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Flashcards in Goldenstien Trauma List 10 Deck (41)
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1

Indications for surgical treatment of tibial plateau fractures (7)

  1. Open fracture
  2. Vascular injury
  3. Compartment syndrome
  4. Articular step/gap > 3 mm
  5. Varus/valgus instability ≥ 10° compared to the contralateral knee
  6. Condylar widening > 5 mm
  7. Any medial plateau injury

2

Tibial plateau fracture complications (12)

  1. Arthritis
  2. Loss of meniscal tissue
  3. Stiffness
  4. Compartment syndrome
  5. Peroneal nerve injury (type IV)
  6. Popliteal artery injury (type IV)
  7. Venous thromboembolism
  8. Infection
  9. Wound dehiscence/skin slough
  10. Malunion
  11. Nonunion
  12. Knee ligamentous instability

3

Injuries associated with tibial shaft fractures (5)

  1. Head/chest/abdominal injuries
  2. Ipsilateral femur fracture
  3. Ipsilateral knee ligament injury
  4. Neurovascular injury
  5. Ipsilateral fibula fracture

(Proximal → distal)

4

Indications for surgical treatment of tibial shaft fractures (16)

  1. > 10° sagittal plane angulation
  2. > 5° coronal plane angulation
  3. > 1 cm shortening
  4. >10 degree rotational malalignment
  5. Transverse/oblique fractures of the middle 1/3
  6. < 50% cortical apposition
  7. Tibia fracture with intact fibula
  8. Tibia/fibula fracture at the same level
  9. Segmental fracture
  10. Open fracture
  11. Compartment syndrome
  12. Vascular injury
  13. “Floating” knee
  14. Knee ligamentous injury
  15. Polytrauma
  16. Pathologic fracture

5

Goals of surgical treatment of tibial shaft fractures (5)

  1. Timely wound coverage/closure
  2. Prevention of infection
  3. Restoration of limb length, alignment, rotation and stability
  4. Fracture healing
  5. Return of function

6

Steps of nonoperative management of tibial shaft fractures (4)

  1. Long-leg cast with knee in 15° of flexion
  2. Non-weight bearing until soft callus forms (XR, no pain on palpation)
  3. Switch to PTB cast or fracture brace with progressive WB and PT
  4. Discontinue immobilization when clinical and radiographic healing

7

Principles of surgical treatment of tibial shaft fractures (5)

  1. Aggressive management of open injuries
  2. Early soft tissue coverage
  3. Restore limb length, alignment and rotation
  4. Stable internal fixation
  5. Early knee and ankle ROM

8

Principles of plate fixation of tibial shaft fractures (5)

  1. Avoid disruption of fracture hematoma/remaining soft tissues
  2. Proper plate contouring
  3. Use of large fragment hardware
  4. 8 cortices on each side of the fracture
  5. Lag screws for interfragmentary compression only if placed with minimal soft tissue disruption

9

Advantages of nail fixation over plate fixation/ex-fix of tibial shaft fractures (5)

  1. Decreased time to union (both – closed #)
  2. Increased union rate (both – closed #)
  3. Decreased malalignment (ex-fix)
  4. Decreased secondary surgeries (ex-fix)
  5. Shorter time to weight bearing (ex-fix)
  6. Improved functional outcome (ex-fix)
  7. Shorter hospital stay (ex-fix)

10

Methods to avoid valgus/procurvatum deformity in IM nailing of proximal 1/3 tibial shaft fractures (5)

  1. Posterior and lateral blocking screws
  2. Lateral start point
  3. Nailing in extension
  4. Suprapatellar nailing
  5. Unicortical plating

11

 Indications for amputation with tibial shaft fractures (9)

  1. Limb is a threat to patient’s life
  2. Non-viable limb
  3. Irreparable vascular injury
  4. Warm ischemia time > 6 hours
  5. Severe crush with minimal viable soft tissue
  6. Irreparable ipsilateral foot trauma
  7. Reconstruction demands incompatible with patient’s personal/sociologic/economic needs
  8. Salvage may precipitate MOSF/ARDS
  9. Segmental tibial loss > 8 cm

12

Complications of tibial shaft fractures

  1. Anterior knee pain (30 - 50% resolve with hardware removal)
  2. Compartment syndrome (5%)
  3. Infection (deep 1% closed, 25-50% IIIB)
  4. Vascular injury
  5. Malunion
  6. Nonunion
  7. Wound healing complications
  8. Delayed union

13

Risk factors for delayed union/nonunion of tibial shaft fractures (3)

