Goldenstien Trauma List 9 Flashcards Preview

4-Goldstien list > Goldenstien Trauma List 9 > Flashcards

Flashcards in Goldenstien Trauma List 9 Deck (40)
Loading flashcards...
1

Femoral shaft fracture IM nailing decision-making factors (8)

  1. Timing of surgery
  2. Associated injuries
  3. Patient positioning
  4. Direction of nailing
  5. Start point
  6. Fracture pattern
  7. Use of traction
  8. Reaming

2

Indications for retrograde femoral nailing (9)

  1. Obesity
  2. Pregnancy
  3. Distal fracture
  4. Polytrauma patient
  5. Bilateral femur fractures
  6. Ipsilateral femur and tibial shaft fractures
  7. Ipsilateral acetabular fracture
  8. Ipsilateral pelvic fracture
  9. Ipsilateral femoral neck fracture

(Patient, fracture, associated injuries)

3

Things to check after completion of IM nailing of a femoral shaft fracture (5)

  1. Femoral neck
  2. Rotation
  3. Fracture site for distraction
  4. Leg length
  5. Knee ligamentous stability

(Proximal → distal)

4

Complications of femoral shaft fractures (9)

  1. Hemorrhage/shock
  2. Fat embolism syndrome/ARDS
  3. Infection
  4. Pudendal nerve palsy
  5. Thigh compartment syndrome
  6. Non-union
  7. Malunion (IR if supine, ER if lateral – 20% > 15°)
  8. Heterotopic ossification (25%)
  9. Leg length discrepancy

5

Methods to decrease the amount of fat embolism during IM nailing of femoral shaft fractures (6)

  1. Deep cutting flutes
  2. Short reamer heads
  3. Smaller diameter reamer drive shafts
  4. Flexible reamers
  5. Slow longitudinal reamer velocity
  6. Venting

6

Risk factors for femoral shaft fracture non-union

- Motion 

- Avascularity

  1. o Open fracture
  2. o Large surgical exposure
  3. o Smoking
  4. o NSAIDs

- Fracture gap

  1. o Bone loss
  2. o Distraction

- Infection

- Medical comorbidities

7

Goals of treatment of femoral shaft fracture non-union (6)

  1. Correct malalignment
  2. Fracture site compression
  3. Stable internal fixation
  4. Eradicate infection
  5. Facilitate rehabilitation
  6. Achieve osseous union

8

Options for treatment of femoral shaft fracture nonunion (5)

  1. Nail dynamization
  2. Exchange nailing
  3. Open bone grafting
  4. Plate osteosynthesis
  5. External fixation

9

Classification of distal femur fractures (AO-33) (9)

- A – extra-articular

o 1 – simple

o 2 – butterfly

o 3 – comminuted

- B – partial articular

o 1 – lateral condyle

o 2 – medial condyle

o 3 – coronal split (Hoffa’s #)

- C – complete articular

o 1 – T/Y type

o 2 – metaphyseal comminution

o 3 – metaphyseal and articular comminution

10

Principles of fixation of distal femur fractures (7)

  1. Radiolucent table for visualization of hip and knee
  2. Tourniquet
  3. Anatomic reduction of intraarticular fragments with lag-screw/temporary fixation
  4. Traction to set length/alignment of supracondylar segment
  5. Minimal disruption of hematoma/soft tissues
  6. Stable bicondylar fixation
  7. Early post-operative range of motion

11

Complications of supracondylar femur fractures (9)

  • Vascular injury
  • Open fracture
  • Quadriceps tendon disruption
  • Post-traumatic arthritis
  • Knee stiffness
  • Infection
  • Non-union
  • Malunion
  • Loss of fixation (varus collapse)

12

Causes of decreased blood flow with supracondylar femur fractures (4)

  1. Vessel injury
  2. Entrapment in the fracture site
  3. Kinking
  4. Vessel spasm

13

Classification of knee dislocation (Kennedy) (5)

Type 1: anterior (30-50%)

Type 2: posterior (25%)

Type 3: medial (5%)

Type 4: lateral (15%)

Type 5: rotatory (5%)

14

Classification of knee dislocation (Schenck) (5)

- KD-I: single cruciate

- KD-II: both cruciates

- KD-III: both cruciates and

o M – MCL

o L – LCL

- KD-IV: both cruciates, MDL and LCL torn

15

Knee dislocation associated injuries (6)

  1. Vascular injury (33%)
  2. Neurologic injury (peroneal nerve axonotmesis #1(30%) – KD-IIIL)
  3. Compartment syndrome
  4. Fractures/microfractures
  5. Meniscal injury
  6. Tendon injury

16

XR findings suggestive of knee dislocation (7)

  • Obvious dislocation
  • Irregular/asymmetric joint space
  • Mild tibiofemoral subluxation
  • Lateral capsular sign (Segond fracture)
  • Ligamentous avulsions
  • Rim fractures
  • Osteochondral defects

