Hemorrhagic shock

• Adult 70 kg male à 5L blood

• Children (2-10 y.o.) 75-80 mL/kg blood
Brachial Plexus Injury
Roots
Pattern Primary Deficiency
Involved
Upper brachial plexus C5 and C6 Shoulder abduction and
(Erb-Duchenne) 15% external rotation
Elbow flexion
Extended upper brachial C5, C6, and C7 Above plus
plexus Elbow and digital
20-35% extension
Lower brachial plus C8 and T1 Hand intrinsic muscles
(Dejerine-Klumpke) 10%
Total brachial plexus lesion C5 – T1 Entire plexus
50-75%
Peripheral brachial plexus Variable
lesion
Brachial Plexus Injury
Pre-ganglionic features Post-ganglionic features:
1. Paralysis of scapular muscle or 1. Tenderness to percussion in
diaphragm supraclavicular / infraclavicular
2. Horner’s Syndrome (ptosis, miosis, region à Tinnel sign
enophthalmus, anhidrosis) 2. Absence of sweating (sympathetic
3. Severe vascular injury interruption)
4. Associated cervical spine fractures 3. Minimal preservation of movement
(partial injury)
5. Spinal cord injury
Neer classification
• Group 1: middle 1/3
• Group 2: distal 1/3
Neer Classification of Lateral third Clavicle
o Type 1: lateral to CC ligaments
o Type 2a: medial to CC ligaments
o Type 2b: between CC ligaments (conoid torn,
trapezoid intact)
o Type 3: fx into ACJ
• Group 3: proximal 1/3
Ideberg (glenoid fx)
• Type I: anterior avulsion fx
• Type Il: transverse/oblique fx through glenoid; exits
inferiorly
• Type Ill: oblique fx through glenoid, exits superiorly
• Type IV: transverse fx exits through the scapula body
• Type V : II + IV

Kuhn Acromial Fracture Classification

Type I : Nondisplaced or minimally displaced
Type Il : Displaced but does not compromise the subacromial
space
Type Ill : Displaced and compromises the subacromial space
Coronoid fracture Regan and Morrey
I: Coronoid process tip fracture
II: Fracture of 50% or less of height
III: Fracture of >50% of height
Olecranon fracture
Mayo classification

Schatzker classsification
Radial Head fracture
Elbow dislocation
• Anatomic description, based on
anatomic location of olecranon
relative to humerus
posterolateral most common
• Posterolateral most common
• Simple vs complex
• Simple
• Complex
• Associated fracture, may be in the
form of terrible triad and harus
posteromedial rotatiory instability
By direction of forearm bones:
• Posterior
• Posterolateral (80%)
• Medial
• Lateral (rare)
• Anterior (rare)
• Divergent (rare)
Monteggia fracture
Sacral fracture

• a
Hx: High-energy trauma, pain, inability to WB

PE: LE (lo ext) may be malrotated.

Inspect skin for Morel-Lavalle lesion.
Neuro exam. (esp Sciatic nerve)

XR: AP pelvis,
(Judet views) are essential.
obturator : anterior column and posterior wall
"spur sign“ = both column fx
iliac : posterior column and anterior wall
Roof arc angle: center of head to fx (45° is WB )

CT: Essential to accurately define fx (size, impaction, articular

involvement, LB ) & do preop planning
Subtrochanteric fracture
Subtrochanteric fracture
Femoral shaft fracture
Femoral shaft fracture
Distal femur fracture
Descriptive
• Supracondylar
• intercondylar

OTA: 33
• A: extraarticular
• B: partial articular
• portion of the articular surface remains in
continuity with shaft
• 33B3 is in the coronal plane (Hoffa fragment)
• C: complete articular
• articular fragment separated from the shaft
Tibial Shaft Fractures
Descriptive:
• 42A : Simple fracture patterns
• 42B : Wedge patterns
• 42C : Complex/comminuted patterns
Tibial Plafond Fractures
Ruedi/Allgower (3 types):
I : Non or minimally displaced
II : Displaced: articular surface incongruous
III: Comminuted articular surface
Ankle Fracture Variants
• Bosworth fracture-dislocation
• hyperplantarflexion injury (6%)
Danis-Weber Anatomic/descriptive
• curbstone fracture
• A - infrasyndesmotic • isolated medial
• avulsion fracture of posterior
(generally not associated malleolar
tibia resulting from tripping
with ankle instability) • isolated lateral
• LeFort–Wagstaffe fracture
• B - transsyndesmotic malleolar
• AITFL avulsion off anterior
• C - suprasyndesmotic • isolated posterior
fibular tubercle usually seen
malleolar
with SER-type fracture
• bimalleolar-
patterns
AO/OTA equivalent
• Tillaux–Chaput fracture
• 44A - infrasyndesmotic • bimalleolar
• AITFL avulsion of anterior
• 44B - transsyndesmotic • trimalleolar
tibial margin (tibial
• 44C - suprasyndesmotic counterpart of LeFort–
Wagstaffe fracture)
 HEMICORD LESION

