Miller's Review Trauma Flashcards
Ortho trauma review
1
Q
What does citrate in pRBCs cause
A
Hypocalcemia
2
Q
What is a massive transfusion protocol?
A
10U in 24 hours or 4U in 4 hours
3
Q
Labs that suggest adequately resuscitated trauma patient
A
Normal vitals or mild tachycardia, lactae <2.5-4.0, pH > 7.25, base deficit <5.5 and base excess >-5.5
4
Q
Who gets damage control surgery?
A
Unstable patients
5
Q
Injuries that merit delay in definitive pelvis and femur fracture fixation
A
Severe abdominal (>50% risk reduction if delayed >12 hours), brain and chest injuries.
6
Q
SIRS criteria
A
T >38, HR >90, RR>20 or PaCO2 <32, WBC <4 or >12
7
Q
What is early appropriate care
A
Fixation of unstable spine, pelvis, acetabulum and femur fractures within 36 hours if adequately resuscitated
8
Q
Post-injury inflammatory response timing in adults vs kids
A
Adults response peaks at 2-5 days post injury and they can develop multi-organ failure 2-10 days post injury. In kids, it can be seen immediately after injury.
9
Q
Timing to convert ex-fix in femur and tibia without increased risk of infection
A
3 weeks in femur, 2 weeks in tibia
10
Q
Timing for soft tissue coverage in open fractures
A
Should cover within 7 days to limit infection risk
11
Q
Algorithm for treating bone loss in trauma
A
<5cm defect -> Masquelet. >10cm defect -> bone transport. 5-10cm defect, dealer’s choice.
12
Q
LEAP study difference in salvage vs amp group
A
Salvage group had more re-admissions, re-operations and complications. Other outcomes were similar and decreased with time between the groups. Ability to return to work and psychosocial status were linked to outcomes with no difference between amp and salvage.
13
Q
Metabolic demand increase seen with Syme, BKA and AKA?
A
Syme 15%, BKA 10% (40% if too short or bilateral), AKA 70%
14
Q
Compartment pressure measurement thresholds
A
Within 30mmHg of diastolic pressure
15
Q
Nerve at risk in single vs dual incision fasciotomy
A
Single = CPN. Dual = SPN.
16
Q
Differences between single and dual incision fasciotomy
A
No difference in infection, fracture union or need for skin grafting. Regardless of technique, all patients with compartment syndrome are at increased risk for nonunion and infection.
17
Q
Fasciotomies for thigh compartment syndrome
A
Lateral incision to get anterior and posterior compartments +/- medial incision to get adductor compartment +/- extend into posterior hip approach if gluteal compartment involved.
18
Q
Fasciotomies for foot compartment syndrome
A
Dual dorsal incision medial to the 2nd and lateral to the 4th ray to decompress all 9 compartments.
19
Q
Fasciotomies for arm compartment syndrome
A
Direct lateral incision for anterior and posterior compartments
20
Q
Fasciotomies for forearm compartment syndrome
A
Volar superficial and deep layers, mobile wad and dorsal compartment + carpal tunnel release
21
Q
High vs low velocity GSW
A
High >2000 ft/sec, low <2000 ft/sec
22
Q
GSW operative indications
A
Low velocity if in subarachnoid or joint space, contaminated wound, associated vascular injury or if bullet passed through abdominal cavity. High velocity wounds all get I&D.
23
Q
OTA strong recommendations for DVT prophylaxis in trauma patients
A
LMWH preferred over other agents, mechanical prophyalxis used, no routine use of IV filter unless documented PE/DVT despite adequate anticoagulation
24
Q
Pathophysiology of fat emboli syndrome
A
Inflammatory response to embolized fat results in petechial rash, mental status changes and pulmonary infiltrates
25
PaO2/FiO2 inf ARDS
<200
26
How to position a pregnant trauma patient
Left side down lateral decubitus
27
Risk factors for elder abuse
Dementia, functional disability, disruptive behavior and poverty
28
Function of sacrospinous and sacrotuberous ligaments
Sacrospinous resist ER, sacrotuberous resist vertical translation
29
APC 1 vs APC 2
>2.5cm of anterior pubic diastasis, anterior SI joint widening = APC II
30
What is the stable fracture fragment?
