Trauma Flashcards
Abx prophylaxis
1 - Gustillo grade I injuries?
2- Grade 2?
3 - Grade 3?
Grade I/II : 1st gen cephalosporin
Grade III: cephalosporin + amino glycoside
Add PCN for farm injuries or bowel contamination (clostridium)
Class I shock (% blood loss/mL)?
Class II-% loss and sx?
Class III?
Class IV?
Class I: 15%, <750 mL
Class II: 15-30%, 750-1500 mL, HR increases, Tx w/ fluid
Class III: 30-40%, 1500-2000 mL, HR >120, deceased BP, urine decreased, decreased pH, Tx with fluid AND blood
Class IV: >40%, >2000 mL, >140 BPM, negligible urine, lethargic/coma, tx w/ fluid and blood
Adequate resuscitation markers - Lactate? gastric mucosal pH? base deficit?
Serum lactate: <2.5 mmol/L
Gastric mucosal pH: >7.3
Base deficit: -2 to +2
Highest risk of viral transmission following blood trasfusion - Hep C, Hep B, HIV?
Hep B - 1 : 205,000
Hep C - 1: 1.8 million
HIV - 1 : 1.9 million
Indications for DCO?
GCS <8 Bilateral femoral fx Multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock Pulmonary contusions Hypothermia <35 C Head injury IL6 over 500 pg/dL
What is acute inflammatory window after trauma?
2 to 5 days after injury, surge of inflammatory markers
Parameters for Early Appropriate Care?
Lactate <4.0 mol/L
ph > 7.3
Base excess > -5.5
Try to fix spine/pelvis/femur/tab w/in 36 hours
Adults or children have a more robust inflammatory response after trauma? What system affected first for each?
Adults more robust initial inflammatory response
Adults: Pulmonary
Children: dampened initial, then affects all organs simultaneously
Low velocity vs high velocity GSW (m/s, type of Gustillo injury)
Low velocity: <350 m/s or <2000 ft/s (handguns); Gustillo I or II
High velocity: >600 m/s or >2000 ft/s, Gustillo Type III; assault rifles/hunting rifles
Indications for surgery after GSW
Articular involvement unstable fx Presentation >8 hrs after GSW Tendon involvement Superficial fragment in palm or sole
Retained bullet in lumbar spine w/o neuro deficits and perforated bowel - Tx?
IV broad spectrum abx for 7 days
% increase with: 1- Syme 2- BKA (long vs short) 3- Vascular BKA 4: AKA
Syme: 15% BKA long: 10% BKA short: 40% Vascular BKA: 40% AKA: 68% trauma, 100% vascular
Wound healing after amp - good prognosis?
TcPO2 >30
ABI >0.45
Total lymphocyte count >1500
Albumin > 3.0 g/dL
Treatment for post amputation neuroma? Phantom limb pain
Neuralgia: Target muscle regeneration (TMR)
Phantom pain: mirror therapy
Contraindications to HBOT
History of COPD - blebs
Hx of bleomycin Tx - pneumonitis
Pneumothorax
Insulin pump - malfunction or deformation of device under pressure
After BKA, removal of dog ears damages what arteries for flap?
Sural and saphenous arteries
Hip fx mortality at 1 month and 1 year
1 month: 6%
1 year: 30%
Hip fx pt with head injury, ISS >25, hip fx and requires intubation in trauma bay. What is greatest risk of mortality at 1 year?
Intubation: in hospital 10%, 1 year 79% morality
Head injury 1 year 51%
hip fx: 6% and 30%
ISS: 73% at one year
Block to use to decrease opioid usage, delirium and length of stay for hip fx?
Fascia iliaca block
muscles of anterior leg compartment? Nerve? Vessel?
Tib ant, EHL, EDL, PT
Nerve: Deep peroneal
Vessels: Anterior tib vessels
Lateral leg muscles? Nerve?
Peroneus longus and brevis
Nerve: Superficial peroneal
Deep posterior leg muscles? Nerve? Vessels?
Popliteus, FHL, FDL, Posterior tib
Nerve: Tibial nerve
Vessel: posterior tib vessel
Superficial posterior leg muscles? Nerve?
Gastroc, soleus, plantaris
Nerve: Medial sural cutaneous nerve
Position of foot for least pressure in leg compartments while in cast?
Resting platarflexion
30-50% less pressure
Signs of pediatric compartment syndrome?
Analgesia requirements, agitation, anxiety
Saline load test for knee: 95% sensitivity? 99%?
95%: 155 mL
99: 175 mL
Tx of gonococcal septic arthritis?
3rd gen cephalosporin (ceftriaxone), PCN and tetracyclines not effective 2/2 resistance
Types of Necrotizing fasciitis: Type 1? Type 2? Type 3? Type 4?
Type 1: Polymicrobial, most common 80-90%, seen in DM, cancer
Type 2: Monomicrobrial (GAS), 5% cases, seen in healthy patients
Type 3: Marine vibrio vulnificus, marine exposure
Type 4: MRSA
LRINEC scoring system
Score >6 92% of nec fasc CRP >150 = 4 pts WBC <15 = 0, 15-25 = 1, 25+ =2 Hb >13.5 = 0, 11-13.5 =1, <11 = 2 Na <135 = 2 Cr >141 = 2 Glucose >10 (mmol/L) = 1
Abx tx for nec fasc?
Generally polymicrobial PCN Aminoglycoside Metronidazole Clindamycin
Cierny-Mader classification for osteomyelitis (Anatomic location and host)
Anatomic location
Stage 1: Medullary
Stage 2: Superficial/cortical
Stage 3: Localized (medullary and cortical)
Stage 4: Diffuse (entire bone w/ bone loss)
Host type
Type A: normal
Type B: Compromised
Type C: Tx worse than infection
Def of sequestrum and involucrum?
Sequestrum: Devitalized bone that serves as infxn nidus
Involucrum: New bone around area of bony necrosis
How does VAC improve wound bed?
Decreases after load in capillary bed
Dilates arterioles - proliferation of granulation tissue
Removes interstitial fluid (contain inhibitory factors that suppress formation of fibroblasts, vascular endothelial cells)
Eliminates superficial purulence (Reduces anaerobic colonization
Removal excess fluid - maintains osmotic gradient
Biofilm process - 2 stages
Step 1: Adhesion, regulated by adhesions
After several bacteria attached –> step 2 –> quorum sensing/cell to cell communication
Allows maturation of biofilm and expression of genes that activate virulence factors
Preganglionic brachial plexus injuries - definition? Symptoms/signs?
