-
BBFF: associated injurueued
-
Prognosis in BBFF ORIF depends on
Restoration of radail bow
-
Forearm interosseus membrane composition
- Central band: key band to reconstruct
- Accessory band
- Distal oblique bundle
- Proximal oblique cord
- Dorsal oblique accessory cord
-
BBFF indications conservative mgmt 2
- Undisplaced BBFF
- DIstal 1/3 ulnar shaft with: <50% displacement and <10 degrees angulation.
-
Approach for distal/middle 1/4 radius fracture
Henry
-
Approach for middle/proximal radius
Thompson
-
Approach to ulna
BTW ECU/FCU
-
BBFF ORIF plate chpice
3.5 mm LCDP
-
BBFF compartment syndrome increased risk
- High energy crush
- Open Fx
- Low velocity GSW
- Vascular injuries
- COagulopathies
-
Ulnar shaft #: immobilization type
Long vs short arm: equivalent results
-
Removal of HO in BBFF: timing
6 months: in conjunction with radiotherapy
-
Fenoral neck fracture mortality:
-%
-Predictors
- -30% within 1 year
- -Pre injury mobility
Renal failure 45% mortality at 2 years
-
NOrmal femoral:
-neck shaft angle
-Anteversion
- -130 degrees +/- 7
- -10 degrees +/- 7
-
Blood supply femoral head 4
- - Medial femoral circumflex: main > becomes lateral epiphyseal artery
- - Lateral femoral circumflex
- - Inferior gluteal
- - Ligamentum teres
-
Garden classification
- 1: valgus impacted
- 2: Complete undisplaced
- 3: Complete partially displaced
- 4: Complete fully displaced
-
Pauwels classification
- 1: < 30 degrees from horizontal
- 2: 30-50 degrees
- 3: >50 degrees (most unstable)
-
Femoral neck fracture indication for cannulated screws
- -Garden 1: in elderly
- -Displaced femoral neck in young patient in conjunction with anatomic reduction
-
Indications for DHS in femoral neck fracture
- -Basicervical
- -Femoral neck with vertical pattern in young patient > biomechanically stronger
- - Also DHS has less failure but more AVN
-
Timing of surgery in elderly
Within 4 days no difference in outcomes
-
Cannulated screws technique tips
- -Start above LT
- - Inverted triangle
-
Dislocation in THA vs hemi
5-7 times higher in THA in fracture setting
-
Treatment of a femoral neck non union
Valgus intertrochanteric osteotomy + blade plate
-
Radial nerve location based on condyles
- 14 cm prox to lat epicondyle
- 20 cm prox to medial epicondyle
-
Holstein lewis fracture
spiral fracture of the distal thrid humerus associated with radial nerve neuropraxia
-
Humeral shaft fractures indication for conservative mgmt
- <20 degrees anterior angulation
- <30 degrees varus valgus
- < 3 cm shortening
-
Absolute indications for ORIF midshaft humerus 6
- Severe soft tissue injoury or bone loss
- Vascular injury requiring repair
- Brachial plexus injury
- floating elbow
- open fracture
- compartment syndrome
-
Relative indications for midshaft humerus orif
- Bilateral humerus
- Polytrauma with lower extremity injury
- Pathologic #
- SOft tissue that precludes bracing
- Short oblique or transverse # patters
-
Molding of coaptation splint
valgus: typically fall into varus
-
Radial nerve palsy: first to recover
last to recover
- brachioradialis
- extensor indicis
-
Humerus nailing nerves at risk
- Radial nerve: lat to medial locking screw
- Musculocutaneus: AP screw
-
Vit D deficiency type of non union
Oligotrophic
-
IMN humerus vs plating
- Higher reoperation
- Higher impingement
-
Radial nerve enters the posterior compartment
10cm proximal to radiocapitallar joint: pierces intercompartmental fascia
-
How to find radial nerve in posterior compartment
Find posterior antebrachial cutaneous nerveradial nerve proximally
-
Proximal humerus fracture: preserved vascularity if
>8mm of calcar are attached to articular segement
-
Vascular supply of proximal humerus
Posterior humeral circumflex: Recent studies suggest it is the main supply
Anterior humeral circomflex: 2 branches >anterolateral ascending branch, arcuate artery.
-
Course of anterior humaeal circomflex
Parallel to lateral aspect of long head of biceps in bicipetal groove
-
Neer classification
Considered a separate fragment if: displacement>1cm or angulation >45.
Parts: GT, LT< Shaft, articular surfaxce
-
Proximal humerus #: common injury
Axillary nerve: up to 45%
-
Risk of AVN in proximal humerus # increased if 4
- 4 part
- head split
- short calcar segments
- disrupted medial hinge
-
Proximal humerus # malunion type
varus apex anterior
-
Location of shoulder prosthesis relative to what structure
Pec major: should be 5.6 proximal to tendon
-
Structure at risk in anterolateral acromial approach
Axillary nerve
-
Axillary nerve distance from the acromion
7 cm
-
Most common complication of proximal humerus ORIF
screw penetration/cut off
-
Hip fracture mortality rate
30% within one year
-
6 factors increase mortality in ip fractures
- Male
- Intertroch: compared to FN
- Operative delay >2
- Age >85
- 2 or more pre existing conditions
- AASA III or IV
-
Tip apex distance
AP + lat <25mm
-
Calcaneus fracture mechanism
Traumatic axial loading
-
Anterior process fracture mechanism
INversion and plantar flexion foot: avulsion of bifurcate ligament
-
Calc #'s: constant fragment
Superomedial fragment: Includes sustentaculum tali. Stabilized by strong ligaments
-
Extra-articular cal fractures: mechanism
Avulsion from contraction of gastrocs
-
Calcaneus fracture associated ortho injuries
- Vertebral fracture
- Extension into the CC joint: 60%
- Bilateral calc: 10%
-
Calcaneus anatomy: facets
- Posterior: Largest and major weight bearing
- Middle:Anterolateral. On sustentaculum tali
- Anterior: COnfluent with middle facet
-
Tendon at risk with calc orif
FHL: runs inferior to post facet of calc. Can be irritated by long screws
-
Sustentaculum tali: tendon under it
Ligaments attached
- FHL
- Deltoid, talocalcaneal ligaments
-
Bifurcate ligament
In calcaneus: Connects dorsal anterior process to cuboid and navicular
-
Extra articular calc fractures
- Anterior process: bifurcate lig avulsion
- Sustentaculum tali
- Calc tuberosity: achilles tendon avulsion
-
2 calcaneus fracture classifications
- -Essex lopressi: Tongue type, joint depression type
- - saunders: based on number of fracture lines seen at the widest point of the posterior facet
-
Essex lopressi classification
Primary fracture line goes from the posterior facet then
- -TOngue type: exits posteriorly
- -Joint depression: # exits behind posterior facet
-
Broden view: aim
technique
- Visualize posterior facet
- Ankle neutral dorsiflexion: take x rays at 10-40 degrees of IR
-
Harrris view: goal
Technique
- -See if varus/valgus/shortening
- -Foot maximal dorsiflexion and angle beam 45 degrees
-
Xray measurements for calc fractures + normal values
Bohler angle: 20-40. From superior aspect of tuberosity to top of posterior facet + from top of posterior facet to anterior process.
