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000. STICK WITH IT > STICK WITH IT AND MEMORIZE > Flashcards

STICK WITH IT AND MEMORIZE Flashcards

1
Q

Anterior (Smith Robinson) Approach to the Cervical Spine

A

Exposure: C3-T1

Approach:
- position: supine
- transverse incision at apropriate level based on fluoro along medial border of SCM
- incise through skin, SQ tissue and then sup fascia and split platysma
- split deep cervical fascia and retract strap muscle medially and SCM laterally
- incise pretracheal fascia, protecting sup and inf thyroid vessels within fascia medially and carotid sheath laterally
- incise prevertebral fascia, protect sympathetic chain and recurrent laryngeal n and split longus colli midline
- elevate subperiosteally
- confirm level with spinal needle in disc

Dangers:

  1. Recurrent Laryngeal Nerves (right more vulnerable than left)
  2. Sympathetic Nerves - can have Horner’s Syndrome
  3. Carotid Sheath Contents (Carotid A, V, Vagus N.)
  4. Retropharyngeal Hematoma
  5. Trachea
  6. Esophagus
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2
Q
  • ASIA Exam
  • steps
  • grade
  • neurogenic shock
  • spinal shock
A

Steps:
* determine if patient in spinal shock - bulbocavernosus reflex (S2-S4)
* determine neuro level of injury - sensation at dermatomes, motor at myotomes
* determine if complete or incomplete
- complete = no sacral sparing, bulbocav present, 0/5 motor, 0/2 sensory
- incomplete = sacral sparing muscle contraction, sensation
* determine ASIA grade
* A = complete = no motor or sensory below level of injury/sacral segments, not sacral sparing
* B = Incomplete = Sensory preserved below neurologic level + includes sacral segments S4-5
* C = incomplete = sensory and motor preserved below neurologic level – 50% muscles have power grade <3
* D = incomplete = motor preserved below neurologic level – 50% muscles have power grade 3+
* E = Normal – motor and sensory normal (must have previously had an abnormal exam)

neurogenic shock: hypotension, bradycardia secondary to loss of sympathetic tone due to spinal cord injury

spinal shock: temporary loss of motor and sensory due to SCI demonstrated by loss of bulbocavernosus reflex

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3
Q

anterior spine bony landmarks

A

hard palate - arch of atlas
lower border of mandible C2-3
hyoid - c3
thryroid cartilage C4-5
cricoid cartilage C6
carotid tubercle C6

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4
Q

General Spine exam

UMN signs

A
  • I will perform a thorough neurological examination following ASIA guidelines including gait, general inspection, palpation of the spine, testing myotomes and dermatomes from C5-T1 and L2-S1.
  • I will assess for tone, clonus, reflex
    tone, DRE and special tests
  • Gait: heel, toe, tandem heel to toe, rhomberg
  • inspect: spinal deformities, sagittal and coronal alignemnt
  • palpation of spine and paraspinal muscles
  • myotomes
    - C5 elbow flexors
    - C6 wrist extensors
    - C7 elbow extensors
    - C8 finger flexors
    - T1 finger abductors
     - L2 hip flexors
- L3 knee extensors
- L4 ankle dorsiflexors 
- L5 long toe extensors
- s1 ankle plantar flexors
  • dermatomes
    C5 – Lateral upper arm
    C6 – Lateral forearm and thumb
    C7 – Middle finger
    C8 – Medial forearm and 4th/5th fingers
    T1 – Medial upper arm

L2 – Upper anterior thigh
L3 – Medial thigh and medial knee
L4 – Medial lower leg and medial malleolus
L5 – Lateral lower leg + dorsum of the foot
S1 – Lateral foot and heel, posterior calf

  • tone: clonus, >3 ankle or wrist beats
  • reflexes
    - biceps c5-6
    - triceps C7-8
    - knee L2-4
    - ankle S1
  • special tests
    - UMN: hoffman, inverted radial reflex, finger escape sign, grip and release test, hyperreflexia, sustained clonus, babinski, gait instability
    • SLR, femoral nerve stretch, spurling, lhermitte
    • Post void residual
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5
Q

OC instability
* acquired in which population
* xray measurements
* tx algorithm

A
  • down syndrome
  • Harris rule of 12
    • BAI: basion post axial interval, N < 12mm
    • BDI: basio-dens interval N 4-12mm
  • power ratio
    C-D/A-B
    C-D (Basion to post. arch)/A-B (Ant. arch to opisthion)
    Ratio = 1 (normal);
    >1.0 = anterior dislocation; <1.0 = posterior dislocation, odontoid fracture, atlas ring fracture
  • sx almost all traumatic cases

OC fusion: prone with Mayfield – keep head in neutral
Put plate just below level of External Occipital Protuberance: bone thickest midline
C1/C2 screws
Rods contoured and connected to plate

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6
Q

atlas fracture
types
xray measurements
tx principles

A

Type 1: Isolated anterior/posterior arch fracture
Type 2: Jefferson burst fracture bilateral fracture of anterior and posterior arch due to axial load – stability based on integrity of transverse ligament
Type 3: Unilateral mass fracture – stability based on integrity of transverse ligament

Measurements
Check ADI
<3mm (<5mm peds);
>7mm = injury to transverse ligament
Odontoid:
check sum of lateral mass overhang: N < 7mm
lat atlandodens interval N < 2mm of asymmetry

stable (intact lig) - collar, halo
unstable (lig not intact) - C1-2 fusion, C1 LM screws, C2 pedicle screws or C1-2 transarticular screw via facet

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7
Q

Atlanto axial instability
* acquired conditions at risk
* spine xray measurements
* tx principles

A

Adults: Down syndrome, RA, Os odontoid
Peds: JRA, Morquio syndrome (lysosomal storage), trauma (rotatory subluxation)
Children can have pseudosubluxation at C2-3

Flex-extension views:
* ADI: Distance between anterior dens and posterior border of ant. Atlas
- <3 mm = normal in adult
- (<5mm in child);
- >7mm = injury transverse lig.;
- >10mm = unstable in RA

  • PADI/SAC: Distance between posterior dens and posterior arch of atlas
    • > 13-14mm = normal;
    • <13-14mm = increased risk of neuro injury- unstable in RA

unstable - C1-s fusion,
also have C0 instability then C0-2 fusion

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8
Q

Odontoid fracture
- classification
- RF nonunion
- Tx algorithm

A

Anderson + D’alonzo
Type 1: Oblique avulsion tip of odontoid – alar ligament avulsed
Must R/O OC dissociation – check stability with flex/ex films
Type 2: Fracture through waist – high risk nonunion
Type 3: Fracture extends into body of C2 + involves C1-2 joint

  • RF for nonunion: 4-6mm displaced (>50% nonunion), posterior displacement, fracture comminution, angulation >10 degrees, age >40, smoker, delay in tx.
  • Must get CTA to check vert

Os odontoid = observe
- Type 1: Cervical collar for 6-12 weeks – usually develop fibrous union

  • Type 2 young: No RF for nonunion = HALO; RF for nonunion = OR
    Posterior C1-C2 fusion via posterior approach
    Strongest construct = C1-C2 transarticular screw (contraindicated if vert abnrormal)
    Posterior C1 lateral mass screw-C2 pedicle/pars/laminar screw
    Sublaminar wiring – Gallie – not often used
    Anterior odontoid osteosynthesis in young patient with type 2/3:
    Has to be reducible and oblique fracture pattern and patient body habitus (no osteoporosis, obese, comminution, reverse oblique)
    Via anterior approach to C-spine – preserve ROM, higher failure rate
  • Type 2 elderly: Poor surgical candidate: collar – otherwise fix
    Do not use HALO in elderly – high risk for aspiration
  • Type 3: Cervical collar for 6-12 weeks
    Cx: 50% loss of neck motion
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9
Q

Hangman Fracture
* type of injury
* mechanism
* classification + tx

A
  • traumatic spondylolisthesis of C2 due to bilateral fracture of pars interarticulatris
  • usually hyperextension, usually neuro intact
    Levine and Edwards:
  • Type 1: nondisplaced, C2-3 stable; collar
  • Type 2: displaced >3mm, angulated, vertical fracture line = unstable; closed reduction with traciton and extension and halo
  • Type 2A: Flexion-distraction with disruption of discoligamentous complex – horizontal fracture line, angulation; closed reduction with hyperextension and halo
  • Type 3: Rare – flexion-compression: Associated C2-3 facet dislocation; reduction and PCDIF vs ACDIF
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10
Q

subaxial c-spine injury
* fracture types
* SLIC
* tx

A

Fracture types
- compression: failure of ant VB, posterior cortex intact, no retropulsion, can be assoc with PLC injury
- burst: # with ext into posterior cortex + retropulsion, assoc with PLC + SCI
- flexion teardrop # - flexion distraction, large quadrangular fragment and retropulsion, assoc with PLC + SCI
- extension teardrop - small fleck avulsed off of anterior endplate, most common at C2, due to extension - STABLE

SLIC
fracture morphology, neuro status, DLC
5+ operate

tx:
- nonop - collar for stable compression and extension teardrop fracture (intact PLC, < 10 kyphosis, < 25% loss of body height)
- op
anterior decompression, corpectomy and strut graft and fusion - minimal inj posteriori and anterior decompression required, lower infeciton, lower EBL, shorter OR
posterior decompression and fusion with instrumentation - if injury to PLC (higher fusion rase, easier reduction, biomech stable)
combo approach if PLC injured and anterior decompression required

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11
Q

cervical facet dislocation/fracture
* types
* when to get MRI first
* CR
* Definitive tx and ways to do open reduction

A

types:
- uni: monoradiculopathy, 25% subluxation
- bilat: 50% subluxation, increase risk of disc herniation and PLC disrupted
- facet #: usually sup facet
- naked facet sign/reverse hamburger = facet dislocaiton

  • MRI after CR if awake and alert with incomplete SCI or worsening deficit or complete SCI
  • mri before CR if neuro intact, obtunded pt, planing post approach + red or failed CT or neuro decline during CR

MRI to assess disc herniation, PLC injury, cord compression, check vert artery

PSF vs ACDF (depends on disc herniation)

ACDF - if disc herniation
- remove disc, muscle sparing, reduciton more difficult, can use caspar pins, liminar screader, cobb

PSF - no anterior disc, failed anteiror open reduction
- Indicated if no disc, reduciton easier, failed CR anterior, fracture posterior, multilevel
- technique: towel clip on SP, penfield elevator to help lever articular process, resect tip of sup articular process

combo A/P - if anterior disc, unable to reduce, bilat facet, kyphosis, delayed presentation -> anterior discectomy + position plate then posterior second for reduciton + stabilization

