Orthopedics - Trauma Flashcards
Describe the classification system for open fractures
Type I: <1cm with minimal soft tissue disruption
Type II: >1cm with moderate soft tissue disruption
Type IIIA: >10cm with severe and crushing soft tissue disruption, some bone coverage
Type IIIB: >10cm with severe soft tissue disruption requiring soft tissue reconstruction
Type IIIC: >10cm with severe soft tissue disruption requiring soft tissue and vascular reconstruction
Discuss the management of an open fracture
Source - remove foreign body from wound - irrigate copiously - cover wound with sterile dressing - reduce and splint fracture Prevent Infection - tetanus - Gustillo 1 get Ancef for 3 days, Gustillo 2 get Ancef plus Gentamicin for 3 days and Gustillo 3 get grade II plus penicillin if in soil Surgery - OR irrigation within 6-8 hrs
Discuss the presentation and management of a clavicle fracture
Location: - middle third most common and then lateral Mechanism: - fall directly onto shoulder - fall on outstretched hand - direct impact Treatment: - mainly conservative with sling Surgery indications: - open or soft tissue compromise - comminution - non-union in 3-6 months - neurovascular compromise - lateral third fracture
Discuss the presentation and management of a shoulder dislocation
Location:
- anterior in 97% of cases
Mechanism:
- abduction, external rotation and extension for anterior
- 3 E’s (ethanol, epilepsy, electrocution) for posterior
X-ray:
- humeral head displacement, seen on lateral Y view
Complications:
- Bankart lesion (impaction fracture on inferiorolateral glenoid),
- Hill-Sachs lesion (impaction fracture on superolateral humeral head)
- neurovascular injury (AVN, axillary nerve injury)
- rotator cuff tear
Treatment: closed reduction
- External rotation: supine with elbow flexed to 90 -> externally rotate shoulder
- Milch: patient supine with arm abducted to 90 and externally rotated to 90 -> traction in line with humerus
Discuss the presentation and management of distal radius fractures
Mechanism:
- fall on outstretched hand
X-ray:
- fracture of distal radius
- Colle’s fracture (dorsal displacement of radial head)
- Smith’s fracture (volar displacement of radial head)
Treatment:
- non-operative: closed reduction and immobilization
- operative: ORIF if will not be able to get proper radial parameters, assessment of DRUJ
What are the normal radiographic parameters of the distal radius?
Radial inclination: 23 degrees
Radial length: 11 mm
Palmar tilt: 11 degrees
Discuss the presentation and management of a scaphoid fracture
Mechanism:
- axial compression or hyper extension of wrist with fall on outstretched hand
Presentation:
- snuffbox tenderness (even without visible fracture require re-evaluation in 1-2 weeks)
Complications:
- scaphoid blood supply is distal to proximal
- so midline to proximal fractures require greater care
Management:
- non-operative: more proximal the fracture is the longer the cast + thumb spica remains (3-5 months)
- operative: open fracture, displaced fracture, neurovascular compromise
Discuss the presentation and management of a boxer’s fracture (metacarpal #)
Mechanism:
- punching object with closed fist
X-ray:
- fracture of proximal metacarpal (usually the 5th)
Treatment:
- reduction and immobilization to adjacent finger
Complication:
- metacarpal shortening
- deformity of distal fragment
- Fight bite (require I/D if see open wound on knuckles)
Discuss the presentation and management of a hip fracture
Location: - capital (femoral head) - sub-capital (femoral neck) - inter-trochanteric - subtrochanteric Presentation: - shortened and externally rotated Complication: - capital and sub-capital have high risk for AVN Treatment: ORIF - dynamic hip screw (DHS) - hemiarthroplasty (bipolar) for displaced fracture - total joint arthroplasty
Discuss the presentation and management of a hip dislocation
Location: - most are posterior Mechanism: - fall - trauma - contact with great force Presentation: - shortened and internally rotated Treatment: - closed (require reduction within 6 hours - apply traction in direction of femur with possible internal/external rotation and adduction) - open reduction
Discuss the presentation and management of ankle fractures
Classification: related to fracture of fibular
- Weber A: below the ankle joint - stable
- Weber B: in line with ankle joint - variably stable
- Weber C: above line of ankle joint - unstable
Treatment:
- non-operative: closed reduction and splinting
- operative: unstable fracture (bimalleolar or trimalleolar), displaced, neurovascular compromise
Discuss the Salter-Harris classification of fractures for Pediatrics
Type I: Fracture though the physis
Type II: fracture through the physis that extends away from the joint
Type III: fracture through the physis that extends towards the joint
Type IV: fracture through the physis that extends towards and away from the joint
Type V: compression of the physis
Discuss the normal lines visualized on lateral x-ray of the cervical spine
Anterior vertebral line
Posterior vertebral line
Spinolaminar line
Posterior spinous line