Avulsion proximal to DRG - involves CNS - no regen
Horner’s syndrome - sympathetic chain disruption
Winged scapula medially - loss of serrates (long thoracic n), rhomboids (dorsal scapular n)
Motor deficits - flail ext
Sensory intact
Normal histamine test - C8-T1 sympathetic ganglion
EMG shows loss of innervation of cervical paraspinals
Postganglionic brachial plexus findings?
Involves peripheral nervous system - better prog
Sensory deficits
EMG shows maintained innervation of cervical paraspinals
Abnormal histmine test - redness and wheal but NO flare
Horner’s syndrome - Symptoms? When does happen after BPI? Which level?
Drooping of eyelid, pupillary constriction, anhidrosis
Happens ~3 days after injury
Disruption of sympathetic chain at c8 and/or T1 root avulsions
When to do immediate (<1 wk) surgical exploration of BPI?
Sharp penetrating trauma (except GSW)
Iatrogenic
Open injuries
Expanding hematoma or vascular injury
What is an Oberlin transfer?
Ulnar nerve used for upper trunk injury for biceps fxn
% femoral neck fx ass’d w/ femoral shaft fx?
6-9%
Mortality rate at 1 year after femoral neck fx? 2 year mortality in pts with renal failure?
1 year: 30%
2 year in pt w/ chronic renal failure: 45%
Major blood supply to femoral head in adult?
Medial femoral circumflex artery –> lateral epiphyseal artery
Anterior/inferior head from lateral femoral circumflex
Rate of osteonecrosis after hip fx? risk factors? Tx of osteonecrosis?
10-45%
Increased w/ increased initial displacement, non anatomic reduction
Tx: young pt: FVFG vs THA
Older: Hemi vs THA
Nonunion after hip fx rate? Risk factor? Tx?
5-30%
Increased w/ increased displacement, varies malreduction
Tx: valgus intertroch osteotomy (vertical fx to horizontal –> decreases shear)
FVFG (young pt w/ viable fem head)
Arthroplasty
Revision ORIF
When do hip fx fixation methods fail? Percentages of failure after fixation vs arthroplasty?
Most fail in first 2 years
Fixation 45%
Arthroplasty 8%
Higher failure after hip fx with cannulated screws or sliding hip screw?
Cannulated screws have HIGHER REOPERATION rates (not higher implant failure)
Esp for displaced, basicervical and current smokers
When do failure rates stabilize after hip fx operation?
ORIF/fixation and arthroplasty level off at 2 years, then no difference in ongoing failure rates
Risk factors for mortality after hip fx?
Male (37% at 1 yr vs 28%)
Older age
Increased comorbidities
What does Timed Up and Go (TUG) determine? Times at 4 days postop and 3 wks?
Need for walking aid
NOT independence of ADLs
4 days 58 sec (1 min)
3 wks 26 sec (30 sec)
Times above these predict need for walking aid at 2 years
Performing a valgus producing osteotomy for femoral neck nonunion. Currently at 40 degrees from horizontal, place pin at 130 degrees with planned 20 degree osteotomy. What angle for side plate?
150 deg
Guide insertion (130) + osteotomy (20) = side plate angle
Side plates available in 130 deg to 150 degrees
Risk for AVN after hip fx in young vs old? Men vs women?
Higher in those <60 (20%) vs 60-80 (12.5%) vs 80+ (2.5%)
Women 11% vs men 5%
When does mortality risk return to baseline after fem neck fx?
After 1 year returns to that of normal, age-matched controls
FRAX score factors?
Bone density of FEMORAL NECK (not spine)
Current smoking hx
Hx of parental hip fx
prior personal hx of fx before age 50
What other fx increases risk of hip fx at one year?
Proximal humerus fx
Risk factors for increased mortality after intertroch fx?
Male gender (25-30%) vs female (20%) Intertroch (vs FNF) Age >85 comorbidities ASA III and IV
Stable vs unstable intertroch?
Stable - intact posteromedial cortex (resists medial compressive loads when reduced)
Unstable - fx will fall into varus Posteromedial comminution Thin lateral wall (<20 mm suggests postop lateral wall fx) Reverse obliquity Subtract extension
What test to get with isolated greater trochanter hip fx?
MRI - eval for intertroch extension
4 hole vs 2 hole SHS for intertroch fx - which is better?
No difference clinically or biomechanically
Most common failure after intertroch implant fixation?
Implant failure and cutout
Risk factors for increased postop infection after tibia plateau ORIF?
OR time >3 hours
Open fx
Indications for clavicle operative intervention (absolute and relative)
ABSOLUTE indications: Open fx Displaced with skin tenting Subclavian artery/vein injury Floating shoulder Symptomatic nonunion/malunion
Relative indications Displaced with >2cm of shortening Bilateral clavicles BPI Polytrauma
Risk factors for nonunion of clavicle fx treated nonop?
Comminution >100% displacement >2cm shortening Elderly Female Lateral 1/3 fx (11% vs 4.5% midshaft)
Outcome of displaced mid shaft clavicle fx with >2cm shortening treated nonop?
1-5% nonunion
Decreased shoulder strength and endurance
Superior vs anteroinferior plating for clavicle fx: which is higher load to failure? Lower risk of neurovascular injury? Lower removal of deltoid?
Higher load to failure: Superior plating
Lower rate neurovasc injury? anteroinferior plating
Lower removal of deltoid attachment: Superior plating
Advantages of plating clavicle?
Improved results for fx >2cm shortening or 100% displacement
Improved functional outcomes and less pain w/ overhead
Faster time to union (16 wks vs 28 wks)
Decreased symptomatic maluinon rate
Better cosmoses
increased shoulder strength/endurance
Definition of clavicle malunion
Shortening > 3cm
Angulation >30 degrees
Translation >1 cm
% of clavicle plates that require removal?
30%
Nonop vs op clavicle fx: constant shoulder scores and DASH scores?
Improved in operative group at all time points
Operative indications for scapula fx?
