Of the following possible complications from nonoperative treatment, which is the most likely? Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. A current radiograph is shown in Figure A. Where the foot is everted, lateral displacement occurs. The goal of treatment is to protect the area and give the bone time to heal. [ Jernigan, 2017; Gholson, 2011] The fracture location pattern has, however, changed over the years. Unstable injuries require either halo-vest immobilization or surgical stabilization with a fusion. (OBQ07.275) All rights reserved, University of Washington, Department of Orthopaedics and Sports Medicine, Ohio Health Orthopedic Trauma and Reconstructive Services. A 20-year-old woman is involved in a high-speed motor vehicle collision and sustains bilateral tibial plateau fractures as well as the clavicle fracture shown in Figure A. Lake Forest, CA 92630. (OBQ08.219) A 20-year-old male military recruit slams his index finger on a tank hatch and sustains the injury seen in Figure A. It was originally described as a four-part fracture with double fractures through the anterior and posterior arches, but three-part and two-part fractures have also been described. 2022 Lineage Medical, Inc. After discussing the risks and benefits of surgery, he elects to pursue nonoperative treatment. Thesecrucial ligaments include thesyndesmotic ligaments that stabilize the fibula within the incisura in the tibial bone, and another critical ligament is the deltoid complex ligament, which is a broad ligament with a fan-like structure thatoriginates from the medial malleolar to insert in the talus bone; it also subdivides into two ligaments. Current imaging is shown in Figure B. Foothill Ranch, CA 92610. (OBQ09.138) A 33-year-old male sustains a distal humerus fracture and is treated with open reduction and internal fixation of the distal humerus with olecranon osteotomy. Bimalleolar ankle fracture is caused by twisting with multiple force mechanisms, or supination injury. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Bimalleolar ankle fracture is a fracture that occurs in both the lateral and medial malleoli at the distal end of the tibia and fibula bones that articulate with talus bone to form the ankle joint or tibiotalar joint. (SBQ08UE.37.1) Professionalism & Rotation Evaluations Accurate ACGME levels AND summative faculty feedback the residents want. Department of Neurology 811 Kaufmann Medical Building 3471 Fifth Avenue Pittsburgh, PA 15213. Return multiple choice. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Which of the following has been shown to be true regarding operative versus nonoperative treatment of this injury? How PASS is a win for everyone on the team Residents Chief Residents Fellows Program Coordinators Which of the following is responsible for the apex palmar fracture deformity noted on the preoperative radiographs? Conversely, in the inversion mechanism, theprimary ligament injured is the anterior talofibular ligament, and hyper-dorsiflexion trauma might cause syndesmotic ligamenttears or sprains. The foot is usually dislocated medially and superiorly as it is plantarflexed and inverted, usually as a result of a high-energy impact, e.g. She presents to clinic for her 6-month follow-up appointment and reports persistent pain. A 22-year-old left hand dominant laborer sustains the injury shown in Figures A and B as the result of a fall from a ladder. A 17-year-old male jumped headfirst into a shallow lake and sustained a comminuted C1 fracture. 5 mm of prevertebral soft tissue swelling at C2. Open reduction and placement of two 0.045-inch K-wires placed longitudinally through the metacarpal head, Application of a 1.5-mm straight plate applied dorsally through and extensor tendon splitting approach, Open reduction and lag screw fixation with 1.3mm screws through a radial approach, Placement of a 1.5-mm condylar blade plate through a radial approach, Open reduction and retrograde passage of two 0.045-inch K-wires retrograde trough the PIP joint. Radiographic features Please see the article on stress fractures . A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. As compared to treatment with a simple sling, what is the primary advantage of treatment with a figure-of-eight brace? Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. (949) 716-5050. Radiographic features Plain radiograph Small curvilinear fragment close to the medial femoral condyle at the origin of the medial collateral ligament. Diagnosis is made with plain radiographs of the foot. atlas fractures make up to 25% of the injuries of the craniovertebral junction, most commonly associated with high-energy injury mechanisms, osteoporosis predisposes to low energy fractures, higher association with odontoid fractures, 30% less energy requirement to cause atlas fracture when cervical spine is in extension compared to neutral, due to large space for the spinal cord at this level, injuries tend to increase the area availabe for spinal cord at C1, atlas (C1) is a ring containing two articular lateral masses, it lacks a vertebral body or a spinous process, incomplete formation of the posterior arch is a relatively common anatomic variant and does not represent a traumatic injury, makes acute posteromedial bend around Occ-C1 joint and crosses sulcal groove, sulcal groove is a common site for posterior arch injuries/fractures, occipital-cervical junction and atlantoaxial junction are coupled, intrinsic ligaments are located within the spinal canal, provide most of the ligamentous stability. