It is always taut. Usually ruptures off the coronoid. Inserts on inf medial epicondyle to the SUBLIME tubercle (medial coronoid process)

200
Q

How many cortices/screws do you need for good fracture fixation?

A

6 cortices or 3 above fracture and 3 below

201
Q

What is a stresserizer in relation to fracture fixation? What is stress shielding?

A
202
Q

What is the isthmus of the femur?

A

The narrowest part of the IM canal. Limits the size of IM nail that can be placed

203
Q

What are the deforming forces in a femoral shaft fx?

A

Abductors (glut med and min): displace proximal segment into abduction

Iliopsoas: inserts on lesser troch and causes flexion and ext rotation of prox frag

Adductors: varus and axial load on distal frag

Gastroc: displace distal segment apex posterior into extension

Fascia lata: tension band by resisiting adductors

204
Q

What structures are in the anterior compartment of the thigh?

A

Quads, sartorius, iliopsoas, pectineus, femoral artery, vein, nerve and LFCN

205
Q

What structures are in the medial compartment of the thigh?

A

Adductor magnus, longus, brevis. Gracilis, obturator externis, obturatory artery and nerve and Profunda femoris artery

206
Q

What structures are in the posterior compartment of the thigh?

A

Hamstrings (biceps femoris long and short head, semi tend, semi memb), part of adductor magnus, sciatic nerve, perforating vessels of profund femoris, PFCN

207
Q

Reaming of femur and tibia desrupts what blood supply?

A

Endosteal blood supply, which usually returns w/in 2-3 wks. Ok to ream when periosteum is intact but when disrupted from open fx, may want to consider non-reamed

208
Q

If you have a femur fx that does not occur from high energy trauma, what should you think about?

A

Pathologic fx

209
Q

What is the always the last step after fixing a femur fracture?

A

Examination of the knee under anesthesia. Knee injuries are common with femur fx

210
Q

If a pt has a femur fx, what also must you look for?

A

Fx of the femoral neck.About 5% of time, commonly non-displaced basicervical

211
Q

What can you do with a femur fx in the trauma bay to help with patient comfort and make surgical reduction easier?

A

Skeletal traction. General rule is 15% (or 1/9) of body weight.

212
Q

What is the purpose of skeletal traction of the femur?

A

Restore Femoral length, limit rotational and angular deformities, reduce painful spasms and minimize blood loss into thigh

213
Q

What are the landmarks for skeletal traction pins in LE? Where is it safe to place them, medial or lateral?

A

Distal femoral pins should be placed extracapsular to avoid septic arthritis. They should be placed medial to lateral directed away from femoral artery.

Proximal tibia pins placed at level of tibial tubercle. Placed lateral to medial to avoid common peroneal nerve.

214
Q

What classification do open femoral shaft fx get?

A

Automatically type 3 due to soft tissue stripping

215
Q

What accounts for the physiologic valgus of the femur?

A

The medial condyle extends more distal and is more convex

216
Q

What is the anatomic axis of the femur/knee?

A

A line drawn down the shaft of the femur intersecting with a line drawn across the knee joint which is usually parallel to the ground. Usually forms a valgus angulation of 9 degrees.

217
Q

When a distal femur fx presents with an overlying laceration, what must you do?

A

You should load the knee with >120cc’s or more of saline to see if there is contiuity of the wound.

218
Q

What are the deforming forces of a distal femur fx?

A
219
Q

What is most important when treating distal femoral shaft fx?

A

It is NOT absolute anatomic reduction, rather restoration of normal knee joint axis to a normal relationship with hip and ankle

220
Q

What structures are almost always damaged in knee dislocation?

A

ACL/PCL

221
Q

Why is the popliteal artery so vulnerable to injury with knee dislocation?

A

Because it has fibrous tethering at either end which makes it not mobile during trauma. Fibrous tunnel at adductor hiatus and fibrous tunnel deep to the soleus

222
Q

At what knee flexion angle should a lachman be performed?

A

30 degrees

223
Q

Why might you see delayed ischemia after a knee dislocation?

A

From an intimal tear or vasospasm. You must do serial exams on these people.

224
Q

What type of injuries do we see to the popliteal artery with anterior knee dislocation? Posterior?

A

Anterior usually causes an intimal tear. Posterior are frequently complete tears.

225
Q

How is ABI calculated? What is normal? What if it is >1.2?

A

Ratio of systolic BP in ankle (DP or PT whichever is higher) to brachial. Can be used with doppler or normal cuff. Doppler you mark the number when pulse returns to doppler when deflating cuff.

Normal is .9 - 1.2 (some say 1.0-1.4)

> 1.2 usually means calcification of arteries

226
Q

What xray finding may be seen after knee dislocation reduction that may indicate soft tissue interposition?

