Trauma Flashcards
(104 cards)
1
Q
What are the signs of preganglionic brachial plexus injury?
A
- *Preganglionic has WORSE prognosis since it is CNS injury!
1. ) Intact sensory (injury occurs before the dorsal root joins)
2. ) Normal Histamine test (redness, wheel, AND flare)
3. ) Horner’s syndrome
4. ) Medial scapular winging (as a result of the long thoracic nerve taking off at the roots)
5. ) Abnormal cervical paraspinal activity on EMG
2
Q
What are the signs of postganglionic brachial plexus injury?
A
- *Postganglionic has BETTER prognosis since it is PNS injury!
1. ) Motor AND sensory loss
2. ) Abnormal Histamine test (redness, wheel, NO flare)
3. ) No medial scap winging, normal cervical paraspinal muscle activity on EMG
3
Q
What is the only difference b/t IMN vs ORIF w/ plate for treatment of humeral shaft fracture?
A
No difference EXCEPT for:
IMN a/w higher complication rate ->
see higher re-operation rate
initially has higher shoulder pain and stiffness (however, NO diff in shoulder outcomes at 1 year!)
4
Q
What are the values a/w the following parameters that let you know a patient is resuscitated enough for Early Appropriate Care ( = spine, pelvis, femur to be definitively stabilized w/in 36 hrs):
- ) Lactate
- ) pH
- ) Base deficit
- ) IL-6
A
- ) Lactate < 4
- ) pH > 7.25
- ) Base deficit < 5.5
- ) IL-6 < 500
5
Q
What is the timeframe in which definitive soft tissue coverage should be done in order to avoid increased risk of infection?
A
Within 7 days (having a wound vac in place does NOT extend the window for soft tissue coverage!)
6
Q
Which Abx should be used for the following GA injuries:
- ) Grade 1
- ) Grade 2
- ) Grade 3
- ) Water contamination
A
- ) 1st gen cephalosporin
- ) 1st gen cephalosporin
- ) 1st gen cephalosporin + aminoglycoside
- ) Quinolone
7
Q
Management of bone defect:
- ) < 5 cm
- ) 5-10 cm
- ) > 10 cm
A
- ) autograft +/- Masquelet
- ) autograft or transport
- ) Bone transport (1 mm/day)
8
Q
In amputation vs limb salvage - what are the outcomes related to?
A
Neither is necessarily better than the other -> Outcome is related to social/personal/economic resources
9
Q
What is the rate of MRSA in ortho trauma patients?
A
~3% (it’s low!!)
10
Q
For leg compartment syndrome release, what nerve is at risk using the:
1.) Dual incision technique
2.) Single lateral incision technique
Which technique is better?
A
- ) Superficial peroneal nerve
- ) Common peroneal nerve
BOTH techniques are just as good!
11
Q
What is the mechanism for compartment syndrome?
A
Decreased venous outflow relative to inflow (arterial inflow is unchanged)
12
Q
What is Fat Embolism Syndrome?
What do you look for?
What is treatment?
A
Inflammatory response to embolized fat
Look for petechial rash, hypoxemia, pulmonary edema
Tx: ventilation support
13
Q
What values of the following qualify for SIRS:
- ) Temp
- ) HR
- ) Resp rate or PaCO2
- ) WBC
A
- ) Temp > 38 C or < 36 C
- ) HR > 90/min
- ) RR > 20 or PaCO2 < 32 mmHg
- ) WBC > 12k or < 4k
14
Q
What is the obturator outlet view best for?
A
Gives the tear drop view looking down the supra-acetabular corridor of the AIIS
- ) Anterior column screws (needed for LC II crescent fx)
- ) Supra-acetabular pins - startpoint view (then will swing to obturator inlet to make sure down the corridor)
15
Q
What is the obturator inlet view used for?
A
“down the wing view”
To make sure the supra-acetabular screw/pins OR column screw for LC II crescent fx are between the inner and outer tables of the ilium as they pass from the AIIS toward the PSIS (start point is on the obturator outlet, then swing to obturator inlet view)
16
Q
What is the iliac oblique view used for during placement of exfix?
A
To make sure the supra-acetabular pin is above the hip joint and sciatic notch!
17
Q
What are the main 2 risks of supra-acetabular exfix pin?
A
- ) LFCN palsy
2. ) HO
18
Q
- ) What nerve can be affected by anterior infix for pelvis?
- ) What is the most common complication of anterior infix for pelvis?
A
- ) Femoral nerve!
2. ) HO!
19
Q
- ) What nerve is MC injured during SI screw placement?
2. ) What XR view helps to ensure that you stay away from hitting the nerve?
