Goldenstien Trauma List 7 Flashcards
Principles of flexor tendon reconstruction
- Stage I
o Excise tendon remnants
o Pulley reconstruction
o Silicone rod placement (secure distally)
o Aggressive passive ROM
- Stage II (3 months)
o Remove silicone rod
o Tendon graft secured distally
o Bring through pulleys
o Tension and secure
o Rehabilitation
o Delayed tenolysis as needed
Blocks to successful closed reduction of DIP dorsal dislocations
- Volar plate
- Flexor digitorum profundus
- Osteochondral fracture fragment
- Sesamoid bone
Indications for surgical treatment of PIP collateral ligament injuries
- Radiographic evidence of soft tissue interposition
- Displaced Condylar fracture
- Continued instability after 3 weeks of static splinting
Classification of PIP dorsal fracture-dislocations
- Acute
o Type I: < 30% (stable)
o Type II: 30-50% (tenuous)
o Type III: > 50% (unstable)
- Chronic
Indications for surgical treatment of dorsal PIP dislocations
- Open injury
- Irreducible dislocation
- > 40% joint involved and unstable
- highly comminuted “pilon” fracture-dislocations
- chronic injuries
Complications of dorsal PIP dislocations
- Flexion contracture
- Pseudoboutonniere deformity
- Hyperextension instability
Complications of volar PIP dislocations
- Extension contracture
- Progressive boutonniere deformity
- Global instability
Classification of dorsal MCP dislocations
- Simple
- o “no table” test
- o Angular deformity
- o Reduced in flexion
- Complex
- o Shortening with minimal angular deformity
- o MC head caught between flexor tendon/lumbrical and natatory band/intermetacarpal ligaments
- o Irreducible
Indications for MCP collateral ligament injury
- Thumb ulnar
o Complete tear
o Partial tear with ≥ 35° of opening
o Displaced fragment with a Stener’s lesion
- Thumb radial
o Complete tear
o Partial tear with instability/volar subluxation of phalanx
- Finger
o Fracture ≥ 20% of articular surface or 2 mm of displacement
o Index or 5th digit RCL
Complications of thumb UCL injury
- Residual instability
- Pain
- Reduced lateral key-pinch strength
- Volar subluxation of the MCP joint
- Post-traumatic arthritis
Indications for operative treatment of metacarpal and phalangeal fractures
- Unstable fractures
- Irreducible fractures
- Malrotation
- Intraarticular fractures
- Open fractures
- Segmental bone loss
- Multiple fractures
- Fracture with associated soft tissue injury
- Polytrauma patients
Phalangeal fracture complications
- Loss of motion
- Malunion
- Infection
- Nonunion
- Symptomatic hardware
Indications for surgical treatment of metacarpal neck fractures
- > 40° angulation
- < 40° angulation with unacceptable cosmetic deformity
- > 15° angulation of 2nd/3rd MC neck
Indications for surgical treatment of metacarpal shaft fractures
- Malrotation
- Dorsal angulation > 10° (2 or 3) or > 20° (4 or 5)
- Shortening > 3 mm
- Multiple displaced metacarpal shaft fractures
Complications of metacarpal shaft fractures
- Malunion
- Nonunion
- MCP joint contractures
- Extrinsic tightness
- Refracture
Predictors of poor prognosis following hand fracture fixation
- Open fractures
- Intraarticular fractures
- Associated nerve injury
- Associated tendon injury
- Crush injury
Classification of 4th/5th CMC (hamatometacarpal) fracture-dislocations (Cain)
- Type IA: ligamentous injury
- Type IB: dorsal hamate fracture (#1)
- Type II: comminuted dorsal hamate fracture
- Type III: coronal hamate fracture
Complications of CMC dislocations
- Incomplete reduction
- Instability
- Chronic pain
- Weakness
- Post-traumatic arthritis
Classification of thumb metacarpal base fractures (4)
- Bennett’s – partial articular fracture (#1)
- Rolando’s – complete articular with 3 fragments
- Epibasal – extraarticular
- Comminuted
Indications for surgical treatment of thumb metacarpal base fractures (2)
- Articular incongruity ≥ 2 mm
- CMC joint subluxation/instability
Complications of thumb metacarpal base fractures (7)
- Weak lateral key pinch
- Difficulty with opposition
- Stiffness
- Post-traumatic arthritis
- Instability
- Malunion
- Nonunion
Pelvis fracture classification (Young & Burgess) (8)
- Anterior-posterior compression
- o APC I: symphysis widened up to 2 cm, SI ligaments intact
- o APC II: symphysis widened > 2 cm, anterior SI/sacrotuberous ligaments disrupted
- o APC III: symphysis widened > 5 cm, posterior SI/sacrospinous ligaments disrupted
- Lateral compression
- o LC I: anterior ring injury with ipsilateral sacral crush
- o LC II: anterior ring injury with ipsilateral “crescent” fracture
- o LC III: windswept pelvis (LCI with contralateral open book injury)
- Vertical shear
- Combined mechanism
Pelvis fracture classification (Tile) (11)
- Type A: stable
o 1 – avulsion fracture with intact ring
