Trauma Flashcards
1
Q
What is IL-6 associated with in trauma patients?
A
Elevated IL-6 is associated with higher injury severity scores and increased mortality rates in polytrauma patients.
2
Q
Why should tibial nails be reamed without the use of a tourniquet?
A
Limb reperfussion after tourniquet ischemia causes pulmonary microvascular injury.
3
Q
What radiographic findings of a tibial plateau fracture correlate with a meniscal tear?
A
Schatzker type II fractures with >6mm of joint depression and widening >5mm were associated with a lateral meniscal injury over 80% of the time.
4
Q
How do ROM and strength compare between displaced mid shaft clavicle fractures treater operatively and non-operatively?
A
Motion is the same, but strength is decreased to about 80% in planes of motion.
5
Q
True or false current literature has found that clavicle fractures shortened by 2 cm that are treated operatively have better Constant and DASH scores at all points in time that those treated non-operatively?
A
True. See COTS et al. multicenter randomized controlled trial of 132 patients.
6
Q
Should you transpose the ulnar nerve following fixation of an intra-articular distal humerus fracture?
A
No literature supports a decreased incidence of neuropathy after distal humerus fixation. Some paper show an increase of ulnar neuropathy.
7
Q
What is a common injury associated with lateral compression fractures of the pelvis?
A
Closed head injuries?
8
Q
What is the most common complication after displaced alar neck fractures following operative treatment?
A
Post-traumatic arthritis. More common that osteonecrosis as some literature shows rates of sub-alar arthritis to be 100%.
9
Q
What is the golden hour? What percentage of preventable deaths occur during this time?
A
Period of time when life threatening and limb threatening injuries should be treated in order to decrease mortality. 60%
10
Q
What position should pregnant women involved in a trauma be placed in?
A
left lateral decubitus position. Avoid compression of the inferior vena cava.
11
Q
What are the classes of hemorrhagic shock?
A
12
Q
What amount of blood does the average adult have?
Average child (2-10)?
A
4.7-5 Liters for 70kg Male
75-80ml/kg
13
Q
What are laboratory indicators of adequate resuscitation?
A
Urine output .5-1.0 ml/kg/hr (30cc/hr)
Lactate normal <2.5 mmol/L
Base deficit -2 to +2
gastric mucosal pH > 7.3
14
Q
Which virus is most at risk from tranfusion?
A
Hepatits B 1 in 205,000 donations
Hepatitis C 1 in 1.8 million donations
HIV 1 in 1.9 million
15
Q
What parameters should lead you to treat a patient with damage control orthopaedics?
A
ISS >40 without thoracic trauma and ISS > 20 with thoracic trauma.
GCS of 8 or below.
Multiple injuries and hemorrhagic shock.
Bilateral femoral fractures
pulmonary contusion noted on radiographs
Hypothermia <35 degrees
Head injury with AIS of 3 or greater
IL-6 values above 500pg/dL
16
Q
When is the acute inflammatory window where patients are at a higher risk of ARDS?
A
2-5 days.
17
Q
When should femurs be converted form ex-fix to IMN?
tibias?
A
within 3 weeks.
7-10 days.
18
Q
How is Glasgow Coma Scale calculated?
A
Best Motor Response 1-6: None, decerebrate (extension withdrawal), decorticate (flexion withdrawal), normal withdrawal, localized pain, obeys commands.
Best Verbal Response 1-5: None, incomprehensible sounds, inappropriate words, cofused conversation, and oriented.
Eye Opening 1-4: None, to pain, to speech, and spontaneous.
BRAIN INJURY: Severe <9, Moderate 9-12, Minor 13 and above.
19
Q
How is ISS calculated.
A
AIS 1-6 score of 9 body regions. 0- no injury 1- minor 2-moderate 3- severe (not life threatening) 4- severe (life threatening survival probable) 5- severe (survival uncertain) 6- maximal (possibly fatal).
sum of squares for the three highest regions.
Out of 75
Single score of any region of 6 = automatic score of 75
ISS > 15 mortality of 10%
20
Q
What is the New Injury Severity Score (NISS)?
A
Takes three highest scores regardless of anatomic area.
More predicitive of complications and mortality than ISS.
21
Q
How is SIRS calculated?
A
Heart rate > 90 beats = 1
WBC count <4000 OR >12,000 = 1
RR > 20 OR PaCO2 < 32mm = 1
Temperature <36 OR >38 = 1
Score of 2 or more meets criteria for SIRS
22
Q
What advantage has been shown when open fractures undergo I&D within 6 hours compared to 24 hours?
A
No clinical advantage has been shown.
However most centers recommend doing it within 6 hours still.
23
Q
What is an alternative to a saline load to test for traumatic arthrotomy?
A
CT scan.
Some studies have shown this to be more effective.
24
Q
How is tetanus prophylaxis given?
A
Toxoid .5ml regardless of age.
immunoglobulin <5 years old receive 75 U, 5-10 years receive 125 U, > 10 years receive 250 U.
toxoid and immunoglobulin should be given in different locations with different syringes.
25
What abx is recommended for Gustilo type I and II?
1st generation cephalosporin.
Clindamycin or vancomycin if allergies exist.
26
What abx is recommended in Gustilo type III fractures?
1st generation cephalosporin + aminoglycoside.
27
What abx should be added for farm injuries, heavy contamination, or possible bowel contamination?
High dose penicillin for anaerobic coverage.
Soil can have Clostridium botulinum which is a Gram Positive Bacilli.
28
What abx should be added for fresh water wounds?
fluoroquinolones
3rd or 4th generation cephalosporin
29
What abx is recommended for saltwarer wounds?
doxycycline + ceftazidime
Or a fluoroquinolone.
30
When do open fractures with soft tissue defects need to be covered?
The earlier the better. For open tibias \<5 days is desired.
Increased risk of infection beyond 7 days.
31
What is the in hospital mortality rate and at one year post-op for hip fractures in geriatric patients?
6%
30%
32
Geriatric co-management of trauma patients has been demonstrated to yield?
Decreased mortality
Decreased time to surgery
Decreased post-operative complications
Decreased length of stay (controversial)
Improved post-operative mobility
33
What is the second leading cause of death for youth in the United States?
GSW
34
What is yaw in regards to projectiles?
tendency of a bullet to tumble in flight.
35
What has the greatest increase on kinetic energy of a bullet?
velocity.
KE = 1/2M \* Vsquared
36
What is plumbism and what is its systemic effects?
Lead intoxication
neurotoxicity, anemia, emesis, and abdominal colic
37
What is the most commonly assoicated injury with a GSW to the hip and acetabulum?
bowel perforation\>vascular injury\>urogenital injury
38
What is considered a low velocity GSW and what is its comparable Gustillo-Anderon?
High Velicty?
\<350 meters per second or \< 2,000 fps GA I and II
\>600 mps GA III regardless of wound size. High risk of infection.
39
What is the most common reason for amputation?
What is the most common reason for upper extremity amputation?
80% are for vascular insufficiency
Trauma
40
What should be offered to all patients who undergo an amputation?
formal psychological counseling to review coping and stress management techniques.
Psychological effects negatively affect patient-reported outcomes and are associated with worse pain complaints.
41
Is absence of plantar sensation a relative or absolute contraindication to reconstruction in severe lower extremity injuries?
Relative.
Can be some recovery of plantat sensation long term.
42
What has the highest impact on the decision-making process for amputation vs reconstruction?
Severity of soft tissue injury.
43
What is the difference between sickness impact profile and return to work between amputation and reconstruction at 2 years in limb-threatening injuries?
Not significantly different.
44
What is the most important factor in determining patient-reported outcome after treatment for a limb threatening injury?
Ability to return to work.
Approximately 50% are able to return to work.
45
What is the % increase in metabilic demand for bilateral amputation?
BKA + BKA
AKA + BKA
AKA + AKA
40%
118%
\>200%
46
What is the most proximal lower extremity amputation a child can undergo and maintain walking spees without increased energy expenditure compared to normal children?
thru-knee amputation
47
Is there a difference in metabolic demand after amputation for traumatic reasons vs vascular?
