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Questions and Answers

What are the three advantages of a distal locking plate compared to DCS?

Inability to control coronal plane fracture

Ability to control comminuted fragments with different screw trajectories (correct)

Superior fixation in osteoporotic bone (correct)

More soft tissue disruption

What are the three stabilizers of the lateral side of the elbow?

LUCL, radiocapitellar joint, extensor wad insertion

What is most likely injured in a young guy with a simple elbow dislocation?

LUCL

What are the principles of treating an unstable elbow dislocation closed?

Immobilize in elbow flexion at 90 degrees and pronation for 7-10 days. Signup and view all the answers

What are four factors associated with higher mortality after a hip fracture in the elderly?

Delay >48h, age >80, medical comorbidities, male. Signup and view all the answers

List three important radiographic relationships of a Lisfranc injury at the tarsometatarsal joint.

Disruption of the medial column line, dorsal displacement of the 2nd MT base on WB lateral, medial border of 2nd MT base aligning with medial border of middle cuneiform. Signup and view all the answers

What are four long-term problems associated with a radial head fracture?

Chronic pain, instability, decreased strength, arthritis. Signup and view all the answers

What are three ways to avoid overstuffing a radial head replacement?

Undersize head compared to actual radial, match prosthesis height to coronoid, ensure congruence of ulnohumeral joint space on fluoroscopy. Signup and view all the answers

What are the principles of definitive fracture management of a pilon, excluding soft tissue?

Establish length and alignment of lateral column/fibula, achieve anatomic articular reduction, address metaphyseal comminution. Signup and view all the answers

How do you judge the height of a shoulder hemiarthroplasty?

Tip of prosthesis 5.6cm above pec tendon, soft tissue tensioning, tip of the GT 10mm distal to head, trial in place look at overall position, Xray. Signup and view all the answers

What is the Terrible Triad in elbow injuries?

Radial head fracture, coronoid fracture, elbow dislocation. Signup and view all the answers

How is radial head sizing determined?

2cm from tip of coronoid, direct observation of lateral facet, X-ray for ulnohumeral joint opening, downsize 1 size. Signup and view all the answers

What kind of component do you use for radial head replacement?

Modular metal head. Signup and view all the answers

What are the complications of overstuffing the radial head?

Pain, decreased range of motion, post-traumatic stiffness. Signup and view all the answers

What classification is used for coronoid fractures?

Reagan and Morrey. Signup and view all the answers

What is the Zanca View X-ray?

15 degrees cephalad, 50% penetration, centered over AC joint. Signup and view all the answers

What classification is used for AC joint injuries?

Rockwood Classification. Signup and view all the answers

What are the surgical options for AC joint injuries?

Hook Plate, Bosworth Screw, Anatomic AC Joint Reconstruction, Weaver-Dunn Procedure, Tightrope Procedure. Signup and view all the answers

What are the principles of tendon transfers?

Supple joint, 4+-5/5 strength, expendable tendon, similar direction of pull, healthy tissue bed, synergistic action, direct route. Signup and view all the answers

What are the tendon transfers for the radial nerve?

PT - ECRB, FCR (FCU) - EDC, PL - EPL. Signup and view all the answers

How can you maximize your chances of success for locker posterior shoulder dislocation?

Full muscle relaxation, good exposure, ensure joint is empty, disimpact the humeral head. Signup and view all the answers

What are the causes of recurrent posterior instability?

Glenoid bone loss, posterior labral tear, retroversion of glenoid, reverse Hill-Sachs. Signup and view all the answers

What are the unfavorable outcomes following a capitellum fracture?

Stiffness, heterotopic ossification, infection, arthritis, nerve injury. Signup and view all the answers

What are the principles of incision and drainage (I&D)?

Hold antibiotics, take 5 samples, check stability of hardware. Signup and view all the answers

What are indications for fixation of radial head?

Displacement, articular step, mechanical block. Signup and view all the answers

What are the safe zones for fixation of the radial head?

90-110 degrees arc from Lister's tubercle, full supination and pronation, posterior plate placement. Signup and view all the answers

What indications lead to a radial head replacement?

Activity level, multiple fragments, associated with elbow dislocation. Signup and view all the answers

What joints are affected by a distal radius malunion?

DRUJ, radiocarpal, midcarpal. Signup and view all the answers

What are the most common symptoms of distal radius malunion?

