Dorsal Scapular nerve course and innervation
Pierces middle scalene deep to Levator Scapulae.
Innervates: Levator Scapulae, Rhomboid minor and major
Long thoracic nerve course and innervation
Anterior surface of serratus anterior w/ lateral thoracic artery
Innervates: Serratus anterior
Suprascapular nerve course and innervation
Under transverse scapular ligament in suprascapular notch then spinoglenoid notch (area of compression)
Innervates: Supraspinatus and Infraspinatus
Lateral Pectoral nerve course and innervation
Medial to Medial pectoral nerve with pectoral artery
Innervates: Pectoralis major and minor
Thoracodorsal nerve course and innervation
With thoracodorsal artery deep to Lat
Innervates: Latissimus dorsi
Axillary nerve course and innervation
Inferior to capsule, through quadrangular space, bends anterior ~5cm distal to acromion
Innervates:
Deep banch- Deltoid
Superficial branch- Teres minor
Deltoid innervation
Axillary nerve
Pectoralis major innervation
Medial and Lateral Pectoral nerve (medial runs lateral to lateral)
Pectoralis minor innervation
Medial pectoral nerve
Serratus Anterior innervation
Long Thoracic nerve
Subclavius innervation
Nerve to the subclavius
Rotator cuff muscles and innervation
Supraspinatus- suprascapular nerve
Infraspinatus- Suprascapular nerve
teres minor- Axillary nerve
Subscapularis- Upper and Lower Subscapular nerve
Gerdy's tubercle
Proximal lateral tibia
Insertion of IT band
Pubic diastasis
Symphysis alone- <2.5 cm
Symphysis and sacrospinous ligament- >2.5 cm
Symphysis, sacrospinous, sacrotuberous, and posterior sacroiliac- unstable vertically, posteriorly, and rotationally
Radiographic signs of Pelvic Instability
Sacroiliac displacement of 5mm in any plane
Posterior fracture gap (rather than impaction)
Avulsion of 5th lumbar transverse process, lateral border of sacrum (sacrotuberous lig), or the ischial spine (sacrospinous lig)
Equinus position
fixed plantar flexion
Pediatric ankle fracture classification
Dias and Tachdjian: Lauge Hansen + Salter Harris
Supination external rotation
Pronation external rotation
Supination plantar flexion
Supination inversion- I- fibular physis. II- tibial physis as talus wedges into articular surface (intraarticular and leads to growth disturbance)
Toddler's fracture
Spiral fracture of tibia in a patient < 2.5 yrs old
boys > girls
right > left
Mechanism- ER of foot with fixed knee
Tx: 2-3 weeks LLC --> 2-3 weeks SLC
Pediatric Tibial Tubercle fracture classification and treatment
Watson Jones:
I- small fragment avulsed through 2° ossification center
II- 2° ossification center coalesced, fracture at level of horizontal physis
III- fracture line passing proximal through tibial epiphysis and into joint
Ogden modification:
A- minimally displaced/noncomminuted
B- displaced or comminuted
Tx:
IA- LLC 4-6 weeks
IB, II, III- Opperative- screws and pins
Pediatric knee ossification centers
Distal femur- Appears at 39th fetal week, closes at 16-19 yrs, growth of 9mm/yr
Proximal tibia- Appears 2 mo, closes 16-19 yrs, growth 6mm/yr
Tibial tubercle- Appears 9 yrs, closes 15-17 yrs
Pediatric leg length discrepancy s/p femur shaft fracture treatment
2-10 years old:
<2 cm shortened- spica cast (overgrowth of 1.5 - 2 cm common)
>3 cm shortened- skeletal traction
Acceptable angulation of Pediatric Femoral Shaft fracture
Birth- 2yrs: Varus/Valgus- 30°, A/P- 30°, shortening- 1.5cm
2- 5yrs: Varus/Valgus- 15°, A/P- 15°, shortening- 2.0 cm
6-10yrs: Varus/Valgus- 10°, A/P- 15o, shortening- 1.5cm
11- mature: Varus/Valgus- 5o, A/P- 10o, shortening- 1.0cm
Rotation: 10o, external better tolerated
Pediatric femoral shaft fracture treatment
<6mo: Pavlik harness or posterior splint
6mo- 4yrs: Immediate spica cast
4-12yrs: Flexible or elastic IM nails placed in retrograde fashion. Contraindicated if >100lbs or comminuted. Interlocked nails through greater trochanter is contraversial.
