Traumatology Flashcards
Define open fracture
Direct communication between fracture and environment due to traumatic
disruption of soft tissue and skin.
Increased risk in open fracture
Higher incidence of infection; up to 10% develop acute compartment syndrome.
Classification of open fractures?
- Gustilo Anderson classification
- according to site: Direct/ indirect or according to force: High force/Low force
5 things to do in open fracture treatment
(1) Immobilization
(2) Antibiotics IV
(3) Tetanus prophylaxis as indicated
(4) Irrigation and debridement
(5) Analgesia
3 things deciding management of open fracture
- degree and extent of ST damage
- degree of wound contamination
- underlying health of patient
recommended AB in open would fractures
- Class I-II → cefazolin
- Class III → gentamycin or ceftriaxone
- Soil contamination → metronidazole (Clostridium coverage).
- Seawater contamination → piperacillin/tazobactam (Pseudomonas)
- Freshwater contamination → doxycycline (Vibrio species).
what is used in irrigation of open fracture wound?
isotonic saline solution
Type I - 3L
Type II - 6L
Type III - 9L
acute complications ass with open fractures
Arterial injury
Nerve injury
Fracture blisters
Compartment syndrome
Thromboembolic disease
Fat emboli syndrome
what is the triad of fat emboli syndrome
Hypoxemia
Neurological abnormalities
Petechial rash
Non acute complications of open fracture
Osteomyelitis or infectious arthritis
Nonunion or malunion
Post-traumatic arthritis
3 R’s basis of fracture management
Reduction
Retention
Rehabilitation
how to cover the bone in open fractures
temporary muscle flap with artificial skin
or temporary skin graft
what is osteomyelitts
An infection of the bone. Most commonly caused by Staphylococcus aureus.
to do with the wound in an open fracture
- Remove visible foreign bodies and debris.
- Irrigate wound with sterile saline.
- Cover with moist, sterile dressing.
Aim of fracture treatment
o To regain and maintain the normal alignment
o To regain normal function
o To achieve the above objectives for the patient in the shortest time possible
physical examination of fractures
PMS
Puls: most distal puls
Motor: move fingers and toes (dont force!)
Sensation: sensory function distal to fracture
what can an XR tell us about the fracture
o Localize fracture, number of fragments.
o Degree of displacement, angulation, rotation
o Pre-existing diseases in bone.
o Foreign bodies or air in tissues.
Fracture treatment: Traction
Application of a pulling force on fracture to help realign shortened, angulated, and/or displaced fractures.
Short-term traction: a component of many closed reduction techniques.
Long-term traction devices (using braces, pulleys, and/or weights) can be used for immobilization in both conservative and postsurgical fracture management.
Fracture treatment: open reduction
Allows for very accurate reduction, since it is under direct visualization.
indication of open reduction: NO CAST
o Non-union
o Open fracture
o Compromised neurovascular
o Intra-Articular fracture
o Salter-Harris 3,4,5
o Poly-Trauma
o Other: failed closed reduction, not able to cast or apply traction due to
site (e.g. hip fracture), pathologic fracture, potential for improved function with ORIF
Fracture treatment: retention
Holds the fracture stable and still
1. External fixation
2. Internal fixation
External fixation types
Cast
Splint
Continuous traction
External fixator
indications for an external fixator
factures which are too unstable for a cast or to preserve remaining blood supply.
Define internal fixation
Attached to the side of the bone or inserted through the bone.
* Intramedullary fixations: nails, rods, screws
* Extramedullary fixations: screws, plates, wires
* Percutaneous pinning
Osteosyntheisis definithion
Defined as fixation of a bone. It is a surgical procedure to treat bone fractures in which bone fragments are joined with screws, plates, nails or wires.
what is the biological basis of bone healing
Day 1-5: Hematoma and local inflammation
Day 5-15: Soft callus formation (fibrocartilaginous callus)
week 2-3: Hard callus formation (bony callus)
Beond: Bone remodeling
what happens when soft callus develops
Mesenchymal stem cells recruited to the area begin to differentiate into fibroblasts, chondroblasts, and osteoblasts.
what happens when hard callus develops
Cartilaginous callus begins to undergo endochondral ossification
3 main ways of fracture treatment
- conservative
- external fixation
- internal fixation
why do we do external fixation in children?
to avoid pin fixation of growth plate
types of external fixators
pin fixator
ring fixator
hybrid fixator
how to achieve absolute stability?
Lag screws crossing the fracture obliquely
Compression plates over fracture
Tesion bands (olecranon, patella)
typical fracture where internal fixation is used?
vertebral fracture
types of disslocation
Congenital deformity cause
Traumatic cause due to violence/trauma
Pathological: tuberculosis of hip
Paralytic disslocation: poliomyelitis (muscle power imbalance)
define disslocation
Disruption of the normal anatomic position of joints resulting in a deformity, immobility. treatment is closed reduction with traction.
