Trauma Flashcards
in field triage transport first or fluids first?
always transport first, fluids after
pre-hospital blood products - do they help?
no more than non-blood products in reducing mortality
when is femoral traction for femur fracture CONTRA indiciated
if obvious knee injury
ISS score method
take the three highes AIS scores (1-6); any score of 6 automatically makes ISS 75 - ie nonsurvivable
SBP cuttoff as risk factor for mortality
90mmHg
key value that indicate shock
sbp < 90; lactate > 2; base deficit > 4; TEG values that indicate HYPO coag; hypothermia< 35degC
when to fix pelvic ring, spine, femur or acetab frx
WITHIN 36 hrs IF lactate < 4; base def < 5.5; or pH > 7.25
leading cause of death in americans < 45 years
injury
ISS cut off for poly trauma
16 on ISS
m/c location for nonfatal GSW
extremities
damage by shotgun - which factors
distance, mass of pellet and shoot pattern
are bullets sterile
NO, need to give tetanus
transabdominal GSW causing a EXTRA-articular STABLE fracture
non op is ok with 24 hrs broad spec abx
percentage of pts with associated injuries with OPEN fractures
typically one third
when to give tetanus toxin
if clean or dirty would and > 10 years since last dose, if clean and < 3 doses or unknown, if DIRTY then give both toxoid and TIG
if ABI < 0.9 get which study
angio
which abx to add for fresh water injury
fluoroquinolone
irrigation guidelines
no diff in revision surgery for high vs low vs super low pressure; more revision when using soap vs nl saline solution; no diff when compared to bacitracin; more wound complication with baci
when to provide flap coverage for open frx
within 5-7 days; infection rate is 5 vs 31%
comorbids effect on open long bone frx infection
ASA A -5%; then 15% then 31%
retoversion during femur IMN leads to
externally rotated gait
advntage of NPWT in open wounds and incisions
helps reduce infection, improve grannulation bed, reduce drainage and and accelerate primary closure, improve tissue edema
fixation of ankle fractures in diabetics
add syndesmotic screws and prolonged immobilization
most cost effective option for mid shaft clavicle fracture
sling and delayed surgery if needed
calcium sulfate vs phosphate
phosphate is stronger and takes longer to resorb
where to apply clamp for syndesmosis
at level of syndesmos and mid tibia
posterior mal with syndemosis injury
FIX the posterior mal - even if small size
distal third tibia frx - IMN vs plate
better alignment with plate and NO difference in union, infection, or wound issues
most common associated injuries with plateau
lat meniscus, then ACL and then collaterals; up to 50% have meniscus injury; highest in schatazker 2 and 4
allograft is osteoinductive or conductive
osteoconductive
if lisfranc is suspected but xrays are negative what next
WB xrays of foot. Ligamentous injuries don_t need a CT
early fixation of hip fracture reduces
pna rate, DVT rate, complication rate, and mortality iat 30 days if done within 48 hrs
mortality in trauma with TXA
early TXA administration within 3 hours can reduce mortality
main benefit of ex-fix to pelvis
allows for stable clot - does NOT offer “rigid” fixation
plate fixation for which olecranon fractures
comminuted, poor bone quality, fracture lines distal to the trochlear midpoint, those invovling cornoid process and monteggia frx dislocation
comanagement of geriatric hip fractures leads to
decreased overall mortality (not inpatient); improved ambulation at discharge, lower costs per patient, lower LoS, lower complication and readmission rates
benefits of THA in active hip frx
better outcomes, lower overall long term costs, lower revision rates
subtle lisfranc widening parameters
interMT space > 2.7mm or space between medial cuneiform and 2nd MT > 2mm
tx of poterior Sternoclavicular dislocations
first try closed reduction in OR
higher risk of infection with which plateaus
bicondylar, male, smoker, higher ASA, or pulm disease
ASIA A vs B
B would have some sensory remaining - even if its just perianal sensation
whats more common in displaced fem neck frx non union or malunion
NON-union
recommended ex fix pin care guidelines
shower and dry dressing - no data on peroxide vs CHX
how to approach coronoid fractures
medially based FCU split - needs a buttress plate; or can use medial hotchkiss approach
hotchkiss approach to elbow
most anterior of the medial approaches
non union with bulbous appearing cortex is a
HYPERtrophic non-union
patient RF for non-union
DM, obesity, nicotine, (Meds - nsaids, steroid, antiepileptics and anticoag), endocrine abnormalities
contraindication to electrical stim device for nonunion
synovial pseudoarthrosis; mobile non-union; fracture gap > 1cm
oligotrophic non union can look like
atrophic non-union as in they have no callus but have viable bone ends
definition of atrophic non-union
have avascular or hypovascular bone ends - may require a osteogenic and osteoinductive bone graft to address
pseudoarthrosis has joint fluid T/F
T - has synovial fluid
RIA advantage and disadvantage
large volume of graft but lots of EBL
where is fracture shortening better tolerated
UE is tolerated better than LE
limit of angular deformity at distal humerus
10 valgus; 15 varus;
tolerance of angular deformity at knee or ankle
10deg max; even as little as 5 deg can lead to hip or knee OA
Ciery-Mader Stage of osteo
Stage 1-4; 1 is IM; 2 is superifical bone only; 3 is whole cortex with invovled endosteum - but not circumferential at the axial level; 4 is entire segment.
