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  1. syndesmosis on xray
    • decreased tibiofibular overlap 
    • normal >6 mm on AP view
    • normal >1 mm on mortise view

    • increased medial clear space 
    • normal less than or equal to 4 mm

    • increased tibiofibular clear space 
    • normal <6 mm on both AP and mortise views
  2. lauge hansen
    • (SA)-
    • Talofibular sprain or distal fibular avulsion
    • Vertical medial malleolus and impaction of anteromedial distal tibia


    • (SER)-
    • Anterior tibiofibular ligament sprain
    • Lateral short oblique fibula fracture (anteroinferior to posterosuperior)
    • Posterior tibiofibular ligament rupture or avulsion of posterior malleolus
    • Medial malleolus transverse fracture or disruption of deltoid ligament

    (PA)

    • Medial malleolus transverse fracture or disruption of deltoid ligament
    • Anterior tibiofibular ligament sprain
    • Transverse comminuted fracture of the fibula above the level of the syndesmosis

    (PER)

    • Medial malleolus transverse fracture or disruption of deltoid ligament 
    • Anterior tibiofibular ligament disruption
    • Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint
    • Posterior tibiofibular ligament rupture or avulsion of posterior malleolus
  3. indications orif ankle
    • any talar displacement 
    • displaced isolated medial malleolar fracture
    • displaced isolated lateral malleolar fracture

    • bimalleolar fracture and bimalleolar-equivalent fracture
    • posterior malleolar fracture with > 25% or > 2mm step-off
    • Bosworth fracture-dislocations

    open fractures
  4. femur shaft fracture associated injuries:
    • ipsilateral femoral neck fracture
    • 2-6% incidence  often basicervical, vertical, and nondisplaced
    • missed 19-31% of time

    • bilateral femur fractures
    • significant risk of pulmonary complications
    • increased rate of mortality as compared to unilateral fractures
  5. 3 compartments of the thigh
    • anterior
    • -sartorius
    • -quadriceps

    • posterior
    • -biceps femoris
    • -semitendinosus
    • -semimembranosus

    • adductor
    • -gracilis
    • -adductor longus
    • -adductor brevis
    • -adductor magnus
  6. Winquist and Hansen Classification and OTA
    • Type 0 • No comminution
    • Type I • Insignificant amount of comminution
    • Type II • Greater than 50% cortical contact
    • Type III • Less than 50% cortical contact 
    • Type IV • Segmental fracture with no contact between proximal and distal fragment

    • 32A -Simple 
    • • A1 - Spiral
    • • A2 - Oblique, angle > 30 degrees
    • • A3 - Transverse, angle < 30 degrees

    • 32B - Wedge 
    • • B1 - Spiral wedge
    • • B2 - Bending wedge
    • • B3 - Fragmented wedge

    • 32C - Complex 
    • • C1 - Spiral
    • • C2 - Segmental
    • • C3 - Irregular
  7. retrograde intramedullary nail with reamed technique (6)
    • ipsilateral femoral neck fracture 
    • floating knee (ipsilateral tibial shaft fracture) 
    • ipsilateral acetabular fracture
    • multiple system trauma
    • bilateral femur fractures
    • morbid obesity
  8. complications femur shaft
    • HO- 25%
    • pudendal nerve-10% frature table
    • malunion/rotational allignment-
    • --prox 30%/ distal fracture 10%
    • --
    • use of a fracture table increases risk of internal rotation deformities ;fracture comminution; night-time surgery

    non union 10%
  9. Gustilo-Anderson Classification of Open Tibia Fractures
    Type I-Limited periosteal stripping, clean wound < 1 cm

    Type II-Mild to moderate periosteal stripping, wound >1 cm in length

    Type IIIA-Significant soft tissue injury (often evidenced by a segmental fracture or comminution), significant periosteal stripping, wound usually >5cm in length, no flap required 

    • Type IIIB-Significant periosteal stripping and soft tissue injury, flap required due to inadequate soft tissue coverage (STSG doesn't count).
    • Treat proximal 1/3 fxs with gastrocnemius rotation flap
    • middle 1/3 fxs with soleus rotation fla
    • distal 1/3 fxs with free flap. 

    Type IIIC-Significant soft tissue injury (often evidenced by a segmental fracture or comminution), vascular injury requiring repair to maintain limb viability  

    For prognostic reasons, severely comminuted, contaminated barnyard injuries, close range shotgun/high velocity gunshot injuries, and open fractures presenting over 24 hours from injury have all been later included in the grade III group.
  10. tibial shaft
    closed low energy fxs with acceptable alignment
    • < 5 degrees varus-valgus angulation
    • < 10 degrees anterior/posterior angulation
    • > 50% cortical apposition
    • < 1 cm shortening
    • < 10 degrees rotational malalignment
  11. IM Nailing indications tibial shaft #
    • unacceptable alignment with closed reduction and casting
    • soft tissue injury that will not tolerate casting
    • segmental fx
    • comminuted fx
    • ipsilateral limb injury (i.e., floating knee)
    • polytrauma
    • bilateral tibia fx
    • morbid obesity


    • medial parapatellar-most common 
    • can lead to valgus malalignment when used to treat proximal fractures

    • lateral parapatellar
    • helps maintain reduction when nailing proximal 1/3 fractures
    • requires mobile patella
  12. fracture reduction techniques tibia im nail (5)
    • spanning external fixation (ie. traveling traction)
    • clamps
    • femoral distractor
    • small fragment plates/screws
    • intra-cortical screws
  13. tibia shaft # complications:
    • knee pain- over 50%
    • malunion-high incidence of valgus and procurvatum (apex anterior) malalignment in proximal third fractures
    • varus malunion leads to ipsilateral ankle pain and stiffness

    • delayed union if union at 6-9 mos.
    • nonunion if no healing after 9 mos.
    • malrotation-most commonly occurs after IM nailing of distal 1/3 fracture ( plate fibula to prevent)
    • compartment 1-9%
    • liss plate- superficial peroneal nerve hole 11-13 ( ehl and first webspace)
  14. non union tibia shaft treatment
    • nail dynamization if axially stable
    • exchange nailing if not axially stable 
    •    -reamed exchange nailing most appropriate for aseptic, diaphyseal tibial nonunions with less than 30% cortical bone loss.    
    •    -consider revision with plating in metaphyseal nonunions
    • posterolateral bone grafting if significant bone loss
    • non-invasive techniques (electrical stimulation, US)
    • BMP-7 (OP-1) has been shown equivalent to autograft 
    • compression plating has been shown to have 92-96% union rate after open tibial fractures initially treated with external fixation
    • fibular osteotomy of tibio-fibular length discrepancy associated with healed or intact fibula
  15. tibial plateay assoc. conditions
    • lateral meniscal tear more common than medial
    • associated with Schatzker II fracture pattern  


    • medial meniscal tear:
    • -most commonly associated with Schatzker IV fractures

    • ACL injuries
    • more common in type V and VI fractures (25%)

