MCQs – Trauma 2

MCQs-trauma 2
Delayed splenic rupture can occur in 5% of splenic injuries, and begins as a subcapsular hematoma that can irritate the diaphragm and cause left shoulder tip pain.

– after the initial saline resuscitation, start with TYPE SPECIFIC blood (can get it in 10 minutes) – it is ABO compatible and Rh compatible

– the most specific test for fat embolism is a lowered platelet count. “A normal platelet count generally rules out fat embolism syndrome. An early thrombocytopenia of 100,000 RBC/cc or > 500 WBC/cc; >50,000 RBC/cc is indeterminant.

– the usual source of pelvic bleeding is venous – arterial embolization treat the 6-10% with arterial bleeding

– for pelvic trauma, urogenital injury is common. 16% bladder trauma, 7% associated urethral trauma, 6% associated genitourinary trauma with both.

– so for the wide pelvic fracture, the most common is bladder rupture

– male urethra is divided by the urogenital diaphragm into three parts:
1. the prostatic urethra between bladder and superior leaf of the urogenital diaphragm (posterior urethra)
2. the membranous urethra which traverses the urogenital diaphragm
3. the anterior urethra distal to the inferior leaf of the urogenital diaphragm

– most injuries are at the junction of membranous and prostatic urethra – characteristically the prostatic urethra tears just above the superior leaf of the urogenital diaphragm; the detachment of the prostatic urethra from the membranous urethra causes the prostate to be felt to be riding high.

– blunt trauma with a severe perineal blow (handle-bars) may crush the bulbous urethra (the first part of the anterior urethra) just below the urogenital diaphragm and rupture it.

– there may be a correlation between type of pelvic injury and urethral trauma – symphyseal disruption, bilateral pubic rami fractures, or vertical shear.

– the straddle fracture is a four pillar injury to the anterior ring, involving all four pubic rami anteriorly. Technically, it is an isolated anterior injury (Tile A2-3) with no posterior injury. Theoretically, they are caused by a direct blow, but in reality, most are lateral compression injuries and do have a posterior lesion. If you had to chose between a Malgaine type fracture versus a straddle fracture as a cause for bladder trauma, go with Malgaigne.

– bladder injury is a good indicator of overall severity of injury

– the pelvic injury that communicates with rectum needs irrigation, debridement, fixation, and diverting colostomy

– contraindication to ilioinguinal approach is the acetabular fracture with a big posterior wall fragment – you cannot see it from the inside!

– for a large posterior wall fracture with instability, you need lag

ORIF Tibial Plateau And Tibial Shaft

ORIF tibial plateau and tibial shaft

– 52 year old gentleman in skiing accident; lateral split depression fracture of anterior/lateral tibial plateau, and long spiral shaft fracture with anterior butterfly extending very proximally, making the shaft un-nailable.

Surgeon: O’Brien

Positioning: Supine with tourniquet; ski-jump under leg.

Description:

Anterolateral incision at the knee, extended down the tibia just a fingerbreadth lateral to the crest to do an anterior approach to the tibia. Incise through the layers of the knee to reach the synovium, and incise the joint, releasing the hemarthrosis (be ready for the squirt of blood!). Watch out for the meniscus – look for a tear in it and maybe put a stay suture through it. Then extend the
incision distally and subperiosteally strip the lateral aspect of the anterior tibia. Beware exposing the medial side, as you want to leave that as untouched as possible.

This case was interesting because there was a huge long spiral butterfly fragment posteriorly as well, which we could not reduce – exposing it to reduce it would have devascularized it completely. We used unicortical screws through a lateral buttress plate (a DC plate with a buttress for the lateral plateau). He uses 16 mm screws for the unicorticals. We used partially threaded cancellouw screws through the buttress plate under the plateau to secure the plateau fragments.

ORIF Open Pilon Fracture

ORIF open pilon fracture – AO C2; complex metaphyseal

52 year old herion/cocaine addict transferred from UBC, having fallen off a ladder. Open wound laterally, which in fact was from the fibula. Xrays demonstrated a comminuted metaphysis, but the articular surface was not that badly smashed. This looked worse intraoperatively.

Surgeon: O’Brien

Positioning: Fracture table with calcaneal traction pin to get the thing out to length and so that we could both work at the same time – someone exposing the tibia, the other the fibula.

Description:

The exposure to the fibula is the standard thing. The exposure to the tibia is a curved incision, coming along the medial side of the crest, then curving gently over the medial malleolus; This brings you down upon tib ant; and the tibia is exposed by incising down to bone along the medial aspect of tib ant, then lifting the anterior compartment off subperiosteally.

The metaphyseal bone was totally smashed. We started with the metaphysis rather than the articular surface, then built our way down.