- Glissane: 130-145

-
CT scan calc fractures: reformating
30 degree semicoronal
-
Calcaneus fracture: indications conservative mGMT 4
- -COmorbidities
- -Sanders I
- -extra articual fracture with<2mm dispalcement and intact achilles
- -Anterior process involving <25% CC joint
-
Timing for calc ORIF
Wait 10-14 days for blisters to settle
-
Calc fracture: factors for bad outcome
- age>50
- Obesity
- Mabual laborer
- CSSR
- Smoker
- Bilateral cal
- Multiple trauma
- Vasculopathies
- Men do worse than women
-
Calc fracture indication for primary arthrodesis
Sanders 4: combined with ORIF to restore height
-
Positive heel squeeze test sign of
calc strss fracture
-
Calc malunion: surgery
indications 4
Subtalar distraction arthrodesis
- -decreased calc height
- -Decreased talocalcaneal angle
- -Decreased talar declination angle
- -COllapsed joint from VN
-
Physical exam finding in missed foot compartment syndrome
Clawing toes: contracture of intrinsic muscles
-
Calc fracture risk of wound issues 3
-
Distal radius fractures associated injuries 5
- DRUJ
- Radial styloid
- TFCC
- Scapholunate: disi
- Lunotriquetral: visi
-
Die punch #
Depressed fracture of the lunate fossa
-
Distal radius x ray parameters: normal/acceptable
Radial height
Radial inclination
Step off
VOlar tilt
- 11mm: <5mm shortening
- 23 degrees: <5 degree change
- congrous: <3mm step off
- 11 degrees: dorsal angulation <5degrees or within 20 degrees of contralateral side
-
Complications of clsoed reduction of distal radius fracture
- EPL rupture
- Acute carpal tunnel
-
Volar plating: tendon issue
FPL: secondary to placing plate past the watershed area
-
EPL rupture treatment
transfer extensor indices to EPL
-
Druj: strongest ligaments
radioulnar ligaments of TFCC
-
Factors for failed closed reduction distal radius fracture
- Jupiter: -Initial displacement
- -Age of patient
- -Metaphyseal comminution
-
Physiotherapy post ORIF DR fracture
No difference compared to home exercice program
-
3 peak times of death after trauma
- -50% within minutes of the trauma: massive blood loss or neuro injury
- -30% within first few days: Neuro injury
- -20% within days-weeks: Multi system organ failure and infection
-
Benefit of an airbag 4
- Decreases rate of:
- -CLosed head injuries
- -Facial fractures
- -Thoracoabdominal injuries
- Need fo rextration
-
ATLS primary survey
- Airway: includes c spine
- Breathing
- Circulation: Includes hemorrage control and rescusitation
- Disability: GCS
- Exposure
-
POsition of pregnant women in trauma evaluation
Left lateral decubitus: limit positional hypotension
-
Hemorrhagic shock classification + treatment
- I: FLuid
- II: FLuid
- III: FLuid + blood
- IV: FLuid + Blood
-
Circulating blood volume:
adult
child
-
Massive transfusion ratio
- 1:1:1
- Rbc:platelets:plasma
-
6 indicators of adequate rescusitation
- MAP>60
- HR<100
- Urine output: 0.5-1ml/kg/hr
- Lactate<2.5:most sensitive indicator of ischemia
- Gastric mucosal pH: >7.3
- Base deficit:-2 to +2
-
Difference between septic shock and hypovolemic shock
SVR in increased in hypovolemic and decreased in septic
-
Parameters to decide who to treat with DCO 8
- ISS>40 (w/o thoracic trauma)
- ISS>20 with thoracic trauma
- GCS <8
- Multiple injuries with intra abdominal trauma/hemorragic shock
- Bilateral femoral fractures
- Pulmonary contusion on CXR
- Hypothermia <35
- IL-6 >500
-
DCO: optimal time for surgery
From 2-5 days: increased risk of ARDS and Multi organ failure because of surge in inflammatory markers.
Only treat life or limb threatening injurues during this period
-
DCO orthopedic conditions to treat 6
- Compartment
- Fracture with vascular injury
- Unreduced dislocations
- Long bone fractures
- Unstable spine fractures
- Open fractures
-
LEAP study outcome measures
SIP (sickness impact profile) and return to work not significantly different btw amputation and reconstruction at 2 years in limb threatening injuries
Most important factor to determine patient reported outcome is ability to return to work
-
Leap study : decicion to amputate based on 2
-Severe soft tissue injury: highest impact on decicion making
- -Absence of plantar sensation: second highest
- Not contraindication to limb salvage
- Can recover in long term
-
Metabolic demand of different amputations (% increased from baseline) 5
- -Syme: 15%
- -BKA: 25%
- -AKA: 68%
- -Through knee:most proximal level to maintain walking speed in children
-
Amputation wound healing improved with 6
- -Albumin >3
- -Ischemic index >0.5
- -Transcutaneous oxygen tension >30 mm hg
- -Toe pressure >40 mm hg
- -ABI > 0.45
- -Total lymphocyte count > 1500
-
Upper extremity amputations indications 5
- -Vascular
- -Soft tissue compromise
- -Malignant tumor
- -Infection
- -COngenital anomalies
-
BKA ideal location
12-15 cm below joint
-
Ertl amputation
Creates a strut from tibia to ficula using a strut from the fibula.
- Original > osteoperiosteal flap
- Mofified. FIxation with screw, suture anchor or endo button
-
Syme amputation:
-definition
-equirements
-benefit
- -Ankle disarticulation
- -Patent tib post
- -more energy efficient than midfoot amputation
-
Chopart amputation:
-definition
-problem
- -Hindfoot amputation: through TN and CC joints.