Closed reduction
- gardner wells pins placed 1cm above pinna in line with external auditory meatus and below equator of skull
- traction started at 10lbs, add 10 lbs every 20 mins
- serial exams and fluoro after each weight (up to 140 is safe)
- manoeuvers:
- unilat with facet distracted to perch postion, rotate head 30 degree past midine in direction of D/L
- stop reduction when facets reduced, change in neurology, change in consciousness, 140 lbs max, distraction at other levells of more than 1.5mm

injuries taht preclude from doing CR
- skull fracture
- distractive spinal injuries (atlantooccipital dissociation)
- type IIA hangman fracture

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12
Q

TLICS
TX algorithm

definition of burst fracture and findings on imaging

complications

A

TLICS - morphology, integrity of PLC, neuro status

burst fracture - posterior element fracture
- fracture of necessity of lamina
- vertical saggital plane fracture through body
- increase interpedicular distance, anterior wedging of VB with loss of height, superior endplate retropulsion

fracture of necessity have incarcerated neural elements in fracture, may spontaneously decompress spinal canal

Tx:
- nonop: neuro intact, <25% kyphosis, <50% VB height loss, <50% canal compromise, intact PLC - tx in TLO Jewett x 3months
- op: PLDIF - 2 level above and below, don’t end at junction; below level of conus can retract thecal sac and bone tamp, otherwise indirect decompression via ligamentotaxis
- transpedicular decompression, burring medial pedicle to access fragments

complications: neuro injury, cauda, DVT, pain, nonunion, scoli/kyphosis, flat back

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13
Q

spinopelvic dissociation
- definition
- principles of spinopelvic fixation

A

Spinopelvic dissociation: both horizontal and vertical fracture lines, upper part of sacrum remains connected to lumber spine, lowest part of sacrum connected to pelvis
- u type sacral fracture

approach
- posterior approach to lower lumbar spine and sacrum
technique
- L5 pedicle screw fixation
- iliac screws parallel to the inclination angle of outer table of ilium
linked with bars and SI screws
- extend to L4 if can’t do SI screws

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14
Q

Halo
- application
- contraindications
- complications

A

pins:
- well supported head, place head overhanging the bed with back panel supporting head
- halo sizing
- local anesthesia
- place pins
- 1cm region above the lateral 1/3 of the orbit, have patient’s eyes closed
- posterior pins: below the equator
- tighten to 6-8 inch-lbs
- apply vest
- post halo xray
- retighten in 24hrs

contraindications:
- skull fracture
- infection at pin sites
- concomittant injuries at pin sites
- flail chest/significant chest injuries
- old age
- obesity
- comorbidities or patient factors affecting compliant use of halo
- patient refusal

complications:
- failure to maintain reduction
- infection
- pin loosening
- pain or inability to tolerate
- dural puncture
- pin protrusion through skull
- abducen nerve palsy
- supraorbital nerve palsy
- supratrochlear nerve palsy
- inability to closed eyes
- res : aspiration, pneumonia, ARDS

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15
Q

incomplete spinal cord injury
definition
types and tx

A

definition: some preservation of sensory and/or motor function below the lesion

central, ant, post, brown sequard, connus medullaris, cauda equinae
- all sacrap sparing

central cord
- motor>sens, UE>LE, distal>prox, sacral sparring
- hyperext, >60, cervical spondylosis
- management
- ICU, MAP >80, c-spine collar, sx within 24h if unstable - >11 angular displacement, VB translation >3.5mm

anterior
- loss of pain, temp, crude touch and motor (lat corticospinal and dorsal column)
- orthostatic hypotension, bladder and or bowel incontinence
- preservation of touch, proprioception, vibration
- management
- BP support, surgery
- bad prognosis

posterior cord
- loss of fine touch, proprioception, vibration (dorsal column)
- preserve motor, pain, temp, crude touch (lateral corticospinal and spinothalamic)

brown sequard
- complete cord hemitransection - penetrating injury
- best motor prognosis
- ipsilateral loss of sensory at level of leesion, ipsliateral loss of motor, proprioception below the lesion and contralateral loss of pain and temperature

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16
Q

anterior vs posterior approach to c spine

A

Anterior:
Pros:
Can do discectomy easier
Shorter OR time
Less blood loss
Lower infection rates
Restore lordosis
Muscle sparing
Cons:
Reduction more difficult if needed
May need to switch to posterior

Risk for adjacent segment disease:
- Plate within 5mm of superior end plate, smoker, female

Posterior:
Pros:
Higher fusion rates
Multilevel fusions
Biomechanically stronger
Easier to do reduction

Cons:
- more blood loss
- longer hospital stay
- higher infection rate

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17
Q

cervical myelopathy

  • RF
  • clinical features
  • p/e special tests
  • classification
  • ddx
  • imaging findings
  • complications
A

SC diameter <13mm

  • RF: congen stenosis, inherited predispoition, degen cervical spondylosis
  • clinical features: neck pain/stiffness, extremity paresthesia, weakness, clumsy, gait instability, urinary retention
  • P/E special tests: finger escape sign, grip and release, long tract signs, babinski, hoffman, inverted radial reflex, hyperreflexia, clonus, lhermitte sign, wide based gaint, romberg
  • classification:
    • modified japanese ortho assoc classification (18 pts), upper motor, upper sens, lower motor, urinary;
    • Ranawat - based on worsening clinical sx and P/E
  • ddx: stroke, mvmt disorder, b12 def, ALS, MS
  • imaging: mri shows effacement of csf, myelomalacia, modified k line predicts if enough posterior drift - sag MRI midpt of spinal canal at c2-7
  • sx goal - prevent progression
  • 1-2 Levels of compression + >10 kyphosis = Anterior alone (ACDF/Corpectomy/hybrid)
  • 1-2 levels of compression + <10 kyphosis = Anterior alone (address OPLL, soft disc, disc osteophytes)
  • 3+ levels + >10 kyphosis = Combined
  • 3+ levels + <10 kyphosis = Posterior alone (laminoplasty, laminectomy, fusion)
  • complications
  • ant: dysphasia, alteration to voice, airway, esophageal, pseudoarthrosis, hypoglossal n injury, horners
  • general: epidural hematoma, vert a injury, C5 n injury, dural tear, infeciotn, post op neck pain, kyphosis, HW failure, pseudoarthrosis/nonunion
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18
Q

OPLL
- definition
- RF
- K-line
- classification
- sx algorithm

A

replacement of PLL with lamellar bone

  • RF: east asian male, DM, obesity, high salt/low meat diet, poor Ca absorption, mechanical stress on PLL, sleep habits, DISH, rickets, hyperparaTH
  • K line XR/CT if OPLL protrude posterior line = neg predictor for post sx alone
  • classification: solitary, segmental, continous, mixed

tx
- surgery if CM symptoms
- Anterior corpectomy +/- OPLL resection – for kyphotic cervical spine
- Posterior laminoplasty/laminectomy + fusion – for lordotic C-spine
- Allows spinal cord to drift away from anterior compression
Risk of OPLL growth post-op

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19
Q

lumbar disc herniation/spinal stenosis
- disc herniation morphology
- special tests
- types
- tx
- far lateral approach
- postitive predictors
- steps to microdiscectomy

A

L4/5

disc herniation morphology
- protrusion (intact anulus fibrosus)
- extrusion (disc crosses disrupted annulus fibrosis)
- sequestered (free fragment, disc material and not continuous with disc space)

associated conditions: achondroplasia - short pedicles, thick lamina, decrease interpedicular distance caudally

special tests: + SLR, contra SLR, femoral n stretch, hyporeflexia, weakness

types
- central - get neurogenic claudicaiton, can cause cauda
- paracentral/paralateral most common affects descing nerve root (L5)
- foraminal/far lateral - affects exiting nerve root (L4)

  • nonop 1st line, AAT, PT, injections, analgesics
  • operative
    • microdiscetomy (laminotomy and discectomy)
    • indications: persisitent pain >6 months, progressive neuro, cauda equina
  • far lateral approach is wiltse - 3-4cm off midline over TP, between multifidus and longissimus
  • positive predictors: leg pain as cheif complain, + SLR, weakness correlates with MRI, married status

microdiscectomy
* Localize level of incision with landmarks + XR – spinal needle
* Midline incision 3-4cm - between paraspinals
* Incise the fascia on side of disc herniation
* Identify lamina + facet capsule
* Create working window – burr to thin lamina – resection with Kerrison – extend lateral to edge of facet complex – complete laminotomy
* Decompression with curette and kerrison - resect ligamentum flavum
* Perform foraminotomy with kerison + remove ligamentum flavum
* Identify nerve roots - make sure free – use nerve root retractor to identify disc herniation
* Excise disk with 15 blade/rongeur

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20
Q

lumbar spinal stenosis
- assoc congenital condition with lumbar spinal stenosis
- exam/features
- mri finding
- sx buzz words

A

associated conditions:
achondroplasia
- short pedicles, thick lamina, decrease interpedicular distance caudally

exam
- neurogenic claudication, walk test

mri
- central stenosis <10mm AP on axial

wide pedicle to pedicle decompression with fusion

SPORT trial - improved pain and function and satisfaction with surgery
- best predictor is comorbidities

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21
Q

spondylolisthesis
- definition
- types
- RF for progression

A

types
- Dysplastic: Congenital defect in pars or abnormal orientation of facet joints/upper sacrum (axial/sag) -> neuro sx. Develop rapidly
- Isthmic: 2A: pars fatigue fracture, 2B: Pars elongation due to multiple healed fractures, 2C: Pars acute fracture
- Degen: Facet instability without fracture
- Traumatic: Acute posterior arch fracture not in pars -> Nonoperative - brace
- Pathologic: Often multi-level – tumor, syphillis, infection -> Operative

RF to progress: Young age (Adolescent growth spurt), female, lumbrosacral kyphosis (slip angle>40), Myerding 2+, dysplastic posterior elements, dome shaped sacrum

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22
Q

Degen spondy
- definition
- RF
- pathophys stenosis at central vs foraminal
- main symptoms
- treatment

A
  • lumbar spondylolisthesis without a defect inthe pars, usually L4/5
  • RF: saggital oriented facets (congenital), sacralization of L5, female
  • Central/lateral recess stenosis = affects descending root = slippage, hypertrophied lig flavum, facet arthrosis – effects L5
  • Foraminal stenosis = affects exiting root = decrease disc height, PL phytes, facet arthrosis -> effects L4
  • mechanical back pain, neurogenic claudication/leg pain, hamstring tightness, cauda equinae
  • treatment:
    • PLDIF - lumbar wide decompression, foraminotomy, fusion
  • complications
  • dural tear, pseudoarthrosis, infection, adjacent segment disease, hypogastric plexus injury (retrograde ejaculation)
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23
Q

isthmic spondy
- definition
- most common level
- RF and RF for progression
- classification
- slip angle
- management