A
- ) L5
2. ) Lateral view and make sure you stay posterior to the iliac cortical density
20
Q
- ) What are 2 main features of a dysmorphic sacrum?
2. ) What does it make difficult/preclude you from?
A
- ) Prominent mammillary process and anterosuperior deficiency of sacral ala
- ) Difficult (smaller area)/or not possible to place S1 screw….S2 area is typically larger - look to place screw here!
21
Q
What is the treatment for APC I and LC I?
A
WBAT w/ walker/crutches
22
Q
What is the treatment for APC II?
A
Anterior pubic symphyseal plate (4-6 hole!)
+/- posterior SI screw (controversial, but used sometimes since occult vertical instability exists!)
23
Q
What is the treatment for APC III, LC III, and vertical shear?
A
Anterior PS plate + posterior fixation (typically SI screw)
24
Q
What is the treatment for LC II?
A
Fix crescent fracture - can use a screw from AIIS to PSIS (get start point on Obturator outlet and then check that it’s down the pillar of bone on the obturator inlet)
25
1. ) Women w/ hx of pelvis fx are at risk for what 2 things in the future?
2. ) Men most common sequeala?
1. ) C-section birth and Dyspareunina
| 2. ) Urethral stricture
26
What XR view is needed to evaluate the direction of SC dislocation?
```
Serendipity view (40 degree cephalic tilt)
Cephalad displacement = anterior
Caudad displacement = posterior
```
27
How do you treat:
1. ) Acute anterior SC dislocation
2. ) Acute posterior SC dislocation
3. ) Chronic posterior SC dislocation
1. ) Closed reduction in ER, observe
2. ) Closed reduction in OR, observe
3. ) Observe (DO NOT ATTEMPT CLOSED REDUCTION!! - retrosternal adhesions)
28
How do you treat SC dislocation in patient < 25 yo:
1. ) Anterior
2. ) Posterior - reducible
3. ) Posterior - irreducible, asymptomatic
4. ) Posterior - irreducible, symptomatic
1. ) Observe - usually won't stay reduced, but will remodel
2. ) Observe, sling
3. ) Observe, will remodel
4. ) Open reduction in OR w/ thoracic surgery back up
29
What are the 5 main risk factors for clavicle nonunion?
1.) 100% displacement
2.) Comminution
3.) Smoker
4.) Female
5.) Old age
(**NOT early mobilization)
30
What is a positive outcome of fixing clavicles fx w/ > 2 cm shortening (other than avoiding nonunion/malunion)?
Better shoulder function
31
1. ) What is the initial treatment for Type I-III AC separations?
2. ) What about IV - VI
1. ) Nonop! Sling x 7d then ROM exercises
| 2. ) Also nonop! (now)
32
How do you treat an AC separation in skeletally immature?
Observation! - it's a physeal fx and will remodel!
33
What are the operative indications for scapular fracture fixation?
1. ) Glenopolar angle < 20 (normal 30-45)...means that glenoid is starting to point more towards the floor
2. ) Body angle > 45 (scapula flexing in sagittal plane)
3. ) Lateral border displaced > 2 cm (when it moves out more laterally, gets in the way of shoulder motion)
34
With a scapulothoracic dissociation what is the a common associated injury that also determines outcome?
Neurologic injury!
35
What did the PROFHER trial show about ORIF vs nonop tx of 2 pt proximal humerus fractures?
No difference in patient outcomes over 2 years!
36
When performing ORIF of proximal humerus fx through the following approaches, what nerve is at risk of injury?
1. ) Deltopec
2. ) Deltoid split
1. ) Musculocutaneous n (medial..can get w/ retractor)
| 2. ) Axillary nerve is 4-7 cm distal to acromion
37
What is the most common complication of ORIF of proximal humerus fracture?
Screw cut out/penetration into joint
| maybe due to inital intraop error or late varus collapse
38
What technique can you use during ORIF of proximal humerus fracture to help avoid varus collapse?
Placement of calcar screws!
39
What are the 2 biggest predictors of humeral head AVN following proximal humerus fx?
1. ) Metaphyseal extension < 8 mm
| 2. ) Disrupted medial hinge
40
What are the 2 main factors you should consider when thinking about ORIF vs arthroplasty for proximal humerus fracture?
1.) Bone stock (both cortical diameter added together > 4 mm)
2.) Humeral head blood supply
Both good -> ORIF
One good -> consider ORIF
Both bad -> arthroplasty
41
What is the treatment for valgus impacted 4-part proximal humerus fx?
ORIF (low energy injury w/ minimal soft tissue disruption)
42
1. ) In patient > 70 yo who is healthy and active (ie operative candidate) w/ a 3 or 4-part proximal humerus fracture - what is treatment?
