Intro to Orthopedics

Question 1

Peaks of Mortality

Answer 1

50% of deaths occur in the first hour (immediate), 30% in the first few hours (early), 20% within weeks of injury (late)

Question 2

Golden Hour

Answer 2

period of time following atraumaticinjury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death

Question 3

Greatest threats to life

Answer 3

Airway, Breathing, Circulation, Disability, Exposure

Question 4

Trauma

Answer 4

Golden hour, Primary survey of greatest threats, imaging, secondary survey, tertiary survey

Question 5

Damage Control

Answer 5

Pelvic volume reduction for unstable pelvic fractures in hemodhynamic instability. In a mutlipy injured patient, only life threatening injuries should be treated in first 2-5 days. Stabilize all other fractures followed by staged definitive management.

Question 6

Open Fracture

Answer 6

Direct communication to external environment. Immediate IV Abx (w/n 3 hours) and urgent irrigaition/debridement. Most common: tibia/phalynx. Mechanism: high energy trauma or inside out. Represent an urgency that requires surgery in 6-24 hours.

Question 7

Evaluating Open Fractures

Answer 7

Obtain brief history. Assess soft tissue damage (size depth, contamination, quality of skin, Gustilo-Anderson Class). Neurovascular exam. X-rays of joints above and below injury. Tx based on injury. Tetanus prophylaxis.

Question 8

Treatment of Open Fracture

Answer 8

1. Abx as early as possible and tailored to soft tissue injury pattern and contamination 2. Tetanus prophylaxis in ER 3. Stabilization of extremities and dressing 4. Urgent Irrigation and debridement 5. Soft Tissue Coverage 6. Reconstruction for Bone Loss

Question 9

Tetanus Prophylaxis

Answer 9

Toxoid 0.5 mL and Ig (5yo: 75U, 5-10yo: 125U, >10: 250U) both IM but different sites)

Question 10

Dressing of Open Fracture

Answer 10

(saline gauze in wound, remove debris, splint or traction)

Question 11

Irrigation and Debridement

Answer 11

Ususally w/n 6 hrs, incision to expose fracture, low pressure irrigation (change from high pressure), Saline with castile soap is effective (Type I: 3L, Type II: 6L, Type III: 9L), Debride devitalized tissue and free one fragments

Question 12

Soft Tissue Coverage

Answer 12

Early coverage is ideal, consider wound vac (negative pressure draining) until definite coverage

Question 13

Reconstruction for Bone Loss

Answer 13

Masquelet technique: cement spacer and temporizing fixation followed by bone grafting in the “induced membrane”

Question 14

Compartment Syndrome

Answer 14

Fascial compartment pressure rises to decrease perfusion; Locations: leg, thigh, foot, shoulder, paraspinals; due to trauma: tight casts, IV fluids, pressure injections, burns, post-ischemic swelling, bleeding, arterial injury

Question 15

Evaluating Compartment Syndrome

Answer 15

Sx: pain out of proportion to clinical findings; Physical exam: pain with passive stretch, paresthias, paralysis, palpable swelling, pulselessness; compartment w/n 30 mm Hg of the diastolic pressure (Δ P)

Question 16

Treatment of Compartment Syndrome

Answer 16

Remove or lessen tight wraps/dressings/casts if possible; perfrom emergent fasciotomy; leave wound open and perform skin grafting or delayed primary closure in 3-7 days

Question 17

Geriatric Trauma

Answer 17

Complicated by related conditions (osteoarthritis/porosis, frequent falls, medical comorbidities); History consideration (mechanism, meds, baseline function, living conditions); Co-management with medical/geriatric service improves outcomes; Surgical management goals are early mobilization, pain control, and return to pre-op functional status

Question 18

Evaluating Geriatric Trauma

Answer 18

Lower threshold for trauma team activation to prevent late recognition of severe injuries; 2* survey: anitcoagulants, consider cause of fall, labs and volume assessment, imaging to include CT eval; Inpatient management: comprehensive geriatric management

Question 19

Geriatric Trauma Service

Answer 19

“G-60 Service” Works in collab with a medical hospitalist, PT/OT, resp therapist, nursing sup w/ geriatric expertise, social worker, nutritionist, PharmD, and palliative care specialist

Question 20

Septic Arthritis

Answer 20

Bacterial Infection of joint; most common in knee; cartilage injury can occur w/n 8 hrs

Question 21

Risk factors for Septic Arthritis

Answer 21

> 80 yrs old, RA, diabetes, cirrhosis, HIV, crystal arthropathy, endocarditis, or recent bactermia, IV drug user, recent joint surgery

