MEMORIZE TRAUMA Flashcards

Question

Injuries with PLRI and PMRI

Answer 1

PMRI 1 Anteromedial facet coronoid 2 LCL avulsion 3 Posterior band MCL (remember anterior band is connected to the AM facet) 4 Radial head intact PLRI 1 Coronoid tip 2 LCL avulsion 3 Anterior band MCL 4 Radial head fracture

Answer 2

1 Female 2 Older 3 Displaced 4 15-20mm short 5 Severe initial trauma 6 Unstable distal third fractures (e.g. Neer 2)

Answer 3

1 Medial displacement > 2.5cm 2 Short > 2.5cm 3 A 45 degree sagittal angular deformity 4 GPA < 22 degrees 5 Articular step > 3mm 6 Displaced double disruption SSSC (floating shoulder)

Answer 4

Strong predictors: posteromedial calcar extension < 8mm, disruption medial hinge > 2mm, anatomic neck Moderate: 3 part, 4 part, > 45 degrees displacement head, tuberosity displacement > 1cm, associated dislocation, head split 1 Anatomic reduction of the medial cortices 2 Inferomedial calcar screw 3 Head-on-shaft impaction (valgus impaction) 4 Fibular strut allograft

Answer 5

1 Increased soft tissue density around scapula (hematoma) 2 Distracted fracture clavicle 3 Distracted AC separation 4 Distracted SC separation 5 Lateralized scapula with index > 1.29 6 Absolute difference between injured and uninjured scapula to spinous process > 1cm

Answer 6

Clavicle fracture – Dual orthogonal plating AC joint – Hook plate with CC screw and anterior plating across AC joint SC joint – Reconstructed with allograft or autograft tendon

Answer 7

< 30° varus/valgus angulation < 20° AP angulation <30 ° rotation < 3cm of shortening Proximal 1/3 fractures, oblique proximal 1/3, increasing fracture gap size, smoking, female

Answer 8

1 Restoration of Shenton’s line 2 Garden alignment index 160 on AP, 180 on lateral 3 Lowell’s alignment S and reverse S on lateral 4 Restoration neck shaft angle (125-130) 1 Varus angulation 2 Inferior offset 3 Retroversion

Answer 9

1 Posteromedial comminution 2 Reverse obliquity 3 Subtrochanteric extension 4 Lateral wall comminution 5 Reverse oblique variant (fracture orientation when viewed on AP looks typical, however on the lateral the fracture extends from proximal-anterior to distal-posterior)

Answer 10

1 Reverse obliquity fractures 2 Subtrochanteric extension 3 Capacious proximal canal 4 Pathological fractures

Answer 11

1 Medialize start point 2 Joysticks 3 Femoral distractor 4 Reduction spoon 5 Blocking screws (medial and posterior on proximal fragment) 6 Schantz pins 7 Clamps 8 Lateral decubitus position neutralizes deforming forces 9 Unicortical plating

Answer 12

1 LT profile 2 Cortical keys 3 Cortical thickness 4 Cortical diameter 5 Use built in version of the nail (Many ways to do this but if centre centre in the neck and head, you can go to a perfect circle of the nail distally, and rotate the knee for a perfect lateral. In this way the rotation of the femurwill match the rotation of the nail.) 6 Clinical comparison contralateral leg (IR ER) CT rotational profile – looks at the axial cut in line of the femoral neck superimposed over the intercondylar axis distally May be compared to contralateral side Prior to union: Remove distal locking screws, correct deformity, re-place locking screws If less than 20 degrees screw holes will likely touch (and cut out) so consider lengthening the nail After union: remove the nail, transverse osteotomy at the CORA and replace the nail 1 Length 2 Alignment 3 Rotation 4 Neurovascular status 5 Femoral neck 6 Knee ligaments

Answer 13

Advantages 1 Lateral decub easier start point in larger patients 2 Reduces sagittal plane deformity Disadvantages 1 Unfamiliarity with positioning and XR 2 Not suitable for polytrauma patients with chest injury 3 Pulmonary complications in patients with lung injuries 4 Increased risk of angular or rotational malalignment 5 Inappropriate for bilateral femurs or floating knee

Answer 14

1 Traction * a Fracture table * b Manual * c Skeletal 2 Noninvasive techniques * a Stack of towels * c Radiolucent triangle * d F tool * e Pushing force (e.g mallet) 3 Percutaneous techniques * a Ball spiked pusher * b Bone hook * c Reduction clamps * e Blocking screws * 4 Open techniques * a Unicortical plating