Open fx
Loss of RC fun
coracoid w/ >1 cm displacement
Glenopolar angle <22 degrees
GH instability
displacement or >25% joint surface (instability)
>5mm glenoid articular step off
Scapular neck:
>1cm medial displacement
>40 degrees
Most common ass’d injury w/ scapula fx?
Rib fx
How to treat humerus nonunion?
Compression plating +/- bone graft (4.5 plate)
Superior to IMN
Where does radial nerve cross humeral diaphysis from: medial epicondyle? lateral epicondyle? Radiocapitellar joint?
Medial epicondyle: 20 cm proximal
Lateral epicondyle: 14 cm proximal
Radiocapitellar joint: 10 cm
Medial collateral ligament of elbow - origin and insertion? what does it restrain? when is it tight?
Anterior bundle originates from distal medial epicondyle, inserts onto sublime tubercle
Restrain to valgus (30-120 deg)
Tight in pronation
Lateral collateral ligament of elbow - origin and insertion? what does it restrain? when is it tight?
Originates from distal lateral epicondyle and inserts onto wrist supinatorus
Stabilizes against posterolateral rotational instability (PRLI)
Tight in supination
Pt has distal humerus fx, Y-type, requiring ORIF w/ pre-existing ulnar neuropathy, unchanged after injury: parallel or orthogonal plates? Decompress nerve?
Parallel plates has greater construct rigidity
Every screw pass thru plate, each screw as long as possible, screws should interdigitate, each screw through as many articular fragments as possible
Decompress nerve (in situ) if previous Sx or if hardware comes in contact with nerve (transposition)
Describe olecranon osteotomy length of osteotomy, apex distal or proximal?
Screw direction into ulna?
Chevron osteotomy apex distal 2cm
Cancellous screw slightly MEDIAL due to various bow of primal ulna
What surfaces of humerus place plate for distal humerus fixation if using orthogonal plates?
Posterolateral and medial surfaces
How to address lack of flexion at elbow after distal humerus fx with fracture united?
Open release of posterior bundle of MCL and excision of osteophytes
Posterior capsule if nec
Long K wire for olecranon osteotomy can affect which nerve?
AIN - thumb IP flexion
Predictors of humeral head ischemia after proximal humerus fx?
<8 mm cal car length attached to articular segment
Disrputed medial hinge
Displacement >1 cm
Angulation >45 deg
NOT the same as developing AVN
What is major blood supply to humeral head?
Posterior humeral circumflex artery
Takes off more distally than anterior humeral circumflex artery
Anterior circumflex goes to anterolateral ascending branch and ARCUATE artery –> main supply to greater tuberosity
What determines if proximal humerus fx has separate “parts” for Neer classification?
Displacement >1cm
45 deg angulation
Determination of humerus plate pullout strength (measurement)
Medial + lateral combined cortical thickness >4mm
ORIF indications for proximal humerus fx
1- Greater tuberosity displaced >5 mm (impingement casting loss abduction and ER)
2- 2, 3, or 4 pt fx in young pt
3- Head splitting fx in young patient
Most common complication of ORIF of proximal humerus fx?
Screw cut out
How to prevent varus collapse in ORIF of proximal humerus fx?
Inferomedial cal car screw in osteoporotic bone
Proximal humerus fx: How far below articular surface of hemiarthoplasty should place getter tuberosity?
How to best determine height of prosthesis?
10 mm
determine height of prosthesis from superior edge of pec tendon –> 5.6 cm between top of humeral head and superior edge of pec tendon
Best predictor of successful outcome after hemiarthroplasty for proximal humerus fx?
Anatomic healing of tuberosities
Acceptable criteria for humerus alignment?
<20 deg anterior angulation
<30 deg varus/valgus
<3 cm shortening
Risk factor for nonunion in nonop tx of humerus fx?
Proximal 1/3 spiral or oblique fx patterns
Absolute Indications for ORIF for humerus fx?
Relative?
Absolute: Open fx Vascular injury Floating elbow BPI Compartment syndrome Periprosthetic humeral shaft fx at the tip of stem
Relative:
Bilateral humerus fx
Polytrauma
Path fx
Weight bearing after plate fixation of humerus fx?
Full crutch weight bearing has no effect on union
Humeral plating vs nailing - union rates? Complications? Shoulder pain? ASES scores? Nerve injury?
Union rate = no difference Complications = higher in IMN group Shoulder pain = higher in IMN group Functional shoulder scores (ASES) = SAME between two groups Nerve injury = No difference
Time point to determine nonunion for humerus fx being treating nonop?
6 weeks w/o callous on XR and fx motion
Radial nerve palsy after humerus fx - % that improve? when do they improve?
When get EMG?
Which muscle comes back first?
Which comes back last?
8-15% overall, 22% w/ distal 1/3 fx
85-90% improve
Recovery at 7 weeks with full recovery at 6 months
EMG at 3-4 months
First muscle: brachioradialis
Last muscle: extensor indicis
Transfers for radial nerve palsy?
1: PT to ECRB
2: FCR to EDC (important to maintain FCU to generate ulnarly directed flexion)
3: PL to EPL
Which nerve to identify when doing posterior approach to humerus to trace to radial nerve?
Posterior antebrachial cuteanous nerve
When to perform excision and triceps advancement for olecranon fx?
Elderly pt w/ osteoporosis
Fx <50% joint surface
Nonunions
Most common issue with ORIF after olecranon fx?
Symptomatic hardware
Safe zone for hardware placement in radial head?
90 deg from radial styloid to Lister’s tubercle
Tx of radial head fx?
Short period of immobilization and early ROM for isolated minimally displaced fx with no mech block
ORIF vs resection vs arthroplasty for >2 mm step off or mechanical block
ORIF outcomes with radial head fx
Wore outcome with 3+ fragments
Kocher approach to radial head - interval? Pros and cons?
Approach
ECU (PIN) and ancones (radial)
Less risk to PIN vs Kaplan
con: risk destabilizing elbow if capsule incision too posterior and LUCL violated
Kaplan approach: interval? Pros and cons vs Kocher?
Approach
EDC (PIN) and ECRB (radial)
Pro: less risk disrupting LUCL and destabilizing elbow vs Kocher (more anterior approach)
Con: higher risk to PIN
How to assess for overstuffing of radial head implant intraop?