A

Widened knee joint spaces, may need to compare to other side. Would require open reduction

227
Q

What is the Segund sign?

A

Also called the lateral capsular sign, it is an avulsion fx of the lateral tibial plateau and often associated with ACL tear but also may be seen with knee dislocation.

228
Q

Bone contusions of lateral femoral condyle on MRI and post tibial plateau are often associated with what?

A

ACL tear

229
Q

After acl reconstruction, should ligament be tightest in flexion or extension?

A

Extension. Think of it like replacing the posteromedial portion which is the most important and it is tight in extension

230
Q

How many facets does the patella have?

A
  1. The lateral facet is the largest.
231
Q

With a patella fx or patella/quad tendon rupture, what may help the patient to retain the ability for knee extension?

A

The medial and lateral extensor retinacula. If they are intact, the patient retains the abiity to extend. Same is true for patella or quad tendon rupture

232
Q

What are the 2 mechanisms of injury for patella fx? Which is more common?

A

Can be direct or indirect trauma. Direct trauma usually is minimally displaced because retinacula remain intact. Indirect is MORE COMMON from a forcible eccentric contraction. Intrinsic strenght of patella overcome. Degree of displacement indicates degree of retinacula tearing

233
Q

Laceration with patella fx requires what?

A

Load the knee w/ 120cc of saline

234
Q

What is bipartite patella?

A

Unfused superolateral portion of patella. Will have smooth margins. 8% of population and bilateral in 50%

235
Q

An increased Q angle may predispose you to what?

A

Patella dislocation. The qu angle is measured by drawing a line from the asis through the center of the patella and an intersecting line from the center of the patella to the tibial tubercle. Shows the lateral directed pull of the quads.

236
Q

What is blumensaat’s line?

A

The lower pole of the patella should lie on a line projected anteriorly from the intercondylar notch on a lateral radiograph at 30 degree flexion.

237
Q

What are 2 ways to investigate for patella alta or baja when considering patella tendon/quad rupture?

A

Insall/Salvati method: ratio length of patella diagonally on lateral xray to length from end of patella to tibial tubercle. .8-1.2 is normal. <.8 is patella alta >1.2 is baja

Blackbourne and Peel method: perpendicular line from tibial plateau and vertical line connecting to distal articular surface of patella with ratio to length of articular surface of patella

238
Q

Insall Salvati index

A
239
Q

Blackburn and Peel

A
240
Q

What is the most frequently fractured tarsal bone?

A

Calcaneus

241
Q

What structure runs just below the sustentaculum tali medially and can be damaged with improper screw or drill placement?

A

Flexor hallucis longus

242
Q

If someone presents with a calcaneus fracture, what other injuries should you check for?

A

Lumbar spine and other LE injuries. ex hip, femur knee, etc. Also compartment syndrome of the foot. Occurs 10%

243
Q

What is Bohler’s angle?

A

An angle formed by drawing a line across the highest point of anterior process to highest point of posterior facet and a tangential line from top of post facet to sup edge of tuberosity. Normal is 20-40 degrees

244
Q

What classification is commonly used for calcaneus fractures? Describe it

A

Sanders. Based on coronal CT scan at widest point of the posterior facet of talus and the number of fragments:

Type I: Nondisplaced posterior facet (regardless of number of fracture lines)

Type II: One fracture line in the posterior facet (two fragments)

Type III: Two fracture lines in the posterior facet (three fragments)

Type IV: Comminuted with more than three fracture lines in the posterior facet (four or more fragments)

245
Q

What is the Hawkins sign in reference to subtalar dislocation/talar neck fx?

A

Hawkins sign is a subchondral talar lucency at approximately 6 weeks postoperatively indicates revascularization of the talus and is a good prognostic factor for this injury

246
Q

What is the most common complication following talar neck fx? What else is a concern?

A

Subtalar arthritis. Over 50% get it. Also tibiotalar arthritis.

Another big concern is AVN

247
Q

What is “snowboarders ankle”

A

Fx of the lateral process of the talus

248
Q

What structure runs between the medial and lateral tubercles of the posterior process of the talus?

A

FHL

249
Q

Where are all the places the talus can fx?

A
250
Q

What xray view gives the best look at the talar neck?

A

Canale view: echnique is maximum equinus, 15 degrees pronated, Xray 75 degrees cephalad from horizontal

251
Q

What is the classification for talar neck fx?

