Trauma - Orthobullets

• Montegia
• Galeazzi

Restoration of radail bow

• Central band: key band to reconstruct
• Accessory band
• Distal oblique bundle
• Proximal oblique cord
• Dorsal oblique accessory cord

• Undisplaced BBFF
• DIstal 1/3 ulnar shaft with: <50% displacement and  <10 degrees angulation.

Henry

Thompson

BTW ECU/FCU

3.5 mm LCDP

• High energy crush
• Open Fx
• Low velocity GSW
• Vascular injuries
• COagulopathies

Long vs short arm: equivalent results

6 months: in conjunction with radiotherapy

• -30% within 1 year
• -Pre injury mobility

Renal failure 45% mortality at 2 years

• -130 degrees +/- 7
• -10 degrees +/- 7

• - Medial femoral circumflex: main > becomes lateral epiphyseal artery
• - Lateral femoral circumflex
• - Inferior gluteal
• - Ligamentum teres

• 1: valgus impacted
• 2: Complete undisplaced
• 3: Complete partially displaced
• 4: Complete fully displaced

• 1: < 30 degrees from horizontal
• 2: 30-50 degrees
• 3: >50 degrees (most unstable)

• -Garden 1: in elderly
• -Displaced femoral neck in young patient in conjunction with anatomic reduction

• -Basicervical
• -Femoral neck with vertical pattern in young patient > biomechanically stronger
• - Also DHS has less failure but more AVN

Within 4 days no difference in outcomes

• -Start above LT
• - Inverted triangle

5-7 times higher in THA in fracture setting

Valgus intertrochanteric osteotomy + blade plate

• 14 cm prox to lat epicondyle
• 20 cm prox to medial epicondyle

spiral fracture of the distal thrid humerus associated with radial nerve neuropraxia

• <20 degrees anterior angulation
• <30 degrees varus valgus
• < 3 cm shortening

• Severe soft tissue injoury or bone loss
• Vascular injury requiring repair
• Brachial plexus injury
• floating elbow
• open fracture
• compartment syndrome

• Bilateral humerus
• Polytrauma with lower extremity injury
• Pathologic #
• SOft tissue that precludes bracing
• Short oblique or transverse # patters

valgus:  typically fall into varus

• brachioradialis
• extensor indicis

• Radial nerve: lat to medial locking screw
• Musculocutaneus: AP screw

Oligotrophic

• Higher reoperation
• Higher impingement

10cm proximal to radiocapitallar joint: pierces intercompartmental fascia

Find posterior antebrachial cutaneous nerveradial nerve proximally

>8mm of calcar are attached to articular segement

Posterior humeral circumflex: Recent studies suggest it is the main supply

Anterior humeral circomflex: 2 branches >anterolateral ascending branch, arcuate artery.

Parallel to lateral aspect of long head of biceps in bicipetal groove

Considered a separate fragment if: displacement>1cm or angulation >45.

Parts: GT, LT< Shaft, articular surfaxce

Axillary nerve: up to 45%

• 4 part
• head split
• short calcar segments
• disrupted medial hinge

varus apex anterior

Pec major: should be 5.6 proximal to tendon

Axillary nerve

7 cm

screw penetration/cut off

30% within one year

• Male
• Intertroch: compared to FN
• Operative delay >2
• Age >85
• 2 or more pre existing conditions
• AASA III or IV

AP + lat <25mm

Traumatic axial loading

INversion and plantar flexion foot: avulsion of bifurcate ligament

Superomedial fragment: Includes sustentaculum tali. Stabilized by strong ligaments

Avulsion from contraction of gastrocs

• Vertebral fracture
• Extension into the CC joint: 60%
• Bilateral calc: 10%

• Posterior: Largest and major weight bearing
• Middle:Anterolateral. On sustentaculum tali
• Anterior: COnfluent with middle facet