Yes
Long BKA 10% vs 40%
Transfemoral 68% vs 100%
48
Average increase in metablic demand for
Syme amputation
BKA (traumatic)
15%
25% (10% for long 40% for short)
49
Wound healing after amputation is improved with what values for:
Albumin
Ischemis Index
TCPO2
toe pressure
ABI
TLC
\> 3.0 g/dl
\> .5 (doppler pressure at level being tested compared to brachial systolic pressure)
\>30mm Hg (ideally 45 mm Hg)
\> .45
\> 1500/mm3
50
Contraindications to hyperbaric oxygen therapy?
Chemo or radiation.
Pressure sensitive implanted medical device such as pacemakers, defibrillators, dorsal column stimulator, and insulin pumps.
undrained pneumothorax.
51
What is the purpose of preserving all motor and sensory branches within operative fields when performing an amputation?
Can result in improved muscle mass and preserve the ability to create myoelectric signals for targeted reinnervation.
52
Is it necessary to perform an adductor myodesis in a transfemoral amputation?
Yes
Improves clinical outcomes
Creates dynamic muscle balance
Provides soft tissue envelope that enhances prosthetic fitting.
53
What is a Gritti-Stokes Amputation?
Aputation through femur near adductor tubercle
Synovium is excised
Patella is arthrodeed to the end of femur
Studies have shown improved outcomes compares to transfemoral amputation.
54
What outcomes have been found when comparing through knee amputations to BKAs and AKAs?
slower walking speeds than BKA
Similar amounts of pain
Worse performance on SIP (sickness impact profile).
Physicians were less satisfied with outomes
Less likely to use prosthesis
More dependence with patient transfers than BKA.
55
What is required for a Sympe amputation?
What is the most important prognostic factor?
patent tibialis posterior artery
stable heel pad
56
What is a Chopart of Boyd amputation?
What is the primary complication?
foot amputation through talonavicular and calcaneocuboid joints
equinus deformity (Avoid by lengthening achilles tendon and transfer of the tibialis anterior to talar neck.
57
What is the common complication of a Lisfranc amputation?
How can it be prevented?
equinovarus deformity
Unopposed pull of tibialis posterior and gastroc/soleus complcex
Prevent by maintaining insertion of peroneus brevis and perfroming achilles lengthening.
58
What is the physical exam consistent with ARDS
mottled or cyanotic skin
resistant hypoxia
intercostal retractions
rales/crackles and ronchi
tachypnea
Chest x-ray will show bilateral pulmonary infiltrates with a normal sized heart.
59
What is the most common cause of compartment syndrome?
Trauma (with specifically fractures 69% of cases)
60
Compartment pressures should be performed how close to fracture site?
within 5cm.
61
What are the indications for emergent fasciotomy for compartment syndrome?
Contraindications?
Clinical presentation consistent with compartment sydnrome.
In obtunded patient compartment pressures within 30mm Hg of diastolic blood pressure. Remember if intra-op measurement must be compared to pre-op blood pressure.
Missed compartment syndrome.
62
What should be done for hemophiliacs before measuring compartment pressures?
Factor VIII replacement.
63
How should a clamp be placed for correct reduction of the syndesomosis?
Lateral tine directly on the lateral malleolar ridge.
Medial tine at the anatomic midportion of the medial tibia. Can be confirmed fluoroscopically as the anterior third of the tibia on a true lateral view of the ankle.
Parallel to the joint line.
Parallel to the anatomic syndesmotic angle.
1-2 cm proximal to the mortise at the level of the incisura.
64
What is the most likely source of arterial hemorrhage in patients with APC pelvic fracture?
LC?
Superior gluteal.
Internal pudendal or obturator artery.
65
What percent of scapula fractures are associated with another orthopaedic injury?
What is most common?
What is the most common non-orthopaedic injury?
80-90%
Rib fractures.
Pulmonary contusion.
66
What degree of displacement of the glenoid from a scapular fracture that doesn't pass through the glenoid (scapular neck) warrants fixation?
translation of 1cm and or angulatory displacement of 40 degrees or more.
67
When should you begin ROM after a scapula fracture?
2 weeks start PT.
68
Indications for fixation of glenoid and coracoid fractures?
\>25% of glenoid, \>5mm of articular step off, and medialization of the glenoid.
Coracoid fracture with \> 1cm of translation.
69
What interval is used for the Judet approach?
Internervous plane between infraspinatus(suprascapular nerve) and teres minor (axillary nerve).
70
What artery is most commonly injured with scapulothoracic dissociation?
Subclavian artery
71
What is the most common result of scapulothoracic dissociation?
Flail extremity
72
What imaging test should be considered in scapulothoracic dissociation?
Angiogram.
73
Why is the junction of the outer and middle third of the clavicle predisposed to injury?
Thinest part of the bone.
Only area not protected by or reinforced with muscle and ligamentous attachments.
74
What is a zanca view on radiographs?
15 cephalic tilt for clavicle fractures.
Helps to determine superior/inferior displacement.
75
Absolute indications for operative fixation of a clavicle fracture?
Open
Skin tenting
Vascular injury
Floating shoulder
Symptomatic non-union or malunion.
76
Relative indications for operative fixation of a clavicle fracture?
\> 2cm of displacement
Bilateral
Brachial plexus injury
Polytrauma
Seizure disorder or closed head injury.
77
What is the rate of non-union after clavicle fractures?
Risk factors for non-union?
1-5%
\> 100% displacement
\> 2cm shortening
Advanced age
Female gender
Comminution
78
What nerve is commonly injured with fixation of clavicle fractures?
supraclavicular cutaneous nerves.
79
Advantages of open reduction and internal fixation of calvicle fractures?
Improved functional outcomes
Less pain with overhead activities
Faster time ot union
Decreases symptomatic malunions
Improved cosemtic and overall shoulder satisfaction
Increased shoulder strength and endurance.
80
True or false female gender is a risk factor for nonunion of calvicle fractures?
True
81
What percent of individuals end up requesting plate removal?
30%
82
True or false a clavicle malunion can present with thoracic outlet syndrome?
True
83
Which AC joint ligament is strongest?
Superior
84
Describe the Neer classification of distal clavicle fractures.
85
List precdictors of humeral head ischemia in order from most to least predictive for proximal humerus fractures?
Calcar length less than 8mm\> disrupted medial hinge\> humeral head angulation more than 45 degrees\> head-split fracture.
86
What amount of displacement of the greater tuberosity in a proximal humerus fracture should lead to ORIF?
\> 5mm
87
What amount of cortical thickness implies good proximal humerus bone quality?
Combined medial and lateral cortical thickness \> 4mm.
88
True or false IM humeral nails have superior rates of fracture healing and ROM when compared to ORIF for proximal humerus fractures?
True
Not really done because it violates the rotator cuff though.
89
What should you assume until proven otherwise in a isolated lesser tuberosity fracture of the proximal humerus?
That there is a posterior dislocation.
90
What is a good fixation option for proximal humerus fractures with greater tuberosity fracture that are displaced and a patient with osteoperotic bone?
Fixation with heavy nonabsorbable sutures.
Avoids hardware pullout leading to impingement.
91
How far sould the greater tuberosity be placed below the articular surface of the humeral head in a hemiarthroplasty being performed for a proximal humerus fracture?
10mm
Can have impairment of ER kinematics and up to 8-fold increase in torque with non-anatomic placement.
92
How do you best determine hieght of the prosthesis for a hemiarthroplasty performed for a proximal humerus fracture?
Off the superior edge of the pectoralis major tendon.
5.6cm between the top of the humeral head and the superior edge of the tendon.
93
Are risk factors the same for humeral head ischemia in the proximal humerus and the risk of developing subsequent avascular necrosis?
No
94
What is the most common complication after ORIF of a proximal humerus fracture?
Screw cut out.
14% in fractures treated with locking plate.
95
What are the greatest risk factors for non-union after a proximal humerus fracture?
SMoking and advanced age.
The particular study was for proximal humerus fractures treated non-op.
96
How should a chonic non-union/malunion of a proximal humerus fracture in the elderly be treated?
Arthroplasty
97
What difference is there between humeral fractures treated with an IMN vs ORIF with a plate for the following?
Facture Union?
Radial Nerve Palsy?
Surgical Site Infection?
Complications?
None
None
None
Higher with IMN
98
What is a Holstein-Lewis Fracture?
A spiral fracture of the distal one-third of the humeral shaft commonly associated with neuropraxia of the radial nerve (22% incidence)
99
What is the criteria for acceptable alignment for non-operative treatment of humeral shaft fractures?
