Ortho

• Pierces middle scalene deep to Levator Scapulae.
• Innervates: Levator Scapulae, Rhomboid minor and major

• Anterior surface of serratus anterior w/ lateral thoracic artery
• Innervates: Serratus anterior

• Under transverse scapular ligament in suprascapular notch then spinoglenoid notch (area of compression)
• Innervates: Supraspinatus and Infraspinatus

• Medial to Medial pectoral nerve with pectoral artery
• Innervates: Pectoralis major and minor

• With thoracodorsal artery deep to Lat
• Innervates: Latissimus dorsi

• Inferior to capsule, through quadrangular space, bends anterior ~5cm distal to acromion
• Innervates:
• Deep banch- Deltoid
• Superficial branch- Teres minor

Axillary nerve

Medial and Lateral Pectoral nerve (medial runs lateral to lateral)

Medial pectoral nerve

Long Thoracic nerve

Nerve to the subclavius

• Supraspinatus- suprascapular nerve
• Infraspinatus- Suprascapular nerve
• teres minor- Axillary nerve
• Subscapularis- Upper and Lower Subscapular nerve

• Proximal lateral tibia
• Insertion of IT band

• Symphysis alone- <2.5 cm
• Symphysis and sacrospinous ligament- >2.5 cm
• Symphysis, sacrospinous, sacrotuberous, and posterior sacroiliac- unstable vertically, posteriorly, and rotationally

• 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)

fixed plantar flexion

• 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)

• 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

• 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

• 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

• 2-10 years old:
• <2 cm shortened- spica cast (overgrowth of 1.5 - 2 cm common)
• >3 cm shortened- skeletal traction

• 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- 15^o, shortening- 1.5cm
• 11- mature: Varus/Valgus- 5^o, A/P- 10^o, shortening- 1.0cm
• Rotation: 10^o, external better tolerated

• <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

• 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

• Proximal 3rd: supination
• Middle 3rd: neutral
• Distal 3rd: pronation

• Salter Harris III of anterolateral tibial epiphysis
• 13-16 yrs old when central and medial portion fused
• External rotation

• transverse, coronal, and sagital
• Explained by physis fusion from central -> anteromedial -> posteriomedial -> lateral

• Female
• Obese
• Pregnant
• Hypothyroid
• RA
• Amyloidosis

• Medial: scaphoid tubercle and trapezium
• Ulnar: Hook of hamate and pisisform
• Palmar: Transverse carpal ligament
• Dorsal: Proximal carpal row

• 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.

• NSAIDS
• Steroid injection
• Carpal Tunnel Release- cut ulnarly

Surgery Recovery- pinch strength- 6 wks, Grip 100%- 12 wks

• 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

Must plate

cannulated screw

• Bimalleolar equivalent
• ORIF
• If you can't tell medial clear space widening- Dorsiflex and ER imaging

• Consious sedation or intraarticular injection before reduction
• Reduce to 90^o, 90^o
• Short leg splint- 3 sided (posterior component)
• Repeat imaging to ensure no lateral talar displacement- medial malleolar skin breakdown
• Recognize fracture vs. fracture/dislocation

• 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

• Radial inclination: 22^o
• Radial length: 11mm
• Volar tilt: 11^o

• LaFontaine criteria
• Pre-Reduction Films
• Determines rate of failure- >2= fx collapse
• -Age > 60yrs
• -Dorsal comminution
• -Dorsal angulation >20^o
• -Ulnar styloid involvement
• -Radiocarpal joint involvement

• Reverse Colles fracture
• Volar angulation
• Unstable fracture pattern

• 90% of distal radius fractures
• Dorsal angulation
• Dorsal displacement
• Radial shift
• Radial shortening

• Shortest distance between inferior cortex of acromion and humerus
• Normal: 1-1.5 cm
• Rotator cuff tear: <6mm

• Radial shaft fracture @ junction of middle and distal 3rd with DRUJ disruption
• Fracture of necessity- needs ORIF

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

• 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- 110^o flexion
• II- 70^o flexion

• Carpal alignment
• - Measured by intersection of 2 lines on lateral X-ray
• - parallel through middle of radius
• - parallel through capitate
• - should intersect within carpus

• 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

• Fracture dislocation of radiocarpal joint
• Shearing mechanism
• Fracture of volar or dorsal radial rim
• Unstable

