Trauma Flashcards
What is the most common tendon ruptured with a fracture treated with volar plating?
FPL
Not EPL.
2 different types of hardware that can be used to fix the fibula when doing pilon ORIF?
- plate/screws
- intramedullary screw or wire
How do you treat a Galeazzi fracture?
- Consider closed treatment if stable after closed reduction
- Usually have to do ORIF radius with pinning of DRUJ. Most common bloack to reduction is interposed ECU.
Repeated visits to ER is a red flag for what?
Domestic abuse
What percentage of the humeral head does the posterior humeral circumflex artery provide?
64%
3 ways to treat HO?
which has evidence supporting it?
NSAIDs (indomethacin)
Bisphosphonates
radiation (700cGy x 1 dose)
None have good evidence
3 indicators HO is mature
Mature, thickened cortex
Distinct separation/demarcation from soft tissue
Presence of a trabecular pattern
*bone scan plays no role now
*Labs (ALP, CRP etc help with diagnosis, but not maturity)
Most important technical step of transfemoral amputation?
Addductor myodesis
Components of TFCC (5)?
central articular disc
meniscal homologue
volar and dorsal radioulnar ligaments
ulnolunate and ulnotriquetral ligament origins
ECU subsheath
It is safer for a proximal A-P locking screw to be proximal or distal to the lesser troch?
Proximal
Ideal length of BKA?
12-15 cm
What is the time cutoff after which you lose the improved outcomes with early repair of miltiligamentous knee injury?
3 weeks
What approach is indicated for open reduction of a) anterior and b) posterior hip dislocations?
Anterior dislocation anterior (Smith-Petersen) approach
Posterior dislocation posterior (Kocher-Langenbeck) approach
What types of plexus injuries does innervation to cervical paraspinal muscles on EMG differentiate between?
Pre and post ganglionic injury (brachial plexus)
What are the only two strong or moderate reccomendations for osteoporotic spinal compression fractures?
Strong recommedation AGAINST vertebraoplasty
(cement without baloon expansion)
Intermediate recommendation FOR 4 weeks of calcitonin if presentation is within 5 days of onset of symptoms
Summarize BMP’s role in tibia fractures
Open tibia fracutres only
Increased union in all open tibia fractures
Decreased infection in grade II open tibias only
(risk of tumour?)
Elderly patient presents 3 days after fall.
Diagnosed with femoral neck fracture.
What is the most relevant non-orthopedic investigation that is required?
Doppler ultrasound
Higher risk of DVT of presentation > 2 days from injury
This was a orthobullets question
Blocks to reduction of lateral subtalar dislocation:
MEDIAL structures
- posterior tibialis tendon
- flexor hallucis longus
- flexor digitorum longus
- Talonavic joint capsule - talar head can buttonhole thru it
- tibial nv bundle
Indications for surgery with a GSW to the lumbar spine include? (3)
1) spinal instability
2) a neurologic deficit is present that correlates with radiographic findings of neurologic compression by the missile.
3) Lead missile is in contact with the cerebrospinal fluid (CSF)
Which pelvic fractures can be treated with WBAT?
APC 1 (no posterior diasthasis)
LC 1 (no crescent fracture)
Four risk factors for AVN in proximal humerus fractures?
- 4 part fracture
- head split
- short calcar segment
- disrupted medial hinge
Mechanism of Bado 1?
Hyperextension
Should you use routine preop traction in elderly patients with hip fracture?
No
JAAOS CPG
What nerve roots are more likely to be injured with sacral fractures?
S2-3 because they occupy a large amount of their foramina comparatively. Injury to S2-S5 will cause impairment of urinary/anal and sexual systems.
Is the saline load test sensitive for traumatic knee arthrotomies?
Unacceptable low sensitivity, even with addition of methylene blue.
Name 5 risk factors for HO (all scenarios)
TBI (worse with decubitus ulcers)
SCI (worse with decubitus ulcers)
Amputation through a zone of injury (worse with blast mechanism)
High ISS
THA
- psoas tenotomy
- cementless
- Smith-pete
TKA
- Anterior femoral notching
- quad trauma
- MUA post-op
Antegrade femoral nail (piriformis start worse)
Distal femoral traction pins (rare)
What do you have to order in addition to standard things when someone has a delayed presentation for hip fracture?
Duplex doppler of bilateral lower extremities
Most common complication of elbow ORIF?
Elbow stiffness
post-discharge hip fracture in elderly, what should you prescribe (or at least set up) for patients (3)
PT: strong evidence for intensive PT
Interdisciplinary care for mild-mod dementia: strong evidence
Multimodal analgesia: strong evidence
Nutritional supplementation/dietetics consult: moderate evidence
Calcium/Vit D: moderate evidence
Osteoporosis evaluation and treatment: moderate
What is needed to consider a SYme?
Post. Tib Pulse and a stable heel pad
What are the benefits of fixing femur fractures within 24 hours?
decreased pulmonary complications (ARDS)
decreased thromboembolic events improved rehabilitation
decreased length of stay and cost of hospitalization
What is the Jean mart method?
Using the angle between a line drawn tangential to the femoral condyles and a line drawn through the axis of the femoral neck to determine if there is rotational malalignment after fixation of a femur
How do you splint/cast medial or lateral epicondyle elbow fractures?
Medial in pronation, Lateral in supination
**** Thumb towards the injury.
Indications for glenoid fixation (fracture characteristics - 3)
- > 25% invovlement with subluxation of humerus
- > 5 mm step
- excessive medialization of glenoid (+1 cm)
How can use you flouro to get proper rotation of a tibial fracture?
Obtain perfect lateral of knee and then rotate c-arm internal by 105-120 degrees and this should give you a mortise view.
Think: From a lateral of knee to AP of ankle you would go internal 90 degrees so to get mortise you add another 15 (105).
In femoral IMN, is it safer for a proximal A-P locking screw to be proximal or distal to the lesser troch?
Proximal
distal=stress riser
What is the union rate of bisphosphonate fractures compared to conventional fractures when treated with IMN?
1:2 (54% v. 98%)
Also have higher complication rate.
What is the most proximal amp. that gives children equivalent walking speeds?
Through knee amputation
Most common impediment to closed reduction of DRUJ?
Tendon of ECU
What differentiates a Milch 1 from a Milch 2 fracture?
Whether or not the lateral intercondylar ridge is intact.
What finding indicates an adequate inlet view?
Overlap of S1 and S2 sacral bodies
Negative prognostic indicators for tibia fractures
high energy fractures
stainless steel nails vs titanium nails
fracture gaps
full postoperative weight bearing
open fractures treated with reamed nailing (?is this correct)
(SPRINT)
What is the difference between the type of nec fasc seen in healthy vs. immunocompromised patients?
immuno = polymicrobial, much more common
healthy = beta hemo GAS, less common (S.Pyogenes)
What is the activity that causes lateral process of talus fractures?
Snowboarding
Name an antibiotic to add for the presence of:
a) fresh water contamination
b) salt water contamination
Fluoroquinolines: add if fresh or salt water injury
Can also use if allergy to cephalosporins
Doxycycline + ceftazidime: Can use for salt water wounds
When comparing operative to nonoperative management of displaced intra-articular calcaneus fractures, what 2 groups of people had better outcomes with surgery?
What was found with all comers?
Women
All-comers NOT on WSIB
All-comers: Equivalent outcomes
What is the significance of roof arc measurements?
Show intact weight bearing dome if > 45 degrees on AP, obturator, and iliac oblique
Need for surgery or not.
Not useful for posterior wall fractures.
For a Lisfranc amputation what deformity is feared and how to avoid it?
- equinovarus
- preserve soft tissue around the base of the fifth MT
Initial abx for nec fasc (4)?
penicillin, clindamycin, metronidazole, and an aminoglycoside then tailor based on cultures
Wound Healing: Ischemic index should be greater than … ?
0.5
Calc fractures:
what is the constant fragment
what makes it constant?