    • compartment syndrome
    • vascular injury
    • commonly associated with Schatzker IV fracture-dislocations
  16. schatzker and moore
    • Type I-Lateral split fracture
    • Type II-Lateral Split-depressed fracture
    • Type III-Lateral Pure depression fracture
    • Type IV-Medial plateau fracture    
    • Type V-Bicondylar fracture
    • Type VI-Metaphyseal-diaphyseal disassociation
  17. Hohl and Moore Classification
    • Type I-Coronal split fracture
    • Type II-Entire condylar fracture
    • Type III-Rim avulsion fracture of lateral plateau
    • Type IV-Rim compression fracture
    • Type V-Four-part fracture

    • Classification useful for
    • 1) true fracture-dislocations
    • 2) fracture patterns that do not fit into the Schatzker classification (10% of all tibial plateau fractures)
    • 3) fractures associated with knee instability
  18. tibial plateau orif indication
    • open reduction, internal fixation  
    • indications
    • articular stepoff > 3mm
    • condylar widening > 5mm
    • varus/valgus instability
    • all medial plateau fxs
    • all bicondylar fxs
  19. associated injury acetabulum fracture
    orthopaedic manifestations

    • lower extremity injury (36%)
    • nerve palsy (13%)
    • spine injury (4%)

    systemic injuries

    • head injury (19%)
    • chest injury (18%)
    • abdominal injury (8%)
    • genitourinary injury  (6%)
  20. name the parts of anterior and posterior column
    • posterior column
    • -quadrilateral surface
    • -posterior wall and dome
    • -ischial tuberosity
    • -greater/lesser sciatic notches

    • anterior column 
    • -anterior ilium (gluteus medius tubercle)
    • -anterior wall and dome
    • -iliopectineal eminence
    • -lateral superior pubic ramus
  21. Judet and Letournel
    • elementary
    • -posterior wall ( gull sign obturator oblique)
    • -posterior column
    • -anterior wall
    • -anterior column
    • -transverse

    • associated
    • -assoc. both column ( spur sign Obt oblique)
    • -transverse + post wall
    • -T shaped
    • -ant column/wall +posterior hemitransverse
    • -post column+post wall.
  22. Judet views + roof arc
    • obturator oblique
    • -posterior wall
    • -anterior column

    • iliac oblique
    • -anterior wall
    • -posterior column

    • roof arc- ap/ obturator + illiaq oblique
    • - if over 45 degeees then stable ( vertical to fracture line(
  23. most common fracture patterns
    younger 

    • -posterior wall 
    • transverse fracture "family"
    • -transverse
    • -T-type
    • -transverse + posterior wall

    elderly 

    • -anterior column (e.g., quadrilateral plate fractures)
    • -anterior column, posterior hemitransverse
    • assoicated both column fractures
  24. approaches acetabulum fracture:
    Image Upload
  25. complications acetabulum orif:
    • Arthritis
    • -80% survival 20 years after surgery
    • ( worse if over 40, assoc fracture and head fracture)

    • -HO ( extensile approach)- indomethacin 5 weeks/ low dose external beam radiation
    •  ( lowest incidence anterior illioinguinal approach)
    • -osteonecrosis- 6-7% or 18% posterior fracture
    • -dvt/pe/bleeding/NV injury/ abductor weakness
  26. pelvic fracture mortality and assoc injuries
    15% closed/ 50% open

    • increased mortality if
    • systolic BP <90 on presentation
    • age >60 years
    • increased Injury Severity Score (ISS) 
    • need for transfusion > 4 units  

    • Associated injuries
    • chest injury in up to 63%
    • long bone fractures in 50%
    • sexual dysfunction up to 50% 
    • head and abdominal injury in 40%
    • spine fractures in 25%
  27. pelvic fracture poor outcome associated with:
    • SI joint incongruity of > 1 cm
    • high degree initial displacement
    • malunion or residual displacement
    • leg length discrepancy > 2 cm
    • nonunion
    • neurologic injury
    • urethral injury
  28. ligaments of pelvis
    • pelvic floor 
    • -sacrospinous ligaments :resist external rotation
    • -sacrotuberous ligaments: resist shear and flexion

    posterior sacroiliac complex

    • more important than anterior structures for pelvic ring stability 
    • -anterior sacroiliac ligaments
    •    resist external rotation after failure of pelvic floor and anterior structures
    • -interosseous sacroiliac 
    •     resist anterior-posterior translation of pelvis
    • -posterior sacroiliac 
    •     resist cephalad-caudad displacement of pelvis
    • -iliolumbar
    •     resist rotation and augment posterior SI ligaments
  29. young burgess classfiication
    Image Upload
  30. TILE classification
    • A: stable
    • A1: fracture not involving the ring (avulsion or iliac wing fracture)
    • A2: stable or minimally displaced fracture of the ring
    • A3: transverse sacral fracture (Denis zone III sacral fracture)
    • B - rotationally unstable, vertically stable
    • B1: open book injury (external rotation)
    • B2: lateral compression injury (internal rotation)
    • B2-1: with anterior ring rotation/displacement through ipsilateral rami
    • B2-2-with anterior ring rotation/displacement through contralateral rami (bucket-handle injury)
    • B3: bilateral
    • C - rotationally and vertically unstable
    • C1: unilateral
    • C1-1: iliac fracture
    • C1-2: sacroiliac fracture-dislocation
    • C1-3: sacral fracture
    • C2: bilateral with one side type B and one side type C
    • C3: bilateral with both sides type C
  31. ex fix
    supra-acetabular pin
    • single pin in column of supracetabular bone from AIIS towards PSIS
    • obturator outlet view 
    •       helps to identify pin entry point
    • iliac oblique view 
    •       helps to direct pin above greater sciatic notch
    • obturator oblique inlet view 
    •       helps to ensure pin placement within inner and outer table
  32. pelvic fracture orif indication
    • symphysis diastasis > 2.5 cm 
    • SI joint displacement > 1 cm
    • sacral fracture with displacement > 1 cm
    • displacement or rotation of hemipelvis
    • open fracture
    • chronic pain and diastasis in parturition-induced  diastasis or acute setting >6cm
  33. urogenital injuries
    • 12-20% of patients with pelvic fractures
    • higher incidence in males (21%)
    • Includes

    posterior urethral tear

    • most common urogenital injury with pelvic ring fracture 
    • bladder rupture
    • may see extravasation around the pubic symphysis 
    • associated with mortality of 22-34%
  34. leap study-amputation indications
    • loss of soft tissue main concern
    • plantar sensation ( falling out of favor)
  35. metabolic wok increase after amputation
    • Syme - 15%
    • transtibial
    • traumatic - 25% average
    • short BKA - 40%
    • long BKA - 10%
    • vascular - 40%
    • transfemoral
    • traumatic - 68%
    • vascular - 100%
    • bilateral amputations
    • BKA + BKA - 40% 
    • AKA + BKA - 118%
    • AKA + AKA - >200%
  36. wound healing ideal requirements ( amputation)
    • albumin > 3.0 g/dL 
    • ischemic index > .5
    • measurement of doppler pressure at level being tested compared to brachial systolic pressure

