Trauma - Upper Extremity (Complete) Flashcards

Question

What are indications and contraindications for tension band wiring olecranon fractures?

Answer 1

Indications: * Isolated transverse fracture (no comminution) proximal to the base of the coronoid Contraindications: * Comminuted * Some oblique fractures * Fracture distal to the bare area involving coronoid base

Answer 2

1. Comminution 2. Oblique fractures 3. Fracture extension to the shaft

Answer 3

1. Anterior interosseous nerve injury 2. Impaired pronation/supination due to mechanical block

Answer 4

1. Tip 2. Body * Imparts rotational stability 3. Anteromedial facet * Resists varus instability 4. Anterolateral facet * Resists posterior forces 5. Sublime tubercle

Answer 5

Based on the lateral radiographic view * Type I – avulsion of the tip of the process * Type II – fragment involving ≤50% of the process * Type III – fragment involving \>50% of the process * IIIA - WIthout elbow dislocation * IIIB - With elbow dislocation

Answer 6

Based on anatomical location of fracture * Type I – TIP * Subtype 1 = ≤2mm of coronoid height * Subtype 2 = \>2mm of coronoid height * Type II – ANTEROMEDIAL * Subtype 1 = anteromedial rim * Subtype 2 = anteromedial + tip * Subtype 3 = anteromedial rim + sublime tubercle (±tip) * Type III – BASE * Subtype 1 = coronoid body and base * Subtype 2 = transolecranon basal coronoid fractures

Answer 7

1. Varus posteromedial rotary instability injury pattern * Coronoid fracture \>15% * Usually anteromedial facet \>20% * LCL complex avulsion * Posterior band of MCL ruptured (anterior band intact) * Radial head intact 2. Valgus posterolateral rotary instability injury pattern * Coronoid fracture \<15% (usually tip) * LCL complex avulsion * Anterior band of MCL ruptured * Radial head fracture

Answer 8

1. Isolated tip fractures ≤2mm 2. Small fractures \<15% in height with a stable elbow

Answer 9

1. Posterior midline incision 2. AMF subtype 1 – LCL repair alone 3. AMF subtype 2+3 – LCL repair and buttress plate * T-plate, miniplate or precontoured plate 4. If elbow unstable after LCL and AMF fixation assess for MCL injury

Answer 10

Pearls * Preoperative planning * Stable fixation of all fragments * Simple fractures: tension band or plate * Complex fractures: plate and screws * Coronoid process can be approached from medial, posterior, or lateral * Radial head can be approached from lateral or posterior * Fix intermediate fragments first, fix coronoid fragments distal to proximal * Intraoperative fluoroscopy * Test the elbow through a full ROM for stability, range, and congruence Pitfalls * Failure to identify and fix all fragments leads to loss of reduction or instability * Nonanatomic reduction of the proximal ulna leads to radial head subluxation, bony impingement, and decreased motion * Poorly placed hardware or screws and pins lead to ulnar nerve problems, decreased motion, or articular degeneration

Answer 11

On average, patients lose 30° of ulnohumeral ROM after plate and combined plate-and-screw fixation * ROM improves after late instrumentation removal

Answer 12

Higher rate of device removal following tension band wiring (11-82%) compared with plating systems (0-20%) * Hardware removal is most frequent complication post olecranon fixation

Answer 13

1. Distal fragment displaces inferiorly, anteriorly, medially (shortened) and rotates anteriorly * Due to weight of arm, pectoralis major, trapezius 2. Proximal fragment displaces superiorly and posteriorly * Due to SCM

Answer 14

1. AP Clavicle 2. AP Clavicle with 20^oof cephalic tilt 3. AP Clavicle with 45^oof cephalic tilt 4. AP Clavicle with 45^oof caudal tilt * 45^o views better for assessing AP displacement

Answer 15

Distraction of the fracture site

Answer 16

Displacement \> 1 bone width (ie, 100%)

Answer 17

1. Fracture-specific * Open fracture * Impending open fracture (skin tenting) * Shortening \>2cm * 100% displacement * Symptomatic nonunion * Comminution * Segmental fractures * Posteriorly displaced medial 1/3 fractures * Clinical deformity/scapular malposition and winging 2. Associated injuries * Vascular injury (subclavian vein/artery) requiring repair * Brachial plexus injury with progressive neurologic deficit * Floating shoulder (clavicle and scapular neck fracture) * Ipsilateral upper extremity fracture * Multiple ipsilateral rib fractures * Bilateral clavicle fractures * Scapulothoracic dissociation 3. Patient factors * Polytrauma requiring early upper extremity WB * Motivation to return to early function * Eg. Elite athlete, self employed, etc

Answer 18

1. Less symptomatic nonunion 2. Less symptomatic malunion 3. More rapid return to function 4. Improved long term function is marginal * May not exceed minimal clinically relevant difference 5. Less overall complications * Operative complications * Hardware irritation * Wound complications * Nonoperative complications * Nonunion * Malunion 6. Improved patient satisfaction (including cosmesis) * Operative – scar and hardware prominence * Nonoperative – droopy shoulder (shoulder ptosis) 7. Frequency of secondary operations equal to nonoperative management (17%) * Operative – reoperate for hardware removal * Technically simple * Less complications * Short rehab * Nonoperative – reoperate for nonunion/malunion

Answer 19

Residual shortening associated with more pain and worse outcome scores * Leads to an altered position of the scapula at rest, causing scapular dyskinesia * Shortening as little as 10% could alter the position of the glenohumeral joint * Shortening \>14 mm in women and \>18 mm in men results in worse functional outcomes scores and decreased strength

Answer 20

Plate Size * 2.7 mm DCP \> 3.5 mm \> 2.7 mm * Low rates of failure and nonunion * Good outcomes Plate Design * Precontoured \> Recon * Similar biomechanical strength * Decreased implant irritation, implant removal * Improved cosmesis * \*\*Females and low BMI patients have increased implant irritation/removal rates, even with precontoured plates * If superior plating is used, precontoured plating systems should be strongly considered Plate Position * Fracture pattern dictates implant position * Comparable implant irritation, time to union, outcome scores * Implant irritation decreased by robust repair of platysma covering the plate * Advantages: * Superior plating – tension-side of the fracture * Anterior-Inferior plating – rotationally stronger construct, plus longer screws Number of plates * Dual plating techniques: * 2.7 or 3.5mm Recon Plate placed anteroinferior + 2.0 or 2.4mm mini-frag plate placed superior * Dual \> Single * Dual vs Superior – better at resisting superior-based loads * Dual vs Anterior-Inferior – better at resisting anterior-based loads * No nonunions (9% nonunion with single plating) * Low rates of implant irritation/removal (3.7%)

Answer 21

Typically, a nail between 2.0 and 3.5mm is used * Goal is for IMN that is 30-40% of the midshaft medullary diameter Timing of removal of nail is variable * Recommended removing at 6 months

Answer 22

Overall 24.6% revision surgery rate * Most common for hardware irritation (12.7%) * Overall implant irritation rate 3.7-40% * Less likely with dual plating * Females 4x more likely to have symptomatic hardware requring removal * Avg 12 months post index surgery * Low rates of nonunion (2.6%), malunion (1.1%), and infection (2.6%)

