Trauma 2.2.pdf

open fractures Gustillo and Anderson Type 1 Type 2 Type 3a Type 3b Type 3c Clean puncture 1cm Extensive lacerat...

open fractures Gustillo and Anderson Type 1 Type 2 Type 3a Type 3b Type 3c Clean puncture 1cm Extensive laceration Massive contamination Open fracture with Simple fracture Moderate Adequate soft tissue Extensive soft tissue ARTERIAL injury Little soft tissue contamination coverage loss damage No extensive soft tissue Server comminution Periosteal stripping High risk amputation damage Bone exposed Moderate comminution Severe comminution talar head MOI: violent dorsiflex of plantarflex foot, divides head into medial and lateral fragment talar neck MOI: forced axial load of tibia through talus where anterior tibia SHEARS off talar head Hawkins classification Stage 1 Stage 2 Stage 3 Stage 4 Nondisplaced talar Displaced talar neck Displaced talar neck fracture with STJ and Displaced talar neck fracture neck fracture with STJ ankle dislocation with STJ, ankle, and TN joint AVN- 0-13% dislocation AVN 83-100% dislocation Best prognosis AVN-20-50% Surgical treatment AVN >91% Surgical Rx Talar body tethered by deltoid ligaments Surgical Rx Hawkins sign- subchondral lucency seen on AP/mortise view talar body Lateral process: snowboarders fracture MOI: COMPRESSION during inversion and dorsiflexion Posterior process Shepherds fracture à posterolateral MOI: forced plantarflexion COMPRESSING the process between tibia and calcaneus NUTCRACKER signà pain with plantarflexion of ankle Cedell fracture à posteromedial MOI: Forced dorsiflexion and pronation leading to AVUSLION of posteromedial tubercle and rupture of deep posterior tibiotalar ligament talar body: MOI: axial compression with plantarflexion upon impact talar dome: Berndt and harty Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 Small area of Partially detached Fully detached without Fully detached and Radiolucent defect subchondral osteochondral displacement displaced underlying lesion compression fragment Conservative Rx Conservative Rx Conservative RX Surgical Rx Lisfranc Nunley and vertullo à low energy Grade 1 Grade 2 Grade 3 Low grade sprain with dorsal capsule tear Elongation/disruption of Lisfranc ligament Disruption of dorsal Lisfranc and plantar (normal xray and + bone scan) complex, intact plantar capsular ligament, greater than 5mm diastasis and structures (xrays with 1-5mm diastasis loss of arch height on lateral WB xray between Met1-met2 on AP WB xray) Conservative Conservative or surgical Surgical mondors sign – plantar ecchymosis piano key test – pressing on dorsal met head cause pain tenting- pressure necrosis in soft tissue envelope 1  Increases with fracture Sanders classification Coronal CT image through widest part of posterior facet Each letter denote location within the posterior facet Type 4 has 4 or more fragment Type A- lateral fracture line Type B- fracture line through middle of facet Type C- medical fracture line adjacent to sustentaculum tali Type 1 – no displacement Type 2- one fracture line (2 fragment) Type 3- 2 fracture lines (3 fragment) Type 4- 3 fracture lines (4 fragment) Rowe classification 1a Fracture of the calcaneal tubercle Extraarticular 1b Fracture of the sustentaculum Tali Extraarticular 1c Fracture of the anterior process Extraarticular 2a Beak fracture of the tuberosity Extraarticular 2b Avulsion fracture of the tuberosity Extraarticular 3 Oblique body fracture not involving the STJ Extraarticular 4 Body fracture involving STJ Intraarticular à tongue type fracture 5 Joint depression with comminution Intraarticular à joint depression fracture Rowa classification What’s fractured Xray image 1a Fall with heel INVERTED or EVERTED, Medial or lateral tubercle Lateral fracture to medial or lateral tubercle 1b Fall with twisting on supinated foot. First Sustentaculum Tali Calcaneal axial stage of joint depression fracture. 1c Supination and plantarflexion Anterior process Medial oblique or lateral MOST COMMON type 1 2a Direct trauma, Superior portion of tuberosity Lateral Spares Achilles tendon insertion BEAK FRACTURE 2b Strong pull of Achilles tendon AVULSION fracture of tuberosity Lateral Involes Achilles 3 Fall from height with heel in varus or valgus Fracture of body without STJ MOST COMMON EXTRAARTICULAR involvement 4 Fall from height with foot plantarflexed Fracture of body that is SAME AS ESSEX LOPRESTI TONGUE TYPE intraarticular 5 Fall from height with foot dorsiflexed Intraarticular fracture with joint SAME AS ESSEC LOPRESTI JOING depression and comminution DEPRESSION FRACTURE SUSTENTACULUM TALI MOI – usually due to load on inverted hindfoot 3 Named ankle fracturs Tillaux-chaput – AITFL avulsion fracture from anterolateral tibia Wagstaff – AITFL avulsion of anteromedial fibula Volkmann: PITFL avulsion fracture from posterior lateral fibula Bosworth: PITFL avulsion fracture from posterior medial fibula Maisonneuve – proximal fibular fracture near fibular neck Midfoot Correct any medial and lateral column shortening Navicular fracture à often shorten medial column Cuboid fracture à often shorten lateral column Most are due to PLANTARFLEXED position of foot Navicular fractures Classified by Watson jones Type 1 Type 2 Type 3 Type 4 Navicular tuberosity fracture Dorsal lip avulsion fracture Navicular body fracture Navicular stress fracture MOI eversion of foot à pull of MOI MOI Often occurs in watershed area posterior tibial tendon and spring 1)plantarflex with inversion à Fall with foot striking while ligament avulse the fragment talonavicular ligament plantarflexed 2)plantarflex with eversion à dorsal talonavicular ligament Navicular body fracture classified by sangeorzan Based on orientation of fracture line and ease of fracture reduction Sangeorzan Type 1 Type 2 Type 3 Transverse fracture Oblique fracture MOST COMMON Central or lateral comminution Dorsal fragment