1
Q
What are the risk factors for humeral shaft non-union? (7)
A
- distraction @ # site;
- open #;
- Vitamin D deficiency;
- segmental fracture;
- infection;
- stiffness;
- patient factors - obesity, smoking, malnutrition,non-compliance
2
Q
What is the natural history of radial nerve recovery following humeral shaft #s?
A
- 8-15% incidence;
- 80-90% improve @ 3 months;
- spontaneous recovery @ 7 weeks;
- full recovery @ 6 months
3
Q
What are the indications for Sx exploration of radial nerve palsy in humeral shaft #s?
A
- open # with palsy;
- no improvement over 3-6 months;
- fibrications seen @ 3 months - EMG
4
Q
What is the pathoanatomic cascade of elbow dislocation?
A
LCL first to MCL last
5
Q
What are the static stabilizers of the elbow? 1st degree and 2nd degree?
A
1st degree - UH joint, anterior bundle MCL, LCL complex;
2nd degree - RC joint, capsule, flexor/extensor origins
6
Q
What are the dynamic stabilizers of the elbow?
A
- anconeus;
- biceps;
- triceps
7
Q
What are associated injuries of radial head #s? (7)
A
- Essex-Lopresti lesions;
- IOM;
- coronoid #s;
- MCL/LCL;
- dislocation;
- terrible Triad;
- carpal #s
8
Q
Where does the MCL insert on the coronoid specifically?
A
- 18.4 mm dorsal to tip;
- anterior capsule inserts 6 mm from tip
9
Q
What is the rate of re-operation for olecranon tension banding?
A
40-80%
10
Q
What is the most common nerve injury with Monteggia #s?
A
PIN
11
Q
How does one treat malunion of Monteggia #?
A
ulnar osteotomy + open reduction of radial head
12
Q
What are the 5 ligaments of the IOM in the forearm?
A
- central band;
- accessory band;
- distal oblique bundle;
- proximal oblique cord;
- dorsal oblique accessory cord
13
Q
What are the indications to Tx nightstick # with no op.?
A
<50% displacement and <10 degrees angulation
14
Q
What distance from RC joint affects stability in Galeazzi #s?
A
- <7.5 cm - 55% unstable;
- >7.5 cm <6% unstable
15
Q
What are the signs of DRUJ injury?
A
- ulnar styloid #;
- widening of DRUJ;
- volar/dorsal displacement;
- radial shortening >=5 mm;
16
Q
What are the factors associated with increased mortality with pelvic ring injuries? (4)
A
- SBP <90;
- age >60;
- increased ISS or RTS;
- need for >= 4 units transfusion
17
Q
What are the complications of temporary iliac embolization? (2)
A
- gluteal necrosis;
- impotence
18
Q
What are the indications for retrograde urethrogram? (3)
A
- blood @ meatus;
- high riding prostate;
- hematuria
19
Q
What is the most common distal humerus shaft #?
A
distal intercondylar #s
20
Q
What is the Jupiter classification for distal humerus #s?
A
- High T - above olecranon;
- Low T - below olecranon;
- H (free trochea - increased risk of AVN);
- Y;
- medial lambda (direction of proximal #);
- lateral lambda (direction of proximal #);
- multiplane T
21
Q
What are the proximal and distal intervals for the medial approach to the elbow?
A
- Proximal - brachialis/triceps (radial) (MCN);
- Distal - brachioradialis/pronator teres (MED)
22
Q
When do you go to 1. lateral decubitus; 2. prone; 3. supine for elbow #s?
A
- LD - isolated single limb trauma;
- prone - spine + contralateral extremity trauma;
- supine - polytrauma
23
Q
What is the most common dislocation of the elbow?
A
posterolateral - 80%
24
Q
What is the Tx algorithm for simple stable elbow?
A
90% - splint X 7 days with early ROM
25
How to do olecranon osteotomy?
1. posterior approach;
2. med + lat skin flaps;
3. identify bare area - sigmoid notch;
4. pre-drill 6.5 mm screw/plate;
5. sponge in UH joint;
6. apex distal chevron;
7. osteotome to complete cut
DO NOT USE IF TEA NEEDED
26
What is the Tx algorithm for simple unstable elbow dislocations?
hinged brace X 2-3 weeks with progressive rehab post brace
27
What is the Tx algorithm for chronic elbow dislocations?
1. open reduction;
2. capsular release;
3. dynamic hinged elbow external fixator
28
What is the number 1 predictor of outcome with radial head ORIF?
\<3 fragments - Good;
\>=3 fragments - Bad
29
What are the cut offs for fragment excision in radial head and coronoid #s?
RH - 25%;
Cap - 25-33%
30
What are the contraindications to radial head excision? (4)
1. presence of destabilizing injury;
2. interosseous ligament injury;
3. coronoid #;
4. MCL deficiency
31
What are the complications of radial head Fxs? (5)
1. pain;
2. PRUJ/DRUJ instability;
3. proximal radial migration;
4. decreased strength;
5. cubitus vulgus
32
Describe Kaplan's approach to lateral elbow.