Depression fx of lunate fossa of articular surface of distal radius

• 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 90^o "safe zone"

• Radial head fracture dislocation
• Interosseous ligament and DRUJ disruption

• I- nondisplaced
• II- displaced w/o instability
• III- instability of ulnohumeral joint

• a- noncomminuted
• b- comminuted

• 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

• Predominantly hand symptoms
• Fibers to FCU and FDP run centrally
• Hand intrinsic fibers are peripheral

• 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

• 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)

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

I-IV: percutaneous screws or lateral placed periarticular plate

V-VI: percutaneous locked plate or hybrid fixator

• Clean- 1.4%
• Contaminated/bite/lake water/barnyard- 14%

• Trapezoid- 30mm from distal tip
• Conoid- 45mm from distal tip

When performing Mumford excision- 10mm removal

• 1st metacarpal
• Intraarticular
• Separation from volar lip
• Pulled proximally and flexed
• Deforming forces- abductor pollicis longus and adductor pollicis

• 1st metacarpal 
• Cominuted intraairticular
• Y or T fracture pattern
• Future DJD

• Dorsal lip- >1mm displaced
• Volar lip- >40% articular involvement

• 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

• 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)

• Neck:
• - >10^o angulation for 2nd and 3rd
• - > 30-40^o for 4th and 5th

• Shaft:
• - >10^o 2nd and 3rd
• - > 20^o 4th and 5th

• Thumb
• - Bennett (type I)
• - Rolando (type 2)

• Opponens pollicis (median)
• Abductor pollicis brevis (median)
• Flexor pollicis brevis superficial head (median)
• Flexor pollicis braves deep head (ulnar)

Adductor pollicis oblique and transverse heads (ulnar)

• Palmaris brevis (ulnar)
• Flexor digiti minimi brevis (ulnar)
• Opponens digiti minimi brevis (ulnar)
• Abductor digiti minimi (ulnar)

• 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

• 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

• Brachioradialis (radial)
• ECRL (radial)
• ECRB (radial)

Radial artery and nerve

• 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)

• Roof: Arcuate (Osborne's) ligament
• Floor: MCL
• Posterior: Triceps medial head
• Anterior: Medial Epicondyle
• Lateral: Olecranon

• 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

• Teres minor
• Teres major
• Triceps long head

Contains: Circumflex scapular artery

• Teres minor
• Teres major
• Triceps long head
• Humerus

Contains: Axillary n., Posterior circumflex a., Humeral a.

• Teres minor
• Triceps long head
• Triceps lateral head

Contains: Radial n., Deep artery of arm

• C1- >10mm
• C3,4- >7mm
• C5-7- >20mm

• Compression fx w/ 25% loss of height
• Angular displacement >11^o Cobb angle between adjacent vertebrae
• Translation > 3.5mm
• Intervertebral disc space separation >1.7mm

• 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

• Levine
• A- isolated bony apophysis
• B- Isolated posterior arch 
• C- Isolated anterior arch
• D- Comminuted, lateral mass, or burst
• E- 3 or more fragments

• Initial- halo traction/immobilization
• Stable (A,B,C)- rigid cervical orthosis
• Unstable- prolonged halo immobilization
• Chronic instability- C1-2 fusion 

• 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

• 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

• uncovertebral joints in cervical spine
• (uncinate process projects superiorly from lateral aspect of vertebral body)

• 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)

Muscular avulsion of spinous process in lower cervical or upper thoracic

• Through lamina on either side of spinous process. 
• Loose element may impinge on cord

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

• 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

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

Superficial- Sternocleidomastoid (lateral), Anterior strap (medial)

Deeper- Carotid sheath (lateral), trachea/esophagus (medial)

L1-L2

T2-T10

T11-L1 (thoracolumbar junction)

• Perianal sensation
• Rectal tone
• Great toe flexion

Burst involves middle column in addition to anterior

Type B (superior endplate)

• Neurologic deficits
• Loss of >50% body height
• Angulation >20^o
• Canal compromise >50%
• Scoliosis >10^o

• 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

• 1st- mechanical
• 2nd- neurologic
• 3rd- mechanical and neurologic

Anterior (greater neurologic improvement than posterior or lateral)

neurologic involvement

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%)

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

• 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

• 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

• 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. 

• 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

• 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

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 2^o 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