    • transcutaneous oxygen tension > 30 mm Hg (ideally 45 mm Hg)
    • toe pressure > 40 mm Hg (will not heal if < 20 mm Hg)
    • ankle-brachial index (ABI) > 0.45
    • total lymphocyte count (TLC) > 1500/mm3
  37. BKA types
    syme-ankle disarticulation ( need patent post tib artery) ( more energy efficient than midfoot)

    pirigof- calcaneous osteotomy _ calc=tib fusion

    chopart- through talonavic and calc-cuboid ( lengthen achilles and transfer tib ant to talus

    lisfranc-get equinavarus due to tib post and equinus- prevent by keeping peroneus brevis

    transmetarasal0- need achilles lengthenin

    great toe- preserve base 1cm base of proximal metaphalynx
  38. Hemorrhagic Shock Classification & Fluid Resuscitation
    Image Upload
  39. indicators of adequate perfusion
    • MAP > 60
    • HR < 100
    • urine output 0.5-1.0 ml/kg/hr (30 cc/hr)
    • serum lactate levels   
    • most sensitive indicator as to whether some circulatory beds remain inadequately perfused (normal < 2.5 mmol/L) 
    • gastric mucosal ph 
    • base deficit  
    • normal -2 to +2
  40. parameters for DCO
    • ISS >40 (without thoracic trauma)
    • ISS >20 with thoracic trauma
    • GCS of 8 or below
    • multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock
    • bilateral femoral fractures
    • pulmonary contusion noted on radiographs
    • hypothermia <35 degrees C
    • head injury with AIS of 3 or greater
    • IL-6 values above 500pg/dL
  41. common complications DR #
    • ECU entrapment in DRUJ
    • malunion/non union
    • radial shortening worst outcome- treat with ulnar shortening
    • epl rupture ( Extensor indicices to epl transfer)
    • DRUJ injury- ulnar nerve neuropathy
    • median nerve- up to 12% low energy; 30% high energy
  42. calcaneous fracture assoc injuries
    check knee, hip, spine

    • extension into the calcaneocuboid joint occurs in 63%
    • vertebral injuries in 10%
    • contralateral calcaneus in 10%

    40% complication rate
  43. Calcaneous osteology
    • posterior facet is the largest and is the major weight bearing surface
    •        the flexor hallucis longus tendon runs just inferior to it and can be injured with errant                drills/screws that are too long 
    • middle facet is anteromedial on sustentaculum tali
    • anterior facet is often confluent with middle facet
    • sinus tarsi
    • between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi

    • sustentaculum tali
    • projects medially and supports the neck of talus
    • FHL passes beneath it 
    • deltoid and talocalcaneal ligament connect it to the talus
    • contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments 
    • bifurcate ligament
  44. essex lopresti classification
    • the primary fracture line runs obliquely through the posterior facet forming two fragments
    • the secondary fracture line runs in one of two planes

    • axial- tongue type
    • transverse fracture in the coronal calcaneal plane that occurs between the posterior facet and the Achilles insertion;
    •             - hence, the secondary fracture line extends from crucial angle of Gissane to posterior border of calcaneus, exiting on superior surface of calcaneus
  45. calcaneous views

    and angles bohler + gissane
    • Broden- for posterior facet
    • -with ankle in neutral dorsiflexion take x-rays at 40, 30, 20, and 10 degrees of internal rotation

    • Harris view 
    • visualizes tuberosity fragment widening, shortening, and varus positioning
    • place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees



    • Bohler angle (normal is 20-40 degrees) 
    • measured from lateral foot x-ray
    • flattening (decreased angle) represents collapse of the posterior facet
    • double-density highlights subtalar incongruity
    • angle of Gissane (normal is 130-145 degrees)   
    • an increase represents collapse of posterior facet
  46. calcaneous orif indication
    • displaced tongue-type fractures  
    • large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm displacement
    • urgent if skin is compromised
    • Sanders Type II and III
    • posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity
    • anterior process fracture with >25% involvement of calcaneocuboid joint
    • displaced sustentaculum fractures
  47. calcaneous poor outcome
    • age > 50
    • obesity
    • manual labor
    • workers comp
    • smokers
    • bilateral calcaneal fractures
    • multiple trauma
    • vasculopathies
    • men do worse with surgery than women
  48. humeral shaft orif absolute indications(5)
    • open fracture
    • compartment syndrome
    • brachial plexus injury
    • floating elbow
    • vascular injury
  49. humeral shaft IM nail indications
    • pathologic fracture
    • segmental fracture
    • severe osteoportic bone
    • overlying skin compromise
    • polytrauma
  50. approach for proximal 1/3 humerus

    approach for middle and distal 1/3
    anterolateral- exension of deltopectoral approach ( radial nerve between brachioradialis and brachialis)

    • posterior- radial nerve found medial to lateral head of triceps ( 2cm proximal to deep head)
    • -radial nerve exits through lateral intramuscular septum 10cm proximal to radiocapitellar joing

    lateral brachial cutaneous nerve on top of brachioradialis- trace it proximally
  51. radial nerve palsy

    observation indictions (4)
    operative indications(3)
    8-15% closed fracture

    • indicated as initial treatment  in closed humerus fractures
    • obtain EMG at 3-4 months
    • wrist extension in radial deviation is expected to be regained first 
    • brachioradialis first to recover, extensor indicis is the last 


    • open fracture with radial nerve palsy (likely neurotomesis injury to the radial nerve) 
    • closed fracture that fails to improve over ~ 3-6 months 
    • fibrillations (denervation) seen at 3-4 months on EMG
  52. interrosseus membrane forearm (5)
    • central band is key portion of IOM to be reconstructed
    • accessory band
    • distal oblique bundle
    • proximal oblique cord
    • dorsal oblique accessory cord
  53. non op forerarm fracture
    isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with

    • < 50% displacement and
    • < 10° of angulation
  54. complications BBF #
    • synostosis- 3-9% worse with one incision
    • compartment syndrome-open fx, high energy crush, gsw low velocity, vascular injury, coagulopathy
    • infection-3%
    • refracture- dont removeplate before 15 mo
    • -large plates 4.5/communited
    • -if remove plate bracing for 6 weeks, then protect weighbearing for 3 month
  55. proximal tibia deforming forces
    • patellar tendon- procurvatum
    • hamstring - distal fragment into flexion
    • pes anserinus- proximal into varus, valgus of fracture
    • anterior compartment musculature
    • -valgus of fracture
  56. proximal tibia # IM NAIL

    poller screws
    • lateral parapatellar
    • ( since lateral causes valgus)

    coronal poller- posterior part of proximal fragment prevents procurvatum

    sagittal-prevents valgus -place on lateral concave side of proximal fragment
  57. pilon fracture - main fragments

    blood supply
    • medial malleolar fragment- deltoid ligament
    • posterolateral-volkmann fragment-PITFL
    • chaput fragment-AITFL