The crescent portion of an LC-II pelvic ring injury is the constant and stable fragment
31
Associated injury in LC1 and 2 injuries
50% have brain injury
32
Associated injury in APC3
Shock in 67%, ARDS in 18%
33
Associated injury in LC3
Bowel in 20%
34
Associated injury in vertical shear pelvic fractures
Shock (63%)
35
What x-ray is used for supra-acetabular pin start point or LC-II screw?
Obutrator outlet, adding oblique gives you the start point for your supra-acetabular screw
36
What x-ray view is used to ensure screws or pins are between the pelvis inner and outer table?
Obturator inlet
37
What x-ray view is used to ensure screws or pins are out of the hip joint and sciatic notch?
Iliac oblique
38
Most common arterial branch bleeder that needs embolization after pelvic fracture in APC injury? LC?
Superior gluteal artery. In lateral compression fractures the obturator is most common.
39
Factors that predict mortality in pelvic fractures
Transfusion in 1st 24 hours, age >60, open fracture and unstable pattern
40
Management of APC2 injuries? APC3?
Needs surgery. Anterior fixation only may be sufficient, can also argue to fix posterior. APC3 gets fixed anterior and posterior.
41
Plate size in fixing pubic symphysis diastasis
4 or 6 hole plate, never 2 hole
42
Where do you want to place an S1 SI screw to avoid the L5 nerve root.
Posterior and inferior to the iliac cortical density on the lateral x-ray
43
Corridor usually blocked in sacral dysmorphism
S1, usually the S2 corridor is still good
44
Structure at risk with anterior SI joint plating
L5, this is done via iliac fossa approach
45
Most common complication associated with posterior sacral plating
Wound complication and hardware infection
46
Treatment of LC1 with incomplete buckle sacral fracture
Non-op WBAT
47
Treatment of LC1 with complete sacral fracture and unilateral or bilateral rami fractures
Some evidence to suggest early perc fixation improves pain and improve mobilization
48
Treatment of LC2 fractures
Perc LC2 screw to fix unstable ileum fragement to stable crescent +/- SI screws
49
Treatment of vertical shear pelvic fractures
Anterior and posterior fixation
50
Risk of neurologic injury with sacral fractures
Zone 1 = 5%, 2 = 28%, 3 = 57%, can be cauda equina
51
Treatment of lumbopelvic dissociation
Lumbopelvic fixation with pedicle and screws into ilium or triangular osteosynthesis
52
Key procedure to minimize risk of infection in open pelvis fracture
Open pelvic injury is often associated with a perforated viscus that requires a diverting colostomy
53
Most important determinant in patients long term outcome after pelvic fracture
Neurologic injury
54
X-ray needed to diagnose anterior and posterior SC dislocation
Serendipity view (40 degree cephalic tilt). Anterior = cephalad. Posterior = caudal displacement.
55
Reduction maneuver for anterior SC dislocation
General anesthesia, abduction, extension and direct pressure over the medial clavicle
56
Posterior SC dislocation reduction maneuver
General, bump under medial scapula, abduction and extension, manipulate with towel clip. Do not technically need thoracic surgeon on standby.
57
Post reduction management of posterior SC dislocation
Sling x 3 weeks, return to sport at 3-4 months. If recurrent instability consider excision and/or medial ligament reconstruction
58
Treatment of delayed posterior SC joint presentation
No closed reduction attempts because of retrosternal adhesions
59
Medical clavicle physeal fracture management
Anterior = observation, can remodel. Posterior = reduce, if irreducible and asymptomatic observe, if symptomatic open reduction with thoracic surgery back up
60
Rate of nonunion in midshaft clavicle fractures
15-20%. Number needed to treat to prevent 1 nonunion is 7.
61
Re-operation rate after clavicle ORIF
18-38% re-operation rate for hardware removal
62
Anterior vs superior clavicle plating
Equal healing rates, less symptomatic hardware and fewer re-operations with anterior plating
63
Distal clavicle fractures at highest risk for nonunion?
II and IV (medial to CC ligaments)
64
Management of distal 1/3 clavicle fractures
Non-op in elderly and stable fractures. In unstable fractures, the union rate is higher with surgery, functional outcomes are the same
65
Operative indications for coracoid/acromion fractures
1cm displacement
66
Operative indications for intra-articular glenoid fractures
2-5mm displacement or instability
67
Operative indications for scapular body fractures
Glenopolar angle <20 (normal 30-45), body angulation >45 or medialization of the glenoid >2cm
68
Judet approach interval
Infraspinatus (SSN) and teres minor (axillary nerve)
69
Indications for surgical management in double disruption of the superior suspensory shoulder complex?