- -Equinus deformity: do achilles lenghtening
-
Complication in pediatric amputation
-Bone overgrowth: Prevent by performing disarticulation or making an epiphyseal cap co cover medullary canal
-
Pelvic ring injury Poor outcome 7
- SI joint incongruity >1cm
- High degree initial diplacement
- Malunion
- LLD > 2cm
- Nonunion
- Neurologic injury
- Urethral injury
-
Pelvic ring ligaments 3
Anterior: Symphyseal (resist ER)
- Pelvic floor
- -Sacrospinous:Resist ER
- -Sacrotuberous: Resist shear
- Posterior
- -Ant sacroiliac
- -Post sacroiliac
- -Interosseaous sacroiliac
- -Iliolumbar
-
Inlet x ray:
-Good x ray if
-Look for
- -S1 overlaps S2 and scrum looks like bowtie
- -AP translation, widening symphysis, Widening SI
-
Outlet x ray:
-Good if
-Look for
- -Pubic symphysis overlies S2 body
- -Vertical shear
- -Sacral fractures
-
Pelvic ring injury classification
types 7
-Young-burgess
- -APC 1-3
- -LC 1-3
- -Vertical shear
-
APC 1-3
-Description
-Treatment
- APC 1
- -Symphysis widening <2.5cm
- -non-op protected weight bearing
- APC 2
- -SYmphisis widening >2,5cm + ANterior SI joint diastasis + disruption sacrotuberous/spinous ligaments
- -ANterior plating vs ex fix +/- POsterior stabilization
- APC 3
- -Disruption ant/post SI ligaments + Sacrotuberous/spinous
- -Same as 2 but need post fixation
-
LC 1-3
-Description
-Treatment
- LC 1
- -Ramus # + Ipsilateral sacral ala compression #
- -Non op: Protected weight bearing
- LC 2
- -Ramus # + Crescent #
- -ORIF vs SI screw
- LC 3
- -Ipsilateral LC + contralateral APC (windswept pelvis
- -Posterior stabilization
- Vertical shear
- -POsterior +/- anterior stabilization
-
Pelvic ring injury with highest risk hypovolemic shock
Vertical shear
-
Source of bleeding in pelvic ring injuries:
-Venous
-Arterial
-Venous plexus + cancellous bone
- Arterial
- -Sup gluteal (most common)
- -Internal pudendal
- Obturator
-
Indications for retrograde urethrogram 3
- Blood at the meatus
- high riding prostate
- hematuria
-
Supra-acetabular ex fix 3 views and the use
- Obturator oblique: Starting point
- Internal oblique: Aim above sciatic notch
- Obturator inlet oblique; Ensure btw ilium tables
-
SI screw: structure at risk
L4-5 nerve roots
-
Nerve at risk during placement of supra acetabular ex fix
LFCN
-
Acetabular # associated ortho injuries 3
- -Lower extremity injury #6 %
- -Nerve palsy (13%)
- -SPine injury (4%)
-
Acetabular # systemic injury 4
- -Head
- -CHest
- -Abdo
- -Genitourinary
-
Acetabular # poor outcomes 5
- -Polytrauma
- -Older age
- -Poor articular congruity
- -Associated femoral head articular injury
- -Intraoperative complications
-
Acetabular posterior column composed of 4
- -Quadrilateral plate
- -Posterior wall and dome
- -Ischial tuberosity
- -Greater and lesser sciatic notches
-
Acetabular anterior column composed of 4
- -Anterior ilium
- -Anterior wall and dome
- -Iliopectineal emminence
- -LAteral superior pubic ramus
-
Corona mortis is
- at risk during
- Anastamosis of external iliac (epigastric) and internal iliac (obturator) Vessels
- -LAteral dissection over supeior pubic ramus
-
Letournel classification 10
- -Post wall
- -Post column
- -Ant wall
- -Ant column
- -Transverse
- -ABC
- -Transverse + POst wall
- - T shaped
- -Ant column + POst hemitransverse
- -Post column + Post wall
-
Gull sign
POsterior wall fracture
-
-
Judet views
- Obturator oblique: Ant column post wall
- Iliac Oblique: Post column ant wall
-
6 radiographic landmarks of acetabulum
- Iliopectineal line: Ant column
- Ilioischial line: post column
- Ant wall
- POst wall
- Teardrop
- Sourcil
- Shenton's line
-
Roof arc measurement:
-goal
-definition
- does not apply
- -Define fracture stability
- -If >45 degrees on all views defined as stable
- -In ABC
-
Non operative posterior wall #indications
- <20% posterior wall involvement
- EUA to define stability look for medial clear space widening
-
Indications for acetubular # ORIF 5
- -Displacement roof >2mm
- -UNstable # pattern (post wall >20 %)
- -Marginal impaction
- -Loose bodies
- Irreducible fracture dislocation
-
Hip dislocation reduction timing
better outcome if <12hrs
-
Acetabular ORIF delayed fixation
- Worse outcome if >3weeks
- Earlier operative time increases chances of anatomic reduction
-
Use of obturator oblique inlet view
Ensure supra-acetabular screw between tables of ilium
-
USe of inlet iliac oblique view
Position of Screw within pubic ramus
-
Chose the approach:
-Anterior wall #
-ANterior column #
-T-shaped
-ABC
-Post column
-Post hemitransverse
- -Ilioinguinal
- -Ilioinguinal
- -Kocher
- -Ilioinguinal
- -KOcher
- -Kocher
-
Ilioinguinal approach risks 4
- Femoral nerve injury
- LFCN injury
- Thrombosis femoral vessels
- Laceration corona mortis
-
KOcher langenbach approach risks 3
- Increased risk HO
- Sciatic nerve injury
- Damage to medial femoral circumflex ( AVN )
-
Treatment of HO in acetabular ORIF
- Usually for POst approach
- -Indomethacin 70mg po qd x 5 weeks
- -Low dose external radiation
- No difference between both
-
x ray to best visualize post wall
Obturator oblique
-
Tibial plateau #, Associated conditions 5
- -Lateral meniscus tear: More common than medial, Associted with Shtzker II
- -Med meniscus tear: Schatzker IV
- -ACL: Shatzker V/VI
- - COmpartment
- -Vascular injury: Shatzker IV
-
Tibial plateau shape:
-Medial
-LAteral
- -Concave + distal to lat plateau
- -Convex + proximal to med plateau
-
Schatzker classification
- I: LAteral split
- II: LAt split/depression
- III: Lat pure depression
- IV: Medial plateau
- V: Bicondylar
- VI: Met-dia dissociation
-
Tibial plateau # non op indications 3
- -Min displaced split or depressed #
- -Low energy, stable varus/valgus alignment
- -Non ambulatory patients
-
Tibial plateau fracture indications ORIF 5
- -Articular step off >3mm
- -COndylar widening >5mm
- -Varus/valgus instability
- -Medial plateau #
- -Bicondylar #
-
Tibial plateau:
-Good outcome if
-Worse outcomes if 3
-Restoration of joint stability
- -Ligamentous instability
- -Meniscectomy
- -Alteration mechanical axis >5 degrees
-
Posteromedial approach to tibial plateau interval
Pes anserinum and medial head of gastrocs
-
Signs of lateral meniscus injury in tibial plateau fracture 2
- -Joint depression > 6mm
