7/4/21 Newsletter: Tibial Plateau Fractures and Vascular Injury

Thanks for reading our newsletter! This document is a collection of the things happening around our community, news in the ortho, business and tech worlds, and other great things we are thinking about and learning! If you have any questions, don’t hesitate to reach out on Twitter or check out our website at orthoconditioning.com.

Recent Posts

Ortho Forge Discussion Highlights

Highlights from the Ortho Forge Community. Here is an adaptation from one of our case discussions.

New topic: 30 year old male in a motor vehicle collision. What’s going on here?

This is a Moore Type 2 tibial plateau fracture (it can extend medially or laterally, as seen in the picture below):

It is similar to Schatzker type 4 tibial plateau (always just the medial plateau):

On exam there is a decreased pulse compared to the contralateral side in the dorsalis pedis and posterior tibial artery, what do you think is going on that caused this?

High energy fractures especially tibial plateau fractures always have compartment syndrome syndrome on the differential, but there is another potential cause for a decreased pulse on your exam other than a late compartment syndrome. (If you have a decreased pulse on compartment syndrome you are really late on diagnosing it).

Both Moore type 2s and Schatzker 4s are fracture dislocations of the knee where the femur follows the medial tibial plateau fragment, dislocating from the intact lateral plateau. This stretches the popliteal artery as it is tethered in the popliteal hiatus causing an intimal tear that can grow/propagate closing off the blood flow to the extremity. This stretching is also prone to happening in knee dislocations. (When the knee dislocates it often causes multiple knee ligament injuries, hence the term “multi-lig” knee injury.)

How do you tell if there has been an injury to the artery?

You check an ankle brachial index (ABI).

How to check an ankle brachial index (ABI)?

Get a manual systolic pressure on an uninjured upper limb with a blood pressure cuff and doppler (so you can hear the pulse). Do the same on the injured lower limb at the level of the ankle (posterior tibial and dorsalis pedis artery). An index <0.9 is concerning for vascular injury assuming pt didn’t already have PAD. Here is a more detailed explanation: (Link)

With considering multi-lig knee injuries as you have to be concerned about vascular injuries with any dislocation (more likely to have numerous ligament injuries in a dislocation event).

This type of artery injury is from stretching and there can be arterial intimal tearing, which is not as clinically obvious as tearing that would cause bleeding into a compartment. There can also be bone fragments that cause arterial injuries in high energy fractures around the knee.

At our institution we do serial ABIs every few hours and repeat exams to see if the measurements/ pulse changes over time. If any ABI measurement is below .9 the plan is to order a CT-angiogram of the extremity, if there is an abnormal result then vascular surgery is consulted.

It is our common practice to get an ABI measurement on all tibial plateau fractures. To recap, it is good to be suspicious of arterial injuries in high energery knee injuries with high energy tibial plateau fractures (Schatzkers 4, 5, 6), knee dislocations, and occult knee dislocations.

Can you have a normal CT-angio and still have an arterial injury?

Yes, an intimal tear may start small and develop over time, that is why serial ABIs are an important tool.

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Ortho News

Ortho Startup Highlight: Plethy

Plethy is a reimaging care and recovery in place company, founded by board certified practicing physicians and tech industry leaders. It is led by their CEO, Rajah Sundaram.

The App used in the virtual care delivery is user friendly – that is easy to follow. Protocols are customizable by providers and patients can now manage their care protocol at home twice a day. In addition, the Clinic team has visibility to the patient’s adherence and recovery progress. Real time telemetry drives personalized care and quicker intervention.

Here are the benefits of having the Plethy Recupe remote monitoring solution.

Tech, Investing, Entrepreneurship

Ethereum: What is Ethereum?

“In essence, ethereum is a public database that keeps a permanent record of digital transactions. Importantly, this database doesn’t require any central authority to maintain and secure it. Instead it operates as a “trustless” transactional system — a framework in which individuals can make peer-to-peer transactions without needing to trust a third party OR one another.”

The main purpose of Ethereum is to enable developers to build and publish smart contracts and distributed applications that can be used without the risks of downtime, fraud, or interference from a third party and provides networking security.

Excerpt from: Burnout is About Your Workplace, Not Your People, Published by the Harvard Business Review (Link)

“According to Christina Maslach, a foremost expert on burnout, social psychologist and professor emerita of psychology at the University of California, Berkeley, we are attacking the problem from the wrong angle.

She is one of three people responsible for the gold standard of measuring burnout — the eponymous Maslach Burnout Inventory (MBI) — and the coauthor of the Areas of Worklife Survey. Maslach worries about the new WHO classification in the IDC11. “Categorizing burnout as a disease was an attempt by the WHO to provide definitions for what is wrong with people, instead of what is wrong with companies,” she explains. “When we just look at the person, what that means is, ‘Hey we’ve got to treat that person.’ ‘You can’t work here because you’re the problem.’ ‘We have to get rid of that person.’ Then, it becomes that person’s problem, not the responsibility of the organization that employs them.”

To Maslach’s point, a survey of 7,500 full-time employees by Gallup found the top five reasons for burnout are:

  1. Unfair treatment at work

  2. Unmanageable workload

  3. Lack of role clarity

  4. Lack of communication and support from their manager

  5. Unreasonable time pressure

“The list above clearly demonstrates that the root causes of burnout do not really lie with the individual and that they can be averted — if only leadership started their prevention strategies much further upstream.

Organizations have a chance, right now, to fix this type of thing. Burnout is preventable. It requires good organizational hygiene, better data, asking more timely and relevant questions, smarter (more micro) budgeting, and ensuring that wellness offerings are included as part of your well-being strategy. Keep the yoga, the resilience training, and the mindfulness classes — they are all terrific tools for optimizing mental health and managing stress. But, when it comes to employee burnout, remember — it’s on you leaders, not them.

List of 24 Investing Podcasts (Link). Here’s the top podcasts that we’ve listened to from the full list:

  1. Acquired – Tells stories of great companies. It started in 2015 as Ben Gilbert and David Rosenthal‘s passion project to explore what made great acquisitions successful. It quickly outgrew its name, expanding beyond corporate transactions to chronicle and analyze the entire journey of enduring institutions.

  1. The Business Brew – This podcast’s mission is to dig deep into the thought patterns and analysis of investors and business people. The podcast stemmed from Bill Brewster’s consistent feeling like he was listening to pre-packaged material while listening to podcasts. Instead, he wanted long form, in depth, discussions about finance, capital allocation, and the psychology of investing/business.

  1. Capital Allocators – Hosted by Ted Seides with an amazing series of guests that discuss all facets of investing. His book Capital Allocators contains all the key lessons from the first 150 episodes of the podcast.

  1. Invest Like The Best- This has become one of the most popular business podcasts on the planet, and for good reason. Patrick O’Shaughnessy is the host and attracts incredible guests to share stories, ideas & methods that always make listeners think.

  1. The Pomp Podcast – Anthony “Pomp” Pompliano mostly focuses on crypto & bitcoin, but he also sprinkles in a lot of other topics related to the big macro. He regularly gets top-notch guests that go deep into specific areas. From billionaires to cultural icons, Pomp helps you get smarter every day.

  1. Sweaty Startup – The Sweaty Startup podcast is hosted by Nick “Tomato KIng” Hubert. It primarily focuses on real estate, but you can still learn a ton of great lessons on investing in general by listening to Nick’s stories, lessons, & guests.

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