Answer 23

Advantages * Smaller incision * Less soft tissue disruption * Less risk to supraclavicular nerves * Avoids subclavian vessels and brachial plexus * Less refracture following hardware removal (compared to plates) * Comparable time to union and outcomes compared to plate Disadvantages * Small clavicular canals limit use (females/small stature) * 10% converted intraop from IMN to plate due to inability to pass the nail into the lateral aspect of the fracture * Increased hardware irritation * Most (all) require hardware removal * Relative contraindication in comminuted and segmental fracture

Answer 24

1. Clavicle shortening \>15-20mm 2. Female sex 3. Fracture comminution 4. Fracture displacement (no bony contact between fragments) 5. Older age 6. Severe initial trauma 7. Unstable lateral fractures (Neer type II) 8. Smoking

Answer 25

7. 5 * 1.7 for patients with \>40% risk of nonunion

Answer 26

ORIF with precontoured clavicle plate * ICBG if atrophic nonunion or bone loss * +/- ICBG if hypertrophic nonunion * Ensure sclerotic ends are prepared back to bleeding bone and drill the medullary canal

Answer 27

1. Trapezoid ligament * lateral to the conoid ligament * 2cm from the AC joint 2. Conoid ligament * Medial to the trapezoid ligament * 4cm from the AC joint 3. Function to prevent superior displacement of the distal clavicle in relation to the acromion * Whereas the AC ligaments prevent horizontal displacement

Answer 28

Distance between the coracoid process and the undersurface of the clavicle = 11-13mm

Answer 29

Neer classification * Type I * Fracture lateral to the CC ligaments * Spares the AC joint * Stable pattern * Proximal fragment stabilized by the CC ligaments, distal fragment by the deltotrapezial fascia * Often minimally displaced * Type II * Proximal fragment is detached from the CC ligament * Type IIa * Fracture is medial to the conoid ligament * Distal fragment remains connected to the CC ligaments (both presumed to be intact) * Unstable (56% nonunion with nonop) * Type IIb * Fracture is between the trapezoid and conoid ligament (conoid ligament is disrupted) * Unstable (30-45% nonunion with nonop) * Type III * Fracture is lateral to the CC ligaments and extends into the AC joint * Stable pattern (risk of AC arthritis) * Type IV * Pediatric pattern * Epiphysis and physis remain adjacent to AC joint with fracture through the metaphysis with displacement * Stable pattern * Type V * Small inferior cortical fragment remains attached to the CC ligaments * Unstable pattern

Answer 30

1. Type I 2. Type II nondisplaced 3. Type III 4. Type IV nondisplaced

Answer 31

1. Due to high risk of nonunion due to displacement, surgery should be offered for the following types: * Type II, displaced * Type IV, displaced * Type V \*\*\*NOTE: nonunion is often asymptomatic and can be managed surgically if becomes symptomatic 2. Open or impending open 3. Vascular injury requiring surgery

Answer 32

1. Described techniques: * Transacromial wire fixation * Modified Weaver-Dunn * Tension band * CC screw * AC hookplate * Locking plate * Arthroscopic treatment * \*\*\*NOTE: second procedure required for CC screw and AC hook plate for hardware removal 2. JAAOS author recommendation: * If distal fragment large: * Distal clavicle locking plate + CC stabilization with suture placed around the corocoid * If distal fragment is small * CC stabilization with nonabsorbable suture * 2 sutures passed around the coracoid and through drill hole in the clavicle 3. Simplified\* * Large distal fragment * Distal clavicle precontoured plate * +/- suture augmentation * Small distal fragment * Hook plate * CC suture stabilization * Suture/tape alone * Suture anchor * Suture button

Answer 33

1. Hardware removal (~3 months) 2. Limitation of shoulder elevation \>90 3. Subacromial impingement 4. Rotator cuff damage/tear 5. Acromion osteolysis 6. Acromion fracture 7. Fracture medial to the implant 8. Unhooking of the plate from the acromion

Answer 34

1. Associated injuries present in 90% of patients 2. Thoracic injury (80%) \> ipsilateral extremity injury (50%) \> head injury (48%) \> spinal fractures (25%)

Answer 35

1. Medial displacement of the lateral border \>25mm 2. Shortening \>25mm 3. Angular deformity \>45° 4. Glenopolar angle \<22° * Angle created at the intersection of a line drawn from the inferior glenoid fossa to the superior apex of the glenoid fossa and a line drawn from the superior apex of the glenoid fossa to the inferior angle of the scapula * Normal ~30-46° 5. Concomitant intra-articular step-off \>3mm 6. Displaced double disruption of the superior shoulder suspensory complex (SSSC) * 'Double disruption’ is the interruption of 2 structures in this ring resulting in an interruption in the suspension between the axial and appendicular skeleton

Answer 36

1. Painful nonunion 2. Concomitant ipsilateral scapula fracture requiring surgery 3. Displacement ≥1cm 4. Two or more disruptions in the SSSC

Answer 37

1. Glenoid 2. coracoid 3. CC ligaments 4. CA ligament 5. Lateral end of the clavicle 6. AC joint 7. Acromion

Answer 38

1. Approaches * Options from Posterior with patient in the lateral decubitus position * Judet incision * Muscular intervals = teres minor and infraspinatus * Elevation of the deltoid, teres minor and infraspinatus is beneficial for highly comminuted fractures and in delayed ORIF * Straight incision * Indicated for fractures about the lateral border or isolated fractures * Minimally invasive approach with windows directly over the site of desired plate placement * Options from Anterior with the patient in the beach chair position * Deltopectoral approach * Indicated for anterior glenoid fractures * Combined or limited incision * Indicated for disruption of the AC joint, coracoid or clavicle 2. Implant options * Reconstruction plates contour around the scapular spine and superomedial angle * Dynamic compression plates provide a rigid construct that is best for the lateral border * Precontoured implants can be used for specific scapular anatomies

Answer 39

Ideberg (modified by Goss) * Classified according to the location of the exiting fracture line * Type Ia - anterior rim * Type Ib - posterior rim * Type II - through glenoid exiting laterally * Type III - through glenoid exiting superiorly * Type IV - through glenoid exiting medially * Type Va - lateral AND medial (II + IV) * Type Vb - superior AND medial (III + IV) * Type Vc - lateral AND superior AND medial (II + III + IV) * Type VI - comminuted

Answer 40

1. Posterior humeral circumflex artery gives off metaphyseal branches to the posteromedial proximal humerus * Recent cadaver study demonstrated the posterior humeral circumflex artery provides 64% of blood supply to the humeral head [JBJS 2010;92:943-8] 2. Anterior humeral circumflex artery gives off the ascending branch (courses lateral to bicipital groove) to form the arcuate artery just below the articular surface

Answer 41

1. Humeral retroversion = avg 30^o retroversion * With respect to the humeral epicondyles 2. Humeral head inclination with respect to the shaft = avg 130^o

Answer 42

1. Based on number of parts (1-4) * Articular surface * Greater tuberosity * Lesser tuberosity * Shaft 2. A separate part is determined if there is \>45 degrees angulation or \>1cm displacement