1. EDC (PIN) + ECRB (RAD);
2. pronate to avoid PIN;
3. can be extended into Thompson approach
33
In what position do you want forearm to apply a plate on the radial neck?
neutral (access to safe zone)
34
Where does the MCL attach on the coronoid - BE SPECIFIC
1. sublime tubercle - 18 mm distal to tip;
2. anteriormedial facet of coronoid is the attachment of anteriormedial bundle of MCL
35
What is the Tx algorithm for coronoid #s fixation?
1. tip = #5 Ethibond sutures via drill holes;
2. retrograde screws for type II + III with;
3. anteriormedial facet injury = buttress plate
36
What are the mechanisms of injury and associated # patterns for olecranon #s?
1. direct blow = comminuted;
2. indirect blow = transverse/oblique
37
What is the non-op Tx protocol for olecranon #s?
1. immobilize @ 45-90 degrees flexion X 3/52; then
2. ROM @ 3/52
38
What are the indications for plate fixation of olecranon #s? (4)
1. comminutal;
2. Monteggia;
3. # dislocations;
4. oblique with coronoid extension
39
What are the indications for olecranon excision + triceps advancement? (3)
1. elderly with osteoporosis;
2. #\<50% of joint;
3. non-unions
40
What are the 2 complications of anterior ulnar cortex perforation in olecranon tension banding technique?
1. AIN injury;
2. decreased pronation
41
What is the Bryan and Morrey classification of capitellar #s?
T1 - large osseous piece;
T2 - shear # (thin), Kocher-Lorenz;
T3 severe comminution, Broberg-Morrey;
T4 - includes capitellum + trochlea (McKee mod.) "double bubble sign"
42
What are the operative options for capitellar #s + the indications for each?
1. ORIF - Type I \>2 mm displacement, Type IV;
2. fragment excision - Type II + III with \> 2 mm displacement;
3. TEA - unreconstructable, elderly, medial column instability
43
What are the indications for TEA? (4)
1. refractory RA;
2. chronic instability;
3. advanced OA;
4. complex distal humerus # in elderly
44
What is the Bado classification for Monteggia #s?
1. Type I - radial head anterior;
2. Type II - radial head posterior;
3. Type III - radial head lateral;
4. Type IV - radius + ulna #
45
What is the most common nerve injury with Monteggia #s?
PIN
46
What is the most common structure blocking radial head reduction after ulnar reduction in Monteggia #s?
annular ligament
47
What is the radius pull test?
pull radius proximally:
1. If \> 3 mm instability - intraosseous membrane injury;
2. If \> 6 mm instability - IOM + TFCC injury
48
How do you perform a radiocapitellar view?
lateral view with gantry @ 45 degree angle to shoulder
49
What does overstuffing lead to in the RC joint? (2)
1. capitellar wear;
2. late instability
50
What is the ROM goal post distal humeral shaft #?
30-130 degrees (functional range)
51
How do you calculate the radial bow?
diagram:
1. a = maximal radial bow = 15 mm = 10% total length;
2. location of maximal bow (%) x/y X 100 = 60% from proximal
52
What are the indications (requirements) to treat forearm # non-op in adults? (3)
1. distal 2/3 ulna #;
2. \<50% displaced;
3. \<10 degrees angulated (96% union rate)
53
What is the most important variable predicting outcomes for ORIF forearm #s?
radial bow
54
What is the union rate for humeral shaft #s?
90%
55
What are the contraindications for humeral shaft #s conservative management?
1. STI or bone loss;
2. vascular injury (requires repair); 3. brachial plexus injury
56
What is the acceptable alignment deformity for humeral shaft #s?
1. \<20 degrees A-P;
2. \<30 degrees V-V;
3. \<3 cm short
57
What is the incidence of radial nerve injury in Holstein-Lewis #s?
22%
58
What are the indications for bone grafting forearm #s in adults?
1. non-unions;
2. ulna/radius # with bone loss \> 1/3 of length;
3. segmental bone loss with open #s
59
What are the approaches for the forearm for radial shaft #s based on location?
1. Volar (Henry) - 1/3 distal, 1/3 middle #s;
2. Dorsal (Thompson) - for middle 1/3, proximal 1/3
60
What are the options for bone grafting radius and ulna #s?
1. ICBG;
2. allograft;
3. FVFG;
4. cancellous iliac crest
61
Name 5 risk factors for forearm compartment syndrome.
1. crush;
2. open #s;
3. low velocity GSW;
4. vascular injuries;
5. coagulopathies
62
What are the 5 ligaments of the IOM of forearm?
1. central band (most important);
2. accessory band;
3. distal oblique bundle;
4. proximal oblique cord;
5. dorsal oblique accessory cord
63
What bone graft has the lowest infection rate for radius/ulna shaft #s?
FVFG
64
When can you perform synostectomy for both bone forearm post ORIF?
4-6 months if RADS/indomethacin used post-op
65
What is the Tx algorithm for non-union of forearm #s failed ORIF?