\< 20 degees of anterior angulation
\< 30 degrees varus/valgus angulation
\< 3cm shortening
Absolute contraindications: severe soft tissue injury or bone loss, vascular injury, brachial plexus injury.
**Radial nerve palsy is not a contraindication to functional bracing.**
100
What is the PPV of a non-union does no callous on radiograph and gross motion at the humeral shaft fracture site at 6 weeks?
100%
101
What is the incidence of radial nerve palsy in humber shaft fractures?
What should you be worries about in open fractures?
What is the prognosis?
8-15% if closed fractures
22% in distal third fractures.
Neuropraxia more common injury in closed while neurotomesis in open fractures is more common.
85-90% improve with observation over 3 months.
102
When do you observe and when do you surgically explore a radial nerve palsy in a humerus fracture?
observe for 3 months in a closed fracture.
If no improvement obtain EMG at 3 months
Fibrillation (denervation) on EMG you should surgically explore.
Open fractures should be explored as more likley to be neurotomesis.
Closed fractures that do not improve after 3-6 months.
103
When is a anterolateral approach to a humerus fracture used?
Where is the radial nerve?
Proximal to middle third shaft fractures.
Radial nerve found between the brachialis and brachioradialis distally
104
When is a posterior approach to the humerus used?
Where is the radial nerve found?
Distal to middle third shaft fractures.
Medial to the long and lateral heads and 2cm proximal to the deep head of the tricpes
**Lateral brachial cutaneous/posterio antebrachial cutaneous nerve serves as an anatomic landmark leading to the radial nerve during a paratricipital approach.**
**Radial nerve exits the posterior compartment through lateral intramsucular septum 10cm proximal to radiocapitellar joint.**
105
What is the most common endocrine or metabilic disorder that leads to nonunions?
Vitamin D deficiency (68%)
106
What is the gold standard treatment for a humeral shaft non-union?
Compression plating with bone grafting.
Bone grafting should be used in atrophic nonunions.
Nearly 100% union rate reported.
In the rare case or recalcitrant atrophic nonunions can consider free fibular grafting.
107
What is the general prognosis after an adults distal humerus fracture?
majority of patients regain 75% of elbow motion and strength
Unsatisfactory outcomes in 25%
108
What adult distal humerus fracture can be treated non-operatively?
Nondisplaced Milch Type 1 fracture(Lateral trochlear ridge is intact)
109
What postoperative protocol is recommended after a distal humerus fracture ORIF that requried an olecranon osteotomy?
No active extension against gravity or resistance for 6 weeks
Can perfrom active-assisted extension and active flexion for the first 6 weeks
No restrtiction on rotation.
All ROM and gentle strengthening at 6 weeks then full strengthening program at 3 months.
110
What is the most common complication after ORIF of a distal humerus fracture?
Elbow stiffness
Heterotopic ossification seen in 8%
**routine prophylaxis is not warranted due to increased rate of nonunion in patients treated with indomethacin.**
111
What position is the arm in to create a capitellar fracture?
Typically a low energy fall onto a partially flexed elbow leading to direct axial compression that creates shear forces.
112
What olecranon fracture characteristic for a non-comminuted fracture determines whether a tension band can be used?
The fracture cannot extend distal to the coronoid.
Also a transverse fracture line is ideal. The more oblizue the fracture becomes the less likely a tension band will work.
113
What is the non-op protocol for o non-displaced olecranon fracture in a low demand elderly individual?
immobilization in 45-90 degrees.
Begin motion as tolerated at 1 week to avoid stiffness.
114
What gauge wire should be used for a tesion band technique for an olecranon fracture?
18 gauge
115
What is the rate of re-operation after tension band fixation of an olecranon fracture?
reported ranges of 40-80%
rate of plate removal is reported to be 20%
symptomatic hardware is the most common complication
116
What is the most common adult elbow fracture?
radial head fracture.
occurs from a fall on an oustretched hand with the elbow in extension and forearm in pronation.
60% of the load across the elbow is through the radiocapitellar joint.
117
What is an Essex-Lopresti injury?
Distal radioulnar joint injury. and interosseous membrane disruption.
This injury plus a radial head fracture leads to complete loss of longitudinal stability.
Leads to proximal migration of the radius and ulnocarpal impaction.
118
Where is the non-articular portion of the radial head?
90 degree arc from radial styloid to Lister's tubercle
This is the safe zone for hardware placement.
119
What is the Mason Classification?
Classification of radial head fractures.
120
What can you do if you are unsure if a radial head fracture is causing a mechanical block to motion?
Aspiration of joint hematoma and injection of local anesthesia will make evaluation easier.
121
How much translation in the sagittal plane is indicative of injury to DRUJ?
\> 50% compared to contralateral side
122
Is there a test to determine if a patient has an Essex-Lopresti Injury?
Radius pull test
\> 3mm translation concerning for longitudinal forearm stability.
123
What is a Greenspan View radiograph?
Radiocapitellar view.
It is a oblique lateral view of elbow
Beam angled 45 degrees cephalad
Allows visualization of the radial head without coronoid overlap.
Helps deted subtle fractures of the radial head.
124
What has a better outcome in a 3 fragment radial head fracture. ORIF or Radial head replacement?
Still can have a good outcome with ORIF. \> 3 fragments better outcomes with radial head replacement.
125
What size fragements can you consider excising from the radial capitellar joint?
Less than 25% surface of radial head.
25-33% of capitellar surface area.
126
True or false: Compared to ORIF for fracture-dislocations and Mason Type III fractures, arthroplasy results in greater stability, lower complication rate, and higher patient satisfaction.
True
127
What complications can be seen afer excision of the radial head?
Muscle weakness
Wrist pain
Valgus elbow instability
HO
arthritis
Proximal radial migration
Cubitus valgus
128
What is the most common major joint dislocation?
What is second?
Shoulder
Elbow
129
Where is the ligament injury in the most common type of adult elbow dislocations?
Most commonly a non-bony avulsion of the lateral epicondylar origin.
Second most common is a midsubstance LCL tear.
130
What are the dynamic stabilizers of the elbow joint?
Anconeus
Brachialis
Triceps
131
What is the rate of recurrent instability after simple dislocations?
1-2% of dislocations.
132
What is considered enough instability on ROM after a closed reduction of an elbow dislocation that you would consider acute surgical fixation for a simple elbow dislocation?
Elbow require more than 50-60 degrees of flexion to maintain reduction.
133
What treatement is generally recommended for a chronic elbow dislocation?
Open reduction, capsular release, and dynmaic hinged elbow fixator to allow early ROM but still protect the repair.
134
If the LCL is disrupted the elbow will be more stable in?
Pronation.
135
If the MCL is disrupted the elbow will be more stable in?
Supination
136
What do you do after operative repair of an elbow if instability persists even after reconstruction of LCL and any extensor origin avulsion?
Likely that the MCL needs to be repaired or reconstructed.
If after all fractures have been repaired and LCL and MCL reconstruced there is still instability then you can consider a hinged external fixator.
137
What nerve injury is typically associated with a brachial artery injury that occurs because of a complex elbow dislocation.
Median nerve injury.
These injuries are rare.
138
Coronoid fractures involving what \_\_% of the coronoid do not confer elbow stability and do not require repair?
10%
If you still have isntability in a terrible triad with a small coronoid fracture after adressing the radial head and LCL next best step is MCL.
139
How soon after ORIF of a complex elbow fracture should you initiate ROM exercises?
48 hours
Post-traumatic stiffness is a very common complication.
140
How does fixation of the LCL change depending on whether the MCL is intact?
Position of the forearm during fixation of the LCL is different.
If MCL is intact LCL is repaired with forearm in pronation.
If MCL is injured LCL is repaired with forearm in supination to avoid medial gapping due to overtightening
For all repairs elbow should be at 90 degrees of flexion.
141
Describe the Bado Classification.
142
functional results depend most on restoration of what after a both bone forearm fracture?
Restoration of radial bow.
143
What extremity fracture should not be allowed to have early weight bearing even in the polytrauma patient?
Both bone forearm fractures.
Have been shown to have a higher risk of secondary displacement of the fracture.
144
What is the rate of synostosis after both bone forearm fractures?
When can you perform excision with low recurrence risk?