FHL: runs inferior to post facet of calc. Can be irritated by long screws

• FHL
• Deltoid, talocalcaneal ligaments

In calcaneus: Connects dorsal anterior process to cuboid and navicular

• Anterior process: bifurcate lig avulsion
• Sustentaculum tali
• Calc tuberosity: achilles tendon avulsion

• -Essex lopressi: Tongue type, joint depression type
• - saunders: based on number of fracture lines seen at the widest point of the posterior facet

Primary fracture line goes from the posterior facet then

• -TOngue type: exits posteriorly
• -Joint depression: # exits behind posterior facet

• Visualize posterior facet
• Ankle neutral dorsiflexion: take x rays at 10-40 degrees of IR

• -See if varus/valgus/shortening
• -Foot maximal dorsiflexion and angle beam 45 degrees

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
• 

30 degree semicoronal

• -COmorbidities
• -Sanders I
• -extra articual fracture with<2mm dispalcement and intact achilles
• -Anterior process involving <25% CC joint

Wait 10-14 days for blisters to settle

• age>50
• Obesity
• Mabual laborer
• CSSR
• Smoker
• Bilateral cal
• Multiple trauma
• Vasculopathies
• Men do worse than women

Sanders 4: combined with ORIF to restore height

calc strss fracture

Subtalar distraction arthrodesis

• -decreased calc height
• -Decreased talocalcaneal angle
• -Decreased talar declination angle
• -COllapsed joint from VN

Clawing toes: contracture of intrinsic muscles

• Open
• DIabetic
• Smoker

• DRUJ
• Radial styloid
• TFCC
• Scapholunate: disi
• Lunotriquetral: visi

Depressed fracture of the lunate fossa

• 11mm: <5mm shortening
• 23 degrees: <5 degree change
• congrous: <3mm step off
• 11 degrees: dorsal angulation <5degrees or within 20 degrees of contralateral side

• EPL rupture
• Acute carpal tunnel

FPL: secondary to placing plate past the watershed area

transfer extensor indices to EPL

radioulnar ligaments of TFCC

• Jupiter: -Initial displacement
• -Age of patient
• -Metaphyseal comminution

No difference compared to home exercice program

• -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

• Decreases rate of:
• -CLosed head injuries
• -Facial fractures
• -Thoracoabdominal injuries
• Need fo rextration

• Airway: includes c spine
• Breathing
• Circulation: Includes hemorrage control and rescusitation
• Disability: GCS
• Exposure

Left lateral decubitus: limit positional hypotension

• I: FLuid
• II: FLuid
• III: FLuid + blood
• IV: FLuid + Blood

• 4.7-5L
• 75-80ml/kg

• 1:1:1
• Rbc:platelets:plasma

• 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

SVR in increased in hypovolemic and decreased in septic

• 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

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

• Compartment
• Fracture with vascular injury
• Unreduced dislocations
• Long bone fractures
• Unstable spine fractures
• Open fractures

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

-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

• -Syme: 15%
• -BKA: 25%
• -AKA: 68%
• -Through knee:most proximal level to maintain walking speed in children

• -Albumin >3
• -Ischemic index >0.5
• -Transcutaneous oxygen tension >30 mm hg
• -Toe pressure >40 mm hg
• -ABI > 0.45
• -Total lymphocyte count > 1500

• -Vascular
• -Soft tissue compromise
• -Malignant tumor
• -Infection
• -COngenital anomalies

12-15 cm below joint

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

• -Ankle disarticulation
• -Patent tib post
• -more energy efficient than midfoot amputation

• -Hindfoot amputation: through TN and CC joints.
• -Equinus deformity: do achilles lenghtening

-Bone overgrowth: Prevent by performing disarticulation or making an epiphyseal cap co cover medullary canal

• SI joint incongruity >1cm
• High degree initial diplacement
• Malunion
• LLD > 2cm
• Nonunion
• Neurologic injury
• Urethral injury

Anterior: Symphyseal (resist ER)

