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Part 2 exam > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

Why are pelvic fractures important in trauma?

A
  • Represent high energy injury
  • Commonly associated with vascular injury
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2
Q

What are complications of pelvic fractures?

A
  • Organ injury eg GI, bladder, genital
  • Neurovascular injury
  • Skeletal injury including spine
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3
Q

What is the initial management of pelvic fractures?

A
  • Primary and secondary survery simultaneously with volume replacement and resuscitation
  • Minimal movement and immobilize - pelvic binder
  • Permissive hypotension, early haemorrhage control, early blood products
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4
Q

When should pelvic trauma go to OT for packing?

A
  • Co-existing major abdo/thoracic haemorrage
  • Major bleeding from open pelvis
  • Unstable with nil angio available
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5
Q

What is angio useful for in pelvic fractures?

A
  • Bleeding from branches of iliac artery
  • Isolated pelvic injury
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6
Q

What is the inital assessment and management of unstable spinal injury?

A
  • assess c spine without removing collar
  • Radiologically
  • Clinically (NEXUS criteria) - GCS 15, not intoxicated, nil distracting injuries
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7
Q

What is neurogenic shock?

A

loss of sympathetic outflow resulting in a bradycardic, vasoplegic, hypotensive state (distributive shock)

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8
Q

What is the managment of acute spinal cord injury and neurogenic shock?

A

A - ?resp failure. Intubate with C spine precautions
B - supplemental O2, lung protective ventilation
C- Large bore access, resuscitate and optomize spinal cord perfusion
D- sequential neurological exam

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9
Q

What is cemented implant syndrome?

A
  • hypoxia, hypotension, arrythmia and CVS collapse
  • possibly fat embolism, air embolism or direct effect of the cement (causing release of inflamm mediators)
  • typically occurs at cementation, prothesis insertion, reduction of the joint or deflation of the tourniquet
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10
Q

What is the management of cemented implant syndrome?

A

-Time limited event
- Increase FiO2
- treat RV failure i.e IV fluids, pulm vasodilators
- Inotropes to maintain RV contactility eg dobutamine and milrinone

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11
Q

What is the management of haemorrhage?

A
  • Find the bleeding
  • Stop the bleeding
  • Rapid and effective restoration of blood volume

Initial measures are pressure, elevation, dressings etc
Invasive measures are sutures, tamponade, IR
Correct coagulopathy (avoiding hypothermia and acidosis)

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12
Q

What is the normal blood product replacement strategy?

A

1:1:1, PRBC, FFP, Platelets then reassess
Often then 1:1:10 PRBC, FFP, cryo

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13
Q

What parameters/blood tests need to be measured in critical bleeding?

A
  • Temp
  • Acid/base
  • Hb
  • iCa
  • Platelets
  • Fibrinogen
  • APTT/INR
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14
Q

What is crush syndrome?

A

prolonged ischaemic and muscular damaged leading to rhabdomyolysis and reperfusion injury on release

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15
Q

What is the management of crush syndrome?

A
  • Reduce fractures and splint joints in functional position
  • Manage compartment syndrome if present
  • Target normal pH and urine output
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16
Q

What are complications of crush syndrome?

A

Hypovolaemia
Hyperkalemia
Hypocalcaemia
Metabolic acidosis
Acute myoglobinuric renal failure
Acute compartment syndrome

17
Q

What is compartment syndrome?

A
  • When circulation and tissues within a closed space are compromised by increased pressure leading to ischaemia
18
Q

What is re-perfusion injury?

A
  • Biochemical change secondary to returning circulation to a previously ischaemic limb
  • Increase systemic K, lactate, Co2, vasoactive substances
  • causes reduction in systemic blood pressure
19
Q

What is fat embolism syndrome?

A
  • clinical diagnosis
  • triad of: resp changes (dyspnoea/hypoxia), neurological abnormalities eg altered GCS, petechial rash
  • higher risk in trauma, delayed immbolisation of fracture and conversvative mx
20
Q

What is the management of fat embolism syndrome?

A
  • supportive
  • early aggressive resus
  • Steroid use is controversial
  • Usually resolves within 7 days
21
Q

What are the issues with patients undergoing scolioisis surgery?

A
  • Analgesia intra and post op
  • PONV
  • Antibiotic prophylaxis
  • Blood loss
  • Spinal cord protection (i.e MAP >60)
  • Spinal cord monitoring
  • Spinal surgery in prone position
22
Q

How do you do spinal cord monitoring in scoliosis surgery?

A
  • somatosensory evoked potnetials and motor evoked potentials
23
Q

What is the usual managment of scoliosis surgery?

A
  • TIVA (lower PONV and doesn’t effect spinal monitoring)
  • Remifentail (avoid NMB so facilitate spinal cord monitoring)
  • Pre warming to avoid hypothermia
  • TXA to prevent blood loss
  • Antibiotics
  • Spinal cord monitoring
  • Multi-modal analgesia
24
Q

What are common intra-operative neuromonitoring modalities?

A
  • Somatosensory evoked potentials
  • Motor evoked potentials
  • EMG
  • EEG
25
Q

What are SEPs and what do they monitor?

A
  • Somatosensory evoked potentials
  • Monitor posterior columns of the spinal cord
  • Generally stimulate peripheral nerves eg ulnar, median and posterior tibial –> singal moves up dorsal column –> somatosensory cortex (where signal is measured)
  • If there is a drop eg brown -sequard injury then can remove any recent surgical implants, increase blood pressure, give steroids, alter surgical approach
26
Q

What are MEPs and what do they measure?

A
  • Motor evoked potentials
  • Measure vental columns of spinal cord
  • Stimulus is over scalp, measure muscle contraction peripherally
  • Measure the amplitude, latency and morphology of muscle contraction
  • More sensitive than SEPs but also more effected by depth of anaesthesia and NMB
27
Q

How does ketamine alter SEPs and MEPs?

A

increases them

28
Q

How does dexmed/clonidine alter SEPs and MEPs?

A
  • Decreases MEPs
  • Nil change to SEPs
29
Q

How does opioids alter SEPs and MEPs?

A
  • Minimal effect
30
Q

What are the local effects of arterial tourniquet?

A
  • Distal limb ischaemia
  • Direct compression of nerves and muscles under tourniquet
31
Q

What are the systemic effects of arterial tourniquet?

A
  • Increased SVR
  • Increased circulating volume (due to smaller overall vasculature in which the volume resides)
  • Increased CO2 post deflation –> increased MV if spont vent, increased cerebral blood volume
  • small increase in potassium and lactate post deflation
32
Q

What are the common complications with arterial tourniquets?

A
  • Nerve injury (most common) - usually direct compression rather than ischaemia
  • Muscle injury
  • Skin injury (prep trapped against skin)
  • vascular injury (may precipitate plaque rupture)
33
Q

How should tourniquet pressures be set?

A
  • Patient dependent
  • Ideally only slightly higher than the limb occlusion pressure (40mm - 80mmHg higher)
  • Clinically more often set to 100 + sys for upper limb and 150 + sys for lower limb
  • Better than using a standard pressure for all patients

Part 2 exam (15 decks)

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