3-9% reported
As early as 4-6 months when prophylactic radiation therapy and/or indomethacin are used postoperatively.
145
When can you remove a plate(s) after forearm fractures?
Other than too early plate removal what leads to increased risk of refracture?
**Do not remove plates before 15 months.** wear functional forearm brace for 6 weeks and protect activity for 3 months after plate removal.
Increased risk with: large plates (4.5mm) comminuted fx, and persisten radiographic lucency.
146
What distance from articular surface has been found to have an increased incidence of DRUJ instability in Galeazzi fractures?
\<7.5 cm instability in 55%
\>7.5 cm unstable in only 6%
147
In what position is the DRUJ most stable?
What ligaments are the primary stabilizers?
Supination
Volar and Dorsal radioulnar ligaments.
148
What are radiographic signs of more likely DRUJ injury?
ulnar styloid fracture
widenting of joint on AP view
Dorsal or volar displacement on lateral view
Radial shortening \>5mm
149
What muscle deforming forces lead to DRUJ subluxation?
Pronator quadratus and brachioradialis.
150
What approach and technique should be used for reduction and stabilization of DRUJ?
if stable after radius fixation then immobilize in supination for 6 weeks.
If reducible but unstable then corss-pin ulna to radius and leave pins in place for 4-6 weeks.
If reduction is blocked (usually by EDU tendon) then open reduction
Approach: dorsal capsulotomy
Also consider open reduction and fixation if there is a large ulnar styloid fragment.
151
What is the most common cause of death overall from pelvic ring fractures?
hemorrhage less than 24 hours
Multi-organ failure after 24 hours.
152
what are the mortality rates after closed and open pelvis fractures.
What is associated with increased mortality
1-15% reported for closed and up to 50% for open fractures.
systolic BP \<90 on presentation
age \> 60 yrs
High ISS or RTS
Tranfusion \> 4units.
153
Which pelvic injury pattern has the greatest potential for sexual dysfunction?
APC injuries.
154
What orthopaedic injuries are most commonly associated with pelvic fractures?
What non-orthopaedic injuries?
Chest injury in up to 63%
Long bone fractures in 50%
Spine fractures in 25%
Non-orthopaedic: urogenital(up to 50% in APC), head (40%), and abdominal (40%)
155
What ligaments are most important for pelvic ring stability?
Posterior sacroiliac complex- acts as a posterior tension band
Strongest ligaments in the body.
Made up of:
Anterior sacroiliac- resist external roation after failure of pelvic floor and anterior structures.
Interosseous sacroiliac- resist anterior-posterior translation of pelvis
Posterior sacroiliac- resist cephalad-caudad displacement of pelvis
156
What ligaments make up the pelvic floor and what forces do they resist?
SACROTUBEROUS: resist shear and flexion
SACROSPINOUS: resist external rotation
157
What percentage of patients with a pelvic fracture will sustain neurolgoic injury?
Up to 10-15%
L5 and S1 are most common.
158
What percentage of the time is hemorrhage from venous injury and arterial injury respectively with pelvic fractures?
80% venous from posterior thin walled venous plexus.
retroperitoneal space can hold up to 4L of blood.
10-20% arterial injury
159
In APC pelvic fractures with arterial bleeding what artery is most commonly implicated?
What arteries are more commonly involved in LC pattern pelvic fractures?
Superior gluteal artery
Internal pudendal and obturator artery
160
How do you obtain an inlet pelvic x-ray?
Bean angled 40 degrees caudad
Adequate imaging when S1 overlaps S2 body (i.e. perpendicular to S1 endplate)
161
How do you obtain a pelivc outlet x-ray?
Bean angled 40 degrees cephalad may be as much as 60 degrees.
Adequate image when pubic symphysis overlies S2 body.
162
What are radiographic signs of pelvic ring instability?
\> 5mm displacement of posterior sacroiliac complex
presence of posterior sacral fracture gap
Avulsion fractures- ischial spine, ishcial tuberosity, sacrum, **transverse process of 5th lumbar vertebrae**
163
Even if not embolizeing what is CT angiography useful for in the setting of pelvic ring fractures?
Determining presence or absence of ongoing arterial hemorrhage
98-100% negative predictive value
164
What determines weight bearing status in a LC 1 pelvis injury?
Simple incomplete sacral fractures with \<1cm of displacement SI joint can be weight bearing as tolerated.
Complete or comminuted sacral component or \>1cm of displacement of SI joint should be treated with TTWB.
165
How do you treat parturition-induced pelvic diastasis?
bedrest and pelvic binder when diastasis is less than 4cm.
\> 4cm same acute treatment but some consideration for operative intervention.
Chronic pain in patients with \< 4cm can consider ORIF.
166
What complications are associated with anterior subcutaneous pelvic fixators?
HO, femoral nerve injury, infection.
167
What should be considered as part of the treatment protocol for an open pelvic fracture with extensive perineal injury or rectal involvement?
Diverting colostomy.
168
What has been assoicated with early pelvic binding and CT?
underestimation of pelvic ring instability.
Fluroscopic exam under anesthesia can be used to assess stability in these circumstances
169
Describe how to place supra-acetabular for pelvic external fixation.
What views are needed?
What structure is at risk?
Place single pin in column of supracetabular bone from AIIS towards PSIS.
Obturator outlet view- helps identify pin entry point
Iliac oblique view- helps to direct pin above greater sciatic notch
Obturator oblique inlet view- helps to ensure pinplacement within inner and outer table
lateral femoral cutaneous nerve at risk.
170
What is an indication for ORIF of a posterior pelvic injury from an anterior approach?
What is a contraindication?
SI joint dislocations that cannot be reduced with closed or percutaneous techniques.
Comminuted sacral fracture patterns
171
What fracture pattern leads to the highest rate of postoperative loss of recution in unstable posterior pelvic ring injuries?
Vertical sacral fractures.
172
What is the most common urogenital injury with pelvic ring fractures?
How is the diagnosis made?
What are some inidcations for further investigation?
Posterior urethral tear
Retrograde urethrocystogram
Above test should be ordered if there is blood at meatus, high riding or excessively mobile prostate, or hematuria.
173
What longterm urogential complications are seen in pelvic fractures?
What is the most common?
urethral stricture- **most common**
impotence
anterior pelvic ring infection
incontinence
parturtion sequelae (i.e. caesarean section)
174
What is the most common nerve injury with anterior subcutaneous pelvic fixator placement?
LFCN is most common
Femoral nerve injury can also occur.
175
What should be considered in a patient with a severe pelvis fracture and a closed head injury preventing early fixation of pelvis?
Vena caval filter for high risk of DVT and PE
176
How do you diagnose chronic instability after a pelvic fracture?
Alternating single-leg-stance pelvic radiographs.
Patient will present with subjective instability and mechanical symptoms.
177
What is the rate of DVT and PE in pelvis fracutes?
Fatal PE?
DVT 60%
PE 27%
Fatal PE 2%
**prophylaxis is essential**
178
What percent of sacral fractures have a neurological injury?
25%
## Footnote
**Presence of neurologic deficit is the most important predictor of outcome.**
179
What is the rate of neurologic injury in a zone 3 Denis classification sacral fracture?
Denis Zone 3 fractures are medial to the foramina.
60% have bowel, bladder, and sexual dysfunction.
**U-type sacral fracture has the highest incidence of neurologic complications.**
180
What construct has the greatest amount of stifness when treating sacral fractures?
Iliosacral and lumbopelvic fixation. Triangular osteosynthesis is another name for lumbopelvic fixation.
Greater than bilateral sacroiliac screws and anterior plating.
181
When ilium fragment remains with the sacrum this is termed a?
Crescent fracture.
182
What artery runs across the SI joint?
Superior gluteal artery.
Exits pelvis via greater sciatic notch.
183
Which pelvic fracture pattern has the highest reported mortality rates?
APC III
184
What acetabular fracture patterns are more common in young patients?
Old patients?
T-type, transverse, transverse+posterior wall, and posterior wall.
Anterior column, anterior column posterior hemitransverse, and both columns.
185
Describe Judet and Letournel Acetabular Fracture Classification.
186
What is the roof arc angle with regard to acetabular fractures?
Angle between vertical line through femoral head and line through fracture.
