Understanding Trauma Management Principles

Hello, I'm Tom Schaller. We're going to discuss trauma part one, general principles of trauma, pelvic trauma, and upper extremity trauma, with exception to the hand and wrist. Following are my disclosures. We're going to try and organize and review the major topics. We're going to identify consistently tested facts, and my take on the recertification is that oftentimes the questions are focused on Recognition of critically important things which require intervention and avoiding aggressive treatment of benign conditions. ATLS of course is where general trauma all starts and understanding ABC's I think is something we're all comfortable with. The questions that you may be presented with typically focus on maintaining your priorities, making sure that you obtain and maintain an adequate airway in the multiply injured patient for example. may they be combative or obtunded. Furthermore, perhaps identification of a pneumothorax or a hemoneumothorax on x-ray and understanding that you need to intervene before moving on to examination or treatment of the extremities. And then finally, hemorrhage control and shock. Shock plays a very large part of the questions that you may encounter related to general trauma principles. And it starts with understanding that For testing purposes, we all have about five liters of circulating volume. So 10% of that, 500 cc's, is an important thing to remember. And it's 30% or 1500 cc's is what will get you into Class III shock, as you can see here in this chart. I make that designation because if you can understand and memorize the critical aspects of Class III shock, you can typically infer the answers. that may be needed if they're inquiring about the other classes or applying this information to questions related to shock. Once you understand the key factors related to tachycardia, decreased urine output, and then also class 3 typically involves some degree of anxiety or altered mental state where class 4 they're typically becoming obtunded or lethargic. Once Someone is in class three or class four shock, then it becomes critical to understand the resuscitative process and also understand how to measure the adequacy of resuscitation. So the fluid resuscitation is a progression, typically starts with two liters upon hitting the trauma bay. If a question gives you information that reflects a transient response, Immediately consider that patient to be in class 3 or class 4 shock. That's a giveaway. Then you're going to move on to either using O-blood or as you have more time you'll progress towards type specific and then finally crossmatch blood. The massive transfusion protocol has become important and significant in dealing with the polytraumatized patient in class 3 or class 4 shock. And it typically involves a one-to-one ratio of PAC cells, platelets, and FFP. The most common side effect of this massive transfusion protocol is thrombocytopenia, which is a tested fact, as well as being aware that hypocalcemia from the citrate that's in the PAC cells can be an issue. Overall, trauma creates a systemic inflammatory response, and this is characterized by elevated cytokines, complement, and hormones. And if you happen to see IL-6 come up as part of a question or an answer, that's usually a critical thing. The response of this systemic inflammatory situation can be intensified by our actions, our treatment of the patient, our resuscitation of the patient, and maybe most critically, our decision-making as it comes to definitive management of their trauma. So out of these concepts have evolved damage control orthopedics. This is the staging of definitive care to limit cumulative trauma. Trauma is associated with this surge of inflammatory mediators and its peak is usually between day two and day five. It's important to know that there is likely a genetic predisposition to have a hyper inflammatory response and those folks can be extremely labile in that two to five days post trauma. So after this initial inflammatory burst, leukocytes are primed for further inflammatory response. So initially there was a very strong move towards this stage to management in the polytraumatized patient, but our understanding of the pathophysiology of the prime response as well as understanding how to resuscitate and measure resuscitation has allowed us to moderate towards what many are calling early appropriate care. And I would point out that if someone is fully resuscitated or adequately resuscitated as reflected by a normal lactate level, it is safe to proceed with definitive care of their orthopedic injuries. Do not be fooled by false resuscitation markers such as adequate urine output or the return of a normal blood pressure, it's critical to have that lactate level when it comes to the test. Some key time frames that are often asked are related to when to convert the temporized fixation or the staged fixation to definitive internal fixation. So going from an X-fix for an intermedullary nail is typically about a three-week window for the femur. and a shorter window of about seven to ten days for the tibia. You need to give a pin site holiday, exchange to new locations if you're having trouble with pin tract issues or if your window is going to be delayed beyond those time frames. Fat embolism syndrome typically occurs between one and three days following the trauma. It's both a mechanical issue of the embolized fat as well as an inflammatory response. to the free fatty acids and their effect on endothelial cells. I think maybe the most testable information is just understanding the classic triad, which involves hypoxemia, respiratory distress, some aspect of mental status changes, typically confusion, and then a petechial rash. Moving on to the other pulmonary complication to be aware of is acute respiratory distress syndrome. Here you'll notice refractory hypoxemia and diffuse infiltrative changes on the chest x-ray. Typically, it looks like a whiteout. There's decreased compliance, and maybe the testable fact here is that these folks need to be ventilated with positive pressure, and corticosteroids have been shown to not be efficacious or improve outcomes. And now on to some orthopedic-specific issues related to general trauma. Open fractures have a few important issues we need to keep in mind. Timing and selection of antibiotics, of course, is critical. Then moving on to appropriately aggressive debridement with irrigation. And the timing of this is not as critical as once thought. Stabilization of the fracture using modern techniques, as well as stabilizing the surrounding soft tissue envelope, and then getting early soft tissue coverage or closure, typically within a five to seven day window. So the classification we're all familiar with and I think to be specific the things I would point out is to keep in mind that it's not just a measurement of the wound that's important, it's also a definition of wound size combined with the severity of the bone injury and that it's best to reserve the classification for when you're in the operating room and you have a full understanding of the zone of injury. The antibiotics are straightforward, typically a first-generation cephalosporin for all grades, and then adding an aminoglycoside for grades 2 and 3, and then some specific circumstances, such as gross contamination, barnyard-type injury would add Clostridia, and then for either fresh or salt water, you'll need to add a quinolone. A recent study has become, I think, very testable and has a lot of information related to what we do with regards to the irrigation. Saline irrigation is the standard, and previous studies have shown that the addition of antibiotic solution is not efficacious. It's also shown that addition of iodine is essentially cytotoxic. But the flow study conclusions have added that high flow, low pressure saline... via cystotubing or other high flow tubing is equivalent to pulsatile lavage and therefore pulsatile lavage is not necessary. Addition of soap in this study actually increased the re-operation rate. We need to close or cover the zone of injury as soon as possible. As soon as that zone of injury is fully understood and stable. Sometimes that can be done primarily at the time of the original surgery. As long as you have proper debridement, full understanding of the zone of injury, they've been given timely antibiotics, not a delayed presentation, and understand that they cannot have organic or water contamination. It's too risky and they typically are best served with a repeat irrigation-debridement thorough exploration. Negative pressure wound therapy does not extend your time frame for providing adequate coverage or closure and if you do have significant bone loss, a current standard for management, particularly of the metathesis or diaphysis, is to stage bone grafting using a polymethyl methacrylate spacer that's impregnated with antibiotics and then return after four to six weeks using either iliac crest bone graft or reamer irrigator aspirator obtained harvest from one of the long bones. Some tested facts recently about negative pressure wound therapy based on the recent literature. I present here and notice that it can help wounds at risk, it can help split thickness skin grafts incorporate faster. And then for the severely at risk lower extremity open fractures, the LEAP study conclusions are summarized for you here. These are frequently tested. Thromboembolic complications are quite common throughout fracture care, but in particular notice pelvic ring fractures as high as 60%. That's why our treatment modalities focus on early mobilization, the use of mechanical compression devices, as well as multiple pharmacologic options. Vena cava filters have largely fallen out of favor. I've listed for you here the majority of pharmacologic agents we have at our disposal. and a very brief description of their mechanism of action. Compartment syndrome, of course, is a key common tested issue in trauma principles. The five P's are what we're classically taught, but really this is a clinical diagnosis and it focuses primarily on the first two, pain out of proportion to the injury and pain with passive stress, stretch of the muscles of that compartment. If you're running into pallor or pulselessness, you're either very far along in the course of compartment syndrome or more likely dealing with an arterial injury as the primary diagnosis. We often supplement the clinical diagnosis of compartment syndrome using objective means measuring the compartment pressure directly. The magic number of 30 millimeters of mercury is critical because it's used in two ways. First, you can use that to determine if their absolute compartment pressure is above 30. That can be an indication for compartment release. Furthermore, if you look at their diastolic blood pressure and then their compartment pressure and take the difference, we consider this the perfusion pressure. And if that delta P is less than 30, that also implies that that compartment is not getting adequate perfusion and should be released. Finally, in the pregnant patient, there's really two issues that are commonly Brought up on the exam and those are patients who are further along than 20 weeks typically need to be placed in the left lateral decubitus position. This helps alleviate vena cava compression which in turn helps improve cardiac output and then furthermore discussions about the diagnostic radiographic studies and even therapeutic procedures where you need radiographic assistance. I would be cautious about withholding those. Even for patients in the first trimester, it's been shown that you need to pursue the appropriate studies and perform the appropriate therapies and that this poses minimal risk to the fetus. Moving on to pelvic ring injuries. We know that there's basically no inherent bony stability. The bones are held together by multiple complex ligamentous and capsular structures. Anteriorly, we have the pubic symphysis, and posteriorly, we have anterior and posterior SI ligaments, as well as the sacrotuborous and sacrospinous ligament complexes. It's interesting to note the orientation of these ligament complexes. For example, the sacrospinous ligament being oriented more horizontally helps resist external rotation forces, while the sacrotuborous ligament complex being oriented more vertically helps resist vertical displacement. Our radiographic evaluation is based on the AP film. It helps us identify and classify the injuries. It also leads us then to the use of the inlet and outlet views which are cephalad and caudad oblique views to help us further understand the pattern as well as the degree of and direction of displacement. Here's the inlet view. It helps us look at anterior-posterior displacement. And when you look at this view, you'd like to see the body of S1 and the body of S2 overlying each other, almost looking like a bullseye. Looking at the outlet view, this helps with cranial and caudal displacement. It also helps you look at the sacrum and the sacral foramina more specifically. And to assess the quality of an outlet view, it's helpful to see that the pubic symphysis should lie approximately across the body of S2 and that will let you know that you've got the appropriate obliquity on that shot. The use of CAT scan of course is critical in fully understanding pelvic ring injuries. It allows us to better visualize the posterior anatomy. It helps us identify and define sacral dysmorphism. It also helps us assess the retroperitoneal hematoma. The significance of the size of the hematoma is still being looked at or potentially seeing a blush of contrast on the initial CAT scan and whether or not that has significance or some sort of predictive value about whether or not the patient may go on to need angiography if they're hemodynamically unstable. The Young-Burgess classification is most frequently used. It's based upon the direction and amount of force