General term fracture types
Pathological fracture: weak bone due to disease
Stress fracture: repetitive minor trauma
Traumaticfracture
- Open fracture
- Closed fracture
Childrens fractures
Greenstick fracture incomplete cortical disruption
physical fracture: involve growthplate
Location of fracture define
Diaphysis: shaft
Metaphysis: Flare btw shaft and joint
Epiphysis: joint surface
Intraarticular: extending into joint surface
Fracture pattern define
Transvers: perpendicular to long axis
Oblique: angular to long axis
Spiral: due to twisting
comminuted: multiple bone fragments
Butterfly: two oblique fracturelines meet
most common clinical pres for fractures
- local swelling
- pain
- bruising
- decreased ROM
- neurovascular signs
absolute minimal X-ray plane?
two views and the entire bone in question
Managment list for TBI
- ABCDE + C-spine
- Intubation if GCS <8 or airway at risk
- Imaging: X-ray for fractures, CT for bleeding, MRI for brain damage
- Maintain CPP > 60 mmHg and ICP < 20 mmHg
- Seizure prophylaxis for 1w
- Blood sugar control
- caloric need is 140% due to inc. metabolic demand
Adult criteria for brain death
- No cerebral function (irreversible coma)
- no brain stem function (neuro exam neg x 2)
- No spontaneous breathing when pCO2 is > 60 mmHg
what can mimic brain death?
- Locked-in syndrome
- Neuromuscular paralysis (severe GBS)
- Severe hypothermia
- Drug intoxication
- Metabolic encephalopathy
when does skull fractures happen (mechanism)
Fractures of the skull occur when a force striking the head exceeds the mechanical integrity of the calvarium.
clinical findings suggestive of skull fracture or intracranial injury
- Altered mental status,
- Focal cranial nerve deficits
- Scalpis irregular lacerations or contusions
- Periorbital or retro auricular ecchymosis
- Headache, nausea and vomiting.
imaging modality of choice if suspected skull fracture?
CT!! no contrast with bone window
XR should only be done if CT not available
types of skull fractures
- Linear
- depressed
- Basilar
- Penetrating
- Diastatic (sutures)
when is linear skull fractures dangerous
-Crossing middle meningeal groove in the temporal bone
- Major venous dural sinuses: bleeding beneath the skull but outside the brain parenchyma
3 things to do in a depressed skull fracture
- prophylactic AB + tetanus
- Anticonvulsants
- Admit to neurosurgery
signs of basilar skull fracture
- Battle sign (retroaurocular)
- Racoon eyes
- CSF rhinorrhea/otorrhea
- Hemotympanum
define TBI
Insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an
associated diminished or altered state of consciousness.
classification of TBI
Mild: GCS 13-15
Moderate: GCS 9-12
Severe: GCS < 8
Define concussion
Mild TBI resulting in headache, brief LOC, and amnesia,
symptoms such as dizziness, without radiographic findings!!
concussion grading
Grade I: no LOC, transient confusion or other symptoms < 15 minutes.
Grade II: no LOC, transient confusion or other symptoms > 15 minutes.
Grade III: LOC for any duration.
Define contusion
focal area of brain injury, varying from a bruise to a focal area of necrosis
Is contusion symptoms acute?
tend to blossom within 48h
common cause of contusion
sudden deceleration of head causes the brain
to impact on bony prominences (temporal, frontal and occipital poles) in coup and countercoup fashion.
what to do with a contusion patient
- Immediate CT; if positive admit patient for minimum 48 hours.
- Observation: vitals, neuro-signs, level of consciousness.
- GCS: Recheck every 2 hours
- If GCS is < 8 do ICP monitoring
*Reduction of cerebral edema with mannitol
indication for surgery in contusion
- progressive neurological deterioration
- Refractory IC HT
- Signs of mass effect om CT
- HbC volume > 50 ml
- GCS < 6-8 + temporal HbC > 20ml
surgical treatment of contusion
- Craniotomy and remove mass lesion
- Decompressive craniotomy
Epidural hematoma
Location
Common cause of bleeding
Source
Structure of CT
speed of growth
Located between dura and periosteum
MMA tear, fracture of temporal bone
CT: convex shape, hyperdense
Fast growing hematoma
treatment of epidural hematoma
always surgery
craniotomy and evacuation of hematoma
Subdural hematoma
Location
Common cause of bleeding
Source
Structure of CT
speed of growth
Between the dura and arachnoid membrane
Accelerating/rotational trauma, shaken baby
Rupture og bridging veins
Concave hyperdens
Slow growing
types of subdural hematoma
Acute: usually young adults
* Severe skull injury
* Contusion and laceration of brain surface
Chronic: predominately in infancy and elderly
* Mild head trauma
* Cerebral atrophy
* Alcoholism
* Coagulation disorder
imaging when suspected blood in brain?
ALWAYS CT!!
Treatment of subdural hematoma
No midline shift: observation
Midline shift: space occupying; craniotomy + draining
Chronic collection: craniotomy and resection of the membrane and drainage.
After surgery, place catheter into ventricles to monitor pressure.
If ↑ ICP: barbiturates, mannitol,
* If it doesn’t help, then hemicraniectomy.
Causes of intracerebral hematoma 9
Hypertension: most common
Cerebral amyloid angiopathy
Arteriovenous malformations
Vasculitis
Neoplasms
Ischemic stroke (due to reperfusion injury)
Coagulopathy (hemophilia, anticoagulant use)
Stimulant use (cocaine and amphetamines)
Trauma
Define spinal cord injury
Spinal cord injury (SCI) is an insult to the spinal cord resulting in a change, either temporary or permanent, in the cord’s normal motor, sensory, or autonomic function.