Helps to define fracture pattern stability
Considered stable if the fracture line exits outside the weight bearing dome of the acetabulum
Defined as \> 45 degrees on AP, obturator, and iliac oblique views
Not applicable for associated both column or posterior wall pattern because no intact portion of the acetabulum to measure.
187
What is a gull sign with regards to acetabular fractures?
represents impaction of superomedial roof
Seen on obturator oblique view
Pathognomonic for posterior wall fractures
188
What is a spur sign?
Represents most caudal part of intact ilium due to medialization of articular components
Seen on obturator oblique view
Pathognomic for ABC fractures
189
When are the greatest and lowest joint reactive forces seen in the hip?
Lowest when toe-touch weight bearing and passive hip abduction.
Greatest seen when rising from a chair on the affected extremity.
190
What patient and fracture characteristics would lead you to treat an acetabular fracture non-operatively with 6-8 weeks TTWB?
High risk, Morbid obesity, Open wound, Late presentation \> 3 weeks.
Fracture characteristics: minimally displaced \<2mm.
\<20% posterior wall fracture but this is controversial. **Recommend EUA with fluoro as the best method to test stability.**
191
True or false pregnancy is not a contraindication to surgical fixation of a acetabular fracture?
True.
192
Better and worse outcomes after ORIF of acetabular fracture are associated with what?
Age \> 55 has been associated with inferior outcomes. (study was fractures with dislocation). 30% late conversion rate to THA in a study of patients older than 60 years.
Hip dislocations reduced less than 6 hours no change in outcomes. Worse outcomes if longer then 12 hours.
Quality of reduction. Should be \< 2mm.
193
For percutaneous column screws what is the obturator outlet and iliac inlet views used for?
Obturator outlet best view to rule out joint penetration.
Iliac inlet view best to determine anteroposterior position of screw within the pubic ramus.
194
What are the four approaches for acetabular fractures?
What fractures are they indicated for?
What are the risks associated?
195
What is the most common complication after acetabular fractures?
What risk factors are associated with this?
Post-traumatic DJD.
80% survival noted at 20 years s/p ORIF.
Risk factors: age\>40, associated fracture patterns, concomitant femoral head injury
196
What is the percent of osteonecrosis after acetabular fractures?
6-7% of all acetabular fractures
18% of posterior fracture patterns
197
What treatment is recommended for HO after ORIF of a acetabular fracture?
Which approach has the highest risk?
Lowest risk?
Indomethacin 5 weeks post-op. Low dose external radiation not shown to be any better.
Extended illiofemoral
Ilioinguinal
198
What potentially fatal injury is associated with posterior hip dislocations in deceleration trauma mechanism injuries?
Thoracic aortic rupture
199
What percent of hip dislocations are associated with other injuries?
What is most common?
What is the rate of sciatic nerve injury?
95%
Ipsilateral knee injuries
10-20% sciatic nerve injury
200
What must be done after all reductions of traumatic hip dislocations?
CT to look for femoral head fractures, loose bodies, and acetabular fractures.
201
What is the rate of the following after traumatic native hip dislocations:
Post-traumatic arthritis?
Femoral head osteonecrosis? What increases this risk?
Sciatic nerve injury?
Recrrent dislocations?
Up to 20% for simple dislocation. Much higher for complex dislocation.
5-40%. Higher with increased time to reduction.
8-20%. Also higher with increased time to reduction.
Less than 2% with proper treatment.
202
What are the two kinds of anterior hip dislocations?
**Superior (pubic) dislocation-** caused by hip abduction, external rotation, and hip extension. Leg appears in extension and external rotation.
**Inferior (obturator)-** Caused by hip abduction, external rotation, and hip flexion. Leg in that postion on presentation as well.
203
What are the three sources of blood supply to the femoral head in an adult?
**extracapsular arterial ring-** Medial circumflex femoral artery is the main supply to the head from profunda femoris. lateral circumflex femoral artery does contribute.
**Ascending cervical branches**
**Artery to theligamentum teres-** from the obturator artery or MCFA. Supples perifoveal area.
204
What percent of hip dislocations are associated with femoral head fractures?
5-15% of posterior dislocations. higher chance the less flexed the hip is at time if injury.
Anterior hip dislocations are usually associated with impaction/identation fractures of the femoral head.
205
What is the pipkin classification of femoral head fractures?
206
How would you treat a Pipkin 1 fracture?
Femoral head fracture that is sub foveal.
Assuming no interposed fragments and a stable hip joint.
TTWB for 4-6 weeks with limited adduction and internal rotation.
207
What are indications for ORIF after a femoral head fracture?
What is the post-op protocol?
Pipkin II with \> 1mm step off
If there is an ssociated neck (Pipkin 3), acetabular fracture(Pipkin 4), or loose bodies in the joint.
Early ROM can begin immediately after. NWB until 6-8 weeks. Radiographs after 6 months to evaluate for AVN and post-traumatic arthritis.
208
What is the advantage of a digastric osteotomy or trocahnteric flip being utilized in treatment of a Pipkin 4 fracture?
Allows both the acetabulum and the femoral head fracture to be treated through one approach. Does require surigcal dislocation of the hip.
209
Which apporach to the hip has higher rates of heterotopic ossification? Anterior or Posterior?
Anterior
210
What is the most expensive fracture to treat on a per-person basis?
Femoral neck fracture.
211
What percent of femoral shaft fractures are associated with femoral neck fractures?
6-9%
The femoral neck fracture should be treated first due to the risk of AVN.
212
What is the most significant predictor of for post-op survival after a femoral neck fracture?
Pre-injury functional independence and mobility.
213
Describe the garden classification?
214
What is Pauwel's Classification and what is it used for?
215
What imaging can be used to assess viability of femoral head after a femoral neck fracture?
There isn't one.
Neither bone scan or MRI are helpful.
216
What should patients with a delayed presentation to the hospital after a hip fracture be screened for?
DVT with duplex ultrasound of both lower extremities.
217
What correlates most closely with non-union in femoral neck fractures?
Varus malreduction.
No correlation between age, gender, and rate of nonunion.
218
What are the failure rates after operative fixation of a femoral neck fracture in patients \>70 years old?
up to two years?
2-10 years?
46% fail within 2 years. 2-10 year follow-up stabilized with a filure rate of approx 2-4%.
219
What factors increase mortality after intertrochanteric hip fracture?
Male gender (25-30%) vs female (20%)
Intertroch higher than femoral neck.
Operative delay of \> 2 days. **Surgery within 48 hours decreeases 1 year mortality.**
Age \> 85 years
2 or more pre-existing medical conditions
ASA classification (ASA III and IV increases mortality)
220
Where is the clacar femorale?
Vertical wall of dense bone that extends from posteromedial aspect of the femoral shaft to posterior portion of femoral neck.
221
What is the most common complication afert fixation of an intertrochanteric hip fracture?
Implant cutout and failure.
Usually occurs within first 3 months.
tip-apex distance \> 45mm associated with 60% failure rate.
222
What causes anterior perforation of the distal femur when placing a IMN?
Posterior starting point in the greater trochanter.
Mismatch of the radius of curvature. Nail with too large of a radius of cruvature (straight nail with short curned femur).
223
What radiographic findings are characteristic of atypical subtrochanteric femur fractures?
Lateral cortical thickening
Increased diaphyseal cortical thickness
Transverse vs. short oblique fracture orientation.
Medial spike (if complete fracture)
Lack of comminution.
**If no fracture but pain and cortical thickening nail. Do not if asymptomatic.**
224
What complications are seen with plate and nail fixation of femoral bisphosphonate fractures?
**Nail:** 1. Increased risk of iatrogenic fracture because of brittle bone and cortical thickening. 2. Increased risk of nonunion with nail fixation resulting in increased need for revision surgery.
**Plate:** 1. Increased risk of plate failure because of varus collapes and slower healing due to intramembranous helaing being inhibited by bisphosphonates.
225
What is the most frequent intraoperative complication with antegrade nailing of subtrochanteric femur fracutres?
Malreduction
Varus and flexion(procurvatum) deformity becuase of deforming forces.
226
What amount of articular step-off is acceptable for femoral head fractures?
1mm or less.
227
How often are femoral neck fractures associated with femoral shaft fractures?
What is the most common femoral neck fracture pattern?
2-6%
Most often basicervical, vertical, and nondisplaced
Missed 19-31% of the time.
228
What is average blood loss from a closed femoral shaft fracture?
