Trauma Flashcards
What are the risk factors for humeral shaft non-union? (7)
- distraction @ # site;
- open #;
- Vitamin D deficiency;
- segmental fracture;
- infection;
- stiffness;
- patient factors - obesity, smoking, malnutrition,non-compliance
What is the natural history of radial nerve recovery following humeral shaft #s?
- 8-15% incidence;
- 80-90% improve @ 3 months;
- spontaneous recovery @ 7 weeks;
- full recovery @ 6 months
What are the indications for Sx exploration of radial nerve palsy in humeral shaft #s?
- open # with palsy;
- no improvement over 3-6 months;
- fibrications seen @ 3 months - EMG
What is the pathoanatomic cascade of elbow dislocation?
LCL first to MCL last
What are the static stabilizers of the elbow? 1st degree and 2nd degree?
1st degree - UH joint, anterior bundle MCL, LCL complex;
2nd degree - RC joint, capsule, flexor/extensor origins
What are the dynamic stabilizers of the elbow?
- anconeus;
- biceps;
- triceps
What are associated injuries of radial head #s? (7)
- Essex-Lopresti lesions;
- IOM;
- coronoid #s;
- MCL/LCL;
- dislocation;
- terrible Triad;
- carpal #s
Where does the MCL insert on the coronoid specifically?
- 18.4 mm dorsal to tip;
- anterior capsule inserts 6 mm from tip
What is the rate of re-operation for olecranon tension banding?
40-80%
What is the most common nerve injury with Monteggia #s?
PIN
How does one treat malunion of Monteggia #?
ulnar osteotomy + open reduction of radial head
What are the 5 ligaments of the IOM in the forearm?
- central band;
- accessory band;
- distal oblique bundle;
- proximal oblique cord;
- dorsal oblique accessory cord
What are the indications to Tx nightstick # with no op.?
<50% displacement and <10 degrees angulation
What distance from RC joint affects stability in Galeazzi #s?
- <7.5 cm - 55% unstable;
- >7.5 cm <6% unstable
What are the signs of DRUJ injury?
- ulnar styloid #;
- widening of DRUJ;
- volar/dorsal displacement;
- radial shortening >=5 mm;
What are the factors associated with increased mortality with pelvic ring injuries? (4)
- SBP <90;
- age >60;
- increased ISS or RTS;
- need for >= 4 units transfusion
What are the complications of temporary iliac embolization? (2)
- gluteal necrosis;
- impotence
What are the indications for retrograde urethrogram? (3)
- blood @ meatus;
- high riding prostate;
- hematuria
What is the most common distal humerus shaft #?
distal intercondylar #s
What is the Jupiter classification for distal humerus #s?
- High T - above olecranon;
- Low T - below olecranon;
- H (free trochea - increased risk of AVN);
- Y;
- medial lambda (direction of proximal #);
- lateral lambda (direction of proximal #);
- multiplane T
What are the proximal and distal intervals for the medial approach to the elbow?
- Proximal - brachialis/triceps (radial) (MCN);
- Distal - brachioradialis/pronator teres (MED)
When do you go to 1. lateral decubitus; 2. prone; 3. supine for elbow #s?
- LD - isolated single limb trauma;
- prone - spine + contralateral extremity trauma;
- supine - polytrauma
What is the most common dislocation of the elbow?
posterolateral - 80%
What is the Tx algorithm for simple stable elbow?
90% - splint X 7 days with early ROM
How to do olecranon osteotomy?
- posterior approach;
- med + lat skin flaps;
- identify bare area - sigmoid notch;
- pre-drill 6.5 mm screw/plate;
- sponge in UH joint;
- apex distal chevron;
- osteotome to complete cut
DO NOT USE IF TEA NEEDED
What is the Tx algorithm for simple unstable elbow dislocations?
hinged brace X 2-3 weeks with progressive rehab post brace
What is the Tx algorithm for chronic elbow dislocations?
- open reduction;
- capsular release;
- dynamic hinged elbow external fixator
What is the number 1 predictor of outcome with radial head ORIF?
<3 fragments - Good;
>=3 fragments - Bad
What are the cut offs for fragment excision in radial head and coronoid #s?
RH - 25%;
Cap - 25-33%
What are the contraindications to radial head excision? (4)
- presence of destabilizing injury;
- interosseous ligament injury;
- coronoid #;
- MCL deficiency
What are the complications of radial head Fxs? (5)
- pain;
- PRUJ/DRUJ instability;
- proximal radial migration;
- decreased strength;
- cubitus vulgus
Describe Kaplan’s approach to lateral elbow.
