Trauma Flashcards

Question

Lauge Hansen Ankle # classification (no RC Q)

Answer 1

"SER: AITFL, fib, PM, MM

SAD: transverse fib, MM

PER: MM, AITFL, high fib, PM

PAbD: MM, AITFL, comminuted fib

"

Answer 2

CSCS

1- crush and laceration

2-secondary missiles (bone fragments, metal fragments from helmet)

3- cavitation

4- shockwave

Energy transfer is dependent on:

1-KE at time of impact (E=1/2mv2)

2-stability and entrance profile (yaw)

3-caliber, configuration of bullet

4-distance and path through body

5-characteristics of tissue impacted

6-mechanism of tissue disruption

Answer 3

Oral Abx for 72 hrs (As effective as IV)

wounds are comparable to Gustillo I/II

Answer 4

Medial (foot goes medial)

-talus: dorsomedial head, posterior tubercle

-lateral navicular

lateral (foot goes lateral)

-cuboid

-ant calc

-lateral talar process

-lat mal

Note: 89% go onto subtalar arthrosis (most symptomatic)

Answer 5

Hard signs: pulselessness, pallor, paresthesias, pain, paralysis, rapidly expanding hematoma, massive bleeding, palpable bruit

-TX: surgical intervention

Soft signs: hx of bleeding in transit, proximity related injury, hematoma over named artery, neuro findings

-Tx: ABI then CTA/Angiography

Answer 6

"For posterior facet calc

IR 40 deg, and tube centered on lateral mal, sequentially moves from 40 deg cephalad to neutral

"

Answer 7

"overall, no difference in SF36 or VAS

pts who do well with sx: female, Age <30, non-wcb, Bohler's>0, Sanders<3,

pts who do poor with sx: older, wcb, high E mech, smoker, DM, labourer

"

Answer 8

ISS

TBI

SCI --> complete>incomplete, higher lvl, younger age

Neurologic compromise (prolonged coma, ventilator use)

DISH, Ankylosing spondylitis, hypertrophic OA

Decubitus ulcers

Antegrade femoral nail (particularly piriformis)

Distal femur traction pins

Amputation through zone of injury (particularly blast)

Surgical approach: Iliofemoral>KL>II> anterior

THA/TKA

Answer 9

resection

Indomethacin 25 TID for 3-6 months

radiation: 700cGy in 72 hrs

Answer 10

"AP: superior border of sacrum even with iliac crest (green), acutely down-sloped sacral ala (blue), non-circular neural foramen (purp), mammilary process (red), residual disc space (yellow)

Inlet: recessed anterior alar cortex

CT: tongue in groove

Note on ICD:

-in Normal pelvis, ICD is coplanar with anterior sacral alar bone

-in dysmorphic pelvis, they are not colinear - the alar anterior cortical limit is anterior and cranial to ICD (ie no safe S1 screw!) - need a 1cm corridor - 10mm screw path gives a margin of 1-2mm around screw- RC EXAM

"

Answer 11

ABC

AC-post hemitransverse

T-type

JAAOS 2018

Answer 12

-PW

-associated both column

Answer 13

"

(1)outlet - obturator oblique

(2A)Inlet - iliac oblique

(2B)Inlet - obturator oblique

"

Answer 14

Major:

-minimal trauma

-transverse #

-complete #

-minimal comminution

-lateral beaking/endosteal scalloping

Minor:

-delayed fracture healing

-prodromal pain

-generalized increase in diaphyseal cortices

-bilateral femur diaphysis #s

Answer 15

-consult endo

-stop bisphosphonates (fracture rate decreases from 40 to 20%), consider tx with teriparatide - recombinant PTH (osteogenic - stimulates osteoblasts)

-labs: ca, vitD

-optimize nutritional status

-fix fracture

-consider fixation of contralateral side

Answer 16

A

Surgical treatment of isolated GT fractures is indicated in healthy patients who have >5 mm of superior GT displacement. Although 3 mm of GT displacement is sufficient to alter rotator cuff (RC) biomechanics, the study by Platzer et al. The magnitude of “acceptable” posterior GT displacement remains unclear