Superomedial fragment (sustentaculum)
This remains “constant” due to medial talocalcaneal and interosseous ligaments (ie it’s attachments to the talus)
Is pregnancy a surgical contra-indication for acetabular fractures?
no
Obtain a fetal U/S pre-op. Xrays are safe.
LMWH is the safest AC.
Name 5 criteria for Gustillo 3 open fracture:
Close range shotgun injuries
High energy GSW
Presentation >24 hours
Contaminated barnyard injuries
Significant comminution or segmentation of fracture
Due to poorer prognosis
Wound >10cm
Vascular injury requiring repair
Injuries requiring soft-tissue coverage
5 things to decrease intramedullary pressure during reaming:
Flexible reamers
Fluted reamers
Fast speed
Small increments
Venting
7 indications for surgery in acetabular fractures
Roof arc angle >45 degrees
Subchondral bone 10mm deep on axial CT not intact
Posterior wall >40%
Displacement of roof >2mm
Marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
Operative indications in lateral third clavicle fractures? (3 patterns)
- fracture is medial to ligaments (2a)
- fracture is through ruptured ligaments (2B)
- comminuted fracture (5)
Are the short and long term outcomes of displaced olecrenon fractures in elderly treated non-surgically good or bad?
Good - Duckworth et al. 2014
Predictors of poor outcome for acetabular fractures
Age greater than 55
Intraarticular comminution
Osteonecrosis
Delay of greater than 12 hours for reduction of an associated hip dislocation (<6 hours ideal)
Intraoperative complications
Femoral head injury
Non-anatomic reduction
What is the best view for ruling out acetabular perforation by screw?
Obturator oblique
Who benefits from operative intervention in intra-articular calc fracutres?
IN all comers, what is the outcomes of operative vs. nonop?
women
<29 years old
light workloads
Comminuted fracture
Bohler’s angle >0-14 degrees (Higher Bohler’s is better)
Anatomic reduction (i.e. if you can restore anatomy)
In all comers, no difference
What finding indicates an adequate outlet view?
Symphesis shoulder overly S2 body
X-ray beam angled ~45 degrees cephalad (may be as much as 60 degrees)
adequate image when pubic symphysis overlies S2 body
ideal for visualizing:
- vertical translation of the hemipelvis
- flexion/extension of the hemipelvis
- disruption of sacral foramina and location of sacral fractures
What is optimal tip-apex distance?
< 25 mm
Where does the deep deltoid insert of the MM?
Posterior colliculus
According to AAOS CPG, what shoud you use in an unstable IT hip fracture in elderly?
cephalomedullary nail
WHat three joints are most predisposed to post-traumatic arthritis?
- ANkle
- Hip
- Knee
Radial nerve injury with humeral shaft fracture, 4 months out an EMG is done. What do fasciculations mean vs. fibrillations?
Fasciculations = healing nerve
Fibrillations = damaged nerve, indication for surgical exploration
(On NCS low amplitude and delayed potentials are bad)
Indications for an arthrotomy in setting of GSW? (2)
- passage through gut
- retained bullet in joint (can lead to lead poisoning)
Injuries asociated with clavicle fracture
(6)
Head injury
Scapular injury/SSSC/scapulothoracic dissociation
Pneumothorax
Vessel injury
Rib fracture
Brachial plexus injury
What exam finding is consistent with peroneal neurapraxia post tibial nailing?
EHL weakness (dropped hallux syndrome)
B/c branch of deep peroneal nerve to EHL is usually the one affected by proximal interlocking
NOT superficial peroneal
(JBJS Br 1999)
Acetabular approach with highest risk of avn to femoral head?
Kocher-Langenbach
How long after a pilon fracture will post-traumatic arthritis typically set in?
1-2 years
What sort of knee dislocation shows a “dimple sign” and why is this significant?
- posterolateral dislocations
- medial femoral condyle buttonholed through the capsule. These are difficult to reduce closed so should be done open urgently.
Femoral Head Fracture Classification. Describe
Pipkin
I: infrafoveal, not involving weight bearing surface
II: suprafoveal, involving weight bearing surface
III: associated femoral neck fracture
IV: associated acetabular fracture
JAAOS CPG Distal radius
Should you use vitamin C?
Yes - moderate evidence FOR use to prevent disproportionate pain
Where is the most common Hoffa fragment located?
Coronal shear fracture of lateral femoral condyle
What are the 5 associated acetabular fracture types?
- T-Type
- Associated both columns (Spur sign)
- Anterior wall, posterior hemi-transverse
- Posterior column and wall
- Posterior wall and transverse
What substitute has the highest compressive strength for filling a bone void (i.e. in tibial plateau fractures)?
Calcium phosphate
Benefits of Hemiarthroplasty over THA in femoral neck fractures
Lower incidence of post-operative dislocation
lower blood loss
lower operative time
Benefits to TEA in intra articular, comminuted distal humerus fractures in the elderly?
McKee et al RCT:
Quicker procedure, improved DASH scores at 6 months, improved elbow ROM, and decreased revision rates.
Frankle et al reccomend TEA if over 65 and: Arthritis, osteoporosis, or other diagnoses requiring steroids
What did the COTs trial tell us about clavicle fractures (shaft)?
They found that Constant and DASH scores were improved in the operative fixation group at all points in time, with union time being 28 weeks in the nonoperative group and 16 weeks in the operative group. Malunion was higher in the nonoperative group as well. This is for 100% displaced fractures.
2 options for ORIF of coronoid (technique)?
- A suture passed through 2 drill holes
- Posterior to anterior lag screws
Grade 1 open tibia treated staged with definitive management 48hrs later with BMP
What are the effects?
Decreased non-union only
Decreased infection rates only for grade III open
In what order should things be fixed in a terrible triad injury?
(1) restore coronoid stability through fracture fixation or capsular repair
(2) restore radial head stability through fracture fixation or replacement with a metal prosthesis
(3) restore lateral elbow stability through repair of the lateral collateral ligament (LCL) complex
(4) repair the medial collateral ligament (MCL) in patients with residual posterior instability
(5) apply a hinged external fixator when conventional repair did not establish sufficient joint stability to allow early motion.
What is the biggest contraindication to using a piriformis start point?
Pediatric patients.
It can cause AVN of the head.
What is a risk for HO in BBFA fractures and when can you safely excise it post-op?
- use of a single incision
- 6 months post op
(don’t worry about bone scan)
4 types of proximal tib-fib instability
Anterolateral - most common
posteromedial
superior
Atraumatic subluxation
What is the 1 year mortality following hip fracture?
14-36%
Also 50% loss of independance
Highest for Intertrochs
What approach is used for thigh fasciotomy?
Anterolateral
A laterally displaced scapula is a radiologic clue to what serious injury?
Scapulothroacic dissociation
Describe the radiographic union score for tibial fractures (RUST)
Look at each cortex on AP and lateral x-ray (4 in total)
Each one given a score
1: fracture line with no callus
2: callus with fracture line
3: callus with no fracture line
Radiographic healing is when bony callus is evident on 3 cortices AND score >/= 7
What does serendipity view assess?
Sternoclavicular joint
What is the characteristic deformity with malunited proximal tibia fractures?
Valgus and procurvatum
What is the most stable type of sacral fixation?
Combined iliosacral and lumbopelvic fixation (triangular osteosynthesis)
What serious condition is often found in conjunction with a posterior hip dislocation?
(not orthopaedic)
Thoracic aortic rupture
Predictors of poor outcome of polytraumatized patient (5)
Base deficit: most important predictor of morbidity and mortality
Elevated IL-6
High ISS
Elevated serum lactate
Intra-operative hypotension In polytrauma patients with severe brain injury
How much humeral head depression is an indication for hemi-arthroplasty?
40%
Three main surgical steps when there is a vascular injury requiring repair following knee dislocation.
- reduce and stabilize e.g. Ex fix first
- vascular repair - remove damaged area and use reverse saphenous graft (or bypass, etc as per vascular sx)
- perform prophylactic fasciotomies
Most important fragment in calcaneus fractures?