- EDC (PIN) + ECRB (RAD);
- pronate to avoid PIN;
- can be extended into Thompson approach
In what position do you want forearm to apply a plate on the radial neck?
neutral (access to safe zone)
Where does the MCL attach on the coronoid - BE SPECIFIC
- sublime tubercle - 18 mm distal to tip;
- anteriormedial facet of coronoid is the attachment of anteriormedial bundle of MCL
What is the Tx algorithm for coronoid #s fixation?
- tip = #5 Ethibond sutures via drill holes;
- retrograde screws for type II + III with;
- anteriormedial facet injury = buttress plate
What are the mechanisms of injury and associated # patterns for olecranon #s?
- direct blow = comminuted;
- indirect blow = transverse/oblique
What is the non-op Tx protocol for olecranon #s?
- immobilize @ 45-90 degrees flexion X 3/52; then
- ROM @ 3/52
What are the indications for plate fixation of olecranon #s? (4)
- comminutal;
- Monteggia;
- # dislocations;
- oblique with coronoid extension
What are the indications for olecranon excision + triceps advancement? (3)
- elderly with osteoporosis;
- # <50% of joint;
- non-unions
What are the 2 complications of anterior ulnar cortex perforation in olecranon tension banding technique?
- AIN injury;
- decreased pronation
What is the Bryan and Morrey classification of capitellar #s?
T1 - large osseous piece;
T2 - shear # (thin), Kocher-Lorenz;
T3 severe comminution, Broberg-Morrey;
T4 - includes capitellum + trochlea (McKee mod.) “double bubble sign”
What are the operative options for capitellar #s + the indications for each?
- ORIF - Type I >2 mm displacement, Type IV;
- fragment excision - Type II + III with > 2 mm displacement;
- TEA - unreconstructable, elderly, medial column instability
What are the indications for TEA? (4)
- refractory RA;
- chronic instability;
- advanced OA;
- complex distal humerus # in elderly
What is the Bado classification for Monteggia #s?
- Type I - radial head anterior;
- Type II - radial head posterior;
- Type III - radial head lateral;
- Type IV - radius + ulna #
What is the most common nerve injury with Monteggia #s?
PIN
What is the most common structure blocking radial head reduction after ulnar reduction in Monteggia #s?
annular ligament
What is the radius pull test?
pull radius proximally:
- If > 3 mm instability - intraosseous membrane injury;
- If > 6 mm instability - IOM + TFCC injury
How do you perform a radiocapitellar view?
lateral view with gantry @ 45 degree angle to shoulder
What does overstuffing lead to in the RC joint? (2)
- capitellar wear;
- late instability
What is the ROM goal post distal humeral shaft #?
30-130 degrees (functional range)
How do you calculate the radial bow?
diagram:
- a = maximal radial bow = 15 mm = 10% total length;
- location of maximal bow (%) x/y X 100 = 60% from proximal
What are the indications (requirements) to treat forearm # non-op in adults? (3)
- distal 2/3 ulna #;
- <50% displaced;
- <10 degrees angulated (96% union rate)
What is the most important variable predicting outcomes for ORIF forearm #s?
radial bow
What is the union rate for humeral shaft #s?
90%
What are the contraindications for humeral shaft #s conservative management?
- STI or bone loss;
- vascular injury (requires repair); 3. brachial plexus injury
What is the acceptable alignment deformity for humeral shaft #s?
- <20 degrees A-P;
- <30 degrees V-V;
- <3 cm short
What is the incidence of radial nerve injury in Holstein-Lewis #s?
22%
What are the indications for bone grafting forearm #s in adults?
- non-unions;
- ulna/radius # with bone loss > 1/3 of length;
- segmental bone loss with open #s
What are the approaches for the forearm for radial shaft #s based on location?
- Volar (Henry) - 1/3 distal, 1/3 middle #s;
- Dorsal (Thompson) - for middle 1/3, proximal 1/3
What are the options for bone grafting radius and ulna #s?
- ICBG;
- allograft;
- FVFG;
- cancellous iliac crest
Name 5 risk factors for forearm compartment syndrome.
- crush;
- open #s;
- low velocity GSW;
- vascular injuries;
- coagulopathies
What are the 5 ligaments of the IOM of forearm?
- central band (most important);
- accessory band;
- distal oblique bundle;
- proximal oblique cord;
- dorsal oblique accessory cord
What bone graft has the lowest infection rate for radius/ulna shaft #s?
FVFG
When can you perform synostectomy for both bone forearm post ORIF?
4-6 months if RADS/indomethacin used post-op
What is the Tx algorithm for non-union of forearm #s failed ORIF?