applied to the pelvis. It does help predict injured structures and also some associated injuries. It does guide some decision-making for the definitive repair, but I point out it does not directly predict mortality. The specific Young-Burgess classification of an injury does not by itself predict mortality. It does predict their transfusion requirement, and as a group you can say that the unstable patterns do predict mortality. but in isolation the unstable patterns one from another cannot be differentiated statistically in terms of predicting mortality and that's important it's been tested frequently. What are reliable predictors of mortality is the patient presenting in shock, having an increased ISS, age greater than 60, and then certainly open pelvic ring injuries. involving the true pelvis, not just the iliac wing, but the perineal area, have a significant mortality risk, probably in the neighborhood of about 25%. So we have these distinct mechanisms of injury and each have their own unique anterior ring characteristics that will help you identify them on radiographs or CAT scan. So there's lateral compression, anterior-posterior compression, and vertical shear. As you can see them here, we typically classify them 1, 2, and 3 for lateral compression, anterior, posterior, and then vertical shear simply stands alone. So lateral compression injury is where you have force applied to the side of the pelvis, creating an internal rotation force on the hemipelvis. They will typically have horizontal or oblique fractures of their rami, which is the giveaway to that mechanism. Type 1, you'll typically see a sacrum fracture and it's ipsilateral to the side of the force. Type 2, you'll also see generally ipsilateral injury of the rami as well as the pathognomonic crescent fracture, which I'll show you in a moment. And then Type 3, the windswept pelvis, where you get a rollover type injury, where you have a lateral compression on the first side and an anterior-posterior compression on the second side. So here's a closer look at LC Type 1. This is where you'll often have an impacted zone 1, zone 2 sacral fracture and then a relatively stable situation where they can weight bearers tolerated and they typically have a low risk of hemodynamic instability. A close-up view of the sacrum shows the buckling or the impaction at the sacral foramen. Type 2, here's your classic crescent fracture. The hemodynamic instability potential is moderate and treatment is with open or closed reduction of that with fixation and I've included a few slides at the bottom that shows how that's done with the so-called LC2 screw that's placed down the corridor from the AIIS to the PSIS with radiographic support. Sometimes that's augmented with an iliosacral screw. Type 3, the windswept pelvis, again typically a rollover injury. The potential hemodynamic instability is high and the treatment must include anterior and posterior fixation. Moving on to the APC injuries, now you're going to see some external rotation force applied to the pelvis to some degree and it leads to the various classifications. Type 1, where you'll see minimal displacement, less than 2.5 centimeters of anterior disruption. You've got disruption of the symphysial area, but no disruption to the sacrospinous or sacrotuberous ligaments. Typical treatment is non-operative with weight-bearing as tolerated and frequent follow-up films. Type 2 is where you've hinged open the SI joint. Your sacrotuberous, sacrospinous ligaments are disrupted, your anterior ligaments to the SI joint are disrupted, and you'll have more than two and a half centimeters of opening in the front. The treatment involves reducing the front of the pelvis and applying a multi-hole plate. This, in many centers, is augmented by the addition of a posterior iliosacral screw, which many believe will help protect or augment the stability of the construct, but by definition is not needed for test-taking purposes. Type 3, now you have full disruption of the sacroiliac joint as well as all the pelvic floor ligaments. The hemodynamic instability risk is quite high and again anterior and posterior reduction and fixation is key. Vertical shear, just as it implies, is a shearing injury and radiographically is typically straightforward to identify. A direct blow to the ilium is important even though it's not a true pelvic ring injury. The incidence of intra-abdominal injuries is high. It can also be an open fracture. and so follow your basic open fracture principles. And if the fracture is amenable to fixation, it's not too comminuted, that can be pursued. In some cases, it's best to treat with functional rehab and allow comminuted fracture to heal by secondary intent. So the classically taught associated injuries, which recently are not as strongly supported by the literature, but I believe still testable, hemorrhage and shock, of course, associated with both the APC injuries and vertical shear injuries and then closed head injuries and intra-abdominal injuries particularly with those LC3s. So let's look at the acute and urgent management of pelvic ring injuries. We need to start with understanding hemodynamic instability and how it plays a role with and interplays with mechanical instability. There's basically a few sources of blood loss to consider in this clinical scenario. You've got intra-abdominal and intra-thoracic bleeding that needs to be assessed and or ruled out. And then we've got our pelvic bleeding, which can come from low pressure sources, cancellous bone fracture surfaces, as well as the venous injuries and venous plexus that surround the pelvis, and then the high pressure and much less common arterial injuries. Everyone needs to be familiar with this basic algorithm, which I would summarize for you simply by saying, if you've identified a complex pelvic ring fracture, the first step is application of a non-invasive pelvic stability device, either a commercial binder or wrap them with a sheet. At that point, if they're hemodynamically stable, they can move on to more definitive imaging and then eventually definitive management. But if they're hemodynamically unstable... Application of the binder helps with those low pressure sources of bleeding. Then they need to be assessed for intrathoracic intra-abdominal injury. Depending on whether or not those are positive or negative, you'll follow this algorithm down and eventually get to the point where if they need a laparotomy it's ideal to have an external fixator placed to provide some bony and soft tissue stability for the general surgeons to do their work and potentially either do pelvic packing or If they continue to have hemodynamic instability and you've made it that far down the algorithm, you may consider them part of that 10% that has a high pressure source of bleeding arterial lesion that needs to be dealt with in angiography. This slide further summarizes that concept. You may be presented with a clinical scenario that includes a radiograph where you may need to identify which vessel is bleeding or you may just need to know the frequency of the most common vessels. The superior gluteal artery is the most common overall. The obturator is the most common if they give you a subtype of lateral compression injury. And then the third most common is the internal pudendal. If you notice an x-ray, it's relatively easy to identify which of these three they're getting at. It's unlikely they will test any of the others. Keep in mind that complications rise significantly with non-selective embolization, where you need to be on the lookout for gluteal necrosis. The definitive management of pelvic ring injuries starts with non-operative management of the stable patterns, LC1 and APC1. These stable injuries can be managed bed-to-chair mobilization with follow-up x-rays weekly or every other week for Approximately six weeks weight-bearing is tolerated. But when you need to deal with the mechanically unstable pelvic ring, you've got options anteriorly and posteriorly that we'll quickly review. External fixation, of course, either at the iliac crest or with pins through the anterior inferior iliac spine are both acceptable. And when combined with appropriate posterior fixation, can give you outcomes that are very similar with... Traditional internal fixation of the anterior ring. This particular example is of one of the internal external fixator devices. ORIF is the more traditional approach for a symphysial disruption using a multi-hole plate. Or for rami fractures, you can also use a plate or, as shown here, either anagrade or retrograde medullary ramus screws that are placed percutaneously. Posteriorly, we also have a few options. You've got anterior SI plating. This is done through an approach at the iliac wing going down the iliac fossa. And you'll note the proximity of the L5 nerve root that I've put in yellow. The plate is placed just adjacent to that. And it's important to note that you need two divergent plates in this area so that you can control flexion and rotation at that area. There's posterior tension plating where you pass a plate posterior to the sacrum itself and then it's on the outer table of the iliac wings. This is a somewhat problematic approach because it involves making open exposure through vertical incisions on both sides of the SI joint and can lead to significant wound complications. Idiosacral screws are by far the most common method. They can be used in conjunction with an open reduction or a closed reduction. And they can be tricky and often tested because you really need to have a good understanding of your imaging and how to apply that imaging when faced with normal sacral anatomy and abnormal sacral anatomy. So understanding the inlet and outlet views, keeping the screw contained, avoiding the neural canal or the intra-abdominal area, and then avoiding the path of the L5 and S1 nerve roots. Talk a little bit more about that. In the normal sacral anatomy, there's an iliac cortical density that you'll see on a true lateral of the sacrum, and that's outlined here in red. The L5 nerve root would sit just anterior to that, and so the blue circle represents the safe location for passing a iliosacral screw. If it is behind or caudal to that line, you should be safe to avoid the L5 nerve root. And so here is one sequence that demonstrates the safe passage of an iliosacral screw, and some compare it to passing a screw through an hourglass. You've got a relatively wide area where the screw can start and a relatively wide area where the screw can end, but the neck of that hourglass occurs as you're advancing the pin to the sacral ala and you're approaching where the L5 nerve root and the S1 neural tunnel is. That's when you need to check that lateral view and look for that iliac cortical density and make sure your pin is behind it. Once you're there you can advance past that level and now at this point the screw can certainly end anterior to that line in the S1 body. Or it could continue on and be a through and through screw by staying behind that line the whole way all the way to the opposite sacroiliac joint as you see here. But the dysmorphic sacrum is a topic that is complex, but I think in terms of testable material, it's understanding what it looks like, being able to recognize it on images such as these, and then just understand that it makes the S1 corridor very difficult. It makes it such that you need to utilize the CAT scan, you need to identify where the L5 and S1 nerve positions are and understand that you typically can only get a unilateral, not a through and through screw in this situation. If you need to go all the way across, S2 is usually still available for that option. Specifically talking about the classification of sacral fractures, we have the dentist classification and what comes up in terms of testable material typically relates to methods of fixation and the frequency of neurologic injury. So you see here about a 57% chance with zone 3 is the most common when it comes to this classification scheme. However, keep in mind that transverse fracture patterns can have up to a 90% incidence. Zone 1, typically impacted, they can, weight bearers tolerated. If it's displaced and part of an unstable pattern then you treat it accordingly. Zone 2, transferaminal region, you have limited bone contact because of the foramen, limited friction between the fragments and can be highly unstable. So this particular pattern, you need to be careful about your choices of fixation and maximizing stability. If it's impacted, Certainly you can watch them closely and proceed with non-operative management, but if it's displaced it is very unstable potentially and you need to be aware of late displacement or over compression. And so this specific configuration of fixation has been biomechanically superior to SI screws alone. Triangular osteosynthesis which involves placement of a pedicle screw in in the ipsilateral L5. as well as an iliac wing bolt in conjunction with the iliosacral screw to help prevent and buttress against that late displacement. Zone 3 involves a spinal canal. They can present with symptoms of cauda equina syndrome, and unilateral may have some preservation of bladder function, but if they have bilateral, they'll certainly have complete neurogenic bladder. And direct decompression is favored as the appropriate answer on the test. U-shaped or jumper's fractures need lumbopelvic fixation. Analyzing the sagittal view of the CAT scan is key where you'll see that kyphotic deformity. And open pelvic ring fractures, as I alluded to earlier, we need to stick to the established orthopedic principles, stabilize the fracture, and they typically need a diverting colostomy to avoid contamination of the region, and it carries about a 25% mortality risk. Internal degloving, or the Morel lesion, is a situation where you can be at high risk for infection, even if it's a closed space injury. They require staged management of the