Constant fragment - sustentaclum tali
Work off of this fragment
5 indications for acetabular fracture fixation?
displacement of roof (>2mm)
posterior wall fracture involving > 40-50%
marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
What are the surgical approaches for an a) axillary or b) subclavian artery injury in an unstable patient with a scapulothoracic dissociation?
a) high lateral throacotomy with vascular repair
b) median sternotomy with vascular repair
Describe dynamic vs. static tension band
Dynamic: produces more compression force with loading
ie: olecranon, patellar
Static: produces a relatively constant force
ie: medial malleolus
Hip fractures in the elderly should have OR within what time frame?
48 hours
JAAOS CPG
Treatment for transabdominal GSW with intra-articular contamination?
Urgent I and D
Wound Healing: ABI should be greater than … ?
0.45
Factors for poor outcome post ORIF calcanues
age > 50
obesity
manual labor
workers comp
smokers
bilateral calcaneal fractures
multiple trauma
vasculopathies
men do worse with surgery than women
Secondary stabilizers of elbow (3)
Radiocapitellar joint capsule
origins of flexors and extensors
How do you investigate for urologic injury in pelvic fractures and what are the indications (3)?
retrograde urethrocystogram
indications for retrograde urethrocystogram include:
- blood at meatus
- high riding or excessively mobile prostate
- hematuria
Outcomes of spinal vs. GA in elderly with hip fractures?
Similar outcomes
Strong evidence
AAOS CPG 2014
Now you can tell your patients it doesn’t matter
Femoral neck fractures treated under what time frame have better outcomes
NO association between time to treatment of femoral neck fractures and outcome
outcomes based on QUALITY of reduction
Nonanatomic reduction leads to higher rates of AVN
With DRUJ instability associated with distal radius fractures, what is a sign on xray, what is the intra-operative test and what structure is most likely damaged if testing is positive?
- ulnar styloid fracture
- shuck test
- Radioulnar ligaments of TFCC
What is the rate of posterior mal fractures with a) spiral distal third fracture and b) any tibial shaft fracture ?
a) 40%
b) 10%
How long after fracture fixation before CRP starts to decrease in cases of no infection?
48 hours
What part of the urethra is most commonly injured in pelvic trauma?
Bulbous (or bulbomembranous)
JAAOS CPG Distal radius
What is the role for PT and early wrist ROM?
PT: limited evidence for
Early ROM: moderate evidence against - NO early ROM
Cemented or uncemented stems in arthroplasty for hip fractures in the elderly?
Moderate evidence supports preferential use of cemented femoral stems in patients undergoing arthroplasty for femoral neck fractures
AAOS CPG Sept 2014
Indications for tibial plateau ORIF
Articular stepoff >3mm (controversial)
Condylar widening >5mm
Varus/valgus instability
All medial plateau fractures
(These are like knee dislocations)
All bicondylar fractures
What are the two advantages of IM nail of tibia over casting?
- shorter time to union
- shorter time to weight bearing
Where does the saggital Poller screw go with proximal tibia fractures?
In the lateral aspect of the proximal fragment - it directs the nail medially to prevent valgus
Where does the coronal Poller screw go with proximal tibia fractures?
In the posterior aspect of the proximal fragment - prevents procurvatum deformity by directing nail anteriorly
What is the cut off of over-stuffing RH replacement and how do you assess it (give 3 ways)
No more than 2.5 mm
- Best assessed under direct visual examination of lateral UHJ.
- take intra-op xrays. Asses by visualising the lateral aspect of the ulnohumeral joint when the radial head is resected and comparing this to when the trial radial head is reduced in place. The lateral UH joint shouldnt be divergent with the radial head.
- size radial head replacement with excised anatomic head (if possible)
One study shows it shouldn’t go more than 1 mm proximal that the lateral aspect of coronoid.
What are the symptoms of Fat Emboli Syndrome?
The major clinical features of FES include hypoxia, pulmonary edema, central nervous system depression, and axillary or subconjunctival petechiae.
What nerve at risk with AIIS screws?
LFCN
Outcomes of locking vs. nonlocking plates in tibial plateau fractures
equivalent complications and outcomes vs. non-locking plate
Three indications for plate fixation of olecrenon fracture?
- comminution
- extension past the coronoid
- in the setting of associated instability
Three risk factors for malunion after treatent of femur fracture with IM nail?
- night time surgery
- use of a fracture table
- fracture comminution
TEA vs. ORIF for comminuted distal humerus fractures in elderly.
Name important Outcomes
4 things
TEA has:
- Less OR time
- Better functional outcomes at 2 years
- No difference in reoperation rates
- No difference in ROM
Indications for Damage control orthopaedics (7):
ISS Score:
- ISS > 40 in a patient WITHOUT thoracic trauma
- ISS > 20 in patient WITH thoracic trauma
Blood loss:
- Multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
Bilateral femoral fractures
Pulmonary contusion on CXR
Hypothermia
Head injury with AIS greater than or equal to 3
Any patient “in-extremis”Indications of patient in extremis: 3 out of 4 of:
- BP
- Platelets
- Temperature
- Major soft tissue injuries
Name 6 risks of radioulnar synostosis
(there are 13)
Trauma related
Monteggia fracture
both bone forearm fractures at the same level
open fracture,
significant soft-tissue lesion
comminuted fracture
high energy fracture
associated head trauma
bone fragments on the interosseous membrane
Treatment related
use of one incision for both radius and ulna
delayed surgery > 2 weeks
screws that penetrate interosseous membrane
bone grafting into interosseous membrane
prolonged immobilization
Where does the blood supply for patella come from chiefly?
Inferior
Distal radius fractures: Predictors of loss of reduction
Lafontaine’s Criteria
Dorsal angulation >20 degrees
Comminution:
- Dorsal comminution >50%
- Palmar comminution
- Intra-articular comminution
Initial displacement >1cm
Initial radial shortening >5mm
Associated ulnar fracture
Severe osteoporosis
Primary stabilizers of elbow? (3)
Anterior bundle of MCL
LCL
Ulnohumeral articulation
Braking time post lower extremity fractures are decreased until when? Base line at?
Significantly decreased for 6 weeks after initiation of weight bearing
Baseline at 8-9 weeks
What single patient factor nearly doubles the mortality of patients 2 years following hip surgery for fracture?
Chronic renal failure
Acceptable alignment parameters for humeral shaft fracture?
What does the Cierny calssification describe?
Osteomyelitis:
- medullary
- superficial
- local
- diffuse
** 3 and 4 are indications for I and D along with sinus tract and abscess and failure of conservative treatment
Also host type:
Host Type
Type A = Normal
Type B = Compromised
Type C = Treatment is worse to patient than infection
What is a Holstein-Lewis fracture?
A spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve
Advantages of ORIF clavicle fracture
Midshaft displaced
Advantages:
Improved results with ORIF for clavicle fractures with >2cm shortening and 100% displacement
Improved DASH and Constant scores with operative management at all time points
Improved functional outcome/less pain with overhead activity
Faster time to union
Decreased symptomatic malunion rate
Improved cosmetic satisfaction
Improved overall shoulder satisfaction
Increased shoulder strength and endurance
Decreased overall complications (JBJS2012 - McKee)
Disadvantages
Increased risk of need for future procedures
Removal of hardware COMMON (30%)
Debridement for infection
4 xray findings of DRUJ injury?
- ulnar styloid fx
- widening of joint on AP view
- dorsal or volar displacement on lateral view
- radial shortening (≥5mm)
Indications for surgery for clavicle fractures
Absolute:
Unstable group II (IIA, IIB, V)
Displaced fracture with skin tenting
Subclavian artery or vein injury
Floating shoulder
Symptomatic nonunion
Posteriorly displaced group III fractures (posterior displaced medial fracture)
Displaced Group I (middle 1/3) (100% displaced) with >2cm shortening
Relative:
Brachial plexus injury
Questionable b/c 66% have spontaneous return
Closed head injury
Seizure disorder
Polytrauma patient
After you fix the radius in a Galeazzi fracture (radius), what do you do?
