Trauma Flashcards
What is IL-6 associated with in trauma patients?
Elevated IL-6 is associated with higher injury severity scores and increased mortality rates in polytrauma patients.
Why should tibial nails be reamed without the use of a tourniquet?
Limb reperfussion after tourniquet ischemia causes pulmonary microvascular injury.
What radiographic findings of a tibial plateau fracture correlate with a meniscal tear?
Schatzker type II fractures with >6mm of joint depression and widening >5mm were associated with a lateral meniscal injury over 80% of the time.
How do ROM and strength compare between displaced mid shaft clavicle fractures treater operatively and non-operatively?
Motion is the same, but strength is decreased to about 80% in planes of motion.
True or false current literature has found that clavicle fractures shortened by 2 cm that are treated operatively have better Constant and DASH scores at all points in time that those treated non-operatively?
True. See COTS et al. multicenter randomized controlled trial of 132 patients.
Should you transpose the ulnar nerve following fixation of an intra-articular distal humerus fracture?
No literature supports a decreased incidence of neuropathy after distal humerus fixation. Some paper show an increase of ulnar neuropathy.
What is a common injury associated with lateral compression fractures of the pelvis?
Closed head injuries?
What is the most common complication after displaced alar neck fractures following operative treatment?
Post-traumatic arthritis. More common that osteonecrosis as some literature shows rates of sub-alar arthritis to be 100%.
What is the golden hour? What percentage of preventable deaths occur during this time?
Period of time when life threatening and limb threatening injuries should be treated in order to decrease mortality. 60%
What position should pregnant women involved in a trauma be placed in?
left lateral decubitus position. Avoid compression of the inferior vena cava.
What are the classes of hemorrhagic shock?
What amount of blood does the average adult have?
Average child (2-10)?
4.7-5 Liters for 70kg Male
75-80ml/kg
What are laboratory indicators of adequate resuscitation?
Urine output .5-1.0 ml/kg/hr (30cc/hr)
Lactate normal <2.5 mmol/L
Base deficit -2 to +2
gastric mucosal pH > 7.3
Which virus is most at risk from tranfusion?
Hepatits B 1 in 205,000 donations
Hepatitis C 1 in 1.8 million donations
HIV 1 in 1.9 million
What parameters should lead you to treat a patient with damage control orthopaedics?
ISS >40 without thoracic trauma and ISS > 20 with thoracic trauma.
GCS of 8 or below.
Multiple injuries and hemorrhagic shock.
Bilateral femoral fractures
pulmonary contusion noted on radiographs
Hypothermia <35 degrees
Head injury with AIS of 3 or greater
IL-6 values above 500pg/dL
When is the acute inflammatory window where patients are at a higher risk of ARDS?
2-5 days.
When should femurs be converted form ex-fix to IMN?
tibias?
within 3 weeks.
7-10 days.
How is Glasgow Coma Scale calculated?
Best Motor Response 1-6: None, decerebrate (extension withdrawal), decorticate (flexion withdrawal), normal withdrawal, localized pain, obeys commands.
Best Verbal Response 1-5: None, incomprehensible sounds, inappropriate words, cofused conversation, and oriented.
Eye Opening 1-4: None, to pain, to speech, and spontaneous.
BRAIN INJURY: Severe <9, Moderate 9-12, Minor 13 and above.
How is ISS calculated.
AIS 1-6 score of 9 body regions. 0- no injury 1- minor 2-moderate 3- severe (not life threatening) 4- severe (life threatening survival probable) 5- severe (survival uncertain) 6- maximal (possibly fatal).
sum of squares for the three highest regions.
Out of 75
Single score of any region of 6 = automatic score of 75
ISS > 15 mortality of 10%
What is the New Injury Severity Score (NISS)?
Takes three highest scores regardless of anatomic area.
More predicitive of complications and mortality than ISS.
How is SIRS calculated?
