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
What percentage of syndesmotic stability is contributed by the PITFL?
42%
JAAOS 2013 Irwin
(post mall fractures)
Name three types of posterior malleolus fractures
- Posterolateral oblique
- Transverse medial extension
- small-shell avulsion
ORIF of posterior mall vs syndesmotic screws? Which is more stable?
ORIF posterior mall restored 70% of syndesmotic stiffness vs 40% with syndesmotic screws
(from cadaveric biomech study)
2013 JAAOS posterior mall #s
Xray criteria for syndesmotic reduction
Tibfib overlap 6mm on AP and 1mm on mortise (1cm above plafond)
Tibfib clear space of at least 5-6mm on both AP & mortise (1cm above plafond)
Medial clear space of 4mm or less on mortise
On lateral, anterior border of fibular should cross 50% of tibial physeal scar. (Must be perfect lateral)
Describe Lauge-Hansen classification
SAD supination adduction
- ATFL or fib avusion
- Vertical medial mall
SER supination ER
- ATFL
- Fibular # at joint (antinf to postsup)
- PITFL/post mall
- Medial mall
PAB pronation abduction
- Deltoid/medial mall
- ATFL
- Comminuted fibula transverse # above joint
PER
- Deltoid/medial mall
- ATFL
- Short oblique or spiral fibula above joint
- PITFL or posterior mall
Operative treatment of displaced midshaft clavicle fractures results in:
Better constant and DASH scores
Lower time to union (16 wks vs 28 wks with nonop)
Lower incidence of symptomatic malunion and nonunion
Better patient satisfaction with outcome/appearance
COTS 2007 jbjs
Acceptable reduction criteria for humeral shaft?
<20 anterior angulation
<30 varus/valgus
<3cm short
Variable associated with late subtalar fusions after calc #
Male WSIB patients
Heavy labour types
Those who had Bohler’s <0
Benefits of TEA after distal humerus fracture in elderly
Better functional outcomes
Shorter OR time
Lower reoperation rate
Bottom line from BESTT trial?
(1.5mg/ML dose of BMP2)
Fewer reoperations and faster healing in all patients.
Lower infection rate in Gustillo III fractures.
Take home message from SPRINT trial?
Reamed nails in closed fracture had less reoperation and auto-dynamization (in 1 year) compared to unreamed in closed fractures.
Open fractures: Reamed = unreamed.
Increased metabolic demands (% over baseline) for various levels of amputation?
BKA
25% trauma
40% vascular
AKA
70% trauma
100% vascular
Bilateral?
BKA/BKA: 40%
BKA/AKA? 120%
AKA/AKA? >200%
RFs for femoral nonunion
Non anatomic reduction
High pauwel angle
Degree of initial displacement
Posterior comminution
TAD >25mm
Smoking
High BMI
Postoperative predictors of poor outcome in acetabular fractures
Non anatomic reduction
Anterior hip dislocation
Posterior wall involvement
Marginal impaction
Damage to femoral head
Incongruent WB dome
Age >40
Use of Iliofemoral approach
Who should be treated with DCO?
ISS>40
ISS>20 with thoracic trauma
Multiple trauma, abdo/pelvis with hypotension
Lung contusions
Bilat. femur fractures
Temp <35
Head injured with AIS <3
Abx for barnyard injury?
Automatic gustillo 3!
Ancef/Gent/Pencillin
or
Clinda/Gent/Flagyl if pen allergic
Abx for freshwater injury and organism of concern?
Vibrios, aeromonas, pseudomonas
Cipro (or any fluoroquinolone)
and/or
Ceftazidime
Abx for salt water injury (and organism of concern)
Vibrio, aeromonas
Give Cipro
(or ceftaz)
Where is the PUDA
Usually 5cm distal to the olecranon tip. Average angle of 6 degrees.
Jupiter modification of Bado 2 (posterior monteggia)
2A: ulna fracture involved greater sigmoid notch
2B: involved metaphysis distal to coronoid
2C: more distal into shaft
2D: comminuted ulnar fracture
(All are associated with posterior dislocation of radial head +/- radial head #)
Options for olecranon bone loss or super comminution?
Excision and triceps advancement (classically say up to 50% of olecranon can be removed without affecting stability of elbow. Must attached triceps dorsally on ulna.
If dorsal cortext out to length, can smooth out articular side - will fill in w/ fibrocartilage.
Interpose block of IGBG. Fix with antegrade K wires and multiple tension bands.
Can use tip of ipsilateral olecranon for autografting a new coronoid.
Nonunion rate of closed treatment of humeral shaft
<2% as per Sarmiento et al
Three factors correlated to failure of nonop mgmt of AC joint injuries
Age >40
Higher grade of injury
WSIB claim
Indications for operative mgmt of scapular fractures (from AAOS ICL 2015)
Glenoid articular step 4mm or more
Medialization of 20mm or more
Angulation 45degrees or more (on Y view)
Glenopolar angle of less than 22 deg
2 factors leading to poorer outcomes in clavicle fractures
Associated rib fractures
Scapular winging
What is the NNT (surgery) to prevent nonunion in clavicle ORIF?
What is the NNT to prevent symptomatic malunion?
7.6
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