3.5 mm LCDP with autogenous cancellous bone grafting
What are the risk factors for refracture following ORIF of forearm #s? (4)
- removing plates < 15 months;
- large plates (4.5 mm) - should use 3.5 mm;
- comminuted #s;
- persistent radiographic lucency
What is the rehab following plate removal in the forearm?
functional forearm brace X 6/52 and protected activity X 3/12
What are the treatment related risk factors for radioulnar synostosis? (5)
- one incision technique;
- delayed Sx > 2/52;
- screws penetrating into IOM;
- bone grafting into IOM;
- prolonged immobilization
What are the acceptable criteria for ORIF of DR #s?
- radial height 11 mm +/- 5 mm;
- radial inclination 22 degrees +/- 5 degrees;
- articular stepoff < 2 mm;
- volar tilt 11 degrees +/- <5 degrees dorsal
List 5 technical considerations for ex-fix for DR #s.
- relies on ligamentotaxis;
- radial shaft pins under direct visualization (SRN at risk);
- non-spanning for extra articular;
- carpal distraction <5 mm;
- limit to 8/52 + aggressive OT/PT of digits
A FPL rupture with Volar plate fixation is associated with what plate position?
distal to watershed area
What is the most common nerve injury with DR #s? And what is the incidence in high energy injuries?
median nerve injury @ 30%
What are the indications for actue CTR in DR #s? (2)
- progressive neuropraxia;
- neuropraxia does not improve with reduction + lasts > 24-48 hours
What is the Tx algorithm for EPL rupture post DR #?
If iatrogenic - cut = end to end repair;
If degeneration - EIP to EPL transfer
What are the most important ligaments for DRUJ stability?
radioulnar ligaments of TFCC
What are the indications for ORIF of ulnar styloid #s?
- displaced through base;
- sigmoid notch #s;
- Galeazzi #s;
- TFCC avulsions in the face of unstable DRUJ
What are the anatomical distance parameters for stable vs unstable Galeazzi #s?
- If <7.5 cm from articular surface = 55% unstable;
- If >7.5 cm, then only 6% unstable
What is the position of most stability for the DRUJ?
volar + dorsal radioulnar ligaments most stable in supination
What are the primary stabilizers of the DRUJ?
volar and dorsal radioulnar ligaments
What are 4 signs of DRUJ injury? (radiographic)
- ulnar styloid #;
- widening of DRUJ (AP) - compare contralateral;
- volar/dorsal displacement (lat);
- radial shortening >= 5 mm
What is the approach to DRUJ reduction and stabilization?
dorsal capsulotomy between 3/4 compartments
How long for DRUJ stabilization if stable post distal radius reduction + ORIF?
6 weeks in a cast
How long to leave pins in situ following DRUJ pinning?
4 weeks
What is likely to block a DRUJ reduction?
ECU tendon
What are the deforming forces causing persistent DRUJ instability?
- gravity;
- PQ (pronator quadratus);
- BR (brachioradialis)
What is the geometry of the sigmoid notch of the DRUJ that makes it unstable?
- shallow;
- 50% radius curvature of the ulnar head
What is the major stabilizer of the DRUJ? And which 2 ligaments?
TFCC;
volar and dorsal radioulnar ligaments
What is the leading cause of death for pelvic ring injuries? (APC)
hemorrhage
What is the most common cause of death for lateral compression pelvic ring injuries?
head injuries
What are 4 indications for mortality in pelvic ring injuries?
- SBP <90;
- age >60 yoa;
- increased ISS or RIS;
- transfusion >= 4 units
List 5 associated injuries with pelvic ring injuries.
- chest (63%);
- long bone # (50%);
- head/abdomen (40%);
- spine # (25%);
- urogenital (12-20%)
List 7 poor prognosis indications for pelvic ring injuries.
- SI joint incongruity >= 1 cm;
- increased initial displacement;
- malunion/residual displacement;
- LLD >= 2 cm;
- nonunion;
- neurological injury;
- urethral injury
What are the strongest ligaments in the body?
posterior sacroiliac complex
Why do children usually get pubic rami #s + iliac wing #s and not pelvic ring injuries?
open triradiate cartilage makes the iliac wing weaker than bone (reverse in adults with closed wings)
What is the physical exam for pelvic ring injuries?
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 #
Describe the pelvic inlet view.
- gantry approx. 45 degrees caudad;
- adequate when S1 overlaps S2;
- used for assessing the AP dimension of S1
Describe the outlet view of the pelvis.
- xray beam angled 45 degrees cephalad;
- adequate when pubic symphysis overlies S2 body;
- used to assess sup/inf translation sacrum + foramina
What are 3 radiographic sign of posterior sacral instability?