A

lumbar spondy due to defect in the pars interarticularis (spondylosis)

L5/S1 most common

RF: inuit, increase PI, hyperext activities, spina bifida
RF for progression: <15, progressive disc degen, L4/5

meyerding Classification:
- Grade 1: < 25%, Grade 2: 25-50%, Grade 3: 50-75%, Grade 4: 75-100%, Grade 5>100%

Slip angle: Angle between inferior surface of vertebral body and line perpendicular to posterior surface of sacrum – normal is 0-10; >50 = high risk of progression

mangement:
- Nonop: Observe low grade 1-2 slip: activity mod/PT/meds/Bracing
- Operative: Low grade + failed nonop 4-6 months, high grade slips, neuro sx.
L5-S1 fusion + decompression +/- reduction (high grade with unbalanced pelvis - max 50%) otherwise in situ fusion
neuromonitoring, L5 nerve root widely decompressed and visuzlied prior to reduction
If spondyloptosis = L5 vertebrectomy + L4-S1 fusion (2 stages) – if sag balance maintained = insitu fusion

Pars repair = failed nonop and spondylolysis (L4 or higher) – minimal DDD, no slip, no disc

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24
Q

Adult spinal deformity
- normal cervical, thoracic and lumbar measurement
- equation
- c7 plumb line normal values
- What are compensations for SVA?
- flat back syndrome
- methods to correct deformity? How much correction?
- RF for pseudoarthrosis

A
  • cervical lordosis 20-40
  • thoracic kyphosis 10-40
  • lumar lordosis ~30 more than thoracic kyphosis (40-60)
  • PI = SS +PT = ~ 55 =/- 10
  • PI doesn’t change with position
  • PT normal is <20
  • PI = SS +/- 10
  • < 45 PI = LL, as you get older difference increases with PI > LL
  • C7 plumb line pass within few mm of post superior corner of S1, ABN >2.5cm, ant = +, post = (-)
  • To compensate for SVA – create pelvic retroversion to increase PT = hip extension, knee flexion, hypolordosis
  • Iatrogenic pathology – use of distraction instrumentation in posterior column or compressive anterior instrumentation;
  • Smith peterson osteotomy SPO – 10 degrees/level; need mobile disc or osteotomized ant fusion mass
  • pedicle subtraction osteotomy PSO – 30-35 degrees/level
  • vertebral column resection VCR – 45 degrees/level; needs ant and post recon, multiplanar
  • > 55, <12 vert fusion, TL kyphosis >20, OA of hip jt, + sagital balance >5cm @ 8wks post op, incomplete sacropelvic fixation
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25
Q
  • cancers that mets to spine
  • SINS score
  • NOMS
  • modified tokuhashi
  • radiosensitve tumours
  • radioresistant tumours
A
  • breast, thyroid, prostate, renal, lung
  • SINS:
    • 6 categories: Location, Pain relief unloading of spine, type of lesion, radiographic spinal alignment, vertebral body collapse, posterolateral involvement of spine (facet/pedicle/CV joint)
    • <6 stable, 7-12 impending, >12 unstable
  • NOMS
    • neurologic - degree of spinal cord compromise
    • oncologic - radiosensitive vs radioresistance tumours
    • mechanical - instability/pain/SINS score
    • systemic - ability of patient to tolerate intervention
    • determine if need: radiation vs sterotactic radiosurgery, decompress/separation surgery and stabilization
  • modified tokuhashi - predicts prgnosis, guide tx decision; categories functional score, extraspinal mets, mets to VB, mets internal organs, primary site of CA
  • radiosensitive(NOMS LBP)
    • neuroendocirne, ovarian, MM, seminoma, lymphoma, breast, prostate
  • radioresistant (SMRT CA)
    • sarcoma, melanoma, RCC, thyroid, colorectal, adenocarcinoma
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26
Q
  • ant vs post column tumours
  • tx options for osteoid osteoma
A

Anterior
- mets, MM, plasmocytoma, lymphoma, chordoma, hemangioma, EG, GCT
Posterior
- osteoid osteoma, osteoblastoma, osteochondroma, ABC, chondrosarc, osteosarc, ewing

osteoid osteoma
- NSAIDs, radiofreq therma ablation, en block resection

ABC
- marginal resection vs en bloc, consider emboliz

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27
Q

Spine infection
- 4 red flags on hx when assessing back pain
- What are 4 things that enhance with gadolinium?
- RF for bacterial spine infection
- other non spine related test you should get
- Name 4 indications for surgical management
- What are 3 RF for failure of medical management
- mngmnt

A

4 red flags on hx when assessing back pain:
Constitutional sx.
Constant unrelenting pain
Bowel bladder dysfunction
Night pain
Leg weakness

What are 4 things that enhance with gadolinium?
Scar tissue
Infection (discitis, abscess rim enhance)
Tumors
Vascular lesion
Recurrent disc is dark

RF for bacterial spine infection?
- advanced age, immunocompromised, DM, IVDU, HIV, malignancy, chronic steroid use, renal failure, septicemia, spinal sx, intravasc devices, presence of foreign bodies

other non spine related test you should get
- TEE

Name 4 indications for surgical management?
Failed nonop/medical manageemnt
Progressive neuro
Deformity correction
Need for stabilization/decompression

What are 3 RF for failure of medical management:
Incomplete or complete SC deficit
Age >65
DM
MRSA

Management
- medical: abx after blood and tissue culture
- if fusion, used autograft instead of cages/allograft

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28
Q

spine TB
- patterns
- RF
- workup and findings
- TX

A

patterns
- peridiscal, central, anterior

RF
- immunocompromised, travel, homeless, known exposure

workup and findings
- CBC, ESR/CRP, Tb skin test, interferon gamma release assay, PCR, CXR with isilateral hilar mediastinal lymphadenopathy, osteolysis/kyphosis on TL spine xray
MRI shows T2 heterogenous high signal with sublig spread,

CT guided bx - acid fast bacilli smear, PCR path for caseating granuloma

spine at risk signs of dev kyphosis: separation of facet jts, retropulsion, lateral translation, toppling

tx
- RIPE - rifampin, isoniazid, ethambutol, pyrazinamide: 6-18months, serial clinical and radiographic evals
- sx if failed medical tx, neuro def, instability

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29
Q

Rheumatoid spine
* patterns
* methods of assessing basilar invaginaton
* surgical indications
* methods of C1-2 fixation
* extra-artic manifestation of RA
* periop considerations

A

3 patterns of cspine disease
* C1-2 instability
* Basilar invagination – atlantoaxial impaction
* Subaxial subluxation

  • RF for progression: male, RF +, higher CRP, SQ nodules, adv peripheral jt diesase

methods of assessing basilar invagination:
* Clark station - N C1 at 1/3 of dense
* Ranawat index
* Macreas, McGregors, Chamberlains
* cervicomedullar angle abn <135

  • Ranawat classification: 1: no neuro; 2: subjective weakness with hyper-reflexia, 3 – objective weakness, UMN, normal gati, 4: weakness, UMN, gait change

What are the surgical indications for patient with RA
* Progressive neuro deficit
* Mechanical neck pain not responding to meds
* XR RF for impending neuro innjury
* PADI <14/SAC <14
* Cervicomedullary angle <135
* AAI (ADI >10mm
* Odontoid migration past 1st clark station

What are methods of C1-2 fixation
* C1-2 intraarticular screw (MAGERL)
* C1 lateral mass, C2 pedicle screws (HARMS)
* Sublaminar wirining (Gallie)

extra-articular manifestations of RA?
- Rheumatoid nodules, Small vessel vasculitis, Episcleritis, Pleural effusion (exudative), Pericarditis (exudative), Anemia

periop considerations:
* A- Anesthesia/Airway: Obtain anesthesia consult
* B- Bone - Osteoporosis
* C- C-spine – Flex-ex views
* D- Drugs – Consult Rheum – drug cessation 2 weeks preop/postop, steroid stress dose
* S – Skin/soft tissue management: Thin skin, altered soft tissue

XR: subaxial subluxation of vertebral body >4mm or 20% listhesis
Cervical body height/width ratio: abnormal <2.0

consider preop HALO with subaxial subluaxation or basilar invagination

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30
Q

Dural Tear
- intra op management
- post-op management
- RF
- complications of persistent dural tears
- tests to detect CSF

A

Principles: Visualize the tear, protect neural elements, repair the tear, Watertight closure

**Intra-op tear **
* Exposure – visualize whole tear – get lighting/scope
* Head of bed down – decrease fluid pressure
* Reduce neural elements if exposed
* water tight primary closure with 6-0 prolene (Non-absorbable, monofilament) starting at the apex
* Adjuncts if needed: Dural patch, fibrin sealant, fat grafts, fascia lata, lumbodorsal fascia
* Test repair with valsalva (40 mmHg x15-20s)
* Tight fascial and wound closures in layers
* Keep supine bedrest for 48 hrs (no evidence) if lumbral; If cervical (sitting)
* discuss with patient complication in OR

RF: OPLL (14x more likely), revision surgery, ossified ligamentum flavum, synovial cysts, age, experience of spine surgeon

Post-op tear
Sx of persistent CSF leaks post-op
- Positional headache nausea, photophobia, Back pain and fullness, Abducens nerve palsy, Fistula formation and pseudomeningocoele, CSF leak from wound or subfascial drain

Management:
- Symptomatic early: Image with MRI, r/o infection, monitor and discuss may need surgery
- Ongoing symptomatic: Primary dural repair 6-0 prolene, fibrin glue augment, possible dural patch
- IR consult for subdural drain to decrease subarachnoid pressure

Complications of persistent dural tears
- Spinocutaneous fistula, Pseudocyst, Meningitis, Nerve root entrapment, Cranial nerve palsy, Mass effect, Wound healing complications and infections

  • B-2 transferrin assay can detect CSF
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31
Q

Ank spond
* genetic mutation
* periop consideration
* dx criteria
* systemic feature
* difference between AS and DISH
* P/E test
* investigations
* surgical principles

A

genetic mutation: HLA b27, seronegative

peri-op considerations:
* Resp function: Restrictive lung disease
* Meds: Consult medicine/Rheum: consider holding biologics
* Anaesthesia consult: Intubation with rigid spine - glide scope
* Hb level – bleeding risk, iron supplement
* Bone quality – calcium/vitamin d
* Modifiable: stop smoking, optimize nutrition
* Operative: Positioning, Transfers, instrumentation, hemostasis