3.5 mm LCDP with autogenous cancellous bone grafting
66
What are the risk factors for refracture following ORIF of forearm #s? (4)
1. removing plates \< 15 months;
2. large plates (4.5 mm) - should use 3.5 mm;
3. comminuted #s;
4. persistent radiographic lucency
67
What is the rehab following plate removal in the forearm?
functional forearm brace X 6/52 and protected activity X 3/12
68
What are the treatment related risk factors for radioulnar synostosis? (5)
1. one incision technique;
2. delayed Sx \> 2/52;
3. screws penetrating into IOM;
4. bone grafting into IOM;
5. prolonged immobilization
69
What are the acceptable criteria for ORIF of DR #s?
1. radial height 11 mm +/- 5 mm;
2. radial inclination 22 degrees +/- 5 degrees;
3. articular stepoff \< 2 mm;
4. volar tilt 11 degrees +/- \<5 degrees dorsal
70
List 5 technical considerations for ex-fix for DR #s.
1. relies on ligamentotaxis;
2. radial shaft pins under direct visualization (SRN at risk);
3. non-spanning for extra articular;
4. carpal distraction \<5 mm;
5. limit to 8/52 + aggressive OT/PT of digits
71
A FPL rupture with Volar plate fixation is associated with what plate position?
distal to watershed area
72
What is the most common nerve injury with DR #s? And what is the incidence in high energy injuries?
median nerve injury @ 30%
73
What are the indications for actue CTR in DR #s? (2)
1. progressive neuropraxia;
2. neuropraxia does not improve with reduction + lasts \> 24-48 hours
74
What is the Tx algorithm for EPL rupture post DR #?
If iatrogenic - cut = end to end repair;
If degeneration - EIP to EPL transfer
75
What are the most important ligaments for DRUJ stability?
radioulnar ligaments of TFCC
76
What are the indications for ORIF of ulnar styloid #s?
1. displaced through base;
2. sigmoid notch #s;
3. Galeazzi #s;
4. TFCC avulsions in the face of unstable DRUJ
77
What are the anatomical distance parameters for stable vs unstable Galeazzi #s?
1. If \<7.5 cm from articular surface = 55% unstable;
2. If \>7.5 cm, then only 6% unstable
78
What is the position of most stability for the DRUJ?
volar + dorsal radioulnar ligaments most stable in supination
79
What are the primary stabilizers of the DRUJ?
volar and dorsal radioulnar ligaments
80
What are 4 signs of DRUJ injury? (radiographic)
1. ulnar styloid #;
2. widening of DRUJ (AP) - compare contralateral;
3. volar/dorsal displacement (lat);
4. radial shortening \>= 5 mm
81
What is the approach to DRUJ reduction and stabilization?
dorsal capsulotomy between 3/4 compartments
82
How long for DRUJ stabilization if stable post distal radius reduction + ORIF?
6 weeks in a cast
83
How long to leave pins in situ following DRUJ pinning?
4 weeks
84
What is likely to block a DRUJ reduction?
ECU tendon
85
What are the deforming forces causing persistent DRUJ instability?
1. gravity;
2. PQ (pronator quadratus);
3. BR (brachioradialis)
86
What is the geometry of the sigmoid notch of the DRUJ that makes it unstable?
1. shallow;
2. 50% radius curvature of the ulnar head
87
What is the major stabilizer of the DRUJ? And which 2 ligaments?
TFCC;
volar and dorsal radioulnar ligaments
88
What is the leading cause of death for pelvic ring injuries? (APC)
hemorrhage
89
What is the most common cause of death for lateral compression pelvic ring injuries?
head injuries
90
What are 4 indications for mortality in pelvic ring injuries?
1. SBP \<90;
2. age \>60 yoa;
3. increased ISS or RIS;
4. transfusion \>= 4 units
91
List 5 associated injuries with pelvic ring injuries.
1. chest (63%);
2. long bone # (50%);
3. head/abdomen (40%);
4. spine # (25%);
5. urogenital (12-20%)
92
List 7 poor prognosis indications for pelvic ring injuries.
1. SI joint incongruity \>= 1 cm;
2. increased initial displacement;
3. malunion/residual displacement;
4. LLD \>= 2 cm;
5. nonunion;
6. neurological injury;
7. urethral injury
93
What are the strongest ligaments in the body?
posterior sacroiliac complex
94
Why do children usually get pubic rami #s + iliac wing #s and not pelvic ring injuries?
open triradiate cartilage makes the iliac wing weaker than bone (reverse in adults with closed wings)
95
What is the physical exam for pelvic ring injuries?
skin - scrotal/labial swelling, flank hematoma, degloving injuries, posterior SI echymosis;
neuro - L5/S1 lumbosacral plexus, rectal (tone + sens);
urogenital - hematuria;
vaginal/rectal exam - mandatory to rule out open #
96
Describe the pelvic inlet view.
1. gantry approx. 45 degrees caudad;
2. adequate when S1 overlaps S2;
3. used for assessing the AP dimension of S1
97
Describe the outlet view of the pelvis.
1. xray beam angled 45 degrees cephalad;
2. adequate when pubic symphysis overlies S2 body;
3. used to assess sup/inf translation sacrum + foramina
98
What are 3 radiographic sign of posterior sacral instability?