- > 5 mm posterior sacral displacement;
- posterior sacral # gap;
- avulsion #s of ischial spine, ischial tuberosity, sacrum, transverse process of L5
Pelvic ring injury associated with the highest risk of hypovolemic shock?
- vertical shear (63%);
- mortality rate up to 25%
What is the most common source of hemorrhage of the pelvic ring?
posterior venous plexus (80%)
What are the most common sources of arterial bleeding + associated # pattern?
- superior gluteal artery (APC injuries);
- internal pudendal (LC injuries);
- obturator artery (LC injuries)
What goes first - pelvic ex-fix or laparotomy?
pelvic ex-fix
What arteries do you temporarily embolize for pelvic bleeding?
internal iliac
What are the 2 complications for arterial emboliation of the internal iliacs?
- gluteal necrosis;
- impotence
List 5 indications for ORIF of pelvic ring injuries.
- symphysis diastasis > 2.5 cm;
- SI joint displacement > 1 cm;
- sacral # with > 1 cm displacement;
- rotational deformity of hemipelvis;
- open #
What is the risk of anterior SI plating?
L4-L5 injury
What is the most common injury with SI screw placement?
L5
What is the most common complication with posterior SI tension plating?
painful hardware
What 2 views do you need for SI screw placement and what do they tell you?
- pelvic inlet = AP translation;
- pelvic outlet = sup/inf translation
What view do you need for your SI screw entry point?
lateral sacral view - place screw posterior to iliac cortical density (ICD)
What is the most common urogenital injury in pelvic ring injuries?
posterior urethral tear
What are the indications for retrograde urethrocystogram?
- blood at meatus;
- high riding prostate;
- hematuria
What is the maximum pubic diastasis accepted post-partum for acute injury?
4 cm
What is the order of fixation of pelvic ring injury with acetab #s?
fix ring 1st;
then fix acetab
Where does the L5 nerve root cross the sacral ala?
2 cm medial to the SI joint
What artery crosses the SI joint?
superior gluteal artery
What is the most important predictor of prognosis in sacral #s?
neurologic injury
What are complications of mistreated sacral #s?
- neurologic injury;
- urologic injury;
- sexual dysfunction;
- rectal dysfunction;
- lower extremity dysfunction
What Denis type sacral # has the highest rate of neuro injury?
Denis type #3 (60%)
How many sacral #s will xray alone miss? (in a percentage)
70%
What is the non-operative indication for sacral #s?
- <1 cm displacement;
- no neurologic deficit
What are the operative indications for sacral #s? (4)
- displaced > 1 cm;
- soft tissue compromise;
- persistent pain after non-op Tx;
- displacement after non-op Tx
What construct has the highest strength for unstable sacral #s?
iliolumbar fixation + iliosacral fixation (triangular osteosynthesis)
What is the most common sacral root injury with sacral body #s?
S2
What 2 structures insert on the AIIS?
- direct head of rectus femoris;
- Y ligament (ligament of Bigelow)
What is the most common associated injury with acetab #s?
low extremity injuries (36%)
The corona mortis is associated between which vessels?
- external iliac (epigastric);
- internal iliac (obturator)
What are the elemental # patterns in the Letournel classification?
- anterior column;
- posterior column;
- anterior wall;
- posterior wall;
- transverse
What is the only elementary acetab # to involve both columns?
transverse
What are the associated # patterns of the Letournel classification of acetabular #s?
- both columns;
- posterior column + posterior wall;
- anterior column or wall + posterior hemitransverse;
- T-type;
- transverse + posterior wall
What is the most common associated # of Letournel?
transverse + posterior wall
What is the best method to test for treatment of posterior wall #s?
dynamic fluoroscopy
What is the concept of secondary congruence and in which fracture type does it happen?
In both column acetab # the fragments remain congruent with an intact femoral head in a new usually medialized position
What xray sign is pathogromonic for a both column #?
spur sign (Most displaced ilium fragment on the obturator oblique view)
What are the indications for non-op management of acetab #s? (6)
- <2 mm displaced;
- <20% posterior wall (controversial) (dynamic fluoroscopy best test);
- femoral head congruent with acetab.;
- both column # with secondary congruence (out of traction);
- roof arc >45 degrees;
- contraindications to Sx - obese, dirty wound, DVT
What are the 3 contraindications to acetab Sx?
- obese;
- dirty wound;
- DVT
What are the indications for ORIF of acetab #s? (6)
- displacement > 2 mm of roof;
- posterior wall 40-50%;
- marginal impaction;
- loose bodies;
- irreducible #/dislocation;
- pregnancy is NOT a contraindication
What is the most accurate way of determining posterior wall accuracy of ORIF and reduction?