Assess DRUJ:
If reduced and stable: 6 weeks casting in supination
IF reduced but not stable: pin for 6 weeks
IF not reduced: Dorsal capsulotomy, remove interposed tissue, usually ECU, fix any large styloid boney fragments, pin for 6 weeks in supination
How much fluid do you bolus in a paediatric trauma patient?
20mL/kg
Which direction of subtalar dislocation is more common? More likely to be open?
Medial more common
Lateral more likely to be open
4 indications for fixation of sacral fractures
- displaced fractures >1 cm
- soft tissue compromise
- persistent pain after non-operative management
- displacement of fracture after non-operative management
How much do you want to preserve for great toe amps?
1 cm proximal phalanx. This preserves plantar fascia, sesamoids and FHB.
What combination of pressure and solution type should you use for open fracutre I&D?
Saline better than soap (soap had increased reoperation rates)
Pressure doesn’t matter - can be very low, low or high pressure
(FLOW study NEJM 2015)
What has to be elevated out of the way when using an anterolateral approach for talar neck orif?
EDB
Most important predictor of 1 year survival after femoral neck fracture in elderly
Preoperative mobility
Other risks for mortality include:
Male sex
preoperative cognitive impairment
CRF
Delay in surgery > 4 days
TIbial plateau fractures with highest rate of vascular injury?
What must you do?
Shatzker IV: represents medial fracture dislocation
Must do ABI
What are the three factors that influence development of post traumatic OA in the long term?
Congruity
Instability
Alignment
JAAOS 2014
What is the primary treatment for delayed EPL rupture following closed treatmnet of DR fracture?
EIP to EPL transfer.
Best order for insertion of cannulated screws?
1-inferior screw along calcar (posterior aspect)
2-posterior/superior screw
3-anterior/superior screw
Starting point at or above level of lesser troch
Where is characteristic location for a bipartite patella?
Superolateral
Risk factors for wound problems after operative management of calcaneus fracture? (3)
Open fractures
>
Diabetes
>
Smoking
2 absolute indications for amputation following trauma
crush injury with warm ischaemia time >6hrs
Non-repairable arterial injury
How long should DM patients be immobilized post ankle ORIF?
Twice as long as normal
What is the danger of using a retrograde entrypoint posterior to Bloomensats line?
Damage to cruciate ligaments.
Do you need to give prolonged ABx for a low velocity GSW to femur when planning for a nail?
No
What is the union rate of bisphosphonate fractures compared to conventional fractures when treated with IMN?
1:2 (54% v. 98%)
Also have higher complication rate.
Components of LRINEC system?
- CRP (mg/L) ≥150: 4 points
- WBC count (×10^3/mm3): <15: 0 points, 15–25: 1 point, >25: 2 points
- Hemoglobin (g/dL): >13.5: 0 points, 11–13.5: 1 point, <11: 2 points
- Sodium (mmol/L): <135: 2 points
- Creatinine (umol/L): >141: 2 points
- Glucose (mmol/L): >10: 1 point
- score > 6 has PPV of 92% of having necrotizing fasciitis
Which Denis zone of the sacrum has the highest rate of neurologic injury?
Zone 3, medial to foramina
(Transverse is even higher but isn’t in the Denis classification)
(Zone 1 is lateral and Zone 2 is through foramina)
5 indications for DCO ortho
ISS > 40
ISS > 20+ thoracic/abdominal injury
Bilateral lung contusion
Bilateral femur fracture
Evidence of shock
- Decreased urine output (<50mL/hr)
- sBP < 90mmHg
Lactate >2.5
Triad of Death
- Coagulopathy (Fibrinogen <1)
- Hypothermia (T < 35C)
- Acidotic (pH < 7.2), base excess >8mmol/L
Massive Transfusion Protocol (Transfusion > 4U)
Exaggerated inflammatory response: IL-6 > 800pg/mL
Initial mean pulmonary arterial pressure >24mmHg
Increase of >6mmHg in pulmonary arterial pressure during IM Nailing
Presumed OR time >6 hours
Arterial injury & hemodynamic instability
Increased ICP
Three risk factors for malunion after treatent of femur fracture with IM nail?
- night time surgery
- use of a fracture table
- fracture comminution
What is the Sanders classification based on?
Number of articular fragments seen on the coronal CT image at the widest point of the posterior facet
What is a specific technique to prevent varus collapse when doing a proximal humerus locking plate?
Placement of an inferomedial calcar screw
What is the biggest risk fracture for non-union in open tibia fractures?
Gapping at fracture site.
Also transverse fracture.
(some would use BMP-2 - however some new literature disagrees… something about cancer)
What nerve branch will serve as a landmark to the radial nerve during a paratricipetal approach?
Lateral brachial cutaneous
4 characteristics of bisphosphonate related fractures?
- lateral cortical thickening
- transverse or short oblique fracture orientation
- medial spike
- lack of comminution
- subtroch (not always)
What are the 5 simple acetabular fracture types?
- Posterior wall (Gull Sign)
- Posterior Column
- Anterior wall
- Anterior column
- Transverse
How do you reduce a subtalar dislocation?
- sedation
- Flex knee and plantarflex foot
- Inversion/Eversion depending on direction of dislocation
- Get a post op CT to look for fractures or intraarticular bodies.
How far is sublime tubercle from tip of coronoid?
18 mm
Foot compartments and what is is them?
9 main compartments
- medial
- abductor hallucis
- flexor hallucis brevis
- lateral
- abductor digiti minimi
- flexor digiti minimi brevis
- interosseous (x4)
- central (x3)
- superficial
- flexor digitorum brevis
- central quadratus plantae
- deep
- adductor hallucis
- posterior tibial neurovascular bundle
- superficial
How do you assess DRUJ on xray?
Lateral with arm in neutral rotation.
An unstable DRUJ will displace dorsally by full width of ulna
Can also do dynamic CT
Which has superior union rates post open tibia fracture, autogenous ICBG vs. BMP2?
Equivocal
JAAOS CPG Distal radius fracture
What is operative criteria?
Post-reduction:
radial shortening >3mm
dorsal tilt >10 degrees
or intra-articular displacement or step-off >2mm
If fixing at sternoclavicular dislocation, what are the principle of surgical management?
- If acute perform closed reduction with entire chest prepped, have throacic surgery on backup
- If chronic (> 3 weeks) do open reduction, can use towel clamp to help reduction, consider repair of soft tissues
*** Put bump between shoulders. Push POSTERIORLY on the shoulder to reduce while pulling anteriorly on the clavicle with a towel clamp.
*** With chronic injuries there is a worry that there is fibrous tissue connecting the clavicle to mediastinum so dont do closed reduction.
Distla 1/3 tib/fib fracture
Outcomes of fibular plating in addition to tibial fixation (doesn’t matter what type)
Early: increased nonunion
Late: decreased late malalignment
What views for placing AIIS screws and why?
obturator outlet to get start point
obturator inlet to see the path between the tables
iliac inlet to ensure you dont go into GSN
there is no single view (just think about pelvis anatomy). also see JAAOS
What is the main indication for posterior (Kocher-Langenbeck) approach with digastric osteotomy? (i.e. what traumatic condition(s))
Femoral head fracture with posterior wall fracture. If posterior wall is small can just leave it and fix head via anterior approach
What approach is used with posterior wall, posterior column and most t-type/transverse fractures?
Kocher-Langenbach
What is the salvage option post femoral neck fixation with:
a) nonunion or b) AVN >50%?
a) Valgus intertrochanteric osteotomy
b) Free vascularized fibula graft
Which types of Monteggia should be casted in supination?
1 and 3 (anterior and lateral)
How many segmental rib fractures needed for a flail chest?
3 or more
Which view allows for assesment of Screw position between the inner and outer tables of the ilium?
Obturator-oblique inlet view
Advantages to plating of humerus vs. nailing?
