Fractures Flashcards
What is the acronym for indications for Open reduction?
NO CAST: Nonunion, Open fx, Compromise of blood supply, Articular surface malalignment, Salter harrris grade III-IV, Trauma pts who need early ambulation
What is the classification for open fx?
Gustilo and Anderson. Types I-III. Based on wound size, soft tissue coverage. Final typing made after surgery
What is the classification for open fx?
Gustilo and Anderson. Types I-III. Based on wound size, soft tissue coverage. Final typing made after surgery
What are the 5 steps in initial treatment of an open fx?
- prophylactic abx: cefazolin or cefoxitin/gentamycin. 2. Debride 3. Tetanus shot 4. Lavage w/irrigation within 6hrs 5. ORIF
Describe Type I open Fx?
<1cm wound, low contamination, inside-out pattern, minimal soft tissue inj
What is the classification for open fx?
Gustilo and Anderson
what is this
What are the 4 osseous segments of Neer classification?
humeral head, humeral shaft, greater, lesser tuberosity
What are the deforming muscular forces on the osseous segments of Neer?
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
What provides the major blood supply to humeral head?
Arcuate artery (ascending branch of the ant circumflex humeral artery) runs in intertubercular groove.
Post circumflex hum artery also provides supply
What type of fx of proximal humerus is at most risk for osteonecrosis? Why?
Fracture of anatomical neck because they disrupt humeral head vascular supply
What nerve must be tested in proximal humerus fx?How?
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.
What defines a “part” in Neer classification of prox hum fx?
A part is > 1cm displaced or >45 degrees angulation
What is treatment of one-part minimally displaced prox humerus fx?
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
Fx of lesser tuberosity are commonly associated with what?
Posterior dislocation (assume post dis until proven otherwise)
How are 2 part anatomic neck fx treated?
Associated with high incidence of osteonecrosis. Generally in young pts ORIF. In older pts usually prosthesis like a hemiarthroplasy
What would be a good surgical approach for a greater tuberosity fx?
Superior deltoid split
What is a mnemonic to remember the ossification centers around the elbow?
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
What is anterior humeral line and its significance in supracondylar fx?
When extended distally, this line should intersect the middle third of the capetellum. Often lost in supracondylar fx
3 fat pads near elbow?
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
What are the 2 types of supracondylar fx?
Extension and Flexion Types. Extension is 98% in peds
What classification is used for supracondylar fx?
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
How do you treat pediatric supracondylar fx? (extension or flexion)
Type I? Type II? Type III?
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
What is the MC Neurologic injury with supracondylar fx? How would it present?
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
Most common vascular injury in supracondylar fx?
Brachial artery. CHECK pulses before and afer reduction. Especially after elbow flexion is performed
Malreduction in supracondylar fx commonly leads to what angular deformity (10-20%)?
Cubitus Varus. Occurence is <3% with pinning
What is the terrible triad of the elbow?
- Posterolateral dislocation
- Fx of coronoid
- Fx of radial head
- LCL is usually torn also and needs repair. MCL may be torn.
What classification is used for radial head fx?
Mason. types I-IV
Classification? Treatment?
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
Classification? Treatment?
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
Classify? Treat?
Mason Type II fx of radial neck. >30 deg angulation
Treat: Usually ORIF, especially if block to motion
Classify? Treat?
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
Classify? Treat?
Mason Type IV radial head fx with elbow dislocation
Treat:
Classify? Treat? Associated with?
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
What other injuries are readial head fx associated with?
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,
Describe Monteggia Fx
Fx of proximal ulna with dislocation of radial head. Types I-IV
What is the classification used for Monteggia fx? Describe each.
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:
What is the treatment for a Monteggia fx?
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
What is the most common nerve injured in a Monteggia Fx?
PIN
Describe. Classification? Treat?
Monteggia Fx. Bado Type I. Treatment ORIF
What is the classification for these?
Monteggia. Bado Types I-IV
What is a nightstick Fx?
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
What is it
Nightstick fx
What is it?
Monteggia Type II (Bado) Fx
Radius dislocate post with fx of ulna
What is a Galeazzi Fx?
A fx of the distal 1/3 of radial shaft with shortening forces causing DRUJ dislocation
What is a reverse Glaeazzi?
A fx of the distal ulna with associated disruption of the DRUJ
Why is Galeazzi called the “fracture of necessity”?
Because it requires ORIF to achieve a good result
What is the tretament for Galeazzi?