    • Ant tibial artery
    • btw 2 heads gastroc anterior to IOM between tib and and EHL
    • becomes doraslis pedis

    • Post tibial artery
    • deep in posterior compartment of the leg
    • medial and plantar arteries ( behind medial mal)

    • peroneal artery
    • takes off 2.5 cm off distal popliteal fossa
  58. pilon nerves
    tibial nerve (L4-S3) 

    • crosses over popliteus from the popliteal fossa and splits 2 heads of gastrocnemius
    • passes deep to soleus coursing to the posterior aspect of the medial malleolus
    • terminates as medial and lateral plantar nerves
    • muscular branches supply posterior leg (superficial and deep posterior compartments)

    common peroneal nerve (L4-S2)

    • winds around neck of fibula and runs deep to peroneus longus
    • divides into superficial and deep peroneal nerves

    superficial peroneal nerve

    • courses along border between lateral and anterior compartments of leg
    • supplies muscular branches to peroneus longus and brevis (lateral compartment)
    • terminates as medial dorsal and intermediate dorsal cutaneous nerves

    deep peroneal nerve 

    • courses along anterior surface of IOM
    • supplies musculature of anterior compartment and sensation to first web space


    saphenous nerve (L3-L4)

    • continuation of femoral nerve of the thigh
    • becomes subcutaneous on medial aspect of knee between sartorius and gracilis
    • supplies sensation to medial aspect of leg and foot

    sural nerve (S1-S2)

    • formed by cutaneous branches of tibial (medial sural cutaneous) and common peroneal (lateral sural cutaneous) nerves
    • lies on lateral aspect of leg and foot
  59. Russel taylor classification
    • Type I- No extension into piriformis fossa
    • Type II-Extension into greater trochanter with involvement of piriformis fossa
    •  •  look on lateral xray to identify piriformis fossa extension
  60. ASBMR Task Force Case Definition of Atypical Femur Fractures (AFFs)

    Major (5)
    minor(8)
    • major:
    • Located anywhere along the femur from just distal to the lesser trochanter to just proximal to the supracondylar flare 
    •  Associated with no trauma or minimal trauma, as in a fall from a standing height or less
    •  Transverse or short oblique configuration
    •  Noncomminuted 
    •  Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex

    • Minor
    • Localized periosteal reaction of the lateral cortex
    • Generalized increase in cortical thickness of the diaphysis
    • Prodromal symptoms such as dull or aching pain in the groin or thigh
    • Bilateral fractures and symptomscomplete fractures involve only the lateral cortex  
    • Delayed healing
    • Comorbid conditions (eg, vitamin D deficiency, rheumatoid arthritis, hypophosphatasia)
    • Use of pharmaceutical agents (eg, BPs, glucocorticoids, proton pump inhibitors)
    • Specifically excluded are fractures of the femoral neck, intertrochanteric fractures with spiral subtrochanteric extension, pathological fractures associated with primary or metastatic bone tumors, and periprosthetic fractures
  61. most common complication with subtroch fracture
    varus/procurvatum
  62. compartment syndrome causes (7)
    • Trauma
    •    -fractures (69% of cases)
    •    -crush injuries
    •    -contusions
    • gunshot wounds

    • tight casts, dressings, or external wrappings
    • extravasation of IV infusion
    • burns
    • postischemic swelling
    • bleeding disorders
    • arterial injury
  63. pathoanatomy of compartment syndrome
    • local trauma and soft tissue destruction> 
    • bleeding and edema > 
    • increased interstitial pressure > 
    • vascular occlusion > 
    • myoneural ischemia
  64. compartments of the leg
    • anterior compartment- dorsiflexion
    • -tib ant
    • -ehl
    • -edl
    • -peroneus tertius

    • lateral compartment-plantar flexion and eversion
    • -peroneous longues
    • -peroneus brevis

    • deep posterior compartment-plantar + eversion
    • -tib post
    • -FDL
    • -FHL

    • superficial posterior compartment
    • -gastrocs
    • -soleus
    • -plantaris
  65. physical exam compartment
    • pain
    • parasthesia
    • paralysis
    • poikilothermia
    • pulselessness
  66. compartment syndrome stryker needle technique
    • ant compartment-1cm lateral  to tibia ( within 5cm of fracture)
    • deep posterior-posterial to medial border of the tibia
    • lateral compartment-posterior border of fibula
    • superificial- middle calf
  67. hemophilliac compartment synddrome what to give
    give factor 8 replacement
  68. fasciotomy leg
    • anterolateral- 1 cm anterior to fibula- protect superifical peroneal nerve
    • -longitudonal incison to identify the raphe

    • posteromedial-1cm posterior to tibia- protect saphenous vein
    • - detach soleal bridge
  69. single lateral fasciotomy
    • single lateral incision from head of fibula to ankle along line of fibula
    • reach deep posterior compartment by following interosseous membrane from the posterior aspect of fibula and releasing compartment from this membrane

    common peroneal nerve at risk with proximal dissection
  70. retrograde IM nail- how much distal bone do we need
    need 4 cm
  71. hoffa fracture
    • coronal plane fracture of condyle
    • use lateral  parapatellar or medial lateral posterior ( pt prone)
  72. plumbism
    • can be caused by intrarticular missile or spine
    • neurotoxicity
    • anemia
    • emesis
    • abdominal colic
  73. GSW velocity
    • low- <350 mtrs/sec (gustillo 1-2)
    • medium- 350-500 mtrs/sec
    • high- >500 mtrs/sec ( gustillo 3)
  74. GSW to hand
    • surgical debridement + orif
    • -unstable
    • articular involvement
    • -8 or more hours after injury
    • -tendon involvement
    • -superficial fragments in palm
  75. GSW to femur
    • IM nail-
    • -low velocity i&D

    • ex-fix
    • -high velocity
    • -stabilize soft tissue aggressive I&d
    • -vascular injury
  76. GSW SPINE
    broad spectrum abx for 7-14 days ( with perf viscus)

    • surgical debridement
    • -neuro compromise ( makes sense with imaging)
    • -incomplete motor deficit is relative indication
  77. risk factors elders abuse (5)
    • increasing age
    • functional disability 
    • child abuse within the regional population 
    • cognitive impairment
    • gender is NOT a risk facto
  78. distal humerus fracture pattern:

    elbow flexed <90

    elbow flexed >90
    • flex < 90-
    • -axial load- transcolumnar fracture

    • flex >90
    • -intercondylar fracture
  79. medial epicondyle muscle origin
    • pronator teres
    • FCR
    • PL
    • FDS
    • FCU
  80. common extensors-lateral condyle
    • anconeus 
    • ECRL 
    • ECRB 
    • extensor digitorum comminus 
    • EDM 
    • ECU
  81. elbow ligament
    MCL
    LCL
    • MCL
    • -distal medial epicondyle to sublime tubercle
    • -primary restraint to valgus (30-120)
    • - tight in pronation