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: QID: 211138 FIGURES: A Type & Select Correct Answer. An open-mouth odontoid radiograph is useful to evaluate for disruption of the transverse ligament which leads to lateral displacement of the lateral masses relative to each other. Spine Infections, Tumors, & Systemic Conditions. Which of the following factors increase the risk of nonunion in midshaft clavicle fractures when treated nonoperatively? shorter operative time. OC Sports and Rehab 41 reviews. Diagnosis can be made radiographically with AP and cephalic tilt clavicle x-rays. They include, primary stabilizer of atlantoaxial junction, prevents posterior migration of the odontoid into the spinal canal, connects the posterior odontoid to the anterior atlas arch, inserting laterally on bony tubercles of the lateral mass, connect the odontoid to the occipital condyles, relatively strong and contributes to occipitalcervical stability, connects the posterior body of the axis to the anterior foramen magnum and is the cephalad continuation of the PLL, occipital condyles articulate with C1 superior articular processes, provides ~50% of cervical spine flexion and extension range of motion, contains anterior and posterior joint capsules, articulation between the inferior facet of C1 and superior facet of C2, aticulation between the dens (C2) and the anterior arch of the atlas. Willis AA, Kutsumi K, Zobitz ME, Cooney WP 3rd. Midshaft Clavicle fractures are common traumatic injuries caused by a direct impact to the shoulder girdle and is most commonly seen in young, active adults. (OBQ08.54) The femoral and tibial plateau fractures are open with no gross contamination, and there is an ipsilateral Morel-Lavelle lesion of the left thigh. The most common mechanism that cuts this ligament is foot eversion or external rotation force. "Plough" fracture is an isolated anterior arch fracture caused by a force driving the odontoid through the anterior arch. (OBQ13.55) Atlas Fractures & Transverse Ligament Injuries are traumatic injuries usually caused by high-energy trauma with axial loading in young patients (Jefferson Fracture) or low-energy falls in elderly. summary Metacarpal Fractures are the most common hand injury and are divided into fractures of the head, neck, or shaft. A nutcracker fracture of the cuboid refers to a cuboid bone fracture with associated navicular avulsion fracture due to compression between the bases of 4 th and 5 th metatarsals and calcaneus bone. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) This joint is in the mortise and tenon joint classification. Open Fractures Management - Trauma - Orthobullets ORTHO BULLETS Join nowLogin Select a Community MB 1Preclinical Medical Students MB 2/3Clinical Medical Students ORTHOOrthopaedic Surgery IMInternal Medicine ENTEar, Nose and Throat GSGeneral Surgery PRSPlastic Surgery About Bullet Health Join Our Team ORTHOBULLETS Events A 45-year-old male falls onto his left shoulder while biking and an injury radiograph is shown in Figure A. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Which of the following radiographic measurements would best indicate disruption of the transverse ligament? The most common ligament injury or cut is the deltoid ligament (medial ligamentous) during the medial malleolar fracture, causing joint instability. The avulsion fracture typically involves the meniscofemoral fibres of the deep medial collateral ligament. Atlas Fractures & Transverse Ligament Injuries. (OBQ08.168) (OBQ12.255) The injury usually occurs secondary to the traumatic abduction of the forefoot. Which of the following is true regarding open reduction and screw fixation of this injury? If disrupted, halo vest (for bony avulsion) or C1-2 fusion (for intrasubstance tear)(see Dickman classification below). 1-3 The mechanism of injury is the application of high-intensity forces to the body blackhead 2022 new march 90s hippie movies texas city . A 35-year-old right hand dominant man falls from a ladder and sustains the injury seen in Figure A. Copyright 2022 Lineage Medical, Inc. All rights reserved. Rotational deformity. (SBQ17SE.3) A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. Epidemiology Incidence Dickman Transverse Ligament Injuries Classification, Bony avulsion at tubercle on C1 lateral mass, neuro deficits uncommon in isolated C1 fractures, associated C2 fractures have a higher risk of neuro deficit, decreased sensation in the occipital region, 60-degree oblique radiographs to indetify posterior arch fractures, open-mouth odontoid view important to identify atlas fractures, identify late instability following nonoperative treatment, increased widening of C1 lateral masses compared to C2 (LMD), increased distance of the atlantodental interval (ADI), fracture involving the posterior or anterior arch, occipitocervical distraction/dissociation, measured on lateral radiographs and flexion-extension views, < 3 mm = normal in adult (< 5mm normal in child), 3-5 mm = injury to transverse ligament with intact alar and apical ligaments, > 6.9 mm (rule of Spence) or 8.1mm with radiographic magnification (rule of Heller), increased thickening of retropharyngeal soft tissue (>9.5 mm) suggests an anterior arch injury, radiographs have a lower sensitivity of detecting unstable atlas fractures than CT and MRI, should be ordered for every case of suspected cervical spine injury, study of choice to delineate fracture pattern and