fracture and tissues and you can handle it either way. Either starting with staged management of the tissues, deferring definitive management of the bone injury, or you can definitively manage the bone injury and then gradually stage your wound closure to try and minimize the risk of infection. Negative pressure wound therapy has been very helpful here. The commonly tested complications of pelvic ring trauma are DVT, Urethral stricture in men after urethral disruption is the most common. And then dyspareunia and an increased c-section rate are the most common issues for women. And chronic pain if there's one centimeter or greater of residual posterior displacement. Moving on to upper extremity trauma, starting with the sternoclavicular dislocation. Its diagnosis is typically best defined on the CAT scan where we can see anterior or posterior dislocation. We can see involvement of the mediastinal structures. We can also see if perhaps it's more of a fascial injury as opposed to a true dislocation if the patient is an older adolescent or young adult. But also be aware of the serendipity view, which is a 40-degree cephalic tilt that helps visualize what is typically difficult to see on an AP chest radiograph. By taking that obliquity of 40 degrees, it converts an anterior or posterior displacement into a cephalad or caudad appearance which is more easy to identify. And so we've got our anterior and posterior dislocations. The anterior is the most common. It's also the least dangerous. It can be treated by closed reduction either in the emergency department or the operating room and it tends to be unstable more so than a posterior dislocation. With the posterior dislocation, you need to be aware of the dysphagia or other compressive symptoms. The patient will usually present with their chest and their shoulder drawn forward. They too can have a closed reduction, but it's best done in the operating room, and it should be done with thoracic surgery on standby because of the proximity of the mediastinal structures and their potential for injury. Where I think the test taking issues are most likely is understanding the pseudodislocation or the patient who is in the neighborhood of 20 to 25. This can represent really a medial clavicle-fisial injury and that as long as they are not having symptoms this can be left to remodel even if it reduces and then is unstable, re-displaces, it can be left to remodel. Furthermore, Beware of the delayed presentation if you're presented with a vignette of a patient who presents with a posterior dislocation. Do not do a closed reduction if it's not an acute presentation. The risk of adhesions is too high. Clavicle fracture is certainly the middle third most common and most commonly tested. The majority of these get closed management but the two issues that we Try and avoid with our open management with our intervention is the risk of non-union which is about 15% and you see the risk factors here and then the risk of symptomatic malunion which is about 10% so slightly lower. The goal of the ORIF is to lower these potential complications. Interestingly a recent question revolved around what is the most cost effective method of treatment and that actually actually implied that treatment with non-operative methods initially and then pursuing operative management based upon symptoms was the most cost-effective means of treating a patient. When it comes to the most common complication infraclavicular numbness comes from sacrificing the supraclavicular nerves and then the most common reason for re-operation is hardware prominence. Lateral third fractures are also important and I think they can be a little bit difficult when it comes to the test because we lack a significant level one or level two evidence to guide us. If presented with a question with a young healthy typical adult and you're faced with one of the medial instability type subgroups that you see pointed out here I think the answer is typically best to treat these with internal fixation to avoid the delayed union and nonunion risk. However, a majority of the nonunions are asymptomatic, so if you have a low demand patient, I think the correct answer is likely observation. Have them avoid the risk of surgery and likely go on to an asymptomatic nonunion. We're familiar with the AC joint injuries and how they're classified. Type 1 and type 2 AC injuries are typically treated non-operatively. Type 3 injuries are somewhat controversial. If you're presented with a patient who is a heavy laborer or an elite athlete and potentially their dominant extremity, I would treat them operatively. And then types 4 through 6 with open reduction internal fixation. You have options involving either AC fixation alone coracoclavicular fixation alone or combining the two. Isolated fractures of the scapula, relatively uncommon representing less than 1% of all fractures, but they are important because they're typically associated with high-energy trauma and you need to be aware of and look out for pulmonary injury. The majority of them are non-operative. Treatment of them is generally symptomatic, non-surgical with functional rehabilitation. Maybe short-term immobilization in a sling, but then progressively moving as comfort allows. Union is typically not a problem. But there are surgical indications, and currently they focus upon either significant glenohumeral instability, which can come from a substantial displaced portion of the glenoid, or a large displaced gap or step-off of the glenoid, which can lead to arthrosis. Extra-articular neck fractures that have substantial angulation or medialization can be relative indications for surgery and this is typically done through a modified GIDE approach. You can see the muscle interval between the infraspinatus and teres minor innervated by the suprascapular and axillary nerve and all of this is part of the SSSC or the superior shoulder suspensory complex. This The topic has got a little bit of controversy around it. When it was first described, it was thought that two disruptions of this complex was equivalent to what most were calling a floating shoulder. And therefore, by definition, more than one disruption in this ring mandated surgical intervention. Subsequent studies have shown that obligatory surgery for Dual or even three or four disruptions of the SSSC is not mandatory. Surgical stabilization is indicated when you have specific indications for each individual disruption of the complex. For example, an intra-articular fracture of the glenoid that was substantially displaced should be addressed surgically for those reasons, not just because it's part of a double disruption of the SSSC. Scapulothoracic dissociations, there's relatively benign form where the inferior edge gets trapped between the ribs, but more importantly the lateral displacement where you get a closed traumatic four-quarter amputation essentially. And this is a significantly tested concept sometimes presented with a AP chest x-ray requiring you to make the identification of the scapular body. moved away from the midline. Sometimes you'll see a widely distracted clavicle fracture or EC separation that will tip you off and it's important to remember that the neurologic injury is what determines the long-term outcome. Their vascular injury and the relatively high incidence of that determines the short-term outcome. Shoulder dislocations are the most commonly dislocated joint in the body. Make sure that you have appropriate x-ray examination provided to you on your test question. Otherwise, that may be the answer to the question is just ensuring you have adequate x-rays. There's anterior dislocations for young folks. The recurrence rate is high for folks older than age 50. Beware of the incidence of cuff rupture and then the inferior dislocation has a greater incidence of neurovascular injury. The posterior dislocation is relatively rare. It's associated with seizures and shocks, and it must be ruled out by having that complete radiographic series, but sometimes they'll present just one film with that classic light bulb sign, and that can tip you off to the diagnosis. The impaction fracture, or the reverse Hill-Sachs lesion, is a common topic, and understanding the progression of treatment for that, if it's relatively small, it can be left alone. If it's medium-sized, transposing the lesser tuberosity with the subscap into that defect is the treatment, or if it's large or chronic, then some form of arthroplasty is typically pursued. Fractures of the proximal humerus are most often treated closed, but about 15-20% benefit from surgical management, but it's difficult because there's no clear standard of care. A recent... A randomized prospective trial has tried to help clear that up, and we'll cover that in a second. The classification system, we all know, based upon these four anatomic structures and whether or not they are displaced greater than a centimeter or angled greater than 45 degrees, then we consider them significant. So here's the two simple ones, a two-part greater tuberosity. If that greater tuberosity is displaced greater than 5 or certainly 10 millimeters, then... it is optimally treated surgically to avoid weakness and impingement. A rare injury is the two-part lesser tuberosity fracture, but it should be typically addressed surgically to avoid weakness of internal rotation or sometimes impingement with internal rotation. What's a little bit hazy or murky is the two-part or even three-part surgical neck fractures. The Proffer trial, which was published recently, describes Looking at two-year follow-up and functional outcome of these patients and found no significant difference whether they are treated operatively or non-operatively. There are some potential problems or some critiques of this study, though, and it's based upon the age of the patient population as well as the potential of a selection bias. So I'm going to present some other indications to help guide the treatment. If it's stable or impacted. I think that these can be treated with early range of motion and follow-up films, functional rehabilitation to ensure no late displacement. However, if it's unstable, distracted, or greater than 50% displaced in a young adult, treat with ORIF, typically with a locked plate and screw construct. The most common complication is intra-articular penetration, either acutely at the time of surgery or delayed with subsidence of the fracture. And then in the older adult, or IF, if they have good bone stock and preserve vascularity to the head, versus acute arthroplasty if they do not. And so we need to talk about how do you assess those factors. Well, this study by hurdles commonly cited and commonly tested, these factors are involving how much bone is still intact at the metaphyseal region. of the articular surface. If there's greater than eight millimeters of bone in that region, that implies intact vascularity to the head. And then furthermore, the medial hinge, whether or not the medial hinge is intact, will help you predict preserved vascularity to the head. So if you have a situation specifically of a four-part valgus impacted, I make this point and show you this example. Regardless of... Patient age and even relative bone stock, this pattern by itself does very well with RIF, typically with locked plate and screw construct. Hemiarthroplasty is best reserved for those with poor bone stock or impaired vascularity and the subtypes or different options when it comes to arthroplasty need to be differentiated. And for a hemiarthroplasty, this is someone with no pre-existing arthrosis and someone who you don't have any evidence to suggest poor rotator cuff function, you would go on to perform a hemiarthroplasty and a key landmark is using the pectoralis major tendon insertion and you know that about five and a half centimeters proximal to that is a very reliable landmark for placement of head height. It can also help you in terms of your retroversion. Outcomes of hemiarthroplasty are really tied specifically to how well the tuberosities do and it makes good sense that if you have a nonunion you'll often see weakness or pseudo paralysis and malunion if you do not properly place the lesser tuberosity you can get limitation of external rotation or if you do not tension the greater tuberosity properly you can have difficulty with overhead motion The questions related to whether or not to use a hemi or a reverse fortunately give you very clear indication of either pre-existing cuff dysfunction or they will somehow imply knowledge that there is a major cuff issue and this is the answer you should choose. Humeral shaft fractures, the majority are amenable to non-operative management with initially a coaptation splint and then transitioning to this functional type brace that allows the patient to begin movement of their arm and you can expect very good results with this in a patient who the cuff fits properly they're compliant with functional rehabilitation they have the ability to perform that rehabilitation you can accept a fair bit of deformity at the humerus and still get a very good cosmetic and functional outcome the problem is identifying these issues that are contraindications for the brace. Either severe soft tissue injury that precludes the use of that circumferential brace, proximal neuromotor dysfunction such as a brachial plexopathy where they would not be able to use the muscles of the arm and create that hydraulic effect that helps align the fracture, or if they have just a general inability to maintain or obtain that reduction with the brace either due to body habitus or fracture pattern. Fracture comminution is definitely not a contraindication to use of the brace. So here's our indications for surgery. Open fracture, vascular injury or floating elbow, where we want to get early motion, that's critical. Relative indications include failure of clothes management, failure of use of the functional