Heart rate > 90 beats = 1
WBC count <4000 OR >12,000 = 1
RR > 20 OR PaCO2 < 32mm = 1
Temperature <36 OR >38 = 1
Score of 2 or more meets criteria for SIRS
What advantage has been shown when open fractures undergo I&D within 6 hours compared to 24 hours?
No clinical advantage has been shown.
However most centers recommend doing it within 6 hours still.
What is an alternative to a saline load to test for traumatic arthrotomy?
CT scan.
Some studies have shown this to be more effective.
How is tetanus prophylaxis given?
Toxoid .5ml regardless of age.
immunoglobulin <5 years old receive 75 U, 5-10 years receive 125 U, > 10 years receive 250 U.
toxoid and immunoglobulin should be given in different locations with different syringes.
What abx is recommended for Gustilo type I and II?
1st generation cephalosporin.
Clindamycin or vancomycin if allergies exist.
What abx is recommended in Gustilo type III fractures?
1st generation cephalosporin + aminoglycoside.
What abx should be added for farm injuries, heavy contamination, or possible bowel contamination?
High dose penicillin for anaerobic coverage.
Soil can have Clostridium botulinum which is a Gram Positive Bacilli.
What abx should be added for fresh water wounds?
fluoroquinolones
3rd or 4th generation cephalosporin
What abx is recommended for saltwarer wounds?
doxycycline + ceftazidime
Or a fluoroquinolone.
When do open fractures with soft tissue defects need to be covered?
The earlier the better. For open tibias <5 days is desired.
Increased risk of infection beyond 7 days.
What is the in hospital mortality rate and at one year post-op for hip fractures in geriatric patients?
6%
30%
Geriatric co-management of trauma patients has been demonstrated to yield?
Decreased mortality
Decreased time to surgery
Decreased post-operative complications
Decreased length of stay (controversial)
Improved post-operative mobility
What is the second leading cause of death for youth in the United States?
GSW
What is yaw in regards to projectiles?
tendency of a bullet to tumble in flight.
What has the greatest increase on kinetic energy of a bullet?
velocity.
KE = 1/2M * Vsquared
What is plumbism and what is its systemic effects?
Lead intoxication
neurotoxicity, anemia, emesis, and abdominal colic
What is the most commonly assoicated injury with a GSW to the hip and acetabulum?
bowel perforation>vascular injury>urogenital injury
What is considered a low velocity GSW and what is its comparable Gustillo-Anderon?
High Velicty?
<350 meters per second or < 2,000 fps GA I and II
>600 mps GA III regardless of wound size. High risk of infection.
What is the most common reason for amputation?
What is the most common reason for upper extremity amputation?
80% are for vascular insufficiency
Trauma
What should be offered to all patients who undergo an amputation?
formal psychological counseling to review coping and stress management techniques.
Psychological effects negatively affect patient-reported outcomes and are associated with worse pain complaints.
Is absence of plantar sensation a relative or absolute contraindication to reconstruction in severe lower extremity injuries?
Relative.
Can be some recovery of plantat sensation long term.
What has the highest impact on the decision-making process for amputation vs reconstruction?
Severity of soft tissue injury.
What is the difference between sickness impact profile and return to work between amputation and reconstruction at 2 years in limb-threatening injuries?
Not significantly different.
What is the most important factor in determining patient-reported outcome after treatment for a limb threatening injury?
Ability to return to work.
Approximately 50% are able to return to work.
What is the % increase in metabilic demand for bilateral amputation?
BKA + BKA
AKA + BKA
AKA + AKA
40%
118%
>200%
What is the most proximal lower extremity amputation a child can undergo and maintain walking spees without increased energy expenditure compared to normal children?
thru-knee amputation
Is there a difference in metabolic demand after amputation for traumatic reasons vs vascular?