• Pelvic floor
• -Sacrospinous:Resist ER
• -Sacrotuberous: Resist shear

• Posterior
• -Ant sacroiliac
• -Post sacroiliac
• -Interosseaous sacroiliac
• -Iliolumbar

• -S1 overlaps S2 and scrum looks like bowtie
• -AP translation, widening symphysis, Widening SI

• -Pubic symphysis overlies S2 body
• -Vertical shear
• -Sacral fractures

-Young-burgess

• -APC 1-3
• -LC 1-3
• -Vertical shear

• 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
• -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

Vertical shear

-Venous plexus + cancellous bone

• Arterial
• -Sup gluteal (most common)
• -Internal pudendal
• Obturator

• Blood at the meatus
• high riding prostate
• hematuria

• Obturator oblique: Starting point
• Internal oblique: Aim above sciatic notch
• Obturator inlet oblique; Ensure btw ilium tables

L4-5 nerve roots

LFCN

• -Lower extremity injury #6 %
• -Nerve palsy (13%)
• -SPine injury (4%)

• -Head
• -CHest
• -Abdo
• -Genitourinary

• -Polytrauma
• -Older age
• -Poor articular congruity
• -Associated femoral head articular injury
• -Intraoperative complications

• -Quadrilateral plate
• -Posterior wall and dome
• -Ischial tuberosity
• -Greater and lesser sciatic notches

• -Anterior ilium
• -Anterior wall and dome
• -Iliopectineal emminence
• -LAteral superior pubic ramus

• Anastamosis of external iliac (epigastric) and internal iliac (obturator) Vessels
• -LAteral dissection over supeior pubic ramus

• -Post wall
• -Post column
• -Ant wall
• -Ant column
• -Transverse
• -ABC
• -Transverse + POst wall
• - T shaped
• -Ant column + POst hemitransverse
• -Post column + Post wall

POsterior wall fracture

ABC

• Obturator oblique: Ant column post wall
• Iliac Oblique: Post column ant wall

• Iliopectineal line: Ant column
• Ilioischial line: post column
• Ant wall
• POst wall
• Teardrop
• Sourcil
• Shenton's line

• -Define fracture stability
• -If >45 degrees on all views defined as stable
• -In ABC

• <20% posterior wall involvement
• EUA to define stability look for medial clear space widening

• -Displacement roof >2mm
• -UNstable # pattern (post wall >20 %)
• -Marginal impaction
• -Loose bodies
• Irreducible fracture dislocation

better outcome if <12hrs

• Worse outcome if >3weeks
• Earlier operative time increases chances of anatomic reduction

Ensure supra-acetabular screw between tables of ilium

Position of Screw within pubic ramus

• -Ilioinguinal
• -Ilioinguinal
• -Kocher
• -Ilioinguinal
• -KOcher
• -Kocher

• Femoral nerve injury
• LFCN injury
• Thrombosis femoral vessels
• Laceration corona mortis

• Increased risk HO
• Sciatic nerve injury
• Damage to medial femoral circumflex ( AVN )

• Usually for POst approach
• -Indomethacin 70mg po qd x 5 weeks
• -Low dose external radiation
• No difference between both

Obturator oblique

• -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

• -Concave + distal to lat plateau
• -Convex + proximal to med plateau

• I: LAteral split
• II: LAt split/depression
• III: Lat pure depression
• IV: Medial plateau
• V: Bicondylar
• VI: Met-dia dissociation

• -Min displaced split or depressed #
• -Low energy, stable varus/valgus alignment
• -Non ambulatory patients

• -Articular step off >3mm
• -COndylar widening >5mm
• -Varus/valgus instability
• -Medial plateau #
• -Bicondylar #

-Restoration of joint stability

• -Ligamentous instability
• -Meniscectomy
• -Alteration mechanical axis >5 degrees

Pes anserinum and medial head of gastrocs

• -Joint depression > 6mm
• -Joint widening >5mm

Reconstruction better than repair

Calcium phosphate cement

• - Ipsilateral: Femoral neck (basicervical,verical,undisplaced)
• -Bilateral femur #: Increased risk pulm complications/mortality