Ulnar sided wrist pain, pain with rotational movements, pain from carpal tunnel syndrome. Signup and view all the answers

What are the measurements of scaphoid fracture displacement?

Displacement > 1 mm, 15° scaphoid humpback deformity, radiolunate angle > 15°. Signup and view all the answers

What are indications for scaphoid ORIF?

Proximal pole fractures, displacement > 1 mm, associated with perilunate dislocation. Signup and view all the answers

What does PUDA stand for?

Proximal Ulna Dorsal Angulation. Signup and view all the answers

What blocks to reduction of radial head in Monteggia fractures?

Bony reduction, bony fragments, capsule, annular ligament. Signup and view all the answers

What are the major concerns with chronic SL ligament instability?

Pain, arthritis (SLAC). Signup and view all the answers

What are parameters of adequate resuscitation?

MAP > 60, HR < 100, urine output 0.5-1.0 ml/kg/hr. Signup and view all the answers

What are the risk factors for nonunion of femoral shaft fractures?

Gaping or distraction at fracture site, infection, smoking, malnutrition. Signup and view all the answers

What should you avoid post-op for PW fractures?

Avoid flexion > 90 degrees and avoid adduction for 6 weeks. Signup and view all the answers

What are the disadvantages of a piriformis nail entry point?

Less access to the fracture site, risk of iatrogenic fracture. Signup and view all the answers

What classification systems are used for pelvic ring fractures?

Young and Burgess, Tile classification. Signup and view all the answers

What are the indications for operative management of humeral shaft fractures?

Floating elbow, open injuries, NV injury. Signup and view all the answers

What is the Schatzker classification of tibial plateau fractures?

This classification is used to categorize tibial plateau fractures based on their severity. Signup and view all the answers

What are the factors associated with poor outcomes after amputation?

Level of amputation, infection, wound complications. Signup and view all the answers

What vessels are most likely responsible for compartment syndrome after fractures?

Recurrent anterior tibial artery. Signup and view all the answers

What are the clinical findings of varus malunited femoral neck fractures?

Leg length discrepancy, impingement of the GT, Trendelenburg sign. Signup and view all the answers

What is the Z effect in orthopedic surgery?

Complications from PFN treatment causing screw migration, leading to osteosynthesis failure. Signup and view all the answers

What are the risks of using one incision for both radius and ulna?

Delayed surgery, screws that penetrate interosseous membrane, prolonged immobilization. Signup and view all the answers

Study Notes

Hemiarthroplasty Assessment

Achieve a shoulder hemiarthroplasty height of 5.6 cm above the pectoralis tendon.
Ensure soft tissue tension with biceps, conjoint tendon, and deltoid stability.
The tip of the greater tuberosity (GT) should be 10 mm distal to the shoulder head.
Trial prosthesis placement should avoid inferior subluxation; check via X-ray.

Terrible Triad

Comprised of radial head fracture, coronoid fracture, and elbow dislocation, indicating lateral collateral ligament (LCL) injury.

Radial Head Sizing

Measure 2 cm from the tip of the coronoid.
Utilize direct observation, focusing on the lateral coronoid facet and ensuring ulnohumeral joint stability on X-ray.
Downsize prosthesis by one size for accurate fit.

Radial Head Replacement Component

Utilize a modular metal head component for replacements.

Complications of Overstuffing Radial Head

Results in pain, decreased range of motion (ROM), and post-traumatic stiffness.

Coronoid Fracture Classification (Reagan and Morrey)

Type I: fracture at the tip.
Type II: fracture extending to 50% involvement.

Zanca View X-ray

Requires a 15-degree cephalad angle with 50% penetration, centered over the acromioclavicular (AC) joint.

AC Joint Injury Classification

Use the Rockwood Classification system for categorizing injuries.

Surgical Options for AC Joint

Options include Hook Plate, Bosworth Screw, Anatomic AC Joint Reconstruction, Weaver-Dunn Procedure, and Tightrope Procedure.

Principles of Tendon Transfers

Target a supple joint with a strength grade of 4 to 5.
Select expendable tendons with a similar directional pull and ensure a healthy tissue bed for synergy.