identify associated injuries in the cervical spine, pseudospread of the atlas in pediatric patients, represents asymmetric growth of the atlas compared to the axis, greater atlantal overhang of the lateral masses, occult horizontal fractures of the anterior arch, determine total lateral mass displacement, assess the presence of a vertebral artery injury, fractures involving the anterior and posterior ring, increased radial displacement of the C1 fracture fragments (unstable), bone avulsion injuries of the tubercle (TAL insertion), sagittal split fractures of the lateral mass, lower sensitivity than MRI at detecting TAL injuries, should be ordered in any case there is a confirmed fracture of the atlas, rule out associated unstable ligamentous injuries, increased T2 signal in the TAL suggests intrasubstance injury, increased T2 signal intensity in the TAL on the sagittal and coronal views, increased T2 signal intensity in the spinal cord, increased prevertebral soft tissue T2 signal intensity at C1-2, more sensitive at detecting injury to transverse ligament, increaed T2 signal intensity in the TAL is suggestive of injury, stable Type I fx (intact transverse ligament), controversy exists around optimal form of immobilization, reduce with halo traction before immobilization, require post treatment flexion-extension radiographs to assess for late instability, most often type II odontoid and hangman's fractures, higher association with neurologic injury, some authors prefer Occ-C2 fusion as opposed to C1-2 fusion, no significant downside and lower risk of revision surgery, may consider preoperative traction to reduce displaced lateral masses, C1 lateral mass split fractures (controversial), anterior and posterior techniques described, further randomized trials needed to ascertain role of this treatment, preserves motion compared to occipitocervical fusion, C1 lateral mass - C2 pedicle screw construct (Harm's technique), may be sufficient if adequate purchase with C1 lateral mass screws, 10 medial screw trajectory protects the internal carotid artery, used when unable to obtain adequate purchase of C1 (comminuted C1 fracture), anterior and posterior approaches described, rare complication with displaced posterior ring fractures, radial displacement of fracture increased the surface area of the spinal canal', displaced unilateral sagittal split lateral mass fracture, occipital condyle settles onto the C2 superior articular facet, treat with occipitocervical fusion +/- osteotomy to correct the deformity, present in 20-80% of patients after immobilization, higher rate of complications in patients with delayed C-spine clearance so it is important to clear expeditiously, loss of ~50% of cervical rotation with C1-2 arthrodesis, loss of ~50% cervical flexion with Occ-C2 arthrodesis, higher infection rates in patients treated with posterior approaches, stability dependent on degree of injury and healing potential of transverse ligament, worse long-term patient reported outcomes in fractures with >7 mm of displacement, - Atlas Fractures & Transverse Ligament Injuries, Traumatic Spondylolisthesis of Axis (Hangman's Fracture), Cervical Lateral Mass Fracture Separation, Extension Teardrop Fracture Cervical Spine, Clay-shoveler Fracture (Cervical Spinous Process FX), Chance Fracture (flexion-distraction injury), Osteoporotic Vertebral Compression Fracture, Ossification Posterior Longitudinal Ligament, DISH (Diffuse Idiopathic Skeletal Hyperostosis), Atlantoaxial Rotatory Displacement (AARD), Pediatric Intervertebral Disc Calcification, Pediatric Spondylolysis & Spondylolisthesis. fracture pattern orientation define fragment size and orientation identify marginal impaction identify loose bodies (e.g., post-reduction) look for articular gap or step-off roof-arc measurements view 2 mm fine cuts on axial view findings assess stability of the weight bearing dome based on the exiting fracture line Posterior atlanto-dens interval (PADI) of 16mm, Combined lateral mass displacement of 8.2mm. acetabular fracture causes symptoms diagnosis treatment. locking screw on fracture reduction after volar fixed-angle plating-introduction of the "protection screw" in an extra-articular distal radius fracture model. On exam, he is alert and oriented with normal motor and sensation in the upper and lower extremities. Safe surgical dislocation with a trochanteric flip osteotomy has been shown to be a reliable technique that provides excellent exposure for treating femoral-head fractures with minimal complications. 10/18/2019. What is a reported outcome of surgery when compared to nonoperative management at 1 year postoperatively? A 25-year-old patient is involved in a motor vehicle accident. Treatment depends on location of fracture but generally requires immediate IV antibiotics and urgent irrigation and debridement followed by surgical fixation as needed. fracture is clamped in a volar-dorsal plane instrumentation fracture provisionally reduced with k-wire and fixed with screws or T-plate depending on fracture pattern complication specific to this treatment injury to the superficial branch of the radial nerve wound healing complications if significant edema is present outcomes often associated with additional injuries (30%), the presence of an open wound does not preclude the occurrence of compartment syndrome in the injured limb, obtain information regarding mechanism, location, and timing of injury, the size and nature of the external wound may not reflect the damage