ALL need ORIF to make sure there is anatomical reduction of the DRUJ and stabilization
What are the 4 major deforming forces contributing to loss of reduction in Galeazzi fx that is treated non op?
Weight of hand, brachioradialis, pronator quadratus insertion, thumb extensors and abductors
What is it? Treat?
Galeazzi fx. ORIF
Describe
Galeazzi
What is it?
Galeazzi before and after reduction
What are the different types of acetabular fractures?
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
What are the 5 types of elementary acetabular fx?
Ant wall, ant column, post wall, post column, transverse
What are the 5 types of Associated acetabular fx?
Post wall/post column, Transverse/post wall, T-shaped, Ant column/post hemi transverse, both columns
What determines the fracture pattern in acetabular fx?
Direction of force and position of femoral head at impact
What is it?
Fracture of post wall of acetabulum. MC type of acetabular fx. Associated with Post dislocation. Get Obturator view to see well
What is it?
Fracture of post column
What is it?
Fracture of anterior wall
What is it?
Elementary Fracture of anterior column of acetabulum
What?
Transverse acetabulur fx. Elementary
What?
Associated acetabular, Post wall/Post column
What?
Transverse/Post wall associated acetabular fx
What?
T-shaped acetabular associated fx
What?
Anterior column/posterior hemi transverse
What?
Both Columns acetabular fx
What common nerve injury occurs during acetabular fx? Especially a post wall fx/dislocation?
Peroneal division of sciatic nerve
What are common complications of acetabular fx and treatment of the fx?
avascular necrosis of head of femur, damage to peroneal division of sciatic n (test dorsiflexion), post traumatic arthritis is mc, Hetorotopic ossification after surgery
What are some important radiographic lines to evaluate when looking at acetabular fx?
What portions of the pelvis make up the anterior column?
Superior pubic ramus, anterior acetabular wall, anterior iliac wing, pelvic brim
What classification is used for femoral head fx?
Pipkin I-IV
What is the mechanism of injury for most femoral head fx?
Most associated with posterior hip dislocation from hihg energy trauma
What is immediate treatment for femoral head fx?
waiting >6hrs for reduction inc risk of avn
What is the blood supply to the femoral head?
Medial circumflex femoral artery provides the majority of the superior weight bearing portion. Lateral circumflex and artery of the ligamentum teres supply the remainder.
Classify and Treat?
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.
Classify and treat?
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
Classify and Treat
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
Classify and treat
Pipking type IV femoral head fx. A type I or II injury with associated fx of acetabulum, usually post wall.
ORIF.
What is the classification used for femoral neck fx?
Garden classification Types I-IV
Classify
Garden I fx of femoral neck. Usually incomplete and may have some valgus impaction
Classify
Garden Type II femoral neck fx. Complete and nondisplaced on AP and lateral views. Rarely have a break in the trabeculations
Classify
Garden Type III femoral neck fx. Marked angulation and displacement but no proximal translation of shaft. Trabeculations of femoral head not aligned with acetabulum
Classify
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.
How would you treat a young pt with a femoral neck fx? Even if it is not displaced
How would you treat a displaced femoral neck fx in young pt?
How would you treat an older pt with a femoral neck fx who is still very active?
DO NOT do screw fixation. High rate of failure
How would you treat an older less active pt with a femoral neck fx
What are some complications with femoral neck fx?
Osteonecrosi…especially with displaced fx. Nonunion
Garden type I
Garden Type II
Garden Type III
Garden type IV
What classification is used for intertrochanteric fx?
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
Evans classification for intertrochanteric fx. Based on stability.
What are 2 types of intertrochanteric fx that are inherently unstable?
Basicervical and Reverse Obliquity. DON”T use a sliding hip screw for Reverse obliquity, they have tendency to displace medially after placement
What are 2 common ways to treat Evans intertrochanteric fx?
All get sx. Can use sliding hip screw, except for reverse obliquity, or intramedullary hip scre nail
What classification used for ankle fx?
Which type of fibula fx has higher incidence of syndesmotic disruption? Proximal or distal?
The more proximal the fx the higher the risk
What is the mc cause of death in a pelvic ring fx?
Hemorrhage
What vascular structures commonly cause lots of bleeding in pelvic ring fx?
Venous>Arterial. Internal pudendal art > sup gluteal art
Which pelvic ligaments are most important to pelvic stability?
The posterior sacroiliac complex. Strongest ligaments in the body
Which nerves are we most worried about in pelvic ring fx?
L5 and S1…lumbosacral plexus
What images do we want in pelvic ring fx?