rate of RoH in clavicle frx in various plating styles
no diff in RoH or union b/w Ant or sup plating
rate of non union with DISPLCED midshaft clavicle
15-20%
acromium development
pre (tip), meta (base) and meso (middle)
spur sign in acetab frx
part of hemipelvis still attached to the pelvis - seen on obturator oblique view
worst solvent to be injected at high pressure
oil-based; greeese and CFC based need aggressive debridement, water and latex are least destructive
factors that impact outcomes after solvent injection trauma
involvement of tendon sheath, extent of proximal spread; pressure, delay in surgery
capitellar fracture sign
double arc sign - internal rotation of the fragment or a poor lateral view can mask this
distal femur periprosthetic frx - lock plate vs IMN
lock plate has more NON_union; IMN has more MAL-union
optimal fixation for quad tendon
use knotless SUTURE anchors - least amount of gapping with cycling loading and highest load to failure ; better than transosseous or threaded suture anchor
optimal plate length for distal femur frx
at least 9 holes in shaft allowing for at least 8 holes proximal to fracture
factors that lead to implant failure in distal femur ORIF
obesity, open frx, smoking and YOUNGER age.
factors outcomes in acetab ORIF with posterior wall
lots of comminution, greater than 3 fragments suggests decreased success ;
lateral plateau with 10mm joint depression - look for
lateral meniscus tears , 8x higher chance
open contaminated distal femur fracture tx
ex -fix with I&D and then staged ORIF
tx of open frx in BRAKISH water
doxy and 3rd gen cefalosporin
lock plate vs 95 blade plate with distal femur frx
no difference in hardware removal; but better able to lock plate with associated coronal fragments
tx of vertical sheer hemi pelvis initially
binder and distal femur skeletal traction to reduce the vertically displaced fragment
rate of hardware removal clavicle ORIF
25-30 %
immediate mortality rate after hip fracture in hospital
6%, 30% at 1 year
LEAP study outcomes
amputation and limb salvage had same outcome at 2 years but limb salvage has more re-operation, hospitalization and complication
shortening malunion is better tolerated WHER
Upper extremity
angular deformity allowed at distal humerus
10 deg of valgus and 15 of varus
clavicle blood supply
has no nutrient vessel supply -only periosteeal
what percent of clavicle frx are middle and lateral
80% middle; 15% lateral
clavicle classificaiton systems
overall it_s the ALLman classificaiton; medial is described by dislocation of SC; middle is middle; lateral is NEER classification
clavicle plating
superior is for AXIAL; ant-inferior plating is for bending
non op vs operative clavicle ORIF strengthening
4-6 weeks for ORIF; 6-10 for non-op
ogawa classification of coronoid fracture
1 is nea the base - more unstable; 2 is at the tip
kuhn classificaiton of acromial fracture
1 -non displaced; 2 - displaced but SubAc space preserved; 3 -impingment
scapular frx follow up
xray every 2-3 week if non-op
typical deformity in non op prox humerus
varus and apex anterior
most common complication of prox hum ORIF
screw penetration; not cut out
what inserts on Greater tuberosity of shoulder
SSp, ISP AND terres minor
what supplies GT of prox hum
arcuat artery of Liang - crosses biceps groove via the ANTERIOR circumflex
highest risk of axillary nerve injury seen with what
frx dislocation of prox hum
axilary radiograph uses
to ensure GH reduction but may exaggerate the angular deformities
down side to Neer classification for prox hum frx
POOR interobserver reliability
plate application in prox hum frx
LATERAL to biceps groove; may need to take down anterior third of deltoid insertion
when is IMN contraindicated for prox humerus frx
