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Trauma Flashcards

1
Q

What are the risk factors for humeral shaft non-union? (7)

A
  1. distraction @ # site;
  2. open #;
  3. Vitamin D deficiency;
  4. segmental fracture;
  5. infection;
  6. stiffness;
  7. patient factors - obesity, smoking, malnutrition,non-compliance
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2
Q

What is the natural history of radial nerve recovery following humeral shaft #s?

A
  1. 8-15% incidence;
  2. 80-90% improve @ 3 months;
  3. spontaneous recovery @ 7 weeks;
  4. full recovery @ 6 months
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3
Q

What are the indications for Sx exploration of radial nerve palsy in humeral shaft #s?

A
  1. open # with palsy;
  2. no improvement over 3-6 months;
  3. fibrications seen @ 3 months - EMG
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4
Q

What is the pathoanatomic cascade of elbow dislocation?

A

LCL first to MCL last

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5
Q

What are the static stabilizers of the elbow? 1st degree and 2nd degree?

A

1st degree - UH joint, anterior bundle MCL, LCL complex;

2nd degree - RC joint, capsule, flexor/extensor origins

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6
Q

What are the dynamic stabilizers of the elbow?

A
  1. anconeus;
  2. biceps;
  3. triceps
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7
Q

What are associated injuries of radial head #s? (7)

A
  1. Essex-Lopresti lesions;
  2. IOM;
  3. coronoid #s;
  4. MCL/LCL;
  5. dislocation;
  6. terrible Triad;
  7. carpal #s
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8
Q

Where does the MCL insert on the coronoid specifically?

A
  1. 18.4 mm dorsal to tip;
  2. anterior capsule inserts 6 mm from tip
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9
Q

What is the rate of re-operation for olecranon tension banding?

A

40-80%

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10
Q

What is the most common nerve injury with Monteggia #s?

A

PIN

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11
Q

How does one treat malunion of Monteggia #?

A

ulnar osteotomy + open reduction of radial head

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12
Q

What are the 5 ligaments of the IOM in the forearm?

A
  1. central band;
  2. accessory band;
  3. distal oblique bundle;
  4. proximal oblique cord;
  5. dorsal oblique accessory cord
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13
Q

What are the indications to Tx nightstick # with no op.?

A

<50% displacement and <10 degrees angulation

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14
Q

What distance from RC joint affects stability in Galeazzi #s?

A
  1. <7.5 cm - 55% unstable;
  2. >7.5 cm <6% unstable
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15
Q

What are the signs of DRUJ injury?

A
  1. ulnar styloid #;
  2. widening of DRUJ;
  3. volar/dorsal displacement;
  4. radial shortening >=5 mm;
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16
Q

What are the factors associated with increased mortality with pelvic ring injuries? (4)

A
  1. SBP <90;
  2. age >60;
  3. increased ISS or RTS;
  4. need for >= 4 units transfusion
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17
Q

What are the complications of temporary iliac embolization? (2)

A
  1. gluteal necrosis;
  2. impotence
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18
Q

What are the indications for retrograde urethrogram? (3)

A
  1. blood @ meatus;
  2. high riding prostate;
  3. hematuria
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19
Q

What is the most common distal humerus shaft #?

A

distal intercondylar #s

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20
Q

What is the Jupiter classification for distal humerus #s?

A
  1. High T - above olecranon;
  2. Low T - below olecranon;
  3. H (free trochea - increased risk of AVN);
  4. Y;
  5. medial lambda (direction of proximal #);
  6. lateral lambda (direction of proximal #);
  7. multiplane T
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21
Q

What are the proximal and distal intervals for the medial approach to the elbow?

A
  1. Proximal - brachialis/triceps (radial) (MCN);
  2. Distal - brachioradialis/pronator teres (MED)
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22
Q

When do you go to 1. lateral decubitus; 2. prone; 3. supine for elbow #s?

A
  1. LD - isolated single limb trauma;
  2. prone - spine + contralateral extremity trauma;
  3. supine - polytrauma
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23
Q

What is the most common dislocation of the elbow?

A

posterolateral - 80%

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24
Q

What is the Tx algorithm for simple stable elbow?

A

90% - splint X 7 days with early ROM

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25
Q

How to do olecranon osteotomy?

A
  1. posterior approach;
  2. med + lat skin flaps;
  3. identify bare area - sigmoid notch;
  4. pre-drill 6.5 mm screw/plate;
  5. sponge in UH joint;
  6. apex distal chevron;
  7. osteotome to complete cut

DO NOT USE IF TEA NEEDED

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26
Q

What is the Tx algorithm for simple unstable elbow dislocations?

A

hinged brace X 2-3 weeks with progressive rehab post brace

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27
Q

What is the Tx algorithm for chronic elbow dislocations?

A
  1. open reduction;
  2. capsular release;
  3. dynamic hinged elbow external fixator
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28
Q

What is the number 1 predictor of outcome with radial head ORIF?

A

<3 fragments - Good;

>=3 fragments - Bad

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29
Q

What are the cut offs for fragment excision in radial head and coronoid #s?

A

RH - 25%;

Cap - 25-33%

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30
Q

What are the contraindications to radial head excision? (4)

A
  1. presence of destabilizing injury;
  2. interosseous ligament injury;
  3. coronoid #;
  4. MCL deficiency
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31
Q

What are the complications of radial head Fxs? (5)

A
  1. pain;
  2. PRUJ/DRUJ instability;
  3. proximal radial migration;
  4. decreased strength;
  5. cubitus vulgus
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32
Q

Describe Kaplan’s approach to lateral elbow.

A
  1. EDC (PIN) + ECRB (RAD);
  2. pronate to avoid PIN;
  3. can be extended into Thompson approach
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33
Q

In what position do you want forearm to apply a plate on the radial neck?