12- mature: Flexible nail(if size and pattern present), or interlocked nails (avoid piriformis fossa), or locked submuscular plate
Both bone forearm fracture deforming forces
Proximal 3rd: Biceps and Supinator- flex and supinate proximal fragment. Pronator teres and Pronator quadratus- pronate distal fragment
Middle 3rd: Biceps, Supinator and Pronator teres- Proximal fragment stays neutral. Pronator quadratus- Pronates distal fragment
Distal 3rd: Brachioradialis- Dorsiflex and radially deviates distal fragment. Pronator quadratus, wrist flexors and extensors, thumb abductors also deform
Both bone forearm fracture immobilization position by site
Proximal 3rd: supination
Middle 3rd: neutral
Distal 3rd: pronation
Juvinile tillaux fracture
Salter Harris III of anterolateral tibial epiphysis
13-16 yrs old when central and medial portion fused
External rotation
Juvenile triplane ankle fracture
transverse, coronal, and sagital
Explained by physis fusion from central -> anteromedial -> posteriomedial -> lateral
Carpal tunnel syndrome predisposing factors
Female
Obese
Pregnant
Hypothyroid
RA
Amyloidosis
Carpal tunnel borders
Medial: scaphoid tubercle and trapezium
Ulnar: Hook of hamate and pisisform
Palmar: Transverse carpal ligament
Dorsal: Proximal carpal row
Carpal tunnel contents
9 flexor tendons- FPL most radial
Median nerve- between PL (palmaris longis) and FCR
Recurrent motor branch- 50% extraligamentous, 30% subligamentous, 20% transligamentous. Cut transverse ligament far ulnarly to avoid cutting.
Carpal tunnel syndrome treatment
NSAIDS
Steroid injection
Carpal Tunnel Release- cut ulnarly
Surgery Recovery- pinch strength- 6 wks, Grip 100%- 12 wks
Extensor compartments
2,2,1,2,1,1
1st: Extensor Pollicis Brevis and Abductor Pollicis longus (effected in DeQuervains)
2nd: Extensor carpi radialis longus and Extensor carpi radialis brevis
3rd: Extensor pollicis longus (ruptured in distal radius fracture as it courses around Lister's tubercle)
4th: Extensor digitorum communis and Extensor indices proprius
5th: Extensor digiti minimi
6th: Extensor carpi ulnaris
Vertical medial malleolus ankle fracture treatment
Must plate
Transverse/oblique medial malleolus fracture treatment
cannulated screw
Lateral malleolar fracture with medial clear space widening treatment
Bimalleolar equivalent
ORIF
If you can't tell medial clear space widening- Dorsiflex and ER imaging
ED ankle fracture treatment
Consious sedation or intraarticular injection before reduction
Reduce to 90o, 90o
Short leg splint- 3 sided (posterior component)
Repeat imaging to ensure no lateral talar displacement- medial malleolar skin breakdown
Recognize fracture vs. fracture/dislocation
Rotational ankle fracture classification
Lauge-Hansen
Supination Adduction: medial talar displacement
I- fibula avulsion (low transverse) or LCL rupture
II- verticle medial malleolus fx + I
Supination External Rotation: most common
I- ATFL disruption +/- tib or fib avulsion
II- Spiral fx of distal fib (AI -> PS)
III- PTFL disruption or posterior malleolus avulsion
IV- II + medial malleolus fx or deltoid lig rupture
Pronation Abduction:
I- Medial malleolus fx or deltoid lig rupture
II- I + ATFL rupture or Chaput's tubercle avulsion
III- I + transverse or comminuted fibula fx
Pronation External Rotation
I- same as P-AB I