• -Anterior: Sartorius + Quads
• -Posterior: Biceps femoris + SemiT + Semi M
• -Adductor: Gracilis + adductor brevis/longus/magnus

• Proximal fragment
• -Abducted: glut med/min
• -Flexed: iliopsoas

• Distal fragment
• -Varus (adductors)
• -Extension (gastrocs)

1-1.5L

• -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

• -Ipsilateral Tibial plateau/shaft
• -Morbid obesity
• -Ipsilateral acetabular #
• -Bilateral femur #
• -Polytrauma
• -Ipsilateral femoral neck #

-Colinear with femoral shaft

• -More difficult
• -Damage abductors
• -AVN in younger patients

Reamed: No increase in pulm complications, increased union rates, decreased time to union

Unreamed: Consider in patients with bilateral pulmonary injuries

• -Center intercondylar notch on AP
• -Extension blumensat line on lateral: if posterior can injury cruciate ligaments

• -Priority to femoral neck > avoid AVN
• -Screws for neck + retrograde nail
• -Screws for neck + plate for shaft
• -DHS + retrograde nail

• -use of nsaids
• -smoking

-<10%

-Exchange reamed nail

A/P proximal locking below the LT

Reamed higher union

• >6mm
• >1mm

<4mm

• <5mm
• measured 1 cm above from joint line

8-15 degrees

• Supination - Adduction
• Supination ER
• Pronation Abduction
• Pronation ER
• 

• -Talofibular sprain or Distal fibular avulsion
• -Vertical medial mall + impaction anteromedial distal tibia

• -ATFL sprain
• -Lateral short oblique fibula fracture
• -PTFL rupture or avulsion
• -Medial mall transverse # or deltoid disruption

• -Medial mall transverse # or deltoid disruption
• -ATFL sprain
• -Transverse or comminuted fibula # above level of syndesmosis

• -Medial mall # or deltoid disruption
• -ATFL disruption
• -Lateral mall short oblique or transverse # above level syndesmosis
• -PTFL rupture or avulsion post mall

POsterior dislocation of fibula behind incisura fibularis

• -Isolated undisplaced medial mall #
• -Isolated lat mall # with <3mm displacement and no talar shift
• -Post mall # with <24% joint involvement and < 2mm step off

• -Talar displacement
• -Displaced medial mal
• -Displaced lat mal >3mm
• -Bimalleolar
• -Post mall >2mm step or >25% involvement
• -Open #
• -Bosworth #

• -Increased age
• -Medial mall #
• -Smoking
• -Decreased education
• -EtOH

Restoration of anteromedial marginal impaction leads to better outcome

• -9 weeks after ORIF> return of braking time
• -6 weeks after start of weight bearing for periarticular/long bone fractures

• -Undisplaced or tip avulsion: symptomatic treatment
• -Displaced/talar shift
• -ORIF:lag screw, antiglide plate, tension band

• -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

Restoration of syndesmosis strength to 70% vs 40% for syndesmosis fixation.

Intra op abduction-ER stress on dorsiflexed foot

• -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.

• -Prolonged healing
• -Hardware infection
• -Hardware failure

• -Quadricortical screws
• -Intramedullary k wire in fibula
• -Locked plate

A to P

• -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

• -Unacceptable alignment
• -Soft tissue injury not conductive to casting
• -Segmental #
• -Comminuted #
• -Floating knee
• -Bilateral tibia #
• -Morbid obesity
• -Polytrauma

• TKA or previous ORIF
• Pre existing tibial deformity

• SPRINT trial
• -Reamed superior in closed # for need of future grafting/implant exchange

recent studies > no adverse effects of remed

• -Equivalent time to union
• -Greater radiation exposure
• -Longer surgical duration
• -Lower post op pain scores
• -More difficult HWR