    • LCL
    • distal humeral condyle to crista supinatorus
    • -resists posterolateral rotation instabllity
    • -taut in supination
  82. Milch classification
    • Milch Type I
    • Lateral trochlear ridge intact

    • Milch Type II
    • Fracture through lateral trochlear ridge
  83. Jupiter classification
    high-t :Transverse fx proximal to or at upper olecranon fossa

    Low-T-Transverse fx just proximal to trochlea (common)

    Y-Oblique fx line through both columns with distal vertical fx line

    H-Trochlea is a free fragment (risk of AVN)

    medial lambda- proximal fx line exits medially

    lateral lambda-proximal fx line exits laterally

    mutiplane T-T type with additional fracture in coronal plane
  84. non op casting distal humerus sup/pronation
    • immobilize in supination for lateral condyle fractures
    • immobilize in pronation for medial condyle fractures
  85. ORIF distal humerus exosure percentage
    • olecranon osteotomy 57%
    • triceps-reflecting 46%
    • triceps-splitting 35%
  86. tricep sparing approach
    • identify ulnar nerve- distal to first branch FCU and 15 cm proximal
    • -free trices of medial side to medial intermuscular septum
    • -posterior band of MCL elevated and posterior joint capsule entered to see trochlea

    • -lateral side
    • can divide anconeous
    • find radial nerve
  87. fixation objectives (O'Driscoll)
    • every screw in the distal fragments should pass through a plate
    • engage a fragment on the opposite side that is also fixed to a plate
    • as many screws as possible should be placed in the distal fragments
    • each screw should be as long as possible
    • each screw should engage as many articular fragments as possible
    • the screws in the distal fragments should lock together by interdigitation, creating a fixed-angle structure

    this creates the architecural equivalent of an arch, which gives the most biomechanical stability

    • plates should be applied such that compression is achieved at the supracondylar level for both columns
    • the plates must be strong enough and stiff enough to resist breaking or bending before union occurs at the supracondylar level.
  88. acromioclavicular ligament

    coracoclavicular
    • provides anterior/posterior
    • superior ligament- strongest followed by posterior

    • trapezoid 
    • strongest
  89. zanca view
    5° cephalic tilt (ZANCA view) determine superior/inferior displacement
  90. non op clacvicle nonunion risk factors (4)
    • 2 cm shortening
    • 100% displacement
    • advanced aged
    • female gender
  91. clavicle orif indications (6)
    • open fxs
    • displaced skin tinting
    • subclavian artery injury
    • floating shoulder
    • symptomatic non union
    • symptomatic malunion
  92. clavicle orif advantages (6)
    • improved fucntional outcome
    • faster time to union
    • decreased symptomatic malunion
    • improved cosmesis
    • improved overal shoulder score
    • increased shoulder strength and endurance
  93. clavicle superior vs anteroinferior plating
    • higher load to failure ( superior)
    • less deltoid removal ( superior)
    • inferior bone communition ( anteroinferior)
    • lower risk neurovasc ( anteroinferior)
  94. clavicle malunion definition
    • 3 cm short
    • angulation over 30 degrees
    • translation >1 cm
  95. complications clavicle orif
    • hardware prominence- 30% want it out
    • neurovasc injury-3%
    • nonunion-1-5%
    • infection 4.8%
    • mech. failure 1.4%
  96. colton classification
    • Nondisplaced - Displacement does not increase with elbow flexion
    • Avulsion (displaced)
    • Oblique and Transverse (displaced)
    • Comminuted (displaced)
    • Fracture dislocation
  97. schatzker olecranon
    • Type A-Simple transverse fracture
    • Type B-Transverse impacted fracture
    • Type C-Oblique fracture
    • Type D-Comminuted fracture
    • Type E-More distal fracture, extra-articular
    • Type F-Fracture-dislocation
  98. talar neck fracture % and mechanism
    • 50%
    • forced dorsiflexion with axial load
  99. blood supply talus
    • posterior tibial artery
    • -artery of tarsal canal-
    • -deltoid branch- medial portion talar body

    anterior tibial artery- head and neck

    perforarting peroneal artery-
  100. hawkins classification
    • hawkins 1- non displaced   AVN 0-13%
    • hawkins 2- subtalar dislocation AVN 20-50%
    • hawkins 3- subtalar + tibiotalar AVN 20-100%
    • Hawkins 4 subtalar + tibiotalar + talonavic  70-100%
  101. best view for talar neck
    • Canale view
    • -maximal equinus 15 degrees pronated, 75% xray beam cephalad from horizontal
  102. orif talus
    two approach

    • anteromedial-tib ant/ post tib
    • - preserve deltoid
    • -medial mall osteotomy

    • anterolateral
    • -tibia/ fibula in line with the 4th ray
    • -elevate EDB
  103. hawkins sign
    • subchondral lucency in talus seen on mortise
    • -intact vascularity and resorption
    • -6-8 weeks
  104. mechanism radial head
    FOOSH+ arm in pronation
  105. radial head assoc injuries.
    • LCL- 80% on mri
    • essex-lopresti- DRUJ injury
  106. MCL Structure
    • anterior bundle- primary restraint to valgus
    • posterior
    • transverse
  107. Mason classification
    • type 1- nondisplaced
    • type 2-displaced over 2 mm or angulated
    • type 3-communited and displaced
    • type 4-radial head fracture with assoc elbow dislocation
  108. radius pull test
    3mm translation concerning for longitudinal instabillity
  109. greenspan view
    • beam angled 45 degrees cephalad
    • allows visualization of the radial head without coronoid overlap
    • helps detect subtle fractures of the radial head
  110. radial head resection contraindication
    • presence of destabilizing injuries 
    • forearm interosseous ligament injury (>3mm translation with radius pull test)
    • coronoid fracture
    • MCL deficiency
  111. kocher approach

    kaplan approach
    • ecu ( pin) and anconeous (radial)
    • anteror cristasupinarus to protect lucl
    • cut into supinator
    • less risk of pin

    • EDC ( pin) and ECRB ( radial)
    • less risk of lucl
  112. safe zone plate radial head
    • 90-110 degree arc from radial styloid to lister tubercle
    • Image Upload
  113. terrible triad
    • elbow dislocation
    • radial head/neck
    • coronoid fracture

    lcl-->anterior capsule--> MCL
  114. LCL REPAIR sup/pron

    MCL REPAAIR
    • MCL intact- LCL repaired pronation
    • MCL torn - LCL repaired in supination

    MCL- repair only after LCL and instabillity after extension past 30 degrees
  115. elbow dislocation splinting
    place post-reduction posterior mold splint in flexion and appropriate forearm rotation

    • splint in at least 90° of elbow flexion
    • if LCL is disrupted - elbow will be more stable in pronation
    • if MCL is disrupted - elbow will be more stable in supination
  116. brachial plexus
    • complete involvement all roots 75-80
    • c5-c6 upper trunk-20-25%
    • erb palsy
    • c8-t1 klumpke 0.6-3%
  117. upper vs lower root brachial plexu injury
    • upper- should forced caudally
    • lower- arm in abduction
  118. prognosis brachial plexus
    • upper plexus have better prognosis
    • root avulsion- worst porgnosis
  119. preganglionic lesions:
    • horners- sympathetic chain
    • winged scapula-long thoracic nerve
    • abscence tinel sign
    • elevated hemidiaphragm
  120. Erb palsy
    • c5-c6
    • adducted, internal rotated shoulder
    • pronated & extended elbow

