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What is the triad of death?

blood loss 




What are clinical parameters to help determine a borderline patient?


  • Clinical parameters of a borderline patient
    • ISS >40
    • Multiple injuries (ISS >20) in association with thoracic trauma (AIS >2)
    • Multiple injuries in association with severe abdominal or pelvic injury and hemorrhagic shock at presentation (systolic blood pressure <90 mm Hg)
    • Bilateral femoral fractures
    • Radiographic evidence of pulmonary contusion
    • Hypothermia (temperature <35°C [95°F])
    • Additional moderate or severe head injuries (AIS ≥3) 



What are the parameters that are looked at when deciding DCO vs ETO

Blood pressure (mm Hg)

Blood units given in a 2-hr period

Lactate levels (mg/dL)

Base deficit level (mmol/L)

ATLS classification

Platelet count

Factor II and V (%)

Fibrinogen (g/L) D-dimer (μg/mL)

Temperature °C (°F)

Lung function (Pao2/Fio2 [mm Hg])

Chest trauma scores (AIS)

Chest trauma score (thoracic trauma severity score)

Abdominal trauma (Moore classifi- cation)

Pelvic trauma (AO classification)

External Injury (abraision, crush, burn)


Approach to ATLS

  • 2 large bore IV's, O2, monitors, c-collar and spinal precautions
    • ​call for imaging
  • Airway
    • includes cervical spine control
    • Introduce yourself, ask their name
    • Assess for any obvious facial trauma
  • Breathing 
    • O2 sats, resp rate
    • Look for bruising, chest movement
    • Listen to the lungs
    • Things that can kill them
      • Hemothorax - decreased sounds on one side
      • Tension Penumo - decreased sounds, tachy, low BP, trach deviation
  • Circulation 
    • BP, listen to chest
    • includes hemorrhage control and resuscitation (below)
    • pregnant women should be placed in the left lateral decubitus position to limit positional hypotension 
    • Things that can kill them
      • Hemorrahage
      • Cover bleeding wounds, give antibiotics
      • Cardiac Tamponade
        • Muffled heart sounds, low BP, JVP distension (Beck's triade)
      • assess stability of the pevlis in the rotational and vertical plane
  • Disability - GCS
  • Exposure
    • exposue while preventing hypothermia
  • Once they are stable, reassess vitals
  • Ask for initial blood work
  • Foley, NG tube
  • CXR, Pelvic XR, C-spine XR
  • Then proceed to secondary survery
  • Examine head, eyes, facial trauma
  • Examine c-spine while maintaining precations, logroll the patient to assess back and do a rectal
  • Examine all upper extremity joints
  • Chest for trauma, abdo exam, FAST
  • Pelvis - put on a binder if unstable
  • Examine lower extremity joints
  • Log roll, rectal exam
  • Reduce fractures as needed, keep patient warm
  • Check imaging, repeat blood work
    • Make sure imaging is adequate
  • ​CT chest, abdo pelvis
    • ​spine, head
  • Call appropriate services


What are indications for ampuation

Number one indication is the degree of ispsilateral soft tissue injury

  • Indications for amputation (LEAP)
    • Warm ischemia > 6 hours
    • Tibial nerve disruption with crush
    • OR two of the following
      • serious poly- trauma
      • severe injury of the ipsilateral foot
    • anticipation of a protracted course to obtain soft-tissue coverage and tibial reconstruction
  • 7 considerations
    • Severe Open Tibia with a Mangled Foot (foot not salvageable)
    • Massive Non-reconstructable soft tissue loss
    • Warm Ischemia Time > 6-8 hours
    • Patient with multiple medical comorbities – elderly, renal failure, DM – unable to undergo multiple surgeries
    • Medically unstable patient
    • Rapid progressive infection of the limb in a septic patient
    • IIIB or IIIC with confirmation of lacerated Tibial Nerve
  • LEAP
    • No difference in outcomes comparing amputation to reconstruction
    • Higher risk of re-admission, complications and longer time to recovery with reconstruction
    • If the patient is at high risk for amputation it's better to do it earlier


