Trauma

Classifications

Questions	Answers
1.Describe the Rosenthal Classification?	Zone 1 – Injury to distal phalanx Zone 2 – Distal to nail lunula – treatment is Atasoy flap (plantar V to Y) or Kutler flap (biaxial V to Y) Zone 3 – Distal to DIPJ – treatment generally amputation
2.What is the Jahss classification?	Dislocation of the hallux Type 1 – Dorsal dislocation of proximal phalanx and sesamoids with intact intersesamodial ligamentType 2 – Dorsal dislocation of proximal phalanx and sesamoids A – ruptured intersesamoid ligament B – fracture of sesamoid with ruptured intersesamodial ligament
3.What is the Stewart classification?	Fracture of the base of the 5th metatarsal “EIEIO” Type I: Extra-articular fx at metaphyseal-diaphyseal junction (True Jones Fracture) Type II: Intra-articular avulsion fracture Type III: Extra-articular avulsion fracture Type IV: Intra-articular, Comminuted Type V: Extra-articular avulsion fractures of the epiphysis; only occur in children (Salter-Harris Type I fracture)
4.What is the Torg classification?	Non-union base of the 5th metatarsal Type 1 – Acute injuries Type 2 – Delayed union Type 3 – Non-union
5.Hardcastle classification? Give the Quenu and Kuss description.	Type A: Total incongruity in any plane (QK – Homolateral)Type B: Partial incongruity (QK – Isolateral) B1 – 1st met goes medial B2 – Lesser mets go lateralType C: Divergent (QK – Divergent) C1 – Partial (only 1st and 2nd mets) C2 – Total (all mets involved)
6.Classification system for Navicular trauma?	Watson-Jones Type 1 – Navicular tuberosity Type 2 – Dorsal Lip Avulsion Type 3 – Navicular Body Fractures A: Coronal plane fracture B: Dorso-lateral to plantar-medial fracture C: Comminution Type 4 – Stress Fracture of the Navicular
7.Berndt and Harty classification?	Talar dome fractures Type 1: Chondral Depression. Type 2: Partial OCD fracture Type 3: Nondisplaced complete OCD Type 4: Displaced complete OCD
8.Hawkins classification?	Talar Neck Fractures Type 1 – Non-displaced (13% AVN) Type 2 – Displaced fx with STJ dislocation (AVN 50%) Type 3 – Displaced fx with STJ and ankle dislocation (95% AVN) Type 4 – Displaced STJ, AJ, TNJ dislocation (> 95% AVN)
9.(SAD) Supination Adduction ankle fractures?	Stage 1 – Lateral collateral ligament tear, avulsion fibular fracture (Weber A) Stage 2 – Vertical medial malleolar fracture (Mueller D)
10.(PAB) Pronation Abduction ankle fractures?	Stage 1 – Transverse avulsion fx medial malleolus/ deltoid rupture (Mueller B) Stage 2 – AITFL syndesmotic rupture or avulsion of its insertion Stage 3 – Short, oblique lateral malleolus fracture (Weber B), transverse on lateral radiograph
11.(SER) Supination External Rotation ankle fractures?	Stage 1 – AITFL syndesmotic rupture or avulsion of its insertion Stage 2 – Spiral lateral malleolus fracture (Weber B), long, posterior spike on lateral radiograph Stage 3 – PITFL syndesmotic rupture or avulsion of its insertion Stage 4 – Transverse avulsion fx medial malleolus/ deltoid rupture (Mueller B)
12.(PER) Pronation External Rotation ankle fractures?	Stage 1 – Transverse avulsion fx medial malleolus/ deltoid rupture (Mueller B) Stage 2 – AITFL syndesmotic rupture or avulsion of its insertion Stage 3 – Oblique or spiral fibular fracture suprasyndesmotic (Weber C) Stage 4 – PITFL syndesmotic rupture or avulsion of its insertion
13.Give the stages in Pronation Dorsiflexion ankle fractures.	Stage 1 – Deltoid rupture Stage 2 – Dorsal tibial lip fracture Stage 3 – High fibular fracture Stage 4 – Posterior avulusion/ fracture
14.Sneppen classification?	Talar body fractures Type 1: Osteochondral fracture. Type 2: Sagittal, coronal, transverse body fracture. Type 3: Posterior tubercle fracture. Type 4: Lateral process fracture. Type 5: Crush fracture.
15.Sanders classification system?	Uses widest view of the posterior facet on semicoronal CT cut. Type 1: Non-displaced articular fx. Type 2: Two-part posterior facet fx. Type 3: Three-part posterior facet fx. Type 4: Four-part/comminuted fx. A/B/C division – A is lateral, B central, and C medial to sustentaculum tali
16.Rowe Classification for calcaneal fractures?	Type 1 A – Plantar tuberosity fractures B – Sus tali fracture C – Anterior process fractures Type 2 A – Extra-articular “beak” fracture of the posterior-superior calcaneal body B – Intra-articular “tongue-type” Achilles avulsion fracture Type 3 – Extra-articular calcaneal body fx Type 4 – Intra-articular comminuted fx Type 5 – Intra-articular Joint Depression
17.Essex-Lopresti fracture classification?	Tongue-type and Joint Depression fx
18.What is Hawkins sign and when does it appear?	subchondral radiolucent band that occurs in the talar dome, appears 6-8 weeks
19.Common mechanism of injury for a Lisfranc’s fracture?	Forced dorsiflexion on a plantarflexed foot
20.What does the Lisfranc ligament connect?	base of the second met to the lateral side of the medial cuneiform
21.What are some potential causes of dropfoot?	Trauma to fibula neck (deep peroneal nerve), Guillain-Barre, Charcot-Marie Tooth disease, compartment syndrome
22.What is skin tenting?	when the bone elevates the skin and causes it to lose vascularity
23.What type of anesthesia is most commonly used when you are trying to reduce an ankle fracture?	Hematoma block