    • c5-axillary- deltoid, teres minor weakness
    • suprascapular-weakness in supraspinatus/infraspinatus
  121. klumpke palsy
    • deficit ulnar and median nerve in hand
    • extreme extension wrist
    • hyperextension mcp
    • flexionIP
  122. gold standard imaging for nerve root injury
    • ct myelography
    • -heals with meningocele
    • -3-4 weeks after injury
    • (xray how tp fracture in c-spine)
  123. MRI findings brachial plexus
    • traumatic neuroma
    • pseudomeningocele ( t2 water inside)
    • empty nerve root sleeve( t1 highlight fat)
    • cord shifts away from midline( t1 highlight fat)
  124. emg fibrilliation
    • proximal muscles 10-14 days
    • distal 3-6 weeks
  125. Sensory nerve action potential
    • distinguishes  preganglionic from postganglionic
    • SNAPs preserved in lesions proximal to dorsal root ganglia

    cell body found in dorsal root ganglia

    if SNAP normal and patient insensate in ulnar nerve distribution

    preganglionic injury to C8 and T1



    if SNAP normal and patient insensate in median nerve distribution

    preganglionic injury to C5 and C6
  126. immediate surgical indication brachial plexus (5)
    • sharp penetrating ( excluding gsw)
    • iatrogenic injuries
    • open injuries
    • progressive neurologic deficit
    • expanding hematoma + vascular injury
  127. nerve graft
    • upper and middle trunk
    • sural, medial brachial nerve, medial antebrachial cutaneous nerve
  128. nerve transfer
    use extraplexal source of axons

    • spinal accessory nerve (CN XI)
    • intercostal nerves
    • contralateral C7
    • hypoglossal nerve (CN XII)

    intraplexal nerves

    • phrenic nerve
    • portion of median or ulnar nerves
    • pectoral nerve
    • Oberlin transfer
  129. muscle tendon transfer
    priorities of repair/reconstruction

    • elbow flexion (musculocutaneous nerve)
    • shoulder stability (suprascapular nerve)
    • brachial-thoracic pinch (pectoral nerve)
    • C6-C7 sensory (lateral cord)
    • wrist extension / finger flexion (lateral and posterior cords)
    • wrist flexion / finger extension
    • intrinsic function
  130. bipartite patella
    • superolateral portion
    • bilateral 50%
  131. open # management
    • Fracture management begins after initial trauma survey and resuscitation is complete
    • Antibiotics+ tetanus
    • Control bleeding
    • Assessment
    • Dressing
    • Stabilize
  132. tetanus prophylaxis
    Two forms of prophylaxis 

    • toxoid dose 0.5 mL, regardless of age
    • immune globulin dosing

    • <5-years-old receives 75U
    • 5-10-years-old receives 125U
    • >10-years-old receives 250U
  133. subtalar dislocations %
    25% open

    • 65-80 medial dislocations
    • dorsomedial talar head
    • -posterior process talus
    • -navicular

    • lateral dislocation
    • -cuboid
    • -fibula
    • -lateral process talus
    • -ant. calcaneous
  134. medial subtalar dislocation

    lateral subtaler dislocation
    xrays
    medial: talar head superior to navicular

    lateral:talar head colinear or inferior to navicular
  135. subtalar dislocation treatment
    • closed reduction (60%)
    • -knee flexion and ankle plantar flexion
    • -post reduction ct
  136. open reduction subalar dislocation pitfalls
    • open reduction: 32%
    • -medial dislocation blocked reduction due to:
    • -peroneal tendon
    • -EDB
    • -talonavic capsule

    • lateral dislocation:
    • -posterior tibialis tendon
    • -fHL
    • -FDL
  137. GCS
    • motor
    • -obeys command
    • -localizes pain
    • -normal withdrawal
    • -abnormal withdrawal
    • -extension ( decerebrate)
    • -none

    • verbal
    • 5-oriented
    • 4-confused
    • 3-inappropriate words
    • 2-incoherent
    • 1-none

    • eye opening
    • 4-sponteanous
    • 3-to speech
    • 2-to pain
    • 1-none


    • severe <9
    • moderate 9-12
    • minor 13 and above
  138. Revised trauma score
    • Glasgow Coma Scale (GCS)
    • 4: 13-15
    • 3: 9-12
    • 2: 6-8
    • 1: 4-5
    • 0: 3


    • systolic blood pressure
    • 4: >90
    • 3: 76-89
    • 2: 50-75
    • 1: 1-49
    • 0: 0


    • respiratory rate
    • 4: 10-29
    • 3: >30
    • 2: 6-9
    • 1: 1-5
    • 0: 0
  139. ISS
    based on scores of 9 anatomic regions

    • head
    • face
    • neck
    • thorax
    • abdominal and pelvic contents
    • spine
    • upper extremity
    • lower extremity
    • external
    • Abbreviated Injury Scale (AIS) grades

    • 0 - no injury
    • 1 - minor
    • 2 - moderate
    • 3 - severe (not life-threatening)
    • 4 - severe (life-threatening, survival probable)
    • 5 - severe (critical, survival uncertain)
    • 6 - maximal, possibly fatal

    Abbreviated Injury Scale (AIS) grades

    • 0 - no injury
    • 1 - minor
    • 2 - moderate
    • 3 - severe (not life-threatening)
    • 4 - severe (life-threatening, survival probable)
    • 5 - severe (critical, survival uncertain)
    • 6 - maximal, possibly fatal


    ISS = A2 + B2 + C2

    where A, B, C are the AIS scores of the three most severely injured ISS body regions

    scores range from 1 to 75

    single score of 6 on any AIS region results in automatic score of 75
  140. MESS
    • skeletal and soft tissue injury (graded 1-4)
    • limb ischemia (graded 1-3)
    • shock (graded 0-2)
    • age (graded 0-2)

    score of 7 or more leads to amputation
  141. SIRS
    • heart rate > 90 beats/min
    • WBC count <4000cells/mm³ OR >12,000 cells/mm³
    • respiratory rate > 20 or  PaCO2 < 32mm (4.3kPa)
    • temperature less than 36 degrees or greater than 38 degree
  142. risk factors osteomyelitis
    • recent trauma or surgery
    • immunocompromised patients
    • illicit IV drug use
    • poor vascular supply
    • systemic conditions such as diabetes and sickle cell
    • peripheral neuropathy
  143. osteomyeltis organism based on age
    newborn (<4mo)-S. aureus, Enterobacter species, and group A and B Streptococcus species

    children 4m-4yo-S. aureus, group A Streptococcus species, Kingella kingae, and Enterobacter species

