Trauma chapter Flashcards
How to treat metatarsal fractures
- close reduce to correct sagittal and transverse displacement
- if unable to reduce ORIF with pinning
Etiology of 5th met fractures
- Large ground reactive with failure of stationary foot to evert
- Torsion at the 5th met as a stabilizer to the foot
Why are 5th met fractures hard to heal
- Watershed area of inraosseous blood supply to the metaphyseal region
- Mechanical pull of PB
What are the arteries that provide intraosseous circulation (3)
1) periosteal plexus
2) nutrient artery
3) metaphyseal/epiphyseal arteries
Conservative treatment options for 5th met fracture
-6-8weeks NWB casting
Surgical treatment options for 5th met fracture
-IM screw 4.5 cancellous is narrowiest that should be selected
- Ex-fix
- Trephine arthrodesis with graft from calcaneus
What are the classification systems to describe 5th metatarsal fractures
- Stewart classification
- Torg classification
- Lawrence and Bott classification
Describe the Stewart classification
1) Extra-articular Jones fracture
2) Intra-articular non comminuted fracture
3) Extra-articular avulsion fracture (PB)
4) Intra-articular comminuted fracture
5) Apophysis fracture
Describe Torg Classification
Type I: acute injury
Type 2: delayed union
Type 3: Nonunion
Describe Lawrence and Bott classification
1) Avulsion fracture due to lateral band of plantar fascia or PB contractures
2) Jones fracture due to ground reactive force with failure of the foot to evert
3) Diaphyseal fracture due to chronic stress, and repetitive distractive forces
Surgical treatment of 5th metatarsal fractures
-Tension band… Locking compression with distal ulnar hook plate
What is the etiology of Tailor’s bunion
- structural
- biomechanical: varus 5th toe, flatfoot,
Classification system for Tailor’s bunion
Fallat classification
1) Enlarged 5th met head
2) Lateral bowing
3) Increased IM angle
4) Combination of all 3
Angles to consider with Tailor’s bunion
- Lateral deviation angle: abnormal 8
- 5th MT IMA angle: 8 is abnormal
Surgical procedures used to correct Tailor’s bunions (11)
- Exostectomy
- Arthroplasty
- Davis
- Dickson and Dively
- Devries
- Amberry
- McKeever
- Reverse Hohmann
- Long oblique distal osteotomy
- Reverse wilson
- Reverse Austin
Describe exostectomy
removal of lateral eminence
Describe arthoplasty
removal of part/whole 5th mt head
Describe Davis
reverse Silver
Describe Dickson and Dively
Davis+removal of bursa
Describe DeVries
removal of lateral plantar condyle
Describe Amberry
Davis+removal of base of proximal phalanx
Describe McKeever
resection of 1/2-2/3 of 5th met
Describe reverse Hohmann
transverse osteotomy in neck
Describe long oblique distal osteotomy
Weil osteotomy like cut at the MT neck
Anatomy associated with Lisfranc complex
- Complex composed of dorsal (weakest) Plantar (strongest) and interosseus ligaments
- 2nd TMT joint is the keystone of the arch
- No interosseus ligament between 1st and 2nd MT
Etiology of Lisfranc fracture
- most injuries in Dorsal direction
- Forced abduction
- Twisting with an axial loading of a PF foot
- Motor vehicle accident
Clinical signs present with Lisfranc injury
Plantar ecchymosis sign
Apprehension sign: with FF DF and abduction
Stress exam of midfoot: unstable TMTJ with pronation and eversion
RULE OUT COMPARTMENT SYNDROME
X-ray findings associated with Lisfranc injury
Space between 1st and 2nd MT should be equal inspace with medial and intermediate cuneiform
- Drop in arch
- Fleck sign
What are the classification systems used to describe Lisfranc injuries
- Harcastle
- Quenu and Kuss
- Nunley
When is surgery needed with Lisfranc injuries:
When there is plantar instability and when there is >2mm displacement
How many incisions are used with Lisfranc surgery and what structures are fixated
3 incisions are used.
- medial to 1st met
- in 2nd interspace
- in 4th interspace
ORIF used to achieve arthrodesis of 1st-3rd TMTJ
Do not fuse 4 and 5 because they are essential joints.
What is the etiology of talar neck fracture and what xray view is used
Etiology: axial load+ hyper dorsiflexion. Aviators Astralagus
-Canale X-ray view
What is the etiology of talar head fractures
1) Crush/compression
2) Axial load on navicular
Etiology of talar body fractures
1) osteochondral
2) Comminuted
These have similar rates of AVN as neck fractures
Etiology of posterior process fractures
-Shepard’s or cedell fractures occur with forced PF of the foot.