Answer 17

"Elementary patterns: PC, PW, AC, AW, transverse

Associated patterns: PC + PW, transverse + PW, T-Type, AC + Post Hemi-T, ABC

Distribution

PW 24%

ABC 22%

T-PW 20%

"

Answer 18

NF: clindamycin + pip/tazo (broad spectrum)

GG: clindamycin + Pen G

Answer 19

Surgical factors:

Iliofemoral approach (Highest risk) > Kocher-Langenbeck > Ilioinguinal (Lowest risk)
Complex exposure, double exposures & trochanteric osteotomy increases risk
Soft tissue factors: Debridement of necrotic muscles (Specifically glut minimus) has diminished HO after acetab #

Clinical & Systemic factors: Male, TBI or thoraco-abdominal trauma, Sciatic nerve injury, femoral head injury/ intra-articular debris, Delay to Sx, Ipsilateral femur #, Prolonged mechanical ventilation, early THA for acetabular #

Answer 20

Reduce LOS, readmission rate, time to surgery, complications, mortality rate, hospital acquired complications

Answer 21

Medially it is 20cm above the medial epicondyle
Laterally it is 14cm above the medial epicondyle
Exits groove at 10-14.8cm from lateral epicondyle
Lateral IM septum at 10cm above joint line (never closer than 7.5cm)
Can find radial nerve proximal to lateral epicondyle by taking 1.4x of transepicondylar width (per Kamineni)

Consider measuring this pre-operatively and marking on the skin the expected location of the nerve crossing the intermuscular septum on the skin

Usually within 1-2cm of proximal extent of triceps aponeurosis

Answer 22

"

Hahn-Steinthal --> fracture of capitellum with attached subchondral bone
Kocher-Lorenz --> articular cartilage
Broberg-Morrey --> comminuted fractures
McKee --> capitellar fracture extending into trochlea - RC EXAM

Double arc sign

"

Answer 23

"

Anterior dislocation

Closed reduction is current tx of choice, but there is controversy given good longterm results with nonsurgical management
Technique

Sedation or local or general anestheia
Supine with 3 inch pad between shoulders
Direct pressure on medial clavicle in posterior direction
Immobilize in figure of 8 or Velpeau sling for 6 weeks

Posterior Dislocation

Unreduced posterior dislocation complications

TOS
Vascular compromise
Erosion of medial clavicle into posterior structures

Consult cardiothoracic surgeon if mediastinal involvement

Dyspnea, choking, hoarseness

Can often be reduced closed, and is then stable
Closed Reduction

Traction Technique #1

Thoracic surgeon available
Supine, sedation or GA
4inch bolster between shoulders
Abduct and slightly extend arm
Traction and coutertraction
Bring arm into extension

Traction Technique #2

traction may be applied to the arm in adduction while posterior pressure is applied to the shoulder to lever the clavicle over the first rib

Towel Clip around clavicle

Apply traction and lift anteriorly

Open Reduction

Thoracic surgeon assist
Exposure: preserve anterior capsule (this will provide stability once reduced)

"

Answer 24

2U cross matched blood
If unavailable, I will use type specific blood
If unavailable, I will use O- blood

Answer 25

I will insert a foley, unless contra-indicated

Blood at the meatus
Perineal ecchymosis
Blood in scrotum
High riding prostate
Pelvic fracture

If contra-indicated I would obtain a retrograde urethrogram

Maintain a urine output of 0.5cc/kg/hr

Answer 26

AMPLE

Allergies, medications, past medical history, last po intake, events of the trauma

Head to toe examination

HEAD --> scalp, skull, eyes, ears, facial bones, basal skull fracture
NECK:

