Trauma Flashcards
How does the Sickness Impact Profile relate to lower extremity injuries?
The psychosocial subset does not improve with time.
In regards to the Sickness Impact Profile, women score lower on these things at a 10 year follow up.
decreased quality-of-life scores
increased PTSD rates
increased absentee sick days when compared to males
What are the variables of the SIRS criteria?
heart rate > 90 beats/min,
WBC count <4000cells/mm³ OR >12,000 cells/mm³,
respiratory rate > 20 or PaCO2 < 32mm (4.3kPa),
temperature less than 36 degrees or greater than 38 degrees
What is the cause of death in the first minutes of injury?
50% die from massive blood loss or neurologic injury
What is the cause of death within hours of arrival to the hospital after injury?
most commonly from shock, hypoxia, or neurologic injury
What is the cause of death days to weeks following injury?
multi system organ failure and infection are leading causes
Use of an airbag in a head-on collision significantly decreases the rate of what?
closed head injuries
facial fractures
thoracoabdominal injuries
need for extraction
What is the incidence of PTSD after traumatic event involving orthopedic injuries?
50%; women are 4x more likely to develop PTSD
What is the incidence of depression after traumatic event involving orthopedic injuries?
33%
What is class I hemorrhagic shock?
<15% of EBL; HR, BP, pH, are normal; UOP >30ml/hr
What is class II hemorrhagic shock?
15-30% EBL; HR 100-120 bpm, UOP 20-30 ml/hr; BP and RR are normal
What is class III hemorrhagic shock?
30-40% EBL; HR >120 bpm, BP decreased, UOP 5-15 ml/hr; pH decreased; treat with blood and fluids
What is class IV hemorrhagic shock?
> 40% EBL; HR >140 bpm; UOP negligible, pH decreased; BP decreased; treat with blood and fluids
What is the estimated circulating blood volume in an average adult?
average adult (70 kg male) has an estimated 4.7 - 5 L of circulating blood
What is the estimated circulating blood volume in an average child?
average child (2-10 years old) has an estimated 75 - 80 ml/kg of circulating blood
What are the parameters for moving forward with early appropriate care?
lactate of < 4.0 mmol/L,
pH ≥ 7.25,
base excess ≥ -5.5 mmol/L
What antibiotic is used in grade I and II Gustilo open fractures?
1st gen cephalosporin (eg cefazolin)
When is penicillin added to open fractures?
Farm injury
What antibiotics are used in Grade III open injuries?
1st gen cephalosporin (Gm+ coverage) + aminoglycoside (eg gentamicin) (Gm- coverage)
What antibiotic is used for open fresh water wounds/salt water wounds?
Fluoroquinolones (ciprofloxacin); Doxycycline and 3rd or 4th-generation cephalosporin (e.g. ceftazidime) can be used for salt water wounds
What are the risk factors for elder abuse?
increasing age,
functional disability,
child abuse within the regional population,
cognitive impairment,
gender is NOT a risk factor
An ISS of what should be treated with DCO?
ISS >40 without thoracic injury; ISS >20 with thoracic trauma
Which three patient-factors increase the mortality associated with geriatric fractures?
Increased ISS
Need for mechanical ventilation at admission
Head injury
What are the three main benefits of performing an adductor myodesis during an AKA?
improves clinical outcomes,
creates dynamic muscle balance (otherwise have unopposed abductors),
provides soft tissue envelope that enhances prosthetic fitting
What is the most sensitive exam finding for compartment syndrome?
Pain with passive stretch; most sensitive prior to onset of ischemia
What are the five most common locations of septic arthritis in descending order?
Knee (>50% of cases) > hip > shoulder > elbow > ankle
What are 4 risk factors for gram-negative bacillus septic arthritis?
neonates
IV drug users
elderly
immunocompromised patients with diabetes
What is the most common organism in septic olecranon bursitis?
Staphylococcus aureus (S. aureus), gram positive cocci in pairs and clusters.
What deformity occurs in a Chopart amputation and how is this prevented?
Equinovarus; prevented with transfer of tib ant to talar neck and perform achilles tendon lengthening.
What are the common flexors in the forearm? And where do they originate?