brace, polytraumatized patients, the associated proximal neuromotor injury or certain neuromuscular conditions such as Parkinson's, they won't tolerate that functional brace very well. Treatment is typically with a plate and screw construct, a 4.5 millimeter DCP style, and these folks can weight bear with crutches or a walker. There's a trend towards longer plates and lower screw density. Intramedullary nail fixation. in recent studies shows very similar incidents of union and incidents of infection. So it's really dealer's choice in terms of acute management. You do need to be aware of course of the higher incidence of shoulder problems and you can minimize that technically by being cautious about your starting point should be relatively medial through the articular surface, not through the footprint of the insertion of the cuff. You want to split the cuff carefully and do a nice repair, counter sinking the nail deep to the... articular surface. External fixation is reserved typically for stage management of the most severe injuries. Non-union should be treated with compression plating that can be done in isolation if it's a hypertrophic fracture non-union but otherwise add bone graft. For substantial bone loss or refractory non-union vascularized free fibula treatment is appropriate. I would not use an intramedullary nail for treatment of primary or recurrent nonunion. Radial nerve injury is a highly tested topic. It's most common in the middle and then followed by the distal third of the humerus. It's typically a neuropraxic injury with a high incidence of recovery, usually over three months. It's most commonly associated with transverse fractures but we're all Aware of the Holstein-Lewis pattern, that oblique distal third, where we worry not just about a neuropraxic injury, but the potential for laceration or entrapment of the nerve. The clear-cut management is the scenario where you have a closed fracture with complete radial nerve injury on presentation. The initial management there should be observation. Acute exploration is also clear-cut in situations of open fracture or vascular injury where you'll be going in to repair the fracture anyway. What's controversial is where you get a radial nerve palsy after closed reduction or if you're presented with the Holstein-Lewis pattern, and I think in general they stay away from that controversy with questions. Extra-articular fractures moving closer to the elbow, most commonly on the medial side, the indications. for treatment surgically are if they have associated instability of the elbow or ulnar nerve symptoms and then the extra-articular transverse fractures that you'll commonly see in elderly patients. These can often benefit from internal fixation because of the high incidence of non-union. Treat them with dual plating. The partial articular fractures either from the medial or lateral side are important to understand type 1 and type 2 where type 2 is in either case the fracture that crosses the trochlear ridge. And by crossing that ridge, it creates a situation where there can be ulnohumeral instability. So that implies a greater need for internal fixation to avoid either acute or late instability and displacement at the ulnohumeral joint. Capitellum fractures are... Commonly tested by showing you a radiograph to make sure that you can identify the injury and then understanding, furthermore applying that knowledge towards questions that deal with complex instability of the elbow and how to deal with it. CAT scans are often helpful in full understanding of the injury. Distal humerus fractures that are complete articular, often described in a way anatomically such as T-type. high T-type, low T-type, etc. Here is an example of a high T-type with some extraarticular comminution. How we deal with them is based upon their x-ray, their traction views, and in particular CAT scan is helpful for identifying issues in the coronal plane that are difficult to identify on plane radiograph. And you have a couple options surgically in dealing with these when it comes to the approach. There's a triceps or extensor mechanism preserving technique where you work through medial and lateral sides of the triceps. This is important because if you use this technique it allows you to convert to a total elbow. If you move on to do the osteotomy you no longer can fall back on a total elbow as a bailout if you have a very low or very comminuted pattern and you need to preserve that option, avoid the osteotomy. If you go on to do the osteotomy, this is helpful of course because it gives you more exposure of the fracture in the distal humerus itself, but it also has the effect of just eliminating its pressure and its contact against the distal humerus and those fragments so it helps you clamp and manipulate those fragments more easily. So it's helpful in two ways and the proper technique is a chevron based osteotomy pointing distally. Here's an example of the exposure you can get and by flexion of the elbow you can get almost complete view there at the distal articular surface of the trochlea. So here's an example image of the osteotomy being done and its fixation. And you certainly can pre-drill for your fixation so that after you're done with your osteotomy, done with your internal fixation, it's more straightforward. to replace the osteotomy and fix it in a stable fashion with either tension band or a plate. The goal is anatomic reconstruction with compression wherever possible and certainly you want to follow these principles of using dual plate in either parallel or 90-90 configuration. They're clinically equivalent and using long screws that pass through the plates to engage the opposite column is ideal. For very low fractures, very comminuted fractures, and typically on the exams they'll present a very low demand patient or patient with pre-existing inflammatory disease, that should tip you off to the use of total elbow arthroplasty. The midterm complications for this tend to be bushing wear related, a long-term complication, aseptic loosening. Ulnar neuropathy is approximately 10% intraoperative management of the ulnar nerve. Currently, focus is on not routine transposition. You should release or excise the intermuscular septum, fully expose the nerve, transpose it temporarily while you're doing your fixation. You can sacrifice the articular branch if needed, and then replace the nerve to its anatomic location. Electronon fractures can be non-displaced, either comminuted or not. This is relatively rare, but if followed closely, can be treated non-operatively. If they're displaced and transverse, they can be treated with tension band wiring. Be cautious about these bicortical wires. We like to use them because they're less likely to back out, but they can aggravate the AIN or impair radiocapitellar motion. The oblique or comminuted fractures are best treated with a periarticular plate often with locking screw technology. For very comminuted fractures you can excise up to 50% as long as they have no associated instability. An advancement of the triceps and repair close to the articular surface can lead to a very functional result. The coronoid is an extension anteriorly of the proximal ulna. It helps as a restraint against ulnohumeral instability. It's a buttress against posterior subluxation and resists varus instability. Simple radiographic classification here, type 1, 2, and 3, based upon the lateral radiograph is somewhat helpful, but this more anatomic description has become popular, especially as understanding the anteromedial facet and its role in the elbow function has become better understood. The anteromedial facet... helps resist against varus and posteromedial rotation. It's associated with a rupture of the LCL and therefore can lead to a posteromedial rotary instability. They're at risk of early degenerative joint disease just from simple gravity-based eccentric loading of the joint and then they can get medial-based narrowing of the ulnohumeral articulation. So you need to address both the bone and the ligament injury. And really the bottom line when it comes to the coronoid is treat the associated injuries, treat the instability. If it's a small fragment you may treat it with a suture, if it's a large fragment with either a screw or a buttressing plate. Elbow dislocations are common from a fall on the outstretched extremity when the extremity is planted and the upper body rotates internally around the forearm. You'll get this disruption that goes from the L-U-C-L and proceeds in a medial direction towards the MCL. You need to be aware of recurrent instability in these patients, and recurrent instability represents posterolateral rotary instability, and that is insufficiency or incomplete healing of the LUCL. This acts essentially as a sling for the radial head, and if you're faced with posterolateral rotary instability, you'll often get apprehension with this pivot shift exam, which recreates those same forces, or issues such as clunking or apprehension when a patient goes to rise from a chair. Elbow fracture dislocations basically come in three varieties. The terrible triad where you'll get a combination of rotary forces that lead to bone and ligament instability. Transolecranon fracture dislocations which are usually thought of as a bony instability problem only and the annular ligament by definition is intact. And then the type 2 montasia variants that involve proximal ulna fracture. Possible fracture dislocation of the radial head, but then also PRUJ disruption. So the terrible triad sequence of treatment is as follows. The LUCL should be addressed. It almost always comes off of its attachment at the humerus, and it should be repaired to the isometric point. The radial head should be either repaired or replaced, and the coronoid either repair by suture if small, or repair the capsule if small, or if it's large enough, can be treated with. plate and screws. If you have continued instability after that sequence of events, you can either go on to treat an associated MCL injury or place them in a hinged external fixator. The trans-alecranon fracture dislocation stability is typically restored with anatomic restoration of the proximal ulna. And then the montasia variant, you'll typically have the primary source of instability being the involvement of the coronoid proximal ulna and radial head fractures. And stability usually restored by ORIF, but if that does not occur, you may need to repair the annular ligament, or you need to be aware that your ulnar repair may not be anatomic. So the key is early motion and to augment stability. And so here's a good rule of thumb. If you have an intact ligament, you can point the thumb towards the side of that intact ligament, and that will help augment the stability of your repair. Radial head and neck classification is straightforward and as such it's relatively straightforward in terms of decision making in terms of treatment. It's largely based upon the presence or absence of a mechanical block, presence or absence of stability, and wrist pain whether or not they have an associated DRUJ injury. So we start with of plain films and CAT scan to help us diagnose that, but occasionally an MRI is needed to help diagnose interosseous membrane lesion, the so-called Essex-Lepresti lesion, or DRUJ disruption. And since stiffness is the most common complication, our treatment is focused on restoring range of motion. Stable pattern with no block to motion can be treated with functional rehab. A mechanical block or instability you should either repair or replace. Repairing is done in situations of good bone quality with three or less fragments using either anatomic plates or screws alone. If you have more than three fragments or small fragments move on to replace the radial head. It can be done through a Coker or Kaplan interval as you see here. And be aware of the safe zone where, in particular, if you need to place a plate, you can place one that won't interfere with the PRUJ motion. And be sure not to overstuff the radiocapitellar joint, and using the lateral edge of the coronoid facet is a great landmark to help you avoid that. Non-operative treatment for forearm fractures is relatively rare. Here's an example of the isolated ulna where the distal two-thirds with less than 50% displacement is the ideal situation with minimal angulation. You can expect a high union rate, but if it's in the proximal third or more than 50% displaced, the non-union risk is too high. For both bone forearm fractures, certainly avoid a single incision. Use the traditional Henry or Thompson's approaches, and the critical goal is to restore the radial bow. You work between ECU and FCU for the ulna fracture. Typically, you want to use 3.5 millimeter plates of the DCP variety. Forearm fractures, some special subtypes. The montasia fracture, where the proximal ulna is broken and it's associated with radial head dislocation. Be aware of the 20% PIN palsy rate. ORIF of the ulna is the critical step and it needs to be anatomic. The most common reason for recurrent radial head instability is malreduction. The second most common reason is disruption of the annular ligament which could then need repair. The Galeazzi fracture, also known as the fracture of necessity, is where you have a radial shaft fracture, most commonly in the distal third associated with the DRUJ dislocation. The treatment is to perform anatomic reduction of the radius and if there is difficulty with reduction of the DRUJ after anatomic reduction of the radius it's typically due to an interposed ECU tendon. Once you have the DRUJ reduced, if it's stable in its reduced position, they can be treated by supination alone for approximately six weeks in a splint. If they are Reducible but unstable in the supinated position, you should add pins in the neutral position for approximately four to six weeks. Thank you very much for your time and thank you to JBJS and Miller Review Course.

