calcaneus. (patellar tendon rupture, periarticular avulsion, or displaced menisci) may benefit from acute repair. 10% Orthobullets Team Which of the following is an appropriate initial step in the management of a multiply injured patient with an unstable pelvic ring fracture and hemodynamic instability? Figures A and B are radiographs of a 20-year old male athlete that sustained a high impact tackle during a football game. He is otherwise hemodynamically stable. She subsequently undergoes reduction and percutaneous bilateral iliosacral screw placement. unrestrained passenger MVA (knee against dashboard) falls from height. KDIIIM (ACL, PCL, MCL) and KDIIIL (ACL, PCL, PLC, LCL). For a patient with an unstable pelvic fracture, the amount of blood tranfusions required in the first 24 hours has shown to be most predictive for what variable? [ 3, 2] As in the assessment of any case of pediatric. Calcaneus FX Other Trauma Topics 2023 Bobby Menges Memorial HSS Limb Reconstruction Course often results in transverse fracture or inferior pole avulsion. A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal. 75% (2662/3562) retinacular injury is typical. The patient begins range of motion exercises with her occupational therapist 3 days after surgery, and her elbow dislocates. Greater than 10mm of articular depression. Recalcitrant medial sesamoid stress fracture with fragmentation. 5-15% of posterior hip dislocations are associated with a femoral head fracture because of contact between femoral head and posterior rim of acetabulum. unrestrained passenger MVA (knee against dashboard) falls from height. due to fall, dashboard injury or other high energy mechanism, occurs from rapid knee flexion against contracted quadriceps muscle, often results in transverse fracture or inferior pole avulsion, patella is the largest sesamoid bone in the body, superior 3/4 of posterior surface covered by articular cartilage, articular cartilage thickest in body (up to 1cm), posterior articular surface comprised of two large facets (medial and lateral), each facet separated into smaller facets and divided by vertical ridge, occurs in approximately 2-3% of population, attaches approximately to upper 2/3 of medial patella, acts as primary ligamentous restraint to lateral patellar translation, quadriceps tendon and fascia lata attach to anterosuperior margin of patella, superficial layer formed from rectus femoris tendon, middle layer formed by vastus medialis and vastus lateralis tendons, deep layer formed by vastus intermedius tendon, formed by fascia lata, vastus medialis and vastus lateralis, contributes to strength of extensor mechanism, should be repaired at time of patellar fixation, derives from anastomotic ring originating from geniculate arteries, lies anterior to quadriceps tendon and posterior to patellar tendon, most important blood supply to the patella is located at the inferior pole, patella increases power and mechanical advantage of extensor mechanism by 30-50% by displacing it anteriorly away from the center of rotation, during knee flexion, patella experiences tension from quadriceps and patellar tendon and compressive loads across posterior patella, direct blow to knee or extensor mechanism injury, lacerations, abrasions in setting of open fracture, extensor mechanism and retinaculum disrupted, can aspirate hemarthrosis and inject local anesthetic if patient unable to perform due to pain, saline load test can be performed to rule out concomitant knee joint involvement, obtained with knee in 30 of flexion if possible, degree of fracture displacement correlates with degree of retinacular disruption, indicates disruption of quadriceps tendon, articular step-off > 2-3 mm and displaced fracture gap > 3 mm dictate operative management, sagittal views particularly useful for visualizing distal pole comminution, change in operative plan in 50% of cases with CT, improved understanding of fracture patterns, particularly true in distal pole fracture patterns that are unappreciated on plain radiographs, smooth, regular borders seen on radiographs, caused by failure to unite secondary ossific nucleus, knee immobilized in extension (knee immobilizer, hinged knee brace or cast) with full weight bearing, intact extensor mechanism (patient able to perform straight leg raise), nondisplaced or minimally displaced fractures, active & active assist ROM at 1-2 weeks with resistance exercises beginning at 6 weeks, good or excellent results in >95% of patients with proper