A

neutral (access to safe zone)

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34
Q

Where does the MCL attach on the coronoid - BE SPECIFIC

A
  1. sublime tubercle - 18 mm distal to tip;
  2. anteriormedial facet of coronoid is the attachment of anteriormedial bundle of MCL
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35
Q

What is the Tx algorithm for coronoid #s fixation?

A
  1. tip = #5 Ethibond sutures via drill holes;
  2. retrograde screws for type II + III with;
  3. anteriormedial facet injury = buttress plate
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36
Q

What are the mechanisms of injury and associated # patterns for olecranon #s?

A
  1. direct blow = comminuted;
  2. indirect blow = transverse/oblique
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37
Q

What is the non-op Tx protocol for olecranon #s?

A
  1. immobilize @ 45-90 degrees flexion X 3/52; then
  2. ROM @ 3/52
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38
Q

What are the indications for plate fixation of olecranon #s? (4)

A
  1. comminutal;
  2. Monteggia;
  3. # dislocations;
  4. oblique with coronoid extension
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39
Q

What are the indications for olecranon excision + triceps advancement? (3)

A
  1. elderly with osteoporosis;
  2. # <50% of joint;
  3. non-unions
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40
Q

What are the 2 complications of anterior ulnar cortex perforation in olecranon tension banding technique?

A
  1. AIN injury;
  2. decreased pronation
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41
Q

What is the Bryan and Morrey classification of capitellar #s?

A

T1 - large osseous piece;

T2 - shear # (thin), Kocher-Lorenz;

T3 severe comminution, Broberg-Morrey;

T4 - includes capitellum + trochlea (McKee mod.) “double bubble sign”

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42
Q

What are the operative options for capitellar #s + the indications for each?

A
  1. ORIF - Type I >2 mm displacement, Type IV;
  2. fragment excision - Type II + III with > 2 mm displacement;
  3. TEA - unreconstructable, elderly, medial column instability
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43
Q

What are the indications for TEA? (4)

A
  1. refractory RA;
  2. chronic instability;
  3. advanced OA;
  4. complex distal humerus # in elderly
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44
Q

What is the Bado classification for Monteggia #s?

A
  1. Type I - radial head anterior;
  2. Type II - radial head posterior;
  3. Type III - radial head lateral;
  4. Type IV - radius + ulna #
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45
Q

What is the most common nerve injury with Monteggia #s?

A

PIN

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46
Q

What is the most common structure blocking radial head reduction after ulnar reduction in Monteggia #s?

A

annular ligament

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47
Q

What is the radius pull test?

A

pull radius proximally:

  1. If > 3 mm instability - intraosseous membrane injury;
  2. If > 6 mm instability - IOM + TFCC injury
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48
Q

How do you perform a radiocapitellar view?

A

lateral view with gantry @ 45 degree angle to shoulder

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49
Q

What does overstuffing lead to in the RC joint? (2)

A
  1. capitellar wear;
  2. late instability
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50
Q

What is the ROM goal post distal humeral shaft #?

A

30-130 degrees (functional range)

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51
Q

How do you calculate the radial bow?

A

diagram:

  1. a = maximal radial bow = 15 mm = 10% total length;
  2. location of maximal bow (%) x/y X 100 = 60% from proximal
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52
Q

What are the indications (requirements) to treat forearm # non-op in adults? (3)

A
  1. distal 2/3 ulna #;
  2. <50% displaced;
  3. <10 degrees angulated (96% union rate)
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53
Q

What is the most important variable predicting outcomes for ORIF forearm #s?

A

radial bow

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54
Q

What is the union rate for humeral shaft #s?

A

90%

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55
Q

What are the contraindications for humeral shaft #s conservative management?

A
  1. STI or bone loss;
  2. vascular injury (requires repair); 3. brachial plexus injury
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56
Q

What is the acceptable alignment deformity for humeral shaft #s?

A
  1. <20 degrees A-P;
  2. <30 degrees V-V;
  3. <3 cm short
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57
Q

What is the incidence of radial nerve injury in Holstein-Lewis #s?

A

22%

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58
Q

What are the indications for bone grafting forearm #s in adults?

A
  1. non-unions;
  2. ulna/radius # with bone loss > 1/3 of length;
  3. segmental bone loss with open #s
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59
Q

What are the approaches for the forearm for radial shaft #s based on location?

A
  1. Volar (Henry) - 1/3 distal, 1/3 middle #s;
  2. Dorsal (Thompson) - for middle 1/3, proximal 1/3
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60
Q

What are the options for bone grafting radius and ulna #s?

A
  1. ICBG;
  2. allograft;
  3. FVFG;
  4. cancellous iliac crest
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61
Q

Name 5 risk factors for forearm compartment syndrome.

A
  1. crush;
  2. open #s;
  3. low velocity GSW;
  4. vascular injuries;
  5. coagulopathies
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62
Q

What are the 5 ligaments of the IOM of forearm?

A
  1. central band (most important);
  2. accessory band;
  3. distal oblique bundle;
  4. proximal oblique cord;
  5. dorsal oblique accessory cord
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63
Q

What bone graft has the lowest infection rate for radius/ulna shaft #s?

A

FVFG

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64
Q

When can you perform synostectomy for both bone forearm post ORIF?

A

4-6 months if RADS/indomethacin used post-op

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65
Q

What is the Tx algorithm for non-union of forearm #s failed ORIF?

A

3.5 mm LCDP with autogenous cancellous bone grafting

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66
Q

What are the risk factors for refracture following ORIF of forearm #s? (4)

A
  1. removing plates < 15 months;
  2. large plates (4.5 mm) - should use 3.5 mm;
  3. comminuted #s;
  4. persistent radiographic lucency
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67
Q

What is the rehab following plate removal in the forearm?

