Download Trauma Miller

Trauma – Lower Extremity
Pelvic Fractures
o No bony stability
o Anterior – symphysis pubis
o Posterior
 Interosseus and post SI ligaments –
strongest in body
o Mortality rate > 15%
 Hemorrhage leading cause of death
 Shock and revised trauma score most
useful predictors of mortality
o 12-20% urogenital injuries
 suspected in any anterior ring injuries
 blood at meatus, or high prostate then
retrograde urethrogram
 retrograde cysto should be done on male pt
w/ displaced ant pelv injuries before Foley
(not in females – urethra is short)
o 20% hemodynamic instability
 shock = SBP < 90 mm Hg
 mortality 10x that of normotensive
pt
o Young/Burgess classification
 APC – much higher blood requirements
 Retroperitoneal hemorrhage
 Increased risk of abdominal injury
 APC II MC for death by pelvic
bleeding
 Injures superior gluteal A.
 LC – higher incidence of closed head
injury, lower GCS
 LC II death MC by brain injury
 Injures external iliac A.
 Injures obturator A.
 If hemodynamic stable 3% mortality, if
not 38% mortality
 Arterial bleeding (in order of
frequency)
o Superior gluteal
o Internal pudendal
o Obturator
o Lateral sacral
 Control of bleeding
 Binder
o Not good for LC injury
 Ex-fix (effective if bleeding is
retroperitoneal)
o 2-3 5-mm pins

Therapeutic angiography if ex-fix
doesn’t work
o Mortality lower w/ angio
o ORIF
 Anterior: No need for ORIF lateral to
pubic tubercle w/ stable post ring
 Posterior tension plating – sign ST
complications
 Iliosacral screws – potential injury to L5
N. root (anterior to ala)
 Ilium fx propagated from iliac crest to
greater sciatic notch
o Nonop
 if less than 1 cm post pelv ring
displacement
 displacement less than 2.5 cm w/ intact
post ring
o Pain MC reason for poor outcome
o Poor outcome ass w/
 SI incongruity
 High degree of initial displacement
 LLD > 2 cm
 Nonunion
 Neurologic/urethral injury
Sacral fractures
- Up to 85% w/ pelvic ring injuries
- Lower sacral root dysfunction
o Anal sphincter tone / voluntary
contracture
o Bulbocavernosus reflex
o Perianal sensation
- Zone 1 (50%)
o Alar fractures (min displaced in APC,
LC)
 Vert unstable vertical shear
 6% Neuro injury (L5)
o stable nondisplaced – conservative,
unstable – ORIF ant
- Zone II (34%)
o Transforaminal
o 30% neuro deficits (L5, S1, S2)
o 97% neuro def undiagnosed
o if foramina patent, nonop
- Zone III – medial to foramina
o 60% neuro def
1
Trauma – Lower Extremity
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o caudal injury: bowel, bladder, sex
dysfx
o if neuro def, decompression, ant/post
stab
 unilateral sacral root
preservation adequate for
bowel/bladder
Transverse fx
o Displaced – lateral mass plates
U-shaped fx
o Bilateral transforaminal fx connected
by transverse fx
o Complete spinopelvic diss
o Disruption of cauda equina
o Tx: spinopelvic instrumentation
neuro injury benefit from decompression
o indirect thru reduction/stab
o laminotomy, foraminotomy
SI Jt dislocations
o Complete dislocations are vert
unstable
 Req post pelvic ring fixation
o Ant lig injuries
 Only rotationally unstable
 Fix ant ring only
Retraction medially on sacrum = L5 nerve
root injury
Infx rate after ORIF post ring = 4%
Outcome
o Function worse and mortality higher
with more unstable fx
o Neuro, uro, LE injuries MC causes of
disability, pain, impaired fx
o L5 nerve root least likely to regain nl
fx
o Dyspareunia in 43% of female pt w/
5mm of residual displacement
o 44% of pt w/ sex dysfx after unstable
pelvic inj
o uro inj
 early endo primary realignment
have lower rate of incontinence
and impotence compared to pt
w/ delayed open repair
Acetabular fractures
o Fx pattern det by force vector and position of
fem head
o ½ of pt will have inj to organ system
o Neuro inj 20% of pt
o Peroneal division of sciatic n MC inj
o Interobserver reliability excellent with plain
XX (CT no better)
o ORIF: disp > 3mm
o Roof arc measurements
 Medial, ant, post roof arcs > 45 deg
as meas on AP, obturator, iliac
oblique XX
 Cranial 10mm of acetab on CT scan
corresponds to weight-bearing
domes
o
Column fractures – involve obturator ring
o
Transverse + post wall MC combo fx
o
Combo fx