II- same as P-AB II
III- I + high spiral distal fib fx (PI -> SA)
IV- PTFL disruption or avulsion of posteriolateral tibia
Distal radius normal measurements
Radial inclination: 22o
Radial length: 11mm
Volar tilt: 11o
Distal radius fracture criteria for risk of failure with closed reduction
LaFontaine criteria
Pre-Reduction Films
Determines rate of failure- >2= fx collapse
-Age > 60yrs
-Dorsal comminution
-Dorsal angulation >20o
-Ulnar styloid involvement
-Radiocarpal joint involvement
Smith fracture
Reverse Colles fracture
Volar angulation
Unstable fracture pattern
Colles fracture
90% of distal radius fractures
Dorsal angulation
Dorsal displacement
Radial shift
Radial shortening
Acromiohumeral interval
Shortest distance between inferior cortex of acromion and humerus
Normal: 1-1.5 cm
Rotator cuff tear: <6mm
Galeazzi fracture
Radial shaft fracture @ junction of middle and distal 3rd with DRUJ disruption
Fracture of necessity- needs ORIF
Monteggia fracture and complications
Proximal ulnar shaft fracture with radial head dislocation
Complications
- Radial nerve deep branch paralysis- Most common
- Posterior Interosseous Nerve (PIN) palsy- constant pressure from radial head
- Annular ligament tear
Monteggia fracture classification and treatment
Bado
I- Apex anterior w/ anterior dislocation
II- Apex posterior w/ posterior dislocation
III- fx at metaphysis w/ lateral dislocation
IV- same level both bone fx w/ anterior dislocation
Treatment
I, III, IV- 110o flexion
II- 70o flexion
Distal radius fracture- most influence on outcome
Carpal alignment
- Measured by intersection of 2 lines on lateral X-ray
- parallel through middle of radius
- parallel through capitate
- should intersect within carpus
Chauffeur's fracture
Radial styloid fracture
AKA- backfire fx, hutchinson fx
Compression of scaphoid against styloid w/ wrist in dorsiflexion and ulnar deviation
Associated with intercarpal ligament injury- scapholunate or perilunate dislocation
Barton fracture
Fracture dislocation of radiocarpal joint
Shearing mechanism
Fracture of volar or dorsal radial rim
Unstable
Die punch fracture
Depression fx of lunate fossa of articular surface of distal radius
Radial head fracture classification and treatment
Mason
I- Nondisplaced
II- Marginal fx w/ displacement (impaction, depression, angulation)
III- Comminuted fx involving entire head
IV- Associated w/ elbow dislocation
Treatment
I- possible aspiration of radiocapitellar joint for pain relief
II- only operative if fragment blocking motion or part of a complex injury
III & IV- ORIF or prosthetic replacement, possible late excision of radial head
Hardware only in 90o "safe zone"
Essex Lopresti lesion
Radial head fracture dislocation
Interosseous ligament and DRUJ disruption
Olecranon fracture classification
I- nondisplaced
II- displaced w/o instability
III- instability of ulnohumeral joint
a- noncomminuted
b- comminuted
Ulnar nerve compression sites around elbow (cubital tunnel syndrome)
Medial intramuscular septum- 8cm proximal to medial epicondyle
Arcade of Struthers- aponeurotic band from medial IM septum to medial head of triceps
Medial epicondyle (osteophytes)
Cubital tunnel retinaculum (Osborne's ligament)
Anconeus epitrochlearis- replaces Osborne's ligament in 11% of population causing static compression