- -Joint widening >5mm
-
High energy PLC injury > surgical option
Reconstruction better than repair
-
In the treatment of tibial plateau #, best substance for grafting to avoid subsidence
Calcium phosphate cement
-
Femur fracture - Associated orthopaedic conditions
- - Ipsilateral: Femoral neck (basicervical,verical,undisplaced)
- -Bilateral femur #: Increased risk pulm complications/mortality
-
Thigh compartments (3) and muscles
- -Anterior: Sartorius + Quads
- -Posterior: Biceps femoris + SemiT + Semi M
- -Adductor: Gracilis + adductor brevis/longus/magnus
-
Femur shaft fracture deforming forces
- Proximal fragment
- -Abducted: glut med/min
- -Flexed: iliopsoas
- Distal fragment
- -Varus (adductors)
- -Extension (gastrocs)
-
Blood loss in closed femur shaft #
1-1.5L
-
Femur shaft #
-gold standard
-outcomes improved if
-Exception
- -Anterograde femoral nail
- -Fixation within 24 hrs: decreased ARDS, decreased thromboembolic events, shorter hospital stay
- - Closed head injury: need avoid hypotension and hypoxia > may need ex fix
-
Retrograde femoral nail indications 6
- -Ipsilateral Tibial plateau/shaft
- -Morbid obesity
- -Ipsilateral acetabular #
- -Bilateral femur #
- -Polytrauma
- -Ipsilateral femoral neck #
-
Piriformis entry nail
-Pro
-cons
-Colinear with femoral shaft
- -More difficult
- -Damage abductors
- -AVN in younger patients
-
Femoral nail reamed vs unreamed
Reamed: No increase in pulm complications, increased union rates, decreased time to union
Unreamed: Consider in patients with bilateral pulmonary injuries
-
Retrograde femur nail starting point 2
- -Center intercondylar notch on AP
- -Extension blumensat line on lateral: if posterior can injury cruciate ligaments
-
Femur shaft + ipsilateral femoral neck what to do
-technique 3
- -Priority to femoral neck > avoid AVN
- -Screws for neck + retrograde nail
- -Screws for neck + plate for shaft
- -DHS + retrograde nail
-
Femoral nail risk of non union 2
rate
treatment
-<10%
-Exchange reamed nail
-
In retrograde femoral nail, what screw puts branches of deep femoral nerve/A at risk
A/P proximal locking below the LT
-
Femoral nail rate of union reamed vs unreamed
Reamed higher union
-
Tibiofibular overlap:
-AP
-Lat
-
-
Tibiofibular clear space
- <5mm
- measured 1 cm above from joint line
-
Talocrural angle
8-15 degrees
-
Lauge-hansen classification
-4
- Supination - Adduction
- Supination ER
- Pronation Abduction
- Pronation ER
-
Supination Adduction
-Sequence
- -Talofibular sprain or Distal fibular avulsion
- -Vertical medial mall + impaction anteromedial distal tibia
-
Supination ER
- Sequence
- -ATFL sprain
- -Lateral short oblique fibula fracture
- -PTFL rupture or avulsion
- -Medial mall transverse # or deltoid disruption
-
Pronation Abduction
-Sequence
- -Medial mall transverse # or deltoid disruption
- -ATFL sprain
- -Transverse or comminuted fibula # above level of syndesmosis
-
Pronation ER
-Sequence
- -Medial mall # or deltoid disruption
- -ATFL disruption
- -Lateral mall short oblique or transverse # above level syndesmosis
- -PTFL rupture or avulsion post mall
-
Bosworth fracture dislocation
POsterior dislocation of fibula behind incisura fibularis
-
Ankle fracture > Non operative mgmt (3)
- -Isolated undisplaced medial mall #
- -Isolated lat mall # with <3mm displacement and no talar shift
- -Post mall # with <24% joint involvement and < 2mm step off
-
Ankle fracture indications ORIF - general (7)
- -Talar displacement
- -Displaced medial mal
- -Displaced lat mal >3mm
- -Bimalleolar
- -Post mall >2mm step or >25% involvement
- -Open #
- -Bosworth #
-
Ankle # - worse outcome (5)
- -Increased age
- -Medial mall #
- -Smoking
- -Decreased education
- -EtOH
-
Key technique point for sup-adduction ORIF
Restoration of anteromedial marginal impaction leads to better outcome
-
Ankle fracture - when to drive (2)
- -9 weeks after ORIF> return of braking time
- -6 weeks after start of weight bearing for periarticular/long bone fractures
-
Isolated medial mal # mgmtt:
-Conservative
-Operative
-Techniques (3)
- -Undisplaced or tip avulsion: symptomatic treatment
- -Displaced/talar shift
- -ORIF:lag screw, antiglide plate, tension band
-
Isolated lateral mal #:
-Conservative mgmt 3
-Operative indications 3
-ORIF technique / advantages /disadvantages
-Post operative mgmnt 2
- -Intact mortice, no talar shift, <3mm displacement
- -Talar shift, displacement >2mm, associated syndesmosis injury
- -Lateral plate: Lag screw with neutralization plate or bridge plate. Prominent hardwre
- -Posterior plate: antiglide, lag screw, if placed to distal can irritate peroneals
- -Immobilization 4-6 weeks post ORIF
- - Double immobilization period if diabetic
-
Advantage of post mall fixation
Restoration of syndesmosis strength to 70% vs 40% for syndesmosis fixation.
-
Best way to test syndesmosis
Intra op abduction-ER stress on dorsiflexed foot
-
Syndesmosis ORIF
technique 3
reduction 2
location/angle
Post op 2
- -Screws: 1-2
- -Cortices: 3-4
- -Size: 3.5 or 4.5
- -DIme sign or shentons line
- -2-4cm above joint line angled 20/30 degrees anterior
- -NWB 6 weeks
- - HWR vs broken harware = no difference. Retained intact hardware = worse.
-
Diabetic ankle fracture complications 3
-Enhanced fixation 3
- -Prolonged healing
- -Hardware infection
- -Hardware failure
- -Quadricortical screws
- -Intramedullary k wire in fibula
- -Locked plate
-
SYndesmosis injury, what direction of instabilty for the fibula
A to P
-
Tibia shaft fracture indication conservative mgmt 5
technique
- -Closed low energy fracture
- -<5 degrees varus/valgus alignment
- -<10 degrees ant/post angulation
- ->50% cortical apposition
- -<1cm shortening
- -<10 degrees rotational malaligment
Long leg cast, coonvert to patellar tendon bearing brace at 4 weeks
-
Tibial shaft indication for nail 8
- -Unacceptable alignment
- -Soft tissue injury not conductive to casting
- -Segmental #
- -Comminuted #
- -Floating knee
- -Bilateral tibia #
- -Morbid obesity
- -Polytrauma
-
Tibia nail contraindications
- TKA or previous ORIF
- Pre existing tibial deformity
-
Tibia nail reamed vs unreamed
- SPRINT trial
- -Reamed superior in closed # for need of future grafting/implant exchange
recent studies > no adverse effects of remed