Mechanism of spinal cord injury bimodal distribution
Young individuals with significant trauma
Older individuals that have minor trauma compounded by degenerative spinal canal narrowing.
most spinal injuries is in the
50% is in the cervical spine
ass injuries to spinal cord injury
spinal shock
neurogenic shock
vertebral fractures
vertebral artery damage
Head injury
Types of spinal cord injuries
Complete
Hemisection (Brown-Sequard)
Anterior cord
Central cord
Conus medullaris
Cauda equina
Anterior spinal artery syndrom
What classification is used to classify spinal cord injury?
ASIA scale
A) COMPLETE: No motor no sensory
B) INCOMPLETE No motor some sensory
C) INCOMPLETE some motor some sensory
> 50% of muscles under lesion has grade < 3
D) INCOMPLETE some motor some sensory
> 50% of muscles below lesion has grade > 3
E Normal motor and sensory
define spinal shock
temporary loss of spinal cord function and reflex activity below the level of a spinal cord
injury. Characterized by flaccid areflexic paralysis, bradycardia and hypotension (due to loss of sympathetic tone), and absent bulbocavernosus reflex.
define neurogenic shock
circulatory collapse from loss of sympathetic tone; characterized by hypotension and
relative bradycardia in patients with an acute spinal cord injury, potentially fatal.
types of plegias
Hemiplegia → unilateral lesion.
Monoplegia → one limb affected.
Paraplegia → both lower limbs affected, arm function preserved.
Diplegia → both upper limbs affected, leg function preserved.
Quadriplegia (tetraplegia) → all 4 limbs affected.
during ABCDE when to do neuro?
D - Disability
in a spinal cord injury when do you do spinal exam
in the secondary survey after ABDCE + detailed neuro exam
Managment of spinal cord injured patient
Require intensive medical care and continuous monitoring of vital signs:
1. Cardiac rhythm
2. Arterial oxygenation
3. Neurologic signs
4. DVT prophylaxis
what can cause vertebral fractures
Vertebral fractures can be caused by direct or indirect trauma and are more likely to occur in patients with decreased bone density (osteoporosis, osseous metastases).
categories of vertebral fractures
Fractures may be stable or, if there is a risk of damage to the spinal cord, unstable.
etiology of vertebral fractures
Trauma (car accidents, falls, gunshot wounds)
Pathological fractures
- Osteoporosis (most common)
- Malignancy (e.g., bone metastases)
- Infection (e.g., Pott disease)
Define stable vertebral fractures
The structural stability of the spine remains intact.
No neurologic deficits
Fractures of the anterior column of the spine
Define unstable vertebral fractures
The structural stability of the spine is compromised.
The spine can move as two or more independent units, which may cause spinal cord injury.
Mid-column and posterior column fractures
types of vertebral fractures
- Compression fractures (osteoporosis, metas)
- Wedged fracture
- Vertebra plana
- codfish - Burst fracture
- Fracture disslocation
symptomes of verterbal compression fracture
Often asymptomatic, but may cause acute back pain and point tenderness
Clinical symptoms of vertebral fractures
Local pain on pressure, percussion, compression
Palpable unevenness or disruption of the vertebral process alignment
Paravertebral hematoma
Weakness or numbness/tingling
Neurogenic shock
physical exam in suspecter vertebral injury
- detailer neuro exam
- rectal exam
- imaging
The need for diagnostic imaging following cervical trauma is decided by?
NEXUS criteria: absence of all of the following indicates a low risk for cervical spine injury and no need for imaging:
- Focal neurological deficit
- Posterior midline cervical spine tenderness
- Altered consciousness
- Intoxication
- Painful distracting injury
Imaging in vertebral injury
Anterior-posterior and lateral x-ray
- Discontinued cortex, bone fragments
- Loss of height in the vertebral bodies
CT: The axial image in particular helps localize the fracture and allows for an assessment of stability.
MRI: most sensitive tool for detecting spinal cord lesions
Treatment of vertebral injury
- Immobilization + ABCDE
- Orotracheal intubation
- stable fracture: conservative + analgesia
- Unstable: Spondylodesis
- Minimal invasive procedures:
- Vertebroplasty: injection of bone cement into the fractured vertebra for immediate stabilization
- Kyphoplasty: reexpansion of the fracture through the insertion of an inflatable balloon into the vertebral
Hangman’s Fractures
- Traumatic fracture of the bilateral pars interarticularis of C2.
- Mechanism of injury: hyperextension
- CT is the study of choice to characterize fracture patterns.
Hangmanns fracture classification
Levine-Edwards
Odontoid fracture
- Common fracture of the C2 odontoid process
- Can be seen in low-energy falls in elderly patients, or high-energy traumatic injuries in
younger patients. - Diagnosis can be made with standard lateral and open-mouth odontoid radiographs.
- Some fractures may require a CT scan
classification of odontoid fractures
Anderson-D’Alonzo Classification system
Odontoid cervical fracture treatment
- Hard cervical orthosis (collar immobilization).
- Halo immobilization.
- Surgical: Posterior C1-C2 fusion using trans-articular screws or wires.
Vertebral burst fractures
High-energy traumatic vertebral fractures (fall from height, MVA).