Aponeurosis of 2 heads of Flexor carpi ulnaris (often continuous with Osborne's ligament)
Deep flexor/pronator aponeurosis- 4cm distal to medial epicondyle
Cubital tunnel syndrome symptoms
Predominantly hand symptoms
Fibers to FCU and FDP run centrally
Hand intrinsic fibers are peripheral
Ulnar Tunnel syndrome
Compression of ulnar nerve in Guyon's canal
Most commonly Ganglia (triquitrohamate joint 50%)
Does not involve dorsal cutaneous nerve, FDP of 4th and 5th, or FCU
Zone 1: proximal to bifurcation, both motor & sensory symptoms
caused by hook of hamate fracture and ganglia
Zone 2: deep motor branch, motor symptoms only
caused by hook of hamate fracture and ganglia
Zone 3: superficial sensory branch, sensory symptoms only
caused by ulnar artery aneurysm or thrombosis
Pelvic fracture classification
LC: implosion secondary to lateral force
- I- Sacral impaction on impact side
- II- Posterior iliac wing fracture on impact side w/ posterior ligament disruption. Maintains vertical stability
- III- additional contralateral external rotation injury w/ SI, ST, & SS ligament disruption
APC: anterior applied force, external rotation
- I- <2.5 cm symphyseal diastasis, vertical fx of rami, posterior ligaments intact
- II- >2.5 cm symphyseal diastasis, SI widining secodary to anterior SI, ST, and SS ligament tear, Posterior SI intact
-III- II + posterior SI lig disruption, extreme rotational instability and lateral displacement, highest rate of vascular injury and bleed
VS: vertical displacement (cephaloposterior)
- usually through SI joint
- complete disruption of symphysis, ST, SI, and SS ligaments
- Extreme instability
- High rate of neuro and vascular injury
CM: combined mechanism (crush) (VS&LC)
Pelvic fracture treatment
Nonoperative Rehab: LC-1, and APC-1
Operative indications:
- Open fx or viceral perforation
- Open book or vertically unstable fx w/ hemodynamic instability
- Symphyseal diastasis >2.5 cm
- Leg length discrepancy >1.5 cm
- Rotational deformity
- Sacral displacement >1 cm
- Intractable pain
Iliac wing: plate and lag screws
Diastasis: plate
Sacral: transiliac bar fixation
Tibial plateau fracture surgery
I-IV: percutaneous screws or lateral placed periarticular plate
V-VI: percutaneous locked plate or hybrid fixator
Open hand fracture rate of infection
Clean- 1.4%
Contaminated/bite/lake water/barnyard- 14%
Coracoclavicular ligament distances
Trapezoid- 30mm from distal tip
Conoid- 45mm from distal tip
When performing Mumford excision- 10mm removal
Bennett fracture
1st metacarpal
Intraarticular
Separation from volar lip
Pulled proximally and flexed
Deforming forces- abductor pollicis longus and adductor pollicis
Rolando fracture
1st metacarpal
Cominuted intraairticular
Y or T fracture pattern
Future DJD
Hand PIP surgical indications
Dorsal lip- >1mm displaced
Volar lip- >40% articular involvement
Mallet finger
DIP joint Dorsal lip fracture
disruption of terminal extensor tendon
"Jamming" mechanism of injury
Nonoperative Treatment- Volar splint 6-8 weeks
Surgical indications- volar subluxation of distal phalynx, >50% articular surface, >2mm step off
Operative Tx- CRPP vs. ORIF, tendon reconstruction if >12 weeks old
Jersey finger
DIP joint Volar lip fracture
avulsion of FDP
Ring finger 75% of time- 5mm more prominent during grasp so makes more vulnerable to pulling away