Post column + post wall (thru obt
ring)

Transverse + post wall

T-type (thru obt ring)

Will require extensile
approach

Ant w/ post hemitransverse (thru obt
ring)

Both columns (thru obt ring)
o
Post wall fx
 Disproportionate # of poor outcomes
 32% poor despite perfect
reductions
 RF: delay in red of hip
dislocation, age > 55 yr,
intra-articular, AVN
 Art reduction meas by CT strongly
correlates with long-term outcome
o
Nonoperative tx

Femoral head congruent w/ weightbearing dome

Displacement < 2mm

Displaced fx w/ roof arc > 45 deg

Post wall < 20%

NWB for 10-12 wks

Skel traction rarely indicated as
definitive tx
o
Relative contraindications to surgery

Morbid obesity
2
Trauma – Lower Extremity
o
o
o
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o
o
o
o

Age > 55

Open contaminated wound

Presence of DVT
Surg indications

Displacement of dome > 2mm

Post wall fx > 50%

Marginal impaction

Loose bodies in jt

Incongruent head
Outcome
 Results of perfect reduction ( < 1mm
disp) are superior to those of
imperfect and poor reductions @
long-term f/u
 Poor outcomes – fem head inj and
postop compl
Posterior approach
 Sciatic N. iatrogenic injury 2-10%,
damage to fem head blood supply
Anterior approach
 Femoral N. injury
 LFCN injury
 Corona mortis injury
Extended iliofemoral
 MC used w/ fx plans > 21 days after
inj
 HO
 Post gluteal M. necrosis
HO
 Highest incidence extensile approach
 Lowest incidence ilioinguinal (don’t
need XRT prophy)
 Indomethacin 6 wks postop or low
dose XRT (no diff b/w 2)
Osteonecrosis
 20% in posterior wall fx
post traumatic DJD
 tx: hip fusion or THA
 results of THA not as good as for
OA
Duplex limited to detect prox thrombi
Hip dislocations
- ON 10-15% (of all)
o Posterior 40%
o Anterior 10%
- Anterior dislocation: 50% femoral head fx ?
-
MC complication – post traumatic arthritis
Recurrent dislocation rare
Femoral head fx
- Type I – inf to fovea
- Type II – sup to fovea
- Type III – w/ fem neck fx
- Type IV – w/ acetab fx
- 7% in posterior hip dislocations
- ORIF for > 1mm step off, loose bodies, ass
neck/tab fx
- If ass w/ tab fx – then ORIF of head fx for
early ROM hip jt
- Anterior approach – Smith-Pete
(anteroinferior portion of fem head)
o No increased risk of AVN
o b/w superior gluteal and femoral N
Femoral neck fx
- Women > men
- Whites > blacks
- Younger than pt w/ IT fx
- Nl neck shaft 130 deg, nl anteversion 10 deg
- Blood supply
o Medial femoral circ (wt-bearing
portion of head)
o Lateral femoral circ (ant/inferior head)
o Artery of lig teres
- Displaced fem neck fx
o Early tx – lower rates of ON
o Failure rate of 40% in ambulatory
elderly pt w/ ORIF
- Pauwel’s classification
o Type I – less than 30 deg
o Type II – 30-50 deg
o Type III - > 50 deg
o 40% of initially valgus impacted fx
go to displace
 inc rates of ON, nonunion
o Increased risk of complications w/
increasing vert orientation of fx line
o Pauwel’s III (more vertical) highest
risk of nonunion, ON
- Screws at or above LT, 3 screws if
noncomminuted, 4th if post comminution
- Basicervical fx: sliding hip screw
3
Trauma – Lower Extremity
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Hemiarthroplasty: cemented results >
uncemented
o Post approach – inc risk of dislocation
o Anterolateral approach – abductor
weakness
o Uncemented risks – femoral fx,
prosthesis subsidence, ant thigh pain
o Better outcomes w/ cemented
arthroplasties
o Long-term data shows lower revision
rate for bipolar
o Short-term data – no diff b/w bipolar
and unipolar
THA vs. hemi
o THA w/ 7x greater dislocation
In young pt, inc risk of nonunion, ON
ON 10-45% incidence
o Increased risk w/
 Inc initial displacement
 Inc time to reduction
 Nonanatomical reduction
o Tx: young pt w/ < 50% head
involvement
 Valgus IT osteotomy (80%
success)
o Young > 50% involvement
 Vasc fibular graft vs. THA
o Nonunion: no healing @ 12 mo
 Inc 10-30%
 If nonunion, need MRI to
evaluate ON
Peds fem neck fx
o Screw fixation short of physis