HEAD splitting and osteoporosis
risk of post-traumatic OA in prox hum frx
four part; < 8mm calcar, dislocations
common complication of locked screws in prox hum frx
head penetration
outcomes of prox hum frx
expect improvement up to 1 year; variable outcome based on pre-existing fxn, tuberosity and cuff status
where does IMN canal terminate in humerus
3cm prox to olecranon fossa
dual innervation of brachialis
radial nerve and MSC
interval in posterior approach to humerus
between LATERAL and LONG head of triceps
what exercises are allowed immediately after application of sarmiento
applied 7-10 days after splint - ok to begin isometric biceps, triceps, deltoid . Active wrist and hand exercises too
tolerances for humeral shaft frx
20 apex ant/post; 30 varus valgus; or 15 rotation, 3cm shortening allowed
infection rate of open fractures of humeral shaft
12% withOUT fixation; 10.8% WITH fixation
union rate plate vs IMN for humerus
lower with plates
ex fix of humerus
SPAN the elbow - 2 pins proximal to humeral shaft fracture and in 2 iin Ulna (preferred) - ulna allows for less NV injury and maintained pronation supination
retrograde humeral nails main downside
greater mismatch in size and shape - leads to over reaming
risk of humeral nail interlocks
proximally - axillary artery; lateral antebrachial nn, brachial aa, and median nn - distally
when to consider NCV for rad nn palsy for BASELINE
at 6 weeks for BASELINE testing
triceps sparing approach
involves mobilization of the ulnar nerve with release of extensor mechanism
distal humerus fracture patterns and elbow position
when elbow is flexed past 90 - then you get INTERcoloumn frx; when at 90 - you get transcondylar
posadas frx
distal humerus transcondylar with distal fragment anteriorly displaced - causes concomittant dislocation of radial head and ulna
Milch classification
1 - does not violate lateral trochlear ridge; 2 DOES include Lateral trochlear ridge - hence more unstable as ulna can dislocate
H type pattern of distal humerus is at risk for
trochlear osteonecrosis - free fragment
bryan and morrey classification of Lat Condyle frx
1 - coronal shear (fix); 2 - cartilage sheer, 3 - comminuted compression (generally excise 2-3); 4 - involves MOST of trochlea
how to find radial nerve posteriorly
use later BRACHIAL cutaneous off the post aspect of lateral IM septum - follow proximally to level of deltoid tuberosity on the posterior aspect
when to begin active ROM of elbow after ORIF
7-10 days - goal is early ROM
post op ROM after distal humerus ORIF
usually 105 arc of motion; with loss of extension more common then flexion
position of arm in radial head frx
typically PRONATION -with axial load
tension band for olecranon does NOT resist what forces
angular forces
most common monteggia
Bado 2 - posterior dislocation of Radial head
shape of proximal ulna
has on avg a 6 deg dorsal bend that must be taken into account when placing a plate
coronoid frx implies
elbow instablity event occurred
what part of coronoid is most important for VARUS stability
medial facet and sublime tubercle - key for VARUS stability as MCL inserts there
posterolateral elbow instablity due to which ligament disruption
LCL and coronoid tip frx with possible radial head frx
posteromedial elbow instability due to
also due to LCL disruption but anteromedial coronoid fracture is present
approach for medial coronoid frx
medial approach by splitting FCU heads or more anterior when you need access to anteromedial facet
best fixation for anteromedial coronoid frx
buttress plate via medial approach
main stability offered by coronoid process
anterior and VARUS
MCL status in terrible triad, elbow injury
do NOT need to repair MCL if you address LCL and bony injuries in terrible triad.