- Caused by flexion of the spine that leads to a compression force through the anterior
and middle column of the vertebrae → retropulsion of bone into the spinal canal →
compression of neural elements (canal compromise).
vertebral burst fracture treatment
Non-surgical:
- Thoracolumborsacral orthosis (strap) +/- activity as tolerated; for patients that are
neurologically intact and mechanically stable.
Surgical:
- Posterior instrumented fusion (PIF); mechanical spine stabilization without neural
decompression.
- Neurologic decompression and spinal stabilization.
types of rib injury
Bruises, torn cartilage and bone fractures.
A/O rib fracture classification
Type A: nondisplaced rib fracture
1. transverse/greenstick
2. oblique
3. wedge (butterfly) fragment
Type B: displaced rib fracture (> 2 mm)
1. transverse/greenstick
2. oblique
3. wedge (butterfly) fragment
Type C: comminuted rib fracture
1. zone < 2 cm
2. zone > 2 cm
3. flail fragment(s)
clinical presentation of rib fractures
Pleuritic chest pain
Respiratory distress (e.g., tachypnea, dyspnea)
Chest wall tenderness, bruising, and/or deformity
Crepitus
Flail chest: 3 or more adjacent ribs fractured in two or more places causing paradoxal chest movement
what is treatment of rib fracture method based on?
Isolater one rib or multiple ribs w/wo flail chest
treatment if multiple rib fractures
Multiple rib fractures and/or flail chest
Intubate patients with signs of acute respiratory distress
Manage pneumothorax and/or hemothorax with chest tube placement.
Flail chest: Consult thoracic surgery for surgical management.
complications of rib fracture
Respiratory failure
Pneumothorax
Hemothorax
Atelectasis
Pneumonia
Pulmonary contusion
Intraabdominal organ injury
Define compartment syndrom
Tissue ischemia due to increased pressure within a fascial compartment. It is a surgical emergency characterized by rapidly progressive pain and swelling in an extremity
most common cause of compartment syndrom
muscle edema from direct trauma to the extremity or reperfusion after vascular injury.
Etiology of compartment syndrom
Hematoma, edema from long bone fractures
Reperfusion syndrome with ischemia- reperfusion edema
Burn edema
Edema from venomous animal bites
clinical presentation of compartment syndrom
Pain out of proportion to extent of injury
Wors with passive stretching of muscles
Extreme tenderness to touch
Soft tissue swelling
Tight, wood-like muscles
4 P’s of compartment syndrom (acute limb ischemia)
Pain
Pallor
Pulselessness
Paralysis
diagnosis of compartment syndrom
The following support a diagnosis of ACS.
- Delta pressure > 30 mm Hg in the compartment
- Clinical presentation
how can you measure the compartment pressure in a suspected compartment syndrome?
Stryker Intra-Compartmental Pressure Monitor
Normal pressure is 0-10 mmHg
D pressure = diastolic P ‒ compartment P
D pressure 10- 30 mmHg → need for fasciotomy.
Treatment of compartment syndrom
Surgical emergency and requires emergent fasciotomy, as irreversible tissue necrosis and functional impairment can occur within 4–6 hours of onset.
Fasciotomy: incision(s) in the skin and fascia to relieve compartment pressure and restore perfusion
Postoperative wound treatment: usually left open for delayed primary closure
what is the Achilles tendon
Largest tendon in the human body and provides the attachment of the converged soleus and gastrocnemius muscles to the calcaneus.
where does it normally rupture? (Achilles)
4-6 cm above the insertion on calcaneus, at a hypovascularized region
Risk factors of achilles tendon rupture
Periodic athlete
Corticosteroid treatment
Fluoroquinolone treatment
Previous injury
Types of Achilles tendon rupture
Complete rupture (most common)
Less common
- Partial rupture
- Avulsion of the bony insertion of the Achilles
Achilles tendon rupture clinical presentation
Popping/snapping sound/sensation
Sudden, severe pain in the Achilles tendon
Difficulty mobilizing: loss of plantar flexion
Palpable interruption of affected Achilles
test to see if Achilles is ruptured?
Thompson test: squeezing the calf (e.g., gastrocnemius muscle) of the patient, in the prone position with legs extended
Diagnosis of Achilles rupture
Clinical
Ultrasound (best initial test)
X-ray: to rule out suspected bone fractures
MRI (confirmatory test): only imaging modality that can distinguish between a partial and complete rupture
Treatment of achilles tendon rupture
Conservative therapy
- Icing, rest, analgesia, serial casting
- Rehabilitation
Surgical therapy
- Open or percutaneous tendon repair
- Casting
- Rehabilitation
ahilles tendon surgeries
- Open end-to-end Achilles tendon repair.
- Percutaneous Achilles tendon repair.
- Reconstruction with V-Y advancement flap; for chronic rupture with defect > 3 cm.
Definition of calcaneal fractures
Calcaneal fracture: fracture of calcaneus body
Intraarticular calcaneal fracture (most common): subtalar joint involved
Extraarticular calcaneal fracture
- Subtalar joint not involved
- Usually an avulsion of the anterior process, sustenatculum tali, or calcaneal tuberosity
clinical presentation of calcaneal fractures
Heel pain and tenderness
Swelling and deformity of the foot
Plantar ecchymosis (Mondor sign)
Fracture blisters
Over 75% of patients with an acute calcaneal fracture have another significant injury.
what can you look for on an X-ray that suggests calcaneal fracture?
