Ortho

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Ortho
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Ortho
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  1. Dorsal Scapular nerve course and innervation
    • Pierces middle scalene deep to Levator Scapulae.
    • Innervates: Levator Scapulae, Rhomboid minor and major
  2. Long thoracic nerve course and innervation
    • Anterior surface of serratus anterior w/ lateral thoracic artery
    • Innervates: Serratus anterior
  3. Suprascapular nerve course and innervation
    • Under transverse scapular ligament in suprascapular notch then spinoglenoid notch (area of compression)
    • Innervates: Supraspinatus and Infraspinatus
  4. Lateral Pectoral nerve course and innervation
    • Medial to Medial pectoral nerve with pectoral artery
    • Innervates: Pectoralis major and minor
  5. Thoracodorsal nerve course and innervation
    • With thoracodorsal artery deep to Lat
    • Innervates: Latissimus dorsi
  6. 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
  7. Deltoid innervation
    Axillary nerve
  8. Pectoralis major innervation
    Medial and Lateral Pectoral nerve (medial runs lateral to lateral)
  9. Pectoralis minor innervation
    Medial pectoral nerve
  10. Serratus Anterior innervation
    Long Thoracic nerve
  11. Subclavius innervation
    Nerve to the subclavius
  12. Rotator cuff muscles and innervation
    • Supraspinatus- suprascapular nerve
    • Infraspinatus- Suprascapular nerve
    • teres minor- Axillary nerve
    • Subscapularis- Upper and Lower Subscapular nerve
  13. Gerdy's tubercle
    • Proximal lateral tibia
    • Insertion of IT band
  14. 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
  15. 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)
  16. Equinus position
    fixed plantar flexion
  17. 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)
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. Both bone forearm fracture immobilization position by site
    • Proximal 3rd: supination
    • Middle 3rd: neutral
    • Distal 3rd: pronation
  26. Juvinile tillaux fracture
    • Salter Harris III of anterolateral tibial epiphysis
    • 13-16 yrs old when central and medial portion fused
    • External rotation
  27. Juvenile triplane ankle fracture
    • transverse, coronal, and sagital
    • Explained by physis fusion from central -> anteromedial -> posteriomedial -> lateral
  28. Carpal tunnel syndrome predisposing factors
    • Female
    • Obese
    • Pregnant
    • Hypothyroid
    • RA
    • Amyloidosis
  29. Carpal tunnel borders
    • Medial: scaphoid tubercle and trapezium
    • Ulnar: Hook of hamate and pisisform
    • Palmar: Transverse carpal ligament
    • Dorsal: Proximal carpal row
  30. 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.
  31. Carpal tunnel syndrome treatment
    • NSAIDS
    • Steroid injection
    • Carpal Tunnel Release- cut ulnarly

    Surgery Recovery- pinch strength- 6 wks, Grip 100%- 12 wks
  32. 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
  33. Vertical medial malleolus ankle fracture treatment
    Must plate
  34. Transverse/oblique medial malleolus fracture treatment
    cannulated screw
  35. 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
  36. 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
  37. 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
  38. Distal radius normal measurements
    • Radial inclination: 22o
    • Radial length: 11mm
    • Volar tilt: 11o
  39. 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
  40. Smith fracture
    • Reverse Colles fracture
    • Volar angulation
    • Unstable fracture pattern
  41. Colles fracture
    • 90% of distal radius fractures
    • Dorsal angulation
    • Dorsal displacement
    • Radial shift
    • Radial shortening
  42. Acromiohumeral interval
    • Shortest distance between inferior cortex of acromion and humerus
    • Normal: 1-1.5 cm
    • Rotator cuff tear: <6mm
  43. Galeazzi fracture
    • Radial shaft fracture @ junction of middle and distal 3rd with DRUJ disruption
    • Fracture of necessity- needs ORIF
  44. 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
  45. 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- 70flexion
  46. 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
  47. 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
  48. Barton fracture
    • Fracture dislocation of radiocarpal joint
    • Shearing mechanism
    • Fracture of volar or dorsal radial rim
    • Unstable
  49. Die punch fracture
    Depression fx of lunate fossa of articular surface of distal radius
  50. 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"
  51. Essex Lopresti lesion
    • Radial head fracture dislocation
    • Interosseous ligament and DRUJ disruption
  52. Olecranon fracture classification
    • I- nondisplaced
    • II- displaced w/o instability
    • III- instability of ulnohumeral joint

    • a- noncomminuted
    • b- comminuted
  53. 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
  54. Cubital tunnel syndrome symptoms
    • Predominantly hand symptoms
    • Fibers to FCU and FDP run centrally
    • Hand intrinsic fibers are peripheral
  55. 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
  56. 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)
  57. 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
  58. Tibial plateau fracture surgery
    I-IV: percutaneous screws or lateral placed periarticular plate