Answer 15

Diagnostic Criteria: Fracture is in the subtrochanteric region Major (need 4/5): Associated with minimal/no trauma (fall from standing or less) LATERAL aspect of fracture is TRANSVERSE in orientation Medial cortical spike (if complete fracture) Thickened lateral cortex/beaking Minimal/no comminution. Minor (do not need for diagnosis): Generalized increased cortical thickness in diaphysis, Unilateral/bilateral prodromal pain (ache in groin/thigh) - Bilateral presentation in 53%, Bilateral incomplete/complete femoral diaphysis fracture, Delayed fracture healing. other signs: dreaded black line

Answer 16

1 Percutaneous pointed reduction forceps 2 Bend ball tipped guide wire 3 Blocking screws (on concavity proximal fragment) 4 Universal distractor 5 Unicortical plating 6 Consider fixing fibula

Answer 17

want to fall into procurvatum (quads) and valgus (pes) To avoid procurvatum: insert screw just posterior to midline To avoid valgus: Insert screw just lateral to midline (insert posterolateral) Coronal 1 Lateralize start point 2 Blocking screw on the concavity of the deformity (lateral to midline in proximal segment) 3 Unicortical plating 4 Universal distractor Sagittal 1 Suprapatellar start point 2 Semi-extended position (neutralizes extensor mechanism force) 3 Blocking screw (posterior in proximal segment) 4 More proximal Herzog bend (stays within proximal fragment)

Answer 18

Split, split depression, depression, medial, bicondylar, metaphyseal 1 Restore of mechanical axis 2 Condylar width 3 Articular reduction 4 Knee stability

Answer 19

PCL → ACL → PLC → PMC 1 Arthroscopic ACL/PCL with open corner reconstruction 2 Arthroscopic ACL with open inlay PCL and open corner reconstruction **Achilles allograft for all ligaments** Timing controversial, pros and cons to early vs delayed recon

Answer 20

Static - LCL, popliteus tendon, popliteofibular ligament, posterolateral capsule Dynamic - Biceps femoris, popliteus muscle, ITB, lateral head of the gastrocnemius 1 Nonoperative – Isolated PLC grade 1-2 2 Acute repair within 2 weeks 3 Reconstruction for grade 3 and PLC with multilig a Fibular based (Larsen) reconstruction: Allograft passed through bone tunnel in fibular head, and docked lateral epicondyle b Transtibial double bundle reconstruction (laproad): Allograft is fixed to posterolateral tibia, one branch through fibular head P to A (PFL reconstruction), then into lateral epicondyle (LCL reconstruction), and one branch anterior inferior to lateral epicondyle (popliteus reconstruction)

Answer 21

ligaments * Distal tib fib joint - AITFL, PITFL, TTFL, IOL * Lateral ligaments – ATFL, PTFL, CFL * Medial * a Superficial - Tibionavicular, tibiocalcaneal, tibiospring, superficial posterior tibiotalar * b Deep - Deep anterior tibiotalar, deep posterior tibiotalar 3 angiosomes * supplied by anterior tibial artery, posterior tibial artery, peroneal artery, and multiple skin incisions can be made as long as they are parallel with these angiosomes * 1 Decreased tibiofibular overlap (<6mm on AP and mortise <1mm on mortise) * a Measured 1cm proximal to the plafond * b Overlap between lateral malleolus and anterior tibial tubercle * 2 Increased tibiofibular clear space (≥6mm on AP and mortise) * a Measured 1cm proximal to the plafond * b Distance between medial fibula and lateral incisura * 3 Increased medial clear space (≥4mm on mortise) * a Should be equal to superior clear space on mortise * 1 Radiographic lateral joint line congruity (lateral talus and medial fibula) * 2 Restoration shenton’s line (articular lateral distal tibia aligns with articular medial distal fibula) * 3 Restoration dime sign (unbroken curve connecting distal fibula with lateral process talus) * 4 Talocrural angle restored (83 +/- 4 degrees) * 5 Comparable to contralateral side

Answer 22

Standard 1 Medial (Deltoid ligament) 2 Posterolateral Volkman (PITFL) 3 Anterolateral Chaput (AITFL) 1 Malnutrition 2 Alcoholism 3 Diabetes 4 Neuropathy 5 Peripheral vascular disease 6 Tobacco use Begin with posterolateral constant fragment 2 Fix posteromedial to posterolateral fragment 3 Reduce central impaction 4 Reduce anterolateral fragment 5 Provisional wire fixation 6 Lag screw fixation 7 Fix articular block to diaphysis with periarticular plate 8 Back fill any body defects with bone graft or substitute a If closed then acute bone graft (ICBG) or allograft or bone substitute (calcium phosphate) b If open then abx cement spacer in defect, delayed bone grafting. Valgus pilon = lateral comminution = anterolateral plating Varus pilon = medial comminution = medial plating