Yes
Long BKA 10% vs 40%
Transfemoral 68% vs 100%
Average increase in metablic demand for
Syme amputation
BKA (traumatic)
15%
25% (10% for long 40% for short)
Wound healing after amputation is improved with what values for:
Albumin
Ischemis Index
TCPO2
toe pressure
ABI
TLC
> 3.0 g/dl
> .5 (doppler pressure at level being tested compared to brachial systolic pressure)
>30mm Hg (ideally 45 mm Hg)
> .45
> 1500/mm3
Contraindications to hyperbaric oxygen therapy?
Chemo or radiation.
Pressure sensitive implanted medical device such as pacemakers, defibrillators, dorsal column stimulator, and insulin pumps.
undrained pneumothorax.
What is the purpose of preserving all motor and sensory branches within operative fields when performing an amputation?
Can result in improved muscle mass and preserve the ability to create myoelectric signals for targeted reinnervation.
Is it necessary to perform an adductor myodesis in a transfemoral amputation?
Yes
Improves clinical outcomes
Creates dynamic muscle balance
Provides soft tissue envelope that enhances prosthetic fitting.
What is a Gritti-Stokes Amputation?
Aputation through femur near adductor tubercle
Synovium is excised
Patella is arthrodeed to the end of femur
Studies have shown improved outcomes compares to transfemoral amputation.
What outcomes have been found when comparing through knee amputations to BKAs and AKAs?
slower walking speeds than BKA
Similar amounts of pain
Worse performance on SIP (sickness impact profile).
Physicians were less satisfied with outomes
Less likely to use prosthesis
More dependence with patient transfers than BKA.
What is required for a Sympe amputation?
What is the most important prognostic factor?
patent tibialis posterior artery
stable heel pad
What is a Chopart of Boyd amputation?
What is the primary complication?
foot amputation through talonavicular and calcaneocuboid joints
equinus deformity (Avoid by lengthening achilles tendon and transfer of the tibialis anterior to talar neck.
What is the common complication of a Lisfranc amputation?
How can it be prevented?
equinovarus deformity
Unopposed pull of tibialis posterior and gastroc/soleus complcex
Prevent by maintaining insertion of peroneus brevis and perfroming achilles lengthening.
What is the physical exam consistent with ARDS
mottled or cyanotic skin
resistant hypoxia
intercostal retractions
rales/crackles and ronchi
tachypnea
Chest x-ray will show bilateral pulmonary infiltrates with a normal sized heart.
What is the most common cause of compartment syndrome?
Trauma (with specifically fractures 69% of cases)
Compartment pressures should be performed how close to fracture site?
within 5cm.
What are the indications for emergent fasciotomy for compartment syndrome?
Contraindications?
Clinical presentation consistent with compartment sydnrome.
In obtunded patient compartment pressures within 30mm Hg of diastolic blood pressure. Remember if intra-op measurement must be compared to pre-op blood pressure.
Missed compartment syndrome.
What should be done for hemophiliacs before measuring compartment pressures?
Factor VIII replacement.
How should a clamp be placed for correct reduction of the syndesomosis?
Lateral tine directly on the lateral malleolar ridge.
Medial tine at the anatomic midportion of the medial tibia. Can be confirmed fluoroscopically as the anterior third of the tibia on a true lateral view of the ankle.
Parallel to the joint line.
Parallel to the anatomic syndesmotic angle.
1-2 cm proximal to the mortise at the level of the incisura.
What is the most likely source of arterial hemorrhage in patients with APC pelvic fracture?
LC?
Superior gluteal.
Internal pudendal or obturator artery.
What percent of scapula fractures are associated with another orthopaedic injury?
What is most common?
What is the most common non-orthopaedic injury?
80-90%
Rib fractures.
Pulmonary contusion.
What degree of displacement of the glenoid from a scapular fracture that doesn’t pass through the glenoid (scapular neck) warrants fixation?
translation of 1cm and or angulatory displacement of 40 degrees or more.
When should you begin ROM after a scapula fracture?
2 weeks start PT.