Question 22

Evaluation of Septic Arthritis

Answer 22

Serum Labs (WBC>10,000 w/ L shift, ESR>30, CRP>5); Joint fluid aspirate

Question 23

Joint Fluid Aspirate

Answer 23

Gold standard for Dx and allows directed Abx Tx; Analysis should include: cell count w/ differential, gram stain, culture, Glu level, crystal analysis

Question 24

Lab Results for Septic Arthitis

Answer 24

WBC>50,000 is Dx for Septic Arthritis; WBC>1,100 is septic; Glucose less than 60% of serum level

Question 25

Treatment of Septic Arthritis

Answer 25

Initiate IV Abx (empiric then specific, follow ESR/CRP/WBC); Operative joint irrigation and debridement (arthoscopy vs. open)

Question 26

Joint Reconstruction Management

Answer 26

1 million arthoplasties annually; Medical optimization: Diabetes: HgA1C < 6.7; Obesity: BMI >40; Cardiovascular: Bare metal stint (delay surg 30 days) Drug Eluting stint (delay 12 months); Renal disease/dialysis; MRSA colonization; Tobacco use (cease 6 wks prior to surg); Illicit drug use increases mortality risk 5x

Question 27

Joint Replacement Management

Answer 27

VTE prophylaxis: ACCP mechanincal compression devices with vit K antagonist (warfarin), low-molecular weight (enoxaparin), aspirin, factor Xa inhibitors (apixaban, rivaroxaban), pentsaccharides (fondaprinux), direct thrombin inhibitor (dabigatran); AAOS recommends pharmacologic agent, mechanical compression, or both for patients without increased risk; Neuraxial anesthesia to have lower surgical time, infection, postop cardiac events, transfusion rates, and length of stay; Multimodal pain management: preop cox2 inhibitor (pregablin/gabapentin), Peripheral nerve block (adductor canal), Intraoperative joint infection (morphine, saline, epi, toradol, marcaine), Post-op cox2 (pregabalin, oral opiod)

Question 28

Prosthetic Joint Infection Risk Factors

Answer 28

Active infection, Inflammatory arthroplathies, Lifestly factors (obesity, smoking, alcoholism, IV drugs, poor oral hygeine) Immune suppression via drugs or conditions

Question 29

Evaluation of Prosthetic Joint Infection

Answer 29

Acute: <90 days from surgery (S. aureus); Chronic: >90 days (After 4 weeks biofilm forms on inplant, S. epidermidis)

Question 30

MSIS Criteria

Answer 30

Major: sinus tract communicating with joint, pathogen isolated from two samples; Minor: High CRP (2), High ESR (1), synovial WBC>3000 (3), Alpha Defensin (3), PMN>80% (2), Synovial CRP>6.9 (1) Add total: 1-5= not infected, 2-5= inconclusive, >6= definitely infected

Question 31

Treatment of Prosthetic Joint Treatment

Answer 31

Suppressive Abx (nonsurgical candiates); Polyethylene exchange with IV Abx (acute inf <3 weeks, 4-5 weeks); @ stage replacement arthoplasty (>4 wks post-op, resection of components w. placement of Abx spacer and IV abx, follow ESP CRP, Late >6 weeks- reimplantation)

Question 32

Musculoskeletal Tumors

Answer 32

Prognosis depends on stage of disease, metastasis, skip lesions, histologic grade, tumor size

Question 33

MSK Tumor Staging

Answer 33

Enneking (MSTS) Classification; Malignant 1,2,3 and benign 1,2,3; Grade: metastatic potential; Compartment: within bone

Question 34

Impending Fractures

Answer 34

High risk of fracture due to cortical destruction by tumor (presence of functional pain, >50% cortical destruction); Prophylactic fixation leads to better outcomes, less morbidity/mortality

Question 35

Pathologic Lesion Treatment

Answer 35

1. Obtain Tissue Diagnosis (Sarcoma finding needs referal for neo-adjuvant chemo/radiation) 2. Surgical Fixation (Only if primary neoplasm ruled out, goal is to protect entire bone) 3. Post-op radiation (decrease pain and reduce tumor burdon)

Question 36

Bone Tumor Principlas

Answer 36

Thorough work up, center/hospital must be able ot perform Dx and Tx, Indications: aggressive tumor or soliatry lesion with Hx of carcinoma. Types: fine needle aspiration, core biopsy, incisional biopsy, excisional biopsy