1. \> 5 mm posterior sacral displacement;
2. posterior sacral # gap;
3. avulsion #s of ischial spine, ischial tuberosity, sacrum, transverse process of L5
99
Pelvic ring injury associated with the highest risk of hypovolemic shock?
1. vertical shear (63%);
2. mortality rate up to 25%
100
What is the most common source of hemorrhage of the pelvic ring?
posterior venous plexus (80%)
101
What are the most common sources of arterial bleeding + associated # pattern?
1. superior gluteal artery (APC injuries);
2. internal pudendal (LC injuries);
3. obturator artery (LC injuries)
102
What goes first - pelvic ex-fix or laparotomy?
pelvic ex-fix
103
What arteries do you temporarily embolize for pelvic bleeding?
internal iliac
104
What are the 2 complications for arterial emboliation of the internal iliacs?
1. gluteal necrosis;
2. impotence
105
List 5 indications for ORIF of pelvic ring injuries.
1. symphysis diastasis \> 2.5 cm;
2. SI joint displacement \> 1 cm;
3. sacral # with \> 1 cm displacement;
4. rotational deformity of hemipelvis;
5. open #
106
What is the risk of anterior SI plating?
L4-L5 injury
107
What is the most common injury with SI screw placement?
L5
108
What is the most common complication with posterior SI tension plating?
painful hardware
109
What 2 views do you need for SI screw placement and what do they tell you?
1. pelvic inlet = AP translation;
2. pelvic outlet = sup/inf translation
110
What view do you need for your SI screw entry point?
lateral sacral view - place screw posterior to iliac cortical density (ICD)
111
What is the most common urogenital injury in pelvic ring injuries?
posterior urethral tear
112
What are the indications for retrograde urethrocystogram?
1. blood at meatus;
2. high riding prostate;
3. hematuria
113
What is the maximum pubic diastasis accepted post-partum for acute injury?
4 cm
114
What is the order of fixation of pelvic ring injury with acetab #s?
fix ring 1st;
then fix acetab
115
Where does the L5 nerve root cross the sacral ala?
2 cm medial to the SI joint
116
What artery crosses the SI joint?
superior gluteal artery
117
What is the most important predictor of prognosis in sacral #s?
neurologic injury
118
What are complications of mistreated sacral #s?
1. neurologic injury;
2. urologic injury;
3. sexual dysfunction;
4. rectal dysfunction;
5. lower extremity dysfunction
119
What Denis type sacral # has the highest rate of neuro injury?
Denis type #3 (60%)
120
How many sacral #s will xray alone miss? (in a percentage)
70%
121
What is the non-operative indication for sacral #s?
1. \<1 cm displacement;
2. no neurologic deficit
122
What are the operative indications for sacral #s? (4)
1. displaced \> 1 cm;
2. soft tissue compromise;
3. persistent pain after non-op Tx;
4. displacement after non-op Tx
123
What construct has the highest strength for unstable sacral #s?
iliolumbar fixation + iliosacral fixation (triangular osteosynthesis)
124
What is the most common sacral root injury with sacral body #s?
S2
125
What 2 structures insert on the AIIS?
1. direct head of rectus femoris;
2. Y ligament (ligament of Bigelow)
126
What is the most common associated injury with acetab #s?
low extremity injuries (36%)
127
The corona mortis is associated between which vessels?
1. external iliac (epigastric);
2. internal iliac (obturator)
128
What are the elemental # patterns in the Letournel classification?
1. anterior column;
2. posterior column;
3. anterior wall;
4. posterior wall;
5. transverse
129
What is the only elementary acetab # to involve both columns?
transverse
130
What are the associated # patterns of the Letournel classification of acetabular #s?
1. both columns;
2. posterior column + posterior wall;
3. anterior column or wall + posterior hemitransverse;
4. T-type;
5. transverse + posterior wall
131
What is the most common associated # of Letournel?
transverse + posterior wall
132
What is the best method to test for treatment of posterior wall #s?
dynamic fluoroscopy
133
What is the concept of secondary congruence and in which fracture type does it happen?
In both column acetab # the fragments remain congruent with an intact femoral head in a new usually medialized position
134
What xray sign is pathogromonic for a both column #?
spur sign (Most displaced ilium fragment on the obturator oblique view)
135
What are the indications for non-op management of acetab #s? (6)
1. \<2 mm displaced;
2. \<20% posterior wall (controversial) (dynamic fluoroscopy best test);
3. femoral head congruent with acetab.;
4. both column # with secondary congruence (out of traction);
5. roof arc \>45 degrees;
6. contraindications to Sx - obese, dirty wound, DVT
136
What are the 3 contraindications to acetab Sx?
1. obese;
2. dirty wound;
3. DVT
137
What are the indications for ORIF of acetab #s? (6)
1. displacement \> 2 mm of roof;
2. posterior wall 40-50%;
3. marginal impaction;
4. loose bodies;
5. irreducible #/dislocation;
6. pregnancy is NOT a contraindication
138
What is the most accurate way of determining posterior wall accuracy of ORIF and reduction?
CT Scan
139
What are the risks of anterior approach to acetab #?
1. femoral nerve;
2. LFCN;
3. thrombosis of femoral vessels;
4. laceration of corona mortis (10-15%)
140
What are the risks of posterior approach to acetab #?
