What is the focus of the physical examination?

Concentrate on the bladder, distal limb, neurologic examination, then pelvis

What should you note with abdominal radiographs in regards to a ruptured bladder?

Fluid in the abdomen

Distinct bladder margins

Sublumbar streaking

What else is involved in the physcial exam of the urinary tract?

Palpation

Serum Creatine and BUN

Abdominocentesis

Cystogram with isotonic IV contrast and CO2

Intravenous pyelogram for ureteral or kidney damage

What is the order of the physical exam for a hit by car?

1) Urinary tract

2) Distal limb

3) Physical examination

4) Pelvis

What neurological components are you testing in the back leg?

Lack of sensation in lateral digit indicates disfunctionality of sciatic nerve and a lesion in vertebral disks L4 and L5 (L6,7,S1,2 segs) or disruption at the acetabulum

Lack of sensation in the medial digit indicates disfunctionality of femoral nerve and a lesion in vertebral disks L3 - L4 (L4,5 segs) or disruption cranial to pelvis

How should the pelvis be examined for trauma?

Symmetry

Ability to stand

Pain on palpation of hip

Instability of sacroiliac joint

Rectal examination

What radiographic views should be taken?

Lateral and Ventral dorsal views

When should a pelvic fracture be treated conservatively?

1) Fracture is not greatly displaced

2) Dose not involve acetabulum

3) Pelvic canal is maintained

4) Acetabulum covers femoral head

5) Sacroiliac joint displaced less than 50% and is stable

What are the surgical treatments for acetabular fractures?

Open reduction internal fixation - DCP

Reconstruction

Acetabular plates

Screws, pins wires, methylmethacrylate

Femoral head and neck excision

Trochanteric osteotomy

How is a trochonteric osteotomy performed

The acetabulum is exposed, allowing retraction of middle and deep gluteal muscles.

Tension band repairs the issue by converting tensile forces of gluteal mm into compressive forces

What are common mistakes made in a trochanteric osteotomy tension band repair?

1) Too small an epiphysis

2) Only one K-wire used

3) Too small of a wire gauge

4) Its not done in a figure 8

5) The distal hole is insufficient

6) K-wires are not seated

What are the surgical treatments for an iliace shaft fracture?

ORIF plate fixation with at least 4, if not 6 cortexes and use of ventral lag screws

What's the surgical treatment for a sacroiliac luxation?

Reduction and use of lag screw fixation. Screw's must engage 60% of the sacrum

What are the components of an external skeletal fixation device?

Fixation pins

Pin-gripping clamps

Connecting rods

Fixation frame

+/- IM pin

Prefered devices:

K-E splint

IMEX-SK

Securos

APEF (acrylic frame)

What supplements are used for the ESF?

Lag screws, cerclage wires, and K-wires

What are the advantages of the ESF system?

1) Minimally invasive application

2) Adjustable - to ensure fracture alignment and fixation rigidity

3) Implants can be removed without general anesthesia and surgery

4) Clamps & rods can be reused (NOT fixation pins)

5) Good for fractures with significant injury to overlying soft tissues

What are disadvantages to the ESF system?

1) Pins penetrate soft tissues - impairing muscles, vessels, and nerves, while potentially seeding bacteria

2) Mechanical disadvantage - due to the greater distance from the bone

3) Greater post-op care necessary

What's the difference between a half and full pin?

A half pin doesn't pass all the way through the limb

What are the types of ESF structures and which bones are they good for?

Type 1-a: unilateral and uniplanar: tibia, radius, femur, and humerus

Type 1-b: unilateral and biplantar: tibia, radius, femur*, humerus* (*modification required)

Type II: bilateral and uniplanar: Tibia, sometimes radius

Type III: bilateral and biplanar: Tibia, sometimes radius

What are the advantages of using a IM tie-in configuration?

Adds strength when fixation frame is a great distance from the bone

Especially on femur and humerus

For antebrachium, radius is fixated and ulna gets IM pin (un-tied)

What are the biomechanics of ESF?

Rod diameter

Construct geometry

Pins/segment

Pin diameter

Pin type

Working length - Frame and pin lengths

What is the proper pin diameter?

Thread diameter should be 25% of the bone diameter

What is the appropriate pin number?

Minimum of 3 pins per segment

How should pins be placed?

In the center of mechanically intact bone with pre-drilling and slow speed power insertion.

How should the ESF be managed?

There should be adequate soft tissue release around all pins.  Proper pin-tract hygiene must be high until granulation tissue develops.  There is typically protective bandaging of the frame

What radiographic projection should pin diameter and target spots be determined?

Lateral

When should the hanging limb technique be used to provide approximate fracture alignment?

Radius and tibia

What should be the drill bit

0.1 mm smaller than the core diameter of the pin

What is the appropriate drill bit diameter?

0.1 mm smaller than the core diameter of the pin

Why is fixation pin centering so important?

Proper centering ensures maximum distance between points of near and far cortical engagement and will increase pin-bone longevity and decrease likelihood of iatrogenic fracture

How much space should there be between clamps and skin surface and how long should release incisions be.

1cm

What's the order of pin placement?

Far, far, near,near, middle, middle

How far from fracture should the near pins be?

about 1 bone diameter

How should the ESF be bandaged?

Pack gauze sponges between fixator and skin and apply a Robbert Jones bandage

After granulation tissue, simplify to a bumper bandage

How far from the fracture should the near positions be?

Should be about 1 bone diameter

When should you cut fixation pins?

After alignment of the fractures in post-op radiographs

How long should you wait before doing a staged disassemly of the frame?

6 weeks post-op