ATLS of course is where general trauma all starts and understanding ABC's I think is something we're all comfortable with. The questions that you may be presented with typically focus on maintaining your priorities, making sure that you obtain and maintain an adequate airway in the multiply injured patient for example. may they be combative or obtunded. Furthermore, perhaps identification of a pneumothorax or a hemoneumothorax on x-ray and understanding that you need to intervene before moving on to examination or treatment of the extremities.

And then finally, hemorrhage control and shock. Shock plays a very large part of the questions that you may encounter related to general trauma principles. And it starts with understanding that For testing purposes, we all have about five liters of circulating volume.

So 10% of that, 500 cc's, is an important thing to remember. And it's 30% or 1500 cc's is what will get you into Class III shock, as you can see here in this chart. I make that designation because if you can understand and memorize the critical aspects of Class III shock, you can typically infer the answers.

that may be needed if they're inquiring about the other classes or applying this information to questions related to shock. Once you understand the key factors related to tachycardia, decreased urine output, and then also class 3 typically involves some degree of anxiety or altered mental state where class 4 they're typically becoming obtunded or lethargic. Once Someone is in class three or class four shock, then it becomes critical to understand the resuscitative process and also understand how to measure the adequacy of resuscitation. So the fluid resuscitation is a progression, typically starts with two liters upon hitting the trauma bay. If a question gives you information that reflects a transient response, Immediately consider that patient to be in class 3 or class 4 shock.

That's a giveaway. Then you're going to move on to either using O-blood or as you have more time you'll progress towards type specific and then finally crossmatch blood. The massive transfusion protocol has become important and significant in dealing with the polytraumatized patient in class 3 or class 4 shock.

And it typically involves a one-to-one ratio of PAC cells, platelets, and FFP. The most common side effect of this massive transfusion protocol is thrombocytopenia, which is a tested fact, as well as being aware that hypocalcemia from the citrate that's in the PAC cells can be an issue. Overall, trauma creates a systemic inflammatory response, and this is characterized by elevated cytokines, complement, and hormones. And if you happen to see IL-6 come up as part of a question or an answer, that's usually a critical thing.

The response of this systemic inflammatory situation can be intensified by our actions, our treatment of the patient, our resuscitation of the patient, and maybe most critically, our decision-making as it comes to definitive management of their trauma. So out of these concepts have evolved damage control orthopedics. This is the staging of definitive care to limit cumulative trauma. Trauma is associated with this surge of inflammatory mediators and its peak is usually between day two and day five.

It's important to know that there is likely a genetic predisposition to have a hyper inflammatory response and those folks can be extremely labile in that two to five days post trauma. So after this initial inflammatory burst, leukocytes are primed for further inflammatory response. So initially there was a very strong move towards this stage to management in the polytraumatized patient, but our understanding of the pathophysiology of the prime response as well as understanding how to resuscitate and measure resuscitation has allowed us to moderate towards what many are calling early appropriate care. And I would point out that if someone is fully resuscitated or adequately resuscitated as reflected by a normal lactate level, it is safe to proceed with definitive care of their orthopedic injuries.

Do not be fooled by false resuscitation markers such as adequate urine output or the return of a normal blood pressure, it's critical to have that lactate level when it comes to the test. Some key time frames that are often asked are related to when to convert the temporized fixation or the staged fixation to definitive internal fixation. So going from an X-fix for an intermedullary nail is typically about a three-week window for the femur.

and a shorter window of about seven to ten days for the tibia. You need to give a pin site holiday, exchange to new locations if you're having trouble with pin tract issues or if your window is going to be delayed beyond those time frames. Fat embolism syndrome typically occurs between one and three days following the trauma. It's both a mechanical issue of the embolized fat as well as an inflammatory response. to the free fatty acids and their effect on endothelial cells.

I think maybe the most testable information is just understanding the classic triad, which involves hypoxemia, respiratory distress, some aspect of mental status changes, typically confusion, and then a petechial rash. Moving on to the other pulmonary complication to be aware of is acute respiratory distress syndrome. Here you'll notice refractory hypoxemia and diffuse infiltrative changes on the chest x-ray.

Typically, it looks like a whiteout. There's decreased compliance, and maybe the testable fact here is that these folks need to be ventilated with positive pressure, and corticosteroids have been shown to not be efficacious or improve outcomes. And now on to some orthopedic-specific issues related to general trauma.

Open fractures have a few important issues we need to keep in mind. Timing and selection of antibiotics, of course, is critical. Then moving on to appropriately aggressive debridement with irrigation. And the timing of this is not as critical as once thought. Stabilization of the fracture using modern techniques, as well as stabilizing the surrounding soft tissue envelope, and then getting early soft tissue coverage or closure, typically within a five to seven day window.

So the classification we're all familiar with and I think to be specific the things I would point out is to keep in mind that it's not just a measurement of the wound that's important, it's also a definition of wound size combined with the severity of the bone injury and that it's best to reserve the classification for when you're in the operating room and you have a full understanding of the zone of injury. The antibiotics are straightforward, typically a first-generation cephalosporin for all grades, and then adding an aminoglycoside for grades 2 and 3, and then some specific circumstances, such as gross contamination, barnyard-type injury would add Clostridia, and then for either fresh or salt water, you'll need to add a quinolone. A recent study has become, I think, very testable and has a lot of information related to what we do with regards to the irrigation. Saline irrigation is the standard, and previous studies have shown that the addition of antibiotic solution is not efficacious.

It's also shown that addition of iodine is essentially cytotoxic. But the flow study conclusions have added that high flow, low pressure saline... via cystotubing or other high flow tubing is equivalent to pulsatile lavage and therefore pulsatile lavage is not necessary.

Addition of soap in this study actually increased the re-operation rate. We need to close or cover the zone of injury as soon as possible. As soon as that zone of injury is fully understood and stable.

Sometimes that can be done primarily at the time of the original surgery. As long as you have proper debridement, full understanding of the zone of injury, they've been given timely antibiotics, not a delayed presentation, and understand that they cannot have organic or water contamination. It's too risky and they typically are best served with a repeat irrigation-debridement thorough exploration. Negative pressure wound therapy does not extend your time frame for providing adequate coverage or closure and if you do have significant bone loss, a current standard for management, particularly of the metathesis or diaphysis, is to stage bone grafting using a polymethyl methacrylate spacer that's impregnated with antibiotics and then return after four to six weeks using either iliac crest bone graft or reamer irrigator aspirator obtained harvest from one of the long bones. Some tested facts recently about negative pressure wound therapy based on the recent literature.

I present here and notice that it can help wounds at risk, it can help split thickness skin grafts incorporate faster. And then for the severely at risk lower extremity open fractures, the LEAP study conclusions are summarized for you here. These are frequently tested.

Thromboembolic complications are quite common throughout fracture care, but in particular notice pelvic ring fractures as high as 60%. That's why our treatment modalities focus on early mobilization, the use of mechanical compression devices, as well as multiple pharmacologic options. Vena cava filters have largely fallen out of favor.

I've listed for you here the majority of pharmacologic agents we have at our disposal. and a very brief description of their mechanism of action. Compartment syndrome, of course, is a key common tested issue in trauma principles. The five P's are what we're classically taught, but really this is a clinical diagnosis and it focuses primarily on the first two, pain out of proportion to the injury and pain with passive stress, stretch of the muscles of that compartment.

If you're running into pallor or pulselessness, you're either very far along in the course of compartment syndrome or more likely dealing with an arterial injury as the primary diagnosis. We often supplement the clinical diagnosis of compartment syndrome using objective means measuring the compartment pressure directly. The magic number of 30 millimeters of mercury is critical because it's used in two ways.

First, you can use that to determine if their absolute compartment pressure is above 30. That can be an indication for compartment release. Furthermore, if you look at their diastolic blood pressure and then their compartment pressure and take the difference, we consider this the perfusion pressure. And if that delta P is less than 30, that also implies that that compartment is not getting adequate perfusion and should be released.

Finally, in the pregnant patient, there's really two issues that are commonly Brought up on the exam and those are patients who are further along than 20 weeks typically need to be placed in the left lateral decubitus position. This helps alleviate vena cava compression which in turn helps improve cardiac output and then furthermore discussions about the diagnostic radiographic studies and even therapeutic procedures where you need radiographic assistance. I would be cautious about withholding those.

Even for patients in the first trimester, it's been shown that you need to pursue the appropriate studies and perform the appropriate therapies and that this poses minimal risk to the fetus. Moving on to pelvic ring injuries. We know that there's basically no inherent bony stability. The bones are held together by multiple complex ligamentous and capsular structures.

Anteriorly, we have the pubic symphysis, and posteriorly, we have anterior and posterior SI ligaments, as well as the sacrotuborous and sacrospinous ligament complexes. It's interesting to note the orientation of these ligament complexes. For example, the sacrospinous ligament being oriented more horizontally helps resist external rotation forces, while the sacrotuborous ligament complex being oriented more vertically helps resist vertical displacement. Our radiographic evaluation is based on the AP film.

It helps us identify and classify the injuries. It also leads us then to the use of the inlet and outlet views which are cephalad and caudad oblique views to help us further understand the pattern as well as the degree of and direction of displacement. Here's the inlet view. It helps us look at anterior-posterior displacement.

And when you look at this view, you'd like to see the body of S1 and the body of S2 overlying each other, almost looking like a bullseye. Looking at the outlet view, this helps with cranial and caudal displacement. It also helps you look at the sacrum and the sacral foramina more specifically.

And to assess the quality of an outlet view, it's helpful to see that the pubic symphysis should lie approximately across the body of S2 and that will let you know that you've got the appropriate obliquity on that shot. The use of CAT scan of course is critical in fully understanding pelvic ring injuries. It allows us to better visualize the posterior anatomy.

It helps us identify and define sacral dysmorphism. It also helps us assess the retroperitoneal hematoma. The significance of the size of the hematoma is still being looked at or potentially seeing a blush of contrast on the initial CAT scan and whether or not that has significance or some sort of predictive value about whether or not the patient may go on to need angiography if they're hemodynamically unstable. The Young-Burgess classification is most frequently used. It's based upon the direction and amount of force applied to the pelvis.