o Spica cast
o Emergent treatment
IT femur fx
- Occur in older pt than fem neck fx
- Stable: will resist medial compressive loads
once reduced
- Unstable: collapse into varus, or shaft
medially when reduced
- Early surgery w/in 48h ass w/ decreased 1-yr
mortality
- Tip to apex distance < 25 mm, w/in 1 cm of
subchondral bone
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-
-
IMHS – resist excessive fx collapse,
medialization
o No clear advantage – not used
routinely
o Gamma nail vs. DHS
 Higher rate of compl w/
gamma nail (not sign)
o Percutaneous insertion
o Poss faster rehab
o Risk of shaft fx of tip of prosthesis
DHS
o Tip to apex dist, less than 25 mm
THA
o Maybe god in unstable IT fx w/
osteopenic bone
o Revision rates lower than ORIF
Reverse obliquity – 95 deg fixed angle device
Post op – WBAT
Subtroch fx
- LT to 5 cm distally, younger pt, higher energy
- High compressive forces medially, tensile
forces laterally
- Transition from cancellous to cortical bone
- High rate of implant failure before union
- Russell-Taylor
o I – no extension into piriformis
o II – extension into piriformis
- IM fixation - preferred
o Preserves vascularity
o Load-sharing
o Stronger construct in unstable fx than
plate
o Contraindicated in type II
 Can use IMHS for these
- Gamma nail
o MC complication is lag screw cutout
- EM fixation
o Compromise vascularity of fragments
o Less strong
o Consider BG if medial comminution
o For Type II fx
- If above LT, type II
o Plate device indicated
- Complications: implant failure, nonunion
(defined at 6 mo), malunion
4
Trauma – Lower Extremity
Pathologic Fx of Proximal Femur
- if ORIF fails, than conversion THA improves
function
o high rate of postop infx
Femoral Shaft fx
o Bilateral femur fx – inc risk of complications
(such as pulm)
o Ipsi femoral neck fx – incidence 3%
 Missed 30% time
 If comminuted fx of midshaft – have to
r/o
 Most often – vertical type (unstable)
o Ex fixation
 Indications: unstable polytrauma pt,
severe open fx, vascular injury
 Safely converted to IM fixation w/in 23 wks
o Plate fixation
 Higher incidence of infx, nonunion,
implant failure
 Maybe improved results w/
percutaneous techniques
o Early stabilization of fem shaft fx (w/ multiple
inj) w/in 24h ass w/
 Dec pulm complications
 Dec mortality
 Improved prognosis
 Dec costs
 Inc rehab
 Dec costs of hosp
 BUT – beware of pt w/ severe CHI
o NO indication for dynamically locked IMN
o Antegrade IMN
 Supine
 Less rotational malalignment
 Lat decubitus
 Improved access to piriformis
 Higher rates of malalignment
 Hip dysfx in 40%
o Retrograde IMN – easier, union rates
approach antegrade nailing
 Compl: cart injury, intraart infx,
cruciate ligament injury
 Indications: obesity, ipsilateral tibial
shaft fx, ipsi neck-shaft fx, ipsi tab fx,
o
o
o
o
o
o
traumatic knee arthrotomy (clean),
bilateral femur fx
 Knee stiffness and septic arthritis NOT
sign complications
 Need 2 distal interlocks
Unreamed – dec union rates, inc time to union
 Consider in pt w/ bilateral chest injury
Reamer designs (dec risk of clot)
 Sharp reamers
 Deep flutes
 Reamer shafts small
 Advance slowly
 Reaming
 Increase restoration of
endosteal blood flow
 Decrease interference with
cortical perfusion
GSW
 Low velocity – immediate IMN
 High vel – ex fix vs. IMN
w/ ipsi fem neck fx
 multiple screws and plate/retro IMN
complications: N. injury – pudendal N. palsy,
HO most freq complication (rarely clinically
imp)
 HO increased in reamed IMN
Malunion
 If nail supine – inc internal rotation
 If nail lateral – inc external rotation
Distal femur fx
- 5 cm above metaphyseal flare to art surf
- supracondylar vs. intercondylar
- potential for injury to Popliteal artery w/ sign
displacement
o angiography if no pulses after
reduction
- ND fx:
o Cast bracing, NWB 6 wks (hinged
knee brace)
- ORIF
o Fixed-angle plate device
 Most stable construct (union
rates 92%)
 Need 2 cm for blade or 4 cm
for DCS
5
Trauma – Lower Extremity