2. ) What is treatment if not so healthy
1. ) Reverse TSA (better than ORIF)
| 2. ) Majority of 3 and 4 part fx can be treated nonop in those > 70 yo!!!!!!
43
What is the location of hemiarthrplasty placement in regards to:
1. ) Height of humeral head
2. ) placement of greater and lesser tuberosities
3. ) Version
1. ) 5.6 cm superior to upper border of pec major insertion
2. ) Greater should be 1 cm below top of humeral head -> if too high will have reduced elevation and abduction; Lesser need to avoid placing too laterally or else will have restricted ER
3. ) 25 degrees retroversion from forearm at 90 degrees flexion at elbow
44
Which approach for ORIF of humerus puts radial nerve at greatest risk?
Lateral approach
45
What limits the proximal extent of the posterior approach to the humerus?
Axillary nerve (can get to 80% though!)
46
What is the incidence of radial n. palsy in distal 1/3 humeral shaft fx?
20%
47
What approach should be used to help better visualize and fix distal humerus intra-articular fractures?
Chevron osteotomy 3 cm distal to triceps insertion on bare area
48
What is the best approach for elbow TEA in elderly w/ distal humerus fx?
Posterior triceps sparing
49
K-wires that penetrate anterior cortex of ulna (during tension band fixation) can injure what nerve?
AIN
50
What is the interval for the :
1. ) Kaplan approach
2. ) Kocher approach
1. ) ECRB/EDC (above LUCL so less chance to injury, closer to PIN)
2. ) ECU/Anconeus (closer to LUCL..make sure to get to joint above equator, farther from PIN)
51
What is the treatment for simple elbow dislocation that is unstable?
Immobilize 2-3 wks then transition to hinged brace w/ PRN pronation
(no advantage to acute repair of ligaments!)
**DO NOT immobilize elbow > 3 weeks! Detrimental to motion!
52
After reduction of simple elbow dislocation - you examin stability of valgus laxity and find that the elbow is has laxity in supination so you know there is LCL injury, if pronation does not improve valgus elbow stability what else is likely injured?
MCL
53
What functional movement can test posterolateral rotary instability?
Pushing up out of a chair! -> valgus/supination/axial load
54
During volar approach to the radius for a BBFA fx - what direction do you move the radial artery?
Ulnar!
55
In situation of mangled limbs - what effects outcome the most?
Underlying psychosocial and economic circumstances! - NOT amp vs limb salvage!
56
What pelvic injury has:
1. ) Highest incidence of hemorrhage and shock
2. ) Highest risk of bowel injury
3. ) Highest a/w brain injury
1. ) APC III and VS
2. ) LC III
3. ) LC I & LC II
57
On the axial CT cut, what orientation are:
1. ) Transverse fractures
2. ) Column fracture
1. ) A to P (vertical)
| 2. ) M to L (horizontal)
58
What is the "Spur Sign" seen on XR?
Pathognomonic for both column fracture.
Seen on Obturator oblique
The "spur" is the distal most intact part of the iliac wing and the rest of the acetabulum is medialized relative to this
59
What is the "Gull Sign" seen on XR?
Superomedial dome impaction (typically seen in elderly fx's)
| Poor prognositc sign
60
What are indications for nonop tx of acetabular fractures?
1. ) Displacement < 2 mm
2. ) Intact WB dome: roof arc > 45, femoral head congruent
3. ) Posterior wall < 20%
61
When doing a dynamic stress EUA to determine stability of a posterior wall tab fx, what XR view do you examen under?
Obturator oblique view
62
What other non-musculoskeletal lesion is a posterior hip dislocation associated with?
Traumatic rupture of thoracic aorta
63
What is the MC complication following a hip dislocation?
PTOA
64
What is the surgical approach for Pipkin IV fractures?
Trans-trochanteric flip osteotomy b/c gives exposure to fix posterior wall and head fx and preserves supply to femoral head
65
What fracture pattern is a contraindication to IMN through piriformis fossa?
Fracture w/ extension into piriformis fossa.
| Use extramedullary plate fixation
66
In management of hip fx in elderly patients, the AAOS has what recommendation for general vs spinal anesthesia?
STRONG evidence that there are similar outcomes of spinal vs general anesthesia
67
What patient might you consider unreamed nail of femoral shaft fracture in?
Bilateral chest injury
68
For a femoral shaft fracture, what type of rotational malalignment is most likely seen with:
1. ) Proximal shaft fxs
2. ) Distal shaft fxs
Is internal or external malrotation generally tolerated better?
1. ) Internal malrotation
2. ) External malrotation
Internal malrotation is generally tolerated better
69
After knee dislocation and there are pulses present but ABI <0.9 what test should be ordered?