1. increased HO than anterior;
2. sciatic nerve injury (2-10%);
3. MFCA
141
What are the indications for extended iliofemoral approach to acetab #?
1. both column # if significant comminution;
2. transverse/T-type #s;
3. associated # patterns 21 days post injury
142
What are the complications associated with extended iliofemoral approach to acetab?
1. HO;
2. gluteal muscle necrosis
143
What acetab approach has the lowest incidence of HO?
anterior ilioinguinal
144
What are 5 associated injuries with hip dislocation?
1. posterior wall #s;
2. sciatic nerve injuries;
3. femoral head #s;
4. ipsilateral knee injuries (25%);
5. femoral neck #s
145
What is the position of the hip for posterior dislocations?
flexion, adduction, interior rotation
146
What is the position of the hip for anterior dislocations?
flexion, abduction, external rotation
147
What do you look for on post hip relocation on CT scan?
1. femoral head #;
2. loose bodies;
3. acetab #s;
4. femoral neck #s
148
What is the contraindication to hip dislocation reduction?
femoral neck #
149
What approach do you use for an anterior/posterior hip dislocation respectively?
Anterior - Smith-Petersen;
Posterior - Kocher-Langenbeck
150
What are the complications of simple hip dislocation?
1. sciatic nerve injury (8-20%);
2. femoral head osteonecrosis (5-40%);
3. post-trauma arthritis (20%);
4. recurrent dislocations (2%)
151
What is the Pipkin classification of femoral head #s?
Type I - below ligament teres;
Type II - above ligament teres;
Type III - with dislocation;
Type IV - with acetabular #
152
What are the indications for non-op management of femoral head #s? (4)
1. Pipkin I;
2. Pipkin II \<1 mm step off;
3. no loose bodies;
4. stable hip joint
153
What are the indications for ORIF of femoral head #s?
1. Pipkin II \> 1 mm stepoff;
2. loose bodies;
3. neck/acetabular #;
4. polytrauma;
5. irreducible #/dislocation;
6. Pipkin IV
154
What are the arthroplasty indications for Pipkin #s? (femoral head #s)
1. older patients \<55-60 yoa;
2. displaced Pipkin I and II;
3. Pipkin III and IV
155
What fixation do you use for femoral head #?
1. 2.7 mm or 3.5 mm screws with countersunk heads;
2. headless screws;
3. bioabsorbable screws
156
What are 4 findings (XR) in bisphosphonate-related subtrochanteric #s?
1. lateral cortical thickening;
2. transverse;
3. medial spike;
4. lack of comminution
157
On what side of patient is using a DHS likely to cause itroch # displacement?
Left (direction of screw rotation)
158
What are the indications for arthroplasty in femoral neck #s?
1. severe comminution;
2. pre-existing DID;
3. osteopososis;
4. failed ORIF
159
What are the unstable IT hip #s? (5)
1. LT # (calcar);
2. subtroch. extension;
3. reverse obliquity;
4. comminution;
5. lack of lateral wall
160
What are the factors that increase mortality for hip #s?
1. male;
2. IT vs Fem. neck;
3. delay \> 2 days for Sx;
4. age \> 85 yoa;
5. \> 2 pre existing cond.;
6. ASA III or IV
161
What # increases 1 year hip # rate?
proximal humerus #s
162
What percentage of patients are converted from spinal to GA?
1 in 5 (20%)
163
In hip # surgery, spinal has what 3 advantages over GA?
1. decreased post-op delirium;
2. decreased DVT risk;
3. decreased early post-op death
164
What is the 1 year mortality of hip #s in elderly?
30%
165
What are the 2 most significant determinants of survival post hip fracture?
1. pre-morbid mobiity;
2. pre-morbid cognition
166
Name 2 risk factors for AVN post hip #. Also, name 2 controversial risk factors for AVN post hip #.
Risk factors:
1. initial displacement;
2. poor reduction
Controversial risk factors:
1. time to Sx;
2. evacuation of hematoma
167
What are the Tx options for varus non-union post femoral neck ORIF?
1. valgus IT osteotomy;
2. FVFG (young patient);
3. arthroplasty;
4. revision ORIF with bone grafting
168
What are the Tx options for AVN post ORIF of femoral neck # in young patients?
1. conservative;
2. FVFG;
3. THA;
4. arthrodesis
169
What is the disadvantage of THA vs hemi in femoral neck #s?
5X higher D/L rate
170
What advantage does THA have over hemi in femoral neck #s? (2)
1. improved functional hip scores;
2. lower re-operation rate
171
What are 4 downfalls of sliding hip screws for hip #s?
1. prominent implants;
2. affects biomechanics of hip joint;
3. decreased SF-36 scores;
4. decreased quality of life
172
What is the best XR to delineate femoral neck #s?
traction 15 degrees, internal rotation AP
173
What is Pauwels classification of femoral neck #s?
I - \<30 degrees from horizon;
II - 30-50 degrees from horizon;
III - \>50 degrees from horizon;
Some use 70 degrees instead of 50 degrees
174
What is the Garden classification of femoral neck #s?