17

Indications for immediate surgical intervention for a knee dislocation (4)

  • Open injury
  • Vascular injury
  • Unsuccessful closed reduction
  • Residual soft tissue interposition

18

Indications for external fixation of a dislocated knee (3)

  • Vascular injury
  • Open knee dislocation
  • Residual instability on radiographs in an extension splint

19

Principles of surgical treatment of a dislocated knee/multiligament knee injury (6)

  • Identification and treatment of all torn ligaments
  • Accurate tunnel placement
  • Anatomic graft insertion sites
  • Strong graft materials
  • Secure graft fixation
  • Extensive postoperative rehabilitation

20

Technique of ACL/PCL/PLC surgical treatment (21)

  1. GA, supine, tourniquet, sandbag taped to bed to keep let flexed with side post, gravity flow of the fluid
  2. EUA
  3. Diagnostic arthroscopy of the knee and treat any associated intraarticular pathology
  4. Posteromedial safety incision (5 cm incision, 2/3 below joint line posterior to pes tendons, between semimembranosus and medial head of gastrocs)
  5. Under fluoro guidance and with direct palpation/visualization drill guide is used to place guidewire for PCL tibial tunnel (1 cm below tibial tubercle to anatomic insertion of PCL off posterolateral tibia – drilled with spoon behind the knee)
  6. Overdrill with the appropriate-sized drill to the posterior cortex and finish by hand protecting tip of the guidewire in PM incision
  7. Drill guide through anterolateral portal to drill guidewire for PCL femoral tunnel at anatomic insertion of AL bundle
  8. Overdrill with an acorn bit of appropriate size
  9. Create ACL tibial and femoral tunnels as per isolated reconstruction
  10. Prepare achilles tendon allograft over endobutton and secure in PCL femoral tunnel
  11. Prepare achilles tendon allograft over endobutton and secure in ACL femoral tunnel
  12. Lateral hockey stick incision posterior to LCL ending distally at the level of Gerdy’s tubercle
  13. Skin, subcutaneous tissue, identify and protect the common peroneal nerve
  14. Incise IT band and identify remnants of LCL on proximal fibula/femur
  15. For avulsions off of bone repair with suture anchors
  16. For midsubstance tears with poor tissue quality reconstruction using allograft is preferred (structures of interest are popliteus, LCL and popliteofibular ligament)
  17. Place knee in 90° of flexion and do anterior drawer to restore normal tibial step-off
  18. Secure tibial side of PCL graft
  19. Tension LCL structures with knee in 30° of flexion, internal rotation and valgus
  20. Knee in full extension to tension and secure the ACL
  21. Close

21

Complications of knee dislocations 

  1. Arthrofibrosis (#1 – 40%)
  2. Late instability (35%)
  3. Vascular injury
  4. Amputation
  5. Neurologic injury
  6. Post-traumatic arthritis

22

Risk factors for late instability following knee dislocation (3)

  1. Non-operative treatment
  2. Midsubstance repairs
  3. Early ROM

23

Classification of knee fracture-dislocation (Moore) (5)

  1. Type 1: medial condyle coronal split fracture
  2. Type 2: medial condyle or lateral condyle sagittal fracture
  3. Type 3: “rim avulsion” of lateral joint
  4. Type 4: “rim compression” with contralateral ligament injury
  5. Type 5: 4-part fracture (both condyles, metaphysis and tibial spines)

24

Phases of treatment of knee fracture-dislocation

  • Phase 1: reduction and assessment of injury (ABI, MRI)
  • Phase 2: surgical treatment of fractures
  • Phase 3: early reconstructive phase (hinged ex-fix applied at 3-4 weeks)
  • Phase 4: late reconstructive phase (PLC and ACL 3-4 months)

25

Complications of knee fracture-dislocation (4)

  1. Vascular injury (2, 10, 30, 10, 50%)
  2. Compartment syndrome
  3. Knee instability
  4. Post-traumatic arthritis

26

Classification of proximal tibiofibular dislocations (4)

Type 1: anterolateral (#1 – 65%)

Type 2: subluxation

Type 3: posteromedial

Type 4: superior

27

Risk factors for quadriceps tendon rupture (8)

  1. Obesity
  2. Diabetes
  3. Hyperparathyroidism
  4. Rheumatoid arthritis
  5. Systemic lupus erythematosus
  6. Hemangioendothelioma
  7. Chronic renal failure
  8. Gout

28

Complications of quadriceps tendon rupture (5)

  1. Hemarthrosis
  2. Rerupture
  3. Quadriceps atrophy
  4. Quadriceps weakness
  5. Loss of ROM/extensor lag

29

Classification of patella fractures (5)

  1. Undisplaced
  2. Transverse
  3. Pole
  4. Comminuted
  5. Vertical

30

Disadvantages of partial patellectomy for patella fracture (4)

  1. Patella baja
  2. Altered patellar mechanics/patellar tilt
  3. Decreased quadriceps strength
  4. Decreased patient satisfaction