Trauma Flashcards
Cierney and Mader classification of host in osteomyelitis
A Healthy B Host (diabetes, smoking, chronic disease) B Local (prior surgery, vascular dz, prior trauma, scarring, etc) B combined C Host (multiple uncorrectable diseases, treatment of infection would be worse than infection itself, can’t tolerate surgery.
Indications for acute amputation
Severe soft tissue injury (#1 from LEAP study) Non viable limb Ischemia time >8hrs Irreparable vascular injury Severe crush with minimal viable tissue Loss of plantar sensation is a myth. In LEAP, normal foot sensation at follow up was equal in patients with salvaged leg whether they had numb foot or normal sensation at time of injury.
Structures at risk inserting supraacetabular ex fix pins (2)
LFCN Hip capsule (inserts 16-20mm above acetabulum
Fluoro views needed for supraacetabular exfix pins insertion.
Find corridor on obturator oblique outlet. Verify trajectory, length and away from hip/sciatic notch on iliac oblique inlet. Verify intraosseous path (between inner and outer tables) with obturator oblique inlet view.
Risk factors for dysparuneia in women after pelvic ring injury.
Injury to symphysis present of symphyseal plating Final displacement of symphysis >5mm Hx of bladder rupture at time of injury
In patients with combined pelvic ring and acetabular fractures, which two patterns of acetab fracture are rare, and which two are most common?
Posterior wall and posterior column: very rare in combined setting Transverse and ABC most common in setting of combined ring/acetab fractures.
Regarding angioembolization in setting of acetabular fractures…
Higher rate of wound complications and infection when embolization is performed.
MESS score components?
Skeletal / soft-tissue injury:
Low energy (stab; simple fracture; pistol gunshot wound): 1
Medium energy (open or multiple fractures, dislocation): 2
High energy (high speed MVA or rifle GSW): 3
Very high energy (high speed trauma + gross contamination): 4
Limb ischemia:
Pulse reduced or absent but perfusion normal: 1* Pulseless; paresthesias, diminished capillary refill: 2 Cool, paralyzed, insensate, numb: 3*
Shock: Systolic BP always > 90 mm Hg: 0 Hypotensive transiently: 1
Persistent hypotension: 2
Age (years):
<30: 0
30-50: 1
50: 2
Start point for SI screw
2 cm superior and 2 cm posterior to greater sciatic notch
6 features of sacral dysmorphism
High sacral body (in line with iliac crests)
Mammillary bodies (underdeveloped TPs)
Enlarged, asymmetrical sacral foramina
Tongue-in-groove SI joint on axial CT
Sacral disk visible
Anterior alar indentation seen on inlet view
Indications for lumbopelvic fixation in sacral fracture (Triangular osteosynthesis)
Severely comminuted vertical fracture
Osteoporotic bone
L5-S1 facet joint disrupted
Algorithm for sorting out acetab fracture pattern:
Iliopectineal disrupted? AC or AW
Ilioischial disrupted? PC or PC/PW
Both lines disrupted? Look at obturator foramen.
Foramen intact? Transverse or transverse/PW
Foramen disrupted? Look at iliac wing.
Wing intact? T-type
Wing disrupted? ABC or ACPHT
Ilioinguinal approach, what are the three windows
Lateral window: lat to iliopsoas
Middle: between iliopsoas and ext iliac a/v
Medial: medial to ext iliac a/v
Danger while doing superficial dissection of ilioinguinal approach?
Ilioinguinal nerve (pierces the abdominal wall coming from deep to superficial. Lies just proximal to the inguinal ligament)
Describe ilioinguinal approach
Skin incision along inferior aspect of crest, heading medially to end about 2cm above the symphysis.
Lateral window first: Leave cuff of tissue on crest. Incise external oblique aponeurosis down to the ASIS. Elevate iliacus off inner table. Pack. Can go back to SI joint PRN.
For middle/medial windows: Continue to incise external oblique aponeurosis inline with skin incision (will be about 1cm prox to inguinal ligament). This “unroofs” the inguinal canal. Watch out for ilioinguinal nerve going along with spermatic cord/round ligament.
Next layer is to incise along inguinal ligament and elevate the conjoined tendon of transversalis/internal oblique. Leave 1-2 mm of inguinal ligament attached for closure later on. Be careful of LFCN just medial to ASIS in this layer.
Can pack sponge behind bladder. May need to release conjoined tendon off pubic tubercle and incise rectus sheath to get behind bladder.
Now to develop lacuna musculorum (iliopsoas and femoral nerve) and lacuna vasorum (femoral vessels). Iliopectineal fascia in between these bundles. Clear stuff off the fascia. Release fascia from its attachment on the inguinal ligament and divide it off the pelvic brim. Now can develop windows to see PRN.
Closure: Close rectus sheath PRN. Close conjoined tendon of transversalis/internal oblique to the inguinal ligament. Close ext oblique aponeurosis back to crest. Close skin
Indications for tibial plateau ORIF
>3mm step
Varus/valgus instability
>5mm condylar widening
any medial condyle
any bicondylar
Acceptable criteria for closed tx of tibial shaft
5 varus valgus
10 flex/ext
>50% cortical contact
<1cm short
<10deg rotation
Adjuncts for nailing proximal third tibial fractures
More lateral start point (reduces valgus)
Posterior and lateral blocking screws
Semiextended position (reduces deforming force of extensor mechanism)
Lateral parapatellar approach
unicortical plating
Universal distractor
**Recall typical deformity is valgus and procurvatum
Name three types of posterior malleolus fractures
- Posterolateral oblique
- Transverse medial extension
- small-shell avulsion