Dx criteria
- New York Criteria: Need 1 clinical and 1 XR finding: Clinical: LBP for >3 months (better with exercise), restricted lumbar ROM, restricted chest expansion; XR: SI arthritis

systemic features
- Uveitis, Iritis, Pulmonary fibrosis, Renal amyloidosis, Cardiac conduction abnormality, Ascending aortic – aortitis/stensosi/regurg, autoimmune disease ((UC), psoriasis

differences between AS and DISH - see table

P/E special tests
- kyphosis - chin to chest deformity, chin brow to vertical angle, occiput to wall distance, schober test, chest wall expansion, FABER

investigations: ESR/CRP, HLA b27, RF, creatinine, echo/ekg, eye exam, CXR/CT chest, PFTs

surgical principles: long construct, OP bone, high risk of epidural hematoma, do not correct deformity

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32
Q

intra-op NM loss schpeel

A

Neurological status is monitored by 3 recordings
1 SSEP: Somatosensory evoked potentials, continually monitored
Looks at dorsal columns mostly
Real time insults to cord are recorded but sensitivity is low because most insults are anterior cord
2 MEP: transcranial motor evoked potential
stimulated every few minutes by electrophysiologists, looks at anterior cord.
a Will show delay in recognizing spinal cord injury
b More sensitive than SSEP
3 EMG: Electromyelography; surgeon touches pedicle screw with monopolar probe.
a Impedance is high if pedicle screw is in bone
b Impedance is low if pedicle screw is on a nerve

Management
- Intra-op pause - alert anesthesia, neurphysiologist, call for fluoro and senior colleague
R/o systemic causes
* MAP elevated to >80 mm Hg
* Optimize Hgb, Hct, pH, PCO2 and transfuse if low
* Check body temp - elevate to >36.5°C (97.7°F)
R/o technical problem
* Check status of anesthetic agents
* Check extent of neuromuscular blockade
* Electrode connections
* Check neck and limb positioning
Surgical
* Remove traction
* Decrease or remove corrective forces
* Remove rods
* Remove recent screws
* Evaluate for cord compression with U/S
Wake up test
* Flood surgical field with NW, cover with sponges, decrease sedation until patient awake, ask patient to move their feet, avoid touching the patient, no sensory testing is done, re-sedate patient
* Close and CT if abnormal wake up test

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33
Q

Airway post-ACDF

A
  • Symptoms: Swallowing difficulty, Fullness, Neck mass, Stridor, agitation (hypercarbia)
  • Causes: Hematoma
  • Risk factors
    • Surgical: >3 VB, C2-4, Blood loss >300, OR time 5 hours
    • Patient: Obesity, OSA, Pulmonary disease, Myelopathy, Revision
    • Anesthetic: Multiple attempts, Need for fiberoptic

Management
- Assess patient immediately - need for airway
- Have bronchoscope and surgical airway available
- Vitals, ABCs
- look for clinical signs of airway obstruction (speech, resp rate), examine wound and neck for hematoma
- Notify airway specialist (anesthesia or ENT)
- remove dressing, remove sutures

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34
Q

cervical lateral mass
thoracic pedicle
lumbar pedicle

A

cervical spine
- lateral mass
* Starting point center of lateral mass
* Drill angled 15 degrees superiorly and 30 degrees laterally from starting point
* Unicortical or bicortical purchase

thoracic pedicle screws
- entry point is intersection of lateral border of superior articular process and orizontal line across base of TP
- 5-25 degrees medially, mostly straight

lumbar pedicle screws
- entry point is junction of lateral aspect of superior articular facet and based of TP
- 5-25 medially, parallel to superior endplate

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35
Q

AIS
- age
- RF for progression
- lenke
- exam
- cobb angle
- mri indications
- determine skeletal maturity
- treatment

A

> 10 with >10 degrees of vertebral rotation
RF for curve progression
- curve magnitude > 25 degrees before skeletal maturity
- skeletal maturity: <12yo, open triradiate, peak growth velocty - best predictor
- curve type: thoracic>lumbar, double>single

Lenke classification
* Morphology of curve – 1-6
* Lumbar modifier – A/B/C
* Thoracic sagittal profile – normal is 10-40 (hypo <10, hyper >40)

exam: shoulder eight, truncal shift, rib prominence, adams forward bend test, abdo reflees (syrinx), foot deformity (cavovarus -tethered cord), cafe au lait (NF), hyperlaxity, LLD

cobb angle
* Obtain a frontal spinal X-ray (AP/PA view).
* Identify the upper and lower end vertebrae of the curve (most tilted).
* Draw a line along the top endplate of the upper vertebra.
* Draw a line along the bottom endplate of the lower vertebra.
* Draw perpendicular lines from both of those lines.
* Measure the angle where the perpendiculars intersect — this is the Cobb angle.

MRI indications
- age < 10, male, L thoracic curve, apical kyphosis >30, short curve, rapid progression, excessive kyphosis, neuro symptoms or pain, foot deformity, asymmetric abdo reflex

determine skeletal maturity
* Risser
* Age of menarche
* Tri-radiates
* Olecranon (Sauvergrain method - elbow XR)
* Atlas of Greulich + Pyle - AP left hand
* Tanner

treatment
- cobb angle 25-45 and risser 0-2 = brace 16-23h/day until skeletal maturity
- cobb angle >45 in young patient or 45-60 in mature patients do a PSIF

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36
Q

congenital scoliosis
- RF
- associated conditions
- classification
- tx

A

RF: maternal DM, EtOH, valproic acid, hyperthermia

assoc conditions: cardiac defect, GU defect, spinal cord malformation, VACTERL

classification:
- failure of formation, failure of segmentation or mixed
- unilateral unsegmented bar
- fully segmented hemivertebra
- unicarcerated hemivertebra
- incarverated hemivertebra
- unsegmented hemivertebra
- block vertebrae

treatment:
- observe if no documented progression
- operative if progresion or when high risk of progression

when is hemi epiphysiodesis indicated
- <5yrs, no bar, small correction, no truncal imbalance, curve <40

hemivertebrectomy: wedge/hemivert resection

work up: XR, CT and MRI, ECHO and renal U/S

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37
Q

vertebral artery injury
- RF
- consequence of dominant vert artery injury
- management

A

RFs:
1 Distorted anatomy (infection, tumor)
2 Multilevel corpectomy
3 Oblique troughs
4 Dissection lateral to uncinate

Consequences of dominant vertebral artery injury:
* Vertebrobasilar Insufficiency
* Dizziness, Vertigo, Nausea, Diplopia, blindness, Ataxia (cerebellar), Bilateral weakness, Oropharyngeal dysfunction
* 1 Wallenberg syndrome
* 2 Cerebellar infarction
* 3 Cranial nerve palsies
* 4 Quadriparesis
* 5 Mortality 12%

Goals of Management
1 Control local hemorrhage
2 Prevent immediate vertebrobasilar ischemia
3 Prevent cerebrovascular complications

Management
* Notify anesthesia, anticipate 3-5L blood loss
* Page vascular surgery, interventional Radiology, and call for senior colleague if available
* Control local hemorrhage
- a Two sucker tips up, Tamponade with local pressure, Avoid bone wax for theoretical risk of Embolization, Head of bed to neutral
- if tamponade does not work, get proximal control
- place screw in if posterior and occurs after screw tap
- post-op angiography and possible embolization to prevent pseudo-aneurism

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38
Q

ATLS (short & long)

A

short
- Activate trauma team, place pt on O2, continuous monitors and 2 large bore IV, initiate fluid resuscitation, c-spine immobilization and proceed through primary and secondary survey

long
- Activate the trauma team, 2 large bore IVs and starting bolus, oxygen, c-spine collar in place and monitors and BW sent off and proceed with primary and secondary survey
- Starting with airway, seeing if patient is able to speak and airway is clear from obstruction
- Breathing making sure trachea is midline, bilateral air entry, checking for signs of flail chest and SC emphysema
- Circulation I would check BP and HR, look and attempt to reduce hemorrhage - Tourniquet, pressure, pelvic binder, splint, traction
- Disability - check GSC, pupil size
- Environment - I would expose patient and identify any long bone deformity, treat hypothermia with warming blankets
- Log roll/DRE - I would log roll patient, check for tenderness and step deformity and perform a DRE
- I would request adjuncts including CXR, c-spine and pelvis XR and FAST and reexamine vitals
- Proceed to secondary survey including AMPLE history and complete head to toe from orthopedic perspective checking fo limb deformities and pelvic stability

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39
Q

DCO
- indications
- components
- rationale
EAC
- parameters

A
  • Unstable Patients: Hypotensive, not improving, hypothermia, coagulopathy, acidosis
  • ISS > 40 without thoracic trauma
  • IS5 > 20 w/ Thoracic trauma (Pulmonary contusion on CXR)
  • GCS of 8 or below
  • multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
  • bilateral femoral fractures
  • pulmonary contusion noted on radiograph
  • hypothermia <35 degrees C
  • head injury with AIS of 3 or greater

Early appropriate care (femur, pelvis, acetabulum, spine <36h)
- pH < 7.25 [N 7.35-7.45]
- Base Excess < - 5.5 [N -2 - +2]
- Lactate > 4.0 [N,2.5]

  • **components: **resuscitative surgery, physiologic resuscitation in ICU, definitnive surgical management
  • **Rationale = **prevent second hit, reduce ARDS, SIRS, MODS
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40
Q

chest tube

needle decompression

A

5th intercostal space, anterior to mid axillary line
- go over top of the rib into pleural space with kelly
- anterior and superior for pneumo
- posterio and inferior for hemothorax

needle decompression
2nd intercostal space midclavicular line (tension pneumothorax)

5th ICS, anterior to mid axillary line - safer and more effective - newer standard

14-16 gauge large bore angiocatheter

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41
Q

open fracture
- er managemnt
- OR management

A

ATLS and resuscitation
Tetanus status/prophylaxis
-Tetanus prophylaxis (based on vaccination history and ° of contamination
- Toxoid 0.5ml IM if vaccinates, immune globulin 250U if unvaccinated

Early antibiotics (ideally within 66min)
- Ancef +/- gram neg coverage if type 3/femur/farm
- Gram + coverage in open fracture (ancef)
- Add gram negative coverage for type III open fracture (Gent/tobra/piptazo)
- options if allergic to penicillin for GP coverage: Clindamycin, vancomycin
- Add high dose penicillin for barnyard injuries (i.e. those likely to be contaminated with soil/ feces – risk of clostridium) – 5 million units/24h
- Aquatic: most common is staph/strep
fresh water (aeromans hydraphila): Cipro/Levo (fluoroquinolone)
Salt water (vibrio): Doxy/Ceftazidime

Neurovascular, compartment, soft tissue examination

Bedside I&D (ideally within 24h)
- remove gross debris, cover with sterile

permeable sterile dressing
Fracture reduction and splinting
Repeat neurovascular exam and imaging

  • I will extend the wound proximally and distally.
  • I will perform a meticulous debridement
    layer by layer removing debris and devitalized tissue and bone.
    -I will irrigate with 3-9L of NS based on Gustillo grading, under low flow.
  • If the wound is then clean then re-prep and drape and proceed to stabilize the fracture
    • a If the wound can be closed primarily then proceed to early definitive fixation and closure
    • b If you cannot close then ex-fix outside area of definitive fixation, intra-operative plastic surgery consultation, pack or vac dressing, with plans to definitively stabilize the bone at the time of flap coverage (ideally within 5-7
      days)
  • If high degree of initial gross contamination then pack the wound with proviodine soaked gauze and perform serial debridements every 24-48 hours until the wound bed is clean.
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42
Q

Ex fix
Femur
Tibia
Calc
Foot
Humerus
Elbow
Forearm
Hand
Wrist spanning

increase stability of ex-fix

A

My goal is to restore length alignment rotation of the limb with a stable construct using pins outside the zone of injury and planned definitive fixation.