A

functional forearm brace X 6/52 and protected activity X 3/12

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68
Q

What are the treatment related risk factors for radioulnar synostosis? (5)

A
  1. one incision technique;
  2. delayed Sx > 2/52;
  3. screws penetrating into IOM;
  4. bone grafting into IOM;
  5. prolonged immobilization
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69
Q

What are the acceptable criteria for ORIF of DR #s?

A
  1. radial height 11 mm +/- 5 mm;
  2. radial inclination 22 degrees +/- 5 degrees;
  3. articular stepoff < 2 mm;
  4. volar tilt 11 degrees +/- <5 degrees dorsal
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70
Q

List 5 technical considerations for ex-fix for DR #s.

A
  1. relies on ligamentotaxis;
  2. radial shaft pins under direct visualization (SRN at risk);
  3. non-spanning for extra articular;
  4. carpal distraction <5 mm;
  5. limit to 8/52 + aggressive OT/PT of digits
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71
Q

A FPL rupture with Volar plate fixation is associated with what plate position?

A

distal to watershed area

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72
Q

What is the most common nerve injury with DR #s? And what is the incidence in high energy injuries?

A

median nerve injury @ 30%

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73
Q

What are the indications for actue CTR in DR #s? (2)

A
  1. progressive neuropraxia;
  2. neuropraxia does not improve with reduction + lasts > 24-48 hours
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74
Q

What is the Tx algorithm for EPL rupture post DR #?

A

If iatrogenic - cut = end to end repair;

If degeneration - EIP to EPL transfer

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75
Q

What are the most important ligaments for DRUJ stability?

A

radioulnar ligaments of TFCC

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76
Q

What are the indications for ORIF of ulnar styloid #s?

A
  1. displaced through base;
  2. sigmoid notch #s;
  3. Galeazzi #s;
  4. TFCC avulsions in the face of unstable DRUJ
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77
Q

What are the anatomical distance parameters for stable vs unstable Galeazzi #s?

A
  1. If <7.5 cm from articular surface = 55% unstable;
  2. If >7.5 cm, then only 6% unstable
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78
Q

What is the position of most stability for the DRUJ?

A

volar + dorsal radioulnar ligaments most stable in supination

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79
Q

What are the primary stabilizers of the DRUJ?

A

volar and dorsal radioulnar ligaments

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80
Q

What are 4 signs of DRUJ injury? (radiographic)

A
  1. ulnar styloid #;
  2. widening of DRUJ (AP) - compare contralateral;
  3. volar/dorsal displacement (lat);
  4. radial shortening >= 5 mm
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81
Q

What is the approach to DRUJ reduction and stabilization?

A

dorsal capsulotomy between 3/4 compartments

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82
Q

How long for DRUJ stabilization if stable post distal radius reduction + ORIF?

A

6 weeks in a cast

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83
Q

How long to leave pins in situ following DRUJ pinning?

A

4 weeks

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84
Q

What is likely to block a DRUJ reduction?

A

ECU tendon

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85
Q

What are the deforming forces causing persistent DRUJ instability?

A
  1. gravity;
  2. PQ (pronator quadratus);
  3. BR (brachioradialis)
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86
Q

What is the geometry of the sigmoid notch of the DRUJ that makes it unstable?

A
  1. shallow;
  2. 50% radius curvature of the ulnar head
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87
Q

What is the major stabilizer of the DRUJ? And which 2 ligaments?

A

TFCC;

volar and dorsal radioulnar ligaments

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88
Q

What is the leading cause of death for pelvic ring injuries? (APC)

A

hemorrhage

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89
Q

What is the most common cause of death for lateral compression pelvic ring injuries?

A

head injuries

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90
Q

What are 4 indications for mortality in pelvic ring injuries?

A
  1. SBP <90;
  2. age >60 yoa;
  3. increased ISS or RIS;
  4. transfusion >= 4 units
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91
Q

List 5 associated injuries with pelvic ring injuries.

A
  1. chest (63%);
  2. long bone # (50%);
  3. head/abdomen (40%);
  4. spine # (25%);
  5. urogenital (12-20%)
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92
Q

List 7 poor prognosis indications for pelvic ring injuries.

A
  1. SI joint incongruity >= 1 cm;
  2. increased initial displacement;
  3. malunion/residual displacement;
  4. LLD >= 2 cm;
  5. nonunion;
  6. neurological injury;
  7. urethral injury
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93
Q

What are the strongest ligaments in the body?

A

posterior sacroiliac complex

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94
Q

Why do children usually get pubic rami #s + iliac wing #s and not pelvic ring injuries?

A

open triradiate cartilage makes the iliac wing weaker than bone (reverse in adults with closed wings)

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95
Q

What is the physical exam for pelvic ring injuries?

A

skin - scrotal/labial swelling, flank hematoma, degloving injuries, posterior SI echymosis;

neuro - L5/S1 lumbosacral plexus, rectal (tone + sens);

urogenital - hematuria;

vaginal/rectal exam - mandatory to rule out open #

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96
Q

Describe the pelvic inlet view.

A
  1. gantry approx. 45 degrees caudad;
  2. adequate when S1 overlaps S2;
  3. used for assessing the AP dimension of S1
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97
Q

Describe the outlet view of the pelvis.

A
  1. xray beam angled 45 degrees cephalad;
  2. adequate when pubic symphysis overlies S2 body;
  3. used to assess sup/inf translation sacrum + foramina
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98
Q

What are 3 radiographic sign of posterior sacral instability?

A
  1. > 5 mm posterior sacral displacement;
  2. posterior sacral # gap;
  3. avulsion #s of ischial spine, ischial tuberosity, sacrum, transverse process of L5
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99
Q

Pelvic ring injury associated with the highest risk of hypovolemic shock?