<3 weeks- tendon repair (do not advance >1cm)
ORIF for osseous fragments
Complications- if tendon advanced >1cm, flexion contracture or quadralgia effect (adjacent finger lag in flexion)
Metacarpal fracture surgical indications
Neck:
- >10o angulation for 2nd and 3rd
- > 30-40o for 4th and 5th
Shaft:
- >10o 2nd and 3rd
- > 20o 4th and 5th
Thumb
- Bennett (type I)
- Rolando (type 2)
Thenar compartment
Opponens pollicis (median)
Abductor pollicis brevis (median)
Flexor pollicis brevis superficial head (median)
Flexor pollicis braves deep head (ulnar)
Adductor compartment
Adductor pollicis oblique and transverse heads (ulnar)
Hypothenar compartment
Palmaris brevis (ulnar)
Flexor digiti minimi brevis (ulnar)
Opponens digiti minimi brevis (ulnar)
Abductor digiti minimi (ulnar)
Posterior compartment of forearm
Superficial:
ECU (deep branch of radial n)
anconeus (radial n)
Intermediate:
Extensor digitorum (radial n)
Extensor digiti minimi (posterior interosseous n)
Deep:
abductor pollicis longus (PIN)
extensor pollicis longus (PIN)
extensor pollicis brevis (PIN)
extensor indicis (PIN)
supinator (deep radial n)
Dorsal interosseous artery
Anterior compartment of forearm
Superficial:
Flexor carpi radialis (median n)
Flexor digitorum superficialis (median n)
Flexor carpi ulnaris (ulnar n)
Palmaris longus (median n)
Pronator teres (median n)
Deep:
Flexor digitorum profundus (ulnar and AIN)
Flexor policis longus (AIN)
Pronator quadratus (AIN)
Median, AIN, Ulnar, and Volar antibrachial interosseous nerves
Ulnar and Volar interosseous artery
Mobile wad (of Henry)
Brachioradialis (radial)
ECRL (radial)
ECRB (radial)
Radial artery and nerve
Quadriceps
Rectus femoris (only one with origin on ilium)
Vastus lateralis
Vastus intermedius (deep to rectus)
Vastus medialis
Genu articularis (deep to intermedius, pulls suprapatellar bursa superior)
Femoral nerve (L2-4)
Cubital tunnel borders
Roof: Arcuate (Osborne's) ligament
Floor: MCL
Posterior: Triceps medial head
Anterior: Medial Epicondyle
Lateral: Olecranon
Subclavian artery course, branches and extension
Part I- origin to anterior scalene
- Vertebral
- Internal thoracic (caudally behind ribs)
-Thyrocervical trunk (neck)
- suprascapular (rotator cuff)
Part II- behind anterior scalene
- Costocervical trunk
- superior intercostal a.
- deep cervical a.
Part III- lateral scalene to 1st rib
- Dorsal scapular (Levator scapula,
rhomboids, trapezius)
Axillary- from 1st rib to Teres major
I- proximal to pec minor
- Superior thoracic (seratus a. & pecs)
II- behind pec minor
- Thoracoacromial
- Clavicular (clavicle fx injury)
- Acromial (w/ CA lig, risk in
Subacromial decompression)
- Deltoid (w/ cephalic v., risk with
Deltopectoral approach)
- Pectoral (w/ lateral pectoral n.)
- Lateral thoracic (w/ long thoracic n.)
III- distal to pec minor
- Subscapular
- Circumflex scapular (triangle space)
- Thoracodorsal (w/ thoracodorsal n.)
- Anterior circumflex
- Ascending branch (arcuate a.
supplies most of humeral head)
- Posterior circumflex (quadrangular sp)
Brachial- at lower margin of Teres major
Triangular space (Medial)
Teres minor
Teres major
Triceps long head
Contains: Circumflex scapular artery
Quadrangular space
Teres minor
Teres major
Triceps long head
Humerus
Contains: Axillary n., Posterior circumflex a., Humeral a.
