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Pelvisandacetabulumfractures Sourcil: Teardrop: 01. It refers to the roof 02. Q Lateral border = or the weight- the cortical surface of bearing area of the the cotyloid fossa acetabulum and is (true floor of the characterized by acetabulum). increased sclerosis. It normally has a The medial border = concave shape and the cortical surface in is congruent with the true pelvis. the femoral head. visitorthomcqhub.comformore Ilioischial Line: Iliopectineal Line: 03. Corresponds to the 04. Corresponds to the Posterior column. Anterior column. If disrupted = If disrupted = posterior column anterior column fracture. fracture. Importantangles Neck-Shaft Angle Lateral Center-Edge Angle ● Normal: 125-140° (Wiberg) ● Coxa Vara: < 120° ● Normal: 25-40° ● Coxa Valga: > 140° ● Dysplasia: < 20° ● Overcoverage: > 40° HemorrhagicShockClassification&Fluid Resuscitation % Blood loss Heart rate Blood pressure Urine output pH Mental state Resuscitation Class I <15% Normal Normal >30 mL/Hr Normal Anxious Fluids II 15-30% >100 Normal 20-30 mL/Hr Normal Confused Fluids III 30-40% >120 Decreased 5-20 mL/Hr Acidosis (↓) Lethargic Blood IV >40% >140 Decreased <5 mL/Hr Acidosis (↓) Coma Blood ResuscitationMethods Q Transfusion ratio: 1:1:1 (RBCs: Platelets: Plasma)IndicatorsofAdequateResuscitation ● Q Urine output: 0.5-1.0 ml/kg/hr ● Q Serum lactate: Normal < 2.5 mmol/L ● Gastric mucosal pH ● Base deficit: Normal -2 to +2SepticShockvs.HypovolemicShock ● Septic Shock: Decreased systemic vascular resistance ● Hypovolemic Shock: Increased systemic vascular resistance EarlyAppropriateCare ● Parameters: ○ Lactate < 4.0 mmol/L, ○ pH ≥ 7.25, ○ base excess ≥ -5.5 mmol/L ● Optimal Surgery Timing: Within 36 hours of injury OpenFractures ● Direct communication with the external environment ● Q Antibiotic Timing: Initiate ASAP, within 1 hours BOAST Guidelines ● Q Debridement Recommendations: ○ Debridement should be performed using fasciotomy lines for wound extension where possible ■ Immediately for highly contaminated wounds (agricultural, aquatic, sewage) or when there is an associated vascular compromise (compartment syndrome or arterial disruption producing ischaemia). ■ Within 12 hours of injury for other solitary high energy open fractures. ■ Within 24 hours of injury for all other low energy open fractures.MangledExtremitySeverityScore(MESS) MESS 0 1 2 3 4 Reduced pulse but Pulseless, Cool, paralysis, Limb ischemia normal perfusion paresthesias, slow numb/insensate capillary refill Patient age < 30 30-50 >50 SBP >90 mmHg Transient Persistent Shock consistently hypotension hypotension Medium energy Very high energy Injury Low energy (stab, (dislocation, High energy (high (high speed trauma gunshot, simple speed MVA or rifle mechanism fracture) open/multiple shot) with gross fractures) contamination) Q Score > 7: low likelihood of limb/extremity viability (100% sensitive) >> Predictive of amputation SystemicInflammatoryResponseSyndrome (SIRS) ● Q Criteria: ○ Heart rate > 90 bpm ○ WBC count < 4000 or > 12,000 cells/mm³ ○ Respiratory rate > 20 or PaCO2 < 32 mmHg ○ Temperature < 36°C or > 38°C ● Score of 2+ = SIRS Amputation ● Metabolic Cost of Walking ○ Rule: Increases with proximal amputations ○ Exception: Q Syme amputation is more efficient than midfoot ● Wrist Disarticulation: Preserves radial styloid flare ● Transradial: Easier prosthetic fitting ● Transhumeral vs. Elbow Disarticulation: ○ Elbow disarticulation prevents bony overgrowth in children Amputation ● Transfemoral Amputation ● Objective: Maintain as much length as possible. ● Ideal cut: 10-15 cm above the knee joint for prosthetic fitting. ● Technique: ○ 5 -10 of ADDuction for improved prosthetic