It does help predict injured structures and also some associated injuries. It does guide some decision-making for the definitive repair, but I point out it does not directly predict mortality. The specific Young-Burgess classification of an injury does not by itself predict mortality. It does predict their transfusion requirement, and as a group you can say that the unstable patterns do predict mortality.

but in isolation the unstable patterns one from another cannot be differentiated statistically in terms of predicting mortality and that's important it's been tested frequently. What are reliable predictors of mortality is the patient presenting in shock, having an increased ISS, age greater than 60, and then certainly open pelvic ring injuries. involving the true pelvis, not just the iliac wing, but the perineal area, have a significant mortality risk, probably in the neighborhood of about 25%. So we have these distinct mechanisms of injury and each have their own unique anterior ring characteristics that will help you identify them on radiographs or CAT scan. So there's lateral compression, anterior-posterior compression, and vertical shear.

As you can see them here, we typically classify them 1, 2, and 3 for lateral compression, anterior, posterior, and then vertical shear simply stands alone. So lateral compression injury is where you have force applied to the side of the pelvis, creating an internal rotation force on the hemipelvis. They will typically have horizontal or oblique fractures of their rami, which is the giveaway to that mechanism. Type 1, you'll typically see a sacrum fracture and it's ipsilateral to the side of the force. Type 2, you'll also see generally ipsilateral injury of the rami as well as the pathognomonic crescent fracture, which I'll show you in a moment.

And then Type 3, the windswept pelvis, where you get a rollover type injury, where you have a lateral compression on the first side and an anterior-posterior compression on the second side. So here's a closer look at LC Type 1. This is where you'll often have an impacted zone 1, zone 2 sacral fracture and then a relatively stable situation where they can weight bearers tolerated and they typically have a low risk of hemodynamic instability. A close-up view of the sacrum shows the buckling or the impaction at the sacral foramen. Type 2, here's your classic crescent fracture.

The hemodynamic instability potential is moderate and treatment is with open or closed reduction of that with fixation and I've included a few slides at the bottom that shows how that's done with the so-called LC2 screw that's placed down the corridor from the AIIS to the PSIS with radiographic support. Sometimes that's augmented with an iliosacral screw. Type 3, the windswept pelvis, again typically a rollover injury.

The potential hemodynamic instability is high and the treatment must include anterior and posterior fixation. Moving on to the APC injuries, now you're going to see some external rotation force applied to the pelvis to some degree and it leads to the various classifications. Type 1, where you'll see minimal displacement, less than 2.5 centimeters of anterior disruption. You've got disruption of the symphysial area, but no disruption to the sacrospinous or sacrotuberous ligaments.

Typical treatment is non-operative with weight-bearing as tolerated and frequent follow-up films. Type 2 is where you've hinged open the SI joint. Your sacrotuberous, sacrospinous ligaments are disrupted, your anterior ligaments to the SI joint are disrupted, and you'll have more than two and a half centimeters of opening in the front.

The treatment involves reducing the front of the pelvis and applying a multi-hole plate. This, in many centers, is augmented by the addition of a posterior iliosacral screw, which many believe will help protect or augment the stability of the construct, but by definition is not needed for test-taking purposes. Type 3, now you have full disruption of the sacroiliac joint as well as all the pelvic floor ligaments. The hemodynamic instability risk is quite high and again anterior and posterior reduction and fixation is key.

Vertical shear, just as it implies, is a shearing injury and radiographically is typically straightforward to identify. A direct blow to the ilium is important even though it's not a true pelvic ring injury. The incidence of intra-abdominal injuries is high. It can also be an open fracture. and so follow your basic open fracture principles.

And if the fracture is amenable to fixation, it's not too comminuted, that can be pursued. In some cases, it's best to treat with functional rehab and allow comminuted fracture to heal by secondary intent. So the classically taught associated injuries, which recently are not as strongly supported by the literature, but I believe still testable, hemorrhage and shock, of course, associated with both the APC injuries and vertical shear injuries and then closed head injuries and intra-abdominal injuries particularly with those LC3s.

So let's look at the acute and urgent management of pelvic ring injuries. We need to start with understanding hemodynamic instability and how it plays a role with and interplays with mechanical instability. There's basically a few sources of blood loss to consider in this clinical scenario.

You've got intra-abdominal and intra-thoracic bleeding that needs to be assessed and or ruled out. And then we've got our pelvic bleeding, which can come from low pressure sources, cancellous bone fracture surfaces, as well as the venous injuries and venous plexus that surround the pelvis, and then the high pressure and much less common arterial injuries. Everyone needs to be familiar with this basic algorithm, which I would summarize for you simply by saying, if you've identified a complex pelvic ring fracture, the first step is application of a non-invasive pelvic stability device, either a commercial binder or wrap them with a sheet.

At that point, if they're hemodynamically stable, they can move on to more definitive imaging and then eventually definitive management. But if they're hemodynamically unstable... Application of the binder helps with those low pressure sources of bleeding.

Then they need to be assessed for intrathoracic intra-abdominal injury. Depending on whether or not those are positive or negative, you'll follow this algorithm down and eventually get to the point where if they need a laparotomy it's ideal to have an external fixator placed to provide some bony and soft tissue stability for the general surgeons to do their work and potentially either do pelvic packing or If they continue to have hemodynamic instability and you've made it that far down the algorithm, you may consider them part of that 10% that has a high pressure source of bleeding arterial lesion that needs to be dealt with in angiography. This slide further summarizes that concept. You may be presented with a clinical scenario that includes a radiograph where you may need to identify which vessel is bleeding or you may just need to know the frequency of the most common vessels.

The superior gluteal artery is the most common overall. The obturator is the most common if they give you a subtype of lateral compression injury. And then the third most common is the internal pudendal. If you notice an x-ray, it's relatively easy to identify which of these three they're getting at.

It's unlikely they will test any of the others. Keep in mind that complications rise significantly with non-selective embolization, where you need to be on the lookout for gluteal necrosis. The definitive management of pelvic ring injuries starts with non-operative management of the stable patterns, LC1 and APC1.

These stable injuries can be managed bed-to-chair mobilization with follow-up x-rays weekly or every other week for Approximately six weeks weight-bearing is tolerated. But when you need to deal with the mechanically unstable pelvic ring, you've got options anteriorly and posteriorly that we'll quickly review. External fixation, of course, either at the iliac crest or with pins through the anterior inferior iliac spine are both acceptable. And when combined with appropriate posterior fixation, can give you outcomes that are very similar with...

Traditional internal fixation of the anterior ring. This particular example is of one of the internal external fixator devices. ORIF is the more traditional approach for a symphysial disruption using a multi-hole plate.

Or for rami fractures, you can also use a plate or, as shown here, either anagrade or retrograde medullary ramus screws that are placed percutaneously. Posteriorly, we also have a few options. You've got anterior SI plating. This is done through an approach at the iliac wing going down the iliac fossa.

And you'll note the proximity of the L5 nerve root that I've put in yellow. The plate is placed just adjacent to that. And it's important to note that you need two divergent plates in this area so that you can control flexion and rotation at that area. There's posterior tension plating where you pass a plate posterior to the sacrum itself and then it's on the outer table of the iliac wings. This is a somewhat problematic approach because it involves making open exposure through vertical incisions on both sides of the SI joint and can lead to significant wound complications.

Idiosacral screws are by far the most common method. They can be used in conjunction with an open reduction or a closed reduction. And they can be tricky and often tested because you really need to have a good understanding of your imaging and how to apply that imaging when faced with normal sacral anatomy and abnormal sacral anatomy.

So understanding the inlet and outlet views, keeping the screw contained, avoiding the neural canal or the intra-abdominal area, and then avoiding the path of the L5 and S1 nerve roots. Talk a little bit more about that. In the normal sacral anatomy, there's an iliac cortical density that you'll see on a true lateral of the sacrum, and that's outlined here in red. The L5 nerve root would sit just anterior to that, and so the blue circle represents the safe location for passing a iliosacral screw.

If it is behind or caudal to that line, you should be safe to avoid the L5 nerve root. And so here is one sequence that demonstrates the safe passage of an iliosacral screw, and some compare it to passing a screw through an hourglass. You've got a relatively wide area where the screw can start and a relatively wide area where the screw can end, but the neck of that hourglass occurs as you're advancing the pin to the sacral ala and you're approaching where the L5 nerve root and the S1 neural tunnel is.

That's when you need to check that lateral view and look for that iliac cortical density and make sure your pin is behind it. Once you're there you can advance past that level and now at this point the screw can certainly end anterior to that line in the S1 body. Or it could continue on and be a through and through screw by staying behind that line the whole way all the way to the opposite sacroiliac joint as you see here.

But the dysmorphic sacrum is a topic that is complex, but I think in terms of testable material, it's understanding what it looks like, being able to recognize it on images such as these, and then just understand that it makes the S1 corridor very difficult. It makes it such that you need to utilize the CAT scan, you need to identify where the L5 and S1 nerve positions are and understand that you typically can only get a unilateral, not a through and through screw in this situation. If you need to go all the way across, S2 is usually still available for that option. Specifically talking about the classification of sacral fractures, we have the dentist classification and what comes up in terms of testable material typically relates to methods of fixation and the frequency of neurologic injury. So you see here about a 57% chance with zone 3 is the most common when it comes to this classification scheme.

However, keep in mind that transverse fracture patterns can have up to a 90% incidence. Zone 1, typically impacted, they can, weight bearers tolerated. If it's displaced and part of an unstable pattern then you treat it accordingly.

Zone 2, transferaminal region, you have limited bone contact because of the foramen, limited friction between the fragments and can be highly unstable. So this particular pattern, you need to be careful about your choices of fixation and maximizing stability. If it's impacted, Certainly you can watch them closely and proceed with non-operative management, but if it's displaced it is very unstable potentially and you need to be aware of late displacement or over compression. And so this specific configuration of fixation has been biomechanically superior to SI screws alone.

Triangular osteosynthesis which involves placement of a pedicle screw in in the ipsilateral L5. as well as an iliac wing bolt in conjunction with the iliosacral screw to help prevent and buttress against that late displacement. Zone 3 involves a spinal canal.

They can present with symptoms of cauda equina syndrome, and unilateral may have some preservation of bladder function, but if they have bilateral, they'll certainly have complete neurogenic bladder. And direct decompression is favored as the appropriate answer on the test. U-shaped or jumper's fractures need lumbopelvic fixation. Analyzing the sagittal view of the CAT scan is key where you'll see that kyphotic deformity. And open pelvic ring fractures, as I alluded to earlier, we need to stick to the established orthopedic principles, stabilize the fracture, and they typically need a diverting colostomy to avoid contamination of the region, and it carries about a 25% mortality risk.

Internal degloving, or the Morel lesion, is a situation where you can be at high risk for infection, even if it's a closed space injury. They require staged management of the fracture and tissues and you can handle it either way. Either starting with staged management of the tissues, deferring definitive management of the bone injury, or you can definitively manage the bone injury and then gradually stage your wound closure to try and minimize the risk of infection.