Remove C-spine collar, maintain inline traction

CHEST

ABDO

PELVIS

Consider vaginal exam if concerned about open pelvic fracture

EXTREMITIES

CNS

SPINE

Roll patient maintaining spinal precautions
Palpate length of spine, looking for open wounds, areas of tenderness, step deformities
Rectal exam looking for tone, voluntary contraction, presence of blood

Answer 27

surrogate of end organ perfusion

Top 3: Lactate<2.5, BD -2 to 2, gastric pH>7.3
Physiologic:

MAP>60
U/O 0.5cc/kg/hr
HR<100
Temp >35
PaO2/FiO2>300

Acidosis-related

Lactate <2.5
pH>7.25
Gastric Mucosal pH >7.3 (OITE)
Base deficit (normal -2 to +2) - excess is >8

No Coagulopathy

Plts>90
Fibrinogen>1

Answer 28

Multi-organ system dysfunction
Pneumonia
Decubitus ulcers
Vascular abnormalities
Psychological disturbances
Gastrointestinal stasis

Answer 29

polytrauma: AIS>18
9-6-3-2-1

9 anatomic areas, each gets a score out of 6, Top 3 are squared (^2), for 1 AIS score

9 anatomic areas; head, face, neck, thorax, abdomen, spine, upper extremity, lower extremity, external
Scored:

None
Minor
Moderate
Serious
Severe
Critical
Not Survivable

Answer 30

Approach to polytrauma to minimize the effect of the second hit

Avoid:

Multi-organ failure (MOF)
ARDS

Initial priority --> HSS - hemorrhage control, soft tissue management, provisional stability

Answer 31

"

Immediate

Severe brain, high spinal cord injury, rupture of heart or large vessels
Only prevention interventions can stop these deaths

Minutes to Hours

The Golden hour: shock, hypoxia, head injury

Examples, hemo/pneumothorax, ruptured spleen, liver lacs, pelvic fractures
Deaths in this time period can often be prevented by expedient care

Days to weeks

Sepsis and multiorgan failure

"

Answer 32

Blood at the meatus
Perineal ecchymosis
Blood in the scrotum
High riding or non palpable prostate
Pelvic fracture

Not necessarily contraindications just indications to do a retrograde urethrogram before you place one

Answer 33

"

Acute respiratory failure characterized by decreased PaO2 and a diffuse, massive extravasation of fluid into the interstitial space of the lungs
Release of inflammatory mediators results in organ dysfunction (increased vascular permeability)
Pulmonary arterial wedge pressure <18mmHg (no left atrial hypertension)

Ventilator support

Avoid toxic FiO2, barotrauma

General organ support
Outcomes:

30-40% mortality rate

"

Answer 34

Thermal damage above 50deg C creates irreversible damage to osteocytes

To decrease temperatures:

Predrill

Reduces temperatures by half

Irrigate during drilling
Use power to insert pins (hand insertion creates higher time at high temperatures)

Answer 35

"

SIRS is mostly being replaced by qSOFA- score from 0-3. 70% of sepsis deaths are in patients with scores of 2or 3.

Systolic BP <100
Altered metal status (GCS <15)
Elevated RR (>22 breaths /min)

"

Answer 36

Tobacco cessation
Glycemic control
Nutritional optimization
Management of metabolic and endocrine abnormalities

Brinker (JOT 2007) Metabolic and endocrine abnormalities in patients with tibial non-unions

Correction leads to healing in >25% without intervention

Poor vascularization

Answer 37

Colour
Consistency
Contractility
Capacity to bleed

Answer 38

Massive tissue damage (high velocity weapon)
Vascular injury
Progressive neurological deficit
Obvious contamination or necrosis
Joint involvement
GI tract involvement/contamination
Compartment syndrome
Uncertainty as to type of weapon used
Unstable fracture pattern requiring operative stabilization
Selected spinal involvement cases
Tendon injuries
Superficial fragments in palm or sole

Answer 39

"

if ABI<0.9 --> CT Angio

"

Answer 40

"

5 principles

Early dx and debridement
Abx - broad-spectrum
Aggressive resuscitation
Frequent Re-evaluation
Nutritional Support