indications, open reduction and internal fixation (ORIF), extensor mechanism failure (unable to perform straight leg raise), may be preferred over tension band in cases of significant articular sided comminution, used alone or as supplement to primary fixation, high rates of union (>95%) despite technique, rates of nonunion higher with open fracture, symptomatic hardware requiring removal is common, WBAT in hinged knee brace with flexion limited to 30 for 4 weeks and progressed incrementally thereafter, comminuted extra-articular inferior pole fracture measuring <40% patellar height, patellar tendon should be advanced into defect on anterior surface of patella, decreases strength of extensor mechanism to increasing degree based on size of fragment removed, severe and extensive comminution not amenable to salvage, imbrication of quadriceps/patellar tendons, decrease in extensor mechanism strength >50%, midline longitudinal incision centered over patella, expose articular surface either through fracture site or retinacular rents, can alternatively perform lateral parapatellar arthrotomy and invert patella if retinaculum is not damaged or if better visualization of articular surface is desired, avoid extensive soft tissue dissection to preserve blood supply and viability of skin flaps, remove devitalized fragments and loose bodies, converts tensile forces generated by quadriceps complex at anterior surface into compressive forces at articular surface, difficult to manipulate and high re-operation rates due to painful hardware or wire migration, has 75% tensile strength of 18-gauge stainless steel wire but performs similarly clinically, lower rates of hardware removal when suture used, tension band using longitudinal 4.0 mm cannulated screws, biomechanically superior to tension band construct, versatile with multiplanar screw options available, effective in stabilizing distal pole fractures with comminution, less fracture gapping compared to tension band wiring, used alone or to augment additional fixation such as interfragmentary lag screws or tension band construct, important to place tension wire at superior aspect of construct where more soft tissue coverage is available, consider using braided suture as opposed to 18-gauge stainless steel wire, plates may have lower rates of hardware irritation compared to tension banding. In the emergency room he is alert and oriented and is hemodynamically stable. What is the most common urological injury associated with this injury pattern? calcaneus. After unsuccessful attempts at closed reduction, it is noted that the pulses are no longer palpable and the foot is cool. second most common tarsal fractures after calcaneus fxs. A 43-year-old male suffers a knee injury and undergoes the operation seen in Figures A and B. (OBQ18.82) technique (see below) arthroscopy. Septic Arthritis - Adult. No vascular injury is identified. A radiograph is shown in Figure A. (OBQ04.123) Septic Arthritis is the inflammation of the joints secondary to an infectious etiology, most commonly affecting the knee, hip, and shoulder. These classifications need to be simple, easy to apply clinically and reproducible, with high concordance between surgeons.6, 7, 8 The. A massive transfusion protocol is initiated. This is an AAOS Self Assessment Exam (SAE) question. 85% (1536/1804) 3. The Gartland classification is a system of categorizing supracondylar humerus fractures, Orthobullets; 0.00 (0 votes) Original source: https://en.wikipedia.org .Classification Stability most commonly used and reliable classification two types stable definition intact posteromedial cortex clinical significance will resist medial compressive loads once reduced unstable ligament avulsion off the humeral origin. The Gartland classification is a system of categorizing supracondylar humerus fractures, Orthobullets; 0.00 (0 votes) Original source: https://en.wikipedia.org .Classification Stability most commonly used and reliable classification two types stable definition intact posteromedial cortex clinical significance will resist medial compressive loads once reduced unstable Open reduction and reconstruction plating of the symphysis, Protected weightbearing and binder as needed and observation, Open reduction and wiring of the symphysis. Osteology. Osteology. He subsequently develops the post-traumatic condition shown in Figure A. She has no evidence of neurologic deficit on examination. Diagnosis is made radiographically with pelvic radiographs and further characterized with CT scan. A 34-year-old female presents to the trauma bay with hemodynamic instability following a motor vehicle collision. If pulses do not return, perform popliteal artery exploration. account for 13-23% of talus fractures. Team Orthobullets (D) Trauma A 47-year-old male sustained a comminuted calcaneus fracture in a motorcyle accident. An anteromedial coronoid fracture. (OBQ10.154) Disruption of sacrospinous and sacrotuberous ligaments. 