Pronator teres, Palmaris longus, FCR, FDS, FDP; medial epicondyle
What are the common extensors of the forearm and where do they originate?
Aconeus, EDC, ECRL ECRB, EDM, ECU; lateral epicondyle
Where does the anterior bundle of the medial (ulnar) collateral ligament originate and insert?
Originates from the distal medial epicondyle and inserts on the sublime tubercle
What is the primary function of the medial collateral ligament of the elbow?
Primary restraint to valgus stress from 30-120 degrees
When is the medial collateral ligament of the elbow tight? Pronation or supination?
Pronation
Where does the lateral collateral ligament of the elbow originate and insert?
originates from distal lateral epicondyle and
inserts on crista supinatorus
What is the primary function of the lateral collateral ligament of the elbow?
stabilizer against posterolateral rotational instability
When is the lateral collateral ligament of the forearm tight? Pronation or supination?
Supination
How far proximal from the triceps aponeurosis can the radial nerve be found?
3.9 cm (2 FBs)
How far proximal from the elbow articular surface is the radial nerve found?
15 cm can be found in the spiral groove
When does the radial nerve branch into the PIN and superficial radial nerve?
At the level of the radial head
Just proximal to the elbow, the radial nerve can be found running between what two muscles?
Brachioradialis and brachialis
In the setting of a distal humerus fracture in an adult, when is an olecranon osteotomy contraindicated?
If the patient needs a total elbow arthroplasty (distal bicolumnar elderly patient)
What nerve complication can occur with an olecranon osteotomy?
AIN palsy, check FPL in recovery
What are the indications for a total elbow arthroplasty in the setting of distal humerus fractures?
communited articular fractures in osteoporotic bone
inflammatory conditions (e.g. RA)
When performing a hemiarthroplasty for a proximal humerus fracture, how far below the articular surface do you place the greater tuberosity?
8 mm (head to tuberosity distance = HTD)
Nonanatomic placement of the tuberosities in a shoulder hemiarthroplasty results in what impairment?
nonanatomic placement of tuberosities results in impairment in external rotation kinematics with an 8-fold increase in torque requirements
When performing a shoulder hemiarthoplasty for a proximal humerus fracture, the height of the prosthesis is best determined by what?
The superior edge of the pec major tendon; 5.6cm between top of humeral head and superior edge of tendon
Why is repair of the greater tuberosity recommended when performing a RSA?
It improves shoulder ROM
What is the most common complication following periarticular locking plating fixation for a proximal humerus fracture?
Screw cut out (up to 14%)
What surgical approach increases the risk of axillary nerve injury in surgical fixation of proximal humerus fractures?
Anterolateral (deltoid-split) approach
How far below the acromion is the axillary nerve found?
axillary nerve is usually found ~5-7cm distal to the tip of the acromion
Weakness in what exam testing is found when a patient has a lesser tuberosity nonunion?
lesser tuberosity nonunion leads to weakness with lift-off testing
What are the greatest risk factors for proximal humerus fracture nonunions?
Smoking and age
What nerve innervates Latissimus dorsi?
Thoracodorsal nerve
What position is the upper extremity in when a radial head fracture occurs?
FOOSH - arm extended and in pronation (allows more force to be transmitted through the radius)
What is the most common ligamentous injury in a radial head fracture?
Lateral collateral ligament injury
What are the characteristics of an Essex-Lopresti injury?
Radial head fracture, IOM injury, DRUJ injury
What part of the radial head lacks subchondral bone?
The anterolateral 1/3 lacks subchondral bone (makes it an easily fractured area)
What percent of load transfer across the elbow occurs through the radiocapitellar joint?
60%
Where does the lateral ulnar collateral ligament attach insert?
Supinator crest on the ulna
What is the primary stabilizer to valgus stress of the elbow?
medial (ulnar) collateral ligament, specifically the anterior bundle; radial head is the second
What are contraindications to radial head excision?
presence of destabilizing injuries:
forearm interosseous ligament injury (>3mm translation with radius pull test),
coronoid fracture,
MCL deficiency
What is the interval for the Kocher approach to the elbow?