PCL Avulsion Of A Large Posteromedial Piece Of The Tibial Plateau

PCL Avulsion of a large posteromedial piece of the tibial plateau

34 year old man with a valgus hyperextension injury to the left knee. Presented to UBC with a painful swollen knee. X-rays showed an avulsion of the posteromedial tibial plateau. We examined the patient under anesthesia to decide how to fix this – his MCL was relatively stable, so we chose a posterior approach. If his MCL was torn completely, we would have used a medial approach to fix the ligament and curl the exposure posteriorly to get at the piece.

Surgeon: O’Brien

Positioning: Prone with tourniquet.

Description:

Posterior approach to the knee. The knee crease is just proximal to the knee joint. The crease is marked, then a curved incision is made starting medially proximally, then beginning the gentle curve just distal to the crease, and extending it distally. The key is to find the short saphenous vein distally, which is a fairly large vein. The medial sural cutaneous nerve usually travels with the vein, so this is how you pick it up. Then follow the nerve up proximally to find the tibial nerve in the popliteal fossa. The artery and vein are below it, with the artery technically lying medial to the vein. (Artery-Vein-Nerve in a medial to lateral direction). Once you get down here you will see the superior geniculates come off the artery.

The neurovascular stuff is retracted laterally; watch for little branches of the vein and artery that may tether the bundle medially – these were cauterized. This brings you down to the capsule. The medial head of gastrocs can be gently stripped off the capsule and mobilized medially using the tenotomies and a key elevator. The capsule is then incised. Be ready for the hemarthrosis. The exposure may get you into the knee a bit more proximally than you might expect – we ended up originally in the top part of the intercondylar notch and had to work to get distal enough. The distal exposure is facilitated by stripping the medial gastrocs off the capsule.

Once the capsule was stripped off, the fragment was visualized and secured with two partially threaded cancellous screws. Great case.

ORIF Of Intercondylar Distal Humerus Fracture

ORIF of Intercondylar Distal Humerus Fracture

27 year old Japanese snow-boarder who landed on her extended arm, dislocating her elbow and fracturing her distal humerus. Her dislocation was partially reduced in Whistler, but her postreduction film showed that her medial column piece was flipped anteriorly and not articulating with the ulna. The lateral column piece was articulating with the radial head.

Surgeon: O’Brien

Positioning: Prone

Description:

Posterior approach to the distal humerus. The patient lays prone with the elbow hanging over a bolster, and the Mayo stand is prepared so that the hand can hang in a sterile pouch. Sterile tourniquet is used to save tourniquet time. The incision is straight over the top – no curving. Sharp dissection down to the fascia, then strip the subcutaneous fat off the fascia both medially and laterally. Then fish out the ulnar nerve, which is best found a bit more proximally coming through the medial intermuscular septum along the medial head of triceps. It inclines posteriorly here to lie in the groove behind the medial epicondyle, then enters the forearm between the humeral and ulnar heads of the flexor carpi ulnaris, which is the first muscle it supplies in the forearm.

The nerve is picked up and dissected out proximally – you need to get enough slack on the nerve so that it can be moved around a bit. Then expose the proximal ulna/olecranon on both the medial and lateral sides – using a 15 blade to strip subperiosteally. You need to get all the way around both sides to be able to see the joint surface. Then prepare for the osteotomy. The 3.2 drill is used to drill through the olecranon – this drill MUST go STRAIGHT DOWN THE PIPE because the partially threaded cancellous screw that you put down to fix the osteotomy is a 6.5 mm screw and IT WILL NOT FIT if you don’t drill straight down the olecranon in both planes. Tap. Then draw out the Chevron on the dorsal cortex and use the micro-sagittal saw to get through the main part of the olecranon. The final part (including articular surface) is done by inserting an osteotome and cracking it off. Peel back triceps with the olecranon.

By peeling back triceps, you should get good exposure of the distal humerus. This was a nice, non-comminuted fracture. The first thing we did was to get the articular surface together. We took the medial column and drilled the 2.5mm drill from the fracture surface, perfectly in the middle of the piece and parallel to the trochlea, back out the medial epicondyle. We did in this “retrograde” kind of way because you can then ensure that the screw will go through the center of the piece. We then reduced the medial to lateral column and held it with reduction clamps. The channel in the medial piece was used as a drill guide to drill across into the lateral column and secured with a single partially threaded screw.

The distal humerus is then reduced back onto the shaft. Technically, you want bi-planar fixation, with the lateral plate lying posterolaterally, and the medial plate lying more along the medial crest. He uses DC plates rather than pelvic recon.

ORIF Humeral Shaft – Anterior Approach

ORIF Humeral Shaft – Anterior Approach

23 year old motorcyclist with totally crushed foot, pelvic injury, pulmonary contusion, head injury, and humeral shaft fracture. Indication to fix humerus – multi-trauma. Fracture was kind of distal, so we could have used the posterior or anterior approach, but with the patient having a bad chest we did it anteriorly. O’Brien calls this the anterolateral approach of Henry, which is in conflict with what Hoppenfeld calls it (the anterior approach). He does make the point that the anterior approach is more difficult for distal humeral shaft fractures because the brachialis is less mobile here, as it is closer to its insertion on the ulna and therefore cannot be lifted off the humerus as readily.