Direct reduction via lateral
approach
 Contraindicated w/ coronal fx
o Retro IMN
 Useful for SC fx w/o
comminution
 Preferred in osteoporotic bone
and periprosthetic fx
 Less axial/rot stab
 Inc knee pain postop
Knee dislocations
- 3 out of 4 primary lig restraints out
- 50% present when reduced
- 30% vascular injury (50% when ant-post
dislocation)
- 23% neuro injury
- ABI: nl ABI > 0.9 (less than that is injury)
- No preop arteriogram if hard signs
(hematoma, absent pulses, bruit, etc.)
- Arteriogram if soft signs post reduction
o Revascularize w/in 6 hr
o Reverse saphenous vein grafts
o Fasciotomies indicated after vasc
repair
- Ligamentous injury
o Acute repair < 3 wks
o Delayed > 3 wks
o Most imp to repair post capsule PLC,
PCL
o Treat MCL nonop
- Complications
o MC is stiffness
o 23% neuro injury
Patella fx
- If unable to actively extend knee jt – then sign
extensor mech injury
- Transverse, vertical, or stellate fx
- Displacement = 3 cm fragment separation, or
2 mm art surf displacement
o Can be accepted
o Intact ext mechanism
o Hinged knee brace 4-6 wks, WBAT
- ORIF vs. partial patellectemy
- NO role for complete patellectemy
- Partial patellectemy
-
o For extraarticular distal pole fx
o Severe comm. Fx
o Preserve large piece and reattach
patellar ligament anteriorly
 Inc tilting force w/in trochlea
o Open fx
 Tx as closed fx following
debridement
o Complications
 MC: symptomatic HDWR
 Loss of reduction (up to 20%)
 Nonunion < 5%
Active extension delayed for 6 wks
Patellar dislocations
- Reduce w/ knee full extension
- High redislocation rate
- Injury to medial PF ligament
o No indication for immediate repair
Patellar lig rupture
- Active adult pt < 40
- Risks
o Patellar tendonitis
- Ligament avulsion from distal pole
- Tx: direct primary repair nonabsorb sutures
o Patellar drill holes or suture anchors
o Supplement w/ cerclage wire or tape
Quad tendon rupture
- MC than patellar lig
- Older pt w/ comorbidities
- Dx more difficult (consider MRI)
- Intrasubstance tears 2 cm above prox pole
- Tx: surgery if loss of active knee extension
o End-to-end primary repair
o Cerclage not necessary
o Worse results w/ late repair
Tibial Plateau Fx
- Males peak 4th decade, females 7th decade
- Ass injuries, meniscal tears 47%, MCL >
ACL, compartment sx, > 50% soft tissue
injuries
- Medial plateau fx – high energy – always need
ORIF
- Nonop
6
Trauma – Lower Extremity
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-
-
o < 3mm stepoff, stable knee to full
extension (< 10 deg varus-valgus)
o hinged brace w/ early ROM, delayed
weight-bearing
ORIF
o Condylar widening > 5 mm
o Joint depression > 1 cm
o Art stepoff > 3 mm
o All med plateau
 Goes into varus (worst
results)
o All bicondylar fx
o Complications
 Soft-tissue-related
 Avoid Y incision
Ex fix
o Best for bicondylar fx
o Can be used w/ limited open or
percutaneous fixation
o Hybrid ring
 Allows early knee motion
 80% good to excellent results
 keep thin wires > 14 mm
from jt
o Bridging ex fix
 Temporary stabilization
 Good for ligamentotaxis
o Outcomes
 Inc risk of posttraumatic
arthritis 5-7 yrs
 Worse w/ lig instability
 Worse results w/ meniscectemy
Arthroscopically-assisted red
o Compartment sx a risk
o No studies have shown superior
outcome
Tibial spine fx
- Types I-III
o Fix II that don’t reduce
o Fix all III’s w/ suture fixation
Tibial Shaft Fractures
o Nonop
 LLC for 4 wks (for low energy fx)
 Transition to functional brace at 4 wks
o Acc alignment
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