Visually assess the LATERAL ulnohumeral joint for gapping (medial widening only seen after over lengthening radial head by 6+ mm)
Arm position during approach for Kocher or Kaplan approach? During plate application?
Approach:
Arm fully pronated to protect PIN
Plate arm position: Neutral to judge bare area from Listers to radial styloid
Elbow dislocation order of events?
Progress from lateral to medial
1-LCL fails (primary lesion) - gen avulsion from lateral epicondyle, but can be midsubstance
MCL fails last
What position to splint an elbow dislocation after reduction?
When can go back to light duty?
At least 90 deg for 5-10 days, then therapy (early ACTIVE ROM)
Proceed with light duty at 2 weeks after injury
What injuries are ass’d w/ posterior hip dislocation?
Ostenecrosis of femoral head
Posterior wall fx
femoral head fx
sciatic nerve injury
**Ipsilateral knee injury (up to 25%)
Position of leg w/ posterior hip dislocation? Anterior?
Posterior dislocation
Flexion, adduction, IR
Anterior dislocation
Flexion, abduction, ER
Thoracic aortic rupture is ass’d with what orthopedic injury?
Hip dislocation
8% of hip dislocation have aortic injury
Knee injury ass’d with high E hip dislocation in 93% cases on MRI
Test to get after hip reduction in native hip?
CT scan
How much blood can closed femoral shaft hold?
Tibial shaft?
Femoral shaft: 1000-1500 mL
Tibial shaft: 500-1000 mL
Using piriformis nail at Troch start point for femoral nail will result in what deformity?
Varus
Risk factors for rotational malunion in femoral shaft fx
Proximal fx (30% vs distal 10%)
Use of fx table - Internal rotation deformities
Fx comminution
Night time surgery
highest union rate in femoral shaft nonunion with IMN?
Highest union is with plate augmentation and IMN retention
Plate fixation union 96% vs exchange nail 73%
Allows deformity correction
Acceptable malrotation in femoral shaft fx?
<15 degrees
Workup to determine if hip fx in pt with femoral shaft fx
1- Dedicated AP int rot XR
2- 2 mm/fine cut CT fem neck
3- Intraop fluoro lateral prior to fixation
4-Postop AP and lateral of hip before awakening pt
Normal femoral neck anteversion?
10-25 degrees
Proximal femoral fx develop what type of malrotation? Distal fx?
Prox fx: Internal malrotation (prox portino ER 2/2 short ext rot, so distal portion is relatively internally rotated)
Distal fx: Ext malrotation (distal frag pulled external rot 2/2 lateral gastroc and plantaris = ext rot)
what type of femoral neck fx seen with ipsilateral femoral shaft fx?
Basicervical, vertical, nondisplaced
why does indomethacin cause more nonunion than other NSAIDs?
Indomethacin works primarily on IGF-1 vs other on COX. IGF-1 important for bone healing
Bisphosphonate subtroch fx characteristics?
Focal lateral cortical thickening
Transverse fx
Medial spike
Lack of comminution
Bisphosphonate femoral fx issues with 1-nail, 2 plate vs conventional fx?
Nail - increased risk of iatrotrogenic fx
Plate: higher risk of hardware failure
% of knee dislocations with peroneal nerve injuries?
25%
% of unstable Weber B with syndesmotic injury?
~40%, reason for ext rot stress test intraop or Cotton
Types of knee dislocations, mechanism, and ass’d injuries
1. Anterior Most common (30-50%), hyperextension injury PCL tear Arterial injury 2/2 intimal tear HIGHEST rate of peroneal n injury
2. Posterior 2nd most common 30-40% Axial load to flexed knee (dashboard) HIGHEST rate of vascular injury HIGHEST rate of complete popliteal tear
- Lateral or medial
Varus or valgus force
Lateral: ACL and PCL
Medial: PLC and PCL - Rotational
Usually irreducible - condyle buttonhole through capsule
Most common complication after knee dislocation?
Stiffness/arthrofibrosis (nearly 40%)
Which tibial plateau fx’s are ass’d w/ lateral meniscus tear? Medial meniscus?
Lateral meniscus: Schatzker II, >10 mm articular depression
Joint widening >5 mm
Medial meniscus: Schatzker IV
Which tibial plateau fx’s are ass’d w/ ACL injuries?
Type IV and type VI fx’s
Which tibial plateau is more convex? Which is more distal?
More convex: lateral plateau
More distal: Medial plateau
Strongest predictor of long term success after ORIF of tibial plateau?
Limb alignment
Joints stability
Risk factors for infxn after tibial plateau ORIF?
Male Smoking Pulmonary disease Bicondylar OR TIME >3 HOURS
Open fx
Fx requiring fasciotomy (but timing to definitive fixation does not increase infxn risk)
Issue with definitive ex-fix for tibial plateau fx?
Inappropriately high risk of malunion rate
What has highest compressive strength for filling metaphysical void after tibial plateau fx?
Calcium phosphate cement
Does timing of definitive fixation for tibial plateau fx requiring fasciotomy have an impact on infection risk?
No - no difference if ORIF before fasciotomy, at time of fasciotomy, at fasciotomy closure or after closure
What size screws for tibial plateau fx with a lateral buttress plate (Schatzker II)?
- 5 mm screws, nonblocking followed by locking (if osteoporotic)
- 5 mm and 6.5 mm have been shown to be inferior for sustains joint surface elevation (3.5 mm rafting screws better vs two 6.5 cancellous screws)
Steps to fix terrible triad elbow injury?
Deep to superficial 1-Coronoid ORIF if needed 2-Radial head 3-LCL 4- UCL/MCL if still unstable vs ex fix
How to splint a terrible triad elbow injury - medial side intact? medial and lateral side disrupted?
Medial side intact
Flexion - Increases bony stability
Pronation: Most stable position, int. rot. torque applied to wrist causes ulna to pivot about intact medial side soft tissue of elbow and close gap on lateral side
Both disrupted: flexion and neutral rotation
Components of interosseous membrane of forearm
Central band - key portion to reconstruct Accessory band distal oblique bundle Proximal oblique bundle Dorsal oblique accessory band
Ulnar shaft fx - nonop treatment criteria?
Isolated nondipslaced fx
Distal 2/3 ulnar shaft fx with:
1: <50% displacement
2: <10 degrees of angulation
96% union rate, but ok to fix due to long time to union
Synostosis after BBFFx ORIF: rate? ass’d with what factor? When can HO be resected?