Triangular interval (Lateral)
Teres minor
Triceps long head
Triceps lateral head
Contains: Radial n., Deep artery of arm
Lateral x-ray C-spine prevertebral swelling distance by level
C1- >10mm
C3,4- >7mm
C5-7- >20mm
Radiographic markers of C-spine instability
Compression fx w/ 25% loss of height
Angular displacement >11o Cobb angle between adjacent vertebrae
Translation > 3.5mm
Intervertebral disc space separation >1.7mm
Odontoid distances
Atlas-dens interval- <3mm (5mm in child)
Space for cord (Posterior odontoid to anterior cortex of posterior arch of atlas)- >13mm
Dens-basion interval- <12mm
Posterior axis line- <4mm anterior to basion
Lateral atlas-dens intervals- symmetric and 2mm or <
McGregor's line (hard palate to most caudal occiput)- if dens >4.5mm above, then basilar invagination
Powers ratio- Basion to posterior arch of atlas/ Opisthion to anterior arch of atlas <1
Atlas fracture classification
Levine
A- isolated bony apophysis
B- Isolated posterior arch
C- Isolated anterior arch
D- Comminuted, lateral mass, or burst
E- 3 or more fragments
Atlas fracture treatment
Initial- halo traction/immobilization
Stable (A,B,C)- rigid cervical orthosis
Unstable- prolonged halo immobilization
Chronic instability- C1-2 fusion
Odontoid process (Dens) fracture classification and treatment
Anderson and D'Alonzo
I- Oblique avulsion of the apex (5%)
II- Fx at waist (junction of body and neck). Watershed area with high rate of nonunion which can lead to myelopathy (60%)
III- Base, extending into cancellous body of C2 and possibly the lateral facets (30%)
Tx
I- immobilize in cervical orthosis
II- screw fixation or C1-2 posterior fusion due to high nonunion rate
III- halo immobilization
Hangman's fracture
Traumatic spondylolisthesis of C2 (pars interarticularis fracture)
Effendi classification
I- nondisplaced, no angulation, translation <3mm, C2-3 disc intact, relatively stable
Ia- Unstable lateral bending, involves one pars interarticularis and extending to body on contralateral side
II- Significant angulation, translation >3mm, C2-3 disc disruption, most common (56%)
IIA- flexion- posterior longitudinal lig rupture, anterior intact, no translation, traction contraindicated
III- C2 anterior dislocation with extension, most associated with spinal cord injury
Joint of Luschka
uncovertebral joints in cervical spine
(uncinate process projects superiorly from lateral aspect of vertebral body)
C3-7 fracture classification
Allen-Ferguson
I- compressive flexion- "teardrop" fracture (from anterior body through inferior subchondral plate)
II- Vertebral compression- burst fx
III- Distractive flexion- dislocations
IV- Compressive extension
V- Distractive extension
VI- Lateral flexion
VII- Misc. (Clay shovelers, sentinel, ankylosing spondylitis, gunshot)
Clay shoveler's fracture
Muscular avulsion of spinous process in lower cervical or upper thoracic
Sentinel fracture
Through lamina on either side of spinous process.
Loose element may impinge on cord
Cervical distraction device placement
Gardner-Wells tongs- one fingers width above pinna of ear in line with external auditory canal
Halo ring
- 1 cm above ears.
- Anterior pins- below equator of skull above supraorbital ridge, anterior to temporalis muscle, over lateral 2/3 of orbit.
- Posterior pins- variable to maintain horizontal orientation
- 6-8lbs of pressure
Indications for anterior upper cervical spine approach in trauma
1. Screw fixation of Type II odontoid fx
2. Fusion and plating of C2-3 for IIA or III hangman's fx
3. Arthrodesis of AA articulations after failed posterior fusion
Lower C-spine approach indications
Posterior- open reduction of dislocated facet joints
Bilateral lateral mass plating- teardrop fx, facet fx, facet dislocations
Anterior- vertebral body burst fx w/ cord compression
Anterior approach to subaxial spine plane
Superficial- Sternocleidomastoid (lateral), Anterior strap (medial)
Deeper- Carotid sheath (lateral), trachea/esophagus (medial)
Conus medullaris end level
L1-L2
Spine region with smallest ratio of spinal canal to spinal cord
T2-T10
Most thoracic and lumbar injuries occur at what region
T11-L1 (thoracolumbar junction)
Sacral sparing triad
Perianal sensation
Rectal tone
Great toe flexion
Compression vs Burst fx
Burst involves middle column in addition to anterior
Burst and compression fx most common type
Type B (superior endplate)
Early stabilization of burst fracture indications
Neurologic deficits
Loss of >50% body height
Angulation >20o
Canal compromise >50%
Scoliosis >10o
Denis Three column model of spine stability
Anterior- anterior longitudinal ligament, anterior half of vertebral body, and anterior annulus
Middle- posterior longitudinal ligament, posterior half of body and annulus
Posterior- Neural arch (pedicles, facets, and laminae) and posterior ligamentous complex ( supraspinous ligament, interspinous ligament, ligamentum flavum, facet capsules)
Instability if 2 columns are disrupted
Degrees of spinal instability
1st- mechanical
2nd- neurologic
3rd- mechanical and neurologic
Thoracolumbar spine fx with incomplete neurologic injury approach to decompression
Anterior (greater neurologic improvement than posterior or lateral)
Predictor of dural tear in burst fx
neurologic involvement
Clavicle fracture classification
Allman
Group I- middle third (80%).