Answer 23

Canale * 1 Max plantarflexion of ankle * 2 15° pronation * 3 Beam 75° from horizontal hawkin classification * TYPE I: Undisplaced AVN < 10% * TYPE II: Subtalar dislocation (most common) AVN up to 50% * TYPE III: Subtalar and tibiotalar (body usually dislocates posteromedially) AVN close to 100% * TYPE IV: ST TT TN dislocation AVN ~ 100% * 1 Dual incision approach anteromedial (medial tib ant) anterolateral (tertius and peroneals) * 2 Anatomic reduction under direct visualization and canale/Kelly views, avoiding varus * 3 Lateral partially threaded compression screw (antegrade or retrograde) or plate * 4 Medial fully threaded buttress screw * 5 Bone graft any defects necessary to prevent varus collapse * a ICBG, allograft

Answer 24

**Broden’s view: posterior facet calcaneus** 1 Neutral dorsiflexion 2 Leg is internally rotated 30-40° 3 Four radiographs are made at 40° (anterior aspect facet), 30°, 20° and 10° (posterior aspect facet) of cephalad tilt **Harris axial view/Saltzman –** demonstrates the body of the calcaneus and subtalar joint; 1 Stand on cassette 2 Beam is directed 45° caudal from behind indications for ORIF * 1 Displaced intra-articular fractures * 2 Fracture >25% involvement of CC joint * 3 Displaced tuberosity * 4 Fracture-dislocation of the calcaneous * 5 Open * 6 Pending open tuberosity * 7 Compartment syndrome

Answer 25

Radiographic signs * 1 Medial border of 2nd MT aligns with the medial middle cuneiform (AP view) * 2 Medial border of 4th MT aligns with the medial cuboid (oblique view) * 3 Dorsal subluxation TMT (lateral) * 4 Widening >2mm between 1st MT/medial cuneiform and 2nd MT * 5 Diastasis first and second ray * 6 Fleck sign – avulsion fracture off the base base of the 2nd MT or medial cuneiform

Answer 26

**Young Burgess** - 1 Lateral compression (LC); LC-I: horizontal ramus + sacral ala buckle LC-II: horizontal ramus + crescent LC-III: windswept pelvis (LC1 with contralateral SI opening) - 2 Anterior-Posterior compression (APC) APC-I <2.5cm symphasis diastasis APC-II Symphasis diastasis > 2.5cm + anterior SI opening APC-III > 2.5cm symphasis diastasis, anterior/posterior SI opening - 3 Vertical shear (VS) – inlet/outlet views show malrotation of hemipelvis, different heights of hemipelvis **Indications for ORIF anterior pelvic ring** 1 >2.5cm of symphysis diastasis on either static or dynamic (EUA) imaging 2 Augment posterior fixation in vertical shear fractures 3 Augmentation of posterior fixation in completely unstable pelvic fractures 4 Augmentation of posterior fixation in osteopenic bone 5 Significantly displaced rami fractures 6 Locked symphysis 7 Straddle fractures **Relative indications for ORIF posterior ring** 1 Complete disruption of the SI joint (anterior and posterior SI ligaments) 2 Vertical displacement 3 Displaced crescent fractures (iliac wing fractures that enter and exit both crest and greater sciatic notch or SI joint) 4 Displaced sacral fracture 5 Complete sacral fractures with potential for displacement 6 Lumbopelvic disassociation **Reduction technique** 1 Closed - a Traction - b Pelvic sheets - c IRTOTLE technique – internal rotation and taping of the lower extremities 2 Percutaneous - a Anterior frames - b Oblique frames - c Ball spiked pusher - d Supra-acetabular pins for joystick - e Clamps 3 Open - a Anterior/posterior/lateral window **Approach to packing** 1 Anterior incision stoppa approach over pelvic brim splitting the linea vertically 2 Protect the bladder and place 3 packs of sponges on each side following the quadrilateral plate and pelvic brim, packing from posterior to anterior 3 The patient must have these removed within 48 hrs

Answer 27

Letournell * Elementary fracture patterns - Posterior wall, posterior column, anterior wall, anterior column, transverse * Associated fracture patterns - Posterior column and posterior wall, transverse and posterior wall, anterior column (or wall) and posterior hemitransverse, T-shaped, both column * Most common to least common: posterior wall > ABC > TPW > T type > Transverse > PC+W > ACPHT > AC > Anterior wall **Negative predictors after ORIF** 1 Age >40 2 Nonanatomic reduction 3 Hip dislocation 4 Weight bearing dome or posterior wall involvement 5 Femoral head involvement 6 Initial displacement ≥20mm

Answer 28

1 Lateral window – lateral to the iliacus muscle/femoral nerve a Exposes the iliac crest, internal iliac fossa as far medial as the SI joint to the pelvic brim 2 Middle window – between iliopsoas/femoral nerve and external iliac aa/vein a Exposes anterior wall, pectineal eminence, pelvic brim, quadrilateral plate 3 Medial window – Between external iliac vessels and permatic cord/round ligament a Exposes superior pubic ramus and symphasis