AP pelivs, inlet view, outlet view, CT
What is considered a “stable” pelvic ring injury?
One that can withstand normal physiologic forces without abnormal deformation
What are the classifications for pelvic ring fx?
APC (anteriorposterior compression I-III)
LC (lateral compression I-III)
Vertical shear
What is the most common type of pelvic ring fx?
Lateral compression type I. Anterior oblique ramus fx with sacral compression. Stable and usually no surgery
What classification is used for pelvic fx?
Young and Burgess
Classify and Treat
APC type I. <2.5cm pubic diastasis. Intact posterior ligaments (may have vertical rami fx)
Treat: usually Non op and protected weight bearing
Classify and Treat
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
Classify and Treat
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
Classify and Treat
LP I pelvic fx. Oblique ant ramus fx with ipsilateral sacral compression
Treat: Non op with careful protected weight bearing
Classify and Treat
LP type II pelvic fx. Oblique rami fx with ipsilateral ilium fx dislocation causing SI injury.
Treat: ORIF ilium
Classify and Treat
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.
Classify and Treat
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.
Vertical shear fx
APC I fx
Symphysis widening < 2.5 cm
Non-operative. Protected weight bearing
APC II
Symphysis widening > 2.5 cm. Anterior SI joint diastasis . Posterior SI ligaments intact.
Anterior symphyseal plate or external fixator
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
LC I
Oblique ramus fracture and ipsilateral anterior sacral ala compression fracture
Non-operative. Protected weight bearing
LP II
Ramii fracture and ipsilateral posterior ilium fracture dislocation (Crescent fracture).
Open reduction and internal fixation of ilium
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.
What is cancellous bone?
Cancellous bone = spongy one = trabecular bone
Has a higher surface area:mass ratio because it is less dense
Where do we commonly find cancellous bone?
At the end of long bones and interior of vertebrae
Which Frykman classifications for distal radius are extra articular?
I and V (or II and VI)
What is the Frykman classification?
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
What?
Frykman I (II would be addition of ulnar styloid fx)
What?
Frykman III (IV would be including ulnar styloid)
Intrarticular fx involving radiocarpal joint
What
Frykman V (6 is w/ulnar styloid): Fx of distal radius with intraarticular involvement of the DRUJ
what?
Frykman VII (VIII w/ ulnar styloid). Distal radius fx invovlig intraarticular of both radiocarpal and DRUJ
What is normal radial height, inclination and volar tilt?
What are acceptable parameters after fx?
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
What classification is used for tibial plateau fx?
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
What?
Schatzker type I: lateral plateau split fx
What
Schatzker II: lateral split fx with lateral depression
Classify
Schatzker III: pure lateral depression fx
Classify
Schatzker type IV: split fx of medial plateau
Classify
Schatzker type V Bicondylar plateau fx
Classify
Schatzker VI: Plateau fx with metadiaphyseal separation
When would you consider operative treatment in a tibial plateau fx vs non op?
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.
What are the most common tibial plateau fx?
Lateral, especially Schaztker type II (lateral split with depressed fx)
What are some major complications from tibial plateau fx?
Compartment syndrome, posttraumatic arthritis and popliteal artery injury
What major complication should be watched for in tibial shaft fx?
Compartment syndrome
What is the weber classification for ankle fx?
Based on the level of the fx of the fibula.
A= below plafond
B= at plafond
C= above plafond
What should the tip to apex distance be for the lag screw in DHS placement in femoral head? How measured? Why important?
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.
How is a subtroch fx defined?
A fx betweenthe lesser trochanter and a point 5 cm distal
What are the deforming forces in a sub troch fx?
Proximal frag: iliopsoas > flexion, short rotators > ext rot, glut med and min > abduction
Distal portion: Adductors > proximal pull and into varus
What is the classification commonly used for subtrochanteric fractures?
Russell-Taylor:
Broken up into types I and II based on whether the fx extends into the piriformis fossa or not
What are the 2 most common ways to treat subtrochanteric fx?
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.
Type Ia subtroch fx (Russell Taylor).
Fracture that does NOT extend into piriformis foss and LT is still attached to proximal fragment.
Type Ib subtroch fx. (Russell Taylor) Fx does NOT extend into piriformis but does involve LT
Type IIa subtroch fx. Extends into piriformis fossa but the lesser troch is intact still. (Russell Taylor)
Type IIb subtroch fx. Extends into piriformis fossa and LT is also comminuted. (Russel Taylor)
Type III garden fx of femoral neck usually falls into what direction?