A

Hawkins Types I-IV

I: non displaced fx of the neck w/out any subluxation

II: talar neck fx with subtalar dislocation

III: neck fx with subtalar and tibiotalar dislocation

IV: neck fx with subtalar/tibiotalar/talonavicular dislocation

252
Q

What is the likelyhood of AVN for talar neck fx (Hawkins I-IV)

A

I: 0-20% II: 20-50% III: 50-90% IV: 90-100%

253
Q

What is an os trigonum?

A

Unfused portion of the lateral tubercle (part of posterior process) of talus

254
Q
A

Talar neck fx: Hawkins type I

10-20% risk AVN. May be treated non surgical with SLC for 8-12 wks w/ first 6 wks nwb

255
Q
A

Displaced talar neck fx with subtalar dislocation. Hawkins II

ORIF

256
Q
A

Talar neck fx displaced with subtalar and tibiotalar dislocation. 50-90% risk avn.

ORIF

257
Q
A

Displaced talar neck fx with subtalar, tibiotalar, and talonavicular subluxation. 90-100% risk avn. ORIF

258
Q

What is the most common subtalar dislocation? What is worse?

A

Medial is more common. 85%. Lateral has worse prognosis

259
Q

With medial subtalar dislocation (foot is medial), which soft tissue structures may prevent complete reduction?

A

Extensor digitorum brevis, extensor capsule…possibly peroneal tendons

260
Q

With lateral subtalar dislocation, what soft tissue structures may prevent proper reduction?

A

Most commonly the Posterior tibialis tendon….FHL and FDL are also possible.

261
Q

After reduction of a subtalar dislocation, what other imaging should be done?

A

CT to make sure that there are no intraarticular fragments

262
Q

What type of calcaneus fractures require emergent ORIF?

A

Avulsion fractures of tuberosity

263
Q

What are the 4 factors to assess for muscle viability?

A

Color (beefy red), consistency (firm and not easily disrupted), capacity to bleed, contractability (test w/cautery)

264
Q

What are the tolerances for humeral shaft fractures?

A

20 deg AP, 30 deg varus/valgus, 3cm shortening

265
Q
A

Distal 1/3 spiral/oblique fracture of humerus, also known as Holstein Lewis fx. About 20% have radial nerve neuropraxia

266
Q

What is the gold standard treatment for the majority of humeral shaft fractures?

A

Coaptation splint or 7-10 days (mold with valgus to prevent varus angulation) and then functional bracing

267
Q

What motions are regained first with radial nerve palsy? Which muscle first? Last?

A

Wrist extension and radial deviation come back first. Brachioradialis comes back first and extensor indices last

268
Q

In a proximal humerus fx, when is it indicated to fix the greater tuberosity with ORIF?

A

When it is >5mm displaced (other parts are 1cm displaced)

269
Q
A

Ant and Post shoulder dislocation

270
Q

Functional outcomes after both bone forearm fx depend on what?

A

Restoration of the radial bow

271
Q

With placement of a volar plate AFTER a distal radius fracture, what tendon is at risk for rupture?

A

Flexor Pollicis longus

272
Q

What tendon is at risk for rupture with a non-displaced (or displaced but less commonly) distal radius fracture?

A

EPL

273
Q

What is the last step of the case after fixing a tibial plateau fx?

A

Exam of knee under anesthesia. About 50% of them have knee ligament injuries/meniscal injuries

274
Q

What are the tolerances for tibial shaft fx?

A

closed low energy fxs with acceptable alignment
< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening

275
Q

Proximal 1/3 tibial shaft fx commonly fall into what direction?

A

Valgus and Procurvatum (apex anterior)

276
Q

What is the outerbridge classification for cartilage injury?

A

I-IV

I: softening and swelling

II: lesions and fissures that don’t reach subchondral bone and are <1.5cm

III: lesions that do reach subchondral bone and are >1.5cm

IV: exposed subchondral bone

277
Q

What is Comolli sign?

A

It is triangular swelling of the post thorax just over the scapula and is indivative of a hematoma resulting in increased compartment pressures.

278
Q

When present, how often is an os acromiale bilateral?

A

60% of time. Occurs in 3% of population

279
Q

When someone has a scapula fx, what other injuries must you worry about?

A

Injuries to and around chest. For example: rib fx, pneumothorax, lung contusion, spine injury. A chest radiograph must be part of workup

280
Q

What is a floating shoulder?

A

When there is a fx of the clavicle along with scapula which basically disconnects the UE from the axial skeleton

281
Q

What is scapulothoracic dissocation?

A

Traumatic disruption of the scapula from the posterior chest wall. Life/limb threatening. 80% have brachial plexus injury. 88% have subclavian artery injury. Present after severe traction injury. Check for pulselessness. Do angiography if so.

282
Q

What is a West Point View good for?

A
283
Q
A

Fractures and Pimp Questions (3 decks)

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