Intro to Ortho Surgery Flashcards
What are the “three peaks of mortality”?
How does this relate to the “golden hour”?
The 3 peaks of mortality refers to the 3 time periods following a trauma when death is most likely.
- In the first few minutes 50% of deaths
- In the first hours 30% of deaths (primarily blood loss or airway complications)
- Days to weeks following trauma the remaining 20% die (usually clots or infections)
The “golden hour” is referencing the first hour following trauma when over 50% of deaths can be prevented with intervention.
What does the primary survey of a trauma patient entail?
A - airway
B - breathing
C - circulation
D - disability
E - exposure
When a patient enters with an unstable pelvic fracture and hemodynamic instability, what is an important step in damage control?
Regarding a patient with multiple injuries, what should be the top priority in the first 2-5 days?
Pelvic volume reduction - you don’t want the patient to lose all blood volume into the pelvis, so a pelvic binder could be placed to reduce the chance of this
First 2-5 days should involve treating only life threatening injuries. Allowing the body time to chill after trauma. Stabilizing all other fractures then making a definitive treatment plan.
What are the steps of evaluation of an open fracture?
Give associated classifications/tests.
- Brief history - get mechanism
- Assess soft tissue damage
Gustilo-Anderson classification -
Neurovascular damage
Ankle Brachial Index (ABI) - Xrays
- Treatment - based on injury
- Tetanus prophylaxis - if not in the last 5 years
What are the most common sites of open fractures?
What are the two dichotomous ways in which you can get an open fracture?
What is the standard timeline of treatment of an open fracture?
Tibia and phalanx are the most common
- *Outside-in** : high energy trauma
- *Inside-out** : pointy fracture
- IV abx within 3 hours
- Tetanus if not in last 5 years
- Stabilize and dressing
-
Irrigate and debridement
-incision to expose fx
-low pressure irrigation
- saline with Castile soap (type I 3L, type II 6L, type III 9L) -
Soft Tissue Coverage
(consider wound vac until definitive coverage) - Reconstruction for bone loss
Urgent surgery - 6-24 hours (no longer emergent with rushing to OR)
What is the basic mechanism for injury due to compartment syndrome?
What are common locations for this to occur?
What are common causes of this?
Fascial structures surround groups of muscles in the body, when anything causes this pressure to rise perfusion could be decreased resulting in death of the muscle.
Common Locations:
leg
thigh
forearm
foot
shoulder
paraspinals
Common Causes:
trauma
tight casts
IV fluids
pressure injections
burns
post-ischemic swelling
arterial injuries
What are the symptoms of compartment syndrome?
What are the physical exam findings?
What lab/test value could confirm your diagnosis?
Symptoms: pain out of proportion to clinical findings
Physical exam:
pain with passive stretch or incompressible compartments
Late findings:
paresthesias, paralysis, palpable swelling, pulselessness
Compartment pressure within 30 mmHg of diastolic pressure
What are common complications when considering geriatric trauma?
What are considerations when taking the history?
What are the goals of surgical management?
What can improve outcomes?
Complications:
Osteoarthritis or Osteoporosis
Frequent Falls
Medical Comorbidities
History Considerations:
Mechanism - were they dizzy before they fell?
Medication
Baseline function
Living conditions/situation
Goals of surgical management:
early mobilization
pain control
return to pre-op functional status
Co-management with medical/geriatric services improves outcomes
What is involved in secondary survey of a geriatric trauma patient?
Secondary survey:
anti coagulation?
consider cause of fall
labs and volume assessment (if found down could be hypovolemic)
imaging
What is septic arthritis?
Where is the most common site?
What are some common risk factors?
Why is it important to catch this diagnosis quickly?
Septic arthritis: bacterial infection of a joint
most commonly the knee
Common Risk Factors:
over 80 years old
diabetes
RA
cirrhosis
HIV
recent bacteremia or joint surgery
IV drug use
Can quickly (within 8 hours) begin destroying cartilage
What results would you expect of a patient with septic arthritis?
WBC
ESR
CRP
What should joint fluid aspirate be tested for?
WBC > 10,000
over 50,000 is diagnostic
over 1,100 is diagnostic in a prosthetic joint
ESR > 30
CRP > 5
Aspiration of joint fluid is the gold standard:
cell count with differential
gram stain
culture
glucose level (would expect low)
crystal analysis (rule out gout)
What is the standard treatment for septic arthritis?
IV abx
Empiric: Vancomycin
Organsims specific
Monitor ESR, CRP, and WBC to determine effectiveness
Joint Irrigation and Debridement
arthroscopically or open
What are some conditions/diseases that should be monitored/tested prior to arthroplasty to minimize risk to the patient?
Diabetes: HgA1C < 6.7 (wound complications)
Obesity: BMI >40
Cardiovascular: stents delay surgery
Renal disease: dialysis increases complications
MRSA colonization: attempt to decolonize
Tobacco use: cessation 6 weeks prior
Illicit drug use: increases mortality by 5x
What agents are used to decrease risk of venous thromboembolism following joint replacement?
Mechanical compression device PLUS
One of the following:
warfarin
enoxaparin
aspirin
apixaban or rivaroxaban
fondaparinux
dabigatran
What are the benefits of neuraxial (spinal) anesthesia?
What is the preop, intraop, and postop standard for multimodal pain management of joint replacement surgeries?
Benefits: lower surgical time, infection, postop cardiac events, transfusion rates, and length of stay
Preop: COX-2 inhibitor with pregabalin or gabapentin
peripheral nerve block (adductor canal)
Intra-operative joint injection: morphine, saline, epinephrine, Toradol, Marcaine
Post-op: COX-2 Inhibitor, pregabalin, oral opioid
What are three main risk factors of a prosthetic joint infection?
- Active infection
- Immune suppression
- Lifestyle factors
What is the most common etiological agent within 90 days of prosthetic joint replacement?
What is the most common after after 90 days?
S.aureus within 90 days
S.epidermidis after 90 days
What are the treatment options for a prosthetic joint infection if…
the patient is not a surgical candidate
it is an acute infection (<3 weeks postop)
Infection over 4 weeks after surgery
If…
Not a surgical candidate:
suppressive abx forever
_Acute infection (\<3 weeks):_ polyethylene (plastic) exchange with IV abx
Over 4 weeks after surgery:
Resection of components with abx spacers
with IV abx
follow ESR and CRP
Late reimplantation
Prognosis of musculoskeletal tumors are based on what 5 factors?
What system is used to classify stages of the tumor?
What is used to classify this?
Define grade and site.
- Stage
- Metastasis
- Skip lesions
- Grade
- Tumor size
Enneking (MSTS) Classification:
Malignant: I, II, III and Benign: 1, 2, 3
Determined using: grade, site, and metastasis
Grade: metastatic potential
Site: intra- or extra- compartmental (within the bone)
Why do musculoskeletal tumors increase risk of fracture?
What is one of the first symptoms of this?
What treatment could improve outcomes?
Cortical destruction by the tumor
Functional pain - increases concern that a fracture will occur
Prophylactic fixation leads to better outcomes
What are the treatments for pathologic lesions of musculoskeletal tumors?
- Tissue Diagnosis
- Surgical Fixation
- Post-op Radiation
What are the principles of bone tumor work up?
What are the types of biopsy
- Thorough work up prior to biopsy
- Make sure you can diagnose and treat at the center
- Indications: aggressive tumor or solitary lesion with hx of carcinoma
Types of Biopsy:
fine needle aspiration
core biopsy
incisional biopsy
excisional biopsy
