Intro to Orthopedics Flashcards
Peaks of Mortality
50% of deaths occur in the first hour (immediate), 30% in the first few hours (early), 20% within weeks of injury (late)
Golden Hour
period of time following atraumaticinjury during which there is the highest likelihood that prompt medical and surgical treatment will prevent death
Greatest threats to life
Airway, Breathing, Circulation, Disability, Exposure
Trauma
Golden hour, Primary survey of greatest threats, imaging, secondary survey, tertiary survey
Damage Control
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.
Open Fracture
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.
Evaluating Open Fractures
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.
Treatment of Open Fracture
- 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
Tetanus Prophylaxis
Toxoid 0.5 mL and Ig (5yo: 75U, 5-10yo: 125U, >10: 250U) both IM but different sites)
Dressing of Open Fracture
(saline gauze in wound, remove debris, splint or traction)
Irrigation and Debridement
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
Soft Tissue Coverage
Early coverage is ideal, consider wound vac (negative pressure draining) until definite coverage
Reconstruction for Bone Loss
Masquelet technique: cement spacer and temporizing fixation followed by bone grafting in the “induced membrane”
Compartment Syndrome
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
Evaluating Compartment Syndrome
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)
Treatment of Compartment Syndrome
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
Geriatric Trauma
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
Evaluating Geriatric Trauma
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
Geriatric Trauma Service
“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
Septic Arthritis
Bacterial Infection of joint; most common in knee; cartilage injury can occur w/n 8 hrs
Risk factors for Septic Arthritis
> 80 yrs old, RA, diabetes, cirrhosis, HIV, crystal arthropathy, endocarditis, or recent bactermia, IV drug user, recent joint surgery
Evaluation of Septic Arthritis
Serum Labs (WBC>10,000 w/ L shift, ESR>30, CRP>5); Joint fluid aspirate
Joint Fluid Aspirate
Gold standard for Dx and allows directed Abx Tx; Analysis should include: cell count w/ differential, gram stain, culture, Glu level, crystal analysis
Lab Results for Septic Arthitis
WBC>50,000 is Dx for Septic Arthritis; WBC>1,100 is septic; Glucose less than 60% of serum level
Treatment of Septic Arthritis
Initiate IV Abx (empiric then specific, follow ESR/CRP/WBC); Operative joint irrigation and debridement (arthoscopy vs. open)
Joint Reconstruction Management
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
Joint Replacement Management
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)
Prosthetic Joint Infection Risk Factors
Active infection, Inflammatory arthroplathies, Lifestly factors (obesity, smoking, alcoholism, IV drugs, poor oral hygeine) Immune suppression via drugs or conditions
Evaluation of Prosthetic Joint Infection
Acute: <90 days from surgery (S. aureus); Chronic: >90 days (After 4 weeks biofilm forms on inplant, S. epidermidis)
MSIS Criteria
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
Treatment of Prosthetic Joint Treatment
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)
Musculoskeletal Tumors
Prognosis depends on stage of disease, metastasis, skip lesions, histologic grade, tumor size
MSK Tumor Staging
Enneking (MSTS) Classification; Malignant 1,2,3 and benign 1,2,3; Grade: metastatic potential; Compartment: within bone
Impending Fractures
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
Pathologic Lesion Treatment
- 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)
Bone Tumor Principlas
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