It usually gets partially displaced into Varus
Fx of the femoral shaft may commonly be associated with what other injury/fx?
Fracture of the ipsilateral femoral neck
How is a distal femur fx defined?
From the articular surface to 5 cm above metaphyseal flare
What are the deforming forces on a distal femur fx?
Quads/hamstrings > shortening
Gastroc > post displacement
How is varus defined?
Varus is when the DISTAL bone heads TOWARD midline
How is valgus defined?
Valgus is when the DISTAL bone heads AWAY from midline
What is the cotton test?
Tests integrity of tib-fib syndesmosis. Place clamp around fibula after fixation and pull laterally to test.
How much displacement/shortening of a clavicle fx is toelrated before ORIF is indicated?
<2cm`
What are the 4 signs of osteoarthritis?
Joint space narrowing, osteophytes, subchondral sclerosis, subchondral cysts
What are some of the common causes of AVN?
Trauma, corticosteroids, EtOH, inflammatory disorders
What muscles are innervated by Radial Nerve?
Triceps, Anconeus, lateral ½ of Brachialis, ECRL, Brachioradialis
Which muscles are inervated by the PIN?
All muscles of 6 dorsal compartments except ECRL. Add supinator
Which muscles are innervated by the ulnar nerve?
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
Which finger is most commonly involved in jersey finger?
Ring finger because it is the most prominent with grip. (75% of cases)
What are the flexor zones of the hand?
Which muscles are innervated by the AIN?
Radial 1/2 of the FDP, Pronator quadratus, FPL
Which meniscus is more commonly torn in acute injury?
Lateral meniscus (medial is more common with chronic injury/degeneration)
What is a Barton fracture?
What is the most commonly injured ligament in the hand?
The volar scapholunate ligament…leads to scapholunate dissociation. May see Terry Thomas sign (>3mm distance between scaphoid and lunate on xray with clenched fist)
What is gamekeeper thumb? Difference between that and skiers? What is stenor lesion?
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.
What muscle is a major deforming force in distal radius fx that causes much of the shortening? Where does it insert?
Brachioradialis. It inserts on volar aspect of radial styloid
Where is a common place for PIN to be compressed?
Arcade of froshe
What is the eponym for a distal 1/3 spiral humerus fracture with radial nerve palsy? What physical exam sign would you see?
Holstein Lewis Fracture. See Wrist drop
Which muscles have dual innervation?
Brachialis (musculocutaneous and radial), FDP (ulnar and median), flexor pollicis brevis (ulnar/median), lumbricals (ulnar/median), adductor magnus (sciatic/obturator),
What is the classification for periprosthetic fractures?
Vancouver A-C (B has parts 1-3)
When doing a distal clavicle resection, how much from medial to lateral do you want to take? What happens if you go too medial?
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
What is one of the most important things to determine when looking at an xray of a periprosthetic fx?
If the component is stable or loose
What are the six radiographic lines to examine when looking at an AP pelvis, especially with pelvic trauma?
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)
What are the six radiographic lines to examine when looking at an AP pelvis, especially with pelvic trauma?
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)
Theiliopectineallineisdisrupted(whitearrow)indicating anterior column fracture. There is also a comminuted fracture through the posterior column and posterior acetabular wall (black arrow).
The anterior (black arrow) and posterior (white arrow) walls of the acetabulum.
Impacted fracture of the right femoral neck with valgus angulation.
Bilateral slipped capital femoral epiphysis
What is a common displacement of an intertrochanteric fx? Why? What are the deforming forces?
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.
In an intertrochanteric fx with displaced greater troch, what additional tretment is required?
You need a troch plate
Why do patients with OA with valgus knees commonly have numbness and tingling in their feet?
Due to peroneal nerve irritation/compression
A compression fx of the femoral neck is on what side?
The inferior (medial) side. They tend to heal well.
What makes an intertrochanteric fx unstable?
Reverse Obliquity, Subtroch extension, large posteromedial fragment (medial calcar/lesser troch)
What nerve do we worry about with humeral shaft fx? Especially distal humerus?
Radial nerve
When/If you are suspicious of a fx going into a joint, what should you do?
Get a CT. Ex: distal humerus, tibial plateau, pilon, etc
What does every orthopedic physical exam need to include?
Inspection for open injuries, sensory/nerve distribution, vascular/pulse, AROM/PROM, strength
What part of the radial head is most likely to fx? Why?