-
Tibial shaft fracture percutaneous plate vs IMN 5
- -Equivalent time to union
- -Greater radiation exposure
- -Longer surgical duration
- -Lower post op pain scores
- -More difficult HWR
-
Tibial shaft fracture risk for non union 3
- Gapping at # site
- Transverse #
- Open #
-
Tibial shaft fracture reduction techniques 5
- Femoral distractor
- Unicortical plate
- Blocking screws
- Clamps
- External fixator
-
Tibia shaft fracture complications 6
- Compartment syndrome
- Malunion: Valgus/procarvatum
- Knee pain: 50%
- Non Union: treat with exchange nail or compression plating +/1 posterlateral bone graft
- Malrotation
- Nerve injury: sup peroneal in liss plate
-
tibial shaft fractures: use of tourniquet leads to
Increased post op pulmonary complications
-
Tibial shaft fracture with increased risk of varus malunion
Shaft with intact fibula
-
Transient peroneal neuropraxia physical exam finding
Weak EHL
-
Location of superficial peroneal nerve with respect to tibia liss plate
around hole 11-13
-
Proximal tibia # malunion: most common
- Valgus
- Procarvatum: apex anterior
-
Proximal tibia # deforming forces
- Patellar tendon: Procarvatum
- Hamstring: Distal fragment into flexion
- Pes Anserinum: Proximal fragment into Varus
-
Indications for conservative mgmt proximal tibia # 5
- < 5 degrees varus valgus
- <10 degrees sagital angulation
- >50% cortical apposition
- <1 cm shortening
- <10 degrees rotation
-
Approach ideal for proximal tibia nail
Semiextended position:suprapatellar
-
Starting point tibia IMN
- Proximal to anterior margin of articular surface
- Medial to lateral tibial spine
-
IMN fracture reduction techniques
Poller screws: Posterior > prevents procarvatum. Lateral concave side > prevent valgus
Unicortical plating
Femoral distractor
Nail in semiextended position
-
Pilon fracture typical fragments
- Medial malleolar (deltoid)
- Postrolateral: Volkman > PITFL
- Anterolateral: Chaput > AITFL
-
Pilon # 5 factors for poor prognosis
- Lower level education
- Pre existing comorbidities
- Male
- WOrk related
- Lower income
-
Vascular anatomy of leg 3
Ant, tibial A: First branch > passes btw 2 heads of tib post and IO membrane. BTW Tib ant and EHL. Ends as dorsalis pedis
Post tibial A: Terminates in medial and lateral plantar
Peroneal: 2.5 cm distal to fossa. Terminates as calc branches
-
Sural nerve composition
- Tibial:medial
- Peroneal: lateral
-
Acute mgmt of tibial pilon #
Temporizing ex-fix for 10-14 days
-
Pilon # ex fix frame
A frame: 2 tibial pins and one trans calc pin
-
Definition of subtrochanteric
Area 5 cm below LT
-
Subtrochanteric fracture deforming forces
- Abduction: GLut med/min
- Flex: Iliopsoas
- ER: Short ER
-
Atypical femur fractured Major criteria
- Anywhere along femur distal to LT and proximal to supracondylar flare
- No or minimal trauma
- Transverse or short oblique
- Non Comminuted
- Medial Spike if complete
-
Atypical femur fracture minor criteria
- Lateral beaking
- Generalized increased cortical thickness of diaphysis
- Prodromal symptoms
- Bilateral fractures
- Delayed healing
- Comorbidities
- MEDS: BP'S, steroids, PPI
- No FN, IT, metastatic #'s
-
Malunion after subtroch IMN: most common
Varus and procarvatum
-
4 compartments of leg + muscles
- Anterior: Tib. ant, EHL, EDL, peroneus tertius.
- Lateral: Peroneal brevis/longus
- Deep post: Tib post, FDL, FFHL,
- Sup. post: Gastrocs, soleus, plantaris
-
Compartment pressure measurements: location
Values
- WIthin 5 cm fracture site
- Diastolic differential pressure <30
-
Fasciotomy 2 incisions
Anterolateral: Identify sup peroneal nerve. Fasciotomy 1 cm ant and 1 cm post to intermuscular septum
Posteromedial:Protect saphenous n/v. Incise sup peroneal + detach soleal ridge from back of tibia
-
Structure at risk with single incision fasciotomy
common peroneal N
-
Hoffa #
Distal femur coronal plane fracture: 38% in Type C #'s
-
Distal femur #: requirement for retrograde nail
4 cm intact distal femur: classically used for extra articular, non comminuted.
-
Distal femur # classic approach
Anterolateral: Incision from TT to anterior 1/3 distal femoral condyle
-
Distal femur fracture nonunion rate and location
19%: in metaphyseal area
-
Distal femur ORIF how to check screw lenght
AP knee with leg in 30 degrees IR
-
Lead intoxication 4
- Neurotoxicity
- Anemia
- Emesis
- Abdominal Colic
-
Low velocity GSW: Speed
Open # type
gun type
- <2000 ft/sec
- 1-2
- Shot gun, hand gun
-
High velocity GSW: speed
open #
Gun type
- >2000 ft/sc
- 3 regardless of size
- Assault rifle/hunting rifle
-
GSW associated with bowel injury
-
5 indications for operative mgmt GSW
- Articular involvement
- presentation >8 hrs
- Unstable #
- Tendon involvement
- Superficial fragment in palm or sole
-
Indication for I&D in spine GSW
Motor weakness with retained fragemnt in the spinal canal
-
Risk factors for elder abuse 4
- Increasing age
- Functional disability
- Child abuse within regional population
- Cognitive impairement
-
Caretaker factors for elder abuse 3
- Substance abuse
- Financial dependence on abuse
- Perceiving the caretaker as a burden
-
Clinical signs of elder abuse 5
- Unexplained injuries
- Delays in seeking care
- Repeated fractures/burns
- Change in behaviour
- Poor hygene
-
Risk of partner domestic abuse 4
- Female
- 19-29
- Low SES
- Pregnant
-
Mechanism for intercondylar distal humerus fracture
Axial load with elbow flexed >90 degrees
-
Inserts on sublime tubercle
Anterior bundle of elbow MCL
-
primary restraint to valgus stress at the elbow from 30 to 120 degrees
Elbow MCL
-
Stabilizer against posterolateral rotatory instability
LCL
-
Classification of distal humerus fractures
Milch
- Type 1: Lateral trochlear ridge intact
- Type 2: # through lateral ridge of trochlea

-
3 approaches to distal humerus fracture
- Olecranon osteotomy
- Tricep split
- Tricep sparing
-
Approach to distal humerus: medial side
Identify ulnar nerve up to first motor branch to ECU.
Elevate triceps from posterior aspect of elbow
elevate posterior bannd of MCL
-
Approach to distal humerus: lateral side
Identify radial nerve proper: if fracture mid/distal
-
Olecranon osteotomy technique
Locate bare area of sigmoid notch.
Make chevron: apex distal.