Rate: 3-9%
Ass’d w/ single incision approach
HO can be resected with low recurrence rate as early as 4-6 months post injury when XRT or indomethacin are used
Risk of re-fracture after ORIF risk factors? When to remove? Brace afterwards?
Risk factors:
Removing plates too early (<15 months)
4.5 plates
Comminuted fx
Keep plates at least 15 months
Brace for 6 weeks and protect activity for 3 months after hardware removal
Classic Henry approach to proximal radius: which direction for radial artery? supinator? arm in supination or pronation?
Radial artery medial
Supinator laterally (with PIN)
Arm in supination - displaces PIN away from dissection
Distal radius fx, normal and acceptable criteria for: radial height? radial inclination? Articular stepoff? Volar tilt?
Radial height: nl = 13 mm, <5 mm shortening
Radial inclination: nl=23 deg, change <5 deg
Articular stepoff: nl= none, accept up to 2 mm
Volar tilt: nl 11 deg; dorsal angulation <5 deg or w/in 20 deg of contra
Findings of syndesmotic injury:
Decreased tibiofib overlap (AP/mortise)
Medial clear space?
Increased tibiofib clear space?
Tibiofibular overlap
AP: >6 mm, mortise: >1 mm
Medial clear space: normal <4mm
Tibiofibular clear space
Meassure 1 cm above joint
Normal <6mm (AP and mortise)
Supination adduction injury pattern
1: Talofib sprain or distal fib avulsion
2: vertical medial mal w/ impaction anteromedially
SER ankle fx pattern?
1: Anterior tibiofibular ligament sprain
2: Fibula fx (anteroinferior to posterosuperior) vs PER (anterosuperior to posterior inferior)
3: PITFL rupture or posterior malleolus fx
4: Medial malleolus fx/disruption deep deltoid
Pronation ABduction ankle fx pattern?
1- Medial malleolus transverse fx or deltoid disruption
2- ATFL sprain
3- High fibula fx, comminuted
Pronation external rotation ankle fx pattern?
1-Medial malleolus transverse or deltoid disruption
2- ATFL disruption
3-Fib fx (anterosuperior to posteroinferior)
4- PITFL or posterior malleolus
How much does tibiotalar contact pressure increase with 1 mm shift of talus?
42%
Most important factor for satisfactory outcome after ankle ORIF?
Length of recovery?
Worse outcome characteristics?
Most important factor: anatomic reduction
Length of recovery: 2 years
Worse outcomes with: Smoking Decreased education Alcohol use Medial malleolus fx
Postop rehab after ankle fx:
Time to braking normalized at?
How long after weight bearing?
Braking time normalizes at 9 weeks
Braking time significantly increased until 6 weeks after weight bearing in longer bone fx and periarticular fx’s
Medial malleolus ankle fx fixation: which is better - lag by technique using 3.5 full threaded screw or partially threaded 4.0?
3.5 mm lag by technique
Increased insertional torque and lower rate of radiographic screw loosening
When is it ok to use only lag screw fixation for lateral malleolus fx?
spiral pattern when screws can be placed at least 1 cm apart
% of stiffness restored to syndesmosis when posterior malleolus is fixed vs isolated syndesmotic fixation?
70% with posterior malleolus
40% with syndesmotic fixation alone
Hyperplantarflexion variant ankle fx injury pattern?
Vertical shear fx of posteromedial tibial rim
Spur sign = dbl cortical density of inferomedial tibial metaphysis
Fix with antiglare plating
What direction is syndesmosis most unstable?
How to reduce syndesmosis with clamp/placement of clamp?
Where to angle screws?
Instability greatest in AP plane
Place reduction clamp on mid medial tibia and fibular ridge
Angle screws posterior to anterior 20-30 deg
Differences in syndesmotic fixation methods?
No difference in RCT (Wikeroy 2010) in tricortical or quadricortical fixation
Worse outcomes with ass’d posterior malleolus fx, obesity, difference in syndesmotic width >1.5 mm, CT confirmed tib/fib synostosis
Bosworth fracture dislocation
Rare fx/dislocation of ankle where fibula becomes entrapped behind tibia and becomes irreducible
Can cause compartment syndrome
Ligaments of ankle syndesmosis
1-Anterior inferior tibiofibular ligament (AITFL)
From anterolateral tubercle of tibia (Chaput) to anterior tubercle of fibula (Wagstaffe)
2-Posterior-inferior tibiofibular ligament (PITFL)
Posterior tubercle of tibia (Volkmann) to posterior lateral malleolus
**Strongest component
Doesn’t tear during ankle fx
3-Interosseous membrane
4-Interosseous ligament
Distal continuation of IOM
Main restrain to proximal migration of talus
5-Inferior transverse ligament
DRF ORIF indications?
1- XR finings indicating instability (pre-reduction XR)
2- Drosal angulation >5 deg or >20 deg of contralateral
3- volar or dorsal comminution
4- Displaced intra-articular fx > 2mm
5- Radial shortening > 5 mm
6- ulnar shaft f
7- Dorsal or volar Barton fx (volar ulnar corner sports volar lunate facet)
8- Loss of reduction in cast
LaFontaine predictors of instability for DRF
Pt w/ 3+ factors have high chance of loss of reduction
- Dorsal angulation >20 deg
- Comminution
- Initial displacement >1 cm
- **Initial radial shortening >5 mm (most important)
- Ass’d ulnar fx
- Severe osteoporosis
complications of closed tx of DRF?
Same overall outcome as ORIF
CTS
EPL rupture***
What tendon ruptures with volar DRF ORIF? Risk factor?
FPL
Ass’d with plate placement distal to watershed area (most volar margin of radius closest to the flexor tendons)
What nerve is at risk with distal radius spanning ex fix proximal pins?
Superficial radial nerve
Treatment of EPL rupture in closed DRF?
EIP to EPL transfer
Vit C dosage after DRF?
500 mg for 50 days
what does shuck test test after ORIF of DRF? Which ligaments?
Assesses DRUJ after DRF fixation
Specifically tests radioulnar ligaments
AAOS guidelines for treating DRF
1- ORIF for post reduction radial shortening >3 mm, dorsal tilt >10 deg, intra-articular step off 2 mm
2- Rigid immobilization for non op t
3 Use of true lateral to assess DRUJ
4 Begin early ROM of wrist after stable fixation
5 Use Vitamin C
Contraindication to percutaneous pinning of DRF?