ECU (PIN) and anconeus (radial n)
When performing the Kocher approach to the elbow, you want to incise the capsule where? And why?
incise capsule in mid-radiocapitellar plane;
anterior to crista supinatoris to avoid damaging LUCL
What position should the forearm be in when performing the Kaplan or Kocher approach to the elbow to protect PIN?
in both Kocher and Kaplan approaches, the forearm should be pronated to protect PIN
What is the interval for a Kaplan approach to the elbow?
EDC (PIN) and ECRB (radial n)
When plating for radial head/neck fractures, what is the distal extent for plate placement?
bicipital tuberosity is the distal limit of plate placement; anything distal to that will endanger PIN
What are risk factors for humeral shaft nonunion?
vitamin D deficiency (most common), open fractures, segmental injuries, smoking and obesity
In patients with scapular fractures, what other fracture is MOST commonly observed?
Rib fractures are the most commonly observed fractures associated with scapular fractures.
What are the risk factors for mid-shaft clavicle fracture nonunions?
shortening (<2cm), comminution (z-deformity), female gender, advancing age, smoking
What are the complications of non-operative management of midshaft clavicle nonunions?
nonunion (10-15%), malunion, deformity/poor cosmoses, decreased shoulder strength and endurance
What is the posterior approach to the scapula? And what is the inter-nervous plane?
Surgical fixation of a scapular neck fracture is performed via the Judet approach, a posterior approach to the scapula/glenoid. The internervous plane is between the infraspinatus (suprascapular nerve) and the teres minor (axillary nerve).
What is the criteria for nonoperative (conservative) treatment of humeral shaft fractures?
<20 deg of angulation on AP, <30 deg varus/valgus angulation, and <3 cm of shortening
What are the LaFontaine Criteria?
radial shortening (most predictive of instability, followed by dorsal comminution),
severe osteoporosis,
associated ulnar fracture,
dorsal comminution,
dorsal angulation > 20°,
initial displacement > 1cm
initial radial shortening > 5mm
Of the LaFontaine criteria, what is the most predictive of instability?
Radial shortening < 5 mm (followed by dorsal comminution)
How any LaFontaine criteria need to be met in order to predict loss of reduction?
3
The superior border of the pectoralis major tendon can be used to determine accurate restoration of what when performing an arthroplasty for a proximal humerus fracture?
the superior border of the pectoralis major insertion (PMI) has been shown to be the most reliable instrument to assess humeral prosthesis height and retroversion
How far below the superior border of the humeral head does the pectoralis major tendon insert?
pectoralis major tendon inserts 5.6 cm distal to the superior aspect of the humeral head
In patients over 60 years of age with a proximal humerus fracture, what is the most common complication of ORIF of the proximal humerus fracture?
Screw cut out/penetration
In fixation of proximal humerus fracture with plates and screws, a neck shaft angle of what predicts failure?
varus malreduction (head-shaft angle<120 degrees); Agudelo et al retrospectively reviewed 153 patients at a level-one trauma center treated with proximal humerus locking plates, investigating modes of failure for the implant. They determined that varus malreduction (head-shaft angle<120 degrees) was the most common mode of failure in their group.
What are the absolute indications for operative management of humeral shaft fractures?
Absolute indications of operative management include open fracture with severe soft tissue injury, vascular injury requiring repair, and a coexisting brachial plexus injury.
What is the treatment for post-traumatic elbow stiffness?
Supervised exercise therapy with static or dynamic progressive elbow splinting over a 6 month period has shown to have the greatest improvement on DASH scores and functional range of motion (ROM) in patients with post-traumatic elbow stiffness. Treatment is usually maintained over a period of 6-12 months. Surgery is considered when nonoperative therapy fails.
What nerve is at risk when placing the AP distal interlocking screw for humeral nailing? The lateral to medial?
The musculocutaneous nerve is at risk with anterior to posterior distal locking screw placement. The radial nerve is at risk with lateral to medial screw placement.
What is the main blood supply to the humeral head?