to the deeper structures, if concern for vascular insult, ankle brachial index (ABI) should be obtained, vascular surgery consult and angiogram is warranted if ABI < 0.9, consider saline load test or CT scan if concern for traumatic arthrotomy, some studies now show CT scan more sensitive than saline load test for the knee, obtain radiographs including joint above and below fracture, evaluation for traumatic arthrotomy of the knee, a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise, mutlidisciplinary training of open fracture management has been associated with decreased timing to antibiotic administration, antibiotic type indicated by injury pattern and location, ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days, infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment, incidence of fracture related infection range from <1% in grade I open fractures to 30% in grade III fractures, definitive reconstruction and fracture fixation, once soft tissue coverage is obtained and an adequate sterility is achieved, definitive treatment with internal fixation leads to significantly decreased time to union, improved functional outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation, studies show increased infection rate when antibiotics are delayed for more than, continue for 24 hours after initial injury if wound is able to be closed primarily, continue for 24 hours after final closure if wound is not closed during initial surgical debridement (48 hours for type III wounds), clindamycin or vancomycin can also be used if allergies exist, 1st generation cephalosporin + aminoglycoside, some institutions use vancomycin + cefepime, farm injuries, heavy contamination, or possible bowel contamination, penicillin for anaerobic coverage (clostridium), fluoroquinolones or 3rd or 4th generation cephalosporin, doxycycline + ceftazidime or a fluoroquinolone, toxoid and immunoglobulin should be given intramuscularly with two different syringes in two different locations, guidelines for tetanus prophylaxis depend on 3 factors, complete or incomplete vaccination history (3 doses), splint, brace, or traction for temporary stabilization, decreases pain, minimizes soft tissue trauma, and prevents disruption of clots, remove gross debris from wound, do not remove any bone fragments, place sterile saline-soaked dressing on wound, little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED, as this can push debris further into wound, recent meta-analysis (GOLIATH study) have, to minimize risk of infection for type III fractures, within 12 hours for type IIIB open tibia fractures, extend wound proximally and distally in line with extremity to adequate expose open fracture, low-pressure bulb irrigation vs. high-pressure pulse lavage, studies have shown that low pressure bulb irrigation is less expensive than high pressure pulse lavage and has no difference in infection rates or union rates, saline vs. saline with castile soap vs. antibiotic solution, studies have shown that saline with castile soap had decreased primary wound healing problems when compared to antibiotic solutions, on average, 3L of saline are used for each successive Gustilo type (i.e 9L for type III), thorough debridement of devitalized tissue is critical to prevent deep infection, bony fragments without soft tissue attachments should be removed, performed at the time of initial debridement, external fixation is temporary initial treatment of choice for majority of high energy open fractures of the lower extremity, significantly contaminated wounds with large soft tissue defects, beads made by mixing methylmethacrylate with heat-stable antibiotic powder, vancomycin and tobramycin most commonly used, early soft tissue coverage or wound closure is ideal. Which of the following treatment methods has been shown to have the lowest rate of nonunion and symptomatic malunion? The Cyma line can also be disrupted 4 The transverse ligament is disrupted, the fracture is unstable and should be treated with either a rigid orthosis, halo immobilization, or surgical stabilization, The transverse ligament is intact, the fracture is stable and can be treated in a soft cervical collar, It is classified as Anderson and D'Alonzo Type II because the fracture extends into the C1/C2 facet, It is classified as Anderson and D'Alonzo Type III because the fracture extends into the C1/C2 facet, The imaging findings are relatively common and represent a congenital incomplete formation of the posterior arch and not a traumatic injury. The commonly fractured bones are the calcaneus, cuboid and navicular. (OBQ11.118) Fractures that disrupt the pelvic ring predispose patients to bleeding given the large network of arterial and venous anastomoses. Indirect pull of the central slip on the distal fragment and the interossei insertions at the base of the proximal phalanx, Intrinsic muscle fibrosis and intrinsic minus contracture, PIP joint volar plate attenuation and extensor tendon disruption, Rupture of the central slip with attenuation of the triangular ligament and palmar migration of the lateral bands, Flexor tendon disruption with associated overpull of the extensor mechanism. J Trauma. Stability determined by the integrity of the transverse ligament. Both Bone Forearm Fracture ORIF - Trauma - Orthobullets ORTHO BULLETS Join nowLogin Select a Community MB 1Preclinical Medical Students MB 2/3Clinical Medical Students ORTHOOrthopaedic Surgery IMInternal Medicine ENTEar, Nose and Throat GSGeneral Surgery