24.Where is Tillaux-Chaput fx located?	AITFL avulsion from the anterolateral tibia
25.Where is Wagstaff fx located?	AITFL avulsion from the anteromedial fibula
26.Where is the Volkmann fx located?	PITFL avulsion from the posterior-lateral tibia
27.Where is the Bosworth fx located?	PITFL avulsion from the posterior-medial fibula
28.What is the classification system for acute Achilles Tendon Rupture?	Kuwada Type 1 – Partial tear involving <50% of tendon Type 2 – Complete tear w/ 6cm deficit
29.What is strain?	change in length over original length
30.Time it takes for a stress fracture to appear on x-ray ?	10-21 days because 30-50% of the cortex has been lost
31.Weber and Cech classification for non union fractures?	1) Hypertrophic – elephant foot, horse hoot, oligotorophic 2) Atrophic – torsion wedge, comminuted, defect, atrophic
32.Muller Classification for medial malleolar fracture?	Type A- avulstion fracture Type B- Transverse fractue Type C – oblique fracture Type D- vertical fracture

Open Fractures

Questions
1.What are 5 podiatric surgical emergencies?	1. Infection with emphysema (gas gangrene) 2. Open fracture/dislocation 3. Compartment syndrome 4. Necrotizing Fasciitis 5. Neurovascular compromise
2.Treatment of open fractures?	Incision and Drainage Copious Lavage Eventual reduction and fixation of the fracture
3.What are the 6″P’s” of compartment syndrome?	Pain out of proportion and not controlled by analgesics. Pain with passive dorsiflexion of the toes Paralysis Pulselessness Paresthesia Pressure Pallor
4.How to diagnose compartment syndrome?	Diagnose when pressure reading is above 30-40mmHg
5.What instrument do you use?	wicks catheder
6.Gustilo-Anderson Classification System:	Type 1 – wound <1cm, no extensive soft tissue damage Type 2 – >1cm no extensive soft tissue damage Type 3 – Wound >5cm w/ extensive soft tissue damage A – Adequate soft tissue coverage B – Extensive soft tissue damage with periosteal stripping and massive contamination C – Arterial damage requiring primary repair. High amputation rate!
7. What antibiotics are recommended in the original Gustilo-Anderson article for Class I, II, and III open fractures?	Type I: first generation cephalosporin (Ancef) Type II: first generation cephalosporin (Ancef) and an aminoglycoside (Gentamycin, tobramycin, amicacyn) Type III: first generation cephalosporin (Ancef) and an aminoglycoside

8.Treatment for Gustilo-Anderson Classification of Open Fractures IIIB?	Extensive soft tissue damage with periosteal stripping and massive contamination. Cannot reapproximate soft tissue coverage Abx choice: Ancef (or high dose PCN), Clindamycin and Aminoglycoside
9.Gustilo-Anderson Classification of Open Fractures IIIC	Extensive soft tissue damage with periosteal stripping and massive contamination Cannot reapproximate soft tissue coverage Arterial damage requiring primary repair Abx choice: Ancef (or high dose PCN), Clindamycin and Aminoglycoside
10.What is is a gun shot wound considered in the classification system?	automatically it is Gustilo-Anderson type III (3)

11.What antibiotic do you need in the case of a soil-contaminated wound?	penicillin
Which Abx in open fractures?	Grade 1: 1st gen cephalosporin (Ancef) Grade 2/3: add gentamicin
ABCDE’s of Trauma?	Airway, Breathing, Circulation, Disability, Environment
Why are open fractures considered emergenyc?	bone sensitive to infection, significant forece damages blood vessels
A farm injury is considered what Gustilo classification?	Type 3
MESS classification (1990)	mangled extremity severity score, a score of >7 increases likelihood of amputation
What are the basic principles in open fracture?	Get it clean – Abx, tetanus, irrigate Get it stable – splint in ER, ORIF Do it fast – “golden window”, start abx asap
What if you are allergic to Ancef?	Clindamycin 600mg QID
What if your open wound is exposed to water?	Ciprofloxacin 400-600mg BID

Antibiotic treatment for open fractures?	1st gen cephalosporin: Ancef 1-2 grams q8hrs Aminoglycoside: Gentamycin 80mg q8-12hrs 3rd gen cephalosporin: Rocephin 1-2 grams q24hrs Penicillin (farm exposure) 5 million Units q24hrs Clindamycin (ancef allergy) 600mg q6hrs Ciprofloxacin (water expose) 400mg q12hrs
When do you stop abx?	3 days if no active infection and final closure
Tetanus toxoid protocol?	Tetanus toxoid (0.5mL) 3 injections given as infancy, 1 give 4-7 yo, 1 given 12-15 yo, and booster required every 10 years.