Group II- distal third (15%).
- type I- Minimal displacement. Fx between conoid and trapezoid or CC and AC ligaments
- type II- Displaced. Fx medial to CC ligament
A- Conoid and trapezoid attached distally
B- Conoid torn. Trapezoid attached distally
- type III- Fx of articular surface of AC joint. No ligament injury. Confused w/ 1st degree sprain.
Group III- proximal third (5%)
Clavicle fx treatment
Minimally displaced- sling immobilization 4-6 weeks
Surgical indications
- open fracture
- associated neurovascular compromise
- skin tenting
- Controversy- midshaft "Z" deformity and type II fractures
Operative techniques
Plate and screw- anteroinferior has less prominent hardware than superior
IM fixation- (Hagie pin, Rockwood pin) complications in 50% cases
AC joint sprain classification
I- AC ligament sprain
II- AC lig tear w/ joint disruption; CC lig sprain
III- AC and CC lig torn w/ AC dislocation
IV- Distal clavicle displaced posteriorly through trapezius
V- Distal clavicle displaced >100% superiorly
VI- Distal clavicle displaced inferiorly
Total Hip Arthroplasty- Posterior approach
Split Gluteus maximus
Cut external rotators
- Piriformis
- Superior Gemellus (SER)
- Obturator Internus (SER)
- Inferior Gemellus (SER)
- NOT Quadratus femoris
Repair Short external rotators (SER) to prevent dislocation
Dangers
- Sciatic nerve- reflecting Piriformis protects
- Inferior Gluteal artery- injured in proximal extension
- Medial Femoral Circumflex artery- under Quadratus femoris
Total Hip Arthroplasty- Anterolateral approach
Tensor fascia latae retracted anteriorly
Detach Gluteus medius and minimus
Danger
- Descending branch of LFCA- under rectus femurs
- Femoral nerve- caused by vigorous medial retraction. Lays on posts muscle w/ artery and vein.
Total Hip Arthroplasty- Anterior approach
Retract Sartorius medially
Retract Tensor Fascia latae laterally
Retract Gluteus medius laterally
Cut Rectus femoris
Dangers
- Lateral Femoral Cutaneous nerve- retract anteriorly
- Femoral nerve- Damaged by vigorous medial retraction
- Ascending branch of Lateral Femoral Circumflex artery- must be ligated
Anterior approach to Clavicle
Incision directly along clavicle
Deppen incision through Platysma
Dangers
- Brachial plexus- passed directly inferior to middle 3rd of clavicle
- Subacromial a. & v.(2nd part of subclavian)- passes directly inferior to middle 3rd
Ligaments
- Coracoclavicular- trapezoid and conoid
Other muscle attachments
- Sternocleidomastoid (CNXI)- superiomedially
- Trapezius (CNXI)- superiolaterally
- Deltoid (axillary)- inferiolaterally
- Pectoralis major (lateral & medial pectoral)- inferiomedially
- Subclavius (N. to subclavius)- inferior middle 3rd
Osteomyelitis classification
Cierny
Host immune status:
A- normal
B- some compromise
C- significant compromise
Type 1
- medullary osteomyelitis w/ endosteal nidus
- does not require bone graft
Type 2
- superficial affecting outer surface of bone
- examples: infected plate on fx, exposure 2o tissue loss, adjacent abscess to cortex
- treatment:
- stabilization not required
- hardware removal
- debridement of avascular outer cortex down to bleeding bone (paprika sign)
- antibiotic beeds
- coverage
- bone grafting
Type 3
- well marginated sequestration of cortical bone
- can be excised but creates instability
- Treatment:
- stabilization
- debridement
- abx beads
- coverage
- bone grafting
Type 4
- permeative destructive lesion causing instability
- example: infected tibial nonunion