PRSPlastic Surgery About Bullet Health Join Our Team ORTHOBULLETS A Gallie C1-2 fusion with sublaminar wiring of C1 to the spinous process of C2 is a valid treatment option for which of the following injury patterns? According to the Lauge-Hansen and the Weber classifications, this fracture is unstable, and it classifies as Supination-External Rotation Injuries III, V (Weber Type B) thatrequires operative intervention. Orthobullets Team Trauma - Tibial Plateau Fractures Technique Guide. Treatment is nonoperative or operative based on patient activity and demands, along with degree of displacement, shortening, and comminution. zsr ammo 9mm review; anonymous ways to receive money; auto electrician tafe. When discussing nonunion, which of the following is the best estimate for risk of nonunion with nonoperative treatment? treatment step to reduce the. higher grade Gustillo-Anderson classification. A pelvic ring fracture is a severe fracture with 2 breaks in the circular ring, leading to an unstable pelvis and a potentially unstable patient. 0000044467 00000 n Diagnosis is made with plain elbow radiographs. Epidemiology Associations 50% are associated with other C-spine injuries 33% are associated with a C2 fracture 25-50% of young children have a concurrent head injury Decreased chance of nonunion with nonoperative treatment, Improved Constant and DASH scores with operative treatment at all time points, Increased symptomatic malunion rate with operative treatment, Increased time to union with operative treatment. The second and third metatarsals receive the majority of stress during ambulation and are less mobile compared with the other metatarsals. Traditionally, children aged 4 - 11 years are less likely than adolescents and adults to suffer a scaphoid fracture. A 28-year-old male patient dives head first into a shallow pool. Fracture healing involves a complex and sequential set of events to restore injured bone to pre-fracture condition stem cells are crucial to the fracture repair process periosteum and endosteum are the two major sources Fracture stability dictates the type of healing that will occur mechanical stability governs the mechanical strain 20 apex volar angulation . He realized after returning to his residency following a period as a consultant at The Boston Consulting Group, that there were opportunities for improvement in the orthopaedic surgery training process. (OBQ11.63) Haringtons' Criteria. Harington's criteria. The most common mechanismthat cuts this ligament isfoot eversion or external rotation force. The patient is interested in pursuing surgical intervention. 4% (73/1698) 3. occlusion of a coronary artery disrupts the blood supply to a region in the myocardium. Sling immobilization as opposed to figure-of-eight brace. Copyright 2022 Lineage Medical, Inc. All rights reserved. At the outset, treatment will involve a . 1% (19/1698) 2 >2mm shortening . Isolated anterior or posterior arch fracture. Which of the following factors is associated with the highest rate of nonunion of a midshaft clavicle fracture? Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. Degloving injury orthobullets The Morel-Lavallee lesion (MLL) was initially described by a French surgeon named Maurice Morel-Lavallee in 1853, as a closed degloving injury where the skin and superficial fascia are traumatically separated, creating a dead space. timing of flap coverage for open tibial fractures remains controversial, increased risk of infection beyond 7 days, increase by 16% for each day beyond day 7, early studies demonstrated increased infection with delay beyond 72 hours, however recent studies do not support this finding (LEAP study), can proceed with bone grafting after wound is clean and closed, negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved (increased risk of infection if open >7 days), open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology, Masquelet technique ("induced-membrane" technique), 1st stage: I&D, cement spacer and temporizing fixation, 2nd stage: placement of bone graft into "induced membrane" and definitive fixation, Studies show optimal time frame for bone grafting to be, fracture related infection ranges from <1% in grade I open fractures to 30% in grade III fractures. Maisonneuve Fracture Orthobullets - Ankle Fractures Trauma Orthobullets / The maisonneuve fracture is a spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane. After nine months of conservative treatment, he continues to complain of pain. A postoperative radiograph is shown in Figure A. . after 30 minutes of severe ischemia, the damage becomes irreversible. Stable injuries can be treated with immobilization in a cervical collar. Copyright 2022 Lineage Medical, Inc. All rights reserved. A 31-year-old male sustains the injury shown in Figure A. The most common ligament injury or cut is the deltoid ligament (medial ligamentous) during the medial malleolar fracture, causing joint instability. rw Fiction Writing. Immobilization of the distal interphalangeal joint is required for 2 weeks post-operatively, High rates of post-operative infection are common, Open reduction via an approach through the nail bed leads to significant post-operative nail deformity, Range of motion of the DIP joint in the affected finger is usually less than 10 degrees post-operatively, Type in at least one full word to see suggestions list, Management of Proximal Phalanx Fractures & Their Complications, Middle Finger, Proximal Phalangeal Head - Bicondylar