What is the complete gustilo classification

  • Grade 1
    • skin lesion < 1 cm
    • clean
    • simple bone fracture with minimal comminution
  • Grade 2
    • skin lesion > 1 cm
    • no extensive soft tissue damage
    • minimal crushing
    • moderate comminution and contamination
  • Grade 3
    • Extensive skin damage with muscle and neurovascular involvement AND/OR
    • High-speed crush injury
    • Segmental or highly comminuted fracture
    • Segmental diaphyseal loss
    • Wound from high velocity weapon
    • Extensive contamination of the wound bed
    • Any size open injury with farm contamination
  • A
    • Extensive laceration of soft tissues with bone fragments covered
    • usually high-speed traumas with severe comminution or segmental fractures
  • B
    • Extensive lesion of soft tissues with periosteal stripping and contamination
    • severe comminution due to high-speed traumas
    • usually requires replacement of exposed bone with a local or free flap as a cover
  • C
    • Exposed fracture with arterial damage that requires repair


What is the criteria of SIRS

  • Heart rate > 90 beats/min
  • WBC count less than 4000 cells/mm³ OR greater than 12,000 cells/mm³
  • Respiratory rate > 20 or  PaCO2 < 32mm (4.3kPa)
  • Temperature less than 36 degrees or greater than 38 degrees


Approach to an irreducible talus

  • Attempt in emerg
  • Stimen pin in the calcaneus
  • femoral distractor
    • two small pins in each segment
  • medial malleolar osteotomy is your open approach


What are the risk factors for radioulnar synostosis

  • trauma related
    • Monteggia fracture
    • both bone forearm fractures at the same level
    • open fracture,
    • significant soft-tissue lesion
    • comminuted fracture
    • high energy fracture
    • associated head trauma
    • bone fragments on the interosseous membrane
  • treatment related
    • use of one incision for both radius and ulna
    • delayed surgery > 2 weeks
    • screws that penetrate interosseous membrane
    • bone grafting into interosseous membrane
    • prolonged immobilization


Diagnosis?  Management?

Radioulnar Synostosis

  • History 
    • previous trauma or surgery in forearm
    • Take a complete history of the circumstances of the break and associated risk factors
    • Pain
      • pain with incomplete synostosis
      • no pain with complete synostosis
  • Physical exam 
    • pronation and supination blocked both actively and passively
    • Limited supnation is more limiting
    • Usually ned 45/45
  • Radiographs 
    • recommended views 
      • AP and lateral of forearm, elbow, and wrist
    • bony bridge between radius and ulna 
  • CT to help clarify location
  • Historically people would get bone scan, but this is no longer recommended
  • No longer need to wait until maturation, this only causes further atrophy and weakness
  • surgical resection of synostosis
    • indications 
      • post-traumatic synostosis that impairs function
    • excision indicated at 4-6 months
    • Approaches
      • Distal - ECU/FCU, watch for ulnar nerve
      • Middle - Henry approach
      • Proximal - boyd
    • Interposition
      • fascia lata is best
      • Fat not recommended, but should be used other than nothing
      • If not comfortable can use bone wax or gelfoam
    • Adjunt
      • Proximal radial head excision
      • Darrach, sauve kapanji
      • Some authors have tried TEA with variable success, but this is not routinely recommended due to limited function and complications
  • Small cases series of proximal radius resection distal to synostosis - rehab with brace
    • Contraindicated with essex-lopreseti lesion
  • Post-op
    • Nighttime splinting alternating sup/pro
    • Aggressive PT, strength starting at 6 weeks
  • Recurrence/Prevention
    • No good evidence to show prophlaxis following hip surgery
    • No good evidence for radiation post-excision of synostosis except in TBI
    • Some people use indomethecin, but this is not well established
    • Recurrence is treated with repeat excision after disucssion with the patient
      • May require a more aggressive procedure
      • Beware risk of nerve injury and infection, especially around the elbow
  • results 
    • results of resection are poor except for midshaft synostosis


Work-up for this fracture?

  • Full PMHx, smoker, amulatory status
  • Physical exam
    • 10% open
    • neurovascular
    • may need to do ABI
  • Plain XR
    • 30% will miss a hoffa's fracture
  • CT 
    • obtain with frontal and sagittal reconstructions
    • useful for 
      • establish intra-articular involvement
      • identify separate osteochondral fragments in the area of the intercondylar notch
      • identify coronal plane fx (Hoffa fx) 
        • 38% incidence of Hoffa fx's in Type C fractures 
      • preoperative planning
  • Angiography 
    • indicated when diminished distal pulses after gross alignment restored


Benefits of a fixed angle locking construct over DCS

  • Locks to plate - better varus control
  • Better control of comminution with multiple points of fixation
  • Lock or compress as needed
  • Less invasive insertion, less tissue disruption
  • Has the versatility to use around  TKA