Answer 43

1. Strong predictors * Posteromedial metaphyseal head extension \<8mm * Disruption of the medial hinge * \>2mm of shaft displacement in any direction * Only relevant if posteromedial metaphyseal head extension \<8mm * Anatomic neck fractures 2. Moderate to strong predictors * 4-part fractures * Angular displacement of the head \>45° * Displacement of tuberosities \>10mm * Glenohumeral dislocation * Head split * 3-part fractures * Medial (vs. lateral) shaft displacement

Answer 44

1. Stable nondisplaced or minimally displaced fractures 2. Patients not fit for surgery 3. Elderly patients with low functional demands

Answer 45

1. Radiographically * Impaction and interdigitation of fragments * Eg. valgus-impacted fracture with impaction of anatomical neck into the metaphysis 2. Clinically * Palpation of proximal fragment with rotation of the arm will result in fragments moving as a unit and feeling of crepitation (due to bony contact) if stable

Answer 46

1. Three- or four-part fracture dislocations 2. Head split fractures 3. Pathological fractures 4. Open fractures 5. Associated neurovascular injury 6. Displaced two-part surgical neck fractures 7. \>5mm displacement of greater tuberosity fracture 8. Displaced 3-part fractures 9. Displaced 4-part fracture in young patient

Answer 47

1. CRPP 2. IM nail 3. Plate 4. Hemiarthroplasty 5. rTSA

Answer 48

1. Loss of medial calcar support 4 ways to prevent varus displacement include: * Anatomic reduction of the medial cortices if no comminution * Inferomedial calcar screw * Oblique locking screw in the inferomedial quadrant of the head * Head-on-shaft impaction * Can be achieved with a valgus impaction osteotomy * Fibular strut allograft

Answer 49

5mm of superior displacement in healthy population * Consider 3mm displacement if patient requires prolonged overhead activity

Answer 50

Superior and posterior due to pull of supraspinatus, infraspinatus and teres minor

Answer 51

Anterior and medial due to pull of subscapularis

Answer 52

Adducted and anteriorly displaced due to pull of pectoralis major

Answer 53

1. Avulsion * Small fragment with a horizontal fracture line relative to the long axis of the humerus * Arthroscopic or mini-open deltoid split utilizing double-row suture anchor repair or transosseous fixation techniques 2. Split * Large fragment with a vertical fracture line relative to the long axis of the humerus * Arthroscopic or mini-open deltoid split utilizing double-row suture-bridge, interfragmentary compression screws, or a small locking plate augmented with sutures through the RC tendon 3. Depression * Inferiorly displaced and impacted GT * Nonop

Answer 54

1. Displaced 2-part fractures 2. 3 part fractures without significant comminution 3. 4 part fractures in active patients \<65 with acceptable bone stock and minimal comminution

Answer 55

1. Beach chair position with C-arm from head of bed 2. Deltopectoral approach (start 1-2cm lateral to corocoid) 3. Place sutures in the supraspinatus and infraspinatus to control the greater tuberosity and in the subscapularis to control the lesser tuberosity 4. Reduce the humeral head by correcting varus/valgus displacement 5. Reduce the tuberosities 6. Provisional K-wire fixation 7. Confirm reduction on AP and lateral views 8. Place locking plate posterior to the bicipital groove and sufficiently inferior to avoid impingement * 5-8mm distal to top of GT 9. Thread RC sutures through proximal plate prior to plate fixation 10. Place two locking screws proximally and one distal * This allows final correction in the sagittal plane 11. Place final locking screws in head (usually 5) and final distal screws (usually 3) 12. Tie RC sutures to plate 13. Under live fluoro confirm screw length, no intra-articular perforation and no impingement

Answer 56

1. Screw penetration (most common) 2. Screw cutout (loss of fixation) 3. Varus collapse 4. Plate impingement 5. Osteonecrosis

Answer 57

1. 2 part surgical neck fractures 2. Concomitant humeral shaft fracture 3. Impending pathological fracture 4. Select 3 and 4 part fractures

Answer 58

More medial (typical of straight nails) * Advantages * Avoids supraspinatus tendon * Better healing of supraspinatus muscle (compared to tendon) * Theoretically less rotator cuff tendinopathy (and less pain) * Disadvantages * Articular cartilage damage More lateral (typical of nails with proximal lateral bend) * Advantages * Avoids articular cartilage * Disadvantages * Supraspinatus tendon damage

Answer 59

1. Intial varus malalignment \>20° in whom anatomic reduction can not be achieved intraoperatively 2. Moderate or severe osteopenia 3. Age \>55 with 3 or 4 part fracture dislocations or head split 4. Malunion 5. Nonunion 6. Hardware failure 7. Osteonecrosis of humeral head following osteosynthesis

Answer 60

1. Tuberosity position and healing * Bone graft from humeral head applied between the prosthesis and tuberosities * Tuberosities are sutured to each other, to the shaft through drill holes, to the lateral fin, and a medial cerclage suture around the prosthesis * Final tensioning of the sutures should be done with arm slightly flexed and neutral to slight external rotation * Rotator interval is closed with arm in neutral to slight external rotation 2. Humeral height * Place top of humeral head prosthesis 56mm proximal to the superior border of pectoralis major tendon * GT and LT fragments should reduce anatomically under minimal tension at the prosthetic interface 3. Humeral head version * Recommended 20-30° retroversion * References * Bicipital groove * Place the lateral fin of the prosthesis 30° posterior to the posterior margin of the bicipital groove * Transepicondylar axis (forearm)

Answer 61

1. The pectoralis major tendon should be 5.6cm below the height of the top of the humeral head 2. Appropriate soft tissue tension of deltoid and long head of biceps 3. Top of humeral head relative to superior glenoid 4. Top of prosthesis relative to GT * Head should be 5-16mm proximal to the GT 5. Top of humeral head relative to inferior acromion * (?fingerbreadth)

Answer 62

Modular stem convertible to a rTSA

Answer 63

Prosthesis: 1. Too proud 2. Too retroverted 3. GT too low Leads to posterior migration of the GT and poor function

Answer 64

Tuberosity union

Answer 65

1. Age \>65 (\>70) with 3 and 4 part fractures 2. Relative indications * Risk factors for inferior functional results from plate osteosynthesis or hemiarthroplasty * Irreparable fracture * High risk of osteonecrosis * Poor tuberosity bone quality * Osteoporosis and/or comminution * Preexisting chronic RTC tear * Preexisting arthritis 3. Prerequisites * Functioning deltoid (axillary nerve) * Adequate glenoid bone stock

Answer 66

Absolute * Permanent axillary nerve dysfunction * Global deltoid dysfunction * Global brachial plexopathy

Answer 67

1. Axial shuck test * Axial traction on adducted humerus * Optimal is 1-2mm of gapping 2. Lateral instability * Lateral dislocation force applied with one finger on calcar * Assess ease of dislocation/subluxation 3. Adduction deficit * Gravity adduction * Due to overlengthened humerus or glenoid baseplate too superior 4. Strap muscle tightness * In neutral extension should contribute to joint compression