-
Fixation steps to distal humerus fracture
First fix articular component then build to medial/lateral column
-
Distal humerus orif:plate configuration
2 orthogonal plates
2 parallel plates
-
Distal humerus ORIF post op protocol
Splint to 70 degrees
Remove splint at 1 week
Begin ROM: AROM+AAROM, no PROM
Strenghtening at 6 weeks
-
Distal humerus ROIF and heterotrophic ossification
Do not use: has been shown to increase the rate of no union
-
Distal humerus # malunion deformity 2
Cubitus valgus: lateral column fractures
Cubitus varus: medial column fractures
-
Double arc sign
Distal humerus capitellar shear fracture
-
Most common complication of distal humerus #
decreased ROM
-
Midshaft clavicle fracture deforming forces
SCM: Pulls medial fragment superiorly
Pec major: Pulls distal fragment inferiorly
-
AC joint: static stabilizers 3 + strongest within each
- AC ligament: Strongest is superior ligament
- CC ligaments: trapezoid, conoid. Conoid is strongest
- Capsule
-
AC joint dynamic stabilizer
-
Zanca view x ray
For clavicle #
15 degree cephalic tilt: determine sup/inf displacement
-
Clavicle # indication for ORIF: absolute 6
- Open
- Skin tenting
- Vascular injury
- Floating shoulder
- Symptomatic malunion
- Symptomatic non union
-
Clavicle # advantages of ORIF 5
In pationts with >2cm shortening and 100% displacement
- -Less pain with overhead activities
- -Faster time to union
- -Decreased symptomatic malunion
- -Improved cosmetic
- -Improved strenght and endurance
-
Non operative clavicle fracture protocol
- Sling
- Start ROm 2 weeks
- Strenghtening 6 weeks
-
Olecranon fractures mechanism of injury + fracture pattern 2
- Direct blow: Comminuted #
- Indirect: FOOSH, transverse/oblique #
-
Olecranon ORIF 3 techniques/indications
- Tension band: transverse
- Plate: COmminuted, oblique fractures
- Excisision + tricep advancement: Elderly patients. Fracture involves < 50% joint surface
-
Olecranon tension band: nerve at risk
AIN
-
Talar neck # mechanism of injury
Forced dorsiflexion with axial load
-
Blood supply to talus 4
Posterior tibial artery: via artery of tarsal canal(dominant supply)
Anterior tibial artery: head and neck
Perforating peroneal: via artery of tarsal sinus
Deltoid artery: supplies body
-
Talar neck fracture classification
Hawkins
- I: Non displaced > 0-10%
- II:Subtalar dislocation> 25-50%
- III: Subtalar and tibiotalar > 20-100
- IV: ST + TT + TN > 70-100%
-
Canale view: used for
How to do it
-View of talar neck
-Maximus equinus, 15 degrees pronation, x ray 75 degree from horizontal
-
Treatment of extruded talus
Replaced and treated with ORIF
-
Talar neck fracture complications 5
- Post traumatic OA
- Mal-union
- Non-union
- Infection
- Wond dehiscence
-
ORIF talar neck # approach
2 approaches
-Anteromedial: btw Tib ant/post. Preserve deep deltoid ligament (blood supply). may need medial mall osteotomy
-Anterolateral: btw tib/fib in line with 4th ray. Elevate EDB
-
Hawkins sign
Subchondral lucency best seen in mortice view at 6-8 weeks
Indicates intact vascularity: resorption of subchondral bone
-
Talar neck fracture malunion deformity + treatment
Varus: medial opening wedge osteotomy
Leads to Decreased subtalar eversion> weight bearing on lateral border of foot.
-
Varus malalignment after a talar neck fracture with medial comminution causes a decrease in what motion
Eversion
-
Radial head fracture mechanism of injury
FOOSH: elbow in extension and forearm pronation
-
Deficiency in what ligament leads to posterolateral rotatory instability
LUCL
-
Lateral collateral ligament complex components 4
- LUCL
- Radial collateral ligament
- Accesory lateral collateral ligament
- Annular ligament
-
Elbow MCL bundles
- Anterior: primary stabilizer to valgus stress
- Posterior
- Transverse
-
Radial head provides 2 types of stability
Valgus: Secondary restraint to valgus
Longitudinal: Restraint to proximal migration of the radius
-
Radial head fracture classification
Mason
- I: non diplaced, displacement <2mm
- II: Displaced > 2mm or angulated.
- III: Comminuted and displaced > mechanical block
- IV: Associated with elbow dislocatio
-
Radial head # indication for ORIF
- Mason II with block to motion
- Mason III when ORIF feasable
- Presence of other complex elbow injuries
-
ORIF radial head with worse outcomes if
>3 fragments
-
Indications for radial head arthroplasty 2
Mason type 3 with >3 fragments where ORIF not possible
Elbow # dislocations/essex lopresti lesion
-
Mason 3 ORIF vs arthroplasty
Better outcome with arthroplasty: stability, patient ssatisfaction
-
Indications for radial head resection
Low demand patient
In delayed setting to treat persistent pain
-
Location of PN nerve
Muscle substance of supinator: 4 cm distal to radial head
-
How to protect PIN
Forearm pronation during lateral approach to elbow
-
Kocher approach interval
- ECU (pin)
- Anconeus (radial)
-
-
kocher vs kaplan approach
- Kocher: less risk of PIN/radial n. injury. More risk damaging LUCL
- Kaplan: More risk nerve injury, less risk damaging LUCL
-
radial head orif: Plate placement
Safe zone: radial styloid to lister's tubercle with arm in neutral rotation.
Bicepetal tuberosity: is distal limit of plate placement
-
Terrible triad definition
- Elbow dislocation
- Radial head/neck fracture
- Coronoid fracture
-
Coronoid: restraint position
POsterior subluxation beyond 30 deg of flexion
-
Inserts on sublime tubercle
Anterior band of MCL
-
Avulsion site of LCL
Usually from distal humerus
-
ORIF for coronoid fracture involving<10%
Not necessary
Only address if: instability persisting after addressing radial head/LCL complex > MCL repair > coronoid
-
Position of arm when fixing LCL
- In pronation/flexion: MCL intact
- In supination/flexion: Injured MCL > avoid medial gapping from overtightening.