Double disruption in and of itself is not an indication. Treat each isolated injury as you would for its isolated operative indications
70
Most common vascular injury seen in scapulothoracic dissociation
Subclavian artery
71
What determines outcomes in management of scapulothoracic dissocation?
Neurologic injury, seen in 90%, return of function unlikely, 50% have a flail arm and 21% have an amputation
72
Operative management of engaging reverse Hill-Sachs in posterior shoulder dislocation
If 20-40% defect, transpose LT with subscap into defect. If >45% or >6 months out consider arthroplasty or structural allograft.
73
Hertel’s criteria for predicting humeral head ischemia after proximal humerus fracture
<8mm metaphyseal extension, disrupted medial hinge, 4 part fracture, >45 degrees angulation, head split
74
Operative indications for 2 part proximal humerus fracture
Young person with >50% displacement
75
ORIF vs arthroplasty indications for 3 and 4 part proximal humeral fracture
Young person, may consider in active patient <70 with good bone stock and vascularized head. Consider RSA if >70.
76
Where should the greater tuberosity sit in relation to the implant after shoulder hemiarthroplasty?
10mm below the implant, 5.6cm proximal to pec insertion
77
Acceptable alignment in humeral shaft fractures
20 degrees A/P angulation, 30 degrees varus/valgus angulation, 15 degrees malrotation and 3cm shortening
78
Contraindications to functional bracing humeral shaft fractures
Severe soft tissue injury, body habitus, unreliable patient, unable maintain reduction, recumbancy and nerve injury
79
Absolute indications for operative management of humeral shaft fractures
Open, vascular injury, floating elbow, intra-articular extension
80
Relative indications for surgical management of humeral shaft fractures
Failed close management, polytrauma, associated brachial plexus injury, nerve injury after reduction, pathologic fracture, neuromuscular conditions, delayed/nonunion
81
Preferred approach for proximal 1/3 humeral shaft fractures
Anterolateral
82
Preferred approach for maximal humeral shaft visualization
Posterior, proximal limit is axillary nerve
83
Nerves at risk for distal interlocks of a humeral nail
L->M = radial nerve. A ->P = musculocutaneous nerve.
84
Indication for acute exploration of humeral shaft fracture with radial nerve palsy
Open or vascular injury, otherwise observe up to 3-6 months. Consider EMG/NCS at 6 weeks
85
Where do you make the olecranon osteotomy
3cm distal to the triceps insertion into the bare area
86
Ligament to release in post-traumatic elbow contractures
Posterior band of the MUCL
87
Splinting a post-elbow dislocation when MCL feels intact vs when it feels disrupted
If it feels intact, splint in pronation to minimize posterolateral rotary forces. If MUCL and LUCL not intact, splint in neutral because pronation will cause valgus instability.
88
Dorsal Thompson approach interval
ECRB and EDC
89
What portions of the pelvis make up the anterior and posterior columns?
Anterior column = anterior ilium, wall, dome, iliopectineal eminence and superior ramus. Posterior column = quadrilateral plate, posterior wall, dome, ischial tuberosity and notches
90
What view is this
Obturator oblique, shows the anterior column and posterior wall
91
What view is this?
Iliac oblique, shows the posterior column and anterior wall
92
5 elementary acetabular fractures
Posterior wall, posterior column, anterior wall, anterior column and transverse
93
5 combined type acetabular fractures
Posterior column + posterior wall, transverse + posterior wall, t-type, anterior + hemitransveres and both column
94
Type of acetabular fractures with disrupted iliioischial and iliopectineal lines
INTACT OBTURATOR: transverse or transverse + posterior wall. DISRUPTED OBTURATOR WITH INTACT ILIAC WING = T-type. DISRUPTED OBTURATOR WITH DISRUPTED ILIAC WING = ant + post hemitransverse or both column fracture (spur sign, shown)
95
What is the stable fragment in an associated both column acetabular fracture?
The proximal ilium, the whole articular segment is medialized
96
What is this sign?