Femur: anterolateral/lateral 6mm
Tibia: anteromedial / 5mm
Calcaneus: 4mm transcalcaneal pin placed from medial to lateral in the safe zone of the calcaneal tuberosity
Foot : talar neck/cuboid / 3 mm
Humerus: anterolateral / 5 mm
Elbow: Spanning frame
A 2 x 5mm anterolateral humerus
B 2 x 4mm proximal ulna pins placed posterior subcutaneous boarder (FCU, ECU split)
Forearm: Ulnar/radial border / 4 mm
Hand: 2nd metacarpal dorsal / 3 mm
Wrist Spanning
2 x 3mm pins 2nd MC base
2 x 4 mm pins radial shaft (junction 1/3 2/3 avoiding superficial radial nerve and artery) between BR ECRL

Avoid heat (sharp bits, fluted, pause, irrigate)
Protect soft tissue (sleeves, incise)
Avoid joints, NV structures

Increase Pin Diameter (most important way to increase stability)
Increase Number of Pins
Increase pin spread
Decrease Pin-Fracture Distance
Decrease Rod-Bone Distance
Double stack Rods
Stiffer Rods
Multiplanar Fixation

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43
Q

Ex-fix pelvis

A

1. Iliac crest/wing external fixation pins (for DCO)

a. Start point – 3-4cm posterior to the ASIS centred between the inner and outer tables
b. Fluoro image used – obturator outlet view (60° cranial tilt)
c. Pin direction – superior to inferior directed towards the supraacetabular bone

2. Supraacetabular external fixation pins (not in DCO)

a. Start point – centre of the teardrop visualized on obturator outlet view and at least 2cm above superior acetabulum
b. Fluoro image used – obturator outlet view for start point, iliac oblique view for depth and to ensure ~1-2cm above sciatic notch, obturator inlet view for visualization of pin along its entire length between inner and outer tables
c. Pin direction – AIIS to PIIS

Advantages
- Pins are out of the way of abdominal procedures
- Two pins are sufficient (one on either side)
- Fixation is excellent
- Allows for direction of closure of open book injury in the same plane
- Biomechanically superior in resisting rotational forces and equal control of flexion/extension forces compared to iliac crest pins

Disadvantages
- More dependent on fluoro

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44
Q

Compartment forearm/arm fasciotomies

compartment syndrome fasciotomies thigh/leg

A

I will perform an open release of all compartments, debridement of any necrotic tissue (unless pediatric), intra-operative plastic surgery consultation for coverage followed by sterile dressing +/- vac. Post-operatively I will continue antibiotics while wound is open and return to the OR in 24-48 hours for repeat assessment.

1 Forearm:
a Dual incision fasciotomy;
- Volar (radial to FCU, or other) and dorsal approach releasing from carpal tunnel to lacertus fibrosus including superficial and deep flexor, extensor compartments and mobile wad
b Separate incision for carpel tunnel if using henry approach (e.g. post op ORIF)

2 Arm:
a Dual anterior posterior incisions releasing anterior and posterior compartments.

3 Thigh:
a Lateral single incision fasciotomy releasing anterior and posterior compartments.
b Usually medial compartment does not need to be released but if concerned can do from lateral incision or separate medial.

4 Leg:
a Two incision fasciotomy, anterolateral (gerdy’s tubercle to lateral malleolus) and posteromedial (posteromedial boarder of tibia)
b anterolaterally identify protect SPN, incise above and below the lateral septum for anterior and lateral
compartment.
c Posteromedially, protect saphenous nerve and vein follow the tibia to release superficial, deep flexor compartments and soleus bridge.

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45
Q

compartment fasciotomy foot

compartment fasciotomy hand

A

I will perform an open release of all compartments, debridement of any necrotic tissue (unless pediatric), intra-operative plastic surgery consultation for coverage followed by sterile dressing +/- vac. Post-operatively I will continue antibiotics while wound is open and return to the OR in 24-48 hours for repeat assessment.

5 Foot:
a Three incision fasciotomy, dorsal 2, 4 and medial, releasing all 9 compartments (4 interossei, 3 central, medial and lateral)
b Dorsal 2nd MT incision for adductor hallucis and second/third interosseous
c Dorsal 4th for remaining central compartments, lateral compartment
d Medial incision for medial compartment

3 Hand:
a Four incision fasciotomy with separate incision for carpel (or extend hypothenar incision)
b Thenar, hypothenar and dual dorsal (over 2nd and 4th metacarpals) incisions
c Release all 10 compartments
d Compartments released: 4 dorsal interosseous, 3 volar interosseous, adductor policis, thenar and hypothenar.

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46
Q

TRAUMA

BKA

AKA

A

BKA
* * 1 Hand breadth below tibial tubercle, create a long posterior flap
* 2 Identify and tie off ant and post tib artery; identify and cut SPN and DPN nerves sharply under tension
* 3 Perform osteotomy of tibia cutting the fibula 1cm short, beveling bony edges
* 4 Myodesis of the gastrocnnemius to anterior periosteum
* trim dog ears and tension free closure

AKA
* Position: supine, tourniquet.
* Mark Desired bone length, Fishmouth shaped incision
* Deepen the incisions through the subcutaneous tissue and deep fascia.
* Isolate the femoral artery/vein in the femoral canal on the medial side of the thigh and tie off
* Cut femur bone using saw and bevel edges
* Cut sciatic nerve and saphenous nerve sharply under tension
* Muscle attachments:
* Attach adductor and hamstring muscle groups to the bone with suture
* Bring the quadriceps muscle (“quadriceps apron”) posteriorly and attach to the posterior thigh fascia.
* trim dog ears and tension free closure

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47
Q

HO
- definition
- RF
- classificatoin
- workup
- prophylaxis
- when to do surgery

A
  • Formation of ectopic lamellar bone in soft tissues

RF
- male, traumatic brain injury, spinal cord injury, burns, delay in teratment, revision surgery, injury/surgery to acetabulum/THA/elbow fracture/distal humerus, ank spon/DISH, blast injury

Brooker
- see table

workup
- H&P, radiographs, CT, MRI if by NV structures, bone scan (detect HO earlier), ALP

prophylaxis
- NSAIDs indomethacin 25mg PO TID for 6 wks
- radiation single fraction doe 24 hrs preop to 72h post op (700-800 Gy)

surgery
- persistent symptomatic HO despite nonop management,
- delay surgical intervention until ALP levels normalize and HO mature on xray/look stable

48
Q

Signs Aortic
Rupture (symptoms, clinical signs, radiographic signs)

A

1 Symptoms: Chest pain, interscapular pain, confusion, parasthesias/weakness in the legs

**2 Clinical Signs: **hypertension, hypotension, interarm pressure > 20mmHg, signs of regurg (bounding pulses, wide
PP, diastolic murmur), findings suggestive of tamponade (muffled heart sounds, hypotension, pulsus paradoxus,
JVD, kussmaul)

3 Radiographic signs
a Mediastinal enlargement > 8 cm and/or 25% of the width of the thorax
b Deviation of the trachea to the right
c Deviation of the NG tube to the right
d Obliteration of the contours of the aortic knob
e Lowering of the left main stem bronchus
f Opacification of the space between the aorta and pulmonary artery
g Left sided hemothorax/pleural effusion
h Apical capping
i Calcium sign > 5mm
j Loss of aortic knob

49
Q

Nerve Injury Management

A

Management Principles
* Splint to prevent contractures
* PT/OT referral to maintain ROM
* EMG 6 weeks and 3 months
* Early plastic surgery referral for possible nerve surgeries (decompression, or nerve/tendon transfer)
* Anticipate prolonged recovery requiring 6-9 months, notify the patient of this
* Surgical intervention
- Axillary nerve palsy decompressed at 3 months, neurotization between 3-6 months
- Radial and other nerve tendon transfers considered at 1 year, potentially earlier decompression

50
Q

Axillary Nerve/Tendon transfer

Musculocutaneous tendon transfer

A

Axillary nerve
Neurotization (medial triceps branch to axillary nerve transfer)
Tendon transfers: Pec major transfer, trapezius transfer

MSC nerve
innervates: biceps, brachialis, coracobrachialis
options:
1. sternocostal head of pec major to biceps tendon
2. lat dorsi to biceps/radial tuberosity
3. steindler flexorplasty - proximal advancement of flexor pronator mass origin

51
Q

radial nerve palsy - tendon transfer

A

Biceps to triceps,
PT to ECRB,
FCR to EDC,
PL to EPL (FDS4 if no PL)

52
Q

median nerve palsy - tendon transfer

A

low median nerve palsy

loss: thumb opposition
- Opponensplasty (FDS 4 to APB),

high median nerve palsy also have

loss of thumb IP flexion (FPL)
- BR to FPL

loss of finger flexion 4-5
- FDP 4 & 5 side to side with FDP 2 & 3

if high median nerve palsy FDS4 does not function, therefore use EIP to APB

53
Q

ulnar nerve palsy - tendon transfer

A

High lesion – lose function of FDP 4-5 + power pinch
Effects FCU, FDP 4-5, intrinsics
Deformity – no clawing, loss of FDP 4-5
Tendon transfer:
-Finger flexion: FDP 4-5 side-side transfer of FDP 2-3 (as long as median nerve intact)
- If median nerve not intact – use ECRL
- power pinch/thumb adduction: ECRB to adductor pollicis with interposed graft (smith)