CT Scan
What are the risks of anterior approach to acetab #?
- femoral nerve;
- LFCN;
- thrombosis of femoral vessels;
- laceration of corona mortis (10-15%)
What are the risks of posterior approach to acetab #?
- increased HO than anterior;
- sciatic nerve injury (2-10%);
- MFCA
What are the indications for extended iliofemoral approach to acetab #?
- both column # if significant comminution;
- transverse/T-type #s;
- associated # patterns 21 days post injury
What are the complications associated with extended iliofemoral approach to acetab?
- HO;
- gluteal muscle necrosis
What acetab approach has the lowest incidence of HO?
anterior ilioinguinal
What are 5 associated injuries with hip dislocation?
- posterior wall #s;
- sciatic nerve injuries;
- femoral head #s;
- ipsilateral knee injuries (25%);
- femoral neck #s
What is the position of the hip for posterior dislocations?
flexion, adduction, interior rotation
What is the position of the hip for anterior dislocations?
flexion, abduction, external rotation
What do you look for on post hip relocation on CT scan?
- femoral head #;
- loose bodies;
- acetab #s;
- femoral neck #s
What is the contraindication to hip dislocation reduction?
femoral neck #
What approach do you use for an anterior/posterior hip dislocation respectively?
Anterior - Smith-Petersen;
Posterior - Kocher-Langenbeck
What are the complications of simple hip dislocation?
- sciatic nerve injury (8-20%);
- femoral head osteonecrosis (5-40%);
- post-trauma arthritis (20%);
- recurrent dislocations (2%)
What is the Pipkin classification of femoral head #s?
Type I - below ligament teres;
Type II - above ligament teres;
Type III - with dislocation;
Type IV - with acetabular #
What are the indications for non-op management of femoral head #s? (4)
- Pipkin I;
- Pipkin II <1 mm step off;
- no loose bodies;
- stable hip joint
What are the indications for ORIF of femoral head #s?
- Pipkin II > 1 mm stepoff;
- loose bodies;
- neck/acetabular #;
- polytrauma;
- irreducible #/dislocation;
- Pipkin IV
What are the arthroplasty indications for Pipkin #s? (femoral head #s)
- older patients <55-60 yoa;
- displaced Pipkin I and II;
- Pipkin III and IV
What fixation do you use for femoral head #?
- 2.7 mm or 3.5 mm screws with countersunk heads;
- headless screws;
- bioabsorbable screws
What are 4 findings (XR) in bisphosphonate-related subtrochanteric #s?
- lateral cortical thickening;
- transverse;
- medial spike;
- lack of comminution
On what side of patient is using a DHS likely to cause itroch # displacement?
Left (direction of screw rotation)
What are the indications for arthroplasty in femoral neck #s?
- severe comminution;
- pre-existing DID;
- osteopososis;
- failed ORIF
What are the unstable IT hip #s? (5)
- LT # (calcar);
- subtroch. extension;
- reverse obliquity;
- comminution;
- lack of lateral wall
What are the factors that increase mortality for hip #s?
- male;
- IT vs Fem. neck;
- delay > 2 days for Sx;
- age > 85 yoa;
- > 2 pre existing cond.;
- ASA III or IV
What # increases 1 year hip # rate?
proximal humerus #s
What percentage of patients are converted from spinal to GA?
1 in 5 (20%)
In hip # surgery, spinal has what 3 advantages over GA?
- decreased post-op delirium;
- decreased DVT risk;
- decreased early post-op death
What is the 1 year mortality of hip #s in elderly?
30%
What are the 2 most significant determinants of survival post hip fracture?
- pre-morbid mobiity;
- pre-morbid cognition
Name 2 risk factors for AVN post hip #. Also, name 2 controversial risk factors for AVN post hip #.
Risk factors:
- initial displacement;
- poor reduction
Controversial risk factors:
- time to Sx;
- evacuation of hematoma
What are the Tx options for varus non-union post femoral neck ORIF?
- valgus IT osteotomy;
- FVFG (young patient);
- arthroplasty;
- revision ORIF with bone grafting
What are the Tx options for AVN post ORIF of femoral neck # in young patients?
- conservative;
- FVFG;
- THA;
- arthrodesis
What is the disadvantage of THA vs hemi in femoral neck #s?
5X higher D/L rate
What advantage does THA have over hemi in femoral neck #s? (2)
- improved functional hip scores;
- lower re-operation rate
What are 4 downfalls of sliding hip screws for hip #s?
- prominent implants;
- affects biomechanics of hip joint;
- decreased SF-36 scores;
- decreased quality of life
What is the best XR to delineate femoral neck #s?
traction 15 degrees, internal rotation AP
What is Pauwels classification of femoral neck #s?
