MSK and Trauma Flashcards
What is included in the primary survey?
Airway with c-spine protection
Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability - What injuries are we observing that are obvious to the naked eye
Exposure/Environment - Fully undress the patient
First step in shock therapy for hypovolemic shock
IV Crystalloids
What are the components of the Secondary Survey?
History
Physical exam: Head to toe
Complete neurologic exam
Special diagnostic tests
Re-evaluation
When do you start the secondary survey?
After:
The primary survey is complete
ABCDE’s are reassessed
Vital functions are returning to normal
Symptoms and exam findings of hypovolemic shock
AMS, anxiety
Cold, diaphoretic skin
Tachycardia
Tachypnea, shallow respirations
Hypotension
Decreased urinary output
Treatment of hypovolemic shock
Fluid resucitation
–LR rather than NS because of Na
–Don’t worry about the volume. If they end up in heart failure, that’s fine. You can fix that with medicines.
–Monitor response
–Prevent hypothermia - pRBC are refrigerated
pRBC:FFP - 1:1 ratio
If infusing a lot of blood products, watch the K and Ca - can result in hyperK and hypo Ca
What is a battle sign indicative of?
Basilar skull fracture
Likely need surgery and ppx antibx
What is the Monro-Kellie Doctrine
There is only so much room in the skull so if something presses on the brain, CSF or venous volume will decrease
If there is no venous return from the brain, the brain will become hypoxic
Cause of epidural hematoma
Often associated with skull fracture
Middle meningeal artery tear
Clinical presentation of epidural hematoma
Initial LOC, followed by lucid interval, followed by vomiting and rapid decompensation to LOC
Can be rapidly fatal - needs evacuation and bone flap
Causes of subdural hematoma
Venous tear/brain laceration
When do you interfere with subdural hematoma
If >5mm of midline shift, recommend rapid surgical evacuation
Below what GCS should intubation be considered?
GCS of 8 and below should likely be intubated because the LOC could get worse
Why is Mannitol used in brain injury?
Creates an osmotic gradient that stalls cerebral swelling
What is the best type of imaging for facial fracture?
Non contrast CT Face
What is a LeFort Fracture?
The LeFort fracture is the most concerning of the maxillofacial fractures
Involves the maxilla and/or skull base
“Dish face”
Management of trauma to the neck
Unless the impaled object is acting like a lever or definitely obstructing the airway, DO NOT REMOVE IT!
If there is bleeding, compression one side of the neck - low threshold to intubate
If the injury is strangulation/hanging:
–Apply a hard collar
–Assess for hoarseness (suggests injury to the larynx/hyoid bone)
–Assess for crepitus - trachea is no longer intact
–Obtain CT c-spine and CTA head and neck
What is Horner’s Syndrome
Damage to the sympathetic trunk (nerve fibers running from the base of the skull to the coccyx).
Caused by carotid dissection or direct injury to the bundle of nerve fibers
Symptoms occur on the same side as the lesion of the sympathetic trunk:
-Miosis - constriction of the pupil
-Ptosis
-Anhydrosis - decrease in sweating
What is L’hermittes Sign?
Elicited with the neck flexed and causes an electrical sensation that runs down the back and into the limbs. Generally uncomfortable.
Indicates possible MS and compression of the spinal cord in the neck from cervical spondylosis, disc herniation, tumor and Arnold-Chiari malformation
What are the NEXUS criteria
Scale utilized to rule out the need for imaging for neck injuries
If all are negative, no need for x-ray of the neck:
-There is no posterior or midline cervical tenderness
-There is no evidence of intoxication
-The pt is A&Ox3
-There is no focal neurological deficit
-There are no painful distracting injuries
What is a Jefferson fracture?
Burst fracture of C1
What is a teardrop fracture?