A
  1. vertical shear (63%);
  2. mortality rate up to 25%
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100
Q

What is the most common source of hemorrhage of the pelvic ring?

A

posterior venous plexus (80%)

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101
Q

What are the most common sources of arterial bleeding + associated # pattern?

A
  1. superior gluteal artery (APC injuries);
  2. internal pudendal (LC injuries);
  3. obturator artery (LC injuries)
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102
Q

What goes first - pelvic ex-fix or laparotomy?

A

pelvic ex-fix

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103
Q

What arteries do you temporarily embolize for pelvic bleeding?

A

internal iliac

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104
Q

What are the 2 complications for arterial emboliation of the internal iliacs?

A
  1. gluteal necrosis;
  2. impotence
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105
Q

List 5 indications for ORIF of pelvic ring injuries.

A
  1. symphysis diastasis > 2.5 cm;
  2. SI joint displacement > 1 cm;
  3. sacral # with > 1 cm displacement;
  4. rotational deformity of hemipelvis;
  5. open #
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106
Q

What is the risk of anterior SI plating?

A

L4-L5 injury

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107
Q

What is the most common injury with SI screw placement?

A

L5

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108
Q

What is the most common complication with posterior SI tension plating?

A

painful hardware

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109
Q

What 2 views do you need for SI screw placement and what do they tell you?

A
  1. pelvic inlet = AP translation;
  2. pelvic outlet = sup/inf translation
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110
Q

What view do you need for your SI screw entry point?

A

lateral sacral view - place screw posterior to iliac cortical density (ICD)

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111
Q

What is the most common urogenital injury in pelvic ring injuries?

A

posterior urethral tear

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112
Q

What are the indications for retrograde urethrocystogram?

A
  1. blood at meatus;
  2. high riding prostate;
  3. hematuria
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113
Q

What is the maximum pubic diastasis accepted post-partum for acute injury?

A

4 cm

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114
Q

What is the order of fixation of pelvic ring injury with acetab #s?

A

fix ring 1st;

then fix acetab

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115
Q

Where does the L5 nerve root cross the sacral ala?

A

2 cm medial to the SI joint

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116
Q

What artery crosses the SI joint?

A

superior gluteal artery

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117
Q

What is the most important predictor of prognosis in sacral #s?

A

neurologic injury

118
Q

What are complications of mistreated sacral #s?

A
  1. neurologic injury;
  2. urologic injury;
  3. sexual dysfunction;
  4. rectal dysfunction;
  5. lower extremity dysfunction
119
Q

What Denis type sacral # has the highest rate of neuro injury?

A

Denis type #3 (60%)

120
Q

How many sacral #s will xray alone miss? (in a percentage)

A

70%

121
Q

What is the non-operative indication for sacral #s?

A
  1. <1 cm displacement;
  2. no neurologic deficit
122
Q

What are the operative indications for sacral #s? (4)

A
  1. displaced > 1 cm;
  2. soft tissue compromise;
  3. persistent pain after non-op Tx;
  4. displacement after non-op Tx
123
Q

What construct has the highest strength for unstable sacral #s?

A

iliolumbar fixation + iliosacral fixation (triangular osteosynthesis)

124
Q

What is the most common sacral root injury with sacral body #s?

A

S2

125
Q

What 2 structures insert on the AIIS?

A
  1. direct head of rectus femoris;
  2. Y ligament (ligament of Bigelow)
126
Q

What is the most common associated injury with acetab #s?

A

low extremity injuries (36%)

127
Q

The corona mortis is associated between which vessels?

A
  1. external iliac (epigastric);
  2. internal iliac (obturator)
128
Q

What are the elemental # patterns in the Letournel classification?

A
  1. anterior column;
  2. posterior column;
  3. anterior wall;
  4. posterior wall;
  5. transverse
129
Q

What is the only elementary acetab # to involve both columns?

A

transverse

130
Q

What are the associated # patterns of the Letournel classification of acetabular #s?

A
  1. both columns;
  2. posterior column + posterior wall;
  3. anterior column or wall + posterior hemitransverse;
  4. T-type;
  5. transverse + posterior wall
131
Q

What is the most common associated # of Letournel?

A

transverse + posterior wall

132
Q

What is the best method to test for treatment of posterior wall #s?

A

dynamic fluoroscopy

133
Q

What is the concept of secondary congruence and in which fracture type does it happen?

A

In both column acetab # the fragments remain congruent with an intact femoral head in a new usually medialized position

134
Q

What xray sign is pathogromonic for a both column #?

A

spur sign (Most displaced ilium fragment on the obturator oblique view)

135
Q

What are the indications for non-op management of acetab #s? (6)

A
  1. <2 mm displaced;
  2. <20% posterior wall (controversial) (dynamic fluoroscopy best test);
  3. femoral head congruent with acetab.;
  4. both column # with secondary congruence (out of traction);
  5. roof arc >45 degrees;
  6. contraindications to Sx - obese, dirty wound, DVT
136
Q

What are the 3 contraindications to acetab Sx?

A
  1. obese;
  2. dirty wound;
  3. DVT
137
Q

What are the indications for ORIF of acetab #s? (6)

A
  1. displacement > 2 mm of roof;
  2. posterior wall 40-50%;
  3. marginal impaction;
  4. loose bodies;
  5. irreducible #/dislocation;
  6. pregnancy is NOT a contraindication
138
Q

What is the most accurate way of determining posterior wall accuracy of ORIF and reduction?

A

CT Scan

139
Q

What are the risks of anterior approach to acetab #?