Fracture - Fixation, Cleveland Combined Hand Fellowship Lecture Series 2020-2021, PIP Fracture & Dislocation: Case of the Week - Shaan Patel, MD, Ring Finger Proximal Phalanx Fracture in 16M, Fracture of the base of proximal phalanx of 5th finger. Bimalleolar ankle fracture is caused by twistingwith multiple force mechanisms, or supination injury. Displaced avulsions may take longer to heal, but do so with low rate of complications. Decreased personal care and hygiene impairment, No advantage, equivalent result between a simple sling and figure-of-eight brace, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Orthopaedic Summit Evolving Techniques 2020, Midshaft Clavicle Fractures: When To Operate Or Treat Non-op - John D. Adams, MD, Middle Atlantic Shoulder & Elbow Society Annual Meeting 2021, Panel: "There is a fracture, I must fix it" - Clavicle, AC, SC Joint Injuries; Let's Goooo! Open reduction and intramedullary nailing. Atlas Fractures & Transverse Ligament Injuriesare traumatic injuries usually caused by high-energy trauma with axial loading in young patients (Jefferson Fracture) or low-energy falls in elderly. Thank you. clavicle fractures account for 2.6-4% of all adult fractures Demographics often seen in young, active patients most common in males < 30 years old Location 75-80% of all clavicle fractures will occur in the middle third segment Etiology Pathophysiology mechanism of injury fall onto lateral aspect of shoulder (85%) direct impact to clavicle Intra-articular Tubercle fracture that extends to intra-articular area May extend to metatarsal-cuboid joint or to the joint with 4th metatarsal. Medium-velocity: Between 1,200 ft/s (340 m/s) and 2,000 ft/s (610 m/s) These are more typical of shotgun blasts or higher caliber handguns like magnums. (OBQ04.176) (SBQ12TR.3) What is the most appropriate initial management of the patient's injuries in . fall from height or road traffic collision. Diagnosis is made clinically by assessing the size and nature of the external wound as well as obtaining radiographs of the bone at the location of the soft tissue injury. 2009; 67:746-751. An isolated orthopaedic injury is sustained to the upper extremity with no compromise of skin integrity or neurovascular function. This fracture can lead to disabling long term sequelae following treatment, makingthis type of fracturehave a poor prognosis.[1][2][3][4][5][6][7][8][9]. Her clinical exam does not reveal skin tenting or neurovascular injury, but shortening is measured at 2.6 cm. After a long discussion of the risks and benefits the patient elects to undergo nonoperative management. Decreased shoulder strength and endurance. (OBQ10.101) (SBQ12TR.3.1) - Moderated by Brad Parsons, MD, Displaced midshaft clavicle fracture - ORIF vs nonop - Debate, Question SessionClavicle Shaft Fractures, Peroneal Tendon Subluxation & Dislocation, Beaumont Royal Oak & Taylor Orthopaedic Residency. Stability determined by the integrity of transverse ligament. the tibia is the most common site of post-surgical osteomyelitis following surgical treatment of open fractures, delay in defintive soft tissue coverage greater than 7 days. [PubMed: 19820581] 12. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Which of the following treatment options is most appropriate? Which of the following radiographic parameters measurements suggests transverse ligament rupture? It is supported by ligaments to stabilize the talus under the tibia and the tibia with the fibula. infarction patterns 164 plays . History and etymology most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). Treatment is based on which metacarpal is involved, location of the fracture, and the rotation/angulation of the injury. clavicle fractures account for 2.6-4% of all adult fractures, 75-80% of all clavicle fractures will occur in the, fall onto lateral aspect of shoulder (85%), junction of the outer and middle third is the thinnest part of the bone, posterosuperiorly by sternocleidomastoid muscle, inferomedially by pectoralis major and and weight of arm, open fractures usually result from medial fragment "buttonholing" through platysma, ipsilateral scapular fracture (floating shoulder), significantly distracted/widened fracture fragments, widened interval between scapula and spine, flat laterally, tubular centrally, and prismatic medially, provide superior/inferior stability to AC joint, clavicular head originates superiorly on medial third, stabilizes distal clavicle and assists with shoulder abduction, shortening of clavicle decreases lever arm of deltoid, originates from anterior lateral third clavicle, acromion, and scapular spine, originates from occiput and C-T spine spinous process, inserts on lateral posterosuperior third of clavicle, acromion, and scapular spine, clavicular head originates from anteroinferior surface of medial half of clavicle, inserts on crest of greater tubercle of humerus, lateral to bicipital groove, protects NV structures which pass deep to muscle and displace clavicle inferiorly, originates from 1st rib and costal cartilage, cutaneous nerves that run vertically over clavicle and supply superior chest wall, passes posterior and underneath clavicle near junction of medial and middle third, subclavian vein closest to clavicle and anterior to artery and plexus, middle third is weakest portion of clavicle, transitional of the bone in both curvature and in cross-sectional anatomy, only area not supported by ligamentous or muscular attachments, popping or