Ortho and soft tissue Flashcards
List the gustilo open fracture classification levels
i) Open # with < 1 cm wound
ii) Open # with > 1 cm wound
iiia) Same as ii, but soft tissue coverage may be inadequate after debridement and there is periosteal stripping
iiib) Inadequate soft tissue coverage
iiic) Inadequate soft tissue and requires vascular repair
What are complications of fractures (7)
1) infection
2) hemorrhage
3) vascular injury
4) nerve injury
5) avascular necrosis
6) compartment syndrome
7) fat emboli
What is the approach to fracture management?
1) Control bleeding
2) Splint and reduce if vascular compromise
3) Cover with sterile saline soaked guaze
4) IV Abx prophylaxis
5) Tetanus prophylaxis
6) DVT prophylaxis
What are the nexus criteria for radiographic evaluation?
1) no midline tenderness
2) no EtOH
3) Normal alertness
4) No focal neurological deficit
5) No painful distracting injury
What are the high level concepts of the Canadian c-spine rule?
In order to not require a radiograph, the patient must have no high risk factors, they must have at least one low risk factor and then a range of neck motion is assessed
What is the difference between Jefferson/Burst and a Hangman fracture?
Jefferson/Burst involves C1 while hangan’s fractures involves C2
What are the tile classifications of pelvic fractures?
A) Stable
B) Partially stable
C) Unstable (posterior arch disrupted completely)
What is cauda equina syndrome?
Constellation of symptoms associated with compression of the cauda equina bundle of nerves below the spinal cord - results in leg pain, back pain, loss of rectal tone
What are potential complications of pelvic injuries?
1) Hemorrhage
2) Urological injury
3) Neurological injury (cauda equina etc)
What is the pathophysiology of compartment syndrome?
Too much pressure in non-expanding space cuts off vascular blood supply ultimately leading to acidosis and necrosis
Venous system compressed first, decrease drainage and increasing pressure
What are 3 different way to cause compartment syndrome?
Increase contents (blood, hematoma) Decrease compartment size (fascia, cysts) External pressure (from casts)
How do you diagnose compartment syndrome?
Clinical diagnosis - 5 P’s
Pain (out of proportion) Pallor Pulselessness Paresthesia Paralysis
What are complications of compartment syndrome?
HyperK (Rhabo) Myoglobinuria (renal failure) Infection Contractures Lactic acidosis
What kind of fracture is most likely source of fat embolism?
Long bone fractures
What distinguishes crush syndrome from compartment syndrome?
Crush syndrome is the downstream manifestations of compartment syndrome as a consequence of toxin release
What are early causes of death in crush syndrome?
1) Hypovolemia (3rd spacing)
2) HyperK
3) Dysrythmias
What is the approach to crush syndrome?
ABCDE Treat hemorrhagic shock if present Call ETP for consult Cardiac monitoring If QRS Wide -> give CaCl2, NaHCO3, Insulin/Glucose, Nebulized Ventolin
What bacteria causes Necrotizing fasciitis?
Type 2 - Group A streptococcus, Type 1 is polymicrobial
Where is Nec Fas most common?
Extremities (Legs)
What mind you see on an xray for a patient with nec fasc and why?
Free air in the tissue consistent with bacterial off gasing
What would be general presentation of patient with early nec fasc?
Pain out of proportion, young healthy, CT/US would have free air in soft tissue
What is the difference between osteoarthritis, rheumatoid arthritis and septic arthritis?
Osteoarthritis is a complex inflammatory disorder of the joints thought to be caused by proinflammatory mediators and cartilage degradation due to use, but it is usually associated with unilateral or focal joints.
Rheumatoid arthritis is an autoimmune disorder in which the inflammation of the joints occurs in more than one joint (symmetrical)
Septic arthritis is an infection of the joint.
What is the pathophysiology of gout?
Gout occurs when high levels of uric acid in the blood stream crystallize in joints causing inflammation and pain, usually in the big toe.
What is the pathophysiology of osteomyelitis?
Infection of the bone caused either by bacteremia or post surgery.
What is the pathophysiology of osteoporosis?
Decreased bone density with increased risk of fractures caused by loss of bone mass/density due to too much breakdown (osteoclasts) or not enough creation (osteoblast) activity.
Why does rheumatoid arthritis cause a difficult airway?
Two possible mechanisms:
1) Decreased mobility due to joint inflammation
2) Osteoporosis due to prolonged steroid use leads to fractures
Which muscle in the neck should you evaluate with neck stab wounds?