The anterolateral portion because it has less subchondral bone
If you see a radial head fx, what must you also evluate?
DRUJ to make sure there is not an essex-lopresti fx
What is the most common direction for elbow dislocation?
Posterolateral
What makes up the MCL of the elbow?
Anterior bundle, Post bundle and Transverse ligament
What is the most important restraint to valgus stress at the elbow? Where are its insertions?
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)
How many cortices/screws do you need for good fracture fixation?
6 cortices or 3 above fracture and 3 below
What is a stresserizer in relation to fracture fixation? What is stress shielding?
What is the isthmus of the femur?
The narrowest part of the IM canal. Limits the size of IM nail that can be placed
What are the deforming forces in a femoral shaft fx?
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
What structures are in the anterior compartment of the thigh?
Quads, sartorius, iliopsoas, pectineus, femoral artery, vein, nerve and LFCN
What structures are in the medial compartment of the thigh?
Adductor magnus, longus, brevis. Gracilis, obturator externis, obturatory artery and nerve and Profunda femoris artery
What structures are in the posterior compartment of the thigh?
Hamstrings (biceps femoris long and short head, semi tend, semi memb), part of adductor magnus, sciatic nerve, perforating vessels of profund femoris, PFCN
Reaming of femur and tibia desrupts what blood supply?
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
If you have a femur fx that does not occur from high energy trauma, what should you think about?
Pathologic fx
What is the always the last step after fixing a femur fracture?
Examination of the knee under anesthesia. Knee injuries are common with femur fx
If a pt has a femur fx, what also must you look for?
Fx of the femoral neck.About 5% of time, commonly non-displaced basicervical
What can you do with a femur fx in the trauma bay to help with patient comfort and make surgical reduction easier?
Skeletal traction. General rule is 15% (or 1/9) of body weight.
What is the purpose of skeletal traction of the femur?
Restore Femoral length, limit rotational and angular deformities, reduce painful spasms and minimize blood loss into thigh
What are the landmarks for skeletal traction pins in LE? Where is it safe to place them, medial or lateral?
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.
What classification do open femoral shaft fx get?
Automatically type 3 due to soft tissue stripping
What accounts for the physiologic valgus of the femur?
The medial condyle extends more distal and is more convex
What is the anatomic axis of the femur/knee?
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.
When a distal femur fx presents with an overlying laceration, what must you do?
You should load the knee with >120cc’s or more of saline to see if there is contiuity of the wound.
What are the deforming forces of a distal femur fx?
What is most important when treating distal femoral shaft fx?
It is NOT absolute anatomic reduction, rather restoration of normal knee joint axis to a normal relationship with hip and ankle
What structures are almost always damaged in knee dislocation?
ACL/PCL
Why is the popliteal artery so vulnerable to injury with knee dislocation?
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
At what knee flexion angle should a lachman be performed?
30 degrees
Why might you see delayed ischemia after a knee dislocation?
From an intimal tear or vasospasm. You must do serial exams on these people.
What type of injuries do we see to the popliteal artery with anterior knee dislocation? Posterior?
Anterior usually causes an intimal tear. Posterior are frequently complete tears.
How is ABI calculated? What is normal? What if it is >1.2?
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
What xray finding may be seen after knee dislocation reduction that may indicate soft tissue interposition?
Widened knee joint spaces, may need to compare to other side. Would require open reduction
What is the Segund sign?
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.
Bone contusions of lateral femoral condyle on MRI and post tibial plateau are often associated with what?
ACL tear
After acl reconstruction, should ligament be tightest in flexion or extension?
Extension. Think of it like replacing the posteromedial portion which is the most important and it is tight in extension
How many facets does the patella have?
- The lateral facet is the largest.
With a patella fx or patella/quad tendon rupture, what may help the patient to retain the ability for knee extension?
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
What are the 2 mechanisms of injury for patella fx? Which is more common?
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
Laceration with patella fx requires what?
Load the knee w/ 120cc of saline
What is bipartite patella?
Unfused superolateral portion of patella. Will have smooth margins. 8% of population and bilateral in 50%
An increased Q angle may predispose you to what?
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.
What is blumensaat’s line?
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.
What are 2 ways to investigate for patella alta or baja when considering patella tendon/quad rupture?
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
Insall Salvati index
Blackburn and Peel
What is the most frequently fractured tarsal bone?
Calcaneus
What structure runs just below the sustentaculum tali medially and can be damaged with improper screw or drill placement?
Flexor hallucis longus
If someone presents with a calcaneus fracture, what other injuries should you check for?