Answer 68

1. Increase polyethylene size 2. Implant humeral stem proud or deep 3. Change glenosphere diameter 4. Lateralize the glenosphere

Answer 69

Improved external rotation \*\*\*Note * In both hemiarthroplasty and rTSA, healing of the GT leads to superior clinical outcomes * However, in rTSA healing of the GT is not a prerequisite for a good outcome

Answer 70

1. Radiographic finding likely due to contact between the scapular neck and polyethylene during adduction * Associated with: * Loss of baseplate fixation * Poor patient outcomes * Is an independent risk factor for failure 2. Predictors of notching include: * Superior position of glenosphere * Medialization of the centre of rotation * High BMI

Answer 71

1. Characterized by lateral displacement of the scapula due to traumatic disruption of the scapulothoracic articulation 2. Involves a spectrum of osseous, muscular, vascular and neurologic injuries 3. Intact overlying skin is a feature

Answer 72

SC joint and/or Clavicle fracture and/or AC joint * Most commonly associated with a distracted clavicle fracture

Answer 73

Musculoskeletal → vascular → neurologic

Answer 74

Pulselessness

Answer 75

1. Preganglionic – limited healing potential 2. Postganglionic – greater healing potential

Answer 76

1. Increased soft tissue density in vicinity of scapula (hematoma) 2. Distraction of a clavicle fracture, AC joint or SC joint 3. Scapular lateralization * Measure distance between thoracic spinous process to medial border of scapula at the same level for both injured and uninjured sides * Scapular index = injured distance/uninjured distance * \>1.29 is scapulothoracic dissociation until proven otherwise * Difference \>1cm is consistent with scapulothoracic dissociation

Answer 77

1. Convential angiogram 2. CT myelography * Identifies pseudomeningocele and preganglionic nerve injury * Perform \>3 weeks after injury * Allows time for blood clot to resorb and pseudomeningocele to form 3. MRI * Most effective for postganglionic nerve injury 4. EMG/NCV * Initially performed at 3-4 weeks postinjury then every 6 weeks to monitor recovery

Answer 78

Zelle Classification * Type 1 - isolated MSK injury * Type 2A - MSK and vascular injury * Type 2B - MSK and incomplete neurological injury * Type 3 - MSK, vascular and incomplete neurological injury * Type 4 - MSK injury and complete brachial plexus avulsion

Answer 79

1. Vascular injury determines the urgency of surgery * In presence of a vascular injury requiring repair: * Generally the orthopedic injury (clavicle fracture, AC or SC injury) is repaired to protect the vascular repair * Upper extremity fasciotomies are performed * If no vascular injury the orthopedic injuries are dealt with when patient condition allows 2. Orthopedic injuries * Fixation is often redundant due to the severe soft tissue injuries requiring increased stabilization * Clavicle fracture – dual orthogonal plating * AC joint – hook plate with CC screw and anterior plating across AC joint * SC joint – reconstructed with allograft or autograft tendon 3. Neurological injuries * Generally delayed

Answer 80

1. 52% = flail extremity 2. 21% = early above elbow amputation 3. Outcome largely determined by the neurological injury

Answer 81

AO/OTA classification * Simple fractures (type A) * Wedge fractures (type B) * Complex fractures (type C)

Answer 82

1. Superior border of pectoralis major 2. Supracondylar ridge

Answer 83

30° varus/valgus angulation 20° AP angulation 15° rotation 3cm of shortening

Answer 84

Absolute indications * Unacceptable alignment by closed means * Polytrauma * Bilateral humeral shaft fractures * Floating elbow * Intra-articular extension * Progressive nerve palsy or nerve palsy after closed manipulation * Vascular injury requiring repair * Neurologic deficit after penetrating injury * Nonunion * Pathologic fracture * Skin condition precludes bracing (eg. burns) * High velocity gun shot wounds Relative indications * Open fractures * Segmental fractures * Noncompliant patients * Obesity or large breasts * Periprosthetic fractures * Transverse or oblique middle 1/3 fractures * Long oblique fracture of the proximal 1/3

Answer 85

Coaptation splint or hanging cast for 5-7 days * Followed by functional bracing (Sarmiento) and cuff-and-collar * Coaptation splint should be as high up in the axilla as possible and over the deltoid, molded into valgus * Functional bracing allows elbow and wrist ROM, shoulder ROM should be avoided until fracture is stable

Answer 86

1. Proximal 1/3 fractures 2. Oblique pattern in the proximal 1/3 3. Increasing fracture gap size 4. Smoking 5. Female

Answer 87

1. ORIF with plate * Most treated with 4.5mm LC-DCP with 3-4 bicortical screws above and below * Lag screw if possible in simple fractures or as bridge plate in comminuted fractures 2. IM nail (antegrade/retrograde) 3. External fixation

Answer 88

1. Anterolateral for proximal 2/3 fractures * Identify the musculocutaneous nerve deep to biceps and radial nerve between brachialis and brachioradialis 2. Posterior approach for distal 1/3 fractures * Document location of radial nerve relative to plate if a posterior approach is utilized

Answer 89

1. Distal fractures \> proximal fractures 2. Transverse and spiral fractures \> comminuted or oblique NOTE: no difference between open or closed

Answer 90

1. Open fracture 2. High-velocity gunshot or penetrating injury 3. Vascular injury 4. Nerve deficit after closed reduction (controversial) 5. Distal third (Holstein-Lewis) fracture (controversial)

Answer 91

1. Comminution 2. Segmental fractures 3. Pathological fractures

Answer 92

1. Shoulder pain and impingement 2. Reoperation for hardware removal Note – no difference in fracture union, radial nerve injury, and infection

Answer 93

1. Intra-articular fractures * Single-column fractures * Medial (high/low) * Lateral (high/low) * Divergent * Two-column fractures * Jupiter classification * High T * Proximal or at level of olecranon fossa * Low T * Through olecranon fossa * Y pattern * Oblique portion through both columns * H pattern * Trochlea is detached from medial and lateral columns * Medial lambda * Proximal fractures exits medial * Lateral lambda * Proximal fracture exits lateral * Capitellar fractures * Trochlear fractures 2. Extra-articular/intracapsular * High transcolumnar fracture * Extension * Flexion * Abduction * Adduction * Low transcolumnar fracture * Extension * Flexion 3. Extra-capsular fractures * Medial epicondyle * Lateral epicondyle

Answer 94

1. To prevent failure at the supracondylar level through loss of fixation in the distal fragments and thereby maximize the potential for union and full elbow mobility after a severely fractured distal humerus, 2 principles must be satisfied: * Fixation in the distal fragment must be maximized * All fixation in distal fragments should contribute to stability between the distal fragments and the shaft. 2. There are 8 technical objectives by which these principles are met: 1. Every screw in the distal fragments should pass through a plate * No screws are placed in the distal fragments before application of plates (use k-wires) 2. Engage a fragment on the opposite side that is also fixed to a plate 3. As many screws as possible should be placed in the distal fragments 4. Each screw should be as long as possible 5. Each screw should engage as many articular fragments as possible 6. The screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure 7. Plates should be applied such that compression is achieved at the supracondylar level for both columns 8. The plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level 3. Practically: * Use of "parallel" plates that permit at least 4-6 long screws to be placed in the distal fragments, from one side across the other * Ccrews placed at the epiphyseal level interlock, increasing the stability of the construct * The plates must be contoured or precontoured to the normal geometry of the distal humerus to allow screw placement at the appropriate places and also not to be too prominent under the skin * Precontoured plates easier and more consistent