Gull sign indicating superomedial acetabular dome impaction. It is associated with quadrilateral plate displacement and is a very poor prognostic sign.
97
Non-operative indications for acetabular fractures
Displacement <2mm, intact weight bearing dome (roof arc >45 degrees, shown), posterior wall <20% (stable on fluoro exam under anesthesia)
98
Fluoro stress exam for posterior wall acetabulum fractures
General, flex hip to 90 deg w/neutral rotation, apply axial load and see if it subluxates on the obturator oblique view
99
Acetabular fracture with worst prognosis
T-type, requires more extensive and/or combined approaches to obtain reduction
100
Indications for ORIF + acute THA in acetabular fractures
Osteoporotic and/or significant comminution in elderly patients.
101
Surgical approach for most anterior acetabular fractures
Modified Stoppa. Extraperitoneal intrapelvic approach through the rectus abdominis. Look out for corona mortis 5cm lateral to symphysis
102
Approach for T-type acetabular fractures
Kocher-Langenbeck for posterior, Stoppa for anterior
103
Most common complications seen in acetabular fractures
Post-traumatic arthrosis, HO (greatest in extended iliofemoral and KL approaches, debride minimus if traumatized), DVT/PE, iatrogenic nerve injury (sciatic, femoral)
104
What determines clinical outcomes after acetabular fractures?
Good outcomes correlated with anatomic articular reduction, surgery <10-14 days, no femoral head chondral injury, no comminution, no acetabular impaction, age <55
105
Indication for extensile approach to acetabulum
Both column and anterior + posterior hemitransverse
106
Why should a patient with a posterior hip dislocation be a full trauma activation?
They are associated with traumatic rupture of thoracic aorta
107
Most common complication seen after post traumatic hip dislocation
Post-traumatic arthritis > AVN
108
Operative algorithm for femoral head fractures
Pipkin I (below fovea) and II (above fovea) typically have an anterior and inferior fracture fragment that can be approached anteriorly, no risk for AVN here. Pipkin III: fix neck and head from front. For Pipkin IV (femoral head + posterior acetabulum fracture): treat with trans-trochanteric approach to address both the femoral head and acetabulum.
109
Pauwel’s classification
As you progress from grade I to III, rates of osteonecrosis and AVN increase
110
In hospital and one year mortality for geriatric femoral neck fractures
In hospital 6%, 1 year 22%
111
Operative management of basicervical femoral neck fracture compared to more proximal femoral neck fractures
FAITH trial showed better outcomes with DHS compared to cannulated screw fixation in basicervical fractures only. Screws also did worse than DHS in smokers.
112
Most common complication of displaced femoral neck fractures in young patients
AVN > non-union
113
Normal timed up and go test
If patient can get up walk 10 feet and sit down within 12 seconds they will likley not need an ambulatory device.
114
FRAX score
10 year probability of fragility fracture calculator based on clinical factors and bone mineral density
115
Surgical management of femoral head varus nonunion/malunion after fracture in young patient with no AVN
Valgus intertrochanteric osteotomy
116
Most important indicator in determining stable vs unstable intertrochanteric femur fracture
Integrity of the lateral wall
117
AAOS hip fractures strong recommendations
General vs spinal = equivalent outcomes. Arthroplasty if displaced femoral neck. CMN for instable intertroch and subtroch. Standard transfusion thresholds. Intensive post-discharge PT. Interdisciplinary care and multi-modal pain control.
118
Timing of fixation of femoral shaft fractures
Decreased pulmonary complications, decreased VTE, faster rehab, lower hospital costs if fixed within 24 hours. Contra-indicated in severe closed head injury.
119
When to consider unreamed femoral nail?
Bilateral fractures or blunt chest trauma have increased risk of pulmonary complications and mortatility, consider not reaming in bilateral injuries or those with blunt chest injury. Otherwise always ream because the union rate has been shown to be higher if reamed.
120
Location of proximal interlocks for retrograde IMN
At or above the level of the lesser trochanter to avoid stress riser and vascular injury if more distal
121
Indications for retrograde IMN for femoral shaft fracture
Distal 1/3, obese, floating knee, bilateral femur fractures, ipsilateral neck-shaft fracture, ipsilateral acetabular fracture.
122
Malunion seen after fixing femoral shaft fractures by table/positioning?