Volar comminution
What nerve is at risk with retraction during volar approach to distal radius using FCR splitting approach?
Palmar cutaneous nerve
4-6 cm proximal to wrist crease
Travels between median nerve and FCR
Supplies thenar region
Most stable construct in U type sacral fracture?
Triangular osteosynthesis/lumbopelvic fixation
Chance of nerve injury with Denis 1, 2, 3 sacral fractures
Zone 1: 6%
Zone 2: 28%
Zone 3: 57%
Distal 1/3 clavicle fx - important ligaments? Where do they insert? Which is stronger?
Conoid (medial) - 4.5 cm from end of clavicle
-strongest
Trapezoid (lateral) - 3 cm form end of clavicle
Provide primary resistance to superior displacement of lateral clavicle
Which distal clavicle fx to operate on?
Neer Type IIA, IIB, V
IIA = fx medial to coracoclavicular ligaments w/ conoid and trapezoid intact (sig medial clavicle displacement)
IIB = fx between coracoclavicular ligaments (sig medial clavicle displacement)
Type V: comminuted fx pattern (not intra-articular which is type III)
Ligaments intact, sig medial displacement
Open Fx
Vascular injury
Floating shoulder
Most common cause of death in lateral compression pelvis injury?
closed head injury
Increased mortality after pelvic fx ass’d with?
1 - SBP <90 on presentation
2: >60 y/o
3: Need for transfusion >4 units**
4: APC III injury **
Sexual dysfunction % after pelvic ring fx?
Up to 50%
Poor outcome after pelvic ring fx ass’d with?
SI incongruity of >1cm *** LLD > 2cm*** High degree initial displacement Malunion/nonunion urethral injury
Where does common iliac system begin?
Where does corona mortis connect?
Near L4 at bifurcation of abdominal aorta
Corona mortis (connection between obturator system from anterior division of internal iliac and external iliac/epigastric) at 6.2 cm from pubic symphysis
Define APC injuries
APC I: Symphysis widening <2.5 cm
APC II: Symphysis widening >2.5 cm, anterior SI joint diastasic, posterior SI ligaments intact, sacrospinous and sacrotuberous disrupted
APC III: Disrupted posterior SI ligaments
Ass’d with vascular injury ***
Highest mortality***
Lateral compression injuries
LC I: Ramus fx and ipsilateral anterior sacral ala compression fx
LC II: Rami fx and ipsilateral posterior ilium fx dislocation (crescent fx)
LC III: Ipsilateral LC and contralateral APC (windswept pelvis)
Vertical shear pelvic ring injury
Ass’d with highest risk of hypovolemic shock (2/3)
Mortality rate 25% (less than APC III)***
Radiographic signs of pelvic instability
> 5 mm displacement of posterior SI complex
Posterior sacral fx gap
Avulsion fx: ischial spine, ischial tuberosity, sacrum, TP of 5th lumbar**
Causes of hemorrhage after pelvic ring fx
1: Venous (80%), shearing of posterior thin walled venous plexus
2: arterial 20%
- Superior gluteal artery most common (APC injury w/ posterior ring injury)***
- Internal pudendal (anterior ring LC injury)
- Obturator/LC injury
Parturition induced diastasis tx?
<4cm diastasis: pelvic binder in acute setting and bedrest
> 4-6 cm: ORIF for chronic pain
When is anterior and posterior ring stabilization required in pelvic ring fx?
Vertically unstable fx
Urogenital injury w/ pelvic ring fx: how often? most common injury? When to get further tests? Tx? Most common long term complication?
1- about 20% in males (more common in males)
2- Most common injury: posterior urethral tear, less common = bladder rupture (extravasation aboard pubic symphysis, high mortality)
3- Get further testing (RUG) with blood at meatus, hematuria, high riding prostate
4- Tx: suprapubic Cath (conta’d in anterior ring plating cases), if need anterior plating then surgical repair at time of plating
5: Complications: urethral stricture (most common)***
Impotence
Infxn
Incontinence
Most common nerve injury after INFIX?
1: LFCN ***
Can also injure femoral nerve***
DVT and PE rate after pelvic ring fx?
DVT approx 60%
PE: 25%
Fatal PE approx 2%
How to diagnose chronic instability of pelvic ring?
Single leg stance pelvic XR
Most important factor increasing risk of postop infxn after pelvic ring fx?
1: BMI***
Others: Morel-Lavallee, ass’d acetabular fx fixation***, GU or abdominal trauma, increased blood transfusion, increased OR time
***Pelvic embolization NOT increased risk
Advantage of supraacetabular pins vs iliac crest pins?
They do not interfere or contaminate future approaches to pelvics or acetabulum involving the LATERAL window
Obturator outlet view, find tear drop of bone, place pin 2 cm pros to hip joint to avoid hip capsule. Blunt dissection and guide sleeve to prevent LFCN injury. Iliac oblique when partially inserted to make sure passing superior to superior gluteal notch. Obturator inlet after placement to confirm in bone throughout length
How to perform pelvic packing?
Place pelvic ex-fix followed by packing pelvis with lap pads via sub umbilical incision
Most common ass’d acetabular fx?
Transverse + posterior wall
Obturator oblique view shows?
Anterior column + posterior wall
Iliac oblique view shows?
Posterior column + anterior wall
How to perform EUA for posterior wall fx?
Hip flexed, abducted, axial load
Use obturator oblique view (posterior wall)
Opening of medial clear space*** = instability
Timing of acetabular fx…when do ass’d hip dislocations do worse (timing-wise)?
Earlier OR for acetabular fx ass’d with?
Ass’d hip dislocations should be reduced w/in 12 hrs for better outcomes
Worse outcomes with fx fixation >3 weeks after injury
Earlier OR ass’d w/ increased chance of ANATOMIC REDUCTION***
What radiographic view shows:
1- joint penetration of anterior column screw?
2-Anteroposterior position of screw thru pubic ramus?
3-Supraacetabular pin within tables of ilium
1: joint penetration: obturator outlet/shows cranial/caudal of screw going thru ramus
2: AP in pubic ramus: Iliac inlet
3: w/in tables of ilium: Obturator inlet
Anterior approach to acetabular fx
Windows? Access of each?