Indications for fixation of glenoid and coracoid fractures?
>25% of glenoid, >5mm of articular step off, and medialization of the glenoid.
Coracoid fracture with > 1cm of translation.
What interval is used for the Judet approach?
Internervous plane between infraspinatus(suprascapular nerve) and teres minor (axillary nerve).
What artery is most commonly injured with scapulothoracic dissociation?
Subclavian artery
What is the most common result of scapulothoracic dissociation?
Flail extremity
What imaging test should be considered in scapulothoracic dissociation?
Angiogram.
Why is the junction of the outer and middle third of the clavicle predisposed to injury?
Thinest part of the bone.
Only area not protected by or reinforced with muscle and ligamentous attachments.
What is a zanca view on radiographs?
15 cephalic tilt for clavicle fractures.
Helps to determine superior/inferior displacement.
Absolute indications for operative fixation of a clavicle fracture?
Open
Skin tenting
Vascular injury
Floating shoulder
Symptomatic non-union or malunion.
Relative indications for operative fixation of a clavicle fracture?
> 2cm of displacement
Bilateral
Brachial plexus injury
Polytrauma
Seizure disorder or closed head injury.
What is the rate of non-union after clavicle fractures?
Risk factors for non-union?
1-5%
> 100% displacement
> 2cm shortening
Advanced age
Female gender
Comminution
What nerve is commonly injured with fixation of clavicle fractures?
supraclavicular cutaneous nerves.
Advantages of open reduction and internal fixation of calvicle fractures?
Improved functional outcomes
Less pain with overhead activities
Faster time ot union
Decreases symptomatic malunions
Improved cosemtic and overall shoulder satisfaction
Increased shoulder strength and endurance.
True or false female gender is a risk factor for nonunion of calvicle fractures?
True
What percent of individuals end up requesting plate removal?
30%
True or false a clavicle malunion can present with thoracic outlet syndrome?
True
Which AC joint ligament is strongest?
Superior
Describe the Neer classification of distal clavicle fractures.
List precdictors of humeral head ischemia in order from most to least predictive for proximal humerus fractures?
Calcar length less than 8mm> disrupted medial hinge> humeral head angulation more than 45 degrees> head-split fracture.
What amount of displacement of the greater tuberosity in a proximal humerus fracture should lead to ORIF?
> 5mm
What amount of cortical thickness implies good proximal humerus bone quality?
Combined medial and lateral cortical thickness > 4mm.
True or false IM humeral nails have superior rates of fracture healing and ROM when compared to ORIF for proximal humerus fractures?
True
Not really done because it violates the rotator cuff though.
What should you assume until proven otherwise in a isolated lesser tuberosity fracture of the proximal humerus?
That there is a posterior dislocation.
What is a good fixation option for proximal humerus fractures with greater tuberosity fracture that are displaced and a patient with osteoperotic bone?
Fixation with heavy nonabsorbable sutures.
Avoids hardware pullout leading to impingement.
How far sould the greater tuberosity be placed below the articular surface of the humeral head in a hemiarthroplasty being performed for a proximal humerus fracture?
10mm
Can have impairment of ER kinematics and up to 8-fold increase in torque with non-anatomic placement.
How do you best determine hieght of the prosthesis for a hemiarthroplasty performed for a proximal humerus fracture?
Off the superior edge of the pectoralis major tendon.
5.6cm between the top of the humeral head and the superior edge of the tendon.
Are risk factors the same for humeral head ischemia in the proximal humerus and the risk of developing subsequent avascular necrosis?
No
What is the most common complication after ORIF of a proximal humerus fracture?
Screw cut out.
14% in fractures treated with locking plate.
What are the greatest risk factors for non-union after a proximal humerus fracture?
SMoking and advanced age.
The particular study was for proximal humerus fractures treated non-op.
How should a chonic non-union/malunion of a proximal humerus fracture in the elderly be treated?