Low lesion – develop clawing, decreased pinch
Effects intrinsics – interossei, lumbricals, adductor pollicis, hypothenar
Deformity: hand clawing, Froments sign, Jeanne sign, Wartenberg sign, grip strength <50%, decreased pinch strength

**Tendon transfer: **
- Clawing = FDS -> lateral bands of prox phalanx Or ECRB to intrinsics
-Power pinch/thumb adduction: ECRB to adductor pollicis
-Finger flexion: FDP 4-5 side-side transfer of FDP 2-3 (as long as median nerve intact)

54
Q

common peroneal nerve/foot drop tendon transfer

A

Tib post 4 incision technique transfer from navicular to lateral cuneiform/cuboid

Incision 1: Medial and distal for PTT harvest: medial malleolus and 5cm distal. Harvest
subperiosteally from distal to proximal at naviculocuneiform joint.
Incision 2: 15cm Medial and Proximal to pass the tendon: The soleus and FDL are retracted
posteriorly to expose the PTT, the PTT is then pulled through the proximal incision and tagged with
suture
Incision 3: Lateral and proximal to pass tendon through IOM: EDL is retracted medially and a ~4cm
of interosseous membrane is dissected off the fibula and excised, the PTT is then passed through the
window created
Incision 4: Distal lateral for fixation to lateral midfoot: Incision over the lateral cuneiform. PTT is
tunneled subcutaneously to this incision and anchored to the lateral cuneiform with an interference
screw

55
Q

TRAUMA

infected nonunion shpeel

A

1 Obtain a CT to assess union, and confirm the hardware based on previous operative note
2 Follow old skin incisions
3 Send multiple intraoperative cultures
4 Perform meticulous layer by layer debridement of any devitalized tissue or bone

a If there is solid union: Removal of hardware, curetting screw holes, debriding bony edges, thorough irrigation
including the joint with primary closure

b If there is not a solid union and construct is stable: Irrigate 9L NS under low flow, debride any contaminated
tissue, curette around the plate, and retain hardware.

c If there is not a solid union and the construct is unstable: Removal of hardware and revise ORIF with new
locking plate after thorough irrigation with 9L of NS under low flow

56
Q

Nonunion
- definition
- types
- RF
- management

A

**Definition: **failed to head in expected time frame and is not likely to heal without new intervention; no interval healing on 2 consecutive xrays 6 wks apart

types: septic, aseptic (hypertrophic, oligotrophic, atrophic)

Fracture Factors:
* High-energy trauma
* Open fractures
* Comminuted fractures
* Segmental bone loss
* Fractures with poor vascularity (e.g., scaphoid, femoral neck)
* Fracture displacement
* Interposed soft tissue at fracture site
* Infection at the fracture site
* Pathological fractures

Host (Patient) Factors:
* Smoking
* Diabetes mellitus
* Malnutrition
* Chronic steroid use
* NSAID use
* Alcohol abuse
* Immunosuppression
* Radiation
* PVD
* Poor compliance with treatment
* Age (older patients may heal more slowly)
* Osteoporosis or other metabolic bone diseases

Surgeon (Iatrogenic) Factors:
* Inadequate reduction or fixation
* Inappropriate implant selection
* Excessive soft tissue stripping
* Failure to achieve mechanical stability
* Inadequate post-op immobilization
* Failure to recognize and treat infection
* Premature weight-bearing or mobilization

Management
- obtain previous OR report, rule out infection and do a nutrition and metabolic workup
- Xray/CT scans
- BW: WBC, CRP/ESR, ext lytes, Vit D, Hgb A1C, ALP albumin, thyroid, renal function test
- smoking cessation, nutrition optimization, discontinue meds if possible, optimize medical conditions

57
Q

TRAUMA

Hip dislocation
- hip dislocation (ant/post) management in ER

A
  • 1 AMPLE history
  • 2 Examination
  • a Neurovascular examination
  • b Examine the limb for any injuries that would preclude manual traction
    * i including ligamentous knee injury, midshaft femur, floating knee,etc
  • 3 Prior to reduction have skeletal traction setup available
  • 4 Perform closed reduction
    • a Allis maneuver in flexion adduction internal rotation with an assistant
      * b For anterior hip dislocations In line traction, abduction, external rotation followed by IR and adduction when hip in joint
  • 5 Check stability
    * a Place patient in knee immobilizer in slight abduction to prevent recurrence
    * b For anterior dislocations tape the legs in adduction IR for anterior hip dislocation
  • 6 Post-reduction neurovascular examination, plain films and CT
58
Q

Fat embolism syndrome
- criteria
- Methods to reduce fat emboli when nailing long bone
- management

A

Diagnosis = at least 1 major and 4 minor
Major criteria
* Petechial rash,
* PaO2 < 60mmHg,
* CNS depression,
* pulmonary edema

Minor criteria
* tachycardia, pyrexia 38.5, emboli in retina, fat in urine or sputum, increased ESR, drop hematocrit/platelet

1 Use sharp and fluted reamers
2 Narrow shaft
3 High RPM, slow advancement
4 Over ream compared to size of nail
5 Distal vent

Management
- supportive care: maintenace of adequate oxygenation, stable hemodymanics, blood products as indicated, hydration, ppx for dvt, nutrition

59
Q

Approaches to the elbow - lateral

A

Boyd – subanconeus
Kocher – ECU/anconeus
EDC split
Dorsal Thompson/Kaplan – EDC/ECRB
ECRL/ECRB interval only developed for lateral column procedure

60
Q

Approaches to the elbow - medial

A

Hotchkiss over the top
Flexor pronator split
Bryan Morrey floor cubital tunnel
Taylor-scham approach (medial equivalent of boyd, submuscular interval)

61
Q

TRAUMA

Complex elbow dislocations
- Injuries with PLRI and PMRI

A

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

62
Q

TRAUMA

Proximal humerus fracture
- - predictors for AVN after proximal humerus fracture
- Prevent varus with ORIF proximal humerus

A

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

63
Q

TRAUMA

Humeral shaft fracture
- Acceptable alignment humeral shaft
- RF nonunion humeral shaft

A

< 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

64
Q

TRAUMA

Femoral neck fracture

  • Signs of successful closed reduction of femoral neck
  • What three positions leads to loss of reduction of the femoral neck/ AVN and nonunion?
A

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

65
Q

TRAUMA

INTERTROCH FRACTURE
- Definition: unstable intertroch

A

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)

66
Q

TRAUMA

SUBTROCH FRACTURE
- 8 surgical techniques avoid varus malreduction subtrochs

A

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

67
Q

TRAUMA

Femoral shaft fracture
- Assessing rotation of femoral shaft fractures
- Radiographic test for rotation
- Management of malrotation
- what to do after nailing femur

A

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

68
Q

TRAUMA

ATYPICAL FEMUR FRACTURE
major and minor criteria of atypical femoral fracture

A

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

69
Q

TRAUMA

Distal tibia fracture
- Methods of obtaining reduction in distal tibia fractures when nailing

A

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

70
Q

TRAUMA

proximal third tibia fractures
- how do you fix the coronal vs sagittal plane?

A

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)

71
Q

TRAUMA

Tibial plateau
- Schatzker
- 4 goals of ORIF
tibial plateau

A

Split, split depression, depression, medial, bicondylar, metaphyseal

1 Restore of mechanical axis
2 Condylar width
3 Articular reduction
4 Knee stability

72
Q

TRAUMA

**Multilig recon **
- order

A

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

73
Q

SPORTS

PLC
- Contents of the
PLC
- PLC treatment
options

A

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)

74
Q

TRAUMA

ANKLE FRACTURE
- Ligaments of the ankle
- angiosomes

  • Radiographic evidence of syndesmotic injury
  • Intraoperative assessment of fibular length
A

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
75
Q

TRAUMA

Pilon
- pilot fragments
- RF soft tissue complications
- General strategy for pilon ORIF

A

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

76
Q

TRAUMA

**Talar neck fracture **
- xray
- classification with avn rate
- surgical principles

A

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
77
Q

TRAUMA

Calcaneus fracture
- specific xrays

  • operative indications calc fracture
A

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

78
Q

TRAUMA

Lisfranc
- Radiographic signs Lisfranc

A

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

79
Q

TRAUMA

**Pelvic ring fractures **
- classification
- Indications for ORIF anterior pelvic ring
- Relative indications for ORIF posterior ring
- reduction technique
- unstable fracture that requires packing

A

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

80
Q

TRAUMA

Sacral fractures
- Features sacral dysmorphism
- classification

A

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%)

81
Q

TRAUMA

**Acetabular fracture **
- classification
- Negative predictors after acetabular ORIF

A

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

82
Q

TRAUMA

**Femoral head fracture **
- classification
- Management

A

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

83
Q

TRAUMA

ACETABULAR FRACTURES
Fixation principles for simple and complex acetabular fractures

A

**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

84
Q

TRAUMA

Options for spiniopelvic fixation

A

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)

85
Q

TRAUMA

Normal physiologic changes in pregnancy

A

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

86
Q

TRAUMA

Bypass for lower
extremity trauma

A

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

87
Q

TRAUMA

Thoracic Outlet Syndrome (TOS):
- Boundaries and Contents
- sites of compression
- symptoms
- workup
- Surgical treatments TOS with Advantages and Disadvantages

A

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

88
Q

ONCOLOGY

Biopsy principles

A
  • tourniquet control
  • small longitudinal incision, to be incorporated into resection specimen
  • through intramuscular compartment
  • meticulous hemostasis
  • do not udermine/raise flaps
  • avoid n/v structures and joints
  • biopsy soft tissue if present
  • watertight closure
  • drain if necessary in line with incision, place distal, avoid if possible
  • send frozen section for lesional tissue to make sure it is consistent with differential and adequate amount
  • send for C&S
89
Q

ONCOLOGY

Radiation
- goals
- radioresis vs radiosens
- RF for radiation induce fractures

A

goals
- allow surgeon to work closer to important N/V structure, therefore allowing limb salvage and improved funciton
- decrease risk of local recurrence - treat microscopic disease that is in surrounding edema

radiosensitive: lumg breast, prostate, lymphoma, MM
redioresistant: RCC, thyroid carcinoma, melanoma, GI adenocarcinoma

complications
- early: delayed wound healing, infection, skin desquamation/blistering
- late: fibrosis, joint stiffness, secondary osteosarc, fracture

RF for radiation induced fractures: radiation dose >59Gy, WB bone, female, volume of bone receiving radiation, ant comp resection of femur, age, periosteal stripping, OP