Spinal • Damage to the lateral corticospinal

tract causes ipsilateral upper

Cord
motor neuron-type weakness.
• Interruption of the posterior
TRANSVERSE CORD LESION columns causes ipsilateral loss of

Injury • All sensory and motor

pathways are either
partially or completely
•
vibration and joint position sense.
Interruption of ALS causes
contralateral loss of pain and
interrupted. There is temperature sensation, often
often a sensory level, slightly below the lesion because
meaning diminished the anterolateral fibers ascend two
sensation in all to three segments as they cross in
dermatomes below the the ventral commissure. There
may also be a strip of one or two
level of the lesion
segments of sensory loss to pain
• Common causes of
and temperature ipsilateral to the
transverse cord lesions
lesion, caused by damage to
include trauma, tumors,
posterior horn cells before their
multiple sclerosis, and axons have crossed over.
transverse myelitis • Common causes of Brown–
Séquard syndrome include
penetrating injuries, multiple
sclerosis, and lateral compression
from tumors.
Spinal
CENTRAL CORD LESION
Small lesions
• Damage to spinothalamic fibers crossing in the ventral

Cord commissure causes bilateral regions of suspended

sensory loss to pain and temperature.

Injury
• Lesions of the cervical cord produce the classic cape
distribution; however, suspended dermatomes of pain
and temperature sensory loss can occur with lesions at
other levels as well.
Larger lesions
• Damaged anterior horn cells causes LMN deficits at
the level of the lesion
• Affected corticospinal tracts causes UMN signs, and
the posterior columns may be involved as well.
• Anterolateral pathways are compressed from their
medial surface by large lesions, there may be near
complete loss of pain and temperature sensation
below the lesion except for in a region of sacral
sparing
• Common causes of central cord syndrome include
spinal cord contusion, nontraumatic or posttraumatic
syringomyelia, and intrinsic spinal cord tumors such as
hemangioblastoma, ependymoma, or astrocytoma
 TRANSVERSE CORD LESION

Spinal • Lesions of the posterior

columns cause loss of
HEMICORD LESION
• Damaged anterolateral

Cord vibration and position

sense below the level of
pathways causes loss of pain
and temperature sensation

Injury
the lesion. below the level of the lesion
• With larger lesions, • Damage to the anterior horn
there may also be cells produces LMN weakness at
encroachment on the the level of the lesion.
lateral corticospinal • With larger lesions, lateral
tracts, causing UMN– corticospinal tracts may also be
type weakness. involved, causing UMN signs.
• Common causes include • Incontinence is common
trauma, extrinsic because the descending
compression from pathways controlling sphincter
posteriorly located function tend to be more
tumors, and multiple ventrally located.
sclerosis. Vitamin B12 • Common causes include trauma,
deficiency and tabes multiple sclerosis, and anterior
dorsalis (tertiary spinal artery infarct
syphilis) also affect the
posterior cord.
Odontoid Fracture
Hangman Fracture
Traumatic spondylolisthesis of Axis

• Mechanism
• Hyperextension à leads to fracture of pars
• Secondary flexion à tears PLL and disc allowing
subluxation
• 30% have concomitant c-spine fx
• XR : flexion and extension radiographs show subluxation
• CT : study of choice to delineate fracture pattern
• MRA : consider if suspicious of a vascular injury to the
vertebral artery
• Treatment :
• Non-operative (rigid cervical collar x 4-6 weeks or
closed reduction followed by halo immobilization for
8-12 weeks)
• Operative (reduction with surgical stabilization),
indication :
• Type II with > 5 mm displacement
• Severe angulation Type III (facet dislocations)
Thoracolumbar Burst Fracture
Adult Spinal Deformity
Scapular Winging

medial scapular winging lateral scapular winging

• Etiology : dysfunction of the serratus • etiology : dysfunction of the trapezius (cranial
anterior (long thoracic nerve) nerve XI - spinal accessory nerve)
• weak protraction of the scapula • weak superior and medializing force on the
• excessive medializing scapular retraction scapula
(rhomboid major and minor) • excessive lateralizing scapular protraction
and elevation(trapezius) (serratus anterior, pectoralis major and
• epidemiology minor)
• young athletic patient • epidemiology
• more common than lateral • usually iatrogenic (history of neck surgery)
Adhesive capsulitis (Frozen Shoulder)