Goldenstien Trauma List 7 Flashcards Preview

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Flashcards in Goldenstien Trauma List 7 Deck (41)
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1

 Principles of flexor tendon reconstruction

- Stage I

o Excise tendon remnants

o Pulley reconstruction

o Silicone rod placement (secure distally)

o Aggressive passive ROM

- Stage II (3 months)

o Remove silicone rod

o Tendon graft secured distally

o Bring through pulleys

o Tension and secure

o Rehabilitation

o Delayed tenolysis as needed

2

Blocks to successful closed reduction of DIP dorsal dislocations 

  1. Volar plate
  2. Flexor digitorum profundus
  3. Osteochondral fracture fragment
  4. Sesamoid bone

3

Indications for surgical treatment of PIP collateral ligament injuries

  1. Radiographic evidence of soft tissue interposition
  2. Displaced Condylar fracture
  3. Continued instability after 3 weeks of static splinting

4

Classification of PIP dorsal fracture-dislocations

- Acute

o Type I: < 30% (stable)

o Type II: 30-50% (tenuous)

o Type III: > 50% (unstable)

- Chronic

5

Indications for surgical treatment of dorsal PIP dislocations 

  1. Open injury
  2. Irreducible dislocation
  3. > 40% joint involved and unstable
  4. highly comminuted "pilon" fracture-dislocations
  5. chronic injuries

6

Complications of dorsal PIP dislocations 

  1. Flexion contracture
  2. Pseudoboutonniere deformity
  3. Hyperextension instability

7

Complications of volar PIP dislocations 

  1. Extension contracture
  2. Progressive boutonniere deformity
  3. Global instability

8

Classification of dorsal MCP dislocations 

- Simple

  1. o “no table” test
  2. o Angular deformity
  3. o Reduced in flexion

- Complex

  1. o Shortening with minimal angular deformity
  2. o MC head caught between flexor tendon/lumbrical and natatory band/intermetacarpal ligaments
  3. o Irreducible

9

Indications for MCP collateral ligament injury

- Thumb ulnar

o Complete tear

o Partial tear with ≥ 35° of opening

o Displaced fragment with a Stener’s lesion

- Thumb radial

o Complete tear

o Partial tear with instability/volar subluxation of phalanx

- Finger

o Fracture ≥ 20% of articular surface or 2 mm of displacement

o Index or 5th digit RCL

10

Complications of thumb UCL injury 

  1. Residual instability
  2. Pain
  3. Reduced lateral key-pinch strength
  4. Volar subluxation of the MCP joint
  5. Post-traumatic arthritis

11

Indications for operative treatment of metacarpal and phalangeal fractures 

- Unstable fractures

- Irreducible fractures

- Malrotation

- Intraarticular fractures

- Open fractures

- Segmental bone loss

- Multiple fractures

- Fracture with associated soft tissue injury

- Polytrauma patients

12

Phalangeal fracture complications 

- Loss of motion

- Malunion

- Infection

- Nonunion

- Symptomatic hardware

13

Indications for surgical treatment of metacarpal neck fractures

- > 40° angulation

- < 40° angulation with unacceptable cosmetic deformity

- > 15° angulation of 2nd/3rd MC neck

14

Indications for surgical treatment of metacarpal shaft fractures 

- Malrotation

- Dorsal angulation > 10° (2 or 3) or > 20° (4 or 5)

- Shortening > 3 mm

- Multiple displaced metacarpal shaft fractures

15

Complications of metacarpal shaft fractures

- Malunion

- Nonunion

- MCP joint contractures

- Extrinsic tightness

- Refracture

16

Predictors of poor prognosis following hand fracture fixation

- Open fractures

- Intraarticular fractures

- Associated nerve injury

- Associated tendon injury

- Crush injury

17

Classification of 4th/5th CMC (hamatometacarpal) fracture-dislocations (Cain) 

- Type IA: ligamentous injury

- Type IB: dorsal hamate fracture (#1)