• Gapping at # site
• Transverse #
• Open #

• Femoral distractor
• Unicortical plate
• Blocking screws
• Clamps
• External fixator

• 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

Increased post op pulmonary complications

Shaft with intact fibula

Weak EHL

around hole 11-13

• Valgus 
• Procarvatum: apex anterior

• Patellar tendon: Procarvatum
• Hamstring: Distal fragment into flexion
• Pes Anserinum: Proximal fragment into Varus

• < 5 degrees varus valgus
• <10 degrees sagital angulation
• >50% cortical apposition
• <1 cm shortening
• <10 degrees rotation

Semiextended position:suprapatellar

• Proximal to anterior margin of articular surface
• Medial to lateral tibial spine

Poller screws: Posterior > prevents procarvatum. Lateral concave side > prevent valgus

Unicortical plating

Femoral distractor

Nail in semiextended position

• Medial malleolar (deltoid)
• Postrolateral: Volkman > PITFL
• Anterolateral: Chaput > AITFL

• Lower level education
• Pre existing comorbidities
• Male
• WOrk related
• Lower income

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

• Tibial:medial
• Peroneal: lateral

Temporizing ex-fix for 10-14 days

A frame: 2 tibial pins and one trans calc pin

Area 5 cm below LT

• Abduction: GLut med/min
• Flex: Iliopsoas
• ER: Short ER

• 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

• 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

Varus and procarvatum

• Anterior: Tib. ant, EHL, EDL, peroneus tertius.
• Lateral: Peroneal brevis/longus
• Deep post: Tib post, FDL, FFHL, 
• Sup. post: Gastrocs, soleus, plantaris

• WIthin 5 cm fracture site
• Diastolic differential pressure <30

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

common peroneal N

Distal femur coronal plane fracture: 38% in Type C #'s

4 cm intact distal femur: classically used for extra articular, non comminuted.

Anterolateral: Incision from TT to anterior 1/3 distal femoral condyle

19%: in metaphyseal area

AP knee with leg in 30 degrees IR

• Neurotoxicity
• Anemia
• Emesis
• Abdominal Colic

• <2000 ft/sec
• 1-2
• Shot gun, hand gun

• >2000 ft/sc
• 3 regardless of size
• Assault rifle/hunting rifle

• SPine#
• Pelvic #

• Articular involvement
• presentation >8 hrs
• Unstable #
• Tendon involvement
• Superficial fragment in palm or sole

Motor weakness with retained fragemnt in the spinal canal

• Increasing age
• Functional disability
• Child abuse within regional population
• Cognitive impairement

• Substance abuse
• Financial dependence on abuse
• Perceiving the caretaker as a burden

• Unexplained injuries
• Delays in seeking care
• Repeated fractures/burns
• Change in behaviour
• Poor hygene

• Female
• 19-29
• Low SES
• Pregnant

Axial load with elbow flexed >90 degrees

Anterior bundle of elbow MCL

Elbow MCL

LCL

Milch

• Type 1: Lateral trochlear ridge intact
• Type 2: # through lateral ridge of trochlea
• 

• Olecranon osteotomy
• Tricep split
• Tricep sparing

Identify ulnar nerve up to first motor branch to ECU.

Elevate triceps from posterior aspect of elbow

elevate posterior bannd of MCL

Identify radial nerve proper: if fracture mid/distal

Locate bare area of sigmoid notch.

Make chevron: apex distal.

First fix articular component then build to medial/lateral column

2 orthogonal plates

2 parallel plates

Splint to 70 degrees

Remove splint at 1 week

Begin ROM: AROM+AAROM, no PROM

Strenghtening at 6 weeks

Do not use: has been shown to increase the rate of no union

Cubitus valgus: lateral column fractures

Cubitus varus: medial column fractures

Distal humerus capitellar shear fracture

decreased ROM

SCM: Pulls medial fragment superiorly

Pec major: Pulls distal fragment inferiorly

• AC ligament: Strongest is superior ligament
• CC ligaments: trapezoid, conoid. Conoid is strongest
• Capsule