CT angiography
70
In the case of a distal pole patella fx that is treated w/ excision - what is important about the re-attachment of the patellar ligament?
Make sure to attach it anteriorly so that you don't create patellar tilt
71
What is the best fixation construct for:
1. ) Unicondylar tibial plateau fx
2. ) Bicondylar tibial plateau fx
1. ) Non-locked buttress plating
| 2. ) Locked plating
72
What size long lateral tibial plateau plate do you start worrying about superficial peroneal nerve injury?
> 10 holes
73
Thin olive wires used for external fixation should be how far from the joint?
1.5 cm or more
74
In fixing tibial plateua fx, what are the 2 most important variables?
1. ) Restoration of joint stability
| 2. ) Restoration of mechanical axis
75
What type of meniscus tear is most commonly seen with tibial plateau fractures?
Lateral meniscus peripheral tears (typically a peripheral meniscocapsular avulsion)
76
What were the main findings of the SPRINT study?
No difference in FUNCTIONAL or REOPERATION b/t reamed and unreamed tibial nailing in open fx.
Reamed nailing superior for closed fractures!
*Also, that delaying additional surgery for at least 6 months decreases need for reoperation.
77
According to the LEAP study, what is the most important predictor of eventual amputation?
Severity of soft tissue injury
78
According to the LEAP study, what is the most important predictor of infection?
Transfer to a definitive trauma center
79
What other fracture do you need to evaluate for in spiral distal 1/3 tibia fx?
Posterior malleolar ankle fx (Volkman fragment)
80
What neuropraxia can be seen after tibial IMN?
Peroneal nerve -> decreased EHL strength
81
How do stainless steel nails compare to titanium nails for tibial shaft fx?
Stainless steel a/w increased risk adverse outcomes
82
What is rhBMP-2 approved for?
| rhBMP-7?
rhBMP-2: open tibia fxs
| rhBMP-7: long bone nonunions
83
Do patients reach baseline function after tibial shaft fx by 1 year after surgery?
NO!
84
What is the most common complication a/w tibial shaft fx tx w/ IMN?
Anterior knee pain
85
What is the most common malalignment after IMN of distal 1/3 tibia fx?
Rotational malalignment
86
When should WB be allowed for most ankle fx's?
2 weeks
87
What is the main factor that is important to assess in an ankle fracture when considering operative fixation?
Position of the talus in the ankle mortise
88
When there is a syndesmotic injury, in what plane/direction is there the most instability?
Translational: A to P
89
In talus fractures what area is typically comminuted and if underappreciated what deformity is seen?
Medial comminution
| Varus malunion of talus
90
What is the main blood supply to the talar body?
Artery of tarsal canal (preserve deltoid!) -> branch from the posterior tibial artery
91
What is the most common complication after talar neck fracture?
What is the most avoidable complication after surgical fixation of talar neck fx?
Subtalar arthritis
| Varus malunion - look for the medial comminution!
92
If have a subtalar dislocation, what is the most common material interposed making it irreducible if the dislocation is:
1. ) medial
2. ) lateral
1. ) Medial -> interposed EDB, or fractured head of talus
| 2. ) Lateral -> PT or FHL
93
Lateral to medial calc screws near the sustentaculum can cause injury to what structure?
FHL
94
The lateral extensile incision to the calc risks injury to what nerve?
Sural nerve
95
What is the treatment for closed subtalar dislocations w/o fractures or OCD lesions seen? (ie a simple subtalar dislocation)
Closed reduction and SLC x 4 wks
96
In calc fractures - what is the "constant fragment"?
Sustentaculum tali
97
When should syndesmotic screws be removed?
No earlier than 4 months!
98
Which acetabular fx has the worst prognosis?
T-type -> b/c involves both anterior and posterior columns, also w/ fx through the pubic rami -> so reduction of one column will not help you with the other, as a result need dual approach. Hard to get right!
99
What is the outcome of an acetabular fx ORIF directly correlated with?
Quality of the articular reduction
100
What patient demographic and fracture pattern has highest risk of osteonecrosis after a FNF?
Young patient w/ displaced fracture
101
What is the appropriate treatment for a
| Subtroch fx that involve piriformis fossa
extra medullary plate fixation (proximal femoral locking plate)
102
What Hb level should you start considering transfusion?
< 8
103
For osteoporotic patients w/ distal femur fractures that lack cortical contact - what fixation should you use?
Locked lateral plate
104
1. ) For a closed tibial shaft fx -> which is superior reamed or unreamed IMN?
2. ) For an open tibial shaft fx -> which is superior reamed or unreamed IMN?
1. ) Reamed
2. ) No difference!
* Findings of LEAP study