    4 to adolescent-S. aureus (80%), group A Streptococcus species, H. influenzae, and Enterobacter species

    adult-S. aureus and occasionally Enterobacter or Streptococcus species

    • Sickle cell-
    • S. aureus is typically most common, but Salmonella species is pathognomonic
  144. chronic osteo recurrence %
    30%
  145. cierny classification
    • anatomic:
    • 1-meduallry
    • 2-superficial
    • 3-localized
    • 4-diffuse

    • host type
    • a-normal
    • b-compromised
    • c-treatment worse than infection
  146. xray findinfs osteomyelitis
    • lytic with reactive bone around
    • -30-40% bone loss before visible
    • -sequestrum:devitalized bone as nidus
    • -involucrum-formation of new bone around necrosis
  147. marjolin ulcer
    most commonly squamous cell carcinoma-malignant transformation
  148. medial clavicle physis
    closure at 20-25
  149. SC joint stability
    • posterior capsular ligament- AP stability
    • anterior -superior displacement resistance
    • costoclvicular (rhomboid)-
    • - anterior fasciculus resists superior rotation and lateral displacement
    • -posterior fasciculus resists inferior rotation and medial displacement
    • intra-articular disk ligament- medial di
  150. serendipity view
    beam at cephalic tilt 40 degrees


    anterior dislocation-affected clavicle above contralateral clavicle

    posterior dislocation- affected clavicle below contralateral clavicle
  151. sternocalvicular treatment
    sublux and over 3 weeks- conservative go back to activities in 3 months

    less than 3 weeks- closed reduction +/- thoracics- velpeau bandage, elbow excercises 3 weeks

    • open reduction and recon- posterior dislocation
    • -dysphagia
    • -SOB
    • -decreased peripheral pulses
  152. costoclavicular ligament distance from SC joint
    <15 mm
  153. risk factors nec fasc
    mmune suppression

    • diabetes
    • AIDS
    • cancer

    bacterial introduction

    • IV drug use
    • hypodermic therapeutic injections
    • insect bites
    • skin abrasions
    • abdominal and perineal surgery

    other host factors

    obesity
  154. nec fasc classification
    Image Upload
  155. LRINEC score
    LRINEC Scoring system

    score > 6 has PPV of 92% of having necrotizing fasciitis

    CRP (mg/L) 

    ≥150: 4 points

    WBC count (×103/mm3)

    • <15: 0 points
    • 15–25: 1 point
    • >25: 2 points

    Hemoglobin (g/dL)

    • >13.5: 0 points
    • 11–13.5: 1 point
    • <11: 2 points

    Sodium (mmol/L)

    <135: 2 points

    Creatinine (umol/L)

    >141: 2 points

    Glucose (mmol/L)

    >10: 1 point
  156. abx for nec fasc
    definitive antibiotics

    penicillin G

    for strep or clostridium

    imipenem or doripenem or meropenem

     polymicrobial

    • add vancomycin or daptomycin
    • if MRSA suspected
  157. scapula fracture %
    50% involve body and spine


    Associated injuries (in 80-90%) 

    orthopaedic

    • rib fractures (52%) 
    • ipsilateral clavicle fracture (25%)
    • spine fracture (29%) 
    • brachial plexus injury (5%)

    75% of brachial plexus injuries resolve


    medical

    • pulmonary injury
    • pneumothorax (32%)
    • pulmonary contusion (41%)
    • head injury (34%)
    • vascular injury (11%)
  158. ideberg classification
    Image Upload
  159. ORIF indication scapula fracture
    • glenohumeral instability
    • -5mm glenoid stepoff
    • -25% SA
    • displaced scapula neck f
    • open fracture
    • loss of rotator cuff
    • coracoid with over 1cm displacement
  160. knee dislocations assoc injuries
    • Vacular injuries
    • 5-15% in all dislocations
    • 40-50% in anterior/posterior dislocations 
    • due to tethering at the popliteal fossa
    • -proximal - fibrous tunnel at the adductor hiatus
    • -distal - fibrous tunnel at soleus muscle

    • Nerve injury
    • -common peroneal 25%
  161. Kennedy classification
    in relation to the tibia

    • anterior 30-50%
    • -hyperextension
    • -intimal tear
    • -pcl

    • posterior-25%
    • -complete tear popliteus highest

    • lateral (13%)
    • -ACL/pcl
    • -highest rate peroneal nerve injury

    • medial
    • -PLC and PCL

    • rotational-
    • irreducible
    • buttonhole of femoral condyle
  162. Schenck classificaion
    Image Upload
  163. dimple sign knee dislocation
    butttonholing of medial femoral condyle through medial capsule

    • indicative of an irreducible posterolateral dislocation
    • a contraindication to closed reduction due to risks of skin necrosis
  164. complications knee dislocation
    • arthrofibrosis-38%
    • laxity and instability-37%
    • peroneal nerve injury-25%
  165. proprionumbacterium acnes
    shouldersurgery
  166. pasteurala multicida
    eikenella corrodens
    • cat/dog bite
    • human bite
  167. joint fluid aspirate
    • cell count with differential
    • gram stain
    • culture
    • glucose level
    • crystal analysis
  168. saline load test ( amount/ sensitivity)
    155 ml for 95% sensitivity
  169. humeral shaft non-union
    • 2-10% non-op
    • 5-10% surgical
  170. humeral shaft non-union risk factors
    • distraction at the fracture site on injury films 
    • open fracture
    • metabolic/endocrine abnormalities (Vitamin D deficiency most common) 
    • segmental fracture
    • infection
    • shoulder or elbow stiffness (motion directed to fracture site)
    • patient factors (smoking, obesity, malnutrition, noncompliance
  171. number of cortices on either side of humeral shaft
    8 cortices
  172. risk factors wound hardware infection (10)
    • host immunocompetency
    • extremes of age
    • diabetes
    • obesity
    • alcohol or tobacco abuse
    • steroid use
    • malnutrition
    • medications
    • previous radiation
    • vascular insufficiency
  173. chronic supression infection
    32% rate of chronic infected nonunion persisting or worsening despite suppression
  174. capitellum fracture mechanism
    direct, axial compression with the elbow in a semi-flexed position creates shear forces
  175. concotimant injuries with capitellum fracture
    • radial head
    • lucl
  176. bryan and morrey classification ( with Mcknee modification)
    type 1-large osseus piece capitellum can invole trochlea