A Bohler angle < 20° suggests compression fracture.
treatment of calcaneal fractures
Extraarticular fractures: usually conservative management, avoidance of weight-bearing for 4–8 weeks
Intraarticular fractures: conservative treatment or surgical repair, depending on fracture characteristics
classification of calcaneal fractures
1) A/O classification
- Type A: anterior process fracture
- Type B: mid calc/ trochlear process fracture
- Type C: posterior tuberosity
2) Subtalar joint involvement classification
Extracapsular (25%)
Intracapsular (75%)
- Again with Sanders class based on # of articulating surfaces involved on CT (I-IV)
Surgical method in calcaneal fracture
Zadravcs method:
Percutanous screws inserted into talus, post calcaneus and cuboid. then fixed into place with wires
Ankle fracture etiology
Eversion or inversion injury
Direct trauma
Crush injury
Axial loading (fall from a height, MVA)
Types of ankle fractures
- Lateral malleolar fracture
- Medial malleolar fracture
- Posterior malleolar fracture
- Bimalleolar fracture
- Trimalleolar fracture: fractures of the lateral, medial, and posterior malleoli (post tibia)
- Pilon fracture: of the distal tibia involving the articular surface of the talocrural joint
clinical presentation of ankel fracture
Local pain, swelling and hematoma
Tenderness, especially in the area of the malleoli, the syndesmosis, and the posterior aspect of the ankle joint
Restricted range of movement
Displacement of fot
skin lacerations
Ottawa ankle foot rules
Criteria determine the need for X-rays in patients presenting with traumatic ankle/ foot
injuries.
Ankle x-rays are indicated for pain in the malleolar region + any of the following:
1) Tenderness along the post distal 6 cm of the lateral or medial malleolus
2) Inability to weight-bear
Foot x-rays are indicated for pain in the midfoot region + any of the following:
1) Tenderness at base of the 5th metatarsal
or navicular bone
2) Inability to weight-bear
Classification groups for ankle fractures
Lauge-Hansen:
Foot position and mechanism at injury
SAD: supinated-adducted)
SER: supinated-externally rotated
PER: pronated-externally rotated
PAB: Pronated-abducted
Denis-Weber classification:
Location of fibula fracture
- Infrasyndesmotic A
- Transsyndesmotic B
- Suprasyndesmotic C
Types of ankle sprains
Lateral low ankle sprain
Medial low ankle sprain
High ankle sprain
Define lateral low ankle sprain
Sprain of ≥ 1 of the following lateral ligaments.
Anterior talofibular ligament: most common
Calcaneofibular ligament
Posterior talofibular ligament
Define Medial low ankle sprain
Sprain of medial (deltoid ligament) complex which connects the medial malleolus to the talus
Define High ankle sprain
Sprain of syndesmotic ligaments that connect the tibia and fibula in the lower leg (less common)
ligaments of the ankel
clinical presentation of ankle sprain
Soft tissue swelling
Limited ROM at the ankle joint
Tenderness over the sprained ligament
Increased joint laxity and a prominent talus compared to the uninjured ankle
Impaired weight-bearing and/or antalgic gait
Hematoma may be visible
Ankle sprain treatment
Apply the POLICE principle.
Consider NSAIDs.
Mild to moderate sprains: Provide functional support (e.g., ankle brace) for 4–6 weeks.
Severe injuries: Immobilize the ankle.
POLICE principle stands for
A strategy to minimize inflammation and encourage healing of closed wounds, such as contusions and sprains:
(P) protection
(OL) optimal loading
(I) ice
(C) compression
(E) elevation.
It is a modification of the RICE principle, which recommended resting (R) the injured part.
Ankle fracture complication
arthritis, bone infection, Compartment syndrome, or damage to nerves or blood vessels.
quick summary about tibia fracture and types
Tibial fractures are the most common type of long bone fractures. They are usually caused by direct trauma and may occur proximally (tibial plateau fracture), at the shaft, or distally.
1) Proximal tibial plateau fracture
2) Tibial shaft fracture
3) Distal tibial fracture (pilon)
Proximal Tibia Fracture (plateau fracture and others)
- Affects the knee joint congruity.
o Usually due to high energy trauma.
o Lateral > medial fracture
Proximal tibial fracture clinical presentation
Swollen knee with no possible weight bearing.
Knee can be so swollen that surgery is impossible; set into external fixator until swelling reduces.
associated injuries with proximal tibial fracture
o Meniscal (50%) and ligament tears.
o If severe, it can compress the popliteal artery
o Compartment syndrome (blisters appear first; must do open surgery).
Type of proximal tibial fractures
Tibial shaft fracture classification
AO Classification
o Displaced / comminuted
o Transverse, spiral, oblique
o Rotation / angulation
Treatment of tibial shaft fracture
Split the patella tendon, make a hole into the bone and insert an IM undreamed
interlocked nail.
Open fracture: external fixator until stable, then reconstruction with extensive
irrigation and debridement.
Classification of distal tibial fracture (2)
A/O Classification
o Type A: extraarticular
o Type B: partial articular surface injury
o Type C: complete articular surface injury
Ruedi and Allgower Classification - subdivided
based on amount and degree of comminution.
o Type I: nondisplaced
o Type II: simple displacement + incongruous
joint
o Type III: comminuted articular surface
what is the biggest problem with distal tibial fracture
Will disrupt the ankle joint (congruity and alignment are the biggest issues)
surgical treatment of distal tibial fracture
2 surgery sessions
1: Temporary external fixation, plate synthesis and pilon reconstruction
2: 7-10 after, stabilization with plate and interlocking screws
what cartilages do we have in the knee?