    V-VI: percutaneous locked plate or hybrid fixator
  59. Open hand fracture rate of infection
    • Clean- 1.4%
    • Contaminated/bite/lake water/barnyard- 14%
  60. Coracoclavicular ligament distances
    • Trapezoid- 30mm from distal tip
    • Conoid- 45mm from distal tip

    When performing Mumford excision- 10mm removal
  61. Bennett fracture
    • 1st metacarpal
    • Intraarticular
    • Separation from volar lip
    • Pulled proximally and flexed
    • Deforming forces- abductor pollicis longus and adductor pollicis
  62. Rolando fracture
    • 1st metacarpal 
    • Cominuted intraairticular
    • Y or T fracture pattern
    • Future DJD
  63. Hand PIP surgical indications
    • Dorsal lip- >1mm displaced
    • Volar lip- >40% articular involvement
  64. 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
  65. 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)
  66. 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)
  67. Thenar compartment
    • Opponens pollicis (median)
    • Abductor pollicis brevis (median)
    • Flexor pollicis brevis superficial head (median)
    • Flexor pollicis braves deep head (ulnar)
  68. Adductor compartment
    Adductor pollicis oblique and transverse heads (ulnar)
  69. Hypothenar compartment
    • Palmaris brevis (ulnar)
    • Flexor digiti minimi brevis (ulnar)
    • Opponens digiti minimi brevis (ulnar)
    • Abductor digiti minimi (ulnar)
  70. 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
  71. 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
  72. Mobile wad (of Henry)
    • Brachioradialis (radial)
    • ECRL (radial)
    • ECRB (radial)

    Radial artery and nerve
  73. 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)
  74. Cubital tunnel borders
    • Roof: Arcuate (Osborne's) ligament
    • Floor: MCL
    • Posterior: Triceps medial head
    • Anterior: Medial Epicondyle
    • Lateral: Olecranon
  75. 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
  76. Triangular space (Medial)
    • Teres minor
    • Teres major
    • Triceps long head

    Contains: Circumflex scapular artery
  77. Quadrangular space
    • Teres minor
    • Teres major
    • Triceps long head
    • Humerus

    Contains: Axillary n., Posterior circumflex a., Humeral a.
  78. Triangular interval (Lateral)
    • Teres minor
    • Triceps long head
    • Triceps lateral head

    Contains: Radial n., Deep artery of arm
  79. Lateral x-ray C-spine prevertebral swelling distance by level
    • C1- >10mm
    • C3,4- >7mm
    • C5-7- >20mm
  80. 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
  81. 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
  82. 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
  83. Atlas fracture treatment
    • Initial- halo traction/immobilization
    • Stable (A,B,C)- rigid cervical orthosis
    • Unstable- prolonged halo immobilization
    • Chronic instability- C1-2 fusion 
  84. 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
  85. 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
  86. Joint of Luschka
    • uncovertebral joints in cervical spine
    • (uncinate process projects superiorly from lateral aspect of vertebral body)
  87. 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)
  88. Clay shoveler's fracture
    Muscular avulsion of spinous process in lower cervical or upper thoracic
  89. Sentinel fracture
    • Through lamina on either side of spinous process. 
    • Loose element may impinge on cord
  90. 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
  91. 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
  92. 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
  93. Anterior approach to subaxial spine plane 
    Superficial- Sternocleidomastoid (lateral), Anterior strap (medial)

    Deeper- Carotid sheath (lateral), trachea/esophagus (medial)
  94. Conus medullaris end level
    L1-L2
  95. Spine region with smallest ratio of spinal canal to spinal cord
    T2-T10
  96. Most thoracic and lumbar injuries occur at what region
    T11-L1 (thoracolumbar junction)
  97. Sacral sparing triad
    • Perianal sensation
    • Rectal tone
    • Great toe flexion
  98. Compression vs Burst fx
    Burst involves middle column in addition to anterior
  99. Burst and compression fx most common type
    Type B (superior endplate)
  100. Early stabilization of burst fracture indications
    • Neurologic deficits
    • Loss of >50% body height
    • Angulation >20o
    • Canal compromise >50%
    • Scoliosis >10o
  101. 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
  102. Degrees of spinal instability
    • 1st- mechanical
    • 2nd- neurologic
    • 3rd- mechanical and neurologic
  103. Thoracolumbar spine fx with incomplete neurologic injury approach to decompression
    Anterior (greater neurologic improvement than posterior or lateral)
  104. Predictor of dural tear in burst fx
    neurologic involvement
  105. 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%)
  106. 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
  107. 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
  108. 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
  109. 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. 
  110. 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
  111. 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
  112. 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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