function. ● Adductor Myodesis: ○ Improves clinical outcomes. ○ Creates dynamic muscle balance. ○ Provides a soft tissue envelope for better prosthetic fitting. ● Gritti-Stokes Amputation: ○ Amputation through the femur near the adductor tubercle. ○ Synovium excised to prevent postoperative effusion. ○ Q Patella arthrodesed to the femur for improved end bearing. ○ Q Maintains prepatellar soft tissue without injury. ○ Better outcomes compared to standard transfemoral amputation. Amputation ● Syme Amputation (Ankle Disarticulation) ○ Q Requires a patent tibialis posterior artery. ○ More energy efficient than midfoot amputation. ○ Q Stable heel pad is crucial. ○ Technique: Medial and lateral malleoli removed flush with the distal tibia articular surface. ● Q Bone Overgrowth: Most common complication in pediatric amputations. CompartmentSyndrome ● Leg Compartments: ○ Anterior Compartment: ■ Function: dorsiflexion of foot and ankle (Tibialis Anterior, Extensor Hallucis Longus, Extensor Digitorum Longus, Peroneus Tertius) ■ Q Deep peroneal nerve Affected. ■ Most commonly involved. ○ Lateral: ■ Function: Plantar flexion and eversion (Peroneus longus, Peroneus brevis). ○ Deep Posterior: ■ Function: Plantar flexion and inversion (Tibialis posterior, Flexor digitorum longus, Flexor Hallucis longus). ○ Superficial Posterior: Plantar Flexion (Gastrocnemius, Soleus, plantaris). CompartmentSyndrome ● Physical Exam: 6P ○ Pain with Passive stretch (most sensitive finding). ○ Paresthesia and hypoesthesia (nerve ischemia). ○ Paralysis (late finding). ○ Palpable swelling. ○ Absent peripheral Pulses (late finding). ● Treatment: ○ Operative: Emergent fasciotomy for clinical presentations consistent with compartment syndrome or delta P < 30 mm Hg. ○ Q Intraoperative: delta P is influenced by the Anesthetic agents which will be not accurate measurements, i.e. ONLY observation is required if delta P is < 30 mmHg in anaesthetised patient CompartmentSyndrome ● Foot Compartments ○ Nine main compartments. ○ Q Medial: Abductor hallucis, Flexor hallucis brevis. ○ Lateral: Abductor digiti minimi, Flexor digiti minimi brevis. ○ Interosseous (4). ○ Central (3): ■ Superficial (Flexor digitorum brevis), ■ Central (Quadratus plantae), ■ Deep (Adductor hallucis, posterior tibial neurovascular bundle). ● Treatment: emergent foot fasciotomies via dual dorsal incisions Osteomyelitis ● Unusual organisms: ○ Salmonella: Sickle cell anemia patients , Q Staph Aureus still is the most common. ○ Pseudomonas: IV drug use / Shoe puncture wound from solid material ○ Bartonella: HIV/AIDS patients after cat scratch or bite. ○ Fungal: Immunosuppressed patients. ○ Tuberculosis: Pott’s disease. ● Laboratory Analysis: ○ WBC Count: Elevated in 1/3 of acute osteomyelitis cases. ○ ESR: Usually elevated in acute and chronic osteomyelitis. ○ C-Reactive Protein: Most sensitive test; elevation in 97% of cases. ○ Blood Cultures: May be negative, used for hematogenous osteomyelitis. ● Microbiology: ○ Sinus tract cultures are not reliable. ○ Bone biopsy and culture is the gold standard.NeerClassificationofDistalClavicleFractures Type I: Type IIA: Type IIB: ● Extra-articular, lateral to CC ● Medial to CC ligaments ● Two patterns (between or ligaments ● Significant medial lateral to CC ligaments) ● Minimal displacement, stable displacement, unstable ● Significant displacement, ● Management: Nonoperative ● Management: Operative due unstable to high nonunion rate ● Management: Operative Type III: Type IV: Type V: ● Intra-articular, stable ● Physeal fracture in children, ● Comminuted fracture, ● Potential for AC arthritis stable unstable ● Management: Nonoperative ● Management: Nonoperative ● Management: Operative Scapularfractures Surgical