down side of Kocher approaches
Kocher (ECU/Anconeus) can lead to injury of LCL; (ECU Split) can lead to injury of PIN; Kaplan (ECRL/Common Extensior) is more anterior
downside of overstuffing with radial head replacement
limited flexion and erosion of capitellum
ismetric point of LUCL in elbow
center of capitellum and 2mm anterior to Lat epicondyle
common cause of revision surgery after terrible triad
for stiffness - 25% need surgery for this and usually get about 30-40 degrees
rate of post truamatic OA in terrible triad
60-70% on XR but not often symptomatic
when are central fibers of interosseous membrane of forearm MOST tight
neutral rotation
most common complication after sub Q ex-fix for pelvis
asymptomatic Heterotopic ossification
midhsaft femur fracture with IMN - interlock technique
static on proximal and distal fragments
platuea with low suspicion for vascular injury - do you need ABI
NO - go to ex-fix first
fixation of posterior mal accomplishes the following
resotres incisura competence and therefore reduces syndesmosis malreduction; stabilizes via PTFL, improves ankle surface area, and posterior stabiliy of talus
how does ca-phos dissolve
osteoclast mediated degradation
what factor is associated with non-union, revision and hardware failure of tibia nails
STAINLESS STEEL nails
most common cause of nec-fascitis
POLY microbial; usually includes streptococci A and enterobacter - most common MONO microbial cause is Group A strep
most common assoc diagnosis with nec -fasc
diabetes
rash from wound vac resolves in
48 hours
WHY is wound vac contraindicated in tumor bed
increased angiogenesis and unclear effect on tumor cells
rate of symptomatic malunion in clavicle
about 9%
pilon or distal tibia ORIF with or without fibula fixation
fibula fixation had no effect on alignment, outcomes, or reduction but DID have higher rate of complications related to fibular fixation - hardware removal
RIA vis iiac crest graft
more quantity than anteior iliac crest harvest and less pain; similar effect on union
location of comminution in YOUNG femoral neck frx
inferior and posterior
NPWT on split thickness skin graft
helps incorporate the graft
varus posteromedial vs valus posterolateral
valgus posterolateral is the terrible triad and has a coronoid fracture with radial head fracture; varus posteromedial has the anteromedial coronoid facet fracture
hemorrhag class 1 and 2
1 and 2 are BOTH normotensive, 2 has tachycardia and lower UoP
hemorrhagic class 3 v 4
3 has HR > 120 and confused with UoP 5-15cc/hour’ 4 has NO UoP, lethargic and HR > 140
effect of comanagement protcols for hip frx after 60
improved Mortality, LoS, complication, readmission rates and ambulatory status at discharge - NO effect on surgical time or time to Surgery, blood loss, or INPATIENT mortality
screws vs DHS for hip fracture
DHS better for HIGH pauwels angle
Demineralized bone matrix is osteo-what
osteoinductive (has small amounts of BMP) and osteoconductive
allograft is osteo
osteoconductive only
dropped hallux after tibia IMN
due to transient neuropraxia and NOT due to AP screw - most resolve by 4 months
benefits of ORIF on distal radius in elderly
better motion earlier on, GRIP strength better at 1 year
elderly with posterior wall frx have associated
knee injuries fractures > ligamentous
acceptable malrotation in femur fractures
15 deg
eldery distal radius frx with positive ulnar variance - tx?
NON-op
comminution and strain
motion is distributed over tiny fragments so overall less strain
risk factors for distal femur non-union
short plate length (< 9holes); obesity, smoking, YOUNGER age, and OPEN frx - non-locking screws is NOT a risk factor for early failure
best tx for Lisfranc
FUSION
what is the effect of multidiscplinary team for hip frx
lower overall cost per patient - no difference in inpatient mortality but there is a diff in OVERALL mortality
distal radius ORIF in elderly leads to
better GRIP at 1 year; better xrays
main ligaments of Lis franc
dorsal (weakest) plantar; and oblique interosseous (Strongest)
pelvic bleeding from ring fracture is usually caused by
sup gluteal; but can also be caused by pudendal if near pubic symphisis