Abx choice

Initial empiric therapy and confirmed polymicrobial treated the same- with broad spectrum abx (pip/taz) and clindamycin to reduce endotoxin
Gram positive cocci in clusters represents staph species, so you can start vancomycin to cover gram positive/MRSA and add clindamycin again to prevent endotoxin production
Gram positive chain or pairs represent strep species- so you cover with pip/taz and clindamycin
Clindamycin has shown mortality benefit in staph and strep species due to prevention of endotoxin production

"

Answer 41

Necrotizing Fasciitis

Gas Gangrene (clostridium myonecrosis)

Etiology

Type 1- typically post-operative GI/bowel surgery in immunocompormised host

Type 2- typically trauma in healthy host

Type 3- trauma and marine water exposure

Can be trauma, but most commonly post-operative after GI bowel surgery or in immunocompromised host/ cancer

Exam

Erythematous infection that commonly tracts proximal

Infection commonly tracts distally

Bacteria

Type 1- polymicrobial commonly includes enterobacteria and synergistic effect between bacteria

Type 2- GAS and sometimes staph (gram positive cocci)

Type 3- virbrios species

Clostrium species commonly clostridium perfringes (gram positive bacilli) with relative absence of inflammotory markers and PMNs compared to nec fas

Classification

As above

Differentiate whether clinical presentation consistent with cellulitic/fasciitis or more worrisome myonecrosis phenotype

Scoring Methods

LRINEC

none

Imaging

MRI usually shows hyperintensity due to necrosis of fat and fascia tracking along fascial planes, rarely and in late stages may see muscle involvement (bad prognosis)

MRI may be similar to nec fas but more commonly there is extensive muscle involvement which differentiates it

More likely to get abdominal CT to r/u GI pathology early

Antibiotic treatment

Pip/taz, vanco, clinda

Pen G and clinda

Surgical Treatment

Radical debridment of skin and subq tissue

Radical debridement of skin, subq, fasica, and muscle, more likely to require amputation and fasciotomy then nec fas

Answer 42

Metabolic work up indicated in:

A persistent nonunion despite adequate treatment without obvious technical error
A history of multiple low-energy fractures with at least one progressing to a nonunion
Nonunion of a nondisplaced pubic rami or sacral ala fracture (ie of an insufficiency fracture)

Labs

Vitamin D production

25-hydroxyvitamin D
Calcium
Phosphorus
Magnesium

Parathyroid disorder

PTH
Calcium
Phosphorus

Thyroid disorder

TSH

Adrenal disorder

Cortisol
ACTH

Hypopituitarism

Testorsterone
FSH
LH
Prolactin

Infection

ESR
CRP
CBC
Joint aspiration

Primary Immune disorder

SPEP/UPEP

Others

ALP
IGF-1

Answer 43

-Injuries: high ISS, TBI, SCI, decubitus ulcers

-Diseases: burns, DISH, Ank Spon, hypertrophic OA

-Procedures: antegrade fem nail (piriformis start), distal femur traction pin, amputation through zone of injury, THA (Cementless), TKA, surgical approaches (EIF>KL>II)

Answer 44

Prophylaxis

diphosphenates are mainstay of prophylaxis and approved by FDA

etidronate prevents HO formation by preventing formation of hydroxyapatite crystals

NSAIDS

indomethacin (75mg daily)
rofecoxib (2mg daily X 4 weeks) have good evidence

Radiation(8-10 Gy)
PT (to retain ROM and prevent soft tissue contractures

Surgery

Complete resection when at mature stage

6 months when secondary to trauma
1 year after SCI
1.5 years after TBI

Intra-op Principles- wide exposure, identification of N/V bundles, hemostasis, dead space elimination

Get CT scan to assess HO
Balance decision about when to operate

early resection can prevent contractures, osteopenia, and risk of intra-op fracture
late resection leads to joint stiffness but lower rate of recurrence

Answer 45

Stabilization of a flail chest reduces ventilator time, pneumonia, mortality, and overall medical costs.