Arthroplasty
What difference is there between humeral fractures treated with an IMN vs ORIF with a plate for the following?
Facture Union?
Radial Nerve Palsy?
Surgical Site Infection?
Complications?
None
None
None
Higher with IMN
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 (22% incidence)
What is the criteria for acceptable alignment for non-operative treatment of humeral shaft fractures?
< 20 degees of anterior angulation
< 30 degrees varus/valgus angulation
< 3cm shortening
Absolute contraindications: severe soft tissue injury or bone loss, vascular injury, brachial plexus injury.
Radial nerve palsy is not a contraindication to functional bracing.
What is the PPV of a non-union does no callous on radiograph and gross motion at the humeral shaft fracture site at 6 weeks?
100%
What is the incidence of radial nerve palsy in humber shaft fractures?
What should you be worries about in open fractures?
What is the prognosis?
8-15% if closed fractures
22% in distal third fractures.
Neuropraxia more common injury in closed while neurotomesis in open fractures is more common.
85-90% improve with observation over 3 months.
When do you observe and when do you surgically explore a radial nerve palsy in a humerus fracture?
observe for 3 months in a closed fracture.
If no improvement obtain EMG at 3 months
Fibrillation (denervation) on EMG you should surgically explore.
Open fractures should be explored as more likley to be neurotomesis.
Closed fractures that do not improve after 3-6 months.
When is a anterolateral approach to a humerus fracture used?
Where is the radial nerve?
Proximal to middle third shaft fractures.
Radial nerve found between the brachialis and brachioradialis distally
When is a posterior approach to the humerus used?
Where is the radial nerve found?
Distal to middle third shaft fractures.
Medial to the long and lateral heads and 2cm proximal to the deep head of the tricpes
Lateral brachial cutaneous/posterio antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach.
Radial nerve exits the posterior compartment through lateral intramsucular septum 10cm proximal to radiocapitellar joint.
What is the most common endocrine or metabilic disorder that leads to nonunions?
Vitamin D deficiency (68%)
What is the gold standard treatment for a humeral shaft non-union?
Compression plating with bone grafting.
Bone grafting should be used in atrophic nonunions.
Nearly 100% union rate reported.
In the rare case or recalcitrant atrophic nonunions can consider free fibular grafting.
What is the general prognosis after an adults distal humerus fracture?
majority of patients regain 75% of elbow motion and strength
Unsatisfactory outcomes in 25%
What adult distal humerus fracture can be treated non-operatively?
Nondisplaced Milch Type 1 fracture(Lateral trochlear ridge is intact)
What postoperative protocol is recommended after a distal humerus fracture ORIF that requried an olecranon osteotomy?
No active extension against gravity or resistance for 6 weeks
Can perfrom active-assisted extension and active flexion for the first 6 weeks
No restrtiction on rotation.
All ROM and gentle strengthening at 6 weeks then full strengthening program at 3 months.
What is the most common complication after ORIF of a distal humerus fracture?
Elbow stiffness
Heterotopic ossification seen in 8%
routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin.
What position is the arm in to create a capitellar fracture?
Typically a low energy fall onto a partially flexed elbow leading to direct axial compression that creates shear forces.
What olecranon fracture characteristic for a non-comminuted fracture determines whether a tension band can be used?
The fracture cannot extend distal to the coronoid.
Also a transverse fracture line is ideal. The more oblizue the fracture becomes the less likely a tension band will work.
What is the non-op protocol for o non-displaced olecranon fracture in a low demand elderly individual?
immobilization in 45-90 degrees.
Begin motion as tolerated at 1 week to avoid stiffness.
What gauge wire should be used for a tesion band technique for an olecranon fracture?
18 gauge
What is the rate of re-operation after tension band fixation of an olecranon fracture?
reported ranges of 40-80%
rate of plate removal is reported to be 20%
symptomatic hardware is the most common complication
What is the most common adult elbow fracture?
radial head fracture.
occurs from a fall on an oustretched hand with the elbow in extension and forearm in pronation.