Answer 95

1. The anterior aspect of the distal humerus is the critical part of the articulation that needs to be fixed in order to have a functional joint 2. Stability of the articulation requires the medial trochlea and either the lateral half of the trochlea or the capitellum * Medial trochlea is essential for stable, well-aligned joint

Answer 96

1. Anatomic reconstuction (preferred) 2. Supracondylar shortening * Humerus can be shortened at the metaphyseal fracture site, provided that the overall alignment and geometry of thedistal humerus are restored * Shortening by 1 cm or less creates no apparent loss of function, * Up to 2cm of shortening can be tolerated without serious disturbance of elbow biomechanics

Answer 97

Holstein-Lewis fracture

Answer 98

\*\*\*Note: all involve universal posterior midline incision and raising full thickness medial and lateral fasciocutaneous flaps with identification and protection of the ulnar nerve 1. Paratricipital 2. Tricep split * Useful for open fractures as there is often a defect in the triceps 3. Olecranon osteotomy [J Am Acad Orthop Surg 2010;18:20-30] * Pros: * Best articular exposure * Allows early range of motion * Cons: * Nonunion * Stiffness * Symptomatic hardware 4. Triceps peel 5. Triceps turn down

Answer 99

1. Location from distal humerus * 20.7 ± 1.2cm proximal to the medial epicondyle * 74% of the length of the humerus * 14.2 ± 0.6cm proximal to the lateral epicondyle * 51% of the length of the humerus * Pierces lateral intermuscular septum 10.2 ± 0.4cm proximal to the lateral epicondyle * 36% of the length of the humerus 2. Branches * Multiple to lateral head of triceps * None to medial head of triceps until nerve crosses lateral aspect of humerus * Trifurcates at lateral aspect of humerus: 1. Branch to medial head of triceps 2. Lower lateral brachial cutaneous nerve * Find and trace proximally to find radial nerve proper 3. Continuation of radial nerve to forearm

Answer 100

1. Gerwin approach * Medial and lateral triceps heads along with the radial nerve are mobilized lateral to medial off the humeral shaft * Lateral intermuscular septum is divided distally to allow mobilization of the radial nerve 2. The percentage of posterior humerus exposed for the 3 compared approaches: * 94% = Gerwin approach * 76% = Triceps split with superior mobilization of the radial nerve and lateral head of triceps * 55% = Triceps split 3. The limiting structure of each approach is: * Gerwin = Axillary nerve * Triceps split with radial nerve mobilization = Radial nerve branch to medial head of triceps * Triceps split = Radial nerve

Answer 101

The goal of ORIF is to anatomically reconstruct the elbow joint with a rigid construct that allows for early ROM 1. First, reconstruct the articular segment * Lag fragments together provisionally with threaded k-wires 2. Second, attach the articular segment to a column converting a complete articular fracture to a partial articular fracture 3. Third, dual plating with precontoured periarticular distal humerus locking plates oriented perpendicular (“90-90”) or parallel while observing O’Driscoll’s principles * Parallel plating is the strongest construct 4. Fourth, once fixation complete assess elbow through ROM to assess for hardware impingement

Answer 102

1. Splint at 30-40°flexion and neutral rotation 2. Immediate hand, wrist and shoulder ROM 3. Elbow ROM exercise started 7-10 days postop if fixation stable * If questionable stability max delay is 3 weeks 4. Resistance exercise started following radiographic evidence of healing (8-12 weeks)

Answer 103

1. Elbow stiffness * From prolonged immobilization used to compensate for inadequate fixation 2. Loss of terminal extension 3. HO 4. Loss of fixation * Nonunion at supracondylar level 5. Nerve injury 6. Infection

Answer 104

1. Based on a meta-analysis the incidence of ulnar nerve neuropathy is: * 15.3% = in situ release * 23.5% = transposition 2. COTS trial (2017) * No difference with regards to ulnar nerve symptoms, functional outcomes, or complications for patients treated with either simple decompression or anterior transposition of the ulnar nerve

Answer 105

Comminuted intra-articular fractures in the elderly and in patients with RA

Answer 106

Compared to ORIF, TEA resulted in: * Significantly better Mayo Elbow Performance Score (MEPS) at two years * Superior DASH scores during early follow-up assessments These positive results were also accompanied by a trend towards fewer revision surgeries.

Answer 107

Type 1 - (Hahn-Steinthal) * Involves a fracture isolated to the capitellum with attached subchondral bone Type 2 - (Kocher-Lorenz) * Involves primarily the articular cartilage overlying the capitellum (little subchondral bone) Type 3 - (Broberg-Morrey) * Comminuted capitellum fractures Type 4 - (McKee) * Involves a capitellum fracture that extends medially into the trochlea

Answer 108

1. Radial head fracture 2. LCL disruption 3. Elbow dislocation

Answer 109

Type I (large subchondral fragment) * Two cannulated partially threaded screws inserted P-A perpendicular to fracture plane Type II (lacks subchondral bone) * Cannulated headless compression screw inserted A-P Type III (comminuted) * Small fragment fixation may be achieved with the use of countersunk finethreaded k-wires * Bone defects filled with bone graft (ICBG or synthetic) and/or augmented with locking posterolateral plate fixation

Answer 110

1. Elbow stiffness 2. Posttraumatic arthritis 3. Nonunion 4. Heterotopic bone formation 5. Avascular necrosis 6. Painful hardware 7. Intra-articular hardware 8. Failure of fixation

Answer 111

1. Infection 2. Malunion 3. Nonunion 4. Radioulnar synostosis 5. Re-fracture 6. Compartment syndrome

Answer 112

Line connecting the center of the radial head and ulnar head

Answer 113

1. On an AP radiograph a line is drawn from the radial tuberosity to the most ulnar edge of the distal radius, from this line the longest possible perpendicular line is drawn to the radius 2. Normal = 15.3+/-0.3mm 3. Patients with 80% rotation of the normal forearm have a radial bow of 15+/-1.5mm * I.E. within 1.5mm of the well side

Answer 114

60% of the distance from the radial tuberosity to the ulnar edge of the distal radius

Answer 115

1. Bone with less comminution to restore length 2. If no comminution start with the radius * Creates a rigid forearm to fix the ulna with the elbow flexed

Answer 116

1. Proximal radius: * Thompson approach (ECRB and EDC) – debatable 2. Distal radius: * Volar Henry approach * FCR and BR distally and pronator teres and BR proximally * For plating, requires elevation of: * Pronator quadratus * FPL * FDS * Pronator teres * Pronation allows access to insertion * Supinator * Supination allows access to insertion 3. Ulna: * Subcutaneous border between FCU and ECU

Answer 117

1. 3.5mm compression plate 2. Goal is to restore length, alignment, rotation and radial bow 3. Distal ulna fractures can be fixed with two 1/3 semitubular plates perpendicular (90-90) to avoid implant prominence