• Deltoid
• Trapezius

For clavicle #

15 degree cephalic tilt: determine sup/inf displacement

• Open 
• Skin tenting
• Vascular injury
• Floating shoulder
• Symptomatic malunion
• Symptomatic non union

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

• Sling
• Start ROm 2 weeks
• Strenghtening 6 weeks

• Direct blow: Comminuted #
• Indirect: FOOSH, transverse/oblique #

• Tension band: transverse
• Plate: COmminuted, oblique fractures
• Excisision + tricep advancement: Elderly patients. Fracture involves < 50% joint surface

AIN

Forced dorsiflexion with axial load

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

Hawkins

• I: Non displaced > 0-10%
• II:Subtalar dislocation> 25-50%
• III: Subtalar and tibiotalar > 20-100
• IV: ST + TT + TN > 70-100%

-View of talar neck

-Maximus equinus, 15 degrees pronation, x ray 75 degree from horizontal

Replaced and treated with ORIF

• Post traumatic OA
• Mal-union
• Non-union
• Infection
• Wond dehiscence

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

Subchondral lucency best seen in mortice view at 6-8 weeks

Indicates intact vascularity: resorption of subchondral bone

Varus: medial opening wedge osteotomy

Leads to Decreased subtalar eversion> weight bearing on lateral border of foot.

Eversion

FOOSH: elbow in extension and forearm pronation

LUCL

• LUCL
• Radial collateral ligament
• Accesory lateral collateral ligament
• Annular ligament

• Anterior: primary stabilizer to valgus stress
• Posterior
• Transverse

Valgus: Secondary restraint to valgus

Longitudinal: Restraint to proximal migration of the radius

Mason

• I: non diplaced, displacement <2mm
• II: Displaced > 2mm or angulated.
• III: Comminuted and displaced > mechanical block
• IV: Associated with elbow dislocatio

• Mason II with block to motion
• Mason III when ORIF feasable
• Presence of other complex elbow injuries

>3 fragments

Mason type 3 with >3 fragments where ORIF not possible

Elbow # dislocations/essex lopresti lesion

Better outcome with arthroplasty: stability, patient ssatisfaction

Low demand patient

In delayed setting to treat persistent pain

Muscle substance of supinator: 4 cm distal to radial head

Forearm pronation during lateral approach to elbow

• ECU (pin)
• Anconeus (radial)

• EDC: pin
• ECRB: radial

• Kocher: less risk of PIN/radial n. injury. More risk damaging LUCL
• Kaplan: More risk nerve injury, less risk damaging LUCL

Safe zone: radial styloid to lister's tubercle with arm in neutral rotation.

Bicepetal tuberosity: is distal limit of plate placement

• Elbow dislocation
• Radial head/neck fracture
• Coronoid fracture

POsterior subluxation beyond 30 deg of flexion

Anterior band of MCL

Usually from distal humerus

Not necessary

Only address if: instability persisting after addressing radial head/LCL complex > MCL repair > coronoid

• In pronation/flexion: MCL intact
• In supination/flexion: Injured MCL > avoid medial gapping from overtightening.

Persistent instability following LCL +  fracture fixation

Posterolateral: 80%

Lateral to medial

LCL > MCL

• Ulnohumeral joint
• Anterior bundle MCL
• LCL complex

• Radiocapitellar joint
• Joint capsule
• Origins of common flexor/extensor tendons

• Anconeus
• Brachialis
• Triceps

LCL injury + fracture to anteromedial facet of coronoid

C5-C6:Upper trunk

C8-T1

Caudally forced shoulder

Forced arm abduction

1mm/day

Root avulsion: preganglionic

Avulsion proximal to dorsal root ganglion: Involves CNS which does not regenerate. Worse prognosis

• Horner syndrome: sympathetic chain disruption
• Winged scapula: Loss of serratus anterior(long thoracic), rhomboids (dorsal scapular)