I - valgus impacted;
II - complete Fx, nondisplaced;
III - complete Fx, 50% displaced;
IV - complete Fx, fully displaced
175
Give 2 reasons why femoral neck #s do not heal.
1. bathed in synovial fluid (intracapsular);
2. lack of periosteum
176
How often are femoral neck #s missed with femoral shaft #s?
20-30% of the time
177
What is the incidence of femoral neck #s with femoral shaft #s?
2-6%
178
What is the Winquist and Hansen classification of femoral shaft #s?
Type O - no comminution;
Type I - insignificant comminution;
Type II - \> 50% cortical contact;
Type III -\<50% cortical comminution;
Type IV - segmental #
179
Stabilizing a femoral shaft # within 24 hours leads to what advantage?
1. decreased ARDS;
2. increased mobility (rehab);
3. decreased hospital costs;
4. decreased VTE events
180
What is the complication of nailing a femur in the setting of acute head injury? (2)
1. hypotension;
2. hypoxia
181
What are the indications for retrograde femoral nailing? (6)
1. ipsilateral femoral neck #;
2. floating knee;
3. ipsilateral tibia #;
4. polytrauma;
5. bilateral femur #;
6. obesity
182
ORIF of femural #s is inferior to IMN due to increased rates of what? (3)
1. infection;
2. non-union;
3. hardware failure
183
What are the indications for unreamed femoral nail?
bilateral pulmonary injuries
184
When do you convert ex-fix femur to IMN post DCO?
2-3 weeks
185
What is the complication of femural ex-fix and why?
knee stiffness due to scarring of quadriceps mechanism
186
What are the complications of femoral nailing? (9)
1. heterotopic ossification (HO) - 25%;
2. pudendal nerve injury - 10%;
3. femoral artery/nerve injury - rare;
4. malunion - 10-30%;
5. delayed union;
6. non-union -\<10%;
7. infection;
8. rotation malalignment;
9. MAD (mechanical axis deviation)
187
Name 3 risk factors for malunion in femoral shaft #s.
1. use of fracture table;
2. comminution;
3. nightime Sx
188
Intraoperative hypotension during femoral nailing in head injury patients has been associated with what?
decreased GCS
189
When compared to unilateral femoral shaft #s, bilateral femoral shaft #s have increased rates of what? (4)
1. hypotension;
2. skull #s (open);
3. pelvic #s;
4. mortality
190
What is the average neck shaft angle and the anteversion at the hip?
1. 130 +/- 7 degrees;
2. 10 +/- 7 degrees
191
How does the body weight change from 2-legged stance to 1-legged stance?
1. 0.5 X BW with 2 legs;
2. 4 X BW with 1 leg
192
What defines the subtrochanteric area?
5 cm distal to the LT
193
What is the function of the linea aspera?
compressive strut to accommodate anterior bow to femur
194
What are the indications for ORIF for proximal humeral # in peds?
1. \> 50% displaced;
2. \<2 years growth left;
3. \>45 degrees angulation
195
What are the predictors of screw cut out for DHS in IT #s?
1. TAD;
2. screw position;
3. # pattern;
4. reduction;
5. patient \> 70 yoa
196
What is the incidence of Hoffa Fx in distal femur OTA Type C fractures?
38%
197
What is the arterial injury for displaced distal femur #s?
popliteal artery
198
What OTA type distal femur # is associated most commonly with Hoffa #s?
Type C - 38%
199
What is the post-op protocol for distal femur #s?
non-weight bearing, or touch-toe weight bearing X 6-8 weeks
200
What is the implant of choice for distal femur #s in osteoporoic bone?
retrograde supracondylar nail
201
How far away do you place a blade plate from the knee joint?
1.5 cm
202
How far away do you place a DCS away from the distal femur?
2.0 cm
203
How do you determine appropriate medial intercondylar screw length?
rotate beam 30 degrees internally rotated to shoot parallel to slope of medial condyle
204
What is the satisfactory alignment of distal femur #s malunions after ORIF?
5 degrees in any plane
205
What is the anatomical axis of the distal femur?
5-7 degrees valgus
206
How frequent is bipartite patella and how frequent is it bilateral?
8% and 50% bilateral
207
Where is the thickest articular cartilage of the body?
1 cm in the patella
208
What are the 7 patella # patterns?
1. non-displaced;
2. transverse;
3. pole/sleeve;
4. vertical;
5. marginal;
6. osteochondral;
7. comminuted (stellate)
209
What is the post # non-op protocol for patella #s?
stove pipe cast/Zimmer X 2-3/52 with WBAT followed by progressive AROM in hinged knee brace
210
What are 5 indications for patella ORIF? (tension band)
1. extension mechanism failure;
2. open #;
3. displaced \> 2 mm (articular);
4. displaced \> 3 mm patella;
5. patella sleeve # (kids)
211
What is the biomechanically strongest tension band construct for patella #s?
longitudinal cannulated screws with tension wires
212
What are the indications for patellectomy?
sup/inf pole with \<50% patella height
213
What are 3 key technical points for patella ORIF?