Surgeon: O’Brien.

Positioning: Supine with arm-board.

Description:

The incision lies along the line from the coracoid to the lateral epicondyle. Biceps is encountered and the lateral aspect is located. This fascia is incised and the biceps is lifted off brachialis. The musculocutaneous nerve is found lying on brachialis medially. It is important to be aware that the radial nerve is piercing the area laterally, lying in a furrow between the brachialis muscle medially and the brachioradialis and extensor carpi radialis longus muscles laterally. This is about 5 cm above the lateral epicondyle.

The brachialis is split in line with the fibers, using tenotomy scissors. This tends to make the muscle bleed a fair amount. Be careful when splitting the brachialis that you can stray medially and get into the vessels.

Get down onto bone and expose. Should get 8 cortices above and below the fracture.

ORIF Distal Radius With Carpal Tunnel Release

ORIF Distal Radius with Carpal Tunnel Release

55 year old native woman with displaced volar Barton’s fracture. Ped-struck. Reduced her wrist in emerg. Booked for ORIF; overnight developed worsening symptoms of numbness in her hand globally – we arranged for carpal tunnel release as well.

Surgeon: O’Brien

Positioning: Supine, Boyse table

Description:

Regular prep and drape, with the arm out on the table. The tough part is to ensure that you get enough proximal exposure to put the plate on. Make the incision straight just ulnar to FCR. He does not continue the incision across the transverse crease of the wrist. Cauterize the little veins that come into view in the subcutaneous tissue. Find the tendon sheath of FCR and incise along the radial aspect of it. If you go too radial you’ll incise the radial artery. Mobilize the tendon ulnarly. Incise the undersurface of the tendon sheath. All of the muscles – FPL and FDP are then mobilized ulnarly until you reach pronator quadratus. This is incised along its radial border and peeled subperiosteally ulnarly. This should get you into the fracture hematoma and fracture. Subperiosteal dissection distally gets you into the capsular attachments. Proximal dissection is required to get the plate on.

Bend a bit of spring into the plate, then use it to buttress the distal fragment back on. Secure the shaft, then put a cancellous screw into the distal fragment.

We then made a separate incision for the carpal tunnel. If you carry the regular incision distally you’ll bag the palmer branch of the median nerve. So the options are to make a separate incision, staying ulnar to palmaris longus, or doing the whole procedure through one long incision that is fairly ulnar, and making it longer proximally so as to mobilize everything radially enough to do the ORIF through the tendon sheath of FCR.

ORIF Distal Radius (Volar)

ORIF Distal Radius (Volar)

64 year old woman who fell off horse – completely volarly displaced, intra-articular fracture of the distal radius, with ulnar styloid fracture.

Surgeon: O’Brien

Positioning: Supine, Boyse table

Description:

Regular prep and drape, with the arm out on the table. The tough part is to ensure that you get enough proximal exposure to put the plate on. Make the incision straight just ulnar to FCR. He does not continue the incision across the transverse crease of the wrist. Cauterize the little veins that come into view in the subcutaneous tissue. Find the tendon sheath of FCR and incise along the radial aspect of it. If you go too radial you’ll incise the radial artery. Mobilize the tendon ulnarly. Incise the undersurface of the tendon sheath. All of the muscles – FPL and FDP are then mobilized ulnarly until you reach pronator quadratus. This is incised along its radial border and peeled subperiosteally ulnarly. This should get you into the fracture hematoma and fracture. Subperiosteal dissection distally gets you into the capsular attachments. Proximal dissection is required to get the plate on.

Bend a bit of spring into the plate, then use it to buttress the distal fragment back on. Secure the shaft, then put a cancellous screw into the distal fragment.

Femoral Neck Fracture – Cannulated Screws

Femoral neck fracture; cannulated screws

37 year old poorly coping woman who fell on her left hip, sustaining a valgus impacted fracture that was open along the inferomedial cortex approximately 2 mm, and definitely impacted superiorly.

Surgeon: O’Brien

Positioning: On fracture table, with feet in boots. The right leg was abducted almost to 90 degrees so that the left leg could be adducted – this was a key feature of the reduction.

Description:

The initial reduction didn’t look so good. Traction alone only made the valgus worse. Flexion definitely improved things, and internal rotation brought the inferomedial cortex to within 1 mm. The key was then to adduct the leg to get the cortex lined up.

The cannulated screws were then straightforward. The mistake made was that the first central screw was too low, so that the guide could not be used to put in two inferior screws. As it turns out, the guide is not very good at making the K-wires parallel, and it may be better to simply free hand each one, using the first one (which should be perfect) as the guide.

Distal Humerus – Unicondylar

Humerus – Distal,Unicondylar

-uncommon
-usually intra-articular
-often ass’d with elbow instability
-ORIF recommended