o IMN




Varus-valgus 5 deg
Sagittal plane 10 deg
Cortical apposition 50%
Shortening 1 cm
Rotational alignment w/in 10 deg
Statically interlock for rotational stab
Clinical results of reamed superior (inc
union rate, dec time to union, dec hdwr
failure)
Complications
 Anterior knee pain, incidence
50%
 Higher w/ patellar tendon
splitting
 Pain relief after nail removal
unpredictable (1/3 relief, 1/3
without any relief)
Prox third fx
 High incidence of valgus and
procurvatum (flexion)
 Technique – lateral and parallel
to ant cortex
 Or unicortical plating w/
blocking screws
o Ex Fix
 Useful in prox, distal metaphyseal fx
 Vs. IMN
 No difference in infx rates,
union rates, or time to union
 IMN w/ dec malalignment,
dec secondary surgeries,
shorter time to WB
 Disad: pin tract infx, delayed union in
open fx, higher incidence of
malalignment and malunion
 Overall risk of infx w/ IMN is similar
o For open fx
 No adverse affects of reaming (infx,
nonunion rates)
 Dec HDWR failure w/ reamed
technique
 5-10% infx rate (all-comers)
 10-20% deep infx w/ type III
o No scoring system can be used alone to
determine salvage
o Indications for amputation
7
Trauma – Lower Extremity




Warm ischemia > 6 hrs
Absent plantar sensation
Severe ipsi foot trauma
No sign difference in fx outcomes
salvage vs. amputation
o Mangled extremity
 No limb salvage index has been
statistically confirmed to be reliable in
evaluation and tx
o Complications
 Delayed union 6-9 mo
 Nonunion > 9 mo
 RF: open fx, fx gap after
fixation, transverse pattern,
smokers
 Tx:
 Nail dynamization (axially
stable) – won’t work after 6-9
mo
 Exchange nailing (axially
unstable)
 BG
o Compartment syndrome
 Most sensitive indicator: comp
pressure w/in 30 mm Hg diastolic
BP
Tibial Plafond Fx
- Associated fibula fx: 75%
- Ruedi/Allgower classification
o I: minimally displaced
o II: articular displacement
o III: comminuted, metaphyseal
involvement
- Tx: ORIF, Ex-fix, or combined
o ORIF: rigid fixation w/ early ROM
ankle
 High incidence of ST
complications
 Full thickness flaps essential
 7 cm skin bridges
 no benefits to acute fixation
o Temp bridging ex fix followed by
delayed ORIF @ 10-14 days – tx of
choice
o Ex fixation