2% Open reduction internal fixation of sesamoid with autogenous calcaneus bone graft. Pelvic ring fractures are high energy fractures of the pelvic ring which typically occur due to blunt trauma. complete involvement of all roots is most common, high speed vehicle accidents (mostly motorcycle), with high enough energy all roots can be affected, forced arm abduction (as in grabbing onto something while falling), brachial plexus motor and sensory innervation, avulsion proximal to dorsal root ganglion, involves CNS which does not regenerate little potential recovery of motor function (poor prognosis), loss of serratus anterior (long thoracic nerve) leads to medial winging (inferior border goes medial), loss of rhomboids (dorsal scapular nerve) leads to lateral winging (superior medial border drops downward and protrudes laterally and posteriorly), both pre- and postganglionic lesions can present with flail arm, absence of a Tinel sign or tenderness to percussion in the neck, normal histamine test (C8-T1 sympathetic ganglion), intact triple response (redness, wheal, flare), rhomboid paralysis (dorsal scapular nerve), normal sensory nerve action potential (SNAP), loss of innervation to cervical paraspinals, involve PNS, capable of regeneration (better prognosis), maintained innervation to cervical paraspinals, represents disruption of sympathetic chain via, serratus anterior (long thoracic nerve) and rhomboids (dorsal scapular nerve), if they are functioning then it is more likely the C5 injury is postganglionic, arterial injuries common with complete BPIs, fractures to the first or second ribs suggest damage to the overlying brachial plexus, evidence of old rib fractures can be important if an intercostal nerve is needed for nerve transfer, inspiration and expiration can demonstrate a, fracture may indicate brachial plexus injury, avulsion of cervical root causes dural sheath to heal with, allows blood clot in the injured area to dissipate and meningocele to form, can visualize much of the brachial plexus, CT/myelogram demonstrates only nerve root injury, mass lesions in nontraumatic neuropathy of brachial plexus and its branches, tests muscles at rest and during activity, fibrillation potentials (denervation changes), as early as 10-14 days following injury in proximal muscles, can help distinguish preganglionic from postganglionic, examine proximally innervated muscles that are innervated by root level motor branches, measures sensory nerve action potentials (SNAPs), distinguishes preganglionic from postganglionic, if SNAP normal and patient insensate in ulnar nerve distribution, if SNAP normal and patient insensate in median nerve distribution, can detect reinnervation months before EMG, more sensitive than EMG and NCV at identifying continuity of roots with spinal cord (positive finding), a negative finding can not differentiate location of discontinuity (root avulsion vs. axonotmesis), perform 4-6 weeks after injury to allow for Wallerian degeneration to occur, stimulation done at Erb's point and recording done over cortex with scalp electrodes (transcranial), indicated for near total plexus involvement and with high mechanism of energy, partial upper plexus involvement and low energy mechanism, best not to delay surgery beyond 6 months, usually involves tendon/muscle transfers to restore function, rarely possible due to traction and usually only possible for acute and sharp penetration injuries, commonly used due to traction injuries (postganglionic), preferable to graft lesions of upper and middle trunk, allows better chance of reinnervation of proximal muscles before irreversible changes at motor end plate, donor sites include sural nerve, medial brachial nerve, medial antebrachial cutaneous nerve, vascularized nerve graft includes ulnar nerve when there is a proven C8 and T1 avulsion (mobilized on superior ulnar collateral artery), transfer working but less important motor nerve to a nonfunctioning more important denervated muscle, ulnar nerve used for upper trunk injury for, wrist extension / finger