• Shoulder: Adduction,, IR
• Elbow: Pronated, extended

• Drooping left eyelid
• Pupillary constriction
• Anhidrosis

C8-T1

• Pseudomeningocele
• Empty nerve root sleeves
• Cord shifts away from midline

Posterolateral

inferior pole

• Intact extensor mechanism
• Non displaced #
• Vertical fracture pattern

Severly comminuted inferior ple fractue not amenable to ORIF

Low flow with saline better than the rest

• 1-2: 1st generation cephalosporin. Clinda or vanco if allergy
• 3: 1st generation cephalosporin + aminoglycoside

Toxoid: 0.5ml. If not updated within 5 years

• Immunoglobulin: 
• - <5 75U
• - 5-10 125U
• - >10 250 units

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

• Dyspnea
• fever
• mottled or cyanotic skin

• MIld: PaO2/FiO2 ratio <300
• Moderate: PaO2/FiO2 ratio <200
• Severe: PaO2/FiO2 ratio <100

Supportive: oxygenation using PEEP

Early stabilization of femur fractures

Forced dorsiflexion , axial loading, inversion and external rotation: snowboarders

NOne

• Navicular and sustentaculum tali
• Posterior facet calc and lateral mal

Consists of medial and lateral tubercle separated by groove for FHL

• Type 1: Do not involve articular surface
• Type 2: INvolve the subtalar and tibiotalar joints
• Type 3: have comminution

• Avulsion of posterior deltoid
• Avulsion posterior talofibular ligament

• DIsplacement >2mm
• Lateral process: lateral approach over sinus tarsi reflecting edb distally
• Boyd: combined medial and lateral approach

Lateral talocalcaneal ligament incompetence: does not lead to ankle instability

• High pauwels angle: type 3 > 70
• Garden IV
• Posterior comminution

If no OA can revise with valgus intertrochanteric  osteotomy to make orientation of fracture more horizontal

• 3-4 part
• Humeral head split
• Displaced tuberosity #

• 30 degree retroverted
• 130-140 degrees
• 6mm inferior to upper edge of humeral head

• 3cm from end of clavicle: lateral
• 4,5 cm from the end of the clavicle: medial

Type 1: lateral to CC ligament ....CC ligaments intact >>>non op

• Type 2A
• Fracture 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 3
• Intraarticular extending to AC joint
• Ligaments intact
• Stable
• Non op

• Type 4
• Physeal fracture in skeletally immature
• Ligaments intact
• Stable
• Non op

• Type 5
• COmminuted
• Ligaments intact
• Significant medial clavicle displacement
• ORIF

• Open
• SUbclavian artery or vein injury
• FLouating shoulder: associated scapula  neck #

5-15

• Extracapsular arterial ring: medial femoral circumflex is main contributor
• Ascending femoral branches
• Artery to the ligamentum teres: from obturator of MFCA

• Type 1: infrafoveal
• Type 2: suprafoveal
• Type 3: associated FN #
• Type 4: Associated with acetabular #

• Pipkin 1
• Pipkin 2 with < 1mm step off

• No interposed fragments
• Stable hip joint

• Pipkin 2 >1mm step
• Loose bodies
• Associated acetabular or femoral neck #
• Pipkin 4
• Irreducible # dislocation

• Anterior smith pete or watson jones
• Kocher langenbeck to fix acetabular #

• HO: most common
• AVN
• Sciatic nerve neuropraxia: usually peroneal division
• OA

• 1st generation cephalosporin
• 1st generation cephalosporin + aminoglycoside (gram -ve coverage)
• Penicillin G: farm injury
• FLuoroquinilone: can be used if allergic to clinda or cephalosporin

• Lateral traction to shoulder girdle
• Subclavian artery
• 10%
• Edge of scapula >1cm from spinous process as compared to contralateral side
• Degree of neurologic compromise

18mm from tip

• 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 #

Tip: less than or greater than 2 mm coronoid height

Anteromedial facet

• Anteromedal rim
• Anteromedial rim and tip
• Anteromedial rim and sublime tubercle