Pros and cons of treating a distal femur fracture non-operatively 

  • indications (rare) 
    • nondisplaced fractures
    • nonambulatory patient
    • patient with significant comorbidities
    • Severe osteoporosis
  • Significant complications associated with immobility
    • Decubitus ulcers
    • Thromboelmbolic disease
    • Loss of knee function
  • Recent evidence supports fixation of these fractures to avoid complications


Options for fixation and post-op plan for this fracture (include approaches)

  • ORIF Approaches
    • anterolateral
      • fxs without or with simple articular extension
      • incision from tibial tubercle to anterior 1/3 of distal femoral condyle
    • lateral parapatellar
      • fxs with complex articular extension
      • extend incision into quad tendon to evert patella
    • medial parapatellar 
      • typical TKA approach
      • used for complex medial femoral condyle fractures
      • Can also use a subvastus approach for a less comlicated fracture pattern
    • medial/lateral posterior
      • used for very posterior Hoffa fragment fixation
      • patient placed in prone position
      • midline incision over popliteal fossa
      • develop plane between medial and lateral gastrocnemius m.
      • capsulotomy to visualize fracture
  • Blade Plate Fixation 
    • indications 
      • not commonly used, technically difficult
      • contraindicated in type C3 fractures
    • technique 
    • placed 1.5cm from articular surface
  • Dynamic Condylar Screw Placement 
    • indications 
      • identical to 95 degree angled blade plate 
    • technique 
      • precise sagittal plane alignment is not necessary
      • placed 2.0cm from articular surface 
    • cons 
      • large amount of bone removed with DCS
      • Not good fixation in porotic bone
  • Locked Plate Fixation 
    • indications
      • fixed-angle locked screws provide improved fixation in short distal femoral block
    • Benefits
      • Locks to plate - better varus control
      • Better control of comminution with multiple points of fixation
      • Lock or compress as needed
      • Less invasive insertion, less tissue disruption
      • Less bone remove for central lag screw
      • Has the versatility to use around  TKA
    • Technique
      • lag screws with locked screws (hybrid construct)
      • useful for intercondylar fractures (usually in conjunction with locked plate) 
      • useful for coronal plane fractures 
      • helps obtain anatomic reduction of joint
      • required in displaced articular fractures 
  • Retrograde interlocked IM nail 
    • indications 
      • good for supracondylar fx without significant comminution
      • preferred implant in osteoporotic bone
    • approach
      • medial parapatellar
      • no articular extension present 
      • 2.5cm incision parallel to medial aspect of patellar tendon
        • stay inferior to patella
        • no attempt to visualize articular surface
      • articular extension present 
        • continue approach 2-8cm cephalad
      • incise extensor mechanism 10mm medial to patella
      • eversion of patella not typically necessary
    • pros 
      • requires minimal dissection of soft tissue
      • Greater stiffness
      • Trend toward fewer infections and nonunions when used appropriately
    • cons 
      • Can fail with loss of fixation of distal construction
        • Nail can migrate into the knee
      • less axial and rotational stability
      • postoperative knee pain
    • Causes for malalignment
      • Insufficient fracture reduction
      • Poor starting point
      • Eccentric reaming
  • Post-op
    • Immediate ROM with quads and hamstring strengthening
    • WB at 12 weeks when evidence of union
    • Can start PWB prior to this


Complications of distal femur fracture

  • Failed hardware (in varus)
    • Causes of failure
      • Extensive metaphyseal comminution
      • Poor reduction
      • Poor plate position
      • Early weight bearing
  • Symptomatic hardware
    • lateral plate
    • pain with knee flexion/extension due to IT band contact with plate
    • medial screw irritation 
    • excessively long screws can irritate medial soft tissues
    • determine appropriate intercondylar screw length by obtaining an AP radiograph of the knee with the leg internally rotated 30 degrees
  • Malunions
    • most commonly associated with plating
    • functional results satisfactory if malalignment is within 5 degrees in any plane
  • Nonunions
    • treatment with revision ORIF and autograft indicated 
    • consider changing fixation technique to improve biomechanics


What are the recommendations for safe tourniquette use

  • Pressure
    • Anticipated inflation time <2.5 h
      • Upper extremity ≤250 mm Hg
      • Lower extremity ≤300 mm Hg
    • Anticipated inflation time >2.5 h
      • Consider measuring limb occlusion pressure and using a safety margin of 50–75 mm Hg
      • Consider using a wide, shaped cuff
  • Inflation time
    • Assess the operative situation at 2 h
    • Anticipated duration >2.5 h
      • 10-min deflation interval at that point
      • and at subsequent 1-h intervals. 