Recent evidence has demonstrated that the posterior humeral circumflex artery is likely the main blood supply to the humeral head
What are the predictors of fracture-induced humeral head ischemia
Hertel et al. reported that the highest predictors of humeral head ischemia, from most accurate to least accurate, were calcar length <8mm, disruption of the medial hinge, fracture pattern, displacement of the humeral head >45 degrees, displacement of the tuberosities >10 mm, glenohumeral fracture-dislocation and head-split fractures. They concluded that the most relevant predictors of ischemia were the length of the posteromedial calcar, the integrity of the medial hinge, and the basic fracture type.
What is a Monteggia fracture
proximal third ulna fracture with associated radial head dislocation
What is a Bado I Monteggia fracture?
Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (most common in children and young adults)
What is a Bado II Monteggia fracture?
Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)
What is the most common nerve injury in a Monteggia fracture?
PIN
What is a Galeazzi fracture?
Distal third radial shaft fracture with associated DRUJ injury.
What is the incidence of DRUJ instability in in radial shaft fractures?
55% if radius fracture is <7.5 cm from articular surface; 6% if radius fracture is >7.5 cm from articular surface.
What are the primary stabilizing ligaments of the DRUJ?
Volar and Dorsal radioulnar ligaments
What position is the DRUJ most stable?
Supination
What are the radiographic signs of DRUJ instability?
ulnar styloid fx, widening of joint on AP view, dorsal or volar displacement on lateral view, Radial shortening >5 mm
In what position, and for how long, should the wrist/forearm be splint for treatment of the DRUJ?
Wrist/forearm in supination; immobilized for 6 weeks.
If closed reduction of the DRUJ is blocked, what interposition should be suspected?
interposition of the ECU tendon
How do you prevent refracture after fixation of a Galeazzi fracture?
Do not remove plate before 18 months; 4.5 mm plates increase risk of refracture (use smaller plate); comminuted fractures increase risk
What is the incidence of sacral fractures in pelvic ring injuries?
30-45%
What is the rate of neurologic injury in sacral fractures?
25%
What sacral nerve roots carry a higher rate of injury in sacral fractures?
S1 and S2
What Denis classification of sacral fractures has the highest incidence of nerve injury?
Zone 3 (medial to sacral foramina into the spinal canal); 60% rate of nerve injury; bowel/bladder/sexual dysfunction;
What is the most common fracture classifcation/pattern of sacral fractures?
Denis I - 50%
What nerve is most commonly injured in Denis I sacral fractures?
Nerve injury is rare, but if it occurs, it is most commonly L5 nerve root
What fixation technique is shown to have the greatest stiffness for when used for unstable sacral fractures?
Iliosacral and lumbopelvic fixation - pedicle screw fixation in lumbar spine,
iliac screws parallel to the inclination angle of outer table of ilium, longitudinal and transverse rods
What are the iatrogenic causes of nerve injury in percutaneous sacral fixation for sacral fractures?
Over-compression, Mal-placement of implants
What is the dose of Vitamin C given for CRPS?
500 mg for 50 days
What is the most common mode of failure of the lateral ulnar collateral ligament associated with an elbow dislocation?
The lateral ulnar collateral ligament (LUCL) is often injured with elbow dislocations, and is most commonly injured at the proximal origin.
How long should a simple elbow dislocation be immobilized?
Less than 2 weeks; anything beyond 2 weeks portends greater stiffness
Anteromedial coronoid facet fractures risks what type of instability?
Varus posteromedial rotatory instability
What is primary bone healing?
direct healing by internal remodeling; intramembranous ossification
What ligament is a key stabilizer of the DRUJ and tested with the “shuck test” ?
Radioulnar ligaments of the TFCC
What is the essential lesion that results in the most instability in a terrible triad injury of the elbow?
lateral collateral ligament. Repair of this lesion results in the greatest increase in elbow rotatory stability.
What is the in-hospital mortality rate of geriatric femoral neck fractures?
6%
What is a Segond sign?
Lateral tibial plateau avulsion fracture (associated with ACL tear)
What is a Segond sign indicative of?
ACL rupture
Which meniscal tears are more common in tibial plateau fractures overall?
Lateral meniscal tears (associated with Schatzker II, >10 mm depression, >6mm widening)
Medial meniscal tears are most commonly associated with which Schatkzer pattern?
Schatkzer IV
The ACL is most commonly injured in which Schatkzer patterns?