Supine = IR. Lateral = ER. Traction = too long. No traction = too short.
123
Malunion seen after fixing femoral shaft fractures by location?
Proximal shaft = IR. Distal shaft = ER.
124
Rotational deformity best tolerated in malrotated femoral shaft fractures
IR
125
Degrees of malrotation tolerated in femoral shaft fractures
<15
126
Compared to patients with unilateral femur fractures, patients with bilateral fractures are at increased risk of ___
Death
127
Which condyle is most commonly seen in the Hoffa fracture?
Lateral
128
Most common direction of knee dislocation
Anterior
129
Timing for limb revascularization
Within 8 hours
130
Tibial plateau operative indications
Articular depression <3mm, condylar widening <5mm, all bicondylar and medial plateau fractures.
131
Injury to beware of when using >10 hole lateral tibial plateau plate
SPN
132
Most important treatment variables in determining outcomes in tibial plateau fractures
Restoration of joint stability and mechanical axis. Patients >50 have worse outcomes. Higher risk of TKA with low surgeon and hospital volume.
133
Acceptable parameters in tibial shaft fractures
Varus-valgus <5, sagittal plane <10, cortical apposition >50%, shortening <1cm, rotation alignment within 10 degrees
134
Malunion seen in proximal 1/3 tibial shaft fractures
Valgus and procurvatum
135
Ex-fix vs IMN in open tibial shaft fractures
No difference in infection or time to union. IMN w/better alignment, fewer secondary surgeries and shorter time to WB
136
Reamed vs unreamed IMN in open fractures
No difference in results in reamed vs unreamed for open fractures. Reamed nailing was superior in closed fractures (fewer dynamizations, fewer implant failures)
137
Relative indications for early amputation in open tibia fractures
Warm ischemia >6 hours, severe muscle damage and severe ipsilateral foot trauma
138
Tibial nonunion defined as
No healing by 9 months, delaying treatment for 6 months showed fewer reooperations in the SPRINT trial
139
Predictor for tibial nonunion treatment failure after dynamization or exchange nailing
Persistent gap >5mm
140
Technique for exchange nailing in tibial nonuion
Ream/upsize nail, dynamically lock and fibular osteotomy
141
BMP-2 approved for? BMP-7?
BMP-2 in open tibia fractures. BMP-7 in long bone nonunions.
142
Most sensitive physical exam finding in compartment syndrome
Pain with passive stretch
143
Most sensitive overall indicator of compartment syndrome
Delta P<30 (compartment pressure measurement within 30mmHg of DBP)
144
Highest risk variable for re-operation in tibial shaft fracture
Cortical contact <50%
145
Most common type of malalignment after IMN of distal 1/3 tibia fractures
Malrotation
146
Most common complication after fixation of tibial plafond fractures
Post-traumatic arthrosis
147
Brake time while driving returns to normal at what time point?
6 weeks after patient is cleared for full weight bearing
148
Normal talo crural angle
80 degrees
149
Hawkins classification for talar neck fractures
I) fracture without diplacement II) fracture with displacement at subtalar joint III) fracture with extruded head and reduced TN joint IV) pantalar fracture dislocation
150
Primary blood supply to talar body
Artery of tarsal canal from posterior tibial artery
151
Approach for talar neck fractures
Dual insicions to address dorsomedial comminution
152
Operative management of varus malunion of talar neck fractures
Medial opening wedge osteotomy
153
Interposing structures blocking reduction of medial vs. lateral subtalar dislocations
Medial = fractured talar head fragement, EDB. Lateral = post tibial tendon, FHL
154
Normal Bohler’s angle
20-40 degrees, flattening = collapse of posterior facet
155
Normal angle of Gissane
130-145, increased = posterior facet collapse
156
Sanders classification
Based on number of fracture lines seen in the posterior facet
157
Constant fragement in calcaneus fractures?
Sustentacular fragment
158
Primary fracture line orientation in calc fractures
Anterolateral to posteromedial
159
Treatment of choice for Sanders IV fractures
Can consider ORIF vs primary arthrodesis
160
Factors predicting poor outcome in calc fractures
Smoking, diabetes, age > 50, male, obesity, manual laborer and worker’s comp
161
Surgical management of calc fracture malunion
Distraction bone block subtalar arthrodesis to restor calc height