-
Spanning (best), hybrid ring, or
articulated
Decreased incidence of
wound complications and
deep infx vs. ORIF
No sign inc ankle ROM w/
hybrid
Complications
o Wound slough 10%
o Deep infx 4-35%
o Malunion (Varus)
o Nonunion (metaphyseal junction)
o Posttraumatic arthrosis
Ankle fx
- Biomechanics
o Deltoid ligament (deep portion) –
primary restraint to anterolateral talar
displacement
o Fibula acts as buttress to lateral talar
displacement
o 1 mm lateral talar shift = 42% dec in
tibiotalar contact area
o up to 3 mm lateral malleolar
displacement well tolerated w/ nonop
tx
- no indication for medial ligament repair
(explore only if unable to reduce mortise)
- fix post malleolus if > 25% or if stepoff > 2
mm
o anterior to posterior screw fixation
- Bimalleolar fx
o Lateral and posterior antiglide plating
have = clinical and radiographic
results
o More peroneal irritation w/ antiglide
o Lag screws ok for oblique fx w/o
comminution
- syndesmotic testing
o abduction and ext rotate in OR
o fixation generally not required when
fibula fx w/in 4.5 cm of jt
o single cortical screw 2 cm above jt
o if leave screw in, 30% risk of breakage
o do not remove before 3 mo
o medial clear space widening of 4mm is
unstable
8
Trauma – Lower Extremity
-
o bioabsorbable screws = outcomes w/
metallic screws
complications
o post-traumatic arthrosis rare if
anatomical reduction
o diabetes – incidence of infx 20%
Achilles tendon rupture
- 2-4 cm above calc insertion
- dx missed up to 25% time
- surg repair
o posteromedial incision
o dec rerupture rate and inc plantar
flexion strength
o perc is bad
Talar Body Fx
- osteochondral fx ass w/ ankle fx (SER IV)
- fx of posterior process
o avulsion of post talotibial and
talofibular lig
o posterolateral tubercle MC involved
 FHL close – can be irritated
Talar Neck Fx
- Forced dorsiflexion w/ axial load
- Hawkins
o I: nondisplaced
o II: displaced w/ subtalar dislocation AVN 20%
o III: displaced w/ subtalar and tibiotalar
dislocation
o IV: displaced w/ subtalar, tibiotalar,
talonav dislocation (AVN 100%)
- Long-term complication preventable –
varus malunion
- Dual-incisions recommended
o Approach b/w peroneus brevis and
FHL @ level of posterolateral tubercle
of talus
- Displaced fx req urgent tx – ORIF
- 2 4.0 mm screws
- shoot screws posterior to anterior orientation
o strongest is from post to ant
- titanium screws (need MRI postop)
- NWB 10-12 wks
- Complications
o Post-traumatic arthrosis present in 2/3
of all talar fx
o Arthritis subtalar: 50%
o Arthritis tibiotalar: 33%
o Varus malunion: 25-30% (triple
arthrodesis)
o ON – tx w/ tibiocalcaneal fusion
Talar process fx
- Lateral > medial
- Mechanism
o Inversion/DF/axial loading (+/- ER)
- Often missed
- ND: SLC x 6 wks, NWB
- Displaced: ORIF large, excision small
Subtalar dislocations
- 85% medial
- closed reduction, SLC 4-6 wks
- irreducible lateral: post tib tendon, FHL, FDL
- irreducible medial: EDB, osteochondral fx of
talus
Calcaneus fx
- Sanders classification on coronal CT image
o I: ND post facet
o II: single fx line post facet
o III: 3 post facet fragments
o IV: 4 fragments
o Primary line superolateral to
inferomedial
- Nonop tx
o Closed reduction cannot restore art
congruity
- Operative tx
o Subtalar arthrodesis combined w/
ORIF used for type IV fx
o Restore calc anatomy, reduce articular
surfaces
o No benefit to early surgery
o Extensile lateral approach – most
popular
 L-shaped incision, 0.5 cm
anterior to Achilles tendon
 1.5 cm anterior is lateral
calcaneal artery
9
Trauma – Lower Extremity
-
o Wound complications 10-20% (inc risk
in smokers, DM)
o Comp syndrome: 10%
o Subtalar arthrosis
 Factors ass w/ poor outcome:
age > 50, obesity, manual
labor, WC, men
Outcomes
o Correlate w/ quality of reduction, # of
intra-articular frag
o Predictors of eventual subtalar fusion:
initial nonsurg tx, extent of initial inj,
work comp
o ORIF bilateral worse than unilateral
but still better than nonsurg
Midfoot injuries
- Navicular
o Dorsal lip avulsions MC – SLC
o Tuberosity fx: post tib tendon, ORIF if
displaced
o ORIF
 If frag is 25% of art surf, then
ORIF to avoid subluxation and
arthrosis
 Diastasis > 3 mm
o Body fx
 Type I – transverse in coronal
plane
 Type II – MC – oblique fx
from dorsomedial to plantar lat
direction
 Adduction deform
 Type III – central comm.
 Abd deform
 ORIF
o Stress fx – need CT – SLC NWB
o Nutcracker – compression fx b/w calc
and MT; shortens lateral column –
need ORIF vs. Ex-fix
o Watershed zone is central 1/3
Lisfranc fx-dislocations
- AP view – look medial aspect of middle
cuneiform and medial aspect 2nd MT
- Lisfranc’s ligament
o Base of 2nd MT to medial cuneiform
-
-
ORIF
o 3.5mm screws for medial (1st TMT)
and middle (2nd, 3rd) columns
o K-wires for 4th and 5th
Lateral column may be possible w/ nonop
Complications
o Altered gait, post-traumatic arthrosis
common
Metatarsal Fx
- Cast shoe, WB to comfort
- ORIF for multiple MT fx, or 1st, 5th MT fx
o Displacement greater than 10 deg, 3
mm
 Can result in overload of
displaced plantar frag or t-x
metatarsalgia
- Jones fx – faster healing, return to fx w/ screw
fixation
o Failure of fixation when return to full
act before radiographic union
- Pulsed EMF shown to accelerate healing
Compartment sx of foot
- Ass w/ multiple MT fx, Lisfranc injuries,
calcaneal fx
- 9 compartments of foot
- 2 dorsal incisions is enough
- late sequela: claw toes
Locking plates
- Best in osteoporotic bone w/o cortical contact
- With torsional stresses, locking plates are
worse
Charcot arthropathy
- Joint subluxation
- Non-traumatic
- DM
Fracture patterns
- Torsion = spiral fx
- Compression = T or Y-shaped fx
- Bending = butterfly fragment
- Torsion + bending = oblique
PIP dislocations
10
Trauma – Lower Extremity
-