I - <30 degrees from horizon;
II - 30-50 degrees from horizon;
III - >50 degrees from horizon;
Some use 70 degrees instead of 50 degrees
What is the Garden classification of femoral neck #s?
I - valgus impacted;
II - complete Fx, nondisplaced;
III - complete Fx, 50% displaced;
IV - complete Fx, fully displaced
Give 2 reasons why femoral neck #s do not heal.
- bathed in synovial fluid (intracapsular);
- lack of periosteum
How often are femoral neck #s missed with femoral shaft #s?
20-30% of the time
What is the incidence of femoral neck #s with femoral shaft #s?
2-6%
What is the Winquist and Hansen classification of femoral shaft #s?
Type O - no comminution;
Type I - insignificant comminution;
Type II - > 50% cortical contact;
Type III -<50% cortical comminution;
Type IV - segmental #
Stabilizing a femoral shaft # within 24 hours leads to what advantage?
- decreased ARDS;
- increased mobility (rehab);
- decreased hospital costs;
- decreased VTE events
What is the complication of nailing a femur in the setting of acute head injury? (2)
- hypotension;
- hypoxia
What are the indications for retrograde femoral nailing? (6)
- ipsilateral femoral neck #;
- floating knee;
- ipsilateral tibia #;
- polytrauma;
- bilateral femur #;
- obesity
ORIF of femural #s is inferior to IMN due to increased rates of what? (3)
- infection;
- non-union;
- hardware failure
What are the indications for unreamed femoral nail?
bilateral pulmonary injuries
When do you convert ex-fix femur to IMN post DCO?
2-3 weeks
What is the complication of femural ex-fix and why?
knee stiffness due to scarring of quadriceps mechanism
What are the complications of femoral nailing? (9)
- heterotopic ossification (HO) - 25%;
- pudendal nerve injury - 10%;
- femoral artery/nerve injury - rare;
- malunion - 10-30%;
- delayed union;
- non-union -<10%;
- infection;
- rotation malalignment;
- MAD (mechanical axis deviation)
Name 3 risk factors for malunion in femoral shaft #s.
- use of fracture table;
- comminution;
- nightime Sx
Intraoperative hypotension during femoral nailing in head injury patients has been associated with what?
decreased GCS
When compared to unilateral femoral shaft #s, bilateral femoral shaft #s have increased rates of what? (4)
- hypotension;
- skull #s (open);
- pelvic #s;
- mortality
What is the average neck shaft angle and the anteversion at the hip?
- 130 +/- 7 degrees;
- 10 +/- 7 degrees
How does the body weight change from 2-legged stance to 1-legged stance?
- 0.5 X BW with 2 legs;
- 4 X BW with 1 leg
What defines the subtrochanteric area?
5 cm distal to the LT
What is the function of the linea aspera?
compressive strut to accommodate anterior bow to femur
What are the indications for ORIF for proximal humeral # in peds?
- > 50% displaced;
- <2 years growth left;
- >45 degrees angulation
What are the predictors of screw cut out for DHS in IT #s?
- TAD;
- screw position;
- # pattern;
- reduction;
- patient > 70 yoa
What is the incidence of Hoffa Fx in distal femur OTA Type C fractures?
38%
What is the arterial injury for displaced distal femur #s?
popliteal artery
What OTA type distal femur # is associated most commonly with Hoffa #s?
Type C - 38%
What is the post-op protocol for distal femur #s?
non-weight bearing, or touch-toe weight bearing X 6-8 weeks
What is the implant of choice for distal femur #s in osteoporoic bone?
retrograde supracondylar nail
How far away do you place a blade plate from the knee joint?
1.5 cm
How far away do you place a DCS away from the distal femur?
2.0 cm
How do you determine appropriate medial intercondylar screw length?
rotate beam 30 degrees internally rotated to shoot parallel to slope of medial condyle
What is the satisfactory alignment of distal femur #s malunions after ORIF?
5 degrees in any plane
What is the anatomical axis of the distal femur?
5-7 degrees valgus
How frequent is bipartite patella and how frequent is it bilateral?
8% and 50% bilateral
Where is the thickest articular cartilage of the body?
1 cm in the patella
What are the 7 patella # patterns?
- non-displaced;
- transverse;
- pole/sleeve;
- vertical;
- marginal;
- osteochondral;
- comminuted (stellate)
What is the post # non-op protocol for patella #s?
stove pipe cast/Zimmer X 2-3/52 with WBAT followed by progressive AROM in hinged knee brace
What are 5 indications for patella ORIF? (tension band)
- extension mechanism failure;
- open #;
- displaced > 2 mm (articular);
- displaced > 3 mm patella;
- patella sleeve # (kids)
What is the biomechanically strongest tension band construct for patella #s?
longitudinal cannulated screws with tension wires
What are the indications for patellectomy?
sup/inf pole with <50% patella height
What are 3 key technical points for patella ORIF?