Tibia fracture?
1250. Range 1000-1500.
750. Range 500-100.
Open fractures can have double the blood loss.
229
ORIF of femur fractures with plates compared to IM nails has increased rates of?
Infection
Nonunion
Hardware failure
230
Stabilization of a femoral shaft fracture with a femoral nail within 24 hours is associated with?
When would you not want to perform surgery within 24 hours?
Decreased pulmonary complications (ARDS), Decreased thromboembolic events, improved rehabilitation, and decreased length of stay and cost of hospitalization.
Exception is a patient with a closed head injury. Want to avoid hypotension and hypoxemia. Consider provisional fixation instead.
231
When would you consider a retrograde femoral nail?
Ipsilateral femoral neck fracture
Floating knee (ipsilateral tibial shaft fracture)
Bilateral femur fracture (avoids repositioning)
Morbid obesity
232
Using a straight nail with a trochanteric entry point will lead to what complication?
Using a trochanteric nail with a piriformis starting point will lead to what complication?
Varus malalignment
Valgus malalignment
233
Reamed femoral nails are superior to unreamed nails in what ways?
When might you use a unreamed femoral nail?
Increased union rates, decreased time to union, and no increase in pulmonary complications.
bilateral pulmonary injuries and metastatic disease
234
True or false there is an increased rate of septic knee iwth retorgrade nailing of open femur fractures?
False, there is no increase.
235
What is the incidence of pudendal nerve injury when using a fracture table with traction?
10%
236
What is the incidence of heterotopic ossification with a femoral shaft fracture?
25%
rarely clinically significant.
237
How much malrotation is usally well tolerated after a femoral shaft fracture?
What method most accurately determines rotational malalignement?
Is it more common in proximal or distal femur fractures?
15 degrees
Jeanmart method- angle between a line drawn tengential to the femoral condyles and a line drawn through the axis of the femoral neck.
More common with proximal femur fractures.
238
What are risk factors for iatrogenic fractures when fixing femoral shaft fractures?
Antegrade starting point 6mm or more anterior to the intramedullary axis. **Should not confuse this with risk of anterior perforation with to posterior of a starting point.**
Failure to overream canal by at least .5mm
239
What leads to lateral mechanical axis deviation (MAD) and what leads to medial mechanical axis deviation (MAD)?
Lengthening along the anatomical axis of the femur leads to lateral MAD
Shortening along the anatomical axis of the femur leads to medial MAD
240
The anatomical axis of the femur is in how many degrees of varus or vlagus?
6-7 degrees of valgus.
241
Where is the thickest articular cartilage in the body?
Patella, up to 1cm thick.
242
Where is the most important blood supply to the patella located?
Inferior pole.
Comes from anastomotic ring originating from geniculate arteries
243
What are some indications for ORIF of patella fractures?
When might a partial patellectomy be indicated?
Unable to perform a straight leg raise (extensor mechanism failure)
Articular fracture displacement \>2mm
Displaced patella fracture \> 3mm
Comminuted superior or inferior pole fracture measuring \<50% patellar height
**every effort should be made to preserve the patella**
244
By how much is quadricpes torque reduced in a total patellectomy?
50%
Have to perform sufficeint imbrication to avoid extensor lag
Consider advancing VMO as they have better strength and outcomes.
245
What should be done for osteonecrosis of the proximal fragment after ORIF of a patella fracture?
Observe these as most spontaneously revascularize by 2 years.
25% of patella fractures have some osteonecrosis but it is rarely clinically significant.
246
What nerve injury is most common with a knee dislocation?
Most common is common peroneal nerve. (25% incidence with knee dislocations)
Tibial nerve injury is less common
247
What pathoanatomy leads to the high incidence of popliteal artery injuries with knee dislocations?
Artery is tethered at the popliteal fossa
Proximally at the fibrous tunnel at the adductor hiatus
Distally at the fibrous tunnel at the soleus muscle
248
According to Kennedy classification which knee dislocation is consistent with all of the following?
most common
due to hyperextension injury
usually ivolves tear of PCL
arterial injury is generally an intimal tear due to traction
Anterior(30-50%)
249
According to Kennedy classification which knee dislocation is consistent with all of the following?
2nd most common
Due to axial load to the flexed knee
Highest rate of vacular injury
Highest incidence of a complete tear of the popliteal artery
Posterior (30-40% of knee dislocations)
250
According to Kennedy classification which knee dislocation is consistent with all of the following?
due to varus or valgus force
usually involves tears of both ACL and PCL
Highest rate of peroneal nerve injury
Lateral (13%)
251
According to Kennedy classification which knee dislocation is consistent with all of the following?
Varus or valgus force
usually disrupted PLC and PCL
Medial (3% of dislocations)
252
According to Kennedy classification which knee dislocation is consistent with all of the following?
usually irreducible
buttonholing of femoral condyle through the capsule
Rotational (4%)
Posterolateral is most common rotational dislocation. Will have a **dimple sign** from the medial femoral condyle buttonholed through the medial capsule.
253
What position should the knee be fixed in with an external fixator after a knee dislocation?
20-30 degrees
254
What is the most common complication after a knee dislocation?
Stiffness (arthrofibrosis) 38%
Not Vascular injury as it is 5-15% of all knee dislocations
40-50% of anterior and posterior knee dislocations have a vascular injury
255
What percent of knee dislocations have instability leading to redislocation?
Redislocation is uncommon
However, 37% have some degree of instability.
256
What is the Schenck Classification used for?
Knee dislocations
Based on the number of ruptured ligaments
257
Ligamentous reconstruction/repair after a knee dislocation has been shown to have improved outcomes with?
Early treatment within 3 weeks.
258
Which fracture pattern has the highest incidence of lateral meniscal tears?
Schatzker II
259
Medial meniscla tears are most commonly associated with which tibial plateau fracture?
Schatzker IV fractures.
260
Which Shatzker fractures have the highest incidence of ACL injuries
25% incidence with Type IV and VI
261
What are the indications for ORIF of plateau fractures?
Articular stepoff \> 3mm
Condylar widening \> 5mm
varus/vlagus instability
all medial plateau fxs
all bicondylar fxs
Definitive treatment with ex-fix/Ilizarov +/- limited open/percutaneous fixation of articular segment is severe open fractures with marked contamination or highly comminuted fractures
262
What is associated with postoperative infection after ORIF of a tibial plateau fracture?
Male gender
Smoking
Pulmonary disease
Bicondylar fracture patterns
Intraoperative time over 3 hours
263
Does fixation of a tibial plateau fracture increase risk of infection when down at the following times relative to fasciotomy closure?
Before
Same time
After
No
No
No
264
What has the geater risk of post traumatic arthritis after ORIF of a tibial plateau fracture?
Postoperative joint stepoff or alteration of limb mechanical axis
Alteration of limb mechanical ais more than 5 degrees triples the rate of osteoarthritis
According to Rademakers et al
265
When using a ring fixator for a tibial plateau fracture how for from the joint surface must the wires be kept?
14mm
While this minimizes soft tissue insult and permits knee ROM there are inappropriately high malunion rates.
266
What is the interval used for a posteromedial incision to fix a tibial plateau fracture?
Interval between pes anserinus and medial head of gastrocnemius
267
In a proximal third tibia fracture is the proximal fragment in varus or valgus?
The proximal fragment is in varus. This is becuase of the pull of the pes anserinus.
This should not be confused with the most common deformity from proximal third fractures being procurvatum and valgus.
268
What is acceptable alignment for closed treatment of tibia fractures?
\< 5 deg varus/valgus angulation
\< 10 degrees anterior/posterior angulation
\> 50% cortical apposition
\< 1cm shortening
\< 10 degrees rotational alignment
For closed treatment place in a long leg cast in 10 to 20 degrees of flexion and then convert to a functional brace at 4 weeks.
269
Where is the starting point for a tbial nail?
Just anterior to the anteriro articular margin
Just medial to the lateral tibial spine.
A more medial starting point risk valgus malalignment while a more lateral starting point reduced valgus malalignment.
270
What is the incidence of malunion after nailing of proximal tibia fractures?
rates reported range from 20-60%
Procrvatum can be prevented with nailing in semiextended position
Other aids in prevention are blocking screws, temporary plating, and universal distractors.