A
  1. femoral nerve;
  2. LFCN;
  3. thrombosis of femoral vessels;
  4. laceration of corona mortis (10-15%)
140
Q

What are the risks of posterior approach to acetab #?

A
  1. increased HO than anterior;
  2. sciatic nerve injury (2-10%);
  3. MFCA
141
Q

What are the indications for extended iliofemoral approach to acetab #?

A
  1. both column # if significant comminution;
  2. transverse/T-type #s;
  3. associated # patterns 21 days post injury
142
Q

What are the complications associated with extended iliofemoral approach to acetab?

A
  1. HO;
  2. gluteal muscle necrosis
143
Q

What acetab approach has the lowest incidence of HO?

A

anterior ilioinguinal

144
Q

What are 5 associated injuries with hip dislocation?

A
  1. posterior wall #s;
  2. sciatic nerve injuries;
  3. femoral head #s;
  4. ipsilateral knee injuries (25%);
  5. femoral neck #s
145
Q

What is the position of the hip for posterior dislocations?

A

flexion, adduction, interior rotation

146
Q

What is the position of the hip for anterior dislocations?

A

flexion, abduction, external rotation

147
Q

What do you look for on post hip relocation on CT scan?

A
  1. femoral head #;
  2. loose bodies;
  3. acetab #s;
  4. femoral neck #s
148
Q

What is the contraindication to hip dislocation reduction?

A

femoral neck #

149
Q

What approach do you use for an anterior/posterior hip dislocation respectively?

A

Anterior - Smith-Petersen;

Posterior - Kocher-Langenbeck

150
Q

What are the complications of simple hip dislocation?

A
  1. sciatic nerve injury (8-20%);
  2. femoral head osteonecrosis (5-40%);
  3. post-trauma arthritis (20%);
  4. recurrent dislocations (2%)
151
Q

What is the Pipkin classification of femoral head #s?

A

Type I - below ligament teres;

Type II - above ligament teres;

Type III - with dislocation;

Type IV - with acetabular #

152
Q

What are the indications for non-op management of femoral head #s? (4)

A
  1. Pipkin I;
  2. Pipkin II <1 mm step off;
  3. no loose bodies;
  4. stable hip joint
153
Q

What are the indications for ORIF of femoral head #s?

A
  1. Pipkin II > 1 mm stepoff;
  2. loose bodies;
  3. neck/acetabular #;
  4. polytrauma;
  5. irreducible #/dislocation;
  6. Pipkin IV
154
Q

What are the arthroplasty indications for Pipkin #s? (femoral head #s)

A
  1. older patients <55-60 yoa;
  2. displaced Pipkin I and II;
  3. Pipkin III and IV
155
Q

What fixation do you use for femoral head #?

A
  1. 2.7 mm or 3.5 mm screws with countersunk heads;
  2. headless screws;
  3. bioabsorbable screws
156
Q

What are 4 findings (XR) in bisphosphonate-related subtrochanteric #s?

A
  1. lateral cortical thickening;
  2. transverse;
  3. medial spike;
  4. lack of comminution
157
Q

On what side of patient is using a DHS likely to cause itroch # displacement?

A

Left (direction of screw rotation)

158
Q

What are the indications for arthroplasty in femoral neck #s?

A
  1. severe comminution;
  2. pre-existing DID;
  3. osteopososis;
  4. failed ORIF
159
Q

What are the unstable IT hip #s? (5)

A
  1. LT # (calcar);
  2. subtroch. extension;
  3. reverse obliquity;
  4. comminution;
  5. lack of lateral wall
160
Q

What are the factors that increase mortality for hip #s?

A
  1. male;
  2. IT vs Fem. neck;
  3. delay > 2 days for Sx;
  4. age > 85 yoa;
  5. > 2 pre existing cond.;
  6. ASA III or IV
161
Q

What # increases 1 year hip # rate?

A

proximal humerus #s

162
Q

What percentage of patients are converted from spinal to GA?

A

1 in 5 (20%)

163
Q

In hip # surgery, spinal has what 3 advantages over GA?

A
  1. decreased post-op delirium;
  2. decreased DVT risk;
  3. decreased early post-op death
164
Q

What is the 1 year mortality of hip #s in elderly?

A

30%

165
Q

What are the 2 most significant determinants of survival post hip fracture?

A
  1. pre-morbid mobiity;
  2. pre-morbid cognition
166
Q

Name 2 risk factors for AVN post hip #. Also, name 2 controversial risk factors for AVN post hip #.

A

Risk factors:

  1. initial displacement;
  2. poor reduction

Controversial risk factors:

  1. time to Sx;
  2. evacuation of hematoma
167
Q

What are the Tx options for varus non-union post femoral neck ORIF?

A
  1. valgus IT osteotomy;
  2. FVFG (young patient);
  3. arthroplasty;
  4. revision ORIF with bone grafting
168
Q

What are the Tx options for AVN post ORIF of femoral neck # in young patients?

A
  1. conservative;
  2. FVFG;
  3. THA;
  4. arthrodesis
169
Q

What is the disadvantage of THA vs hemi in femoral neck #s?

A

5X higher D/L rate

170
Q

What advantage does THA have over hemi in femoral neck #s? (2)

A
  1. improved functional hip scores;
  2. lower re-operation rate
171
Q

What are 4 downfalls of sliding hip screws for hip #s?

A
  1. prominent implants;
  2. affects biomechanics of hip joint;
  3. decreased SF-36 scores;
  4. decreased quality of life
172
Q

What is the best XR to delineate femoral neck #s?

A

traction 15 degrees, internal rotation AP

173
Q

What is Pauwels classification of femoral neck #s?

A

I - <30 degrees from horizon;

II - 30-50 degrees from horizon;

III - >50 degrees from horizon;

Some use 70 degrees instead of 50 degrees

174
Q

What is the Garden classification of femoral neck #s?