- fewer complications overall
- less impingement
- equivalent union
What did the SPRINT trial say about reamed vs. unreamed nails for tibia fractures?
Reamed possibly superior to unreamed nails for treatment of closed tibia fxs for decrease in future bone grafting or implant exchange
What is the difference between a tongue type Essex Lopresti fracture and a calcaneal tuberosity avulsion fracture?
In tongue type, there is a primary fracture line that runs obliquely through the posterior facet forming two fragments
and then there is a secondary fracture line that causes the classic “tongue”
In avusion, there is only 1 fracture line and does not have to go into the posterior facet
Risks for wound complications following calc fracture after ORIF?
Open injury (most important)
smoking
DM
Most common cause of Gas Gangrene? And abx required?
Clostridium
Abx should be Pen G and Clindamycin
How do you assess intraop for rotational reduction in a femur fracture?
Clinical assessment of other leg - prep it in
Compare LT profiles (AP of knee, should see 2/3 of LT)
Compare LT profiles: perfect lateral of knee, then rotate 90 deg to get AP of hip. Match LT profile of injured side to good side
Width of cortices
Tornetta technique: perfect lateral of hip and knee on good side & meausre the difference. This difference should be recreated on the injured side
Linea aspera if open
Ultrasound
Computer assisted surgery
Post-op: CT Scanogram using Jean-Mart method
Indications for scapular neck fixation
(fracture characteristics - 2)
- 40 angulation
- 1 cm translation
What are the most important biomarkers to guide resuscitation?
- Base deficit
- Lactate
Where are the incisions for a foot compartment release?
- dorsal - medial aspect of 2nd MT
- dorsal - lateral aspect of 4th MT
What is the Jupiter classification?
Bicolumnar distal humerus fractures (Milch is unicolumnar)
Treatment for significant stiffness caused by HO following fracture of the elbow?
HO excision, capsular release, and/or release of the posterior band of the UCL
** releasing anterior band would cause secondary valgus instability
(Orthobullets uses band and bundle inter-changably. This is referring to the posterior band NOT the posterior bundle of the anterior band)
LEAP study showed what two factors had highest influence on a surgeons decision to amputate?
Severe soft tissue injury
Presence of plantar sensation
(This is a common question, but seems meaningless. Should know that LEAP study DIDN’T show that absence of plantar sensation effected outcomes)
What is an Essex-Lopresti injury and how do you treat it?
- Radial head fracture with an interosseous membrane injury extending to DRUJ
- Pin DRUJ for 6 weeks in neutral. If that doesn’t work may need radial head replacement.
Fractures associated with subtalar dislocation
medial dislocation
- dorsomedial talar head
- posterior process of talus
- navicular
lateral dislocation
- cuboid
- anterior calcaneus
- lateral process of talus
- fibula
What are 3 signs of instability on plain xrays for pelvic ring fractures?
> 5 mm displacement of posterior sacroiliac complex
presence of posterior sacral fracture gap
avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of 5th lumbar vertebrae)
What is the deficit if the clavicle heals more than 2 cm short?
Decreased shoulder strength and endurance (McKee Paper - Toronto 2007)
What happens if a clavicle heals 2cm short?
decreased strength
quicker fatigability
What score gives a numerical value to the top three injuries which are squared to give a final value?
ISS
In proximal humerus fractures what length of medial calcar is associated with a reduced risk of AVN if attached to the articular segment?
8 mm or more
Patient with a closed fracture that requires surgery, but has superifcial burn. what do you do?
Operate as you would without the burn
Can operate through burned skin within 48 hours and is in fact beneficial
After 48 hours, must allow skin to heal first as it is considered colonized (can do an ex-fix)
What position in cast is best to prevent compartment pressure increase (for lower extremity cast)?
0- 30 degrees plantarflexion
6 ways to decrease IM pressure with reaming
a narrow reamer shaft
sharp cutting flutes
deep flutes
a conical shape
Distal venting
Reaming by smaller increments (0.5mm instead of 1mm)
Patient has an open pelvic fracture.
WHat non-ortho procedure is reccomended?
Diverting colostomy
rhBMP-2 is FDA approved in what treatment?
Open diaphyseal fractures of the tibia treated with intramedullary (IM) nail fixation
What should the head to tuberosity distance be when doing shoulder hemi-arthroplasty?
8-10 mm
Six methods to prevent malreduction when nailing proximal tibia fractures?
- lateral parapatellar incision
- make startpoint more lateral
- Poller screws
- unicortical plating
- universal distractor
- nailing in semi-extended position
If doing a distal ulna wafer resection, what is the most important technical consideration?
Maintain ulnar attachment of TFCC
How do you check for compartment syndrome intra-operatively?
Pressure > 30 or within 30 of PRE operative diastolic
Components of forearm IOM?
central band is key portion of IOM to be reconstructed
accessory band
distal oblique bundle
proximal oblique cord
dorsal oblique accessory cord
Deinfe angle of Gissane
The angle formed by the downward and upward slopes of the calcaneal superior surface. (Posterior facet)
Normal: 120-140
(same as Bohlers +100)
What causes the damage to cartilage in septic arthritis?
Release of proteolytic enzymes from PMNs
5 steps of pilon fixation?
- Anatomic reduction of articular surface
- Restore length
- Reconstruct metaphyseal shell
- Bone graft
- Re-attach metaphysis to diaphysis
Treatment for extra-articular transabdominal GSW with stable fracture patterns?
IV ABx and observation
What forearm fractures can be treated non-operatively?
Only distal 2/3 isolated ulnar fracture with less than 50% displacement and 10 degrees angulation.
any undisplaced fracture
All other types of forearm fractures are an indication for surgery.
What do you have to assess after reducing a elbow dislocation?
- congruency of reduction
- stable arc, usually more unstable in extension
surgical intervention if unstable past 60 degrees of flexion
What injury is suspected when a foot presents locked in supination?
MEDIAL subtalar dislocation.
Lateral is less common, more likely to be open and will be locked in pronation.
Dislocation is defined by direction of distal aspect - i.e. the foot.
The blocks to reduction are the structures on the OPPOSITE side of the foot.
Classification of TFCC tears?
type I - traumatic
type II - degenerative (ulnocarpal impaction)
IIA - TFCC thinning
IIB - IIA + lunate and/or ulnar chondromalacia
IIC - IIB + TFCC perforation
IID - IIC + LT ligament disruption
IIE - IID + ulnocarpal and DRUJ arthritis
Do you have to do an arthrotomy when fixing a periprosthetic knee fracture with a retrograde nail?
Yes - to remove and protect the polyethylene liner
After traumatic knee dislocation, what is the best predictor for HO?
High ISS
What is the best measure of height of prosthesis for proximal humerus?
Relation to pec tendon.
The top of humeral head should be 5.6 cm from top of pec tendon.
What is the significance and treatment of varus malunion of a talar neck fracture?
- Causes decreased subtalar eversion
- Medial opening wedge neck osteotomy
Distance from radiocapitellar joint that radial nerve passes through lateral intermuscular septum?
10 cm
What is target for SI screw? (general anatomic structure)
What fluro views to use for what alignment?
S1 vertebral body
outlet radiograph view best guides superior-inferior screw placement
inlet radiograph view best guides anterior-posterior screw placement
lateral sacral view for iliac cortical density - stay inferior to it
On the true lateral projection, identify the S1 body and iliac cortical densities (ICDs) –> they should overlap
The entry point should be anterior in S1 and inferior to the iliac cortical density (ICD), which parallels the sacral alar slope, usually slightly caudal and posterior. The ICD thus marks the anterosuperior boundary of the safe zone for an iliosacral screw which may injure the L5 nerve root if it penetrates this cortex.
If a proximal tibial ex-fix pin is placed within 14 mm of the joint line what is a possible complication?
Septic arthritis
Cast index
How do you measure it and what is good
Max width on lateral / Max width on AP
Closer to 1 = round cast
- 7 is good
- 8 is bad - the rounder the cast, the higher the risk of re-displacement
4 ways to assess for ipsilateral femoral neck fracture in a patient with a femoral shaft fracture?