271
A spiral distal third tibia fracture is most commonly associated with what other ipsilateral skeletal injury?
posterior malleolar fracture
272
True or false reaming with use of a tourniquet is NOT associated with thermal necrosis of the tibial shaft?
True
It is however associated with pulmonary microvascular injury that occurs after limb perfusion when the tourniquet is let down.
273
Long lateral percutaneous locking plates used for tibia fractues have an associated with what complications?
Superficial peroneal nerve injury.
274
Percutaneous plate versus infrapatellar IMN shown to have what?
Equivalent time to union
Greater radiation exposure
Longer surgical duration
Lower postoperative pain scores
More difficulty in hardware removal
275
Does reaming negatively affect any of the following when placing an IMN for open tibia fractures?
Union
Infection
Need for additional surgery
No
No
No
276
What has been shown to acheive the following when used in open tibial shaft fractures?
accelerate early fracture healing
decrease rate of hardware failure
decrease need for subsequent autologous bone grafting
decrease need for secondary invasive procedures
decrease infection rates
rhBMP-2
However more recent studies have not fully supported this and its use remains highly controversial
277
What were some of the notable outcomes of the LEAP study?
Most important predictor of eventual amputation is the severity of ipsilateral extremity soft tissue injury.
Most important predictor of infection other than early abtibiotic administration is transfer to a definitive trauma center.
Study shows no significant difference in functional outcomes between amputation and salvage.
Loss of plantar sensation is not an absolute indication for amputation
278
What can OP-1 be used for in tibia fractures?
Another name for BMP-7
Used in cases of recalcitrant non-unions.
279
What is the most common type of malalignment after IMN of distal 1/3 tibia fractures?
Malrotation or valgus.
280
What is the most common nerve palsy after IMN for a tibia fracture?
transient peroneal nerve palsy. Deep distribution
EHL weakness and 1st dorsal webspace decreased sensation.
281
What are risk factors for a poor clinical outcome and inability to return to work in distal tibia fractures?
Lower level of education
pre-existing medical comorbidities
male sex
work-related injuries
lower income levels
282
When does brake travel time return to normal after a pilon fracture?
6 weeks after weight bearing is allowed.
283
What amount of skin bridges are necessary when using multiple incisions about the ankle?
Generally \> 7cm with full thickness skin flaps
284
What is the difference in reduction and alignment in pilon fractures when the fibula is instrumeted vs not instrumented?
No difference in alignment and reduction
However, there is a higher incidence of hardware removal.
285
What is the most common complication after tibial plafond fractures in the first year?
Wound problems: Dehiscence 9-30%, decrised by waiting 10-14 days to perfrom definitive fixation. Infection 5-15%. Wound slough 10%, may require a free flap.
286
What is the primary restraint to anterolateral talar displacement?
Deep portion of deltoid ligament.
287
True or false, gravity stress radiograph is equivalent to manual stress radiograph?
True
288
What is a double contour sign on a AP ankle radiograph indicative of?
Posterior malleolus fracture
289
Decreased tibiofibular overlap is found with what injury?
What are the normal values for overlap on AP and mortise views?
Syndesmotic injury.
Measure at the point of maximum overlap.
Some reports have not found any correlation with overlap or clear space measurements and syndesmotic injury.
AP view \> 6mm
Mortise view \> 1mm
290
What is a normal medial clear spac measurement and what is an abnormal value predictvie of?
Normal less than or equal to 4mm on mortise or stress view
\> 5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption.
291
Where do you measure tibiofibular clear space and what is a normal value?
1 cm above joint
\<6mm on AP and Mortise views
Increased clear space associated with a syndesmotic injury
292
Describe the Lauge Hansen classification system
293
A 1mm shift of talus leads to how much of a decrease in tibiotalar contact area?
42%
294
When does proper braking response time return to baseline after operatively treated ankle fractures?
9 weeks
295
What are the outcomes after ORIF of ankle fractures?
What is considered the most important factor?
90% have a good functional result. However, recover is prolonged. 2 years to obtain final functional result.
Anatomic reduction most important for satisfactory outcome.
296
What patient factors lead to worse outcomes in ankle fractures?
Smoking, decreased eductaion, alcohol use, and presence of medial malleolar fracture.
297
What is the most common disadvantage of using posterior antiglide plating for fibula frcture?
Peroneal tendon irritation if the plate is placed to distally on the fibula.
298
What posterior malleolar fracture can be treated non-operatively?
\<25% of articular surface involved. This should be evaluated with a CT as radiographs are unreliable.
\< 2mm articular stepoff
syndesmotic stability
**stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior mal compared to 40% in isolated syndesmosis fixation. Still need to remember to stree examine after fixation.**
299
What prevents reduction of the in a "Bosworth fracture dislocation?"
fibula is entrapped behind the tibia.
## Footnote
**Posterolateral ridge of the distal tibia blocks the reduction**
300
Instability of the syndesmosis after injury is greatest in what direction?
Anterior-poseterior direction.
301
What technique should be used for syndesomtic reduction?
What fixation is recommended?
Place reduction clamp on mid-medial tibial ridge and the fibular ridge at the level of the syndesomsis.
One or two cortical screws 2-4cm above the joint. Angled posterior to anterior 20-30 degrees. suture or 1-2 screws with 3-4 cortices. **Unless diabetic**
No difference seen with hardware removal or leaving broken or loose hardware.
Outcome may be worse with maintenance of intact screws.
302
How should fixation differ fro diabetic ankle fractures?
Regardless of whether they have neuropathy
Multiple quadricortical syndesmotic screws (consider even in the absence of syndesmotic injury)
Stiffer more rigid plates instead of 1/3 tubular
NWB for 3 months instead of 4-8 weeks.
High risk of loss of reduction
Deep Infection up to 20% in diabetics.
303
What motion can be lost with posterior fixation of ankle fractures?
Loss of dorsiflexion
304
What is the blood supply of the talar neck?
**Posterior tibial artery-** dominant supply is artery or tarsal canal. deltoid branch of supplies medial portion of talar body (**may be only remaining blodd supply with a displaced fracture**).
**Anterior tibial artery**-supplies head and neck
**Perforating peroneal artery-** via artery of tarsal sinus. Also supplies head and neck.
305
Describe the Hawkins classification and associated AVN rates.
306
What x-ray views is best to demonstrate talar neck fractures?
Canale view
maximum equinus, 15 degrees pronated, and xray 75 degrees cephalad from horizontal
307
How should talar neck fracutres be managed?
All cases require emergent closed reduction in ER
Hawkins 1 can be treated in a cast 8-12 weeks with the first 6 weeks NWB. **Need CT to confrim no articular stepoff.**
All other talar neck fractures should be treated with ORIF. Extruded talus should be replaced and treated with ORIF.
308
What is Hawkins sign, when is it best seen, and what does it signify?
Subchondral lucency best seen on mortize xray at 6-8 weeks.
Indicates intact vascularity with resportion of subchondral bone
309
What is the most common complication after talar neck fracture?
Subtalar arthritis 50%
tibiotalar arthrtis 33%
Osteonecrosis is 31% when includeing all subtypes
310
What are the two approaches for talar neck fracture?
**anteromedial:** between tibialis anterior and posterior tibialis. Preserve soft tissue attachments especially deep deltoid ligament (blood supply for talus in within this area) Medial malleolar osteotomy if needed.
**anterolateral:** Between tbia and fibula proximally in line with 4th ray. Elevate extensor digitorum brevis and remove debris from subtalar joint.
311
What malunion is most common after talar neck fracture?
What can be done?
varus malunion (25-30% of cases)
Leads to decreases subtalar eversion with locked midfoot and hindfoot. Causes weight bearing on lateral border of foot.
Treatment is medial opening wedge osteotomy of talar neck.
312
What can be difficult to see on plain radiographs of the ankle and misdiagnosed as an ankle sprain?
Lateral process fracture.
Type 2 lateral process fractures involve the subtalar and talofibular joints and may require fixation.
313
Describe the different approached used for talus fractures other than talar neck fractures.
314
Regarding subtalar dislocations:
Which are most common?
Which are more likely to be open?
What is the most common associated dislocation?
How often are they associated with fractures?
Medial dislocations
Lateral dislocations more likely to be open (25%). associated with higher energy mechanisms
talonavicular
associated fractures 44% of the time
315
What blocks reduction of a medial talus dislocation
Peroneal tendons, EDB, and talonavicular joint capsule
associated with posterior process of talus, dorsomedial talar head, and navicular fractures.