Fracture that disrupts ant/post ligament and bone
Very unstable
Lower back pain - red flags
Recent significant trauma or mild trauma with pain disproportionate to history/exam
Age >50
Unexplained weight loss
Unexplained fever/immunosuppression
History of cancer
IVDU
Osteoporosis
Prolonged use of glucocorticoids
Focal neurologic deficit or truly disabling symptoms
Duration greater than 6 weeks
Neurogenic Shock: Causes, symptoms, treatment
Can occur in a spinal cord injury at or above level of T6
Is a syndrome of autonomic dysfunction
–bradycardia and hypotension
–Peripheral vasodilation causing hypothermia
Treatment goals:
–SBP >90 - use dopamine
–HR >80
–Keep warm, give warmed IVF
–Immobilize
–Insert foley, acute urinary retention is common
Treat with methylprednisolone and consult
Treatment for cauda equina
Dexamethasone 10mg IV and consult neurosurgery for possible decompression surgery
Clinical presentation of tension pneumothorax
Often the result of blunt trauma
Respiratory distress
Shock
Distended neck veins
Unilateral decrease in breath sounds
Hyperresonance
Cyanosis (late sign)
Clinical manifestations of rib fractures
Pain localized to the area of the fracture
Pleuritic pain
Auscultatory crepitance
Flail chest: 3 or more broken ribs in 2 or more places
Treatment of rib fx
Single, non-displaced: NSAIDs, spirometry
Admit 3 or more rib fx or if underlying organ damage
Admit flail segment
Usually will heal in about 8 weeks
Early management of extremity trauma
Early concerns are vascular compromise and open fractures
Assess and manage vascular compromise:
-Reduce fracture
-Splint fracture
-Assess pulses by palpation or doppler
-Obtain surgical consult
Manage open fractures:
-Apply appropriate splint
-Clean/debride
-Consider time factor
-Obtain ortho consult
-Antibiotic/tentanus status
Symptoms of Compartment Syndrome
Pain
Paresthesia
Pallor
Paralysis
Pulselessness
Poikiothermia (cold)
How to assess for rotator cuff tear
Weakness and pain with abduction and adduction of the shoulder
Job’s Strength Test - resistance of adduction - supraspinatus muscle
Clinical features of shoulder dislocation
Deformity noted plus a depression at the AC joint
Patient cannot move shoulder at all
Most common is anterior dislocation
Posterior (rare)
Inferior (very rare - arm up over head)
Different methods of shoulder reduction
Cunningham - Massage and shoulder shrugs
Milch - rotation of the arm outward and up until it pops back in
Clinical features of radial head fracture and treatment
Usually caused by FOOSH
Pain laterally, held at 80 degree flexion for comfort
Pain in the elbow with supination/pronation
Can see a “sail sign” in an occult radial head fracture
Treatment:
If <2mm displaced - Sling, ice, analgesia
If >2mm displaced - Sling vs ORIF
If comminuted: ORIF
Why is it important to always reduce an elbow
Often associated with neurovascular compromise
Clinical features of a scaphoid fracture
Most common carpal fracture although difficult to see on plain films
Must not be missed as the scaphoid is poorly vascularized
Snuff box tenderness and MOI by FOOSH
If xray negative but clinically appears to have scaphoid fx, consider CT, MRI, bone scan
Immobilize with thumb spica
Treatment of subungual hematoma
Xray to assess for fracture
Relieve pressure by trephination
Management of pelvic fracture
Fractures of the non-load bearing parts of the pelvis generally require no treatment aside from pain medicine and rest
Severe fractures often require ORIF
Could consider pelvic binder to stop the bleeding
CT imaging preferred to find small fx
Tibial plateau fracture: Clinical presentation, diagnostics and treatment
Usually present with knee effusion and inability to bear weight
Concern for compartment syndrome with tibial plateau fx
Get CT if high suspicion and negative XR
Treatment is knee immobilizer, non-weight bearing and surgery
Ankle Sprain: Diagnosis and treatment
Presentation is pain, swelling, ecchymosis
Xray only indicated for point tenderness, swelling and bruising
Treatment is Ace wrap, aircast, crutches, ice, elevation and NSAIDs
Masionneuve Fracture
Proximal fibular fracture accompanying any kind of ankle fracture
Rotational forces are transmitted up to the knee
Always palpate the proximal fibula in any ankle injury and have low threshold to image the whole fibula
Lisfranc Injury: What is it? Treatment?
Injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus
If <2mm displaced: Strict non-weight bearing for 6 weeks
If >2mm, ORIF is indicated
Can cause compartment syndrome and threaten the toes
What is a Jones Fracture and how do you treat it
Proximal 5th metatarsal fracture
Treated with splint and crutches
Management of traumatic pneumothorax
Open pneumothorax (sucking chest wound) is caused by penetrating trauma
Treatment involves 3 sided dressing and placing a chest tube
In tension pneumothorax - insert 14 gauge angiocath into the 2-3rd intercostal space, mid clavicular line
Symptoms of compartment syndrome
Severe ischemic pain
Tensely swollen
Skin perfusion, arterial pulses will be normal
Paresthesia
Passive stretch of muscle is painful
Progressive loss of sensory/motor function
Repeated examinations are required to check for developing compartment syndrome
Diagnosis of compartment syndrome
Use of a Stryker tonometer:
Normal is 0-8mmHg
Compartment syndrome: >30mmHg
What is the perfusion pressure of a compartment (delta pressure)
Delta pressure = Diastolic blood pressure - intra-compartmental pressure
Delta Pressure <30 - indicative of the need for fasciotomy
What is the only type of fracture that you would give an antibiotic for?
Open fracture
What is the difference between a dislocation and a subluxation?
Subluxation is an incomplete dislocation