1. quads/patellar tendon re-attachment;
2. re-attach close to articular surface;
3. medial/lateral retinacular repair
214
What is the most common complication following patella ORIF?
symptomatic hardware - 52% reoperate for hardware removal
215
What knee dislocation has the highest rate of pop. art. injury?
Ant/Post knee dislocation (40-50%)
216
What are the tethering points of the popliteal artery at the popliteal fossa (proximal and distal)?
Proximal - adductor hiatus;
Distal - fibrous tunnel at soleus muscle
217
What is the incidence of common peroneal nerve injury following knee dislocation?
25%
218
What is the most common type of knee dislocation?
Anterior (30-50%)
219
What knee dislocation has the highest rate of complete popliteal artery tear?
Posterior
220
Which knee dislocation has the highest rate of peroneal nerve injury?
Lateral
221
What is the Schenck (KD) classification for knee dislocations?
KD I - multi with ACL or PCL;
KD II - multi with ACL and PCL;
KD III - ACL and PCL plus PMC or PLC;
KD IV - ACL and PCL and PMC and PLC;
KD V - multilig. with periarticular #
222
What is the "dimple" sign in knee dislocations?
MFC buttonholes through medial capsule
223
What does the "dimple" sign mean in knee dislocations?
Irreducible posterolateral D/L and contraindication to closed reduction due to skin necrosis
224
What is the negative predictive value of ABI?
100% if ABI \> 0.9
225
What is the amputation rate after 8+ hours of ischemia time?
86%
226
What are 4 indications for OR after knee dislocations?
1. vascular injury;
2. open #;
3. irreducible dislocation;
4. compartment syndrome
227
What is the order of events in an ischemic limb for vascular intervention? (3)
1. ex-fix;
2. excision of damaged vessel and graft;
3. fasciotomies
228
When to perform Tx of ligament repair following knee dislocation?
improved outcomes with delayed repair \<3 weeks
229
What bone graft substitute has the highest compressive strength for filling voids?
calcium phosphate bone cement
230
Name 3 poor prognostic indications in tibial plateau #s.
1. lig. instability;
2. meniscectomy;
3. alteration of mechanical axis \> 5 degrees
231
What are 5 indications for ORIF of tibial plateau #s?
1. artic. stepoff \> 3 mm;
2. conylar widening \> 5 mm;
3. varus/valgus instability;
4. all medial plateau #s;
5. all biconylar #s
232
What is the non-op Tx protocol for tibial plateau #s?
PWB X 8-12/52 with immediate passive ROM
233
What is the tibial plateau view?
AP knee with 10 degree caudal tilt
234
In what Schatzker classification is medial meniscal tear most common?
Schatzker IV
235
What Schatzker classification is associated with the most common meniscal tear (lateral meniscal tear)?
Schatzker II
236
What tibial plateau Schatzker type is associated with the highest arterial injury?
Type IV medial # D/L
237
What is the strongest predictor of long term success with ORIF of tibial plateau #s?
joint stability
238
How much proximal bone is required for nailing proximal 1/3 tibial #s?
5-6 cm (enough to accept 2 locking screws)
239
What are 8 indications for IM nailing tibial shaft #s?
1. unacceptable casting alignment;
2. soft tissue injury;
3. segmental #;
4. comminuted #;
5. ipsilateral limb injury;
6. polytrauma;
7. bilateral tibia #;
8. morbid obesity
240
What holes in LISS plating of tibia place the SPN at risk?
holes 11-13
241
In open tibial shaft #s, the use of BMP-2 has been shown to have what 4 positive effects?
1. increased fracture healing;
2. decreased need for bone grafting;
3. decreased re-operation;
4. decreased infection
242
What are the relative indications for traumatic amputations in lower extremities?
1. significant soft tissue trauma;
2. significant ipsilateral foot trauma;
3. warm ischemia \> 6 hours
243
What parapatellar approach to use in proximal 1/3 tibial shaft #s and why?
lateral parapatellar approach to avoid valgus deformity
244
What is the complication of varus malunion in tibial shaft #s?
ankle pain and stiffness
245
Where to place bone graft in tibial shaft #s if significant bone loss?
posterolateral
246
Which BMP is = to autograft for grafting tibial non-unions?
BMP-7 (OP-1)
247
What are the 3 fragments of a typical plafond #?
1. medial mall. (deltoid);
2. posterolateral (Volkmann) PITFL;
3. anterolateral (Chaput) AITFL
248
What are the negative prognostic indications for ORIF of pilon #s?
1. lower SES;
2. \> 2 co-morbidities;
3. male;
4. work related injury;
5. lower education level
249
When does brake travel time return to normal following tibial plafond #s?
6 weeks after WB begins
250
A 1 mm shift in talus in mortise leads to how much decrease in tibiotalar contact area?
42% decrease
251
When does brake time return to normal following ORIF of ankle #?
9 weeks
252
What hinders fibular reduction in a Bosworth # D/L?
posterolateral ridge of tibia
253
What is the Canale view?
optimal view of talar neck:
1. maximum equinus;
2. 15 degrees pronated;
3. 75 degrees cephalad
254
What is the most common complication of talar neck #s?
subtalar OA - 50%
255
What is the mechanism of injury for lateral talar process #s?
dorsiflexion, axial-load, inversion, external rotation
256
What are the types of lateral process #s?