Discuss the presentation and management of a Jefferson’s fracture
Location:
- fracture of C1
Mechanism:
- axial loading of head
X-ray:
- widening between odontoid and lateral mass of C1 on odontoid view
- displacement of C1 lateral mass compared to C2
Treatment:
- stable: collar
- unstable (broken transverse ligament): traction, halo, surgery
Discuss the presentation and management of a C2 fracture
Mechanism:
- hyperextension of neck
X-ray:
Odontoid:
- Type 1 - avulsion at tip,
- Type 2 - fracture at base (require surgery)
- Type 3 - fracture extending into C2
Hangman fracture:
- C2 pedicle # resulting in anterior displacement of C2 between C2/C3
Treatment:
- hard collar immobilization, halo, surgical fixation
Discuss the presentation and management of Flexion Teardrop fracture
Mechanism:
- hyperflexion of neck along with axial load
- have associated cervical spine injury
X-ray:
- hyperflexion deformity (kyphotic deformity, anterior displacement, widened spinous process)
- avulsion fracture of anterior vertebral body
- misalignment of spinolaminar line
Management:
- ACDF
Discuss the three columns of the spine
Fracture is unstable if 2 or more columns involved in injury
Anterior column:
- between anterior longitudinal ligament and midline of vertebrae
Middle column:
- between midline vertebrae and posterior longitudinal ligament
Posterior column:
- between posterior longitudinal ligament and supraspinous ligament
Discuss the presentation and management of anterior compression injury of the spine
Mechanism:
- hyperflexion injury
X-ray:
- loss of anterior vertebral height on lateral x-ray
Treatment:
- non-operative: analgesia, activity limitation, bracing
- operative: spinal compression or spinal instability
Discuss the presentation and management of a vertebral burst fracture
Mechanism:
- axial compression
- associated SCI
X-ray:
- fracture in anterior and middle columns
Treatment:
- PSIF for compression or instability of spine
Discuss the presentation and management of a chance fracture in the spine
Mechanism: - flexion injury of spine - associated intra-abdominal injury X-ray: - fracture in anterior and posterior column Treatment: - Risser table with hyperextension of thoracolumbar junction - PSIF
Discuss the presentation and management of spondylolysis and spondylolisthesis
Spondylolysis:
- hyperextension injury causing fracture through pars interarticularis
Spondylolisthesis:
- fracture of pars interarticularis and anterior displacement of vertebrae relative to the one below (anterolisthesis) or above (retrolisthesis) it
Management:
- non-operative: activity modification, rest, analgesia, physical therapy
- operative: PSIF if severe compression or unstable
What is a skiers thumb?
Mechanism:
- extreme radial deviation/abduction of the thumb resulting in tearing of the UCL.
X-ray:
- fracture at the proximal and ulnar portion of the proximal first phalanx.
- May see bone fragment
Treatment:
- require MR or ultrasound to determine if the UCL is stuck within the adductor aponeurosis (Stener lesion), as will require surgery
Differential:
- Gamekeepers thumb is laxity of the ligament resulting in instability of the joint
Describe the terrible triad of the elbow
Elbow dislocation, radial head or neck fracture, coronoid fracture
Mechanism:
- FOOSH with valgus, axial and posterolateral rotatory forces
Presentation:
- varus, valgus instability
X-ray:
- line drawn through Center of radial neck should always intersect Center of capitellum
Treatment:
- initial reduction of elbow but will require ORIF
Discuss the presentation and management of knee dislocations
Mechanism:
- anterior most common from hyperextension and associated with PCL and intimal tear of popliteal artery
- posterior due to axial load on flexed knee and has highest rate of complete tear of popliteal artery
- lateral from varus or valgus force and associated with ACL/PCL injury and peroneal nerve injury
Presentation:
- 50% spontaneously reduce
- more than 3 ligaments have been disrupted/unstable
- ABI >0.9 than serial exams, <0..9 require duplex ultrasound or CT angiography
- if pulses not present do immediate reduction and re-examine
Treatment:
- Ortho emergency so require immediate reduction and possible vascular consult
- open reduction
Discuss the bone healing process
<1 Month
- macrophage and hematoma surrounding site
1 Month
- osteoclast remove sharp edges with callus formation within hematoma
1-3 Months
- bone formation within callus and associated bridging fragments
6-12 Months
- cortical gap bridged by bone
1-2 years
- remodelling in order to achieve proper architecture
Discuss the presentation and management of compartment syndrome
Pathophysiology
- increased pressure lead to decreased venous and lymphatic drainage -> exceed capillary perfusion pressure stopping blood supply -> nerve anoxia to ischemia to necrosis
Presentation
- early have pain with active contraction and passive stretch along with tense compartment
- 5 P’s: pain out of proportion, paresthesia, pallor, paralysis, pulselessness
Management
- remove constrictive dressings and raise limb
- urgent fasciotomy