Answer 46

Partially insert foley, inject 10-15cc of water soluble contrast

Initial blush -> extraperitoneal -> treat with foley if non op pelvis

If open pelvis, decreased intra-pelvic pressure and will not heal with foley
Simultaneous repair with pelvic fixation

Advance to bladder if no leak and inject 200cc

If outlined bowel -> intraperitoneal -> operative intervention

if RUG is positive from urethral injury, then a suprapubic cystostomy tube needs to be inserted
Bladder injury requires prompt diagnosis so as to avoid hyperkalemia, hypernatremia, uremia, acidosis, and peritonitis

Answer 47

"

Tile Classification

A – Stable
B – Vertically stable, rotationally unstable
C – Vertically and rotationally unstable

"

Answer 48

"

Angiography and embolization useful tool in controlling arterial hemorrhage from pelvic trauma
Indication: active arterial bleeding in hemodynamic instability

If + FAST --> ex lap + pelvic packing + ex fix

Reduces need for angioembolization, blood transfusion and mortality

If - FAST --> binder + angioembolization

Tends to be needed more in APC II, III, LC III or Tile Type C but not clearly statistically significant in many studies
CT to detect need for embolization

Look for active extravasation of contrast or presence of pelvic hematoma in unstable patient with pelvic fracture
Sensitivity 60-90%, specificity 92-100%

Most common arteries for embolization:

Internal iliac: 67.2% (Green)
Unnamed arteries branching off internal iliac: 17.0%
Superior gluteal artery(1): 4.4%
Obturator (6): 4.1%
Internal pudendal (7): 3.2%

Earlier embolization is better
Improves mortality in trauma patients

Post embolization mortality rate 16-50% (related to concomitant injuries)

Complications of embolization typically outweighed by benefits and success of resuscitation, but can include wound breakdown, gluteal muscle necrosis, visceral necrosis

"

Answer 49

"

The ""corona mortis"" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins.

It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range 40-96 mm)

"

Answer 50

"

portion of nonarticular ilium above the acetabulum that becomes visible on the obturator oblique view because of medial displacement of the acetabulum

"

Answer 51

RFs for failure

Patient: Age > 40
Injury: Initial displacement of > 2cm, Femoral head lesion, Impaction, Posterior wall involvement, Anterior hip dislocation
Surgery: Non-anatomic reduction, Incongruence of roof, Iliofemoral approach

80% survivorship at 20 years

Answer 52

"

Glenopolar angle < 20o
Medialization >2-3cm (or lateralization depending on theory)
Body Angulation > 40-45o

As seen on the trans-scapular Y view, or on sagittal cuts
40 degrees flexion or extension of glenoid in sagittal plane

Persistent shoulder instability secondary to large boney bankart
>5mm intra-articular step
Floating shoulder (SSSC disruption x 2)

"

Answer 53

Proximal 1/3 most at risk for non-union

Due to deforming forces of pec major (adduction) and deltoid (abduction)
Higher risk of interposition of muscle tissue and long head biceps
Difficulty to immobilize/stabilize

Answer 54

Incision: posterior, then raise lateral fasciocutaneous flap only and do your lateral approach; may not need a medial approach at all if you can access coronoid fracture through your radial head defect

Answer 55

"

AP forearm
Line from radial tuberosity to ulnar edge of distal radius

Perpendicular line drawn where it will be longest to reach radial shaft -> this is location of bow

Should be 60% distal

"

Answer 56

"The combination of valgus, axial, and posterolateral rotatory forces (forearm supination) can result in a ""terrible triad"" injury of the elbow"

Answer 57

Radiographic arthritis with residual intra-articular gap (not necessarily symptomatic)

Worse functional outcomes if severe radial shortening or residual gap +/- ulnar styloid non-union

Ulnar positive is bad (even if present on initial films!)

Answer 58

"-benefits: often PW and fem head fracture - so through a posterior approach you can address PW and then dislocation to get to fem head.