What is the leading cause of death in pelvic fractures?



What are factors associated with poor prognosis following a pelvic fracture (mortality)


  • systolic BP <90 on presentation
  • age >60 years
  • increased Injury Severity Score (ISS) or Revised Trauma Score (RTS)
  • need for transfusion > 4 units 



What are the risks of injuries associated with pelvis fractures; what are you looking for on physical exam

  • hemmorage is the leading cause of death
  • chest injury in up to 63%
  • long bone fractures in 50%
  • head and abdominal injury in 40%
  • spine fractures in 25%
  • urogenital injuries in 12-20%
  • inspection 
    • test stability by placing gentle rotational force on each iliac crest; then gently pull axial traction on the legs to assess for vertical instability
      • low sensitivity for detecting instability 
      • perform only once 
    • look for abnormal lower extremity positioning 
      • external rotation of one or both extremities   
      • limb-length discrepancy
    • skin 
      • scrotal, labial or perineal hematoma, swelling or ecchymosis
      • flank hematoma
      • lacerations of perineum
      • degloving injuries (morel-lavelle)
  • neurologic exam  
    • rule out lumbosacral plexus injuries (L5 and S1 are most common)
    • rectal exam to evaluate sphincter tone and perirectal sensation
  • urogenital exam 
    • most common finding is gross hematuria
    • more common in males (21% in males, 8% in females)
  • vaginal and rectal examinations 
    • mandatory to rule out occult open fracture


What are the ligaments of the pelvis?

  • anterior 
    • symphyseal ligaments 
      • resist external rotation
  • pelvic floor 
    • sacrospinous ligaments
      • resist external rotation
    • sacrotuberous ligaments
      •  resist shear and flexion
  • posterior sacroiliac complex (posterior tension band)
    • strongest ligaments in the body
    • more important than anterior structures for pelvic ring stability 
    • anterior sacroiliac ligaments
      • resist external rotation after failure of pelvic floor and anterior structures
    • interosseous sacroiliac 
      • resist anterior-posterior translation of pelvis
    • posterior sacroiliac 
      • resist cephalad-caudad displacement of pelvis
    • iliolumbar
      • resist rotation and augment posterior SI ligaments


What are adequate inlet/outlet views and what are they used for?

  • inlet view  
    • X-ray beam angled ~45 degrees caudad (may be as little as 25 degrees) 
      • adequate image when S1 overlaps S2 body
    • ideal for visualizing: 
      • anterior or posterior translation of the hemipelvis
      • internal or external rotation of the hemipelvis
      • widening of the SI joint
      • sacral ala impaction
  • outlet view  
    • X-ray beam angled ~45 degrees cephalad (may be as much as 60 degrees)
      • adequate image when pubic symphysis overlies S2 body
    • ideal for visualizing:
      • vertical translation of the hemipelvis
      • flexion/extension of the hemipelvis
      • disruption of sacral foramina and location of sacral fractures


What on a pelvic XR would make you think it is unstable? What further imaging can you do?

  • > 5 mm displacement of posterior sacroiliac complex
  • presence of posterior sacral fracture gap
  • avulsion fractures
  • CT
    • can help you determine if there is occult posterior invovlement
  • Analysis under anesthesia
    • IR for LC
      • overlaps 1-2cm then fix front
      • >2cm fix front and back
    • ER in frog leg for APC1
      • if opens >2.5cm fix front
    • pull legs for vertical instability APC2
      • fix back if presence of saggital instability
    • windswept can apply different stress to each side
  • Single leg standing views can help determine in clinic instability


What it the tile classification?

  • A - stable
    • A1-fracture not involving the ring (avulsion or iliac wing fracture)
    • A2-stable or minimally displaced fracture of the ring
  • B - rotationally unstable, vertically stable
    • B1-open book
    • B2-lateral compression, ipsilateral
    • B3-lateral compression, contralateral (bucket-handle injury)
  • C - rotationally and vertically unstable
    • C1-unilateral
    • C2-bilateral
    • C3-associated acetabular fracture


What is the young-burgess classification?