A

I - valgus impacted;

II - complete Fx, nondisplaced;

III - complete Fx, 50% displaced;

IV - complete Fx, fully displaced

175
Q

Give 2 reasons why femoral neck #s do not heal.

A
  1. bathed in synovial fluid (intracapsular);
  2. lack of periosteum
176
Q

How often are femoral neck #s missed with femoral shaft #s?

A

20-30% of the time

177
Q

What is the incidence of femoral neck #s with femoral shaft #s?

A

2-6%

178
Q

What is the Winquist and Hansen classification of femoral shaft #s?

A

Type O - no comminution;

Type I - insignificant comminution;

Type II - > 50% cortical contact;

Type III -<50% cortical comminution;

Type IV - segmental #

179
Q

Stabilizing a femoral shaft # within 24 hours leads to what advantage?

A
  1. decreased ARDS;
  2. increased mobility (rehab);
  3. decreased hospital costs;
  4. decreased VTE events
180
Q

What is the complication of nailing a femur in the setting of acute head injury? (2)

A
  1. hypotension;
  2. hypoxia
181
Q

What are the indications for retrograde femoral nailing? (6)

A
  1. ipsilateral femoral neck #;
  2. floating knee;
  3. ipsilateral tibia #;
  4. polytrauma;
  5. bilateral femur #;
  6. obesity
182
Q

ORIF of femural #s is inferior to IMN due to increased rates of what? (3)

A
  1. infection;
  2. non-union;
  3. hardware failure
183
Q

What are the indications for unreamed femoral nail?

A

bilateral pulmonary injuries

184
Q

When do you convert ex-fix femur to IMN post DCO?

A

2-3 weeks

185
Q

What is the complication of femural ex-fix and why?

A

knee stiffness due to scarring of quadriceps mechanism

186
Q

What are the complications of femoral nailing? (9)

A
  1. heterotopic ossification (HO) - 25%;
  2. pudendal nerve injury - 10%;
  3. femoral artery/nerve injury - rare;
  4. malunion - 10-30%;
  5. delayed union;
  6. non-union -<10%;
  7. infection;
  8. rotation malalignment;
  9. MAD (mechanical axis deviation)
187
Q

Name 3 risk factors for malunion in femoral shaft #s.

A
  1. use of fracture table;
  2. comminution;
  3. nightime Sx
188
Q

Intraoperative hypotension during femoral nailing in head injury patients has been associated with what?

A

decreased GCS

189
Q

When compared to unilateral femoral shaft #s, bilateral femoral shaft #s have increased rates of what? (4)

A
  1. hypotension;
  2. skull #s (open);
  3. pelvic #s;
  4. mortality
190
Q

What is the average neck shaft angle and the anteversion at the hip?

A
  1. 130 +/- 7 degrees;
  2. 10 +/- 7 degrees
191
Q

How does the body weight change from 2-legged stance to 1-legged stance?

A
  1. 0.5 X BW with 2 legs;
  2. 4 X BW with 1 leg
192
Q

What defines the subtrochanteric area?

A

5 cm distal to the LT

193
Q

What is the function of the linea aspera?

A

compressive strut to accommodate anterior bow to femur

194
Q

What are the indications for ORIF for proximal humeral # in peds?

A
  1. > 50% displaced;
  2. <2 years growth left;
  3. >45 degrees angulation
195
Q

What are the predictors of screw cut out for DHS in IT #s?

A
  1. TAD;
  2. screw position;
  3. # pattern;
  4. reduction;
  5. patient > 70 yoa
196
Q

What is the incidence of Hoffa Fx in distal femur OTA Type C fractures?

A

38%

197
Q

What is the arterial injury for displaced distal femur #s?

A

popliteal artery

198
Q

What OTA type distal femur # is associated most commonly with Hoffa #s?

A

Type C - 38%

199
Q

What is the post-op protocol for distal femur #s?

A

non-weight bearing, or touch-toe weight bearing X 6-8 weeks

200
Q

What is the implant of choice for distal femur #s in osteoporoic bone?

A

retrograde supracondylar nail

201
Q

How far away do you place a blade plate from the knee joint?

A

1.5 cm

202
Q

How far away do you place a DCS away from the distal femur?

A

2.0 cm

203
Q

How do you determine appropriate medial intercondylar screw length?

A

rotate beam 30 degrees internally rotated to shoot parallel to slope of medial condyle

204
Q

What is the satisfactory alignment of distal femur #s malunions after ORIF?

A

5 degrees in any plane

205
Q

What is the anatomical axis of the distal femur?

A

5-7 degrees valgus

206
Q

How frequent is bipartite patella and how frequent is it bilateral?

A

8% and 50% bilateral

207
Q

Where is the thickest articular cartilage of the body?

A

1 cm in the patella

208
Q

What are the 7 patella # patterns?

A
  1. non-displaced;
  2. transverse;
  3. pole/sleeve;
  4. vertical;
  5. marginal;
  6. osteochondral;
  7. comminuted (stellate)
209
Q

What is the post # non-op protocol for patella #s?

A

stove pipe cast/Zimmer X 2-3/52 with WBAT followed by progressive AROM in hinged knee brace

210
Q

What are 5 indications for patella ORIF? (tension band)

A
  1. extension mechanism failure;
  2. open #;
  3. displaced > 2 mm (articular);
  4. displaced > 3 mm patella;
  5. patella sleeve # (kids)
211
Q

What is the biomechanically strongest tension band construct for patella #s?

A

longitudinal cannulated screws with tension wires

212
Q

What are the indications for patellectomy?

A

sup/inf pole with <50% patella height

213
Q

What are 3 key technical points for patella ORIF?