Answer 118

1. Immediate ROM of fingers 2. Forearm rotation after 5-7 days 3. Return to most activities by 3 months

Answer 119

1. Restoration of an anterior coronoid process buttress for the trochlear notch 2. Recognition of the contribution of competent collateral ligamentous complexes in late instability 3. Restoration of radiocapitellar contact

Answer 120

A proximal ulnar fracture at the greater sigmoid notch and anterior dislocation of the elbow, without disruption of the PRUJ

Answer 121

1. Trauma-related * Radius and ulna fracture at the same level * Monteggia fracture * High energy with significant comminution * Significant soft tissue injury/open fracture * Head trauma 2. Treatment-related * Use of bone graft * Single incision approach * Screws that penetrate the interosseous membrane * Delayed surgery (\>2 weeks) * Prolonged immobilization

Answer 122

Proximal ulna fracture with radial head dislocation * Disruption of the PRUJ

Answer 123

1. Bado classification * Type I * Anterior dislocation of the radial head with an anterior angulation of the proximal ulna fracture * Mechanism = pronation injury * 60% - most common in kids, young adults * High energy injury in adults with higher rate of NV complications * Type II * Posterior dislocation of the radial head with a posterior angulation of the proximal ulna fracture * 15% - makes up 70-80% of adult Monteggias * Low energy injury * Assoc with radial head/coronoid fractures and ligament disruption * Coronoif process or radial head fracture is poor prognostic factor * Type III * Lateral or anterolateral radial head dislocation associated with a proximal ulna fracture * 20% * Type IV * Anterior dislocation of the radial head with fractures of the proximal ulna and radius * 5% 2. Jupiter modification of type II * Type IIA * Fractures through the greater sigmoid notch and involve the coronoid * Type IIB * Fractures distal to the coronoid and at the proximal metaphysis * Type IIC * Diaphyseal fractures * Collateral ligamentrs typically spared * Type IID * Comminuted proximal ulna fractures * Involve coronoid and olecranon

Answer 124

1. Anatomic reduction of the ulna 2. Evaluate for associated injuries * Commonly LUCL, coronoid and radial head * Olecranon fracture creates an ‘osteotomy’ to work through to fix the coronoid and occasionally the radial head * Kocher interval can be used to address radial head if not accessible * LUCL is repaired last

Answer 125

1. Nonanatomic ulna fixation * Address by correcting alignment and fixation of ulna 2. Interposed soft tissue in radiocapittelar joint * Address by doing a lateral approach and removing interposition

Answer 126

1. Annular ligament 2. Capsule 3. PIN 4. Distal biceps tendon (lateral to radial head) 5. Brachialis (button hole through)

Answer 127

Distal radius shaft fracture with disruption of the DRUJ * Fracture is usually at the junction of distal and middle 1/3

Answer 128

Fractures of the radius within 7.5cm of the lunate facet appear to be at greatest risk of DRUJ disruption

Answer 129

The TFCC and its palmar and dorsal radioulnar ligaments

Answer 130

1. Pronator quadratus = rotational (pronation) 2. Brachioradialis = shortening 3. APL and EPB = shortening

Answer 131

Type 1 * Apex volar * Distal radius displaces dorsal and distal ulna displaces volar * Mechanism – typically axial load and supination Type 2 * Apex dorsal * Distal radius displaces volar and distal ulna displaces dorsal * Mechanism – typically axial load and pronation * 73% of pediatric Galeazzi fractures

Answer 132

A variant of the classic Galeazzi fracture seen in skeletally immature children and adolescents * Characterized by fracture of the radius with fracture through the distal ulna physis but without disruption of the DRUJ * The distal epiphysis separates, but the ligamentous restraints of the DRUJ do not rupture * Epiphyseal plate is biomechanically weaker than the ligamentous complex that stabilizes the DRUJ * Usually managed non-op with closed reduction and long arm cast * May need ORIF if soft-tissue interposition blocks reduction

Answer 133

1. Fracture of the ulnar styloid base * Controversial in recent literature 2. Widening of the DRUJ on the AP view * Most predictive of instability on XR * A 1% increase in the radial translation ratio (widening of the DRUJ gap by approximately 0.25 mm in a typical individual) associated with a 50% increased risk of instability 3. Dislocation/subluxation of the radius relative to ulna on true lateral view 4. Shortening of the radius \>5mm relative to the distal ulna * Indicates likely injury to TFCC or IOM 5. Asymmetry compared to the contralateral DRUJ

Answer 134

1. Adults require ORIF with LC-DCP plate achieving anatomic reduction of distal radius followed by intra-operative assessment of the DRUJ * Confirm reduction on AP and lateral views followed by assessment of stability in supination and pronation 2. DRUJ is then characterized as reduced and stable, reduced and unstable, irreducible * Reduced and stable = protective splint and early motion * Reduced and unstable = assess for large ulnar styloid fracture OR TFCC tear * None present = K-wire fixation ulna to radius * Ulnar styloid fracture = ORIF with lag screw, tension band or K-wire * TFCC tear = avulses from base of ulnar styloid requiring repair with drill holes or suture anchors * Then fix DRUJ with two 1.6mm K-wires ulna to radius with forearm in supination * Irreducible = surgical exploration to remove block (ECU or fracture fragments) * Then reassess and treat as stable or unstable DRUJ

Answer 135

1. Carpal interosseous ligaments * Scapholunate and lunotriquetral 2. TFCC 3. Chondral lesions

Answer 136

1. Increasing age 2. Greater degree of initial displacement 3. Metaphyseal comminution 4. Prior failure of closed reduction

Answer 137

1. PA wrist * Carpal facet horizon * With volar tilt of articular surface, transverse radiodense line represents the volar rim of the lunate facet because the XR beam is parallel to the subchondral bone of volar rim * With dorsal tilt of articular surface (i.e. fracture), transverse radiodense line represents the dorsal rim of the lunate facet because the XR beam is parallel to subchondral bone of the dorsal rim * Radiocarpal interval (joint space) * Normal ~2mm (\<3mm) * Measure radial height and inclination from the midpoint between volar and dorsal ulnar corner (central reference point) 2. Lateral wrist * True lateral view = pisiform overlaps the distal pole of the scaphoid and is volar to the capitate head * Pisiform dorsal = pronation * Pisiform volar = supination * Congruent distal radius and lunate articular surface (matched radius of curvature) * Colinear lunate and distal radius * Tear drop angle * Best assessed on 10° lateral view * Lift hand 10^oor point beam 10^o proximal * The teardrop represents the volar rim of the lunate facet * Angle formed between line along central axis of the teardrop and a line along the central axis of the radial shaft * Normal = 70° * Angle is decreased if distal radius is dorsally angulated or the volar rim rotates dorsally * Volar tilt * Normal ~11° * AP width of the distal radius * Normal ~19mm