flexion (lateral and posterior cords), Recovery of reconstructed plexus can take up to, infraclavicular plexus injuries have better prognosis than supraclavicular injuries, upper plexus injuries have improved prognosis, other surgeries such as arthrodesis and tendon transfers may be needed. Lack of coronoid fixation with medial buttress plate, Lack of coronoid fixation from lateral approach, Lack of medial collateral ligament repair, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Orthopedic Building at Rush University Medical Center, Coronoid Fx - Open Reduction Internal Fixation with Screws, Type in at least one full word to see suggestions list. A 32-year-old professional skydiver lands awkwardly during a jump. protected weight-bearing and pain control, skeletal traction followed by open reduction and internal fixation, pelvic external fixation followed by sacroiliac screws, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, A1: fracture not involving the ring (avulsion or iliac wing fracture). (OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. (OBQ19.114) A 25-year-old male is involved in a motor vehicle accident and sustains the injury seen in Figure A. -Weight bearing as tolerated (simple, incomplete sacral fracture). Calcaneus FX Other Trauma Topics transverse process fracture likely indicates a root avulsion. Which of the following statements regarding the patient's injury is true? A 32-year-old male is involved in a motor vehicle collision and sustains the injury seen in Figure A. What would be the most appropriate next step in treatment? Treatment is either immobilization or surgical fixation depending on fracture displacement and integrity of the extensor mechanism. (SBQ12TR.41.1) Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. A 37-year-old male is struck by a car while walking at night. (SBQ12TR.88) An anteromedial coronoid fracture. 2% Open reduction internal fixation of sesamoid with autogenous calcaneus bone graft. What is the most appropriate Gustilo-Anderson classification of Computed tomography reveals no asymmetry of the sacroiliac joints. Orthobullets Team Rim avulsion fracture of lateral plateau. He subsequently develops the post-traumatic condition shown in Figure A. Upper brachial plexus palsy 22 months ago, Medial and posterior cord injury from gunshot wound 2 months ago. A 25-year-old male sustains a closed elbow dislocation after falling during a soccer game. talus. 85% (1536/1804) 3. (OBQ12.236) Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Associated injuries. What is the next step in treatment? Hinged knee brace use with functional rehabilitation protocol, Open treatment with internal fixation or excision with patellar tendon advancement, Distal patellar resection and allograft reconstruction, Placement of a cerclage wire from patella to proximal tibia. A pelvis radiograph is shown in Figure A. A fracture of the radial head requiring ORIF, A highly comminuted radial head fracture requiring radial head arthroplasty or resection, A type I avulsion fracture of the coronoid. He presents to the emergency room with bilateral knee injuries. is an intraarticular structure. Symptoms. (SBQ12TR.8) technique (see below) arthroscopy. Which of the following clinical images would be expected in this scenario? His radiographs show a comminuted displaced olecranon fracture involving 25% of the articular surface with global osteopenia. is an intraarticular structure. avulsion fractures (ischial spine, ischial tuberosity, sacrum, transverse process of coronoid tip. (OBQ12.43) Crescent fracture located on the side of impact, Widened anterior SI joint, disrupted sacrotuberous and sacrospinous ligaments with intact posterior SI ligaments, Complete SI disruption with lateral displacement, Sacral compression fracture on side of impact with transverse pubic rami fractures, Open-book injury with contralateral sacral compression fracture. patella sleeve fracture. (OBQ15.63) Calcaneus FX Other Trauma Topics transverse process fracture likely indicates a root avulsion. A 7-year old boy presents to the emergency room following a ATV accident with complaints of left pelvic pain. He is placed in a pelvic binder, and his blood pressure normalizes temporarily. Partial patellectomy is the recommended treatment for which of the following injuries? 