cracking sound near shoulder after fall, acute onset of anterior shoulder pain or directly over clavicle, tender, swelling, crepitus and deformity over clavicle, assess subclavian vessels and brachial plexus, supine may underappeciate displacement with gravity eliminated, evaluate for other injuries (ie proximal humerus, scapula), compare shortening with contralateral side, inferior displacement of lateral fragment, AP clavicle - distance between the corresponding ends of the medial and lateral fragments, AP chest - direct comparison of length of clavicle to the contralateral side, shortening >2cm associated with decrease shoulder strength and endurance, displacement relative to width of clavicle (percent), >100% displacement is a risk factor for nonunion, assess fracture pattern for preop planning, comminution, shortening, articular extension, nonunion, axial, coronal and 3D reconstruction most useful, with contrast if concern for vascular injury, may present with dysphagia, stridor, asymmetric pulses, paresthesias due to compression of surrounding structures, serendipity view or CT best demonstrate displacement, pain and prominence more lateral over AC joint, zanca or axillary views shows displaced distal clavicle relative to acromion, < 1cm displacement of the superior shoulder suspensory complex, elevate and extend shoulder to bring distal fragment to the proximal fragment, figure-of-8 associated with more pain, shortening, and lower compliance than sling, no difference in functional or cosmetic outcomes between sling and figure-of-eight braces, floating shoulder (clavicle and scapular neck fracture), brachial plexus injury (questionable because 66% have spontaneous return), open reduction internal fixation with plate and screws, operative fixation has higher union rate (>94%), similar or better functional outcomes than nonoperative, immobilize using sling or figure-of-eight brace, higher nonunion rate compared to operative management, decreased shoulder strength and endurance, displaced midshaft clavicle fractures healed with > 2cm of shortening, increased plate strength with inferior bone comminution, low rate of symptomatic hardware removal (0-3.7%), biomechanically equivalent or superior to single 3.5mm plate, limited contact, pre-controured, 3.5mm dynamic compression plate, 2.0mm, 2.4mm and 2.7mm plates can be used and combined for dual plating, improved results with ORIF for clavicle fractures with > 2cm shortening and > 100% displacement, improved functional outcomes/less pain with overhead activity, decreased symptomatic nonunion and malunion rate, increased shoulder strength and endurance, increased risk of need for future procedures, sling for 7-10 days followed by active motion, strengthening at ~6 weeks when pain-free motion and radiographic evidence of union, full activity including sports at ~3 months, goal size of intramedullary nail is 30-40% of midshaft diameter, avoids supraclavicular nerves that are commonly injured with plating, hardware migration, implant irritation, secondary procedures, typically requires hardware removal at 6 months, motion at fracture site, no callus on x-ray, DASH <40, pain and increased fatigue with overhead activities, difficulty with shoulder straps and backpacks, clavicle osteotomy with bone grafting, if symptomatic, superior plates associated with increased irritation, superior plates associated with increased risk of subclavian artery or vein penetration, 83% incidence of numbness noted at 2 weeks postop, can improve over time with ~50% having persistent numbness at 1 year, 4% in surgical group develop adhesive capsulitis requiring surgical intervention, Open treatment of clavicular fracture, includes internal fixation, when performed, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. [ Porter, 2018; Evenski, 2009] Fractures through the Distal Third and Waist of the bone are more common than the Proximal third. A 62-year-old woman falls off a bike and sustains the injury shown in Figure A. Orthobullets was founded by Dr. Derek Moore, a practicing orthopedic spine surgeon. Prophylactic fixation is preferred to fixation of actual pathological fracture due to. (OBQ12.89) displacement of femoral neck fracture will disrupt the blood supply and cause an intracapsular hematoma (effect is controversial) Classification Presentation Symptoms impacted and stress fractures slight pain in the groin or pain referred along the medial side of the thigh and knee displaced fractures pain in the entire hip region Physical exam Which of the following statements are true regarding these radiographic findings. when ischemia persists, this can result in myocyte death. March fractures are a subtype of fatigue/ stress fractures. Diagnosis is made by orthogonal radiographs the hand. Due to the capacious nature of the spinal canal at this level these injuries usually present with neck pain without neurological deficits. The risk of infection from these types of wounds can vary depending on the type and pattern of bullets fired as well as the distance from the firearm. decreased morbidity. This type of fracture often affects these ligaments. They occur due to repeated concentrated trauma to a normal bone, classically the 2 nd metatarsal of the foot but can occur in other weight-bearing bones of the lower limb and pelvis. > 50-75% destruction of metaphysis (> 2.5 cm) Permeative destruction of the subtrochanteric femoral region. . ischemia ensues, the myocytes become rapidly dysfunctional. A 22-year-old male sustains a right shoulder injury after being thrown from his motorcycle. (OBQ07.1) Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. 