tx of morelle lavalle with fracture
perc debridement with delayed ORIF OR open debridement with closure of ONLY fascia
what instability does terrible triad lead to
valgus posterolateral - radial head; coronoid and dislocation
varus posteromedial elbow injuries show what structural dmage
LARGE anteromedial coronoid fragment - INTACT radial head
kocher vs kaplan approaches
Kocher (ECU/Anconeus) can lead to injury of LCL; (ECU Split) can lead to injury of PIN; Kaplan (ECRL/EDC split) is more anterior
what must be added to atrophic nonunion fixation
bone graft
amputaiton vs limb salavage
better outcomes at 2 years (statistical and clinically) if compared with patients would need flaps or fusions - once these were controlled- then salvage was clinically but not statistically better
ptsd in trauma
females are 4x higher risk and LE or pelvic injury has 2x higher risk
orif vs IMN for humeral shaft - diff in Rad n injury
NO difference in iatrogenic injury -only proven diff is shoulder complication
pilon outcomes factors
no highschool grad is worse outcome; no diff in outcomes for complextiyof fracture at LONG term
llong bone septic non-union tx
must use spacer - NOT abx nail alone.need to create masquelet for defect as well
how does ca phos get absorbed
via osteoclast
how is hydroxyapatite degraded
macrophage and giant cells
LEAP results at LONG term
equivalent outcomes - return to work is same at 2 years; lifetime cost is 3x HIGHER in amputation group
which traits are seen in sacral dysmorphism
large S1 foramina; residual S1 disk; mamillary bodies; and steep alar slope
dvt ppx reccs for hip frax
ACChest Phys recommends 35 days; but at least 10-14 days; PENTHIFRA study shows fondaparinaux better in DVT rates vs lovenox
how to cover for brackish water
doxy and 3rd gen cefalosporin
should you delay surgery for hip frx on plavix
NOPE
Nsaids vs xrt for HO ppx - whats main conclusion
same equialent efficacy or inefficacy, both a/w non-union
how accurate are pre and post debridement cultures
most open wounds are NEITHER; but generally of cases that become infected, post-debridement is usually 42% - not routinely recommended to get cultures
non union of fem neck frx - tx
valgus ostetomy
risk factors for repeat pelvic angio
continued hypotension; PRE angio transfusion > 2 units; or multiple vessels requiring angio
bisphos on fracture surgery timing
can start within 1 week post-op
knee injury incidene with acetab frx
15% have associated knee injury; upto 30% are fractures
mc complication of IN-FIX for pelvis
asymptomatic Heterotopic ossification
DBX vs Allograft
DBX has BMP so It IS osteoINDUCTIVE; allograft cancellous is DEAD - so only conductive
board answer for valgus impacted
CRPP
femu fracture risk factors for malrotation
diaphyseal comminution
RIA is what type of graft
osteo inductive, conductive and genic
what does triplane look lke on AP and lateral
on AP - SH 3; on lateral SH 2 with post metaphyseal component
tibia flexible IMN post-op tx
still requires splint or cast for a short period of time; non-op needs longer immobilization - no difference in malunion
where do fractures during THA occur
most often at calcar; worst in lateral approach
risk factors for intra-op femur fracture during THA
lateral approaach, UNCEMENTED, full coat during revision; female gender, and age.
r/f for infection after plateau orif
male; pulm disease; high ASA, bicondylar, smoking - NOT renal disease
fibular fixation during pilon leads to
increased complication (mostly due to implant removal) -
bone marrow aspirate Is osteo_.
inductive AND genic
distal femur periprosthetic frx - lock plate vs IMN
plate has more NON union vis retro IMN; retro IMN has more malunion
fators a/w need for hip replacement in acetab frx
older >40; post wall involvement, fem head lesion; impaction; poor post-reduction congruity; intial displacement > 20mm; use of extendediliofem approach
strongest fixation for medial mal lag vs antiglide
antiglide is more biomex stronger for vertical shear mal; transverse frx use the bicortical screw
timing of compartmetn closure and orif for plateau
no diff in infection rate; in terms of when to orif vs when to close fascia
RoH of tibia flexi nails
not needed!