Answer 29

Type I – Infrafoveal Type II – Suprafoveal Type III – Associated neck Type IV – Associated acetabulum **Pipkin I & 2** Supine position Anterior smith pete with T capsulotomy Identify fracture fragment (can rotate the hip to fully expose the donor site) Secure with 1-2 countersunk headless screws **Pipkin 3** Supine position Combined anterior & lateral approaches Sliding hip screw for the femoral neck fracture 1-2 coutnersunk headless screws for the head **Pipkin 4** Lateral decubitus position Kocher langenbeck approach preserving short external rotators Surgical hip dislocation (digastric slide, z capsulotomy, anterior dislocation) 1-2 countersunk headless screws in the femoral head Close the posterior wall, lag screw buttress plate fixation

Answer 30

**1 Anterior wall: Anterior approach with brim plating **2 Anterior column: Anterior approach with lag screw and brim plating** **3 Posterior wall: Posteiror approach with lag screw buttress plate** a contoured parallel to the rim spanning ischium & ilium b small fractures spring plate/suture anchor **4 Posterior column: Posterior approach with lag screw (ischium to ilium) neutralization recon plate** a Alternative is dual plating **5 Transverse** a Infratectal transverse: Posterior approach, anterior column screw posterior dual plating b Juxtatectal or transtectal transverse: Anterior approach with lag screw brim plating **1 T type** a Infratectal T type: Posterior approach, same as transverse b Juxta/transtectal T type: Anterior approach, same as transverse c If performing front and back fix the anterior column first **2 Transverse posterior wall:** a First posterior approach fix transverse component (anterior column screw posterior dual plating) b Then posterior wall (lag screw buttress plate) **3 Posterior column and wall:** a Posterior approach, first fix the column (posterior dual plating) b Then wall (lag screw buttress plate) **4 ACPHT:** a Anterior approach first fix the anterior column (pelvic brim plate, lag screws) b Then posterior column (interfrag screws through brim plate) **5 ABC:** a Anterior approach first fix anterior column (pelvic brim plate) b Then posterior column (interfrag screws through plate) c Alternative is front and back procedure fixing front, then back

Answer 31

**Features of sacral dysmorphism** 1 Upper sacrum collinear with the iliac crest (normally below) 2 Alar mammillary process a Normal mamillary process in lumbar spine, with lumbarization of S1 will have mamillary process 3 Large irregular upper sacral foramina 4 Residual S1-2 disc space 5 Alar slope is more acute on lateral sacral view (not collinear with iliac cortical density) 6 Interdigitated/tongue-in-groove SI articulation (CT) 7 Anterior cortical indentation **Denis Classification ** Type I- vertical fracture lateral to the sacral foramina Type II - vertical fracture through the sacral formina Type III - vertical fracture medial to the sacral formina (neurological injury >50%)

Answer 32

Triangular osteosynthesis a Lumbopelvic fixation via L5 pedicle screws and iliac screws linked with a bar and SI screws Isolated spinopelvic fixation a L4 and L5 pedicle screws and iliac screws linked with bars b Indicated if SI screws not possible (eg. comminuted S1 and S2 bodies)

Answer 33

1 Increased blood volume: Causes attenuated initial response to hemorrhage 2 Increased red cell size/white count: Predisposes DIC 3 Increased HR: Masks early shock 4 Enlarged uterus: Causes aortocaval compression and secondary supine hypotension 5 Decreased functional residual lung volume: Causes hypoxemia 6 Increased minute ventilation: Causes respiratory alkalosis

Answer 34

At inguinal region = saphenous bypass external iliac to femoral Mid femur = saphenous bypass graft femoral to femoral Distal femur = fem-pop bypass

Answer 35

Boundaries of thoracic outlet: Supraclavicular fossa to axilla between first rib and clavicle Contents of thoracic outlet: a Subclavian artery b Subclavian vein c Brachial plexus Sites of compression for thoracic outlet 1 Interscalene triangle a Between anterior scalene, middle scalene and first rib 2 Costoclavicular space a Clavicle, subclavius, costoccoracoid ligament, first rib (posteriorly) and scalenes (anteriorly) 3 Retropectoralis minor space a Subcoracoid, posterior to rib 2-4 and pec minor b Contains axillary artery and vein Symptoms: Vary, nonspecific findings from multiple neurologic issues during day and sleep, arm fullness, pain anyway from occiput to chest Work-up 1 XR for cervical ribs or prominent C7TP 2 CT/MR for space occupying lesion 3 EMG for nerve involvement 4 Anterior scalene block by IR: botox in scalenes can decrease compression surgical tx Transaxillary ADV a Most commonly used approach, allows for complete exposure of first rib b Cosmetic scar c No retraction of neurovascular structures necessary for first rib removal DISADV a Risk of brachial plexus injury