IV and VI
What is the most common malunion deformity in proximal third tibial shaft fractures?
valgus, procurvatum
What are the indications for treating a proximal third tibia shaft fracture non-operatively?
< 5 degrees varus-valgus angulation; < 10 degrees anterior/posterior angulation; > 50% cortical apposition; < 1 cm shortening; < 10 degrees rotational alignment
In subtalar dislocations, medial or lateral dislocations are more likely to be open?
lateral dislocations more likely to be open
With subtalar dislocations, which fractures are associated with a medial subtalar dislocation?
dorsomedial talar head, posterior process of talus, navicular
Which fractures are associated with lateral subtalar dislocations?
cuboid, anterior calcaneus, lateral process of talus, fibula
What is the most important and main blood supply to the talus?
posterior tibial artery via the artery of the tarsal canal. (supplies the majority of the taller body)
The anterior tibial artery supplies what portion of the talus?
The talar head and neck
The perforating perineal arteries supply what portion of the talus?
The talar head and neck via the artery of the tarsal sinus.
What surgical approach is used in medial talus dislocations?
Sinus tarsi approach (lateral based approach), to remove lateral structures blocking reduction
What surgical approach is used in a lateral talus dislocation?
medial based approach between tib ant and posterior tib; removes medial based structures blocking reduction
In talus dislocations, poorer outcomes are associated with which factors?
Lateral dislocations, open fractures, concomitant fractures, high energy mechanisms
What is the malunion deformity seen in mid shaft tibia fractures with an intact fibula?
varus defmority
What is the antibiotic treatment for Grade IIIB open tibia shaft fractures?
cephalosporins + aminoglycoside added in Grade IIIB injuries
What is a normal tib/fib overlap on an AP ankle XR?
> 6 mm; if less than that consider syndesmotic injury
What is a normal tib/fib overlap on a mortise ankle XR?
> 1 mm; if less than that consider syndesmotic injury
In ankle fractures, when does proper braking response time return to baseline?
proper braking response time (driving) returns to baseline at 9 weeks after surgery
What techniques can be used to overcome the malalignment of apex anterior and valgus deformities in proximal third tibia shaft fractures?
- lateral parapatellar approach
- proximal and lateral starting point
- suprapatellar nailing (apex anterior correction only)
- Poller screw in lateral aspect of the proximal segment (concavity of deformity)
- femoral distractor or temporary plating
What is the most common complication following a talar neck fracture?
post-traumatic arthritis; subtalar joint being the most common
In subtalar dislocations, which type (medial or lateral) is more likely to be:
a) common
b) open
c) associated with fracture?
a) common - medial
b) open - lateral
c) associated with fracture - lateral
Which factors lead to an increased risk of complications for unstable ankle fractures?
skin integrity, smoking status, diabetes, peripheral neuropathy; age does not have an effect on complication rate
How long do you maintain nonweightbearing status in patients with operatively fixed diabetic ankle fractures?
maintain nonweightbearing 8-12 weeks post op; instead of 4-8 weeks in normal patients
What are the common deformities seen in malunions of conservatively managed calcaneus fracture?
most common deformities associated with calcaneal fracture malunion are:
-decreased calcaneal height
-increased calcaneal width
-hindfoot varus
-lateral exostosis secondary to lateral wall blow-out
dorsiflexion of the talus resulting in ankle impingement
What are the attachment sites for the bifurcate ligament?
anterior process of the calcaneus and bifurcates to the navicular and cuboid
What ligament is responsible for an avulsion fracture of the anterior process of the calcaneus?
bifurcate ligment
What is the mechanism of injury for an avulsion fracture of the anterior process of the calcaneus?
plantar flexion and inversion
Treating a femoral shaft fracture on a fracture table increases the risk for what deformity?
Internal rotation; fracture table has been shown to induce an internal mal rotation deformity when used to treat femoral shaft fractures.
Is fixation of the fibula in associated tibial plafond fractures associated with higher or lower complication rates?
Higher
When is the most optimal time to repair a nerve transected from a GSW?
1-3 weeks
A sliding hip screw had lower reoperation rates in which patient cohort?
Displaced basicervical femoral neck fractures in current smokers