- Dedicated 15 deg IR AP of affected hip
- Fine cut CT scan of hip (2mm cuts)
- Intraop lateral
- Postop AP and lateral prior to waking the patient up
By using this protocol (ie all 4), decreased delay in diagnosis by 92%
(Tornetta protocol, JBJS 2007)
List risk factors for mortalitiy with IT hip fractures (6)
Intertroch hip fracture (higher than femoral neck)
Age > 85
Male sex
High ASA >/= 3
High comorbidities (high Charlson Comorbidity Index)
Delay to surgery >2 days
What is the recommendation for VTE prophylaxis in trauma?
Start LMWH as soon as possible (within 24h if possible)
Supplement with pneumatic compression devices
Where does radial nerve split into SRN and PIN?
RC joint
Corococlavicular Ligaemnts: The ____ ligament inserts ___ from the end of the clavicle and the ____ ligament inserts ___ from the end of the clavicle.
- Trapezoid, 3 cm
- Conoid, 4.5 cm
How do you immobilize Monteggia fractures?
Bado type:
I: supination, hyperflexion >90 degrees
II: extension
III: Supination
IV: ?
Define Bohler’s Angle
Two lines are drawn tangent to the anterior and posterior aspects of the superior calcaneus
Normal 20-40 degrees
Fixation strategy for displaced Iliac fracture?
Surgical indication for iliac fractures is displacement and whether or not the posterior arch is intact.
For surgical fixation, a pelvic recon or lag screw is placed along the iliac crest, and then a second recon plate is placed along the pelvic brim.
Approaches included:
- posterior approach
- ilioinguinal approach
- Stoppa approach (lateral window)
Nerve at risk for SI screw?
L5 (Courses anterior to S1 body)
what’s the classic appearance of stress fracture on MRI
T1: Low signal
T2: high signal
Mechanism of talar neck fracture
Axial load on foot with talus fixed between tibia and calcaneus
What biphosphonate poses the greatest risk for patholgic femur fracture?
Aledronate
Most common reason for irreducible Radial Head during monteggia surgery?
Non-anatomic fixation of ulna
Distal tibia fractures (extra-art), name 4 advantages of ORIF vs. IMN
Name 1 drawback
Advantages:
Anatomic reduction
Lower nonunion rates
lower malunion rates
Better biomechanics (2x stiffer in axial load)
?infection - says it has low infection but not necessarily compared to IMN
Cons:
More extensive soft-tissue dissection
(this can be helped with MIPO)
Most common complication when using proximal humerus locking plate?
Screw cut out
4 things to look for on CT when evaluating an acetabular fracture?
- fracture type
- loose bodies
- marginal impaction
- Articular steps or gaps
What is a caspase?
Mediator of apoptosis –> Implicated in post traumatic arthritis
What is the preferred approach to femoral head fractures
Generally anterior
Surgical dislocation is an option and has been advocated for recently, but increased risk of AVN
Acetabular fracture extending into sciatic notch - what vessel is most likely injured?
Superior gluteal artery
What substitute has been shown to be equivalent to autograft in tibial non-union revisions?
BMP-7
Most likely organism in Septic arthritis in an IV drug user?
Still Staph aureus, although higher likelihood of pseudomonas
What clinical exam finding is most predictive of function is scapulothoracic dissocation?
Neurologic injury.
Can have a complete plexopathy - mechanism is traction injury to arm. In this case consider forequarter amputation.
Clinical special test to monitor nerve recovery?
Advancing tinels sign
Distal 1/3 tibia/fibula fractures.
What is the only absolute indication for fibular plating?
Disrupted syndesmosis
“Should also be done in medial tibial plating to manage a valgus deformity” (JAAOS 2012)
Where does anterior bundle of elbow MCL insert?
Sublime tubercle
How much length do you need to nail a proximal tibia fracture?
enough for 2 locking screws
depends on manufacturer/design
~5-6cm
In what orientation should your screws be when fixing a vertical medial malleolar fracture?
Parallel to the joint.
Mortality rate at 1 year after hip fracture in elderly
15-35%
Higher with CRF: 45%
Indications for HO prophylaxis in elbow ORIF surgery (2)?
- head injury
- revision surgery
Important clinical questions to answer when evaluating a radio-ulnar synostosis?
- Is it congenital (changes tx decision)
- Painful or not (incomplete are painful)
- Restrictions to ROM and function
- Time since fracture or surgery ( 6 months needed before excising)
What are A, B and C fractures based on the Tile classification?
A= rotational and vertically stable
B= rotationally unstable, vertically stable
C= rotational and vertical unstable
4 predictors of mortality with pelvic fractures?
- Systolic BP drop
- 60 years old
- Increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
- Need for transfusion > 4 units
Where is the typical comminution with talar neck fractures?
Dorsal and medial
(Therefore medial screws are positional and not lag. The lateral screw can be a lag screw usually)
In what plane is syndesmotic stability best assessed?
AP plane (i.e. on lateral)
Benefits of THA vs HA in displaced femoral neck fracture
Lower reoperation rates
Higher functional outcome (Harris hip score)
Lowe incidence of post-operative pain
What advanced imaging modality is best for dx of hip fracture in elderly that is not apparent on plain films?
MRI
JAAOS CPG
On what views do you measure Tibo-Fibular clear space and overlap?
a) clear space on AP, 1 cm above joint
b) overlap on mortise views
What is the major blood supply for the talar body?
posterior tibial artery via artery of tarsal canal then deltoid artery
What direction of knee dislocation has the highest rate of complete popliteal ruptures?
Posterior
Anterior gives you an intimal tear from traction.
What factor most closely associates with nonunion following femoral neck orif?
Varus malreduction
(Thou shall not varus)
Predictors of better outcomes in acetabular fractures
Early surgery: within 24 hours leads to: (Plaisier et al)
- Earlier discharge home
- Better functional outcomes
- Lesser organ dysfunction
Early surgery
- Higher rate of anatomic reduction
- Lower rate of overall complication
Increased hip muscle strength
Poor outcomes for operative management of calcaneus fractures
(10)
Smoker
Vasculopath
Age > 50
Obesity
Male (Women do better with surgery)
Manual labourer
Workers compensation
Bilateral fractures
Vasculopathies
Polytrauma
First and last muscles to recover after radial nerve palsy (high)?
- brachioradialis
- extensor indicis
In closed, extra-articular distal 1/3 tibia fractures with isolated tibial fixation, what are the outcomes of plate vs. IMN?
(wrt frx union and complications)
No difference in union
However higher soft tissue complications with plating
What GI injury is associated with high energy iliac fractures?
Bowel entrapment
Look for free air on CT.
In what direction do soft tissues fail in an elbow dislocation and what structure fails last?
- Lateral –> medial
- Anterior bundle of MCL
Most common type of Monteggia fracture in kids and adults
Kids: type I: anterior radial head dislocation, apex anterior fracture
Adults: type 2: posterior radial head dislocation, apex posterior fracture
Pipken 4 surgial approach
depends on frx pattern
e.g.
kocher-langenback + surgical hip dislocation
plan around acetabular frx pattern, and get access to the head
2 associated injuries with posterior hip dislocation
- Thoracic aorta injury
- Proximal tib-fib dislocation
- acetabular frx
What is significant about the deltoid branch of posterior tibial artery?
It may be the only remaining vasculature following displaced talar neck fracture.
What position is the forearm splinted when repairing LCL?
- Pronation and 90 degrees flexion
- Supination if MCL also disrupted to avoid over tightening
Is there a benefit to physical therapy after closed distal radius fracture?
No benefit over home exersizes
What is the cutoff for good versus bad bone density when using combined cortical thickness?
4 mm
What is the characteristic patient that will fail ORIF of Sanders 2-3 Calcaneus and require secondary fusion?
Male worker’s compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
What is the best treatment for a displaced olecrenon fracture in an elderly, low demand patient?