- quads/patellar tendon re-attachment;
- re-attach close to articular surface;
- medial/lateral retinacular repair
What is the most common complication following patella ORIF?
symptomatic hardware - 52% reoperate for hardware removal
What knee dislocation has the highest rate of pop. art. injury?
Ant/Post knee dislocation (40-50%)
What are the tethering points of the popliteal artery at the popliteal fossa (proximal and distal)?
Proximal - adductor hiatus;
Distal - fibrous tunnel at soleus muscle
What is the incidence of common peroneal nerve injury following knee dislocation?
25%
What is the most common type of knee dislocation?
Anterior (30-50%)
What knee dislocation has the highest rate of complete popliteal artery tear?
Posterior
Which knee dislocation has the highest rate of peroneal nerve injury?
Lateral
What is the Schenck (KD) classification for knee dislocations?
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 #
What is the “dimple” sign in knee dislocations?
MFC buttonholes through medial capsule
What does the “dimple” sign mean in knee dislocations?
Irreducible posterolateral D/L and contraindication to closed reduction due to skin necrosis
What is the negative predictive value of ABI?
100% if ABI > 0.9
What is the amputation rate after 8+ hours of ischemia time?
86%
What are 4 indications for OR after knee dislocations?
- vascular injury;
- open #;
- irreducible dislocation;
- compartment syndrome
What is the order of events in an ischemic limb for vascular intervention? (3)
- ex-fix;
- excision of damaged vessel and graft;
- fasciotomies
When to perform Tx of ligament repair following knee dislocation?
improved outcomes with delayed repair <3 weeks
What bone graft substitute has the highest compressive strength for filling voids?
calcium phosphate bone cement
Name 3 poor prognostic indications in tibial plateau #s.
- lig. instability;
- meniscectomy;
- alteration of mechanical axis > 5 degrees
What are 5 indications for ORIF of tibial plateau #s?
- artic. stepoff > 3 mm;
- conylar widening > 5 mm;
- varus/valgus instability;
- all medial plateau #s;
- all biconylar #s
What is the non-op Tx protocol for tibial plateau #s?
PWB X 8-12/52 with immediate passive ROM
What is the tibial plateau view?
AP knee with 10 degree caudal tilt
In what Schatzker classification is medial meniscal tear most common?
Schatzker IV
What Schatzker classification is associated with the most common meniscal tear (lateral meniscal tear)?
Schatzker II
What tibial plateau Schatzker type is associated with the highest arterial injury?
Type IV medial # D/L
What is the strongest predictor of long term success with ORIF of tibial plateau #s?
joint stability
How much proximal bone is required for nailing proximal 1/3 tibial #s?
5-6 cm (enough to accept 2 locking screws)
What are 8 indications for IM nailing tibial shaft #s?
- unacceptable casting alignment;
- soft tissue injury;
- segmental #;
- comminuted #;
- ipsilateral limb injury;
- polytrauma;
- bilateral tibia #;
- morbid obesity
What holes in LISS plating of tibia place the SPN at risk?
holes 11-13
In open tibial shaft #s, the use of BMP-2 has been shown to have what 4 positive effects?
- increased fracture healing;
- decreased need for bone grafting;
- decreased re-operation;
- decreased infection
What are the relative indications for traumatic amputations in lower extremities?
- significant soft tissue trauma;
- significant ipsilateral foot trauma;
- warm ischemia > 6 hours
What parapatellar approach to use in proximal 1/3 tibial shaft #s and why?
lateral parapatellar approach to avoid valgus deformity
What is the complication of varus malunion in tibial shaft #s?
ankle pain and stiffness
Where to place bone graft in tibial shaft #s if significant bone loss?
posterolateral
Which BMP is = to autograft for grafting tibial non-unions?
BMP-7 (OP-1)
What are the 3 fragments of a typical plafond #?
- medial mall. (deltoid);
- posterolateral (Volkmann) PITFL;
- anterolateral (Chaput) AITFL
What are the negative prognostic indications for ORIF of pilon #s?
- lower SES;
- > 2 co-morbidities;
- male;
- work related injury;
- lower education level
When does brake travel time return to normal following tibial plafond #s?
6 weeks after WB begins
A 1 mm shift in talus in mortise leads to how much decrease in tibiotalar contact area?