Tetanus Immunoglobulin protocol?	Tetanus immunoglobulin (250 units). If wound clean = none given. Dirty wound = give 250 units IM

How many liters of saline you give per Gustillo Anderson classification to irrigate wound?	type 1 = 3L type 2 = 6L type 3 = 9L
What do you clean wounds with?	Sterile saline (effective), lactated ringer, soap
What do you not want to use to clean wound?	betadine solurion, hydrogen peroxide, chlorohexidine is too caustic and damages soft tissue

External fixation


What are some advantages of Ex-Fix?	-good for closed or limited open surgery -achieves multilevel correction -gradual lengthening -postoperative adjustments -possible early WB -good wound surveilance
What are the disadvantages?	“Cage Rage” Pin-track complication Restricted joint motion bulky heavy, patients don’t like, cage rage lots of follow up to prevent infection takes a long time to heal
What are the materials involved in an Ex-Fix?	Half rings wires wires with olives clamps bolts rods posts washers nuts
What are the types of Ex-Fix?	Unilateral Circular Hybrid
What are Ex-Fix made of?	stainless steel/titanium
Describe a unilateral Ex-Fix?	half pins in a linear placement clamp to a fixator (i.e. mini rail)
When do you use a unilateral Ex-Fix?	lengthening, primary fusion, stability

What is a weakness of using a unilateral Ex-Fix?	No stability in the sagittal plane, so it can still move a lot.
What are the two types of circular Ex-Fix?	Ilizarov & Taylor Spatial Frame
What are the properties of an Ilizarov Ex-Fix?	distraction and compression distracts in 2 planes biplane distraction through monoplane hinges
What is the mechanism of action for an Ilizarov?	It adds stabilization by the use of tension wires and half-pins are screwed to the bone.
What is the difference between Ilizarov and Taylor Spatial Frame?	Taylor Spatial Frame allows triplane reduction. Taylor Spatial Frame you need to reduce the deformity before adding on the ex-fix.
What is the mechanism of a Spatial Frame?	Stability is created using rings and tension wires. When the wires are placed under tension, there is an increase in bone stability.
What is a hybrid frame?	Combines one circular frame and at least one unilateral frame
When would you apply an Ex-Fix in an acute setting?	Limb lengthening Infection present Acute trauma stabilization Arthrodesis Charcot Reconstruction
What are the three segments of concern when applying an Ex-fix?	Neck of fibulae Distal metaphyseal flare Ankle joint line
What are we concerned at the neck of the fibula?	The common peroneal nerve
Where is the K wire inserted at the first segment?	Transfibular wires at this level must be inserted through the head of the fibula and away from the neck.
What are we concerned about at the ankle joint line?	The posterior tibial neurovascular bundle now lies posteromedially between flexor digitorum and flexor hallucis longus. wire may transfix the distal belly of flexor hallucis longus, the great toe should be dorsiflexed
44.What are indications for a pin to bar exfix?	-post trauma stabilization -arthrodesis -intraoperative tool

45.What are 4 main types of EXFIXES?	-pin to bar (delta frame) -circular frame (Static or spatial) -monolateral (minirail) -hybrid (circular + delta)
46.What is another name for the monolateral exfix?	minirail, for callus distrction in brachymeatarsia

Pilon Fractures

1.What does CORA stand for?	Center of Rotation Axis
2.What is the vassal principle?	Fixture/stabilization of the primary dislocation will cause the secondary dislocations to reduce. “Restore the keystone and the rest will follow”

*3.What is ligamento taxis?*	ligaments help reduce secondary dislocations when the primary/keystone dislocation is stabilized and reduced.
4.What are the three steps to closed reduction? Charle’s principles?	-exaggerate deformity -distract -reduce -splint
56.What are the three most popular narcotics used for analgesia during closed reductions?	-fentanyl -dilaudid -morphine
57.What are the 4 most common sedatived used for closed reductions?	-propofol -ketamine -etomidate -midazolam
48.Where are pilon fx?	at distal tibia and its articular surface
49.What are the two main mechanism of action of pilon fx?	-rotational injuries -axial loading injuries
Describe a pilon fx caused by axial loading.	-caused by high energy injury -articular comminution and impaction -metaphyseal comminution -major fragment displacement (widening) -soft tissue insult
What are three types of plates used to fix a tibia?	DCP Recon plate Stacked 1/3 tubular plate
52.What are the stages of treatment for a high energy pilon fx?	1) Exfix for traction and stability 2) CT for preop planning 3) Elevate and wait for swelling to go down 4) Reconstruction