Platysma muscle
What is a concerning pathology specifically related to stab wounds to the neck?
Venous air embolism
What is the treatment for a venous air embolism?
Try to get air bubble into area of ventricle less likely to cause problems (base of RV) by putting patient in trandellenberg and left lateral decubitus position
What are the 3 zones of the neck with respect to neck trauma?
1) Zone 1 - Clavicle to cricoid cartilage
2) Zone 2 - Cricoid to angle of mandible
3) Zone 3 - Angle of mandible to base of skull
What’s the difference between hard and soft signs with regards to neck trauma?
Soft signs suggest that its less likely a vascular injury occurred while hard sign suggest high likelyhood of vascular injury
What are the 5 eye vital signs?
1) Visual acuity
2) IOP
3) Pupils
4) Extraoccular movement
5) Visual Fields
Which type of burn is worse, alkaline vs acid and why?
Alkaline is worse because it causes liquefaction necrosis which continues until agent is removed while acid burns cause coagulation necrosis which is self limiting
What is a hyphema? Is it painful?
Blood pooling in the anterior chamber of the eye - it is painful
How do you treat hyphema? What is the major complication?
Elevate head of bed and restrict motion
Rebleeding is the major complication
What is traumatic iridocyclitis?
Inflammation of the iris
What is iridodialysis?
Tearing the iris root from the ciliary body causing a double pupil
What causes an open globe injury?
Increased IOP from blunt injury causes scleral rupture
What would be the diagnosis if the patient is complaining of “flashes and floaters”?
Vitreous hemorrhage
Which cranial nerve is affected by a down and out presentation?
III
Which cranial nerve is affected when you need to tilt your head to one side to correct your vision? Why does it work this happen?
IV - occurs because the extraoccular muscle that is imparied
What CN is injured with a medially deviated eye?
VI
Describe the 3 types of Le Fort fractures
1) Separates teeth from face “floating palate”
2) Pyramid shaped above nose and base at the teeth
3) Craniofacial dissociation
What are the predictors of difficult cric?
S - Surgery H - Hematoma O - Obese R - Radiation distortion T - Tumor
What is Ludwig’s angina?
Bilateral infection of the submandibular space in the deep neck that begins as a cellulitis in the floor of the mouth
What are the 4 structures in the carotid sheath? What is the source of infections of the carotid sheath?
1) IJ
2) ICA
3) CN 9, 10, 12
4) Lymph nodes
Infection source is deep space infections that erode the sheath causing septic emboli
Which form of epistaxis (anterior or posterior) is more common?
What are 3 treatments for this type of epistaxis?
Anterior
1) Silver nitrate
2) Packing
3) TXA on a plegit
What is the ellis classification used for?
To classify dental fractures
What is the significance of trismus in a patient with an oral infection?
Its significant because it can irritate the masseter muslce, spead to the masseteric and other spaces and make for a difficult airway
What is the approach to managing an open globe injury?
1) Avoid high dose ketamine (uptodate)
2) Roc over sux
3) Avoid eye manipulation
4) Place eye shield
5) HOB at 30
6) NV/Analgesia/Sedation
7) Abx
What is the concern with epistaxis and geriatric population and what is the management?
Concerns of blood thinners and hypovolemic losses
stop the bleeding!,
1) txa,
2) rhino rockets,
3) correct coagulopathy (Vit K etc)
What airway structure are in each neck zone?
1) Zone 1 - Trachea, lung apices
2) Zone 2 - Trachea, esophagus, larynx, pharynx
3) Zone 3 - Pharynx
What vascular structures are in each neck zone?
1) Zone 1 - Great vessels (subclavian, brachiocephalic, common carotids, aortic arch, and jugular veins
2) Zone 2 - Carotid and vertebral arteries, jugular veins
3) Zone 3 - Carotid arteries, jugular veins
What are the deep spaces of the neck that can become infected?
1) Prevertebral
2) Danger
3) Retropharyngeal
4) Pretracheal
5) Superficial
What are major concerns with deep space neck infection in relation to difficult airway predictors?
1) Trismus
2) Pooling of saliva
3) Asymmetry or oropharynx
What are considerations for a patient presenting with epiglottitis?
1) Where are they on the spectrum of obstructing?
2) Have they been immunized?
3) What treatments have been ongoing?
How should you manage ludwig’s angina?
As it’s an infection of the submandibular space,
1) evaluate airway patency and intubate/cric if necessary,
2) antibiotics,
3) Surgery for drainage
What is the young burgess classification used for?
Pelvic fractures
