Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 - - - - 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 o o 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 - - - 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 - - - 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 - - - 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 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