The bones are protected and cushioned by two types of cartilage in the knee: articular cartilage and meniscus cartilage.
Describe the knee anatomy
meniscus tear etiology
Young, active patients: traumatic (axial loading and rotation action with a fixed foot during physical activity)
Older patients: degenerative (continuous work in a squatting position)
Zones of the meniscus
3 zones dep on vasculature
Types of meniscus tears
Tears in the coronal plane:
vertical (longitudinal) and horizontal tear
Tears in the transverse plane:
longitudinal (vertical), radial, and oblique tear
clinical presentation of meniscus tear
- Knee pain: exacerbated by weight‑bearing or physical activity
- Joint line tenderness (medial or lateral)
- Restricted knee extension with possible knee instability
*Intermittent joint effusions - Tears in the white zone → serous effusion
- Tears in the red zone → bloody effusion
how to test for meniscus damage`
McMurray test
The patient lies in a supine position.
The examiner holds the patient’s knee in one hand and palpates the joint spaces while holding their ankle in the other.
The examiner brings the patient’s knee to maximal flexion.
For medial meniscus tear, the examiner performs external rotation of the tibia and applies valgus stress while extending the knee.
For lateral meniscus tear, the examiner performs internal rotation of the tibia and applies varus stress while extending the knee.
diagnosis of meniscus lesion
MRI: imaging of choice
Identifies location and extent of meniscal tears
Hyperintense line in meniscus with possible distorted meniscal morphology
Empty groove in the case of bucket handle tears and double PCL sign
Arthroscopy
Both diagnostic and therapeutic with a sensitivity and specificity of ∼ 100%
What is arthroscopy
A minimally invasive surgical procedure in which the inside of a large joint (e.g., knee, shoulder) is directly visualized using an endoscope. Used to diagnose intra-articular pathologies that are not apparent on imaging. Instruments can also be for therapeutic procedures (e.g., removal of bony and/or cartilaginous fragments, ligament and/or meniscal reconstruction).
anatomy of knee ligaments
ACL and PCL connect the femur to the tibia.
MCL merges with the joint capsule of the knee.
LCL connects the femur and the fibula. It does not merge with the joint capsule of the knee.
what is the most commonly injured knee ligament?
ACL
ACL mechanism of injury?
Low-energy noncontact: sports injuries with a twisting mechanism: football, soccer, basketball, skiing, and gymnastics
High-velocity contact injuries (less common): direct blows to the knee causing forced hyperextension or valgus deformity of the knee
physical exam of ACL injury
Knee swelling
Positive Lachman test (most sensitive test)
Positive anterior drawer test
Positive pivot test
how to do the Positive Lachman test in ACL injury (knee)
With the knee joint at 20–30° flexion, the examiner stabilizes the femur and pulls the tibia anteriorly.
Increased tibial anterior gliding (compared to the opposite knee) and a soft endpoint indicate an ACL tear.
ligament tear in knee diagnosis?
Full knee x-ray series: to evaluate for associated fractures or avulsions
MRI: confirmatory test
ACL/PCL tear treatment
Conservative treatment: suitable for patients with mild knee instability, older age, and a relatively sedentary lifestyle
Arthroscopic surgery: typically pursued in competitive athletes and in patients with a relatively active lifestyle, concomitant meniscal or collateral ligament injury, or chronic knee instability
Posterior cruciate ligament (PCL) injury etiology?
Noncontact injury involving hyperflexion of the knee with a plantarflexed foot (seen in athletes)
Direct posterior blow to a flexed knee: seen in motor vehicle accidents (dashboard injury) or athletic contact injury
Rotational injury involving hyperextension of the knee (rare)
PCL tear diagnosis
Positive posterior drawer test
With the patient lying supine and the knee at 90° flexion, the examiner fixes the foot on the table and pushes the proximal tibia backward.
Increased tibial posterior gliding (compared to the opposite knee) and a soft endpoint indicate PCL injury.
classification of patella fracture
etiology of patella fracture
Direct trauma like MVA - comminuted
Indirect rapid knee flexion when contracted quads - transvers or inferior pole avulsion
diagnosis of patella fracture
X-ray
inability to perform straight leg raise
treatment of patella fracture
Knee immobilization in extension if patient can perform straight leg raise.
ORIF with K-wire, screws and plates
Partial patellectomy (2nd to ORIF)
Total patellectomy if severe comminuted fracture
complications of patella fracture
- Chronic anterior knee pain.
- Symptomatic hardware.
- Nonunion.
- Osteonecrosis.
- Post-traumatic patellofemoral osteoarthritis
define tension hemothorax
massive intrathoracic bleeding, causing ipsilateral lung compression and mediastinal displacement
etiology of hemothorax
External trauma
Internal causes
- tumor
- anticoagulation
- aortic dissection
- PE
clinical presentation of hemothorax
*Resp distress
*Neck veins flat from hypovolemia
*Severe shock symptoms
*unilateral absence of breath sounds
*Dullness on percussion
Dx of hemothorax
Upright CXR
*Small hemothorax: unilateral blunting of the costophrenic angle
*Large hemothorax findings include: complete lung opacification
*Mediastinal shift
*Tracheal deviation away from the effusion
FAST US
CT - determine nature of fluid
How to know its blood on CT?