Conservative treatment with a splint at 90 degrees followed by early ROM is a good option with good long term results.
Another option is fragment excision and triceps advancement
(This is based on an orthobullets question)
What is the utility of performing an AP xray with the leg 30 degrees IR prior to fixation of a distal femur fracture?
For determining ideal length of intercondylar screws
Wound Healing: Transcutaneous oxygen tension should be greater than … ?
30 mmHg
Acceptable reduction for tibial shaft fracture
1cm shortening
10 degrees AP angulation
10 degrees rotation
(10 ER, 5 IR according to some)
5 degrees varus/valgus angulation
50% overlap
Three advantages of IM nailing over Ex Fix for open tibia fractures?
- decreased malalignment
- decreased secondary surgeries
- decreased time to weight bearing
(None of these effects are lost by reaming)
(no effect on union or infection)
What type of hip fracture has the highest mortality at 1 year?
Intertrochanteric
What are the 5 recommendations from the AAOS clinical practice guidelines for management of distal radius fractures?
1) surgical fixation for fractures that had a post-reduction radial shortening > 3 mm, dorsal tilt > 10 degrees and intra-articular step off > 2 mm,
2) rigid immobilization for non operative treatment,
3) use of a true lateral to assess the DRUJ,
4) beginning early range of motion of the wrist after stable fixation
5) use vitamin C to help mitigate intractable pain.
Most common cause of death for:
- APC
- lateral compression
- vertical shear
- hemorrhage
- head injury
- hemorrhage
Which Lauge-Hansen type is associated with anteromedial talar impaction?
Supination-Adduction
Consider anteromedial approach to address marginal impaction.
Which acetabular fracture type causes dissociation of acetabulum from inominate bone and what is the characteristic plain film finding?
Associated both columns
Spur sign (Gull Wing sign is posterior wall)
Where do you attache the triceps when doing an olecrenon fragment excision and triceps advancement?
Adjacent to articular surface
Compared with traditional ORIF, MIPO of distal tibia fractures (extra-articular) have a higher rate of what?
Hardware irritation
All other outcomes were the same
What direction will the glenoid displace in a floating shoulder?
Anteromedial
Name 5 ways to decrease IM pressure during reaming
Slow advancement
Frequent pull backs to clear debris
(insert sex joke here)
Deeper flutes
distal venting
reaming by smaller increments (0.5mm rather than 1mm)
Viscosity of substance being reamed - therefore 1st pass is highest IM pressure and it becomes less after b/c of bleeding into canal (decreased viscosity)
What are the 4 types of capitellum fractures?
- Coronal shear –> splint if undisplaced
- Shear of articular cartilage ( splint if undisplaced)
- Comminuted ( fragment excision versus TEA )
- Coronal shear with part of trochlea –> double arc on lateral, always needs to be fixed
What does TUG predict at 2 years post surgery for femoral neck fracture?
Use of ambulatory aids
What is the suggested pain control for pre-op hip fractures in the elderly?
regional anesthesia
JAAOS CPG
How should the forearm be positioned during appraoch for a radial head repair and during plate placement?
- pronation to protect PIN
- neutral during plate placement
Where do you place a proximal humerus locking plate and why?
Lateral to bicipital groove to avoid damaging biceps and ascending branch of anterior humeral circumflex artery
Nerves at risk with anterior SI plating?
L4 and L5
How do you evaluate for chronic pelvic ring instability?
Alternating single-leg-stance radiographs
Most common complication of pediatric amputatations?
Overgrowth –> prevent by doing trans articular amps or using epiphyseal caps
When does braking time return to normal after lower extremity long bone or acetabular fractures?
6 weeks after weight bearing
vs. 8-9 weeks post-ankle ORIF
Compartments of forearm:
- volar
- dorsal
- mobile wad
Indications for surgery following posterior sternoclavicular dislocation? (3)
- dysphagia
- shortness of breath
- vascular deficit
**Mechanism is usually anterior directed force on the shoulder***
3 requirements for non-operative treatment of Femoral Head fracture?
Pipkin I or undisplaced Pipkin II with < 1mm step off
no interposed fragments
stable hip joint
How long after ankle ORIF until proper braking response time is restored?
9 weeks
Treatment options for end stage DRUJ arthrosis (5)?
- hemiresection or interposition arthroplasty of distal ulna
- Resection arthroplasty of distal ulna - matched or Darrach
- DRUJ fusion (Suave kapandji?)
- Ulnar head prostheitc replacement
- Creation of one-bone forearm
Wound Healing: Lymphocyte count should be greater than … ?
1500 / mm^3
Solve for x:
Base deficit should be between -x and +x
Lactate should be < x
x = 2
Three primary stabilizers of DRUJ and what position is it most stable in?
- dorsal radioulnar ligaments
- volar radioulnar ligaments
- TFCC
More stable in supination (because usually ulna dorsally unstable. technically the carpus/radius is translated volar and the ulnar head stays put)
Which of the following are now considered Gustillo 3 due to poorer prognosis?
- Close range shotgun injuries
- High energy GSW
- Presentation >24 hours
- Contaminated barnyard injuries
- Significant comminution or segmentation of fracture
All of them
Name 3 treatment options of femoral neck nonunion
Valgus intertrochanteric osteotomy
free vascularized fibular graft
arthroplasty
What is the classic malunion of a sub-troch fracture?
Varus-procurvatum
What is the treatment for EPL rupture?
Transfer of EIP
Why test serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve) during evaluation of brachial plexus injury?
Tells you whether a C5 injury is pre or post ganglionic
What is a Marjolins ulcer?
Malignant transformation of chronic soft tissue trauma/ulcer- most commonly squamous cell CA
examples: DM ulcers, OM ulcers, burns, etc.
After closed reduction of dislocated hip, what is the mandatory next step?
CT scan to look for:
femur fracture/femoral head fracture
acetabular fractures
incarcerated loose bodies
Two benefits of a reamed nail and one reason you would use un-reamed nail.
- Quicker union
- Higher rate of union
- Bilateral pulmonary injuries
What is a canale view for and how do you do it?
- Talar neck view
- Maximum equinus, 15 degrees pronated, Xray 75 degrees cephalad from horizontal
What runs over anterior sacral ala joint?
L5 nerve.
At risk if SI screw too anterior.
Check this with lateral sacral x-ray.
On the true lateral projection, identify the S1 body and iliac cortical densities (ICDs) –> They should overlap
For SI joint fixation, the ISS is inserted perpendicular to the SI joint, and extends beyond the midline of the sacral body.
For sacral fractures, the ISS is horizontal, allowing it to be inserted to or through the contralateral SI joint, to optimize fixation on both sides of the sacrum.
In capitellum fractures, where does the blood supply of the fragment come from?
(direction, not artery)
posterlaterally
What returns to normal faster following successful treatment of Septic Arthritis: esr or crp?
CRP
ESR is slower to rise following infection and slower to normalize following treatment.
LEAP said Return to work and Sickness impact profile were the same at 2 years after what type of operations?
Limb salvage or amputation
** Also amputation has higher lifetime cost because of prostheses. Both populations have issues with pain and disability in the long term. Educated, rich, caucasians do better in the long term.
JAAOS CPG Distal radius fractues
What must you look for post-reduction?
DRUJ instability with a true lateral
Risk factors for re-fracture of forearm or radius (adult)?
- plate removal before 18 months
- large frag plate
- comminuted fracture
- persistant radiolucency
Transfusion threshold in postop hip fracture patients (elderly)?
STrong evidence supports a blood transfusion threshold of no higher than 8g/dL in asymptomatic postoperative hip fracture patients
Roots associated with ERBs palsy (2)
C5-6
What type of instability is associated with a torn LCL and fractured anteromedial coronoid facet?
Varus posteromedial rotatory instability
What is the “double arc” sign and what xray is it best seen on?