Negative pressure wound therapy has been very helpful here. The commonly tested complications of pelvic ring trauma are DVT, Urethral stricture in men after urethral disruption is the most common. And then dyspareunia and an increased c-section rate are the most common issues for women. And chronic pain if there's one centimeter or greater of residual posterior displacement. Moving on to upper extremity trauma, starting with the sternoclavicular dislocation.

Its diagnosis is typically best defined on the CAT scan where we can see anterior or posterior dislocation. We can see involvement of the mediastinal structures. We can also see if perhaps it's more of a fascial injury as opposed to a true dislocation if the patient is an older adolescent or young adult.

But also be aware of the serendipity view, which is a 40-degree cephalic tilt that helps visualize what is typically difficult to see on an AP chest radiograph. By taking that obliquity of 40 degrees, it converts an anterior or posterior displacement into a cephalad or caudad appearance which is more easy to identify. And so we've got our anterior and posterior dislocations. The anterior is the most common. It's also the least dangerous.

It can be treated by closed reduction either in the emergency department or the operating room and it tends to be unstable more so than a posterior dislocation. With the posterior dislocation, you need to be aware of the dysphagia or other compressive symptoms. The patient will usually present with their chest and their shoulder drawn forward. They too can have a closed reduction, but it's best done in the operating room, and it should be done with thoracic surgery on standby because of the proximity of the mediastinal structures and their potential for injury.

Where I think the test taking issues are most likely is understanding the pseudodislocation or the patient who is in the neighborhood of 20 to 25. This can represent really a medial clavicle-fisial injury and that as long as they are not having symptoms this can be left to remodel even if it reduces and then is unstable, re-displaces, it can be left to remodel. Furthermore, Beware of the delayed presentation if you're presented with a vignette of a patient who presents with a posterior dislocation. Do not do a closed reduction if it's not an acute presentation.

The risk of adhesions is too high. Clavicle fracture is certainly the middle third most common and most commonly tested. The majority of these get closed management but the two issues that we Try and avoid with our open management with our intervention is the risk of non-union which is about 15% and you see the risk factors here and then the risk of symptomatic malunion which is about 10% so slightly lower.

The goal of the ORIF is to lower these potential complications. Interestingly a recent question revolved around what is the most cost effective method of treatment and that actually actually implied that treatment with non-operative methods initially and then pursuing operative management based upon symptoms was the most cost-effective means of treating a patient. When it comes to the most common complication infraclavicular numbness comes from sacrificing the supraclavicular nerves and then the most common reason for re-operation is hardware prominence. Lateral third fractures are also important and I think they can be a little bit difficult when it comes to the test because we lack a significant level one or level two evidence to guide us.

If presented with a question with a young healthy typical adult and you're faced with one of the medial instability type subgroups that you see pointed out here I think the answer is typically best to treat these with internal fixation to avoid the delayed union and nonunion risk. However, a majority of the nonunions are asymptomatic, so if you have a low demand patient, I think the correct answer is likely observation. Have them avoid the risk of surgery and likely go on to an asymptomatic nonunion.

We're familiar with the AC joint injuries and how they're classified. Type 1 and type 2 AC injuries are typically treated non-operatively. Type 3 injuries are somewhat controversial.

If you're presented with a patient who is a heavy laborer or an elite athlete and potentially their dominant extremity, I would treat them operatively. And then types 4 through 6 with open reduction internal fixation. You have options involving either AC fixation alone coracoclavicular fixation alone or combining the two.

Isolated fractures of the scapula, relatively uncommon representing less than 1% of all fractures, but they are important because they're typically associated with high-energy trauma and you need to be aware of and look out for pulmonary injury. The majority of them are non-operative. Treatment of them is generally symptomatic, non-surgical with functional rehabilitation.

Maybe short-term immobilization in a sling, but then progressively moving as comfort allows. Union is typically not a problem. But there are surgical indications, and currently they focus upon either significant glenohumeral instability, which can come from a substantial displaced portion of the glenoid, or a large displaced gap or step-off of the glenoid, which can lead to arthrosis.

Extra-articular neck fractures that have substantial angulation or medialization can be relative indications for surgery and this is typically done through a modified GIDE approach. You can see the muscle interval between the infraspinatus and teres minor innervated by the suprascapular and axillary nerve and all of this is part of the SSSC or the superior shoulder suspensory complex. This The topic has got a little bit of controversy around it. When it was first described, it was thought that two disruptions of this complex was equivalent to what most were calling a floating shoulder.

And therefore, by definition, more than one disruption in this ring mandated surgical intervention. Subsequent studies have shown that obligatory surgery for Dual or even three or four disruptions of the SSSC is not mandatory. Surgical stabilization is indicated when you have specific indications for each individual disruption of the complex.

For example, an intra-articular fracture of the glenoid that was substantially displaced should be addressed surgically for those reasons, not just because it's part of a double disruption of the SSSC. Scapulothoracic dissociations, there's relatively benign form where the inferior edge gets trapped between the ribs, but more importantly the lateral displacement where you get a closed traumatic four-quarter amputation essentially. And this is a significantly tested concept sometimes presented with a AP chest x-ray requiring you to make the identification of the scapular body. moved away from the midline. Sometimes you'll see a widely distracted clavicle fracture or EC separation that will tip you off and it's important to remember that the neurologic injury is what determines the long-term outcome.

Their vascular injury and the relatively high incidence of that determines the short-term outcome. Shoulder dislocations are the most commonly dislocated joint in the body. Make sure that you have appropriate x-ray examination provided to you on your test question. Otherwise, that may be the answer to the question is just ensuring you have adequate x-rays.

There's anterior dislocations for young folks. The recurrence rate is high for folks older than age 50. Beware of the incidence of cuff rupture and then the inferior dislocation has a greater incidence of neurovascular injury. The posterior dislocation is relatively rare.

It's associated with seizures and shocks, and it must be ruled out by having that complete radiographic series, but sometimes they'll present just one film with that classic light bulb sign, and that can tip you off to the diagnosis. The impaction fracture, or the reverse Hill-Sachs lesion, is a common topic, and understanding the progression of treatment for that, if it's relatively small, it can be left alone. If it's medium-sized, transposing the lesser tuberosity with the subscap into that defect is the treatment, or if it's large or chronic, then some form of arthroplasty is typically pursued. Fractures of the proximal humerus are most often treated closed, but about 15-20% benefit from surgical management, but it's difficult because there's no clear standard of care.

A recent... A randomized prospective trial has tried to help clear that up, and we'll cover that in a second. The classification system, we all know, based upon these four anatomic structures and whether or not they are displaced greater than a centimeter or angled greater than 45 degrees, then we consider them significant. So here's the two simple ones, a two-part greater tuberosity. If that greater tuberosity is displaced greater than 5 or certainly 10 millimeters, then...

it is optimally treated surgically to avoid weakness and impingement. A rare injury is the two-part lesser tuberosity fracture, but it should be typically addressed surgically to avoid weakness of internal rotation or sometimes impingement with internal rotation. What's a little bit hazy or murky is the two-part or even three-part surgical neck fractures.

The Proffer trial, which was published recently, describes Looking at two-year follow-up and functional outcome of these patients and found no significant difference whether they are treated operatively or non-operatively. There are some potential problems or some critiques of this study, though, and it's based upon the age of the patient population as well as the potential of a selection bias. So I'm going to present some other indications to help guide the treatment. If it's stable or impacted.

I think that these can be treated with early range of motion and follow-up films, functional rehabilitation to ensure no late displacement. However, if it's unstable, distracted, or greater than 50% displaced in a young adult, treat with ORIF, typically with a locked plate and screw construct. The most common complication is intra-articular penetration, either acutely at the time of surgery or delayed with subsidence of the fracture.

And then in the older adult, or IF, if they have good bone stock and preserve vascularity to the head, versus acute arthroplasty if they do not. And so we need to talk about how do you assess those factors. Well, this study by hurdles commonly cited and commonly tested, these factors are involving how much bone is still intact at the metaphyseal region.

of the articular surface. If there's greater than eight millimeters of bone in that region, that implies intact vascularity to the head. And then furthermore, the medial hinge, whether or not the medial hinge is intact, will help you predict preserved vascularity to the head.

So if you have a situation specifically of a four-part valgus impacted, I make this point and show you this example. Regardless of... Patient age and even relative bone stock, this pattern by itself does very well with RIF, typically with locked plate and screw construct. Hemiarthroplasty is best reserved for those with poor bone stock or impaired vascularity and the subtypes or different options when it comes to arthroplasty need to be differentiated. And for a hemiarthroplasty, this is someone with no pre-existing arthrosis and someone who you don't have any evidence to suggest poor rotator cuff function, you would go on to perform a hemiarthroplasty and a key landmark is using the pectoralis major tendon insertion and you know that about five and a half centimeters proximal to that is a very reliable landmark for placement of head height.

It can also help you in terms of your retroversion. Outcomes of hemiarthroplasty are really tied specifically to how well the tuberosities do and it makes good sense that if you have a nonunion you'll often see weakness or pseudo paralysis and malunion if you do not properly place the lesser tuberosity you can get limitation of external rotation or if you do not tension the greater tuberosity properly you can have difficulty with overhead motion The questions related to whether or not to use a hemi or a reverse fortunately give you very clear indication of either pre-existing cuff dysfunction or they will somehow imply knowledge that there is a major cuff issue and this is the answer you should choose. Humeral shaft fractures, the majority are amenable to non-operative management with initially a coaptation splint and then transitioning to this functional type brace that allows the patient to begin movement of their arm and you can expect very good results with this in a patient who the cuff fits properly they're compliant with functional rehabilitation they have the ability to perform that rehabilitation you can accept a fair bit of deformity at the humerus and still get a very good cosmetic and functional outcome the problem is identifying these issues that are contraindications for the brace.

Either severe soft tissue injury that precludes the use of that circumferential brace, proximal neuromotor dysfunction such as a brachial plexopathy where they would not be able to use the muscles of the arm and create that hydraulic effect that helps align the fracture, or if they have just a general inability to maintain or obtain that reduction with the brace either due to body habitus or fracture pattern. Fracture comminution is definitely not a contraindication to use of the brace. So here's our indications for surgery.

Open fracture, vascular injury or floating elbow, where we want to get early motion, that's critical. Relative indications include failure of clothes management, failure of use of the functional brace, polytraumatized patients, the associated proximal neuromotor injury or certain neuromuscular conditions such as Parkinson's, they won't tolerate that functional brace very well. Treatment is typically with a plate and screw construct, a 4.5 millimeter DCP style, and these folks can weight bear with crutches or a walker.