Steida process: intact medial tubercle
Blood supply to the head/neck of talus, body of the talus and posterior portion of the talus
- Head/Neck: DP and ATA
- Body: Artery to tarsal canal (PTA), artery to tarsal sinus(peroneal)
- Posterior: peroneal artery and calcaneal branches
Describe Canale view:
AP view with foot PF, pronated 15 degrees to view angular deformity of talar neck
Describe Hawkins sign
subchondral sclerosis on AP view at 6-8 weeks and indicates healing
Treatment of talar fractures
surgical emergency if protrusion of bone against skin causing skin necrosis, prompt reduction of fracture needed.
What classification system used for talar neck fractures and what does it say about blood vessels damaged and risk for AVN
Hawkins classification
1: 1 vessel disrupted. 12% risk for AVN
2: 2 vessels disrupted. risk of AVN 20-50%
3: 3 vessels disrupted. Risk of AVN 50-90%
4: all vessels disrupted. Risk of AVN 90-100%
What classification system used for talar body fractures
Sneppen classification
describe sneppen
1: OCD Talar dome- compressive injury
2: Body (coronal/sagittal)- shear, sever DF
3: Posterior tubercle (shepard or cedell)
4: Lateral process- Snowboarder fracture with DF eversion
5: Crush injury
What is the MOI for posterior process fracture
Forced plantarflexion with compression of talar posterior process between the posterior malleoli and calcaneal tubercle
Clinical presentation sign seen with posterior process fractures
Nutcracker sign: pain with forced ankle PF
Which part of the Navicular is considered to be avascular
Plantar central 1/3
What classification system is used to describe navicular fractures
Watson and Jones classification
Describe Watson and Jones classification
I: Fracture of Navicular tuberosity II: Dorsal lip avulsion fracture III: Fracture of the navicualr body. (Sangeorzan) 3A: Coronal 3B: Dorsolateral to plantarmedial 3C: comminution IV: stress fracture
Clinical presentation of Calcaneal fracture
Mondors sign
back pain between T12 and L2
Compartment syndrome
Hoffa’s sign- less taut Achilles tendon
Lateral wall blowout
X-ray views to get when suspecting calcaneal fracure
Brodens view: to view posterior facet
Isherwood view: 3 oblique views to view all facets
Calcaneal axial view: lateral widening and varus orientation
Radiographic angles to keep in mind when dealing with calcaneal fractures
Bohler;s angle: normal 20-40 decrease with fracture
Gissane’s angle:normal 120-145. Increase with fracture
What classification systems are used with calc fractures
-Extraarticular, X-ray: Rowe
Intraarticular, CT: Sanders
Essex-Lopresti
Describe Rowe’s classification
IA: fracture through calcaneal tuberosity
IB: Fracture through sustentaculum tali
IC: fracture through anterior process
2A: Posterior process
2B: Avulsion fracture of Achilles tendon
3: oblique fracture through body but extraarticular
4: oblique fracture through body intraarticular
5: comminuted/joint depression
Describe Sander’s classification
1: any fracture that is non displaced
2A:Displaced lateral
2B: Displaced middle
2C: Displaced medial
3AB, 3AB, 3BC: 3 fragments
4: four comminuted fragments
Describe Essex and Lopresti
A: tongue type
B: Joint depression
What are the goals of surgical treatment of calcaneal fractures (3)
- Restore the height/length
- Prevent varus/valgus
- Prevent posterior facet step off
What are the poiatric surgical emergencies(4)
Gas gangrene
Compartment syndrome
Necrotizing fasciitis
- open fractures
- anything that causes N/V compromise
What classification system is used for open fractures
Gustilo and Anderson
Describe Fustilo and anderson
1- Opening in the skin <1cm
2- Opening in the skin between1-5cm
3A: Greater than 5 cm with great soft tissue coverage
3B: Greater than 5cm with periosteal stripping
3C: Greater than 5 cm with arterial damage3
Fracture blisters, etiology , how to prevent, how to resolve
etiology: due to high energy trauma from mechanical shear force
Early operation prevents formation of blisters
Treatment: best to wait for blister to resolve than cutting through it
How to diagnose compartment syndrome:
Stryker (Wick’s), slit catheter
What are the compartment pressures during a compartment syndrome
Intra-compartmental : >30mmhg
Extra-compartmental: within 10-30mmHg of diastolic BP
Clinical presentation of compartment syndrome
6p’s
Pain out of proportion Paresthesia Pallor Pulselessness Paresis Paralysis Pressure
What is Volkman’s contracture
ischemic necrosis causes muscular contracture
What organism to think of if puncture wound through shoe
pseudomonas
What organism to think of if puncture wound through soil
clostridia
What organism to think of if puncture wound from dog bite
pasteurella multocida
What organism to think of if puncture wound from cat bite
pasteurella multocida
What organism to think of if puncture wound from cat scratch
bartonella henslae
What organism to think of with human bite
eikenella
What classification system for nail injury
Rosenthal
Describe rosenthal classification
Zone 1: distal to distal aspect of distal phalanx
Zone 2: Distal to lunula
Zone3: Distal to most distal joint.
What are the compartments of the foot
9 of them
Superficial and deep centrall
medial
4 interosseus
Lateral plantar
deep interosseus