Attenuation volume is 34-70 HU
how much blood can a hemothorax hold?
up to 3L
Tx of hemothorax
Consult thoracic surgery.
Chest tube insertion
Urgent thoracotomy
location of chest tube insertion
into the 5th intercostal space at the midaxillary line is indicated in most patients.
indications for urgent thoracostomy
*Chest tube output ≥ 1500 mL immediately upon placement
*Chest tube output ≥ 200 mL/hour for 2–4 hours
*Need for multiple blood transfusions
types of pneumothorax
Traumatic PTX
Spontaneous PTX
Tension PTX
types of spontaneous pneumothorax
Primary spontaneous pneumothorax: occurs in patients without clinically apparent underlying lung disease
Secondary spontaneous pneumothorax: occurs as a complication of underlying lung disease
define tension PTX
A life-threatening variant of pneumothorax characterized by progressively increasing pressure within the chest and cardiorespiratory compromise
etiology of spontaneous PTX
Primary (idiopathic or simple pneumothorax)
- Caused by ruptured subpleural apical blebs
Risk factors
- Family history
- Male sex at young age
- Asthenic body habitus (slim, tall stature)
- Smoking (90% of cases)
Secondary (pneumothorax as a complication of underlying lung disease)
- COPD (smoking)
- Infections
- Pulmonary tuberculosis
- Cystic fibrosis
- Marfan syndrome
- Malignancy
Etiology of traumatic PTX
Blunt trauma
Penetrating injury
Iatrogenic pneumothorax
clinical presentation of PTX
Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea
Reduced or absent breath sounds, hyperresonant percussion, decreased fremitus on the ipsilateral side
Subcutaneous emphysema
Tx of PTX
Expectant management for small < 2 cm with no resp distress - will resolve on its own
Needel aspiration with 16-gauge cannula through 2nd IC space MCL. stop if < 2.5L air comes out
Tube Thoracostomy drainage where aspiration failed.
Surgical if persistent air leak > 4 days, tension PTX, failure to expand
what is the surgical treatment for PTX
VATS wedged resection of blebs and bullae
what is the triangle of safety?
Bordered anteriorly by the lateral edge of the pectoralis
major, laterally by the lateral edge of latissimus dorsi,
inferiorly by the line of the 5th
-intercostal space (level of
the nipple), and by the base of the axilla.
types of abdominal trauma?
Blunt trauma: contusion or laceration
Penetrating trauma: direct laceration and bleeding
signs to look for in abdominal trauma patient
Seat-belt sign: ecchymosis in the distribution of the lower anterior abdominal wall. Can be associated with perforation of the bladder or bowel as well as a lumbar distraction fracture.
Cullen’s sign: periumbilical ecchymosis; indicative of intraperitoneal hemorrhage.
Grey-Turner’s sign: flank ecchymoses; indicative of retroperitoneal hemorrhage.
Kehr’s sign: left shoulder or neck pain secondary to splenic rupture. It increases when the patient is in Trendelenburg position or with left upper quadrant palpation (caused by diaphragmatic irritation)
Examinations you do in abdominal trauma patients
- FAST
- Diagnostic peritoneal Lavage
- Ches XR
- CT
FAST protocol?
Consists of 4 acoustic windows:
1) Pericardiac, perihepatic (RUQ)
2) Perisplenic (LUQ)
3) Pelvic (pouch of Douglas)
Performed with the patient supine.
An examination is positive if free fluid is found in any of the 4 acoustic windows, negative if no fluid is seen, and indeterminate if any of the windows cannot be adequately assessed.
Indications of exploratory Laparotomy in abdominal trauma
- Abdominal trauma + hemodynamic instability
- Peritonitis
- Diaphragmatic injury
- Hollow viscus perforation (free IP air)
- Intraperitoneal bladder rupture
- Positive DPL
- Surgically correctable injury seen on CT scan
- Removal of impaled weapon
- Rectal perforation
- Shot gun wound
Examination and management protocol in abdominal trauma
chart
most common organ damaged in blund abdominal trauma
The spleen is the most commonly injured organ in blunt abdominal trauma, and trauma is the most common indication of splenectomy.
what composes the shoulder girdle?
4 articulations (sternoclavicular, acromioclavicular, glenohumeral, and
scapulothoracic)
3 bones (clavicle, scapula, and humerus)
function of rotator cuff
ALL adducts the arm ex. supraspinatus abducts arm.
All ex. rotates except subscapularis int rotates arm
types of shoulder disslocations
- Anterior (97%)
- Posterior
- Inferior (< 1%)
mechanism of anterior shoulder disslocation
arm is externally rotated, abducted, and extended
mechanism of posterior shoulder disslocation
blow to anterior part, axial loading of adducted arm, seizure (violent muscle contractions) or electric shock
mechanism of inferior shoulder disslocation
axial loading of a fully abducted arm or forceful hyperabduction of arm
General symptoms of shoulder disslocation
Severe shoulder pain
Inability to move the shoulder
Empty glenoid fossa
symptoms of anterior shoulder disslocation
The humeral head can usually be palpated below the coracoid process.