-
Indication for MCL repair
Persistent instability following LCL + fracture fixation
-
Most common type of elbow dislocation
Posterolateral: 80%
-
Progression of injury in elbow dislocation
Lateral to medial
LCL > MCL
-
Primary static stabilizers of elbow 3
- Ulnohumeral joint
- Anterior bundle MCL
- LCL complex
-
Secondary static stabilizers of the elbow
- Radiocapitellar joint
- Joint capsule
- Origins of common flexor/extensor tendons
-
Dynamic stabilizers of the elbow
- Anconeus
- Brachialis
- Triceps
-
Cause of varus posteromedial instability fo the elbow
LCL injury + fracture to anteromedial facet of coronoid
-
Erb palsy
C5-C6:Upper trunk
-
-
Mechanism of traumatic upper brachial plexus injury
Caudally forced shoulder
-
Mechanism of injury of traumatic lower root injury
Forced arm abduction
-
Rate of nerve regeneration
1mm/day
-
Worst prognosis brachial plexus injuries
Root avulsion: preganglionic
-
Preganglionic injury:definition
Avulsion proximal to dorsal root ganglion: Involves CNS which does not regenerate. Worse prognosis
-
Lesions suggesting preganglionic brachial plexus injury
- Horner syndrome: sympathetic chain disruption
- Winged scapula: Loss of serratus anterior(long thoracic), rhomboids (dorsal scapular)
-
Erb palsy clinical presentation
- Shoulder: Adduction,, IR
- Elbow: Pronated, extended
-
Horner syndrome 3 features
- Drooping left eyelid
- Pupillary constriction
- Anhidrosis
-
Horner syndrom roots involved
C8-T1
-
MRI signs of root avulsion
- Pseudomeningocele
- Empty nerve root sleeves
- Cord shifts away from midline
-
Location of bipartite patella
Posterolateral
-
MOst important blood supply to patella
inferior pole
-
Indication for conservative mgnt patella # 3
- Intact extensor mechanism
- Non displaced #
- Vertical fracture pattern
-
Indication for partial patellectomy
Severly comminuted inferior ple fractue not amenable to ORIF
-
FLOW trial results
Low flow with saline better than the rest
-
Open # treatment based on gustillo
- 1-2: 1st generation cephalosporin. Clinda or vanco if allergy
- 3: 1st generation cephalosporin + aminoglycoside
-
Tetanus prophylaxis: type/dose
Toxoid: 0.5ml. If not updated within 5 years
- Immunoglobulin:
- - <5 75U
- - 5-10 125U
- - >10 250 units
-
ARDS: 3 phases
Exudative: initially >>membrane comprised of hyaline membrane forms
Proliferative: 3 days >>alveolar exudate resolves or organizes
Fibrotic: 3-4 weeks: alveolar ducts and spaces undergo fibrosis
-
ARDS symptoms 3
- Dyspnea
- fever
- mottled or cyanotic skin
-
3 categories of ARDS based on hypoxemia
- MIld: PaO2/FiO2 ratio <300
- Moderate: PaO2/FiO2 ratio <200
- Severe: PaO2/FiO2 ratio <100
-
ARDS treatment
Supportive: oxygenation using PEEP
Early stabilization of femur fractures
-
Laeral process of talus fracture mechanism
Forced dorsiflexion , axial loading, inversion and external rotation: snowboarders
-
Muscular and tendinous attachments of talus
NOne
-
What articulates with: talar head
Lateral process talus
Posterior process talus
- Navicular and sustentaculum tali
- Posterior facet calc and lateral mal
Consists of medial and lateral tubercle separated by groove for FHL
-
Classification of lateal process talus #
- Type 1: Do not involve articular surface
- Type 2: INvolve the subtalar and tibiotalar joints
- Type 3: have comminution
-
What causes the following: talar posteromedial tubercle fracture
Talar posterolateral tubercle fracture
- Avulsion of posterior deltoid
- Avulsion posterior talofibular ligament
-
Talus fractures other than neck: indications for ORIF + what approach for
Lateral process
Talar body
- DIsplacement >2mm
- Lateral process: lateral approach over sinus tarsi reflecting edb distally
- Boyd: combined medial and lateral approach
-
Excision of a fragment >1cm of lateral process leads to
Lateral talocalcaneal ligament incompetence: does not lead to ankle instability
-
3 Risk factors for femoral head non union
- High pauwels angle: type 3 > 70
- Garden IV
- Posterior comminution
-
Femoral neck non union treatment
If no OA can revise with valgus intertrochanteric osteotomy to make orientation of fracture more horizontal
-
4 fracture characteristics that increase the risk of humeral fracture malunion
- 3-4 part
- Humeral head split
- Displaced tuberosity #
-
Normal humerus anatomy: version
Head shaft angle
GT position
- 30 degree retroverted
- 130-140 degrees
- 6mm inferior to upper edge of humeral head
-
Distal 1/3 clavicle fracture: insertion of trapezoid
Inserion of conoid
- 3cm from end of clavicle: lateral
- 4,5 cm from the end of the clavicle: medial
-
Distal third clavicle fracture classification + treatement
Type 1: lateral to CC ligament ....CC ligaments intact >>>non op
- Type 2AFracture medial to CC ligaments
- CC ligaments intact
- Unstable
- ORIF
- Type 2B# btw CC ligaments >>conoid torn, trapezoid intact
- or # lateral to CC ligaments but CC ligaments torn
- UNstable: medial clavicle displacement
- ORIF
- Type 3Intraarticular extending to AC joint
- Ligaments intact
- Stable
- Non op
- Type 4Physeal fracture in skeletally immature
- Ligaments intact
- Stable
- Non op
- Type 5COmminuted
- Ligaments intact
- Significant medial clavicle displacement
- ORIF
-
3 absolute indications for ORIF distal clavicle #
- Open
- SUbclavian artery or vein injury
- FLouating shoulder: associated scapula neck #
-
Femoral head # % associated with hip dislocation
5-15
-
blood supply to femoral head 3
- Extracapsular arterial ring: medial femoral circumflex is main contributor
- Ascending femoral branches
- Artery to the ligamentum teres: from obturator of MFCA
-
Describe pipkin classification
- Type 1: infrafoveal
- Type 2: suprafoveal
- Type 3: associated FN #
- Type 4: Associated with acetabular #
-
Inidications for non op mgmt of femoral head # (2)
- Pipkin 1
- Pipkin 2 with < 1mm step off
- No interposed fragments
- Stable hip joint
-
Indications for operative mgmt femoral head # 5
- Pipkin 2 >1mm step
- Loose bodies
- Associated acetabular or femoral neck #
- Pipkin 4
- Irreducible # dislocation
-
Surgical approach for: Pipkin 1-3
Pipkin 4
- Anterior smith pete or watson jones
- Kocher langenbeck to fix acetabular #
-
Femoral head # for complications
- HO: most common
- AVN
- Sciatic nerve neuropraxia: usually peroneal division
- OA
-
Chose antibiotic in open #: Gustillo 1
Gustillo 2
Gustillo 3
Farm injury
Fresh water injury
- 1st generation cephalosporin
- 1st generation cephalosporin + aminoglycoside (gram -ve coverage)
- Penicillin G: farm injury
- FLuoroquinilone: can be used if allergic to clinda or cephalosporin
-
Scapulothoracic Dissociation: mechanism
most common vascular injury
Mortality
x ray finding
What determines functional outcome
- Lateral traction to shoulder girdle
- Subclavian artery
- 10%
- Edge of scapula >1cm from spinous process as compared to contralateral side
- Degree of neurologic compromise
-
Insertion of anterior bundle of MCL with respect to coranoid tip
18mm from tip
-
3 associated conditions to coronoid #
- PMRI: coronoid anteromedial facet # and LCL disruptin (from Varus)
- PLRI: Terrible triad ...radial head #, coronoid tip, LCL injury (valgus stress)
- Olecranon # dislocation: large piece olecranon #
-
O drisscoll classification of coronoid #
Tip: less than or greater than 2 mm coronoid height
Anteromedial facet
Anteromedal rim - Anteromedial rim and tip
- Anteromedial rim and sublime tubercle
- BasalCoronoid body and base
- Transolecranon basal coronoid #
-
Describe medial approach to coronoid
- Isolate and protect ulnar nerve
- BTW 2 heads of FCU
-
Scapula #: most common location
Body and spine (50%)
-
Coracoid # classifiction
- Type 1: proximal to CC ligaments
- Type 2: distal to CC ligaments
-
Acromioal fracture classification 3
- Type 1: undispalced
- Type 2: Displaced but does not compromise subacromial space