Indications?
Risks?
Anterior approach/ilioinguinal
Medial window: medial to external iliac vessels
-Access to pubic rami, indirect access to internal iliac fossa and anterior SI joint
Middle window: between iliac vessels and iliopsoas
-Access to pelvic brim, quadrilateral plate
Lateral window: Lateral to iliopsoas (iliopectineal fascia)
-Access to quadrilateral plate, SI joint, iliac wing
Indications: anterior wall and column***
Both column
Posterior hemitransverse
Risk: Femoral nerve injury
LFCN
Thrombosis of vessels
Laceration of corona mortis in 10-15% ***
Posterior approach to acetabular fx
Indications
Risks?
Posterior/Kocher-Langenbach
Indications: Posterior wall and posterior column**
Most transverse and T type
Risks: Increased risk of HO vs anterior approach
Sciatic nerve (2-10%)***
Damage to medial fem circumflex artery/blood supply to head
Extensile approach to acetabular fx
Indications?
Risks?
Extensile/extended iliofemoral
IndicationsOnly approach that allows direct visualization of both columns*
Ass’d fx patter >3 wks out
Some transverse and T-type
Some both column (if posterior comminution present)*
-Risks: Massive HO***
Posterior gluteal muscle necrosis
Modified Stoppa approach for acetabular fx
Indications?
Risks?
Indications: access to quadrilateral plate to buttress comminuted medial wall fx (Both column)
Risk: Corona mortis (must be exposed and ligated)
Long term (20 year) survival for patients s/p ORIF for acetabular fx?
Most common complication? Risk factors?
80%
Most common complication: DJD Risk factors: Age >40*** Ass'd pattern Concomitant femoral head injury***
Other complications: HO, osteonecrosis, DVT/PE
Factors ass’d w/ fetal M&M with acetabular fx?
Injury severity
Mechanism of injury***
Maternal hemorrhage
Bado classification for Monteggia fx
Type I: anterior dislocation of radial head (most common) ***
Type II: Posterior dislocation of radial head
HIGHEST complications and WORST prognosis **
Type III: Fx of ulnar metaphysic (distal to coronoid) with lateral dislocation of radial head
Type IV: Fx of both radius/ulna and dislocation of radial head in any direction
Most common impediment to radiocapitellar reduction after anatomic reduction of ulna in Monteggia fx?
Annular ligament interposition in RC joint
What direction does radial head usually go with Monteggia fx?
Follows apex of ulna***
Apex anterior ulna = most commonly dislocated anteriorly (Bado I, also most common)
Galeazzi fx definition?
Incidence of DRUJ instability related to length from articular surface?
Def: distal 1/3 radial shaft fx + DRUJ injury
Incidence of DRUJ instability:
-If radial fx <7.5 cm from articular surface, DRUJ instability 55%
-If radial fx >7.5 cm from articular surface, DRUJ instability 6%
Primary stabilizers to DRUJ (Galeazzi fx)?
What position most stable in?
Volar and dorsal radioulnar ligaments***
Most stable in supination
What can cause reduction block of DRUJ in Galeazzi fx?
interposition of ECU tendon***
Starting point for tibial nail?
Deformity if started to lateral? Too medial?
Where to place blocking screws for prox 1/3 tibia fx?
Starting point: Medial portion of lateral tibial spine
Too lateral: creates varus (so ok to start slightly more lateral in prox 1/3 tibia fx to decrease valgus deformity)
Too medial: creates valgus deformity
Blocking screws
Coronal blocking: place posteriorly in prox fragment to prevent procurvatum
Sagittal blocking: place lateral in proximal frag to prevent valgus
What deformity does supra patellar nailing help prevent?
Helps prevent apex anterior/procurvatum
Risk of LISS plate for tibia fx?
Superficial peroneal nerve (approx 5 mm from hole 13)
Which BMP to use with open tibial shaft fx?
Which BMP for nonunion tibia fx?
rhBMP-2
Accelerate early fx healing Decrease rate of hardware failure and subsequent bone grafting required Less secondary invasive procedures Decreased infxn rate Not fully supported in newer studies...
Nonunion: BMP-7 (OP-1)
Reamed vs undreamed tibial nails
CLOSED injuries
lower rate of primary events (need for bone grafting, implant exchange or dynamization) -mostly due to less dynamization needed
OPEN injuries
NO differences between reamed and undreamed ***
How close to knee joint can tibial pin be for ex fix?
14 mm or further, knee capsule inserts 14 mm below articular surface
How long to observe a tibia fx before secondary intervention for nonunion?
6 months
When to not use a tourniquet for tibia fx?
Polytrauma with femur fx where femur is nailed
Surgical tx of tibia or ankle with tourniquet increases pulmonary complications
What nerve can be affected by closed nailing of tibia fx?
Deep peroneal nerve, approx 5%, decreased EHL, transient
Most common malalignment when nailing distal 1/3 tibia fx vs plating?
Valgus
IMN malalignment 23% vs plating 8%
70% valgus
4 fragments with pilon fx?
1: medial malleolar - deltoid ligament
2: Posterior malleolus/Volkmann fragment (PITFL)
3: Anterolateral/Chaput (AITFL)
4: lateral malleolus = wagstaffe
Factors that correlate with poor clinical outcome and inability to return to work after pilon fx?
Lower level of education*** Male Pre-existing medical condition Work related injury Lower income level
Anterior tib artery
Which branch of popliteal artery?
Where does it run?
What artery does it terminate as?
Which nerve does it run with?
1st branch of popliteal artery
Passews between 2 heads of posterior tib and IOM
Lies anterior to IOM between tib ant and EHL
Terminates as dorsalis pedis
Runs with deep peroneal nerve
Posterior tib artery
Where does it run?
What artery does it terminate as?
Continues in deep posterior compartment of leg
Goes behind medial malleolus
Terminates by dividing Ito medial and lateral plantar nerves
Runs with tibial nerve
Peroneal artery
Where does take off from popliteal artery?
Where does it run?
What artery does it terminate as?
Main branch takes off 2.5 cm distal to popliteal fossa
Continues in deep compartment, between tib posterior and FHL
Terminates as calcanea branches
Fixation of fibula during pilon fx - helpful?