    • type 2-kocher lorenz fracture
    • -shear of capitellum cartilidge

    • type 3-broberg-morrey fracture
    • -severely communited/ multifrag

    type 4-mckee mod- coronal shear that includes caputitellum and trochlea
  177. capitellar fractures complications
    • Elbow contracture/stiffness (most common) 
    • Nonunion (1-11% with ORIF)
    • Ulnar nerve injury
    • Heterotopic ossification (4% with ORIF)
    • AVN of capitellum
    • Nonunion of olecranon osteotomy
    • Instability
    • Post-traumatic arthritis
    • Cubital valgus
    • Tardy ulnar nerve palsy
    • Infection
  178. galeazzi -dru instability
    if radial fracture is <7.5 cm from articular surface

    unstable in 55% 



    if radial fracture is >7.5 cm from articular surface

    unstable in 6
  179. signs of druj on xray
    • ulnar styloid fx
    • widening of joint on AP view
    • dorsal or volar displacement on lateral view
    • radial shortening (≥5mm
  180. druj orif

    cant reduce:
    cross pin ulna to radius in supination ( keep 4-6 weeks)

    ecu tendon interposed
  181. galeazzi complications
    • compartment syndrome
    • --refracture
    • --removing plate too early
    • --large plates (4.5mm)
    • --comminuted fractures
    • --persistent radiographic lucency
    • do not remove plates before 18 months after insertion
    • DRUJ subluxation

    displaced by gravity, pronator quadratus, or brachioradialis
  182. losed Reduction and Percutaneous Fixation of LC2
    inlet view

    shows anterior-posterior position of SI joint(s) for screw placement 

    outlet view

    shows cephalad-caudad position of SI joint(s) for screw placement  

    lateral sacral view

    ensures safe placement of SI or sacral screws relative to the anterior cortex of the sacral ala and the nerve root tunnel
  183. DVT rate in sacral fracture
    30-50%
  184. anterior hip dislocation types and positioning
    • hip extension results in a superior (pubic) dislocation
    • ---Clinically hip appears in extension and external rotation

    • flexion results in inferior (obturator) dislocation
    • --Clinically hip appears in flexion, abduction, and external rotation
  185. posterior hip dislocation

    assoc. injuries (5)
    increasing flexion and adducton favours simple dislocation

    • osteonecrosis
    • posterior wall acetabular fracture
    • femoral head fractures
    • sciatic nerve injuries 
    • ipsilateral knee injuries (up to 25%)
  186. posterior hip dislocation xray signs (5)
    • femoral head smaller then contralateral side
    • Shenton's line broken
    • lesser trochanter shadow reveals internally rotated limb as compared to contralateral side
    • scrutinize femoral neck to rule out fracture prior to attempting closed reduction
    • AP pelvis and Judet views after reduction to evaluate associated acetabular fractures
  187. scapulothoracic dissociation
    • orthopedics:
    • scapula fractures
    • clavicle fractures
    • AC dislocation/separation
    • sternoclavicular dislocation
    • flail extremity (52%) 

    complete loss of motor and sensory function rendering the extremity non-functional


    vascular injury

    • subclavian artery most commonly injured
    • axillary artery

    neurologic injury (up to 90%)

    • ipsilateral brachial plexus injury (often complete) 
    • neurologic injuries more common than vascular injuries
  188. scapulothoracic joint
    Scapulothoracic joint

    • a sliding joint
    • articulates with ribs 2-7
    • moves into abduction at 2:1 ratio 

    • GH joint 120° 
    • ST joint 60°
  189. scapulothoracic -laterally displaced
    edge of scapula displaced > 1 cm from spinous process as compared to contralateral side
  190. monteggia fractures

    assoc. injuries (5)
    most common 4-10 years of age


    • olecranon fracture-dislocation
    • radial head fx
    • coronoid fx
    • LCL injury
    • terrible triad of elbow
  191. Bado Classification
    type 1-Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head (most common in children and young adults)

    type 2-Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head (70 to 80% of adult Monteggia fractures)

    type 3-Fracture of the ulnar metaphysis (distal to coronoid process) with lateral dislocation of the radial head

    type 4-Fracture of the proximal or middle third of the ulna and radius with dislocation of the radial head in any direction
  192. jupiter classification
    • Image Upload
    • 1-coronoid level
    • 2-metaphyseal-diaphyseal junction
    • 3-distal to coronoid
    • 4-fracture extending to distal half ulna
  193. pin neuropathy
    • radial deviation of hand with wrist extension
    • weakness of thumb extension
    • weakness of MCP extension
    • most likely nerve injury
  194. humereal head anatomy
    • spheroidal 90%
    • avg diameter - 43mm
    • neck shaft angle 130-140%
    • retroverted 30% transepicondylar  axis of the distal  humerus
  195. greater tuberosity humeral head
    horizontal position

    medial edge of tuberosity is 10mm lateral to humeral canal axis

    vertical position

    superior edge of tuberosity is 6mm inferior to upper edge of humeral head
  196. Beredjiklian et al. classification
    type 1- malposition of greater or less tuberosity

    type 2-articular incongruity

    type 3-articular surface  malalignment ( 45% deformity with respect to humeral shaft in coronal/sagital/ axial planes
  197. Boileau et al. classification
    • type 1-humeral head necrosis or impaction
    • type 2-chronic dislocation or fracture dislocation
    • type 3-nonunion of the surgical neck
    • type 4-severe malunion tuberosity
  198. neer classification lat. third
    type 1-lateral to coracoclavicular ligaments ( stable)

    type 2-medial to coracoclavicular (unstable)56% nonunion with non-op

    type 3b-

    Fracture occurs  (1) either BETWEEN the coracoclavicular ligaments 

    • Conoid ligament TORN
    • Trapezoid ligament INTACT



    (2) Fracture occurs LATERAL to coracoclavicular ligaments 

    • Conoid ligmanet TORN
    • Trapezoid ligament TORN

    type 3-intra-articular into AC (stable)

    type 4-physeal fracture

    type 5-communited fracture pattern
  199. ulnar nerve entrapment  ( 7)
    • -pancoast tumor ( first rib, spine, manubrium)
    • -axilla pec
    • -arcade of Struthers
    • -medial intermuscular septum
    • -medial epicondyle
    • -Osborne's ligament
    • -fascia of the FCU
    • -aponeurosis of he proximal edge of the flexor digitorum superficialis

    Image Upload
  200. pipkin
    • type 1- below fovea
    • type 2- above fovea
    • type 3- with fem  neck #
    • type 4-with acetabular fracture
  201. signs of dislocation

    posterior

    anterior
    post: short , adducted, int rotated

    anterior short, abducted, ext rotation
  202. regan and morrey
    • regan and morrey
    • 1-coranoid tip
    • 2- less than 50%
    • 3- more than 50% height
  203. o driscol
    Image Upload
  204. leadbetter manouever
    The leg is abducted with lateral traction and external rotation. The leg is then gently returned to the neutral position and internally rotated. Traction is then reduced to allow impaction of the fragments.
  205. asses femoral neck fracture post reduction
    • tip of gt in centre of the head
    • S on ap and lateral
    • western infirmary glasgow index hip fracture ( 145-155)
    • calcar overlap
    • no translation on the neck
  206. dorsal barton
    can cause carpal tunnel - syndrome

    • flexor digitorum superficialis tendons (four)
    • median nerve (laterally)
    • flexor pollicis longus tendon (laterally)
    • flexor digitorum profundus tendons (four)

Card Set Information

Author:
jaykruijt
ID:
334254
Filename:
trauma
Updated:
2017-10-09 00:07:29
Tags:
ankle
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Description:
for royal college
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