o 2 – nondisplaced pelvic ring injury
o 3 – transverse fracture of sacrum/coccyx
- Type B: rotationally unstable, vertically stable
o 1 – anterior-posterior compression
1: symphysis < 2.5 cm
2: symphysis > 2.5 cm, unilateral posterior injury
3: symphysis > 2.5 cm, bilateral posterior injury
o 2 – lateral compression with ipsilateral posterior crush
o 3 – lateral compression with contralateral posterior opening
- Type C: rotationally and vertically unstable
o 1 – ipsilateral anterior and posterior injuries
o 2 – bilateral hemipelvic disruption
o 3 – any pelvic fracture with an associated acetabular fracture
Correlates of pelvic fracture mechanism of injury (5)
- Fluid resuscitation requirements
- Associated organ injuries
- Energy transmission
- Need for acute pelvic stabilization
- Patient survival
Pelvic fracture associated injuries (9)
- Closed head injuries (LC)
- Chest/abdominal trauma (APC)
- Bowel injury (LCIII)
- Urogenital injury (10%)
- Lumbosacral plexus injury (10%)
- Musculoskeletal injuries (60-80%)
- Hemorrhage (75% - APC II/III)
- Open fractures
- Death (LCIII, APC II/III, open)
- (Proximal → distal)
Signs of a urethral injury (7)
- Scrotal/labial swelling or ecchymosis
- Blood at the urethral meatus
- High-riding/mobile prostate
- Inability to void despite a full bladder
- Elevated bladder on IVP
- Dye leakage on IVP/retrograde urethrogram
- Inability to pass a foley catheter
Options for treatment of hemorrhage associated with pelvic fracture (4)
- Pelvic binder application
- External fixation
- Angiographic embolization
- Retroperitoneal packing
Components of management of open pelvic fractures (5)
- Management of hemorrhage
- ER removal of gross debris, tetanus and antibiotics
- OR layer-by-layer irrigation and debridement
- External fixation of the pelvis
- General surgery assessment for possible diverting colostomy and rectal washout
Indications for nonoperative management of pelvic fractures (3)
- Stable pelvic ring fracture
- Isolated avulsion fracture or iliac wing fracture
- Unstable fractures in patients with contraindications to surgical intervention
XR findings of pelvic fracture instability (5)
- Displacement of posterior SI complex > 1 cm
- Posterior fracture gap
- Avulsion of the L5 transverse process
- Avulsion fractures of the sacrum or ischial spine
- Avulsion fractures of the ischial tuberosity
Indications for surgical treatment of pelvic fractures (5)
- Open fracture
- Symphysis diastasis > 2.5 cm
- Anterior and posterior SI ligament disruption
- Vertical instability
- Sacral fracture with displacement > 1 cm
Indications for surgical stabilization of iliac wing fractures (5)
- Associated with an open wound
- Iliac/flank skin compromise
- Severely displaced/comminuted
- Unstable fractures that compromise pulmonary function
- Bowel entrapment
Options for stabilization of anterior pelvis injuries (3)
- Symphyseal plating
- External fixation
- Screw fixation (ramus #)
Options for stabilization of posterior pelvic ring injuries (6)
- Anterior SI plating
- Posterior SI plating
- Sacroiliac screws
- Transiliac bars/rods
- Posterior transiliac plating
- Spinal-pelvic fixation
Indications for pelvic external fixation (3)
- Temporary stabilization in hemodynamically unstable patient
- Temporary anterior fixation if contraindication to symphyseal plating
- Definitive treatment of pelvic fracture
Contraindications to symphyseal plating (4)
- Non-resuscitated patient
- Contaminated open wound
- Bladder injury (?)
- Female of child-bearing age
Relative contraindications to anterior SI joint plating (4)
- Morbid obesity
- Comminuted ipsilateral sacral fracture
- Iliac crest external fixation
- Ipsilateral colostomy
Complications of posterior SI screw fixation (4)
- Neurologic injury
- Hardware malposition
- Malreduction/malunion
- Failure of fixation
Complications of pelvic fractures (13)
- DVT (35-50% - #1)
- PE (symptomatic 2-10%, fatal 0.5-2%)
- Infection (deep 5-10% if ORIF)
- Hemorrhagic shock
- Nerve injury (10-15%)
- Urogenital injury
- Bladder dysfunction
- Sexual dysfunction/dyspareunia (5-20%)
- Morel-Lavallee lesions
- Malunion
- Osteitis pubis
- Heterotopic ossification (10%)
- Death
Negative prognostic factors for functional outcome following pelvic fracture (10)
- Medical comorbidities
- Higher severity of injury
- Open fractures
- Neurologic injury
- Associated injuries
- Associated soft tissue injury
- Posterior Malreduction
- Leg length discrepancy
- Degenerative SI joint disease
(Patient, injury, surgery, complications)
Indications for surgical treatment of volar PIP dislocations
- if > 40% joint involvement
- Open injury
- Irreducible dislocation
- highly comminuted “pilon” fracture-dislocations
- chronic injuries