predictor of failed fixation for patella
increasing age and fixation with wires; OPEN is not a risk factro
smashed humeral shaft frx what is tx
non-op
distal third tibia frx - IMN vs plate
no diff in union; wound issues or superfiical or deep infection - less malalignment with plate
after reduction of knee dislocation there is no pulse what next
vascular consult and explore popliteal fossa
risk of life threatening injuries with multilig
27%; TBI is 10%; pneumothrax is about 14%; m/c is ipsilatera fracture - 58%
what is best use of extended iliofemoral approach to tab frx
if BOTH columns are involved or malunions or nonunions
adv to tibia IMN vs plate
imn has lower radiation; surgery time and less difficult hardware removal
posterolateral approach to ankle
between FHL and peroneus longus
multiple attempts of closed reduction of fem head is associated with
osteonecrosis
SCH frx with lost perfusion after fixation and no pulse
remove pin and unreduce - artery may be trapped in fracture
what are risk factors for infection after pevlic and acetab frx
obesity with leukocytosis or pre-op angio embolizaion
downside of kocher approach
cannot extend the approach proximally - unlike a more anterior kaplan
main deformity with prox tibia frx IMN
PROcurvatum and valgus
upper limit for rotational difference in femur fractures
15deg
modulus of elasticity of titanium
100MPa
worst WB for acetab frx
standing from seated position
time up and go vs single leg stance
TUG is more for predicting need for walking aid at 2 yeasr; the Leg stance is more for ambulation at 2 y
what is most a/w GSW to hip
bowel perf; visceral injury
what is vitamin C dosing fo CRPS
50days of 500mg
what is mortality of hip fracture IN HOUSE
6% - 30% at 1 year
how does electrostim of bone work for healing
upregulates growth factors aand BMP, TGF B
highest risk of what after patella ORIF
ant knee pain
tibial amutation bridging vs non-bridge
same outcoms but bridging (ERTL) has more complications
actual vs perceived intimate partner violence rates
40% actual; 10% perceived
SPRINT Trial results on risk for adverse events (non union; malunion; hardware failure)
stainless steel nail
best view for medial epicondyle frx dispacement
humeral axial view
tx of distal third tibia frx
plate BOTH tibia and fibula
optimal pin site care
shower and dry dressing - no data on peroxide vs CHX
shortening of the femur does what to mechanical axis
medializes it
pilon fracture plate options
look for ANTERO lateral plate; -not same as lateral; also - nonlocked over locked
most common reason for malreduced mortise
malreduced fibula or lateral malleolus
what to do with partial union of tibia with mild symptoms after IMN
nothing -observ
competitive inhibition of plasminogen activation - what drug
TXA
midline distal third tibia superficial nerve is usually
SUP peroneal - not deep
gull sign is seen when and means what
best on obt oblique - post wall fragment
debridement of open tibia and infection risk
no correlation on TIMING vs infection; BUT there is reduced infection on debridement vs NON-OP
LC fractures and mortality
increases with LC grade due to HEAD injury; only modest climbs due to sepsis, ARDS, shock
APC and mortality
highest rate of fluids, hemorrhage, increasing death rates are due to shock, sepsis, and ARDS - overall highest mortality
distal tibia blocking screws
place it medial to avoid varus - opposite of proximal tibia
open fracture and co-morbidity
greater than 3 is higher risk of infection
mortality of elderly distal femur fractures
typically 25-38% at 1 Year; the same as geriatric hip fractures
risk factors for mortality in elderly distal femur
advanced renal disease; periprosthetic, dementia, CHF, metastases; non-op has higher mortality. Surgery within 4 days REDUCES 1 year mortality
tx of interprosthetic femur fractures with previous distal femur plate
revise the distal femur plate to long one - do not use anterior locking plate
m/c complication of triangular osteosynthesisi
hardware prominence and pain
NON displaced transverse patella frx tx
if intact extensor mechanism - non-op aand immobilize for short time before isometric quad
TXA and adult trauma mortality
TXA can improve mortality rates if given within 3 hours
best imaging for occulat periprosthetic frx
if after negative xray and some time - can get delayed bone scan
if continued elbow instability after terrible triad ORIF then
check LUCL - and fix
best tx for vertical fem neck
SHS and side plate
supra vs infrapatellar IMN for tibia and knee pain1
same incidence
ASIA A vs incomplete
A is complete; if sacral sparing or peri-anal sensation is intact then it CANNOT be A
GSW with transected nerve - when to repair
1-3 weeks later to allow soft tissue declaration
osteomyoplasty transtibial amputation has what restriction
no early fitting or WB due to need for bony union
best way to tension EIP to EPL transfer
awake with local anesthetic
which monteggia has worst prognosis
Bado 2 - posterior dislocation of Radial head; main complications are non-union and plate failure
peroneal instability after ankle fracture - what is a radiographic clue
on lateral view look for fleck sign off fibula -needs repair after trial of bracing