  • Anterior Posterior Compression (APC)
    • APC I
      • Symphysis diastasis < 2 cm
      • Non-operative. Protected weight bearing
    • APC II
      • Anterior SI joint diastasis
      • Posterior SI ligaments remain intact.
      • Anterior symphyseal plate or external fixator
    • APC III
      • Disruption of anterior and posterior SI ligaments (SI dislocation). 
      • APCIII injuries associated with vascular injury 
      • Anterior symphyseal plate or external fixator and posterior stabilization with SI screws
  • Lateral Compression (LC)
    • LC Type I
      • Oblique ramus fracture and ipsilateral anterior sacral ala compression fracture. 
      • Non-operative. Protected weight bearing
    • LC Type II
      • Ramii fracture and ipsilateral posterior ilium fracture dislocation (Crescent fracture). 
      • Open reduction and internal fixation of ilium
    • LC Type III
      • Ipsilateral lateral compression and contralateral APC (windswept pelvis). 
      • Common mechanism is rollover vehicle accident or pedestrian vs auto. 
      • Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference. 
  • Vertical Shear (VS)
    • Posterior and superior directed force. 
    • Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%
    • Posterior stabilization with plate or SI screws as needed. Percutaneous or open based on injury pattern and surgeon preference.


Which pelvic injury is associated with the highest chance of hypovolemic shock

vertical shear


What is the appropriate technique for placing a pelvic binder

  • centered over greater trochanters to effect indirect reduction
  • do not place over iliac crest/abdomen
    • ineffective and precludes assessment of abdomen
  • may augment with internal rotation of lower extremities and taping at ankles
  • transition to alternative fixation as soon as possible 
    • prolonged pressure from binder or sheet may cause skin necrosis
  • working portals may be cut in sheet to place percuatneous fixation


Technique for pelvic ex-fix

  • required if you need to do angio or stabilize the pelvis for positioning/packig
    • definative if
      • open injury
      • bladder rupture requiring surgical repair
  • theoretically works by decreasing pelvic volume 
  • stability of bleeding bone surfaces and venous plexus in order to form clot
  • Don't reduce with the pins because you can open in the back, push from behind as well
  • pins inserted into ilium 
    • Supra-acetabular
      • single pin in column of supracetabular bone from AIIS towards PSIS
        • obturator outlet or "teepee" view to visualize start point
        • iliac oblique - trajectory
        • obturator oblique inlet - path of wire
      • Risk - hip capsule, LFCN
    • Iliac Crest
      • multiple half pins in the superior iliac crest
      • place in thickest portion of anterior ilium, gluteus medius tubercle or gluteal pillar
      • faster in a more urgent situation
  • should be placed before emergent laparatomy 


Indications for pelvic fixation

  • Definative Ex-fix
    • contaminated open pelvis
    • extraperitoneal bladder rupture
  • ORIF
    • symphysis diastasis > 2.5 cm
    • SI joint displacement > 1 cm
    • sacral fracture with displacement > 1 cm
    • displacement or rotation of hemipelvis
    • open fracture
  • Can do assessment under anesthesia to rule out instabilty
  • diverting colostomy may be requried in an open fracture
  • start posterior and work anterior


Options for anterior stabilization of the pelvis


  • single superior plate - pubic symphyis widening
    • supine, make sure you can get all the necessary views before starting
    • apply through rectus-splitting Pfannenstiel approach (Modified stoppa)
    • may perform in conjunction with laparotomy or GU procedure
    • technique
      • confirm reduction with flouro
      • contour plate or use pre-contoured plates
      • two medial screws adjacent to the syphysis are placed first and eccentrically
        • use finger feel for proper screw placement
    • Controversy
      • 2 plates - better for rotational stability
      • 4 or 6 holes - better to use a 6 hole plate and can tailor your construct
  • Ex-fix
    • inferior, but can be used if needed
    • can also be used if the patient becomes unstable
  • Retrograde Screw vs plate
    • Ramii fractures can be often be treated non-op, but may need stabilization
    • Sometimes won't heal 



Pfannsteil approach

  • transverse incision 2 cm above the pubis
  • develop subcutenous plane, incise the linea alba longitudianlly
  • inspect the bladder, use a blunt malleable retractor to protect the space of reitz
  • be cautionous for the corona mortise
  • homans over the superior pubic ramii to retract the retus, then subperiosteial disection
  • some will remove the cartilage in the pubis to promote fusion
  • Options for reduction
    • use a large tenaculum to reduce the symphysis
    • jugabluth clamp 
    • c-clamp
    • ex-fix pins