A
  1. quads/patellar tendon re-attachment;
  2. re-attach close to articular surface;
  3. medial/lateral retinacular repair
214
Q

What is the most common complication following patella ORIF?

A

symptomatic hardware - 52% reoperate for hardware removal

215
Q

What knee dislocation has the highest rate of pop. art. injury?

A

Ant/Post knee dislocation (40-50%)

216
Q

What are the tethering points of the popliteal artery at the popliteal fossa (proximal and distal)?

A

Proximal - adductor hiatus;

Distal - fibrous tunnel at soleus muscle

217
Q

What is the incidence of common peroneal nerve injury following knee dislocation?

A

25%

218
Q

What is the most common type of knee dislocation?

A

Anterior (30-50%)

219
Q

What knee dislocation has the highest rate of complete popliteal artery tear?

A

Posterior

220
Q

Which knee dislocation has the highest rate of peroneal nerve injury?

A

Lateral

221
Q

What is the Schenck (KD) classification for knee dislocations?

A

KD I - multi with ACL or PCL;

KD II - multi with ACL and PCL;

KD III - ACL and PCL plus PMC or PLC;

KD IV - ACL and PCL and PMC and PLC;

KD V - multilig. with periarticular #

222
Q

What is the “dimple” sign in knee dislocations?

A

MFC buttonholes through medial capsule

223
Q

What does the “dimple” sign mean in knee dislocations?

A

Irreducible posterolateral D/L and contraindication to closed reduction due to skin necrosis

224
Q

What is the negative predictive value of ABI?

A

100% if ABI > 0.9

225
Q

What is the amputation rate after 8+ hours of ischemia time?

A

86%

226
Q

What are 4 indications for OR after knee dislocations?

A
  1. vascular injury;
  2. open #;
  3. irreducible dislocation;
  4. compartment syndrome
227
Q

What is the order of events in an ischemic limb for vascular intervention? (3)

A
  1. ex-fix;
  2. excision of damaged vessel and graft;
  3. fasciotomies
228
Q

When to perform Tx of ligament repair following knee dislocation?

A

improved outcomes with delayed repair <3 weeks

229
Q

What bone graft substitute has the highest compressive strength for filling voids?

A

calcium phosphate bone cement

230
Q

Name 3 poor prognostic indications in tibial plateau #s.

A
  1. lig. instability;
  2. meniscectomy;
  3. alteration of mechanical axis > 5 degrees
231
Q

What are 5 indications for ORIF of tibial plateau #s?

A
  1. artic. stepoff > 3 mm;
  2. conylar widening > 5 mm;
  3. varus/valgus instability;
  4. all medial plateau #s;
  5. all biconylar #s
232
Q

What is the non-op Tx protocol for tibial plateau #s?

A

PWB X 8-12/52 with immediate passive ROM

233
Q

What is the tibial plateau view?

A

AP knee with 10 degree caudal tilt

234
Q

In what Schatzker classification is medial meniscal tear most common?

A

Schatzker IV

235
Q

What Schatzker classification is associated with the most common meniscal tear (lateral meniscal tear)?

A

Schatzker II

236
Q

What tibial plateau Schatzker type is associated with the highest arterial injury?

A

Type IV medial # D/L

237
Q

What is the strongest predictor of long term success with ORIF of tibial plateau #s?

A

joint stability

238
Q

How much proximal bone is required for nailing proximal 1/3 tibial #s?

A

5-6 cm (enough to accept 2 locking screws)

239
Q

What are 8 indications for IM nailing tibial shaft #s?

A
  1. unacceptable casting alignment;
  2. soft tissue injury;
  3. segmental #;
  4. comminuted #;
  5. ipsilateral limb injury;
  6. polytrauma;
  7. bilateral tibia #;
  8. morbid obesity
240
Q

What holes in LISS plating of tibia place the SPN at risk?

A

holes 11-13

241
Q

In open tibial shaft #s, the use of BMP-2 has been shown to have what 4 positive effects?

A
  1. increased fracture healing;
  2. decreased need for bone grafting;
  3. decreased re-operation;
  4. decreased infection
242
Q

What are the relative indications for traumatic amputations in lower extremities?

A
  1. significant soft tissue trauma;
  2. significant ipsilateral foot trauma;
  3. warm ischemia > 6 hours
243
Q

What parapatellar approach to use in proximal 1/3 tibial shaft #s and why?

A

lateral parapatellar approach to avoid valgus deformity

244
Q

What is the complication of varus malunion in tibial shaft #s?

A

ankle pain and stiffness

245
Q

Where to place bone graft in tibial shaft #s if significant bone loss?

A

posterolateral

246
Q

Which BMP is = to autograft for grafting tibial non-unions?

A

BMP-7 (OP-1)

247
Q

What are the 3 fragments of a typical plafond #?

A
  1. medial mall. (deltoid);
  2. posterolateral (Volkmann) PITFL;
  3. anterolateral (Chaput) AITFL
248
Q

What are the negative prognostic indications for ORIF of pilon #s?

A
  1. lower SES;
  2. > 2 co-morbidities;
  3. male;
  4. work related injury;
  5. lower education level
249
Q

When does brake travel time return to normal following tibial plafond #s?

A

6 weeks after WB begins

250
Q

A 1 mm shift in talus in mortise leads to how much decrease in tibiotalar contact area?

A

42% decrease

251
Q

When does brake time return to normal following ORIF of ankle #?

A

9 weeks

252
Q

What hinders fibular reduction in a Bosworth # D/L?

A

posterolateral ridge of tibia

253
Q

What is the Canale view?

A

optimal view of talar neck:

  1. maximum equinus;
  2. 15 degrees pronated;
  3. 75 degrees cephalad
254
Q

What is the most common complication of talar neck #s?