- Type II: comminuted dorsal hamate fracture

- Type III: coronal hamate fracture

18

Complications of CMC dislocations 

- Incomplete reduction

- Instability

- Chronic pain

- Weakness

- Post-traumatic arthritis

19

Classification of thumb metacarpal base fractures (4)

- Bennett’s – partial articular fracture (#1)

- Rolando’s – complete articular with 3 fragments

- Epibasal – extraarticular

- Comminuted

20

Indications for surgical treatment of thumb metacarpal base fractures (2)

- Articular incongruity ≥ 2 mm

- CMC joint subluxation/instability

21

Complications of thumb metacarpal base fractures (7)

- Weak lateral key pinch

- Difficulty with opposition

- Stiffness

- Post-traumatic arthritis

- Instability

- Malunion

- Nonunion

22

Pelvis fracture classification (Young & Burgess) (8)

- Anterior-posterior compression

  1. o APC I: symphysis widened up to 2 cm, SI ligaments intact
  2. o APC II: symphysis widened > 2 cm, anterior SI/sacrotuberous ligaments disrupted
  3. o APC III: symphysis widened > 5 cm, posterior SI/sacrospinous ligaments disrupted

- Lateral compression

  1. o LC I: anterior ring injury with ipsilateral sacral crush
  2. o LC II: anterior ring injury with ipsilateral “crescent” fracture
  3. o LC III: windswept pelvis (LCI with contralateral open book injury)

- Vertical shear

- Combined mechanism

23

Pelvis fracture classification (Tile) (11)

- Type A: stable

o 1 – avulsion fracture with intact ring

o 2 – nondisplaced pelvic ring injury

o 3 – transverse fracture of sacrum/coccyx

- Type B: rotationally unstable, vertically stable

o 1 – anterior-posterior compression

 1: symphysis < 2.5 cm

 2: symphysis > 2.5 cm, unilateral posterior injury

 3: symphysis > 2.5 cm, bilateral posterior injury

o 2 – lateral compression with ipsilateral posterior crush

o 3 – lateral compression with contralateral posterior opening

- Type C: rotationally and vertically unstable

o 1 – ipsilateral anterior and posterior injuries

o 2 – bilateral hemipelvic disruption

o 3 – any pelvic fracture with an associated acetabular fracture

24

Correlates of pelvic fracture mechanism of injury (5)

- Fluid resuscitation requirements

- Associated organ injuries

- Energy transmission

- Need for acute pelvic stabilization

- Patient survival

25

Pelvic fracture associated injuries (9)

- Closed head injuries (LC)

- Chest/abdominal trauma (APC)

- Bowel injury (LCIII)

- Urogenital injury (10%)

- Lumbosacral plexus injury (10%)

- Musculoskeletal injuries (60-80%)

- Hemorrhage (75% - APC II/III)

- Open fractures

- Death (LCIII, APC II/III, open)

- (Proximal → distal)

26

Signs of a urethral injury (7)

- Scrotal/labial swelling or ecchymosis

- Blood at the urethral meatus

- High-riding/mobile prostate

- Inability to void despite a full bladder

- Elevated bladder on IVP

- Dye leakage on IVP/retrograde urethrogram

- Inability to pass a foley catheter

27

Options for treatment of hemorrhage associated with pelvic fracture (4)

- Pelvic binder application

- External fixation

- Angiographic embolization

- Retroperitoneal packing

28

Components of management of open pelvic fractures (5)

- Management of hemorrhage

- ER removal of gross debris, tetanus and antibiotics

- OR layer-by-layer irrigation and debridement

- External fixation of the pelvis

- General surgery assessment for possible diverting colostomy and rectal washout

29

Indications for nonoperative management of pelvic fractures (3)

- Stable pelvic ring fracture

- Isolated avulsion fracture or iliac wing fracture

- Unstable fractures in patients with contraindications to surgical intervention

30

XR findings of pelvic fracture instability (5)

- Displacement of posterior SI complex > 1 cm

- Posterior fracture gap

- Avulsion of the L5 transverse process

- Avulsion fractures of the sacrum or ischial spine

- Avulsion fractures of the ischial tuberosity