-
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
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