Radial Nerve Tendon Transfers

Use the following transfers:
- Palmaris Longus (PL) to Extensor Pollicis Longus (EPL)
- Flexor Carpi Radialis (FCR) or Flexor Carpi Ulnaris (FCU) to Extensor Digitorum Communis (EDC)

Shoulder Dislocation Management

Ensure full muscle relaxation, good exposure, and clearance of any joint debris before reduction.

Recurrent Posterior Instability Features

Common characteristics include glenoid bone loss, posterior labral tears (Kim lesions), glenoid retroversion, and reverse Hill-Sachs lesions.

Unfavorable Outcomes Post-Capitellum Fracture

Issues may arise such as stiffness, heterotopic ossification (HO), infections, arthritis, and nerve injuries.

Principles of Incision and Drainage (I&D)

Hold antibiotics initially, obtain five cultures, assess hardware stability, and preserve samples for 14 days.

Montreal Classification of Greater Tuberosity Fractures

Classifications not specified; refer to relevant orthopedic resources for detailed criteria.

Indications for Radial Head Fixation

Required for displaced fractures, articular step-offs, or mechanical blocks.

Classification for Radial Head Fractures

Not specified; consult orthopedic references for classification details.

Safe Zones for Radial Head Fixation

Aim for an arc of 90-110 degrees from Lister’s tubercle to the styloid while avoiding any instability; ensure a safe direct visualization technique.

When to Consider Radial Head Replacement

Therapy consideration factors include patient activity level, smoker status, multiple fragments, elbow dislocation association, and complete articular dislocations.

Distal Radius Malunion Effects

Affects distal radioulnar joint (DRUJ), radiocarpal joint, and midcarpal joints.

Common Symptoms of Distal Radius Malunion

Present with ulnar-sided wrist pain, pain during rotation (DRUJ), and carpal tunnel syndrome-related discomfort.

Scaphoid Fracture Displacement Measurement

Consider significant displacement (>1 mm), scaphoid humpback deformity (>15°), radiolunate angle (>15° DISI), and intrascaphoid angle (>35°).

Necessary X-rays for Scaphoid Evaluation

Required views include AP, lateral, scaphoid view (30-degree wrist extension, 20-degree ulnar deviation), and a 45-degree pronation angle.

Indications for Scaphoid ORIF

Recommended for proximal pole fractures, displacement over 1 mm, significant deformities, and all cases involving perilunate dislocation.

Proximal Ulna Dorsal Angulation (PUDA)

Average measurements indicate 5.7 degrees at roughly 47 mm from the olecranon tip.

Obstacles to Radial Head Reduction in Monteggia Fractures

Include bony reductions, fragments, capsular involvement, annular ligament damage, and nerve impacts.

Chronic Scapholunate Ligament (SL) Instability Concerns

Concerns include persistent pain and the potential for scapholunate advanced collapse (SLAC) arthritis.

Determinants for SL Ligament Tear Fixation

Considerations are based on repair versus reconstruction needs and the presence of any existing arthritis.

Stages of SLAC Wrist

Progression is classified into four stages:
- Stage 1: radial styloid + scaphoid
- Stage 2: radio-scaphoid involvement
- Stage 3: midcarpal changes
- Stage 4: pancarpal destruction.

Radiographic Signs of DRUJ Instability

Signs include widening of the DRUJ, dorsal displacement of the distal ulna, positive ulnar variance, and fractures of the ulnar styloid.

Bone Grafting Indications in Forearm Fractures

Indicated for cancellous autografts in radial and ulnar fractures with significant bone loss, especially segmental or with open injuries, and comminutions affecting over a third of the shaft.

Risk Factors for Synostosis

Trauma-related factors include Monteggia fractures, both-bone forearm breaks at the same level, open injuries, and significant soft tissue damage.
Treatment-related factors involve surgical methods, delay in management, and inappropriate hardware use.

Timeframe for Reimplantation

Cold conditions allow for 12 hours while warm conditions limit reimplantation to 6 hours.

Increasing Distal Femoral Locking Screw Stiffness

Achieve this through additional screws, closer placement to the fracture site, or utilizing locking screws.

Classes of Shock

Not specified; check relevant medical literature for classifications.

Parameters of Adequate Resuscitation

Maintain MAP > 60, heart rate < 100, urine output 0.5-1.0 ml/kg/hr, serum lactate < 2.5 mmol/L, and gastric mucosal pH and base deficit within normal limits.