Lumbar spine and other LE injuries. ex hip, femur knee, etc. Also compartment syndrome of the foot. Occurs 10%
What is Bohler’s angle?
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
What classification is commonly used for calcaneus fractures? Describe it
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)
What is the Hawkins sign in reference to subtalar dislocation/talar neck fx?
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
What is the most common complication following talar neck fx? What else is a concern?
Subtalar arthritis. Over 50% get it. Also tibiotalar arthritis.
Another big concern is AVN
What is “snowboarders ankle”
Fx of the lateral process of the talus
What structure runs between the medial and lateral tubercles of the posterior process of the talus?
FHL
Where are all the places the talus can fx?
What xray view gives the best look at the talar neck?
Canale view: echnique is maximum equinus, 15 degrees pronated, Xray 75 degrees cephalad from horizontal
What is the classification for talar neck fx?
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
What is the likelyhood of AVN for talar neck fx (Hawkins I-IV)
I: 0-20% II: 20-50% III: 50-90% IV: 90-100%
What is an os trigonum?
Unfused portion of the lateral tubercle (part of posterior process) of talus
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
Displaced talar neck fx with subtalar dislocation. Hawkins II
ORIF
Talar neck fx displaced with subtalar and tibiotalar dislocation. 50-90% risk avn.
ORIF
Displaced talar neck fx with subtalar, tibiotalar, and talonavicular subluxation. 90-100% risk avn. ORIF
What is the most common subtalar dislocation? What is worse?
Medial is more common. 85%. Lateral has worse prognosis
With medial subtalar dislocation (foot is medial), which soft tissue structures may prevent complete reduction?
Extensor digitorum brevis, extensor capsule…possibly peroneal tendons
With lateral subtalar dislocation, what soft tissue structures may prevent proper reduction?
Most commonly the Posterior tibialis tendon….FHL and FDL are also possible.
After reduction of a subtalar dislocation, what other imaging should be done?
CT to make sure that there are no intraarticular fragments
What type of calcaneus fractures require emergent ORIF?
Avulsion fractures of tuberosity
What are the 4 factors to assess for muscle viability?
Color (beefy red), consistency (firm and not easily disrupted), capacity to bleed, contractability (test w/cautery)
What are the tolerances for humeral shaft fractures?
20 deg AP, 30 deg varus/valgus, 3cm shortening
Distal 1/3 spiral/oblique fracture of humerus, also known as Holstein Lewis fx. About 20% have radial nerve neuropraxia
What is the gold standard treatment for the majority of humeral shaft fractures?
Coaptation splint or 7-10 days (mold with valgus to prevent varus angulation) and then functional bracing
What motions are regained first with radial nerve palsy? Which muscle first? Last?
Wrist extension and radial deviation come back first. Brachioradialis comes back first and extensor indices last
In a proximal humerus fx, when is it indicated to fix the greater tuberosity with ORIF?
When it is >5mm displaced (other parts are 1cm displaced)
Ant and Post shoulder dislocation
Functional outcomes after both bone forearm fx depend on what?
Restoration of the radial bow
With placement of a volar plate AFTER a distal radius fracture, what tendon is at risk for rupture?
Flexor Pollicis longus
What tendon is at risk for rupture with a non-displaced (or displaced but less commonly) distal radius fracture?
EPL
What is the last step of the case after fixing a tibial plateau fx?
Exam of knee under anesthesia. About 50% of them have knee ligament injuries/meniscal injuries
What are the tolerances for tibial shaft fx?
closed low energy fxs with acceptable alignment
< 5 degrees varus-valgus angulation
< 10 degrees anterior/posterior angulation
> 50% cortical apposition
< 1 cm shortening
Proximal 1/3 tibial shaft fx commonly fall into what direction?
Valgus and Procurvatum (apex anterior)
What is the outerbridge classification for cartilage injury?
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
What is Comolli sign?
It is triangular swelling of the post thorax just over the scapula and is indivative of a hematoma resulting in increased compartment pressures.
When present, how often is an os acromiale bilateral?
60% of time. Occurs in 3% of population
When someone has a scapula fx, what other injuries must you worry about?
Injuries to and around chest. For example: rib fx, pneumothorax, lung contusion, spine injury. A chest radiograph must be part of workup
What is a floating shoulder?
When there is a fx of the clavicle along with scapula which basically disconnects the UE from the axial skeleton
What is scapulothoracic dissocation?
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.
What is a West Point View good for?