42% decrease
When does brake time return to normal following ORIF of ankle #?
9 weeks
What hinders fibular reduction in a Bosworth # D/L?
posterolateral ridge of tibia
What is the Canale view?
optimal view of talar neck:
- maximum equinus;
- 15 degrees pronated;
- 75 degrees cephalad
What is the most common complication of talar neck #s?
subtalar OA - 50%
What is the mechanism of injury for lateral talar process #s?
dorsiflexion, axial-load, inversion, external rotation
What are the types of lateral process #s?
Type I - no articular surface;
Type II - subtalar and talofibular joints;
Type III - comminuted
Pain aggravated by FHL flexion/extension is an indicator of what pathology?
posterolateral talar process #
What #s are associated with medialsubtalar dislocations? (3)
- dorsomedial talar head;
- posterior process of talus;
- navicular
What are the associated #s with lateral D/L of subtalar?
- cuboid;
- anterior calcaneus;
- lateral process of talus;
- fibula
What is the postion of the foot with lateral subtalar D/L?
pronation
What is the position of the foot with medial subtalar D/L?
supination
What structures block medial subtalar D/L?
- peroneals;
- EDB;
- TN capsule
What are 2 indications for olecranon excision and tricep advancement?
- elderly patient with osteoporosis, <50% of joint surface;
- non-unions
What structures block lateral subtalar closed reduction?
- PT tendon;
- FHL;
- FDL
What is the most common # associated with lateral subtalar D/L?
cuboid
What is the Sander’s classification of calcaneous #s?
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
What is the normal Bohler’s angle?
20-40 degrees
What is the normal angle of Gissane?
130-145 degrees
What are the factors associated with likely need for ST fusion? (4)
- male;
- manual labour;
- WSIB;
- Bohler’s - 0 or less
What are the indications for primary ST fusion in calcaneous #s?
Sanders Type IV - must combine with ORIF to maintain height/width/varus
What is the Tx for varus malunion of calcaneous #?
distraction bone block subtalar arthrodesis
What is the CT classification of calcaneal # malunion and associated Tx?
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
What are the factors associated with transfer to Level 1 trauma centre? (4)
- African-American;
- presence of medical comorbidity;
- medicaid;
- male gender
What are the factors associated with poor outcomes with calcaneous #s? (9)
- age >50;
- obesity;
- manual labour;
- WSIB;
- smoker;
- B/L #s;
- polytrauma;
- vasculopathies;
- male
What xray finding is most indicative of meniscal injury in Schatzker II?
widening >6 mm
What type of lateral meniscus tear is associated with Schatzker Type II injuries?
peripheral lateral meniscus tear
What are the deformities in proximal 1/3 tibial shaft #s?
- valgus;
- procurvatum
What is the non-op protocol for proximal 1/3 tibial #s?
- long leg cast X 4/52; then,
- functional brace
What fracture must you rule out before nailing a spiral tibial #?
posterior mall #
What malunion deformity with intact fibula and tibial shaft #s?
varus
What is the appropriate radiograph to obtain for deltoid lig. injury in ankle #s?
- ER stress test - >= 5 mm IS +;
- dorsiflex + ER
What is the blood supply to the talar neck? (40
- artery of tarsal canal (talar body);
- deltoid branch of posterior tibial artery;
- anterior tiial artery;
- perforating peroneal artery via artery of tarsal sinus
How much lateral process can you take out before compromising the lateral talocalcaneal ligament?
1 cm (but it doesn’t matter)
What is the closed reduction maneuver for subtalar D/L?
- knee flexion;
- plantar flexion;
- traction;
- evert (medial D/L), invert (lat. D/L) of hindfoot
What is the mechanism of anterior process #s of the talus?
inversion and plantar flexion cause avulsion of the bifurcate ligament
What are the non-op indications for calcaneous #s? (5)
- small extra articular #s with < 1 cm displacement;
- intact Achilles with <2 mm displacement;
- Sanders Type I;
- anterior process # with less than 25% CC joint;
- too many co-morbidities
What are LaFontaine’s criteria for loss of reduction of DR#s?
- dorsal comminution;
- dorsal tilt >20 degrees;
- ulnar styloid;
- intra articular;
- age >50;
- carpal malalignment;
- shortening >2-3 mm
What is the first movement to be recovered in radial nerve palsy?
wrist extension in radial deviation (BR 1st to recover) (extensor indicis last)
What are 3 reasons IM nailing is superior to ex-fix for early (<24 hours) Tx of tibial shaft #s?
- decreased malalignment;
- decreased re-operation;
- decreased time to WB
What is the incidence of ACL injury in Shatzker IV and V? (orthobullets says type V and VI)
25%