Answer 138

1. AAOS clinical practice guideline [J Am Acad Orthop Surg 2010;18: 180-189] * Radial shortening \>3 mm * Dorsal tilt \>10° * Intra-articular displacement or step-off \>2mm 2. AAOS comprehensive review [AAOS comprehensive review 2, 2014] * Loss of reduction * Ulnar variance \>5mm positive * Dorsal angulation ≥15° * Loss of radial inclination \>10° * Articular gap or step off ≥2mm * Unstable Smith fractures * Volar Barton shear fractures * Open fracture * Fractures associated with neurovascular injuries * Fractures associated with intercarpal ligament injuries * Polytrauma (relative) 3. Rockwood and Green [Rockwood and Green 8th ed. 2015] * Positive ulnar variance \>3mm * Carpal malalignment * Dorsal tilt \>10 if carpus aligned * Neutral if carpus malaligned * Articular gap or step \>2mm

Answer 139

1. CRPP * Options: * Pins across fracture * Pins from radius to ulna * Intrafocal pins (Kapandji technique) 2. ORIF with volar plating 3. ORIF with dorsal plating 4. External fixation * Bridging ex-fix with pins in 2nd metacarpal and radius at distal 1/3-2/3 junction * 3mm pins in 2nd MC at base * 4mm pins in radius between BR and ECRL * Nerves at risk with radius pins = superficial radial nerve and LABC * Nonbridging with pins in the distal fragment and radius at distal 1/3-2/3 junction * +/- augmentation with percutaneous pinning, limited ORIF, bone graft or substitute 5. Distraction bridge plating [JAAOS 2017;25:77-88] * 2 incisions * Over 2nd metacarpal and proximal to outcroppers * Plate is passed deep to outcroppers and superficial to the ECRB and ECRL * Plate is fixed to 2nd metacarpal and radial shaft

Answer 140

1. Superficial radial nerve injury 2. Pin track infection

Answer 141

1. Pin track infection 2. Loss of reduction/malunion 3. Hand stiffness 4. Superficial radial nerve injury

Answer 142

1. Overreduction 2. Tendon injury

Answer 143

1. Screw penetration into DRUJ or radiocarpal joint * Avoid intraoperatively by: * Assessing tilted lateral view * Radius is inclined 22 degrees off the table * Assessing oblique views * Examining flexion/extension at end of procedure 2. Tendon injury * EPL rupture due to screw prominence dorsally * Avoid by reducing measured length of screw by 2mm * Dorsal horizon view * Wrist is hyperflexed and the beam of the fluoroscopy unit is aimed along the longitudinal axis of the radius [J Hand Surg 2011;36A:1691–1693] * Radial groove view * Wrist is flexed almost fully, and the angle between the longitudinal axis of the forearm and the beam was 20° in the horizontal plane (forearm taken ulnar) and 5° in the sagittal plane (forearm taken dorsal) * FPL rupture due to plate prominence * Avoid by ensuring distal end of plate is proximal to watershed line – highest/most prominent point of the volar distal radius

Answer 144

1. Radial column * Consists of the radial styloid and scaphoid fossa * Attachments * Brachioradialis * Long radiolunate ligament * Radioscaphocapitate ligament * Function * Buttress to radial carpal translation * Load bearing with the wrist in ulnar deviation * Holds carpus out to length allowing more uniform distribution of load across the scaphoid and lunate facets * Anchors the radioscaphocapitate ligament which prevents ulnar translation of the carpus * Fracture * Single large fragment from interfossal ridge to the metadiaphysis 2. Intermediate column * Fracture results in 4 fragments * Volar rim * Palmar instability if volar Barton pattern * Axial instability (dorsal carpal translation) if dorsiflexion/impaction pattern * Associated with DUC, dorsal wall +/- free intra-articular fragment * Dorsal ulnar corner (DUC) * May result in articular incongruity of DRUJ * Dorsal wall * Provides stability against dorsal subluxation * Free intra-articular fragments * Volar rim and DUC * Form most of the lunate facet and sigmoid notch * Attachments * Volar rim * Short radiolunate ligament * Volar radioulnar ligament * DUC * Dorsal radioulnar ligament * Dorsal wall * Dorsal radiocarpal ligament 3. Ulnar column * Consists of the distal ulna and TFCC * Role in DRUJ stability and forearm motion 4. Pedestal * Consists of the metadiaphysis of the distal radius * Function: * Supports the radial and intermediate column

Answer 145

Intermediate \> radial \> ulnar * Intermediate = volar rim \> DUC \> free intra-articular fragment \> dorsal wall

Answer 146

1. All screws are extra-articular * Radial inclined lateral view (radiocarpal joint) * AP view (DRUJ) * ROM for crepitation 2. Screws are appropriate length * Lateral view * Dorsal horizon view * Radial groove view 3. Plate position * Proximal to watershed line * Centred on shaft on AP 4. Articular reduction * No intra-articular step or gap * Teardrop angle restored to normal 5. DRUJ stability * Stress in neutral, pronation and supination 6. Missed injury * Scaphoid, ulna, carpal fracture * SL, LT, perilunate

Answer 147

Radial shortening \<5 mm Radial inclination \>15^o Radiocarpal intra-articular step-off/gap \<2 mm Sigmoid notch incongruity \<2 mm Tilt between 15^odorsal and 20^ovolar

Answer 148

1. Articulates with: * Scaphoid fossa of the radius * Lunate * Capitate * Trapezium * Trapezoid 2. 80% of its surface is covered in cartilage 3. Sections include: * Proximal pole * Distal pole * Waist * Tubercle * Ventrolateral aspect of distal pole * Capitate fossa * Lunate fossa

Answer 149

1. Dorsal scaphoid branch of the radial artery * Supplies proximal 80% via retrograde flow 2. Volar scaphoid branch of the radial artery * Supplies distal 20%

Answer 150

1. Proximal pole fractures 2. Displacement \>1mm 3. Humpback deformity * Measurements on sagittal CT * Lateral intrascaphoid angle \>35° * Normal = 30+/-5° * Dorsal cortical angle \> 160° * Normal = 140° * Height-to-length ratio \>0.65 * Normal = 0.6 4. DISI * Radiolunate angle \>15 degrees * Capitolunate angle \>15 degrees * Scapholunate angle \>60 degrees 5. Associated perilunate dislocation 6. Associated distal radius fracture 7. Comminuted fracture 8. Unstable vertical or oblique fractures 9. Delayed presentation

Answer 151

1. PA view * Allows visualization of the proximal pole of the scaphoid 2. Semipronated oblique view * Provides the best visualization of the waist and distal pole regions 3. Semisupinated oblique view * Provides the best visualization of the dorsal ridge 4. Lateral view * Permits an assessment of fracture angulation, carpal alignment, and carpal instability 5. PA view with the wrist in ulnar deviation * Results in scaphoid extension, allowing visualization of the scaphoid in profile

Answer 152

1. Earlier union [J Hand Surg Am. 2016;41(12):1135e1144] * Surgery = 7.1 weeks * Nonop = 11.4 weeks 2. Avoids prolonged immobilization 3. Allows earlier return to activity/work [J Hand Surg Am. 2016;41(12):1135e1144] * Surgery = 6 weeks * Nonop = 11 weeks 4. No difference in rate of union