90
Q

ONCOLOGY

DDx
- benign aggressive lesion
- malignant in adults
- epiphyseal

A

benign aggresive
- ABC, GCT, chondromyxoid fibroma, osteoblastoma, osteochondroma, telangiectatic osteosarcoma

malignant adult
- mets, mm, primary bone tumour (chondrosarc, ewing, malignant fibrous histocytomy, chordoma, osteosarcoma), brown tumour, OM, lymphoma

epiphyseal
- OM, GCT, clear cell chondrosarcoma, chondroblastoma

91
Q

ONCOLOGY

unknown primary tumour workup schpeel

A
  • comprehensive H&P
  • CBC, extended lytes, creatinine, ureal, ALP, LDH, PTH, TSH, LFTs
  • CRP/ESR
  • PSA
  • UPEP, SPEP
  • Imaging
  • full length radiograph, CT/MRI of lesion, CT CAP, bone scan
  • skeletal survey if concern for MM
  • PET
  • biopsy
92
Q

ONCOLOGY

enneking classification

A

Stage IA = low grade, intracompartmental
Stage IB = low grade, extracompartmental
Stage IIA = high grade, intracompartmental
Stage IIB = high grade, extracompartmental
Stage III = metastatic disease

93
Q

ONCOLOGY

Mirel criteria

A

1 Site of lesion (UE, LE, trochanteric region)
2 Nature of lesion (blastic, mixed, lytic)
3 Size of lesion (<1/3, 1/3-2/3, >2/3 of cortex)
4 Pain (mild, moderate, functional)
Graded 1, 2 or 3
Score >8: prophylactic fixation is indicated
Score = 8: Surgeon discretion
Score < 8: Medical management (bisphosphonates, analgesia, etc)

94
Q

ONCOLOGY

hypercalcemia symptoms and management

A
  • symptoms: confusion, malaise, fatigue, abdo pain, N/V, bone pain, kidney stones, polyuria
  • EKG, consult medicine
  • hydration - IV NS to achieve urine output of 200cc/hr
  • diuretic once intravascular volume restored
  • bisphosphonate for long term treatment
  • calcitonin
  • dialysis
95
Q

ONCOLOGY

bone tumours that metastasize to lymph nodes

bone tumours with small round blue cells

A
  • SCARE - synovial sarcoma, clear cell sarcoma, angiosarcoma, rhabdomyosarcoma, epitheloid sarcoma
  • LEARN - lymphoma, ewings, acute leukemia, rhabdomyosarcoma, neuroblastoma
96
Q

ONCOLOGY

tumour follow up schpeels

A

Follow up at 2 weeks, 6 weeks and then every 3 months for 2 years, then every 6 months up until year 5 then annually until year 10 to rule out local recurrence and mets

97
Q

ONCOLOGY

osteosarcoma
- RF
- management
- purpose of chemo, S/E
- factors for worst prognosis
- paroseal vs periosteal

A

RF: previous chemo, bone disorders (pagets, FD, bone infarct, chronic OM, OI), genetic condition (rothmund-thomson sx, li-fraumeni), radiation

overall management: chemo - restaging - limb sparing wide margin resection and recon - adj chemo

S/E of chemo: neutropenia, thrombocytopenia, anemia, heart failure, cariomyopathy

Management:
- review with multiD oncologic team
- BW: LDP, ALP, CBC, LFTs, Cr, Urea
- Echo/MUGA scan, audiogram
- chemo: doxirubicin (adriamycin), high dose methotrexate, cisplatin (MAC ATTACK) (-.0 ifofamide)
- RESTAGE - xrays, full length mri, bone scan, CT CAP
- surgery: wide margin resection + reconstruction
- amp vs tumour prosthesis vs intercalary allo/autografts vs rotationplasty
- adjuvant chemo
- F/U surveillance

Factors for worse prongnosis:
- primary tumour in axial skeleton, mets on presentation, >14yo, increase ALP/LDH, large turmour, inadquate surgical margins, poor responders to neoadj chemo (<90%), pulm nodule >5mm, lymph node involv, relapse <2yrs

parosteal - low grade, posterior distal femur, no chemo
periosteal - int grade, no medullary canal involv, tx same as IM osteosarc

98
Q

SPINE

Spine lines

99
Q

SCAPHOID
- Indications for ORIF scaphoid
- Indications volar approach scaphoid vs dorsal approach

A

Indications
* 1 Proximal pole fractures
* 2 Displacement >1mm
* 3 Associated carpal instability
* 4 Humpback deformity
* - a Dorsal cortical angle (DCA > 160)
* - b Lateral intrascaphoid angle (LISA > 30)
* - c Height to length ratio (HLR > 0.6)
* 5 Radiolunate angle >15 degrees
* 6 Scapholunate angle > 70 degrees
* 7 Associated perilunate dislocation
* 8 Comminuted fracture
* 9 Unstable vertical or oblique fractures

Volar: distal pole, humpback or if preferred for mid-waist
- a Russe approach = Wagner incision, through FCR subsheath, retract FCR ulnarly, ligate superficial palmar
artery, vertical capsulotomy, ranguer small piece of trapezium for appropriate trajectory, obtain reduction,
retrograde variable threaded cannulated screw

Dorsal: proximal pole or if preferred for mid-waist (contraindicated for humpback)
- b Dorsal midline incision over listers tubercle, incise retinaculum, split third and fourth extensor compartment, T
capsulotomy, dorsal antegrade variable threaded cannulated screw

100
Q

VISI
- clinical signs of VISI
- VISI management

A

1Decreased grip strength
2 Tender LT
3 LT shuck = grasp lunate and triquetrum and alternate volar dorsal loads
4 Kleinman’s shear test = same hand position as shuck but lunate is loaded dorsally
5 Compression test = grasp triquetrum and deviate radially and ulnarly

  • 1 Nonoperative – splint, injections, and activity modification
  • 2 LT repair: Open volar & dorsal approach for acute injuries, suture anchors fixation augmented with k wires and dorsal capsular plication
  • 3 LT reconstruction: Distally based slip ECU through bone tunnels triquetrum and lunate from ulnar to radial
  • 4 LT Arthrodesis

Adjunctive procedures
+/- Ulnar shortening osteotomy
+/- Midcarpal arthrodesis
+/- PRC

101
Q

PERILUNATE
- Radiographic signs perilunate
- Reduction maneuver perilunate vs lunate
- mngmnt for irreducible lunate dislocation

A

PA radiograph
* 1 Intercarpal gapping
* 2 Disruption of Gilulas lines (proximal proximal row, distal proximal row, proximal distal row)
* 3 Loss carpal height (carpal height/third metacarpal ~ 0.5)
* 4 Signet ring sign (from scaphoid flexion)
* 5 Piece of pie sign

Lateral view
* 6 Loss collinearity between radius to capitate
* 7 Spilled teacup sign

Perilunate: Extension traction → flexion → finger pushing on lunate
Lunate: Flexion → traction → extension → finger pushing on lunate

102
Q

PEDS HX short & Long

A

I will perform a comprehensive HPI, PMHx, meds, allergies, developmental, peripartum, vaccination, social history

I would perform a comprehensive history of presenting complaint, as well as Pmhx including previous admissions and surgical history, medications, allergies and vaccinations. I would ask about any challenges around pregnancy, birth and peripartum history, developmental history and difficulties with milestones. I would obtain a social history and inquire about home setting, hx of abuse in the home, available supports, parental occupation and exposure to cigarette smoke

103
Q

neonatal P/E

A

I would perform a thorough head to toe general examination looking for features of dysmorphism or congenital abnormalities, signs of spinal dysraphism, and neonatal
reflexes (Moro, grasp, etc).

From an orthopedic perspective I will check the cervical spine, upper and lower
extremities for any congenital abnormalities, ranging each joint, ensuring the hips are
reduced and stable, checking leg lengths.

Details:
General: height, weight, general nutritional status, nevi, hemangiomas, rashes, petechiae,
jaundice, obvious areas of bruising, or deformity
Head: head size and shape, fontanelles (should be present and soft)
Eyes: hyper/hypotelorism, slant of palpebral fissures, EOM, sclera, corea, red reflex
Ears: position of ears, tympanic membranes
Nose: discharge, nasal septum
Mouth and throat: lips for fissures, buccal mucosa, tongue teeth and gums
Neck: trachea midline, thyroid
Chest: heart sounds, breath sounds, pectus deformities
Abdomen: inspection, shape, distension, hernias
MSK:
UE: number of fingers, mobile supple joints, deformity, edema, symmetry, ROM
shoulder elbow wrist
LE: Hips in joint /barlow ortolani Galeazzi, knee ROM, supple joint, ankles and foot
deformities, IR/ER hips
Sacral dimpling
Pediatric reflexes (moro, grasping, etc)

104
Q

CanMED scenario principles

A
  • understand that this is a very difficult situation for the patient and family.
  • I will arrange for private area to sit and
    discuss the matter more fully.
  • Following the SPIKES framework, using non-judgemental, simple intelligible
    speech
  • I will empathetically respond to the patient’s concerns and answer any questions they have
  • while I was not at the original sx, cannot speak for my colleagues
  • my goal is to provide the best care moving forward at this point which involves X

spikes : setting, perception, invitation, knowledge, empathy, summarize or strategize

105
Q

Recommendations
for perioperative
Mx rheumatoid
drugs

A

General algorithm
Continue (MTX and hydroxychloroquine)
1 day (leflunomide)
1 week (SANE -sulfasalazine, azathioprine, NSAID, etanercept)
1 month (the rest)
2 months (rituximab)
Post op NSAIDS re-start POD1-2 and rest are 2 weeks

Specifics from JAAOS
1 NSAIDS – discontinue within 1 week before surgery. Aspirin at least 72 hr
2 MTX -continue
3 Sulfasalazine – 1 week preop
4 Azathioprine – 1 week preop
5 Leflunomide – 1-2 days preop, with cholestyramine to remove active metabolite, start 1-2 week postop
6 Hydroxychloroquine – continue
7 Etanercept – 1 week preop and restart 1-2 week postop
8 Infliximab – hold 1 month preop, reinstated 1-2 weeks postop
9 Golimumab – hold 1month preop restart 1-2 week post op
10 Toclizumab – hold 1 month preop
11 Abatacept – hold 1 month preop
12 Adalimumab – hold 1 month preop
13 Certolizumab – hold for 1 month preop
14 Rituximab – hold for 2 months preop

106
Q

Checklist preop,
intraop, postop

A

Surgical safety checklist prior to induction
1 Confirmed patient, site, procedure and consent obtained
2 Site is marked
3 Anesthetic concerns
4 Allergies
5 Anticipated blood loss greater than 500cc
Checklist/Timout prior to skin incision
1 Confirm all team members know each other
2 Confirm patient name, procedure, side
3 Antibiotics
4 Anticipated critical events
5 Anesthetic concerns
6 Nursing concerns
7 Imaging available
Prior to leaving OR
1 Name of procedure (nursing)
2 Confirm counts are correct (nursing)
3 Specimens labelled (nursing)
4 Surgeon/anesthetic concerns in post operative management

107
Q

nerve damage classification

A

Neurapraxia = Axon intact, myelin damage, endoneurium intact (compression, nerve dysfunction because myelin is disrupted, but all components intact, will re-gain function)
Axonotemesis = Axon and myelin damage, anything except the epineurium may be disrupted
Neurotemesis = Axon and myelin and everything up to and including the epineurium is disrupted

108
Q

Medical errors schpeel

A

I will disclose the error to the patient including the impact of that error on their medical treatment and disclose our
plan to prevent future errors from occurring. I will apologize to the patient and using non-judgemental speech
listen to their concerns and answer any questions they may have.
I will provide appropriate practical and emotional support and document the disclosure.