- Type 3: Displaced and compromises subacromial space
-
Indications for ORIF of scapular # 4
- > 25% articular surface glenoid involvement and humerus subluxation
- Scapular neck displaced: >40 degrees angulation or 1 cm translation
- Open #
- coracoid # with >1cm displacement
-
Judet approach: internervous plane
SUprascapular (infraspinatus) and teres minor (axillary
-
Capitellar # 2 associated injuries
-
Capitellar # classification
- Type 1: large osseous piece
- Type 2: kocher-lorenz>>>shear # of articular cartilage
- Type 3: COmminuted
- Type 4: McKEE coronal shear that includes capitellum and trochlea
-
INdications for ORIF capitellum # 2
+ how to fix
- Displacement >2mm
- Type 4: mckee double arc sign because it involves the trochlea
Lateral column approach
-
Most common: pathogen of Septic arthritis in adults
Location
- Staph aureus
- Knee > hip > shoulder
-
Septic arthritis: timing of cartilage injury
Mechanism of cartilage destruction
- Can start within 8 hours
- Release of proteolytic enzymes from PMN's
-
3 etiologies of bacterial seeding of joints
- Bacteremia
- Diret inoculation from traumaor surgery
- Contiguous spread from adjacent osteomyelitis
-
Most common organism in septic arthritis in young adults
Neisseria Gonorrhea
-
Best way to follow response to treatment in septic arthritis
Follow CRP: normalizes within one week of treatment
-
name of biofilm that protects bacteria from antibiotics
exopolysaccharide glycocalx
-
x ray findings in chronic infections 2
Involucrum: reactive bone surrounding active infection
Sequestrum: retained nidus of infected necrotic bone
-
Crescent fracture: what is it
younge and burgess type
SI fracture dislocation: posterior ilium remains attached to sacrum by posterior ligaments, anterior ilium dislocates with an internal rotation deformity
LC-2
-
Name the posterior pelvic ligaments 4
- sacrospinous
- sacrotuberous
- anterior sacroiliac
- posterior sacroiliac
-
Nerve at risk during placement of si screws
L5 nerve root on sacral ala
-
Mangled extremity severity score: number predictive of amputation
Score 7 or higher
-
Galeazzi fracture: definition
Incidence of druj injury based on location
- Distal 1/3 radius fracture and druj injury
- Fracture < 7.5 mm away from joint: unstable druj 55%...if >7.5 cm>>unstable 6%
-
4 x ray signs of druj injury
- Ulnar styloid #
- WIdening of druj on AP
- dorsal or volar displacement on lateral x ray
- Radial shortening > 5mm
-
If cannot reduce druj, what an be interposed.
ECU tendon
-
Monteggia #: definition
Proximal 1/3 uln fracture and radial head dislocation
-
Bado classificatio
Type 1: Anterior dislocation of radial head....most common in the young
Type 2: posterior dislocation of radial head >>>common in adults
Type 3: lateral dislocation of radial head
Type 4: Fracture of both radius and ulna with dislocation of radius in any directon
-
Monteggia #: most likely nerve injury
How to cast
Block to reduction
PIN
- In supination: if lateral or anterior dislocation
- In pronation: if posterior dislocation
Annular ligament: especially in type 3
-
Subtalar dislocation: most common
most common open
3 associated fractures with medial dislocation
4 associated with lateral dislocation
- Dorsomedial talar head
- Posterior process oftalus
- navicular
- Cuboid
- Anterior calc
- lateral process talus
- Fibula
-
Subtalar dislocatiob: position of foot if medial
Position of foot if lateral
- Locked in supination
- Locked in pronation
-
How to tell direction of subtalar dislocation on lateral xray
Medial dislocation if talar headis superior to navicular
Lateral dislocationif talar head colinear or inferior to navicular
-
Subtalar dislocation: blocks to reduction if medial 3
blocks to reduction if lateral 3
- Peroneal tendons
- EDB
- TN capsule
-
COntraindication to reduction of hip dislocation
Ipsilateral femoral neck fracture
-
What is the next step after reduction of a hip doslocation
CT scan
-
6 factors in nec fasc LRINEC scoring system
- CRP
- WBC
- Hgb
- Sodium
- Creat
- Glucose
-
3 functions of lower sacral nerve roots (S2-5)
- Anal sphincter/voluntary contraction
- Bulbocavernosus reflex
- Perianal sensation
-
Denis classification of sacral fractures
Type 1 Fracture lateral to foramina
Type 2: fracture through foramina...highly unstable if shear component
Type 3: medial to sacral foramina: hihest rate of neuro injury >>bowel and bladdder dysfunction
-
Indication for ORIF of sacral fracture
Displacement >1cm
Decompression if evidenceof neuro injury
-
3 surgical techniques to deal with unstable sacral fractures
SI screw
Posterior tension band plating
Iliosacral and lumbopelvic fixatiob
-
5 causes of pediatric neonatal compartment syndrome
- Fetal posture
- Oligohydramnios
- Umbilical cord loops
- Amniotic band constriction
- Direct birth trauma
-
What compartments to release in forearm compartment syndrome
- Mobile wad: rarely involved (ECRL/ECRB /BR)
- Dorsal
- Volar
-
Compartments in the hand
- 10 total
- 4 dorsal interosseous
- 4 volar interosseus
- Thenar
- Hypothenar
-
forearm fasciotomy technique
2 incisions
Volar incision: Start medial epicondyle and jsut radial to FCU at the wrist + can extend to release carpal tunnel >>>open lacertus fibrosus and fascia over fcu then release fascia of deep compartment
Dorsal incision: lateral and distal to lat epicodnyle btw EDC and ECRB >>decompress mobile wad and dorsal compartemnt
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Describe hand fasciotomy
2 longitudinal incisions over 2nd and 4th metacarpals: dorsal and volar interossei and adductor compartment
Longitudinal incision radial side of 1st MC: decompress thenar
Longitudinal incision over ulnar aspect 5th MC:decompress hypothenar compartment
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SC dislocation: most common direction
More serious
- Anterior
- Posterior: mediastinal structures at risk
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SC joint: most important ligament for Superior displacement
AP displacement
- anterior SC ligament
- Posterior capsular ligament
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SC joint dislocation: what x ray to order
Serendipity view: 40 degree cephalad tilt
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SC joint dislocation: acute anterior <3 weeks
Posterior dislocation
Closed reduction: Abduct, extend, traction to arm and direct pressure over clavicle
Open reduction and reconstruction with thoracic surgery available
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Osteomyelitis: organism present in sickle cell
positive prognostic factor after treatment
- Staph a: but salmonella is classic for sickle cell
- Decrease in ESR: CRP decreases faster
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OSteomyelitis classification
- Stage 1: medullary
- Stage 2: Superficial
- Stage 3: Localized
- Stage 4: diffuse
Host
- Type a: normal
- Tyoe b: compromised
- Type c: treatment is worse than infection
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Popliteal artery: 2 sites of tethering in knee dislocation
- Proximal: fibrous tunnel at adductor hiatus
- DIstal: fibrous tunnel at soleus muscle
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knee dislocation: most common
Highest rate vascular injury
Highest rate peroneal njury
ROtational - what direction + classic finding
- anterior: hyperextension injury
- Posterior: also highest rate of complete transection
- Lateral: varus or valgus force
- Posterolateral: irreducible bc of buttonholing of femoral condyle through capsule
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Contraindication to closed reduction of knee dislocation
DImple sign: buttonholing femoral condyle in posterolateral rotatory dislocation
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