Type I - no articular surface;
Type II - subtalar and talofibular joints;
Type III - comminuted
257
Pain aggravated by FHL flexion/extension is an indicator of what pathology?
posterolateral talar process #
258
What #s are associated with medialsubtalar dislocations? (3)
1. dorsomedial talar head;
2. posterior process of talus;
3. navicular
259
What are the associated #s with lateral D/L of subtalar?
1. cuboid;
2. anterior calcaneus;
3. lateral process of talus;
4. fibula
260
What is the postion of the foot with lateral subtalar D/L?
pronation
261
What is the position of the foot with medial subtalar D/L?
supination
262
What structures block medial subtalar D/L?
1. peroneals;
2. EDB;
3. TN capsule
263
What are 2 indications for olecranon excision and tricep advancement?
1. elderly patient with osteoporosis, \<50% of joint surface;
2. non-unions
264
What structures block lateral subtalar closed reduction?
1. PT tendon;
2. FHL;
3. FDL
265
What is the most common # associated with lateral subtalar D/L?
cuboid
266
What is the Sander's classification of calcaneous #s?
Type I - non displaced;
Type II - 2 fragments in posterior facet;
Type III - 3 fragments;
Type IV - comminuted;
Description of # lines for Type II and IIIs - A-lateral; B-middle; C-medial
267
What is the normal Bohler's angle?
20-40 degrees
268
What is the normal angle of Gissane?
130-145 degrees
269
What are the factors associated with likely need for ST fusion? (4)
1. male;
2. manual labour;
3. WSIB;
4. Bohler's - 0 or less
270
What are the indications for primary ST fusion in calcaneous #s?
Sanders Type IV - must combine with ORIF to maintain height/width/varus
271
What is the Tx for varus malunion of calcaneous #?
distraction bone block subtalar arthrodesis
272
What is the CT classification of calcaneal # malunion and associated Tx?
Type I - lateral exostosis - no ST OA - Tx with lateral wall resection;
Type II - lateral exostosis + ST OA - Tx with lateral wall resection and subtalar fusion;
Type III - lateral exostosis + ST OA + varus malunion - Tx with lateral wall resection and ST fusion and varus osteotomy
273
What are the factors associated with transfer to Level 1 trauma centre? (4)
1. African-American;
2. presence of medical comorbidity;
3. medicaid;
4. male gender
274
What are the factors associated with poor outcomes with calcaneous #s? (9)
1. age \>50;
2. obesity;
3. manual labour;
4. WSIB;
5. smoker;
6. B/L #s;
7. polytrauma;
8. vasculopathies;
9. male
275
What xray finding is most indicative of meniscal injury in Schatzker II?
widening \>6 mm
276
What type of lateral meniscus tear is associated with Schatzker Type II injuries?
peripheral lateral meniscus tear
277
What are the deformities in proximal 1/3 tibial shaft #s?
1. valgus;
2. procurvatum
278
What is the non-op protocol for proximal 1/3 tibial #s?
1. long leg cast X 4/52; then,
2. functional brace
279
What fracture must you rule out before nailing a spiral tibial #?
posterior mall #
280
What malunion deformity with intact fibula and tibial shaft #s?
varus
281
What is the appropriate radiograph to obtain for deltoid lig. injury in ankle #s?
1. ER stress test - \>= 5 mm IS +;
2. dorsiflex + ER
282
What is the blood supply to the talar neck? (40
1. artery of tarsal canal (talar body);
2. deltoid branch of posterior tibial artery;
3. anterior tiial artery;
4. perforating peroneal artery via artery of tarsal sinus
283
How much lateral process can you take out before compromising the lateral talocalcaneal ligament?
1 cm (but it doesn't matter)
284
What is the closed reduction maneuver for subtalar D/L?
1. knee flexion;
2. plantar flexion;
3. traction;
4. evert (medial D/L), invert (lat. D/L) of hindfoot
285
What is the mechanism of anterior process #s of the talus?
inversion and plantar flexion cause avulsion of the bifurcate ligament
286
What are the non-op indications for calcaneous #s? (5)
1. small extra articular #s with \< 1 cm displacement;
2. intact Achilles with \<2 mm displacement;
3. Sanders Type I;
4. anterior process # with less than 25% CC joint;
5. too many co-morbidities
287
What are LaFontaine's criteria for loss of reduction of DR#s?
1. dorsal comminution;
2. dorsal tilt \>20 degrees;
3. ulnar styloid;
4. intra articular;
5. age \>50;
6. carpal malalignment;
7. shortening \>2-3 mm
288
What is the first movement to be recovered in radial nerve palsy?
wrist extension in radial deviation (BR 1st to recover) (extensor indicis last)
289
What are 3 reasons IM nailing is superior to ex-fix for early (\<24 hours) Tx of tibial shaft #s?
1. decreased malalignment;
2. decreased re-operation;
3. decreased time to WB
290
What is the incidence of ACL injury in Shatzker IV and V? (orthobullets says type V and VI)
25%
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