Answer 153

1. Long arm or short arm cast including or not including the thumb leads to equivalent outcomes in the treatment of scaphoid fractures with immobilization 2. Duration ~8-12 weeks * Dependent on clinical and radiographic union * When CT is used to assess union, immobilization is discontinued when \>50% union achieved

Answer 154

Indications: * Distal pole and waist fractures * Humpback deformity Advantage: * Preserves dorsal blood supply

Answer 155

1. Interval between the FCR and radial artery 2. Skin incision can be zig-zag, L-shaped, or at the glabrous/nonglaborus skin border (Wagner) * Proximally parallel to FCR * Distally parallel to the radial aspect of the thenar eminence * “Standard Russe incision is made along the course of the flexor carpi radialis (FCR) tendon and extending distally along the border of the glabrous skin of the thenar eminence”\* 3. The volar FCR sheath is opened and FCR retracted ulnar 4. Radial artery is retracted radial * Superficial palmar artery crosses the surgical field and may need ligating 5. Floor of the FCR sheath and capsule are incised inline with scaphoid to expose the distal 2/3 * Radioscaphocapitate and long radiolunate ligaments are incised

Answer 156

Resecting proximal palmer portion of trapezium

Answer 157

Cannulated headless compression screw * Use the larger Acutrak 2 screw when feasible * Mini-Acutrak 2 system may be necessary if: * Small scaphoid * Fracture is located proximally such that insertion of an Acutrak 2 screw may result in inadvertent propagation of the fracture to the insertion site with fragmentation of the proximal scaphoid

Answer 158

Subtract 4mm from measured length (or more if compression is to be obtained)

Answer 159

Proximal pole fractures

Answer 160

1. 2-3cm Longitudinal incision from proximal Lister’s tubercle extending distal inline with 3rd metacarpal 2. Skin flaps are raised over the extensor retinaculum 3. Extensor retinaculum is incised longitudinally distal to Lister’s along with the dorsal hand fascia 4. EPL, ECRB and ECRL are retracted radially, EDC is retracted ulnarly 5. Radiocarpal T- capsulotomy is performed * Transverse limb parallel to the distal radius proximally, longitudinal limb extending directly over the SL ligament * Capsular flaps are elevated off the SL ligament and scaphoid * Avoid disruption of SL ligament and dorsal scaphoid ridge

Answer 161

Membranous portion of the scapholunate ligament origin

Answer 162

1. PA 2. Lateral 3. 30° pronated lateral view \*\*\*\*Wire is placed along central axis

Answer 163

1. Fixed extension of the lunate \>10 degrees 2. Associated with: * Scapholunate ligament disruption * Displaced scaphoid fracture

Answer 164

1. Fixed flexion of the lunate 2. Associated with: * Lunotriquetral ligament disruption

Answer 165

1. Hyperextension 2. Ulnar deviation 3. Intercarpal supination

Answer 166

Stage I = perilunate dislocation * Dorsal dislocation of the capitate with respect to the lunate while the lunate remains in its normal position in the lunate fossa. Stage II = lunate dislocation * The capitate has reduced from its dorsally dislocated position to become colinear with the radius, dislocating the lunate into the carpal tunnel * Stage IIA * Lunate has subluxated out of its fossa but has rotated \<90° * Stage IIB - lunate rotation \>90°

Answer 167

Disruption of scapholunate ligament → disruption of space of Poirier (capitolunate articulation) → disruption of the lunotriquetral ligament → disruption of dorsal radiocarpal ligament

Answer 168

Area of capsular weakness over the capitolunate articulation between the radioscaphocapitate and radioscopholunate ligaments

Answer 169

Describes the progressive ligamentous injury around the wrist in 4 stages * Stage I * Disruption of the SL and radioscaphocapitate ligaments * Stage II * Disruption of the lunocapitate association * Stage III * Disruption of the LT ligament (perilunate dislocation) * Stage IV * Lunate dislocation

Answer 170

1. Greater arc injury = associated fracture of radial styloid, scaphoid, capitate, lunate, triquetrum, hamate * In naming greater arc injuries, the prefix trans- is used before the name of the fractured bone 2. Lesser arc injury = purely ligamentous injury

Answer 171

1. PA radiograph * Intercarpal gap * Disruption of Gilula carpal arcs * Loss of carpal height with overlapping of carpal bones (particularly capitate and lunate) * Carpal-height ratio = carpal height/length of 3rd metacarpal * Abnormal = \<45% (normal 45-60%) * Scapholunate ligament disruption * Signet ring sign 2. Lateral view * Hallmark is loss of colinearity of the radius, lunate and capitate * ‘Spilled tea-cup sign’ in lunate dislocation

Answer 172

1. Immediate closed reduction (Except for IIB) * Perilunate reduction maneouvre * Fingertraps with elbow at 90 and 10 pounds of traction for 10 mins * First extend the wrist then apply traction then wrist flexion, should feel palpable clunk * Lunate dislocation [IIA only] * First wrist flexion then dorsally directed force applied to lunate to reduce it * Then extend the wrist followed again by traction and wrist flexion while maintaining dorsal directed pressure to lunate * Do not attemtp reduction of IIB lunate dislocation because ineffective and could damage the short radiolunate ligament and its vascular contribution 3. Surgical intervention in 3-4 days after swelling subsides * In greater arc injuries fix the fractures prior to the ligaments * Repair ligaments * Consider suture anchors * Protect repair with intercarpal K-wire or temporary screw fixation * Consider carpal tunnel release if symptoms present

Answer 173

1. Lunate dislocation requiring open reduction 2. Carpal tunnel release

Answer 174

1. Longitudinal starting 3cm proximal to wrist ulnar to the palmaris longus * Angled ulnarly across the wrist then extended inline with the ring finger 2. Transverse carpal ligament is incised 3. Flexor tendons and median nerve are retracted laterally to expose the lunate 4. The lunate is reduced by direct pressure and lunate reduction maneuver 5. Volar capsule and ligaments repaired to maintain reduction 6. Proceed to dorsal approach

Answer 175

1. Allows anatomic reduction of the carpal bones 2. SL ligament repaired from dorsal

Answer 176

1. Longitudinal incision centered over Lister’s tubercle 2. Extensor retinaculum is divided in line with the 3rd dorsal compartment and EPL is retracted radially 3. The 2nd and 4th compartments are elevated off the dorsal capsule 4. A longitudinal or ligament-sparing capsulotomy (along DIC and DRC ligs) is made

Answer 177

1. K-wires are placed in the scaphoid and lunate and used as joysticks * K-wires are placed 45 degrees from vertical from distal to proximal in scaphoid and proximal to distal in lunate * The pins are then made colinear and compressed together to reduce the SL interval 2. Once reduced, reduction is maintained by percutaneous pinning * Pins include LT, SL, SC, TH 3. SL ligament repair follows reduction and K-wire stabilization * Usually with suture anchor 4. Capsulotomy is repaired anatomically and dorsal ligaments are repaired 5. Extensor retinaculum is repaired

Answer 178

K wire removal at 10 weeks and therapy initiated

Answer 179

1. \<3 months may still attempt open reduction 2. \>3 months will require salvage procedure * Proximal row carpectomy * Wrist arthrodesis if degeneration present

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Trauma - Upper Extremity (Complete) Flashcards

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