what to do if ipsilateral fem neck frx with shaft if CT is negative
STILL needs intra-op fluoro
risks for distal forearm fracture redisplacement after closed reduction in kids
higher risk if worse initial translation (NOT angulation)
order of destructiveness in high pressure solvents
water and latex are least; grease and CFC refrigerant are intermediate; oil -based is worst and can require amputation due to chronic inflammation
tx of perilunate dislocation
if < 8 weeks surgery, lig repair; If > 8 weeks - PRC
Faith trial on SHS vs CRPP
similar rates of union, shortening, or re-operation at 2 years; SHS had more AVN, increase LOS
risk factor for shortening with fem neck frx
male, higher weight; older age; and pauwels 3
CTA vs ABI
if post-treatment exam is still asymmetric or concerning, do not need ABI - go straight to angio
best view for retrograde ant column screw
iliact inlet view - allows to see AP position of screw in rami when placing ant column screw
what is associated with mortality in 90 y old after trauma
need for ventilation
tx of periprosthetic humerus frx
ORIF - do not revise arthroplasty unless loose stem - even if cement
if pt is long term bisphos with femur pain and neg xray what next
prophylactic nail - no advanced imaging
traumatic amputation of proximal phalanx should be treated with
removal of ray. The stump weakens grip and gets in the way
short head of biceps innervation in FEMUR
before nerve splits into peroneal and tibial
most common complication of distal radius frx
median nerve dysfunction up to 30% in some high E cases
hybride ex fix vs dual plate for schatzker 5
dual plate has higher deep infection rate; ex fix has more pin site superficial infection and more malunion
what patient factor can cause anterior cortex perforation of IMN in femur
short stature
when to fix vancouver AG
Greater troch frx needs ORIF cables and troch plate
when fixing unstable pelvic ring posteriorly look for_
sacrl dysmorphism - may need SI screw at S1 and Trasnsiliac Transacral at S2
what is risk factor for TKA after cruciate injury
age > 50 – male gender and age <20 are PROTECTIVE
tibia fracure compartment syndrome is a/w with
younger age; open fracture does NOT increase chance of compartment syndrome
debridement of which muscle can prevent HO in acetab frx
glut minimus
does pin care affect infection rate after SCH frx
no difference; only younger age increases risk of infection
downside of kocher langenbach approach
cannot access SI , comminution going into sciatic notch or fractures extending into the wing
downside of helical blade fixation for CMN
higher migration and atypical cut out (superolateral)
what factor is most related to IATROgenic radial nn palsy during humerus ORIF
APPROACH - highest with lateral then with posterior
how long to continue abx after open frx debridement
24-72 hrs
modulus of elasticity equation
stress over strain
toughness is the
area under stress/strain curve
brittle definition
NO plastic deformation before failure
anisotropic vs viscoelastic
aniso is based on direction; visco is based on RATE
adv of locking screw diameter
stronger to shear and bending
rate of fragility fracture
is falling but overall numbers are increasing due to population demographics
what is prolia
denosumab - blocks RANKL - need to supplment with vit D and Ca
vit d def cutt off
< 25
most common sciatic variant
11% split sciatic nerve and spit pirfiromis
vessel damage APC vs LC
apc has Sup glut; LC generally has obturator and pudendal or ext iliac
APC 1 vs 2
in BOTH you have symphsis widening and sacrospinous/tuberous lig tearing; but in APC 2, widening is > 2.5cm and Ant SI is torn too
what is a complication of binder application
pressure sores to soft tissue at 24 hours
which patients get pelvic angio
if refractory to 4 L of transfusion
before inserting foley in pelvic frx
need retro Urethrogram
LC 2 vs tx
post ORIF and LC 3 is ant and bilat post ORIF
common theme b/w APC 3 LC 3 and VS
both vertically and rotationally unstable - anterior ex-fix ALONE is NOT suffiicient
APC 3 a/w
abdominal trauma; high blood loss; shock; and mortality in poy trauma
what are late uro complications in men from pelvic frx
stricture is m/c (up to 30-40%)
poor outcomes a/w with what in pelvic ring fr
poor reduction on posterior ring
femur frx with chest injury what is tx?
consider Ex-fix even if hemodynamically stable if serious lung compromise - reaming can lead to ARDS
osteo tx with bone loss
if < 2cm then acute shortening is ok in UE; but LE typically use distraction osteogeneis for any significant bone defect
typical rate of distraction osteogeneis
1mm/day in .25mm increments (4 times per day)
surgery cut offs for scapular frx
GPA < 22 (normal is 35-40); lateral border offset of 20mm; or angulation of 45 def in scapular Y;
when to get pre-op EMG for glenoid frx
if > 2 weeks since injury and fracture line includes spinoglenoid nothc
what two factors increase risk of prox hum frx osteoNecrosis
<8mm calcar and four part; also head split fracture
after application of sarmiento when to move arm
pendulums right away; can begin isometric biceps, triceps
most common distal hum frx pattern
intercondylar
high E femoral shaft fractures are a/w
chest, pevlic and UE injures