Criteria for Damage Control Operations (DCO)

ISS > 40 without thoracic trauma or > 20 with thoracic trauma, alongside severe multiple injuries or signs of pulmonary contusion.

Posterior Hip Dislocation Failure Indicators

Issues surrounding the capsule, fracture fragments, piriformis, ligamentum teres, and labrum.

CT Evaluation for Posterior Hip Dislocations

Assess for fracture patterns in the femoral head, signs of marginal impaction, bony fragments in the joint, and any femoral neck fractures.

Classification of Femoral Head and Hip Dislocations

Not specified; refer to orthopedic classifications for specifics.

Mirels and Harington’s Criteria for Pathologic Fracture Fixation

Not specifically detailed; consult orthopedic guidelines for definitions and context.

Increasing Instability in Intertrochanteric Fractures

Associated with higher comminution (4+ fragments), lateral wall disruptions, reverse obliquity, and medial calcar comminution.

Z Effect in Femoral Fractures

Complication from proximal femoral nails, where two screws migrate oppositely, increasing risk for osteosynthesis failure.

Pauwel's Criteria

Not specified; find relevant sources for this classification.

Consequences of Excessive Shaft Medialization on Femoral Neck

Increases joint reactive forces, reduces femoral offset, decreases abduction effectiveness, and may lead to knee valgus.

Atypical Femur Fracture Radiographic Features

Signs include subtrochanteric location, lateral cortical thickening, medial spikes, few comminutions, and mainly transverse or short oblique fractures.

Medical Management for Atypical Femur Fractures

Involves collaboration with osteoporosis specialists, implementing bisphosphonate holidays, and supplementing with Vitamin D and calcium.

Surgical Fixation Considerations for Atypical Femur Fractures

Acknowledge higher risks for iatrogenic fracture, non-unions, and plate hardware failures owing to underlying osteoporosis.

Indications for Fixing Contralateral Atypical Femur Fractures

Determined by fracture displacement and symptomatology, particularly in cases occurring 3-6 weeks post-injury.

Handling Stuck Reamers in Atypical Femur Treatment

Options include using a ball-tipped guide wire or creating a cortical window for decompression.

Determining Implant Stability

Based on symptoms pre-fracture, inspecting cement mantle integrity, lucency measurements, postoperative X-ray changes, and intraoperative exploration.

Post-op Positions to Avoid for Piriformis Fractures### Lisfranc Injury Radiographic Relationships

Medial border of the medial cuneiform should align with the base of the medial 1st metatarsal and medial aspect of the navicular.
Dorsal displacement of the 2nd metatarsal base occurs on weight-bearing lateral view, indicating dorsal subluxation.
Medial border of the 2nd metatarsal base should align with the medial border of the middle cuneiform on anteroposterior (AP) view.
Medial border of the 4th metatarsal should align with the medial border of the cuboid on oblique view.
Diastasis greater than 2mm at the base of the 1st and 2nd rays is compared with the contralateral side.

Long-Term Problems After Radial Head Fracture

Chronic pain in the affected elbow region.
Instability noted, especially after excision of fragments.
Proximal radial translation/migration may occur, particularly in elderly patients with radial head resection.
Decreased strength in elbow and forearm.
Development of arthritis in the elbow.
Possible cubitus valgus resulting from malunion.
Risks of overstuffing during replacement and the potential for posterior interosseous nerve (PIN) injury during surgery.
Decreased range of motion and forearm rotation over time.
Post-traumatic osteoarthritis could develop as a complication.
Potential for malunion leading to pain and instability in the elbow.
Chronic wrist pain might arise from proximal migration of the radius.
Risk of non-union and avascular necrosis (rare).

Avoiding Overstuffing in Radial Head Replacement

Use a radial head prosthesis that is undersized compared to the actual radial head on the back table.
Ensure that the height of the prosthesis matches the height of the coronoid at the proximal radioulnar joint (PRUJ).
Confirm through fluoroscopy that the lateral ulnohumeral joint space remains congruent without opening.

Principles of Definitive Fracture Management of Pilon

Establish length and alignment of the lateral column and fibula.
Achieve anatomic reduction of the articular surface.
Address metaphyseal comminution using bone graft or substitute to stabilize the fracture.
Implement a medial or anterior buttress for additional support.

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