There's a trend towards longer plates and lower screw density. Intramedullary nail fixation. in recent studies shows very similar incidents of union and incidents of infection. So it's really dealer's choice in terms of acute management.

You do need to be aware of course of the higher incidence of shoulder problems and you can minimize that technically by being cautious about your starting point should be relatively medial through the articular surface, not through the footprint of the insertion of the cuff. You want to split the cuff carefully and do a nice repair, counter sinking the nail deep to the... articular surface. External fixation is reserved typically for stage management of the most severe injuries. Non-union should be treated with compression plating that can be done in isolation if it's a hypertrophic fracture non-union but otherwise add bone graft.

For substantial bone loss or refractory non-union vascularized free fibula treatment is appropriate. I would not use an intramedullary nail for treatment of primary or recurrent nonunion. Radial nerve injury is a highly tested topic.

It's most common in the middle and then followed by the distal third of the humerus. It's typically a neuropraxic injury with a high incidence of recovery, usually over three months. It's most commonly associated with transverse fractures but we're all Aware of the Holstein-Lewis pattern, that oblique distal third, where we worry not just about a neuropraxic injury, but the potential for laceration or entrapment of the nerve.

The clear-cut management is the scenario where you have a closed fracture with complete radial nerve injury on presentation. The initial management there should be observation. Acute exploration is also clear-cut in situations of open fracture or vascular injury where you'll be going in to repair the fracture anyway.

What's controversial is where you get a radial nerve palsy after closed reduction or if you're presented with the Holstein-Lewis pattern, and I think in general they stay away from that controversy with questions. Extra-articular fractures moving closer to the elbow, most commonly on the medial side, the indications. for treatment surgically are if they have associated instability of the elbow or ulnar nerve symptoms and then the extra-articular transverse fractures that you'll commonly see in elderly patients.

These can often benefit from internal fixation because of the high incidence of non-union. Treat them with dual plating. The partial articular fractures either from the medial or lateral side are important to understand type 1 and type 2 where type 2 is in either case the fracture that crosses the trochlear ridge.

And by crossing that ridge, it creates a situation where there can be ulnohumeral instability. So that implies a greater need for internal fixation to avoid either acute or late instability and displacement at the ulnohumeral joint. Capitellum fractures are... Commonly tested by showing you a radiograph to make sure that you can identify the injury and then understanding, furthermore applying that knowledge towards questions that deal with complex instability of the elbow and how to deal with it.

CAT scans are often helpful in full understanding of the injury. Distal humerus fractures that are complete articular, often described in a way anatomically such as T-type. high T-type, low T-type, etc. Here is an example of a high T-type with some extraarticular comminution. How we deal with them is based upon their x-ray, their traction views, and in particular CAT scan is helpful for identifying issues in the coronal plane that are difficult to identify on plane radiograph.

And you have a couple options surgically in dealing with these when it comes to the approach. There's a triceps or extensor mechanism preserving technique where you work through medial and lateral sides of the triceps. This is important because if you use this technique it allows you to convert to a total elbow. If you move on to do the osteotomy you no longer can fall back on a total elbow as a bailout if you have a very low or very comminuted pattern and you need to preserve that option, avoid the osteotomy. If you go on to do the osteotomy, this is helpful of course because it gives you more exposure of the fracture in the distal humerus itself, but it also has the effect of just eliminating its pressure and its contact against the distal humerus and those fragments so it helps you clamp and manipulate those fragments more easily.

So it's helpful in two ways and the proper technique is a chevron based osteotomy pointing distally. Here's an example of the exposure you can get and by flexion of the elbow you can get almost complete view there at the distal articular surface of the trochlea. So here's an example image of the osteotomy being done and its fixation. And you certainly can pre-drill for your fixation so that after you're done with your osteotomy, done with your internal fixation, it's more straightforward.

to replace the osteotomy and fix it in a stable fashion with either tension band or a plate. The goal is anatomic reconstruction with compression wherever possible and certainly you want to follow these principles of using dual plate in either parallel or 90-90 configuration. They're clinically equivalent and using long screws that pass through the plates to engage the opposite column is ideal. For very low fractures, very comminuted fractures, and typically on the exams they'll present a very low demand patient or patient with pre-existing inflammatory disease, that should tip you off to the use of total elbow arthroplasty. The midterm complications for this tend to be bushing wear related, a long-term complication, aseptic loosening.

Ulnar neuropathy is approximately 10% intraoperative management of the ulnar nerve. Currently, focus is on not routine transposition. You should release or excise the intermuscular septum, fully expose the nerve, transpose it temporarily while you're doing your fixation.

You can sacrifice the articular branch if needed, and then replace the nerve to its anatomic location. Electronon fractures can be non-displaced, either comminuted or not. This is relatively rare, but if followed closely, can be treated non-operatively.

If they're displaced and transverse, they can be treated with tension band wiring. Be cautious about these bicortical wires. We like to use them because they're less likely to back out, but they can aggravate the AIN or impair radiocapitellar motion.

The oblique or comminuted fractures are best treated with a periarticular plate often with locking screw technology. For very comminuted fractures you can excise up to 50% as long as they have no associated instability. An advancement of the triceps and repair close to the articular surface can lead to a very functional result.

The coronoid is an extension anteriorly of the proximal ulna. It helps as a restraint against ulnohumeral instability. It's a buttress against posterior subluxation and resists varus instability. Simple radiographic classification here, type 1, 2, and 3, based upon the lateral radiograph is somewhat helpful, but this more anatomic description has become popular, especially as understanding the anteromedial facet and its role in the elbow function has become better understood. The anteromedial facet...

helps resist against varus and posteromedial rotation. It's associated with a rupture of the LCL and therefore can lead to a posteromedial rotary instability. They're at risk of early degenerative joint disease just from simple gravity-based eccentric loading of the joint and then they can get medial-based narrowing of the ulnohumeral articulation. So you need to address both the bone and the ligament injury.

And really the bottom line when it comes to the coronoid is treat the associated injuries, treat the instability. If it's a small fragment you may treat it with a suture, if it's a large fragment with either a screw or a buttressing plate. Elbow dislocations are common from a fall on the outstretched extremity when the extremity is planted and the upper body rotates internally around the forearm. You'll get this disruption that goes from the L-U-C-L and proceeds in a medial direction towards the MCL. You need to be aware of recurrent instability in these patients, and recurrent instability represents posterolateral rotary instability, and that is insufficiency or incomplete healing of the LUCL.

This acts essentially as a sling for the radial head, and if you're faced with posterolateral rotary instability, you'll often get apprehension with this pivot shift exam, which recreates those same forces, or issues such as clunking or apprehension when a patient goes to rise from a chair. Elbow fracture dislocations basically come in three varieties. The terrible triad where you'll get a combination of rotary forces that lead to bone and ligament instability. Transolecranon fracture dislocations which are usually thought of as a bony instability problem only and the annular ligament by definition is intact. And then the type 2 montasia variants that involve proximal ulna fracture.

Possible fracture dislocation of the radial head, but then also PRUJ disruption. So the terrible triad sequence of treatment is as follows. The LUCL should be addressed. It almost always comes off of its attachment at the humerus, and it should be repaired to the isometric point.

The radial head should be either repaired or replaced, and the coronoid either repair by suture if small, or repair the capsule if small, or if it's large enough, can be treated with. plate and screws. If you have continued instability after that sequence of events, you can either go on to treat an associated MCL injury or place them in a hinged external fixator.

The trans-alecranon fracture dislocation stability is typically restored with anatomic restoration of the proximal ulna. And then the montasia variant, you'll typically have the primary source of instability being the involvement of the coronoid proximal ulna and radial head fractures. And stability usually restored by ORIF, but if that does not occur, you may need to repair the annular ligament, or you need to be aware that your ulnar repair may not be anatomic. So the key is early motion and to augment stability. And so here's a good rule of thumb.

If you have an intact ligament, you can point the thumb towards the side of that intact ligament, and that will help augment the stability of your repair. Radial head and neck classification is straightforward and as such it's relatively straightforward in terms of decision making in terms of treatment. It's largely based upon the presence or absence of a mechanical block, presence or absence of stability, and wrist pain whether or not they have an associated DRUJ injury.

So we start with of plain films and CAT scan to help us diagnose that, but occasionally an MRI is needed to help diagnose interosseous membrane lesion, the so-called Essex-Lepresti lesion, or DRUJ disruption. And since stiffness is the most common complication, our treatment is focused on restoring range of motion. Stable pattern with no block to motion can be treated with functional rehab. A mechanical block or instability you should either repair or replace. Repairing is done in situations of good bone quality with three or less fragments using either anatomic plates or screws alone.

If you have more than three fragments or small fragments move on to replace the radial head. It can be done through a Coker or Kaplan interval as you see here. And be aware of the safe zone where, in particular, if you need to place a plate, you can place one that won't interfere with the PRUJ motion. And be sure not to overstuff the radiocapitellar joint, and using the lateral edge of the coronoid facet is a great landmark to help you avoid that. Non-operative treatment for forearm fractures is relatively rare.

Here's an example of the isolated ulna where the distal two-thirds with less than 50% displacement is the ideal situation with minimal angulation. You can expect a high union rate, but if it's in the proximal third or more than 50% displaced, the non-union risk is too high. For both bone forearm fractures, certainly avoid a single incision.

Use the traditional Henry or Thompson's approaches, and the critical goal is to restore the radial bow. You work between ECU and FCU for the ulna fracture. Typically, you want to use 3.5 millimeter plates of the DCP variety. Forearm fractures, some special subtypes. The montasia fracture, where the proximal ulna is broken and it's associated with radial head dislocation.

Be aware of the 20% PIN palsy rate. ORIF of the ulna is the critical step and it needs to be anatomic. The most common reason for recurrent radial head instability is malreduction.

The second most common reason is disruption of the annular ligament which could then need repair. The Galeazzi fracture, also known as the fracture of necessity, is where you have a radial shaft fracture, most commonly in the distal third associated with the DRUJ dislocation. The treatment is to perform anatomic reduction of the radius and if there is difficulty with reduction of the DRUJ after anatomic reduction of the radius it's typically due to an interposed ECU tendon. Once you have the DRUJ reduced, if it's stable in its reduced position, they can be treated by supination alone for approximately six weeks in a splint.

If they are Reducible but unstable in the supinated position, you should add pins in the neutral position for approximately four to six weeks. Thank you very much for your time and thank you to JBJS and Miller Review Course.

Transcript for:Understanding Trauma Management Principles

Transcript for:
Understanding Trauma Management Principles