The arm is typically held in external rotation and slight abduction.
symptoms of posterior shoulder disslocation
Prominence of the posterior shoulder with anterior flattening
Prominent coracoid process
The arm is held in adduction and internal rotation
dangerous in diagnosis of posterior shoulder disslocation
Posterior shoulder dislocation is frequently overlooked during clinical examination!
what lesion can be seen on humeral head or glenoid labrum after shoulder disslocation?
Hill-Sachs lesion
Seen in 35–40 %, indentation on the posterolateral surface of the humeral head caused by the glenoid rim
Bankart lesion: injury of the labrum and associated glenohumeral capsule/ligaments.
surgical indication in shoulder disslocation
Unsuccessful closed reduction
Concomitant dislocated fracture
Recurrent shoulder dislocations
Reduction of shoulder disslocation:
Anterior: Hennepin tech/Stimson tech
Posterior: Stimson tech
Inferior: Traction
Stimson reduction of shoulder disslocation:
Hennepin reduction of shoulder disslocation:
Etiology of acromioclavicular joint injury
A direct blow (young, male athletes)
Fall on an outstretched arm
classification of AC joint injury
Rockwood-Tossy classification
I = no torn ligaments, only displacement.
II = AC ligament ruptured.
III = AC + CC ligaments ruptured.
IV = similar to III but clavicle displaced
V = superior dislocation of AC joint, ruptured AC ligament, CC ligament, and joint capsule
VI = Inferior dislocation of AC joint, rupture of AC ligament, CC ligament, and joint capsule
Another name for AC joint injury?
shoulder separation
What is shoulder impingement syndrom
- Subacromial bursitis → inflamed bursa
- Rotator cuff tendinitis.
- Rotator cuff tears → partial or full-thickness
- Rotator cuff arthropathies
clinical presentation of shoulder impingement syndrom
- Shoulder pain over lateral deltoid
- Pain exacerbated by overhead activities.
- Night pain may be present as well
Treatment of shoulder impingement syndrom if no tear
Initially treated non-surgically:
Activity modifications
Physical therapy
Local corticosteroids injection
NSAIDs (naproxen, ibuprofen)
Treatment of shoulder impingement syndrom if there is tear
Arthroscopic or open surgical intervention
Diagnostic shoulder arthroscopy
Subacromial Decompression
Acromioclavicular joint resection
define frozen shoulder
gradual development of global limitation of active and passive shoulder motion with an absence of radiographic findings other than osteopenia.
shoulder diseases ass with DM
Frozen shoulder (adhesive capsulitis)
Rotator cuff tendinopathy
Sternoclavicular Dislocation types
anterior, posterior, bilateral
sternoclavicular disslocation clinical presentation
Pain, can’t move shoulder against resistance
Anterior: deformity with palpable bump
Posterior: dysphagia, dyspnea, tachypnea, stridor worse when supine.
Clavicle Shaft Fracture mechanism
o After direct blow to shoulder region, e.g.
fall onto shoulder (e.g. football, hockey)
o Periosteal sleeve avulsion fracture can
result distally.
o Low-energy injury.
Clavicle Shaft Fracture clinical presentation
o Clavicular fracture is of minimal clinical
significance; usually only shoulder pain.
o Shortening due to displacement.
Scapula fracture mechanism
o Needs high-energy impact (MVA)
o Direct trauma to shoulder area.
o Indirect trauma by falling on outstretched
hand.
o Non-accidental injuries in children.
scapula fracture classification
Ideberg Classification
Type I: anterior avulsion fracture
Type II: transverse/oblique fracture through glenoid; exits inferiorly)
Type III: oblique fracture through glenoid, exits superiorly
Type IV: transverse fracture exits through scapular body
Type V: type II + IV
Anatomy of neck humerus
Surgical neck of the humerus
Greater tubercle of the humerus:
Lesser tubercle of the humerus:
Bicipital groove (intertubercular sulcus)
Proximal humeral neck fracture classification
Neer classification based on how many fragments are displaced
1 part
2 part
3 part
4 part
Types of proximal humeral fractures
Surgical neck fracture
Anatomic neck fracture.
Greater tuberosity fracture
Lesser tuberosity fracture
Up to 45% of cases involve nerve injury
which proximal humeral fractures can be treated conservatively?
Most proximal humerus fractures can be treated nonoperatively including:
- Minimally displaced surgical and anatomic neck fractures
- Greater tuberosity fracture displaced < 5mm
(>5mm displacement will result in impingement with loss of abduction and external rotation) - Fractures in patients who are not surgical candidates
surgical treatment of proximal humeral fractures
CRPP (closed reduction percutaneous pinning)
ORIF with calcar screw placement
Intramedullary nailing
Arthroplasty
Humeral shaft (diaphysis) fracture are divided into
Proximal humeral shaft fracture
Middle humeral shaft fracture
Distal humeral shaft fracture
nerve involved in humeral shaft fracture
radial nerve
types of humeral shaft fractures
causes of the different humeral shaft fractures
o Transverse fractures: direct blow to arm.
o Spiral or oblique fractures: indirect trauma from fall or twisting (e.g. arm wrestling).
o Comminuted fractures are more likely with higher impact strength.
cast length in humeral shaft fracture
8 weeks