109
Q

steps for management of IPV

What to say for IPV

A

1 I will validate their feelings (not her fault), unfortunately this is very common
a Ensure this is conversation is confidential
2 Thoroughly document the complaints
a Clinical photographs where applicable
3 Find out if other’s are at risk
a Children
b Elderly
4 Offer support through hospital
a Social services
b Shelter
c Exit plan
d Toll free numbers
e Counselling
f Support groups
g Legal services
4 Work together to document a plan with regards to the orthopedic injury and the social issues, and obtain a
follow-up.

110
Q

Canmeds

A

Medical expert, communicator, professional, collaborator, leader, health advocate, scholar

111
Q

ATLS Peds
- keys differences in peds

A
  • activate ATLS protocol
  • assemble trauma team
  • primary survey and team members start monitors, oxigen, vitals, IV lins, trauma blood and cross match and c spine immobilized
  • airway
  • breathing
  • circulaton
  • IV access intra osseus in prox tibia under 6 yo
  • fluid resus - 20ml/kg RL x 3 boluses

Key Differences in Peds:
* Higher incidence of multi-organ injury
* High BSA to volume ratio - Increased Risk of hypothermia
* Transport : Large head - Boost trunk/occiput cutout spine board  want to avoid passive c-spine flexion
* appropriate sized equipment
* ETT = (age/4) + 4, Chest tube = ETT X 4
* Systolic BP = 80 + 2 X age; Diastolic BP = 2/3 systolic
* Hypotension = 45% loss of blood and occurs precipitously
* R/O child abuse: subdural, retinal hemorrhage, genital trauma, injuries of different ages, burns, posterior rib fracture, bucket handle/corner fractures
* Ask about helmet for bike trauma
* Airway: smaller midface, larger tongue, anterior larynx, short trachea

112
Q

growth plate zones and assoc conditions

A

reserve
proliferative
hypertrophic zone
zone of provision calcification

Reserve zone
- Pathology: Gauchers, Diastrophic dysplasia, Kniest dysplasia, pseudochondroplasia
Proliferative zone
- Pathology: Achondroplasia, SED, Gigantism, MHE
Hypertrophic zone:
Path: SCFE, Rickets, Enchondroma, Mucopolysaccharide, SED, MED, Schmids, Kneist
Fractures through zone of provisional calcification (SH1)
Path: Metaphyseal corner injuries, Scurvy
Secondary spongiosa = metaphysis
Path: Renal SCFE

113
Q

peds infection
- common organisms
- Rf septic arthritis
- poor prognosis
- criteria
- complications

A

Common organisms:
- Neonates: GBS, s. aureus, gram –ve, Kingella
* < 4: S. aureus, s. pneumo, H. influenza, Kingella (hold cultures longer)
* > 4: aureus
* Septic shock – MRSA, MSSA
* Shoe puncture – pseudomonas, s.aureus
* Sickle cell – s aureus/salmonella
* Neisseria – Sexually active/abused (culture mucous membranes), neonate with affected mother, grown on chocolate agar, multiple joints
* Treated with non-op – Ceftriaxone (only I+D if hip joint involved)

RF = premature, c-section, intra-articular metaphysis (Hip, shoulder, elbow, ankle)
Poor prognosis: Age < 6 months, associated OM, hip joint, delay >4 days

ddx hip pain
* Transient synovitis
* Septic arthritis
* OM
* Dysplasia
* SCFE
* Perthes
* MED
* Psoas abscess (can spread to joint via psoas bursa in 15%)
* Discitis
* Malignancy

Kocher Criteria (for septic arthritis of the hip):
* Non–weight-bearing on the affected limb
* Fever > 38.5°C (101.3°F)
* ESR ≥ 40 mm/hr
* WBC ≥ 12,000 /μL

Cx = Early arthritis, AVN, coxa magna, dysplasia, LLD, contracture

114
Q

U/E deformities
- club hand/radial longtidunal deficiency; definition and associated, test
- congenital deficiency of ulna + ulnar sided structures definition: associated test
- congenital radial head D/L: deformity and assoc

Constrictive ring syndrome
- what is it
- - assoc

A

club hand/radial longtidunal deficiency;
- What: Failure of formation of radial forearm, wrist, hand
Thumb + index hypoplasia/absence (80%)
- Bilateral in 50%
- Associated: TAR (thrombocytopenia + absent radius – thumb usually present + have severe genu varum), Fanconi anemia, Holt-Oram (CHD), VACTERL, VATER
- test: CBC, renal U/S, echo - most importants

congenital deficiency of ulna + ulnar sided structures
- What: congenital deficiency of ulna + ulnar sided structures
- Associated: Syndactyly, PFFD, fibular hemimelia, radial head dislocation, elbow instability, synostosis, scoliosis, thumb duplication/hypoplasia

congenital radial head D/L
- usually posterior with bowing and shortening of radius
- assoc: Silvers/Steel, Marfans, achondroplasia, MHE, Ehlers Danlos, Larsen, Ulnar longitudinal deficiency, Downs, Klippel-Feil, arthrogryposis

constrictive ring syndrome
What: Loose fibrous bands of ruptured amnion adhere to and entangle structures of fetus – 90% distal to wrist
Not hereditary – central digits more commonly affected – bands perpendicular to long axis of limb
Associated with: club foot, syndactyly, cleft palate, cardiac defect, encephalocele, craniofacial defect

115
Q

congenital thumb hypoplasia
- assoc
- classification
- tests

A
  • assoc with :Associated: VACTERL, Holt-Oram (CHD), TAR, Fanconi – most important
  • Classification – Blauth: depends on CMC joint stability
    Type 1 – Minor hypoplasia
    Type 2 – all osseous structures present, MCP UCL instability, thenar hypoplasia
    Type 3A – musculotendinous and osseous deficient, CMC intact
    Type 3B - musculotendinous and osseous deficient, deficient CMC
    Type 4 – Floating thumb – only attached via skin and NV
    Type 5 – complete absence
  • echo, kidney u/s abdo u/s

O/E: Hypoplasia of thenar, Pollex abductus (FPL inserts onto extensor tendon), absence of skin creases, 1st web space tightness, UCL laxity = excessive MCP abduction, absent MCP/IP joint
Tx:
- Observe: Type1 – does not require augmentation of thenar musculature for thumb abduction
- Oppenensplasty – for type 1 with deficient thumb abduction (opposition tendon transfer)
- Use FDS or abductor digit minmi
- Release of 1st web space (Z-plasty), opposition transfer, stabilize MCP (fusion, reconstruct UCL with FDS) = Type 2 + 3A
- Pollicization = Type 3B, 4, 5 (turn index finger into thumb)
* Local skin flaps to reconstitute webspace
* Isolate index finger on NV bundle -> reduce new digit and stabilize
* Tendon transfers (EDC -> APL, EIP -> EPL

116
Q

perinatal brachial plexus injury
- RF
- assoc deformities
- prognostic factors
- classification/groups
- treatment

A

RF
- - Multiparous, Macrosomia >4-5kg (14x), vertex/breech, shoulder dystocia (100x), difficult labor/forceps (9x), DM, wt gain >20kg (most have no RF)
**assoc: **
- Glenohumeral dysplasia (70%) - due to internal rotation contracture - features glenoid retroversion, humeral head flattening, posterior subluxation

  • Good prognosis: Erbs palsy, Biceps + deltoid anti-gravity power by 2-3 months, early twitch biceps recovery (if > 5 months then likely incomplete recovery
  • Poor prognosis: Lack of biceps by 3 months, preganglionic injury (avulsion off cord – loss of rhomboid function – dorsal scapular nerve + elevated hemidiaphragm –phrenic nerve, Horners, C7 involved, Klumpke palsy

Classification:
- Group 1: Duchenne-Erbs palsy – C5-6 (45-60%) – upper lesion – best prognosis + Most common
Lateral flexion of head toward contrateral side and ipsilateral depression of shoulder
C5-C6 deficient – Axillary nerve, suprascapular, musculocutaneous, radial nerve
Paralysis of deltoid + biceps – intact wrist/finger extension and flexion = Adducted/IR shoulder, pronated forearm, extended elbow, slight wrist flexion -> deceased shoulder ER -> shoulder subluxes posterior – hand is normal
- Group 2: Intermediate paralysis (30%) – C5-7 – Paralysis of deltoid, biceps, wrist extension, digit extension – intact wrist/digit flexion
- Group 3: Total brachial plexus palsy (20%) – C5-T1 – Flail extremity (No Horners) – no motor or sensory
- Group 4: Total brachial plexus palsy + Horners – Roots C5-T1 – Flail extremity
- Klumpke = < 2% = lower lesion = poor prognosis – C8-T1 (ulnar/median)

Treatment
- Neurotization (neuroma resection) + sural nerve cable graft = postganglionic vs. Nerve transfer = pre-ganglionic injury or root avulsion injury (donate intercostals, spinal accessory nerves) – done at 3-12 months

  • Contractures – often multi-level – work proximal to distal
    IR contracture = 40% = due to large muscles for IR overpower ER  PT > night splint > botox initially
    Done at age 4 = soft tissue = Subscap release + lat dorsi transfer
    Bony procedure = done > age 5 = ER osteotomy of humerus +/- glenoid osteotomy
  • Elbow Flexion contracture = Serial casting and nighttime splinting OR surfical release of anterior capsule + biceps lengthening + night time splinting
    Transfer pec, triceps, steindlers flexorplasty
  • Forearm rotation = supination is worse deformity – rotational osteotomy or re-route biceps around radial head to make it function as pronator
  • Wrist drop = Pronator teres to ECRB, loss of finger extension = FCR to EDC

000. STICK WITH IT (34 decks)

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