Fixation of fibula in pilon fx shown to have higher overall complication rates***
What type of cell death in pilon fx leads to post traumatic arthritis?
Initial superficial zone cartilage cell death via necrosis at fracture margins
Articulations of talus
1: inferior surface articulates with posterior facet of calc***
2: Talar head articulates with navicular and sustenaculum tali
3: Lateral process articulates with posterior facet of calc and lateral malleolus
4: Posterior process consists of medial and lateral tubercles separated by groove for FHL
Blood supply to talar neck
1: Posterior tibial artery
Via artery of tarsal canal (dominant supply)*
Supplies majority of talar body
Deltoid branch of posterior tib artery: supplies medial portion of talar body - may only blood supply remaining in displaced fx*
Anterior tib artery
Supplies head and neck
Perforating perineal artery via artery of tarsal sinus***
Supplies head and neck
Hawkins classification of talus fx
Hawkins I: non displaced, low chance of AVN
Hawkins II: subtalar dislocation, 20-50% AVN
Hawkins III: Subtalar and tibiotalar dislocation, 20-100% AVN
Hawkins IV: Subtalar, tibiotalar, talonavicular dislocation, 70-100% AVN
Most common complication in talus fx?
Other complications
Most common: post-traumatic arthritis*
Subtalar arthritis is MOST COMMON* (50%)
Others
Osteonecrosis, 30%
Hawkins sign, subchondral lucency seen on mortise at 6-8 weeks, intact vascularity w/ resorption of subchondral bone
Varus malunion 25-30%
Causes decreased subtler eversion*
Weight bearing on lateral side of foot
Tx with medial opening wedge of talar neck*
What type of subtalar dislocation is more likely to be open?
Which dislocations do worse?
Lateral dislocation (though less common than medial dislocation 65-80%)***
Lateral more likely to have concomitant fx***
Factors ass’d with poor outcome:
High E mech*
Lateral dislocation* (more high E mech)
Open dislocations*
Concomitant fx involving subtalar joint*
Position of foot for medial subtalar dislocation?
What blocks medial subtalar dislocation?
Foot locked in supination***
Blocked by:
Peroneal tendons
EDB*** (most common)
Talonavicular joint capsule
Position of foot for lateral subtalar dislocation?
What blocks lateral subtalar dislocation?
Foot locked in pronation***
Blocked by:
PT tendon*** (most common)
FHL
FDL
Complications after subtalar dislocation?
Most common: Stiffness***
Post-traumatic arthritis
Subtalar joint most commonly affected, 2/3 symptomatic
Open calc fx: increased infxn rate? increased wound complications?
Open fx: NO increased infxn rate***
INCREASED wound complications***
Anterior process of calc fx: what ligament is disrupted?
Bifurcate ligament***
Runs from anterior calc process to both cuboid and lateral aspect of navicular (Y-ligament)
Fragments of intra-articular fx of calc
Superomedial fragment*
constant fragment*
Includes sustentaculum tali, stabilized by strong ligamentous and capsular attachments
Superolateral fragment***
Includes and intra-articular aspect through the posterior facet
Secondary fx lines
dictate whether there is joint depression or tongue-type fx
Factors ass’d with complications with calc fx?
40% complication rate***
Increased due to mechanism (fall from height), smoking, early surgery
lateral soft tissue trauma increases risk of complication
Why is superomedial/anteromedial fragment constant in calc fx?
Medial talocalc and interosseous ligaments ***
Rads findings for calcaneus fx
Double density sign?
Varus or valgus deformity?
Bohler angle?
Angle of Gissane?
Dbl density: lateral view shows partial separation from sustentaculum –> lateral portion of posterior facet* (medial portion of posterior facet in “constant fragment)*
Varus tuberosity deformity
Bohler angle: line from heist point of anterior process to highest point of posterior facet then line from top of posterior facet to superior edge of tuberosity on lateral
Normal 20-40 deg ***
Represents collapse of posterior facet
Angle of Gissane
Angle between line along lateral margin of posterior facet and line anterior to beak of calc on lateral view
Normal 120-145***
Represents collapse of posterior facet
Surgical outcome of calc fx ass’d with?
Factors ass’d with poor outcome?
Surg outcome correlates with number of intra-articular fragments*** and quality of reduction
Surg tx decreases risk of post traumatic arthritis ***
Factors ass'd w/ worse outcome: Age >50 (similar outcome w/ and w/o surg) Obesity Men do worse than women*** Smokers*** Bohler angle <0 *** Manual laborer*** Worker's comp***
Typical patient who will need secondary subtalar fusion after calc fx?
Male worker’s comp who participates in heavy labor with initial Bohler angle <0 deg
What artery supplies lateral skin for extensile L shaped incision for calc fx?
Lateral calcanea branch of peroneal artery***
Malunion of calc
PE?
Tx?
goals of tx?
PE: limited dorsiflexion, due to dorsiflexed talus with talar declination angle of <20 deg***
Tx: Distraction bone block subtalar arthrodesis***
Chronic pain from subtalar joint
Loss calc height
incongruous subtalar joint/post traumatic DJD
Mechanical block to ankle dorsiflexion (from posterior talar collapse into posterior calc)
Goal to correct the following:*** Hindfoot heigh Ankle impingement subfibular impingement subtalar arthritis
Benefit of Surgery vs non surgical for displaced intra-articular calc fx?
Ass’d with approx 6 fold decrease in risk of post traumatic subtalar arthritis (necessitating subtalar arthrodesis) vs nonsurg***
Most common complication with surgical tx of calc fx?
Wound dehiscence or wound healing issues
What patients do better with surgery vs non surgical for calc fx?
Women*
<29 y/o*
Bohler 0-14 dg*
Sedentary job*
After traumatic intra-articular injury, what molecular change causes post traumatic arthritis?
Intitial SUPERFICIAL ZONE cartilage cell death via NECROSIS at the FRACTURE MARGINS***
Delayed superficial zone cartilage cell death occurs via apoptosis at the fracture margins
Effect of bisphosphonates on fx healing (intertroch) within 3 months of surgical intervention?
No effect***
How long to wait for 2nd stage for Masquelet technique?
when do BMPs peak and how long present after Masquelet?
4-6 weeks***
BMP peaks at 4 weeks and is elevated until 6 months***