316
What blocks reduction of a lateral dislocation?
PT tendon, FHL, and FDL
associated with lateral process of talus, anterior calcaneus, cuboid, and fibula fractures.
317
Is this a medial or lateral subtalar dislocation?
Medial dislocation
talar head will be superior to navicular on lateral view
318
Is the image a picture of medial or lateral dislocation?
Lateral dislocation
talar head will be collinear or inferior to navicular on lateral view
319
What is first line treatment for a subtalar dislocation?
closed reduction and short leg NWB cast for 4-6 weeks
60-70% can be reduced by closed methods
32% will require open reductions
320
What is the most common complication after a subtalar dislocation?
stiffness
Post-traumatic arthritis second most common with 89% demonstrating radiographic arthrosis of which 63% are symptomatic.
321
What is the most common tarsal fracture?
calcaneus
17% open fractures
322
What two fragments are created by the primary fracture line in calcaneus fractures?
Superomedial fragment (constant fragment). Includes sustentaculum tali and is stabilized by strong ligamentous and capsular attachements.
Superolateral fragment. Includes an intra-articular aspect thorugh the posterior facet
Secondary fracture line dictates whether it is a joint depression or tongue-type fracture.
323
Inversion and plantar flexion of the foot that causes an avulsion of the bifurcate ligament causes what kind of fracture?
Anterior process of the calcaneus fracture.
The bifurcate ligament connects the dorsal aspect of the anterior process to the cuboid and navicular
324
What is the sinus tarsi?
between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi.
325
What view is useful for evaluation of intraoperative reduction of the posterior facet of the calcaneus?
How to you obtain this view?
Broden view
With ankle in neutral dorsiflexion and 45 degrees internal rotation. Take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral.
326
What is a harris view?
Visualizes tuberosity fragement widening, shortening, and varus positioning.
Place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees.
327
What are Bohler and Gissane angles?
Will they be increased or decreased with a calcaneus fracture?
**Bohler Angle:** Angle between line from highest point of anterior process to highest poijnt of posterior facet + line tangential to superior edge of tuberosity. Normal 20-40 deg. Loss of this angle represents collapse of the posterior facet.
**Angle of Gissane:** angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus. Normal 120-145. Smaller angle also represents collapse of the posterior facet.
328
What are the indications for non-operative treatment of a calcaneus fracture?
What is the protocol?
Small extra-articular fractures \<1cm with intact achilles tendon and \<2mm displacement. Sanders Type I nondisplaced. Anterior process fracture involving \<25% of calcaneocuboid joint. Comorbidities that preclude good surgical outcome such as chronic smoker, poorly controlled diabetes, PVD.
Cast for 6 weeks. NWB 10-12 weeks. Begin early ROM exercises once welling allows.
329
What factors are associated with the highest likelihood of a secondary subtalar fusion afte rcalcaneus fractures?
Male worker's compensation patient who participates in heavy labor work with an initial Bohler angle less than 0 degrees.
330
What factors are associated with a poor outcome after calcaneus factures?
Age \> 50, ment
Obseity, smokers, vasculopathies
Manual labor, Workers Comp
bilateral calcaneal fractures
331
What supplies the vasculature to the flap used in a extensile lateral L-shpaed incision?
Lateral calcaneal branch of peroneal artery.
332
When do you consider block subtalar arthrodesis for subtalar fusion?
When there is clacaneal height loss and symptoms are from anterior ankle impingement. The mechanical block to ankle dorsiflexion results from posterior talar collapse into the posterior calcaneus.
Also should have chronic pain from subtalar joint and incongruous subtalar joint/post-traumatic DJD.
Surgery should address hindfoot height, ankle impingement, subfibular impingement (lateral wall blowout leading to peroneal impingement), and subtalar arthritis.
333
What is the most common variation of the Hoffa fracture?
How should it be fixed?
Most common variation is a coronal fracture of the lateral femoral condyle.
Best fixed with anterior to posterior screw placement across lateral femoral condyle.
334
dynamic tendon transfer to restore active dorsiflexion of the foot involves transfering a tendon from which native insertion point to which new insertion point?
Medial navicular to dorsal lateral cuneiform
335
What is the positive predictive value of a closed humeral shaft fracture going on to non-union if at 6 weeks there is gross motion at the fracture site and no callus formation?
100%
336
Delay in fixation of acetabular fractures of how long leads to difficulty in achieving reduction and worse outcomes?
3 weeks.
Increased delay has not been shown to increase the chance of neurologic injury, infection, or HO.
337
What has the highest rate of union with a sub-isthmic femoral non-union treated with a nail.
Nail retention and plate augmentation. 96%
Exchange nailing 73%
338
What is the current thoughts on rates of nonunion from displaced middle third clavicle fractures?
15%
Old literature estimated rates of 1%
339
What are the most important predictors of patient satisfaction at 2 years after surgical treatment for a severely mangled foot?
Ability to return to work, absence of depression, faster walking speed, and decreased pain.
Decision for reconstrutction versus amputation, or initial presence of absence of plantar sensation have little impact.
In addition, demographic factors such as age, gender, socioeconomic status, and education level do not predict patient satisfaction.
340
What is a Syme amputation?
What is required in order for one to have a chance at being succesful?
What is the most common complications?
Ankle disarticulation.
Patent and intact Posterior tibial artery. Stable heel pad.
Skin sloughing from a compromised vascular supply and migration of the heel pad due to instability.
341
What are contraindications to an anterior open reduction of an SI joint that is unable to be reduced by closed means?
RELATIVE CONTRAINDICATIONS: comminuted sacral fractures, morbid obesity, iliac wing external fixation, and ipsilateral diverting colostomy.
In the presence of a comminuted sacral fracture aggressive medial dissection would be required and would place the L5 nerve root at risk.
342
According to the LEAP study what performed did not impact the infection or union rates and had no effect on functional outcome?
What lead to longer time to union, poorer functional outcomes, longer time to acheive wieght bearing, and more time in hospital?
Wound debridement within 6 hours vs 6-24 hours, soft-tissue coverage less than 3 days or more. Bone grafting within 3 months or after 3 months.
Definitive treatment with an external fixator lead to worse outcomes in all the areas listed on the other side of the card.
343
ACL injuries are most common in what Schatzker fractures.
Schatzker IV and VI.
Type IV injuries are also associated with medial meniscus disruption, vascular injury, and compartment syndrome.
344
What has been shown to be associated and have increased rate with bilateral femur fractures?
Initial hypotension
Pelvic fractures
Open skull fractures
Mortality
Has not been shown to have increased rates of thoracic/chest wall injury.
345
What happens to chondrocytes after a intra-articular fracture?
When?
How?
Where?
Initial cell death in the superficial cartilage zones at the fracture margins occurs by necrosis.
Apoptosis occurs in a delayed fashion also in the superifical cartilage zones near the fracture margins.
346
When can you drive after lower extremity fractures?
Long bone and periarticular injuries 6wks after initiation of weightbearing.
Ankle fractures with plate fixation. One study says 9 weeks. Another study says 6 weeks after initiating weight bearing.
Total joint arthroplasty. 4 weeks after surgery or 4 weeks after initiation of weight bearing.
347
True or false BKAs and AKAs have similar outcomes?
True, although BKA patients have faster self-selected walking speeds.
348
What happens if the starting point for a trochanteric nail is too lateral?
Varus deformity
Ideal starting poin is just medial to the tip of the greater trochanter.
349
What is considered good adequate cortical thickness for a proximal humerus to proceed with open reduction and internal fixation in proximal humerus fractures?
According to Nho et al article \> or = 4mm.
If less than 4mm then the authors found increased risk of screw pullout and failure. Recommended non-op treatment. suture fixation, or hemiarthroplasty (paper was in 2007 in this day and age would considere reverse).
350
In general what should the plate screw density be for a fracture that is being bridge plated?
\< .5
351
Surgical indications for scapular fractures?
Medial/lateral displacement 20mm or more
Angulation of 45% or more
Medial/lateral displacement of 15mm or more with angulation of 30 degrees.
Double disruptions of the superior shoulder suspensory complex (both displaced 10 mm or more)
Glenopolar angle of 22 degrees or less.
Open fractures