• Basal
• Coronoid body and base
• Transolecranon basal coronoid #

• Isolate and protect ulnar nerve
• BTW 2 heads of FCU

Body and spine (50%)

• Type 1: proximal to CC ligaments
• Type 2: distal to CC ligaments

• Type 1: undispalced
• Type 2: Displaced but does not compromise subacromial space
• Type 3: Displaced and compromises subacromial space

• > 25% articular surface glenoid involvement and humerus subluxation
• Scapular neck displaced: >40 degrees angulation or 1 cm translation
• Open #
• coracoid # with >1cm displacement

SUprascapular (infraspinatus) and teres minor (axillary

• LCL
• Radial head

• 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

• Displacement >2mm
• Type 4: mckee double arc sign because it involves the trochlea

Lateral column approach

• Staph aureus
• Knee > hip > shoulder

• Can start within 8 hours
• Release of proteolytic enzymes from PMN's

• Bacteremia
• Diret inoculation from traumaor surgery
• Contiguous spread from adjacent osteomyelitis

Neisseria Gonorrhea

Follow CRP: normalizes within one week of treatment

exopolysaccharide glycocalx

Involucrum: reactive bone surrounding active infection

Sequestrum: retained nidus of infected necrotic bone

SI fracture dislocation: posterior ilium remains attached to sacrum by posterior ligaments, anterior ilium dislocates with an internal rotation deformity

LC-2

• sacrospinous
• sacrotuberous
• anterior sacroiliac
• posterior sacroiliac

L5 nerve root on sacral ala

Score 7 or higher

• Distal 1/3 radius fracture and druj injury
• Fracture < 7.5 mm away from joint: unstable druj 55%...if >7.5 cm>>unstable 6%

• Ulnar styloid #
• WIdening of druj on AP
• dorsal or volar displacement on lateral x ray
• Radial shortening > 5mm

ECU tendon

Proximal 1/3 uln fracture and radial head dislocation

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

PIN

• In supination: if lateral or anterior dislocation
• In pronation: if posterior dislocation

Annular ligament: especially in type 3

• Medial: 65-80 %
• lateral

• Dorsomedial talar head
• Posterior process oftalus
• navicular

• Cuboid
• Anterior calc
• lateral process talus
• Fibula

• Locked in supination
• Locked in pronation

Medial dislocation if talar headis superior to navicular

Lateral dislocationif talar head colinear or inferior to navicular

• Peroneal tendons
• EDB
• TN capsule

• Tib post
• FHL
• FDL

Ipsilateral femoral neck fracture

CT scan

• CRP
• WBC
• Hgb
• Sodium
• Creat
• Glucose

• Anal sphincter/voluntary contraction
• Bulbocavernosus reflex
• Perianal sensation

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

Displacement >1cm

Decompression if evidenceof neuro injury

SI screw

Posterior tension band plating

Iliosacral and lumbopelvic fixatiob

• Fetal posture
• Oligohydramnios
• Umbilical cord loops
• Amniotic band constriction
• Direct birth trauma

• Mobile wad: rarely involved (ECRL/ECRB /BR)
• Dorsal
• Volar

• 10 total
• 4 dorsal interosseous
• 4 volar interosseus
• Thenar
• Hypothenar

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

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

• Anterior
• Posterior: mediastinal structures at risk

• anterior SC ligament
• Posterior capsular ligament

Serendipity view: 40 degree cephalad tilt

Closed reduction: Abduct, extend, traction to arm and direct pressure over clavicle

Open reduction and reconstruction with thoracic surgery available

• Staph a: but salmonella is classic for sickle cell
• Decrease in ESR: CRP decreases faster

• 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

• Proximal: fibrous tunnel at adductor hiatus
• DIstal: fibrous tunnel at soleus muscle

• 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

DImple sign: buttonholing femoral condyle in posterolateral rotatory dislocation