"

Answer 59

"

both 10-30% risk

"

Answer 60

Rotation

Cortical step sign
Lesser trochanter profile
Neck version method/ Tornetta/ Perfect lateral

Same principle as lesser trochanter sign, just uses different proximal landmark

Use of CT post op (cuts at neck and knee) based on Jeanmart et al.

Length

Bovie cord/ measuring tape
Metal ruler
Cortical length (based off anatomic reduction of cortical fragments)
Full length view of uninjured leg pre-operatively

Alignment

Bovie cord centered at femoral head and middle of ankle

Should go through the centre of knee or slightly medial

Tips and Tricks

Pre-operatively consider determining version of uninjured limb using one of the above methods if fracture is quite comminuted
Drape injured leg free so that you can use the other side for comparison during the operation

Answer 61

JOT 2018 - Nail Fit: Does Nail Diameter to Canal Ratio Predict the Need for Exchange Nailing in the Setting of Aseptic, Hypertrophic Femoral Nonunions?

RFs for Nonunion (requiring exchange nailing)

poor fracture reduction
open fracture
Winquist classification of 4
Poor nail fit - especially with nail fit <70%

Answer 62

radiographic union score of tibias

Evaluates 4 cortices on AP/lat

1 point = no callus, fracture line visible
2 point = bridging callus, fracture line visible
3 point = no fracture line visible
Scores 3-12

Validated for inter/intra reliability but not well for clinical prediction yet

Answer 63

Proximal third --> gastrocnemius rotation flap
Middle third --> soleus rotation flap
Distal third --> free flap coverage

Answer 64

Anteromedial --> medial to tib ant

Tip of MM to base of 1st
Consider cheating posteriorly to facilitate medial malleolar osteotomy
MM osteotomy preserves talar blood supply as deltoid ligament has deltoid artery
Allows view of neck alignment and medial comminution (use position screws)

Anterolateral

Anterior fibular tip (In line with inferior syndesmosis), then in line with 4th ray (higher up than you think!)
Mobilize EDB as a sleeve and protect sinus tarsi contents
Placement of shoulder screw on lateral plate

Answer 65

"

Non-displaced talar neck (<10%) - 9.8%
Dislocation of the subtalar joint (~40-50%) 27.4% - most common
Dislocation of tibiotalar and subtalar (90%) - 53.4%
Dislocation of tibiotalar, subtalar and talonavicular (100%) - 48.0%

"

Answer 66

Indications (JAAOS 2015): comminuted transforaminal sacral fractures from a VS mechanism that cannot be controlled with trans-sacral fixation.
If the fracture line passes medial to the L5/S1 facet joint, the facet joint is intact and there is no vertical displacement
If the fracture line passes lateral to the facet joint, or the L5/S1 facet joint is disrupted and there is comminution, and vertical displacement of the sacral fracture, this injury would be at higher risk for further displacement

Answer 67

Identify borderline patients --> Resuscitate, then reassess

ISS > 20 + Thoracic Injury
ISS > 40
Bilateral Pulmonary Contusions
Abdo/Pelvic Trauma + Shock
Hypothermia
Head injury with AIS>3
GCS<8
IL-6 >500

Criteria

Borderline

Unstable

Transfusion

2-8

5-10

Lactate

< 2.5

>2.5

Platelets

90-110

70-90

Fibrinogen

=1

<1

Temperature

33-35oC

30-32oC

PaO2/FiO2

300-350

200-300

Chest AIS

2

3
Chest AIS:

2 = 2 <3 rib#, clavicle/sternum/scapula #, stab wound into pleura
3/4 = >3 adjacent rib #, unilateral flail segment, chest wall skin avulsion to ribs

Top 3 parameters of resus: Lactate<2.5, BD -2 to 2, gastric pH>7.3

Answer 68

"

Acute non-cardiogenic respiratory failure characterized by decreased PaO2 and a diffuse, massive extravasation of fluid into the interstitial space of the lungs