- “double-arc sign” which represents the subchondral bone of the displaced capitellum and lateral trochlea ridge in a sheer type distal humerus fracture
- lateral of elbow
List some factors that influence development of cartilage damage in the acute phase.
Direct damage to chondrocytes
Early apoptosis and necrosis
Release of pro-inflammatory cytokines
Release of reacitve oxygen species
Matrix disruption
JAAOS 2014
What second dislocation is associated with subtalar dislocations?
Talonavicular
Is a muzzle velocity of 2000 ft/second considered low or high velocity?
Low velocity.
High velocity is greater than 3000 ft/second
Where does the LCL insert (LUCL)?
Crista supinatorus
What is subtalar distraction block arthrodesis for?
What are the specific indications?
What are the 4 goals?
calcaneus malunion
Indications:
- Chronic pain from subtalar joint
- Incongruous subtalar joint/post-traumatic DJD
- Loss of calcaneal height (decreased talocalcaneal angle or decreased talar declination angle)
- Mechanical block to ankle dorsiflexion
4 Goals
Hindfoot height
Ankle impingement
Subfibular impingement
Subtalar arthritis
What is the risk with a long plate for a tibia fracture?
SPN
(Hole 11-13)
What is a clinical finding associated with pre-ganglionic injury at level of brachial plexus?
Horners syndrome
scapular winging
elevated hemidiaphragm
atrophy of paraspinals
many more
i.e. this is a root avulsion/injury so you also get loss of function of pre-clavicular plexus branches/structures
A medial startpoint for IM nail of proximal tibia fracture will lead to:
Valgus malunion
Goals of Calcaneus ORIF
Restore congruity of subtalar joint
Restor Bohler angle and calcaneal height
Restore width (of heel)
Correct varus alignment
What does the Ideberg classification describe?
Glenoid fractures
Start point for tibial nail
just medial to the lateral tibial spine on the AP radiograph
on anterior cortical downslope on lateral view
What is the treatment for symptomatic subtalar arthritis with loss of height and dorsiflexion following calcaneal fracture?
Subtalar distraction arthrodesis using a structural bone graft
Surgial approach for Pipkin 1/2
Smith-Peterson
or
watson jones
± surgical dislocation (but this is a posterior approach)
What is the interval for posteromedial incision to knee?
semimembranosus and medial head of gastrocnemius
Do women have higher rates of clavicle non-unions when treated non-operatively?
Yes
Pin care for ex-fix of hand?
Daily showers and dry dressings
What is the drawback of using a strut allograft over vascularized fibula graft for a BBFA fracture with significant segmental bone loss?
Higher risk of infection
How much of the proximal olecrenon can be excised prior to onset of instability?
50-70 %
2 Options for placing pelvic ex-fix?
Multiple Iliac crest pins or single AIIS pins
Should be done before laparatomy – this is controversial. AO advanced said do it first because laparotomy can cause loss of tamponade if done before ex-fix. Other option is C-Clamp but this will get in the way of posterior fixation.
If you use a LISS plate for a tibia fracture, what screw holes are typically close to SPN?
11-13
so do these open rather than perc.
What is the greatest risk factor for loss of reduction following posterior pelvic ring fixation? (fracture pattern)
Vertical sacral fracture
3 ways to judge reduction in femoral neck fractures
Shenton’s line
Lowell’s alignment theory:
- S shaped head/neck junction on all views
Garden index
- angle of compression trabeculae to femoral shaft on AP should be 160
- angle of compression trabeculae to femoral shaft on lateral should be 180
Femoral neck shaft angle
Wound Healing: Albumin should be greater than … ?
3.0 g/dL
What were you doing when you injured the FHL in calc ORIF?
Putting screws that were too long into the constant (superomedial) fragment
(I was watching Dr. Liew re-do some screws the fellow put in)
Injuries associated with GSW to hip? (3 in order)
bowel perforation > vascular injury > urogenital injuries
Three indications for using a plate to fix a femur fracture and three reasons it is not as good as a nail.
Indications: (there are tons, here are some)
- ipsilateral neck fracture requiring screw fixation
- fracture at distal metaphyseal-diaphyseal junction (depends on fracture pattern. Can nail a lot of these too)
- inability to access medullary canal
Drawbacks:
- Higher nonunion
- Higher malunion
- Higher hardware complications
(there are pros as well; its not all bad)
In distal aspect of anterolateral approach to humerus what two muscles will radial nerve be found between?
Brachialis and brachioradialis
What are three treatments for FES?
1) PPV
2) Fluids
3) Prompt fixation of long bone fractures
How to view entry point for SI screw?
lateral sacral view and pelvic outlet/inlet views
Roof-arc angle is not helpful in what kind of acetabular fracture?
ABC
Posterior wall
What is primary complciation of Chopart amputation and how to avoid?
- equinus
- TAL and TA to talar neck
What is proper technique for syndesmotic screw?
One or two cortical screw(s) 2-4 cm above joint, angled posterior to anterior 20-30 degrees
Blocks to reduction of medial & lateral subtalar dislocations
Medial:
- peroneal tendons
- extensor digitorum brevis
- talonavicular joint capsule
Lateral
- posterior tibialis tendon
- flexor hallucis longus
- flexor digitorum longus
- (and less commonly TN joint capsule too if head buttonholes thru)
Lateral dislocation blocked by medial structures and vice versa b/c talar head is pointed that way
Judet Approach:
- main indication
- interval
- internervous plane
- glenoid/scapular neck fractures
- infraspinatus and teres minor
- suprascapular nerve and axillary nerve
What is the most common variant of Hoffa fracture?
lateral condyle coronal fragment
Typical treatment for Sanders IV?
Primary subtalar fusion
What is the effect of reaming on vascularity surrounding soft tissues?
Increaes vascularity of surrounding soft tissues
Decreases vascularity of bone
JAAOS 2007 (Bong et al)
What fracture pattern is most at risk for spontaneous rupture of EPL?
UNDISPLACED distal radius fractures
How do you tell that you have a perfect AP of the knee?
Fibular bisector
Lateral cortex of tibia bisects fibula
Does reaming with touriquet on result in thermal necrosis?
No
Acetabular fractures: Indications for non-op management
Intact 10mm CT subchondral arc
intact 45 degree roof arc angle on all 3 views
<20% posterior wall frx (>40%=fix, 20-40 is grey zone)
Femoral head congruent with the acetabular roof on all 3 views
Mangement of tetanus prophylaxis?
5-10 years since last dose:
vaccine booster (toxoid)
>10 years since last dose:
vaccine booster (toxoid)
Not immunized or uncertain
clean, minor wound: toxoid
all other wounds: toxoid and Ig
*Only time you give Ig is not immunized and dirty wound
Wound Healing: Toe pressure should be greater than … ?
40 mmHg
Common malreduction/malunion of proximal tibia fracture
Procurvatum (extensor mechanism of knee)
Valgus (pes)
What does braking time return to normal after plafond ORIF?
8-9 weeks after surgery
vs. 6 weeks after weight bearing for LE long bone fractures or pelvic ORIF
With what movements are hip joint reactive forces highest and lowest?
Highest = rising from chair on affected leg
Lowest = Passive abduction and TTWB
Blocks to reduction of medial subtalar dislocation:
LATERAL structures
- peroneal tendons
- extensor digitorum brevis
- talonavic joint capsule (this is a medial structure but talar head can buttonhole thru it in medial dislocation)
- peroneal nv bundle
Complications with flail chest managed non-op? (6)
Prolonged ventilator support
pneumonia
respiratory difficulties
Lengthy stays in ICU
Overall mortality rate of 33%
What are 4 benefits of fixing femur fractures within 24 hours?
decreased pulmonary complications (ARDS)
decreased thromboembolic events
improved rehabilitation
decreased length of stay and cost of hospitalization
Risk factors for nonunion of femoral neck ORIF
- Non-anatomic Reduction – especially VARUS
- Posterior Comminution
- High Shear Angle(pauwel’s angle)
- Poor Implant positioning – TAD
- High Energy Injury with significant fracture displacement