26700 Towne Centre Dr. Ste 110. A 35-year-old patient sustains a bilateral anterior and posterior arch (C1) injury with an intact transverse ligament. > 50% destruction of diaphyseal cortices. Which of the following factors is not a risk factor to the development of this patients diagnosis? You can rate this topic again in 12 months. Higher risk of nonunion with operative management, Higher risk of symptomatic malunion or nonunion with nonoperative management, Earlier return to sport with nonoperative management. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. quicker recovery. 1. Treated with walking cast for 3-6 wks. He presents to the emergency room and radiographs and a CT are performed and shown in Figures A-D. Tibial Plateau Fracture External Fixation . T: 412-692-4600. (OBQ07.25) ranges between 1.8% to 27% depending on the bone involved and grade/fracture type. A 32-year-old female sustains an isolated midshaft clavicle fracture, as shown in Figure A. Team Orthobullets 4 Trauma - Distal Humerus Fractures; Listen Now 19:27 min. What is the most appropriate treatment? Diagnosis is often missed with plain radiographs so a CT scan may be required to make the diagnosis. What is the most likely clinical outcome at one year after injury? Figure A shows the coronal and axial CT images of a 27-year-old male that suffered a fall from a significant height. A competency based surgical skill training & evaluations system that is mobile, user-friendly, and improved technical training. Internal fixation of dorsally displaced fractures of the distal part of the radius. Copyright 2022 Lineage Medical, Inc. All rights reserved. Biomechanical studies have shown that an atlanto-dens interval of >7mm is likely associated with? A 32-year-old female sustained a closed clavicle fracture after a fall as shown in Figures A and B. Metatarsal stress fractures are also called "march fractures" or "marcher's foot." They most commonly occur in the distal second and third metatarsals. The predo When discussing the risks and benefits of operative versus nonoperative treatment for his fracture, which of the following is true? (949) 297-4561. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. March fractures are treated like most types of stress fractures - with simple conservative care techniques. The latest tweets from @orthobullets.Felon finger orthobullets; avengers fanfiction bucky kidnapped; congress park saratoga springs disney; asrock b450 steel legend bios flashback; chester wales; kenmore elite dual fuel range manual; natural body lotion without chemicals; nokia 2 diag port code. Epidemiology Incidence The modes of wear for a total hip arthroplasty : A: Mode 1 or normal wear, B: Mode 2 or subluxation wear, C: Mode 3 or third body abrasive wear, D and E: Mode 4 . A radiograph of the injury is shown in Figure A. Type in at least one full word to see suggestions list. (OBQ05.67) Pathophysiology. (OBQ10.71) Orthobullets. A 34-year-old male sustains the closed finger injury shown in Figure A one week ago. What is the most appropriate management of the clavicular injury? It has a high association with ACL tears and posterolateral corner injuries. an intact transverse ligament, with ruptured alar and apical ligaments, a ruptured transverse ligament, with intact alar and apical ligaments, a ruptured transverse and apical ligament, with an intact alar ligaments, a ruptured transverse and alar ligament, with an intact apical ligaments, a ruptured transverse and alar ligament, and a ruptured tectorial membrane, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course, Type in at least one full word to see suggestions list, Atlas (C1) Fractures & Transverse Ligament Injuries - Review Lecture - Dr. Derek Moore, SpineAtlas Fracture & Transverse Ligament Injuries, Question SessionAtlas Fractures & Transverse Ligament Injuries, Coronoid Fractures & Cardiac Conditions in Sports, Jefferson Fracture Stable, Non-Union Week 12, Orthopaedics Overseas / Health Volunteers Overseas, Atlantoaxial instability from midsubstance transverse ligament tear. Closed reduction and figure of 8 splinting, Sling with abduction pillow to involved side. He elects for nonoperative treatment. Diagnosis is made with plain radiographs of the ankle. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. However, rest alone isn't the only action you'll want to take to help put your march fracture in the past. Fracture at the base of the 5th metatarsal tubercle. (SBQ12TR.23) (SBQ18SP.74) A 28-year-old male sustains the injury seen in Figure A. Due to the capacious nature of the spinal canal at this level these injuries usually present with neck pain without neurological deficits. To minimize risk of infection, debridement recommended to be performed within 24 hours for all type III fractures and within 12 hours for type IIIB open tibia fractures, Contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications, Infection rates higher in open injuries due to blunt trauma compared to penetrating trauma, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. Open reduction and internal fixation with plating, Closed reduction and percutaneous pinning, Nonoperative treatment with a sling and early range of motion. Open fractures are fractures with direct communication to the external environment. 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