Orthpaedics ● Q Thoracic injury (80%) ● Q Rib fractures (53%) ● Hemothorax/Pneumothorax (>30%) ● Ipsilateral extremity injuries (50%) ● Pulmonary contusion (>40%) ● Brachial plexus injury (5-13%) ● Head injuries (35-50%)IdebergClassificationofGlenoidFractures ● Type Ia: Anterior rim fracture ● Type Ib: Posterior rim fracture ● Type II: Q Fracture through glenoid fossa exiting inferiorly ● Type III: Q Fracture through glenoid fossa exiting superiorly ● Type IV: Fracture exiting medially through the body ● Type V: Combinations of Types II/IV or III/IV ● Type VI: Severe comminutionQScapulothoracicDissociation Definition: Traumatic disruption of the scapulothoracic articulation Diagnosis: Edge of scapula displaced > 1 cm from spinous process Mechanism: Lateral traction injury Associated Conditions: ● Scapula and clavicle fractures ● Vascular and neurological injuriesProximalHumerusFractures Ligaments: Coracohumeral, SGHL, MGHL, IGHL (know the function of each ligament??) Blood Supply: Q Posterior circumflex Humeral artery is the main supply. Q Hertel criteria for humeral head ischemia: ● <8 mm of calcar length attached to articular segment ● Disrupted medial hinge ● Increasing fracture complexity ● Displacement >10mm ● Angulation >45° Associated Nerve Injury: Axillary nerve injury (most common) ProximalHumerusFractures Hemiarthroplasty for management of proximal humerus fractures: Indication: Young patients (40-65 years old) with complex fracture-dislocations or head-splitting Technical tips and tricks: ● Cerclage wire or suture to the GT and LT to prosthesis. ● Head - Tuberosity Distance (HTD): Greater tuberosity 8 mm below articular surface of humeral head ● Height of the prosthesis best determined off the superior edge of the pectoralis major tendon ● 5.6cm between top of humeral head and superior edge of tendon Holstein-LewisFracture A spiral fracture of the distal third of the humeral shaft. Radial nerve injury (up to 22%), mostly neuropraxia.NeurovascularrisksofIMnailingofhumeral shaftfractures Radial nerve: with a lateral to medial distal locking screw Musculocutaneous nerve: with an anterior-posterior distal locking screw Axillary nerve: with proximal locking screws in antegrade nails Anterior and posterior humeral circumflex vessels.Tendontransferswithradialnervepalsy Wrist extension Finger extension Thumb extension Pronator teres (PT) to Flexor carpi radialis Palmaris longus (PL) extensor carpi radialis (FCR) or flexor carpi to extensor pollicis brevis (ECRB) ulnaris (FCU) to longus (EPL) extensor digitorum communis (EDC).ExampleQuestions: What is the strongest predictor of future fragility fractures in a 70-year-old female? A. T-score < - 2.5 B. Previous fragility fracture C. Low calcium intake D. Early menopause E. History of Nutritional rickets in infancyExampleQuestions: What is the strongest predictor of future fragility fractures in a 70-year-old female? A. T-score < - 2.5 B. Previous fragility fracture C. Low calcium intake D. Early menopause E. History of Nutritional rickets in infancyExampleQuestions: In which of the following scenarios would damage control orthopaedics be the most appropriate? A. Initial lactate of 4 with current lactate of 2 B. Initial lactate of 1.5 with current lactate of 1.5 C. Initial lactate of 2 with current lactate of 4 D. A single reading of 4 E. Initial lactate of 6 with current lactate of 2.5ExampleQuestions: In which of the following scenarios would damage control orthopaedics be the most appropriate? A. Initial lactate of 4 with current lactate of 2 B. Initial lactate of 1.5 with current lactate of 1.5 C. Initial lactate of 2 with current lactate of 4 D. A single reading of 4 E. Initial lactate of 6 with current lactate of 2.5