Treatment: Ventilator support Avoid toxic FiO2, barotrauma General organ support Outcomes: 30-40% mortality rate Major cause of death in patients with lowest ISS scores

"

Answer 69

(Bhandari, 2003)

Open #
Transverse #
Fracture gap
No: smoking, DM, chronic steroids

Answer 70

A. Gluteus minimus

HO is a common complication after the surgical management of acetabular fractures. It has an incidence ranging from 7% to 100%. Substantial discomfort, stiffness, and poor functional outcomes can be seen in patients with HO. The etiology is multifactorial, and the surgical approach to the acetabular fracture pattern is an important factor in successful management. Debridement of a contused gluteus minimus could prevent the formation of HO. Posterior wall fractures and transverse-posterior wall fractures treated through the Koch-Langenbeck approach have an intermediate risk of developing HO. Debriding the damaged gluteus minimus muscle and single-dose radiation have been shown to decrease the incidence of HO. A low incidence of HO has been seen with the ilioinguinal and the Stoppa approaches, an intermediate incidence with the Kocher-Langenbeck approach, and a high incidence with the extended-iliofemoral approach.

Answer 71

B.

Most cases of ankle arthritis are posttraumatic. Recent research has focused on the synovial fluid environment in the ankle after intra-articular fracture. After injury, an increase in proinflammatory cytokines and matrix metalloproteinases occurs that can lead to degradation of the cartilage. Intra-articular lavage has been proposed as a possible protective intervention to reduce the incidence of posttraumatic ankle arthritis.

Patient nonadherence with postoperative restrictions is frustrating and can increase the risk of postoperative complications, but this factor alone has not been demonstrated to be a risk factor for posttraumatic arthritis unless it leads to a loss of fixation. Inflammatory reactions to instrumentation are rare and have not been associated with posttraumatic arthritis. Prolonged postoperative immobilization can be associated with stiffness of the ankle joint but has not been shown to increase the risk of posttraumatic arthritis.

Answer 72

B. Short-term relationship

Hackenberg and associates described a larger percentage of female patients (83%) than male patients (17%) who were affected by IPV. Of the percentage of males treated, a larger number had more substantial injuries or more than one injury (ranging from 2 to 10). The authors also showed that only 17% of the patients in their series were older. In a respective review of more than 1,000 charts of women treated for IPV, Wong and associates found that 833 patients were married, and 132 were practicing cohabitation. Sprague and associates showed that patients in short-term relationships were at higher risk of IPV (OR .584, 99% CO .396-.860, P=0.0001). The Prevalence of Abuse and Intimate Partner Violence Surgical Evaluation (PRAISE) investigators also showed that, of patients seen in orthopaedic clinics who had experienced IPV, 68% had children, compared with 32% who did not.

Answer 73

C. A femoral head cartilage lesion

Tannast and associates found a cumulative survival rate of 79% after a 20-year follow-up in patients with acetabular fractures who were surgically managed. A femoral head cartilage lesion was an independent negative prognostic factor favoring an early arthroplasty option. Other predictors were nonanatomical fracture reduction, age over 40 years, anterior hip dislocation, postoperative incongruence of the acetabular roof, involvement of the posterior acetabular wall, acetabular impaction, an initial displacement of the articular surface of 20 mm or more, and use of the extended iliofemoral approach. Routt and associates showed, in a review of surgically treated posterior wall acetabular fracture, that posterior wall comminution was not associated with an increased risk of conversion to total hip arthroplasty if reduction resulted in less than 1 mm of diastasis or step-off.