60% of the load across the elbow is through the radiocapitellar joint.
What is an Essex-Lopresti injury?
Distal radioulnar joint injury. and interosseous membrane disruption.
This injury plus a radial head fracture leads to complete loss of longitudinal stability.
Leads to proximal migration of the radius and ulnocarpal impaction.
Where is the non-articular portion of the radial head?
90 degree arc from radial styloid to Lister’s tubercle
This is the safe zone for hardware placement.
What is the Mason Classification?
Classification of radial head fractures.
What can you do if you are unsure if a radial head fracture is causing a mechanical block to motion?
Aspiration of joint hematoma and injection of local anesthesia will make evaluation easier.
How much translation in the sagittal plane is indicative of injury to DRUJ?
> 50% compared to contralateral side
Is there a test to determine if a patient has an Essex-Lopresti Injury?
Radius pull test
> 3mm translation concerning for longitudinal forearm stability.
What is a Greenspan View radiograph?
Radiocapitellar view.
It is a oblique lateral view of elbow
Beam angled 45 degrees cephalad
Allows visualization of the radial head without coronoid overlap.
Helps deted subtle fractures of the radial head.
What has a better outcome in a 3 fragment radial head fracture. ORIF or Radial head replacement?
Still can have a good outcome with ORIF. > 3 fragments better outcomes with radial head replacement.
What size fragements can you consider excising from the radial capitellar joint?
Less than 25% surface of radial head.
25-33% of capitellar surface area.
True or false: Compared to ORIF for fracture-dislocations and Mason Type III fractures, arthroplasy results in greater stability, lower complication rate, and higher patient satisfaction.
True
What complications can be seen afer excision of the radial head?
Muscle weakness
Wrist pain
Valgus elbow instability
HO
arthritis
Proximal radial migration
Cubitus valgus
What is the most common major joint dislocation?
What is second?
Shoulder
Elbow
Where is the ligament injury in the most common type of adult elbow dislocations?
Most commonly a non-bony avulsion of the lateral epicondylar origin.
Second most common is a midsubstance LCL tear.
What are the dynamic stabilizers of the elbow joint?
Anconeus
Brachialis
Triceps
What is the rate of recurrent instability after simple dislocations?
1-2% of dislocations.
What is considered enough instability on ROM after a closed reduction of an elbow dislocation that you would consider acute surgical fixation for a simple elbow dislocation?
Elbow require more than 50-60 degrees of flexion to maintain reduction.
What treatement is generally recommended for a chronic elbow dislocation?
Open reduction, capsular release, and dynmaic hinged elbow fixator to allow early ROM but still protect the repair.
If the LCL is disrupted the elbow will be more stable in?
Pronation.
If the MCL is disrupted the elbow will be more stable in?
Supination
What do you do after operative repair of an elbow if instability persists even after reconstruction of LCL and any extensor origin avulsion?
Likely that the MCL needs to be repaired or reconstructed.
If after all fractures have been repaired and LCL and MCL reconstruced there is still instability then you can consider a hinged external fixator.
What nerve injury is typically associated with a brachial artery injury that occurs because of a complex elbow dislocation.
Median nerve injury.
These injuries are rare.
Coronoid fractures involving what __% of the coronoid do not confer elbow stability and do not require repair?
10%
If you still have isntability in a terrible triad with a small coronoid fracture after adressing the radial head and LCL next best step is MCL.
How soon after ORIF of a complex elbow fracture should you initiate ROM exercises?
48 hours
Post-traumatic stiffness is a very common complication.
How does fixation of the LCL change depending on whether the MCL is intact?
Position of the forearm during fixation of the LCL is different.
If MCL is intact LCL is repaired with forearm in pronation.
If MCL is injured LCL is repaired with forearm in supination to avoid medial gapping due to overtightening
For all repairs elbow should be at 90 degrees of flexion.