  1. Mid-third fractures
  2. Greater initial displacement
  3. Intact/rapidly healed fibula
  4. Open fracture
  5. Opening the fracture site at surgery
  6. Medical comorbidities
  7. Smoking

14

Risk factors for infection in tibial shaft fractures

  1. Open fracture
  2. Delayed soft tissue coverage (> 7-10 days)

15

Risk factors for malunion of tibial shaft fractures (6)

  1. Shorting
  2. Same level fibula fracture
  3. Comminution
  4. Intact fibula
  5. Proximal fracture
  6. Distal fracture

16

Options for soft tissue coverage of open tibial fractures (7)

- Local rotational flaps

  1. o Gastrocnemius (proximal)
  2. o Soleus (mid-1/3)
  3. o Peroneals (mid-1/3)

- Free tissue transfer

  1. o Fasciocutaneous flaps (ALT, volar forearm, lateral arm)
  2. o Myofasciocutaneous flaps (rectus abdominus, latissimus dorsi)
  3. o Free muscle flaps followed by split-thickness skin grafting
  4. o Osteocutaneous flaps (iliac crest, vascularized fibula)

17

Classification of tibial plafond fractures 

Ruedi and Allgower Classification

Type I: Nondisplaced

Type II: Simple displacement with incongruous joint

Type III: Comminuted articular surface

18

Tibial plafond fractures associated injuries (5)

  1. Other axial and lower limb skeletal injuries
  2. Soft tissue injuries
  3. Compartment syndrome
  4. Neurovascular injuries
  5. Head/chest/abdominal injuries

19

Classic AO principles of treatment of tibial plafond fractures (Ruedi & Allgower) (4)

  1. Reconstruct the fibula to restore length
  2. Reconstruct the tibial articular surface
  3. Perform cancellous bone grafting of the distal tibial metaphysis
  4. Stabilize the medial column of the tibia

20

Complications of tibial plafond fractures (7)

  1. Ankle stiffness (50%)
  2. Post-traumatic arthritis
  3. Wound healing complications/skin slough (10%)
  4. Deep/superficial infection
  5. Malunion (varus)
  6. Non-union
  7. Chronic edema

21

Ankle fracture classification (Danis-Weber) (3)

A – fibula fracture below the mortise (SAD)

B – fibula fracture at the mortise (SER/PAB)

C – fibula fracture above the mortise (PER)

22

Ankle fracture classification (Lauge-Hansen) (4)

  1. Supination-adduction: low transverse lateral malleolus and vertical medial malleolus (A)
  2. Supination-external rotation: oblique/spiral fibula and transverse medial malleolus (B)
  3. Pronation-abduction: transverse fibula and transverse medial malleolus (B)
  4. Pronation-external rotation: fibula above mortise (C)

23

Classification of posterior malleolus fractures (3)

Type I: posterolateral oblique

Type II: medial extension

Type III: posterior shell

24

Ankle fractures associated injuries (3)

  1. Peroneal tendon injury
  2. Osteochondral lesions of the talus
  3. Deltoid ligament injury
  4. Foot fractures

25

XR findings suggestive of a deltoid ligament injury (3)

  1. Medial clear space > 4 mm
  2. Medial clear space > 1 mm larger than superior clear space
  3. Late talar subluxation

26

Clinical findings unreliable in diagnosing deltoid ligament injury (3)

  1. Medial ankle tenderness
  2. Ecchymosis
  3. Medial ankle swelling

27

Indications for surgical treatment of ankle fractures (6)

  1. Open fracture
  2. Displaced bimalleolar and trimalleolar fractures
  3. Displaced isolated medial malleolus
  4. Displaced lateral malleolus (> 3 mm short) with evidence of deltoid injury
  5. Posterior malleolus fracture > 25% (with instability)
  6. Syndesmotic disruption

28

 Complications of ankle fractures (10)

  1. Post-traumatic arthritis
  2. Soft tissue problems/skin slough (5%)
  3. Infection
  4. Superficial peroneal nerve injury
  5. Delayed union
  6. Malunion
  7. Non-union
  8. CRPS
  9. Stiffness
  10. Loss of reduction

29

Talar neck fracture classification (Hawkin’s) (4)

Type 1: non-displaced

Type 2: subtalar dislocation

Type 3: subtalar and tibiotalar dislocation

Type 4: subtalar, tibiotalar and talonavicular dislocation

30

Complications of talar neck fractures (7)

  1. Osteonecrosis
  2. Post-traumatic arthritis
  3. Malunion (varus)
  4. Skin necrosis
  5. Infection
  6. Delayed union
  7. Non-union