Volar – injures central slip
Dorsal – injures volar plate
Injury Severity Score
- 6 body regions
o head
o face
o chest
o abdomen
o extremities
o external
- 3 most severely injured body regions have
score squared and summed
- value from 0-75
- if injury of AIS is 6, then ISS score is 75
CRPS
- type I – after traumatic event
- type II – after peripheral nerve inj
Resuscitation
- Bld loss of 1500 cc or 30% blood volume
results in hypotension, tachycardia, decreased
UOP
- Adequate fluid resuscitation
o MAP > 60
o HR < 100
o UOP 1 cc/kg/hr
o Serum lactate < 2.5 mmol/L
 To evaluate effectiveness of
resuscitation of pt
- Fluids
o Crystalloid isotonic solutions
- Antibx
o Cephalosporin grade I/II
o Aminoglycoside grade III
o Farmyard injury – PCN for clostridia
- Pulm complications
o Fat Embolism Syndrome
 Isolated long bone 2%
 Polytrauma 10-15%
 Clinical onset 24-48h
 Inflam response to embolized
fat globules
 Tx prevention and supportive
management
 Dx

Hypoxemia, CNS
depression, petechial
rash, pulm edema
Minor criteria (needs 4)
o ARDS
 Refractory hypoxemia, diffuse
infiltrative changes on CXR
 Decreased lung compliance,
poor gas exchange
 Late sepsis
Compartment sx
- Diastolic BP – CP = delta P (perfusion
pressure)
- > 30 mm
SCI
-
-
-
-
-
Incomplete injury
o Spinal shock – areflexia
o Sacral sparing – voluntary anal
sphincter contraction
o Bulbocavernosus reflex – return
indicates end of spinal shock
o Methylprednisolone
 Initiate < 8 hrs
 Load 30 mg/kg
 Infuse 5.4 mg/kg/hr over 23h if
less than 3h
 3-8 hr, then 48h infusion
Central cord
o Elderly
o Sacral sparing
o UE > LE affected
o Distal > Proximal affected
o Full recovery rare
Brown-Sequard
o Ipsilateral loss motor and
propioception
o Contralateral pain temperature
o Good fx recovery – majority ambulate
Anterior cord
o Usu flex/comp mechanism
o LE > UE
o Preserved proprioception
o Poor prognosis
Posterior cord
o Propioception lost
11
Trauma – Lower Extremity
o Sensation, motor intact
12