A

subtalar OA - 50%

255
Q

What is the mechanism of injury for lateral talar process #s?

A

dorsiflexion, axial-load, inversion, external rotation

256
Q

What are the types of lateral process #s?

A

Type I - no articular surface;

Type II - subtalar and talofibular joints;

Type III - comminuted

257
Q

Pain aggravated by FHL flexion/extension is an indicator of what pathology?

A

posterolateral talar process #

258
Q

What #s are associated with medialsubtalar dislocations? (3)

A
  1. dorsomedial talar head;
  2. posterior process of talus;
  3. navicular
259
Q

What are the associated #s with lateral D/L of subtalar?

A
  1. cuboid;
  2. anterior calcaneus;
  3. lateral process of talus;
  4. fibula
260
Q

What is the postion of the foot with lateral subtalar D/L?

A

pronation

261
Q

What is the position of the foot with medial subtalar D/L?

A

supination

262
Q

What structures block medial subtalar D/L?

A
  1. peroneals;
  2. EDB;
  3. TN capsule
263
Q

What are 2 indications for olecranon excision and tricep advancement?

A
  1. elderly patient with osteoporosis, <50% of joint surface;
  2. non-unions
264
Q

What structures block lateral subtalar closed reduction?

A
  1. PT tendon;
  2. FHL;
  3. FDL
265
Q

What is the most common # associated with lateral subtalar D/L?

A

cuboid

266
Q

What is the Sander’s classification of calcaneous #s?

A

Type I - non displaced;

Type II - 2 fragments in posterior facet;

Type III - 3 fragments;

Type IV - comminuted;

Description of # lines for Type II and IIIs - A-lateral; B-middle; C-medial

267
Q

What is the normal Bohler’s angle?

A

20-40 degrees

268
Q

What is the normal angle of Gissane?

A

130-145 degrees

269
Q

What are the factors associated with likely need for ST fusion? (4)

A
  1. male;
  2. manual labour;
  3. WSIB;
  4. Bohler’s - 0 or less
270
Q

What are the indications for primary ST fusion in calcaneous #s?

A

Sanders Type IV - must combine with ORIF to maintain height/width/varus

271
Q

What is the Tx for varus malunion of calcaneous #?

A

distraction bone block subtalar arthrodesis

272
Q

What is the CT classification of calcaneal # malunion and associated Tx?

A

Type I - lateral exostosis - no ST OA - Tx with lateral wall resection;

Type II - lateral exostosis + ST OA - Tx with lateral wall resection and subtalar fusion;

Type III - lateral exostosis + ST OA + varus malunion - Tx with lateral wall resection and ST fusion and varus osteotomy

273
Q

What are the factors associated with transfer to Level 1 trauma centre? (4)

A
  1. African-American;
  2. presence of medical comorbidity;
  3. medicaid;
  4. male gender
274
Q

What are the factors associated with poor outcomes with calcaneous #s? (9)

A
  1. age >50;
  2. obesity;
  3. manual labour;
  4. WSIB;
  5. smoker;
  6. B/L #s;
  7. polytrauma;
  8. vasculopathies;
  9. male
275
Q

What xray finding is most indicative of meniscal injury in Schatzker II?

A

widening >6 mm

276
Q

What type of lateral meniscus tear is associated with Schatzker Type II injuries?

A

peripheral lateral meniscus tear

277
Q

What are the deformities in proximal 1/3 tibial shaft #s?

A
  1. valgus;
  2. procurvatum
278
Q

What is the non-op protocol for proximal 1/3 tibial #s?

A
  1. long leg cast X 4/52; then,
  2. functional brace
279
Q

What fracture must you rule out before nailing a spiral tibial #?

A

posterior mall #

280
Q

What malunion deformity with intact fibula and tibial shaft #s?

A

varus

281
Q

What is the appropriate radiograph to obtain for deltoid lig. injury in ankle #s?

A
  1. ER stress test - >= 5 mm IS +;
  2. dorsiflex + ER
282
Q

What is the blood supply to the talar neck? (40

A
  1. artery of tarsal canal (talar body);
  2. deltoid branch of posterior tibial artery;
  3. anterior tiial artery;
  4. perforating peroneal artery via artery of tarsal sinus
283
Q

How much lateral process can you take out before compromising the lateral talocalcaneal ligament?

A

1 cm (but it doesn’t matter)

284
Q

What is the closed reduction maneuver for subtalar D/L?

A
  1. knee flexion;
  2. plantar flexion;
  3. traction;
  4. evert (medial D/L), invert (lat. D/L) of hindfoot
285
Q

What is the mechanism of anterior process #s of the talus?

A

inversion and plantar flexion cause avulsion of the bifurcate ligament

286
Q

What are the non-op indications for calcaneous #s? (5)

A
  1. small extra articular #s with < 1 cm displacement;
  2. intact Achilles with <2 mm displacement;
  3. Sanders Type I;
  4. anterior process # with less than 25% CC joint;
  5. too many co-morbidities
287
Q

What are LaFontaine’s criteria for loss of reduction of DR#s?

A
  1. dorsal comminution;
  2. dorsal tilt >20 degrees;
  3. ulnar styloid;
  4. intra articular;
  5. age >50;
  6. carpal malalignment;
  7. shortening >2-3 mm
288
Q

What is the first movement to be recovered in radial nerve palsy?

A

wrist extension in radial deviation (BR 1st to recover) (extensor indicis last)

289
Q

What are 3 reasons IM nailing is superior to ex-fix for early (<24 hours) Tx of tibial shaft #s?

A
  1. decreased malalignment;
  2. decreased re-operation;
  3. decreased time to WB
290
Q

What is the incidence of ACL injury in Shatzker IV and V? (orthobullets says type V and VI)

A

25%

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