Answer 74

- Medial/lateral displacement of 20mm or more

- Angulation of 45^oor more

- Medial/lateral displacement of 15mm or more with angulation of 30^o or more

- Double disruptions of the SSSC (both with >10mm displacement)

- GPA 22^o or less

- Open fracture

Answer 75

- Posteromedial calcar length of the humeral head <8mm

- Loss of medial hinge

- 4-part fracture

- Fracture angulation >45^o

- Tuberosity displacement >10mm

Answer 76

B. Improved function

A meta-analysis looking at the outcomes and complication rates in elderly patients with intra-articular distal humerus fractures treated with total elbow arthroplasty (TEA) or ORIF with locking plates determined that a trend occurred toward a higher rate of major complications and reoperation after ORIF, although this trend did not reach statistical significance. In the only multicenter prospective randomized controlled trial comparing these treatments in the older population, TEA was superior to ORIF as measured by the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder, and Hand scores, especially in the early postoperative period. Surgical time was also shorter in the TEA group, and trends also were observed toward a reduced reoperation rate and improved range of motion in the TEA group, although these trends did not reach statistical significance.

Answer 77

C. Vertebral body

Fragility fractures are exceedingly common and, given the increasing life span of the population, their incidence will greatly increase in years to come. The various fragility fractures have different morbidity and mortality patterns, but the highest likelihood of recurrent fragility fracture occurs after a vertebral compression fracture, followed closely by fractures of the proximal humerus, hip, distal radius, and ankle.

Answer 78

A. Cannulated screws plus tension band using wire

All of the fixation techniques listed have been used in the treatment of patella fractures. Of those listed, cannulated screw fixation with associated wire placement has been shown to provide greater biomechanical stability. Both Burvant and associates and Carpenter and associates showed greater stability in a cadaver model. Burvant described fracture gaps less than half of those seen with traditional modified tension band techniques. Carpenter also described failure at earlier force for screw fixation alone (554 Newtons) than for cannulated screw fixation and wiring (732 Newtons). Benjamin and associates, in a comparison of fixation techniques, described cerclage wire fixation to be the weakest biomechanically, with fracture gaps up to 20 mm.

Answer 79

1. Age >40

2. Non-anatomic reduction

3. Hip dislocation

4. Acetabular roof or posterior wall involvement

5. Articular impaction

6. Femoral head involvement

7. Initial displacement >20mm

Answer 80

MAICE
Meniscal root
Avulsion #
Irreducible!
Chondral injury
Extensor mechanism disruption

Answer 81

Not all high energy fractures are open. This classification emphasizes the importance of viability of the soft tissue envelope at the zone of injury.

Grade 0: Soft tissue damage is absent or negligible

Grade 1: Superficial abrasion or contusion caused by fragment pressure from within

Grade 2: Deep, contaminated abrasion associated with localized skin or muscle contusion from direct trauma

Grade 3: Skin extensively contused or crushed, muscle damage may be severe. Subcutaneous avulsion, possible artery injury, compartment syndrome

Answer 82

Annular ligament

Joint capsule

Biceps tendon

Brachialis (can button hole through)

Answer 83

Line connecting the center of the radial head and ulnar head

Answer 84

On an AP radiograph, a line is drawn from the radial tuberosity to the most ulnar edge of the distal radius. From this line, the longest possible perpendicular line is drawn to the radius.

Normal = 15.3 +/- 0.3mm

Patients with 80% rotation of the normal forearm have a radial bow of 15 +/- 1.5mm (i.e within 1.5mm of the well side)

Answer 85

1. Aggressive I&D in the OR

- Excise contaminated/devilatized tissue, explore wound tract

2. Associated fractures are ex-fixed or IMN

3. IV abx as per open fracture management

4. Tetanus PPx as indicated

5. Repeat I&D in 48 hours

6. Closure by secondary intension, possible graft

Answer 86

1. Intra-articular

2. Retained in the intervertebral disc

3. Compression of the spinal cord

4. Lead toxicity

5. Fragment in palm or sole

Answer 87

1. Length of time projectile has been retained

2. Fragmentation of the projectile

3. Retained in or near synovial fluid

4. Retained within the intervertebral disc

5. Fracture secondary to gunshot

Answer 88

1. Knee ligaments

2. Patella fracture

3. Femoral shaft, neck and head

4. Morel-Lavallee lesion

5. Superior gluteal artery

6. Sciatic nerve