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Talus - Posteromedial Approach to the Talus, ORIF Talar Body Fx with Medial Malleolar Osteotomy. (OBQ13.186) Copyright 2022 Lineage Medical, Inc. All rights reserved. (OBQ07.207) 2% Open reduction internal fixation of sesamoid with autogenous calcaneus bone graft. He has pain and swelling at the elbow without evidence of instability. (OBQ17.175) A 22-year-old collegiate football player presents with persistent left lateral ankle pain 6 months after sustaining an ankle sprain during a game. talus. 91% (2662/2927) 5. proximal migration of sesamoids. A 23-year-old male is involved in a motor vehicle accident and sustains a left open femur fracture, right open humeral shaft fracture, and an LC-II pelvic ring injury. Risk of postoperative fixation failure for a complete sacral fracture has been associated with what variable? (OBQ11.114) An 82-year-old nursing home resident falls onto his elbow while rising from a seated position. talus. (patellar tendon rupture, periarticular avulsion, or displaced menisci) may benefit from acute repair. Presentation. Results from an excessive displacement of head to opposite side and depression of shoulder on the same side producing traction on plexus. Lateral radiograph to clear the cervical spine, External fixator application to the left ankle in the operating room, External fixator application to the pelvis in the operating room, Reduction and splinting of the right forearm. (OBQ12.156) A 36-year-old male sustains an open segmental tibia fracture associated with an overlying 8 cm soft tissue avulsion that requires skin grafting for soft tissue coverage. 20% (229/1149) 4. A 32-year-old male sustains an APC-III pelvic ring disruption after a motor vehicle collision. Multiligamentous injury with periarticular fracture. Calcaneus FX Other Trauma Topics 2023 Bobby Menges Memorial HSS Limb Reconstruction Course fracture displacement and patient activity demands. Her blood pressure is 80/40 and pulse is 140. Rim compression fracture. Anatomy. Which of the following fracture patterns is most consistent with this diagnosis? Osteology. This injury would affect all of the following muscles EXCEPT? Orthobullets Team Trauma Ipsilateral calcaneus fracture. A type I avulsion fracture of the coronoid. Associated with the highest risk of hypovolemic shock (63%); mortality rate up to 25%, test stability by placing gentle rotational force on each iliac crest, low sensitivity for detecting instability, look for abnormal lower extremity positioning, external rotation of one or both extremities, scrotal, labial or perineal hematoma, swelling or ecchymosis, degloving injuries (Morel-Lavallee lesion), rule out lumbosacral plexus injuries (L5 and S1 are most common), rectal exam to evaluate sphincter tone and perirectal sensation, up to 10-15% of patients will sustain neurologic injury, more common in males (21% in males, 8% in females), mandatory to rule out occult open fracture, look for asymmetry, rotation or displacement of each hemipelvis, evidence of anterior ring injury needs further imaging, xray beam angled 40 caudad (may be as little as 25 degrees), adequate image when S1 overlaps S2 body (i.e. Associated injuries. The developer provided this information and may update it over time. Posterior stabilization with plate or SI screws as needed. (OBQ12.156) A 36-year-old male sustains an open segmental tibia fracture associated with an overlying 8 cm soft tissue avulsion that requires skin grafting for soft tissue coverage. Thank you. Bilateral weight bearing as tolerated for Anterior Posterior Compression Type I injury, Touchdown weight bearing on the right for Lateral Compression Type I injury, Bilateral weight bearing as tolerated for Lateral Compression Type I injury, Posterior sacroiliac screw, followed by non-weight bearing for Lateral Compression Type II injury, Posterior sacral plate, followed by non-weight bearing for Lateral Compression Type III injury. A 23-year-old male is an unrestrained driver in a motor vehicle accident and sustains an unstable pelvic ring fracture. She has obvious open fractures of the right forearm and left ankle. Percutaneous or open based on injury pattern and surgeon preference. A merchant view is performed which shows no significant degenerative changes of the patellofemoral joint. -Protected weight bearing (complete, comminuted sacral component. What is the most appropriate Gustilo-Anderson classification of Safety starts with understanding how developers collect and share your data. Recalcitrant medial sesamoid stress fracture with fragmentation. Associated injuries. 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