Orthopedic Surgery Flashcards

Question

Infraclavicular Block

Answer 1

IFCB - cord level Alternative to supraclavicular block in patients w/ severe COPD or respiratory insufficiency Block arm below the shoulder (hand, forearm, elbow, AV fistula) Cords - lateral, posterior, & medial labeled via relation to the axillary artery Supine or semi-sitting w/ head turned away Place transducer in sagittal plane below clavicle medial to coracoid process (away from midline toward axilla) Insert needle cephalad to caudal 2.5-3cm at 45-65°

Answer 2

Sliding the needle medially ↑potential pneumothorax or hemothorax Doppler useful to prevent inadvertent thoraco-acromial artery or pectoral veins puncture

Answer 3

Terminal branches Procedures below the elbow Supine w/ arm abducted & elbow flexed 90° Place transducer in crease b/w biceps & pectoris major Insert needle lateral to medial

Answer 4

Arthroscopic or open | Arthroplasty, fractures, cartilage or ligament repair

Answer 5

L1-L4 ventral rami | Femoral, obturator, lateral femoral cutaneous, ilioinguinal, & iliohypogastric nerves

Answer 6

L4/5 - S1/5 SCIATIC nerve Supplies sensory & motor innervation to the posterior thigh, knee, & lower extremity below the knee w/ exception to sensory innervation provided by the saphenous nerve

Answer 7

Lateral - traditional approach Supine - anterior approach (traction applied to lower extremities) Incision from iliac crest to mid thigh ↑blood loss associated w/ extracapsular - Femoral neck, intertrochanteric, subtronchanteric Revision surgery - longer duration & ↑blood loss

Answer 8

``` Fat embolus Venous thromboembolus - Heparin, ASA, anticoagulant treatment Blood loss - Regional, deliberate hypotension, dilutional anemia - Surgeon skill level ```

Answer 9

``` Regional > General - Less postop cognitive dysfunction - Superior postop analgesia - ↓DVT/PE incidence - Rapid postop rehab - ↓cost Spinal vs. epidural Peripheral nerve blocks - lumbar plexus (psoas compartment block) or fascia iliaca block ```

Answer 10

TKA - total knee arthroplasty Regional generally preferred over general Complete anesthesia requires both lumbar & lumbosacral plexus blockade Significant postop pain

Answer 11

``` Postop pain management essential to recovery PO pre-medicate days → weeks Opioids & neuraxial techniques ERAS protocols - Multimodal pain management - Continuous peripheral nerve block ```

Answer 12

Diagnostic or therapeutic General w/ LMA Minor surgery performed as outpatient Peripheral nerve block rarely indicated

Answer 13

Commonly performed as outpatient procedure Continuous peripheral nerve block Knee bolster allows lower extremity to hang freely opening joint space Need to support non-operative leg to reduce lower back stress

Answer 14

FNB Targets major branch lumbar plexus Dorsal divisions anterior rami L2, L3, & L4 spinal nerves Emerges from psoas muscle border & remains deep to fascia iliaca Provides analgesia to anterior thigh, knee, & medial aspect lower leg Nerve lies lateral to the artery, deep to fascia lata & iliaca, & superior to iliopsoas muscle Two arteries noted, scan cephalad & identify singular femoral artery Supine w/ external extremity rotation Insert needle 30-45° lateral to medial & inject 20mL LA

Answer 15

Vascular puncture & LA injection avoided by observing the needle tip throughout the procedure Lymph nodes potentially appear as hyperechoic nerves - scan proximal & distal to help distinguish (lymph nodes are not continuous)

Answer 16

Targets femoral, obturator, & lateral femoral cutaneous nerve ↑volume 40mL to block all three nerves

Answer 17

ACB Gold standard - pain relief following knee arthroplasty Associated w/ fall risk 2° to quadriceps weakness Sensory nerve blockade w/ minimal motor involvement Position supine w/ slight extremity external rotation LA deposited in fascial plane separating the adductor longus & vastus medialis below the subcutaneous tissues Inject 5mL up to 20mL LA

Answer 18

Myotoxicity d/t LA deposited w/in the muscle Vastus medialis consistently blocked - may provide greater innervation to knee than previously thought (positive benefit)

Answer 19

Innervation supplied by femoral & sciatic nerve Elective vs. traumatic Neuraxial or peripheral nerve blocks are appropriate in combination w/ general or MAC Position - supine, lateral, or prone Thromboprophylaxis

Answer 20

Saphenous nerve (thigh) = femoral nerve terminal branch Distal adductor canal Saphenous superficial in the distal thigh Provides ONLY sensory innervation to the medial aspect lower extremity below the knee Used in conjunction w/ other blocks for surgical procedures involving the ankle & foot

Answer 21

Targets the sciatic nerve slightly proximal to the knee Provides anesthesia for procedures involving the foot & ankle Popliteal fossa nerves are bordered superiorly & medially by the semi-tendinosus & semi-mebranous muscles & superiorly/laterally by biceps femoris muscle Supine w/ operative leg elevated Tibial nerve superior to the popliteal artery & vein U/S scan proximal to locate the bifurcation w/ the peroneal nerve Anisotropy - angle transducer towards foot to improve nerve imaging

Answer 22

FIVE nerves supply innervation to the foot 1. Tibial 2. Deep peroneal 3. Superficial peroneal 4. Saphenous 5. Sural nerve *See nerve innervation pictures (slide 91-92)

Answer 23

Routinely indicated for surgical anesthesia & postop analgesia U/S improves block efficacy even w/ lower LA volumes Supine w/ foot elevated or extended over edge stretcher Identify vasculature first 3-5mL LA injected at EACH nerve

Answer 24

Often used to minimize blood loss & provide bloodless surgical field Inflatable cuff, connective tubing, pressure device, & timer Proper sizing & inflation are critical to ensure safe & effective use Inflation pressure depends on patient BP & extremity NO LONGER THAN 2 HOURS Interrupted blood supply → tissue hypoxia & acidosis Cuff deflation → metabolic waste release → metabolic acidosis, hyperkalemia, myoglobinemia, renal failure Tourniquet pain - 60min (pain, HTN, tachycardia)

Answer 25

Acrylic bone cement used in arthroplasty - Exothermic reaction that results in expansion & hardening Commonly used in elderly patients TJA Cement placement associated w/ sudden hypotension causing bone cement implantation syndrome (BCIS)

Answer 26

Bone cement implantation syndrome Exothermic reaction causes intramedullary hypertension Absorption results in ↓SVR, hypotension, & hypoxemia

Answer 27

``` Pre-existing CV disease or pulmonary HTN ASA class 3 or higher Pathologic fractures, intertrochanteric fracture or long-stem arthroplasty ```

Answer 28

``` Discontinue nitrous during cementation Maximize inspired oxygen concentration 100% FiO2 Euvolemia Creating vent hole in distal femur High pressure lavage α agonist ```

Answer 29

Fat embolism syndrome (FES) associated w/ traumatic injury & surgery to long bones Incidence 3-4%

Answer 30

``` Age 20-30yo Male Hypovolemia shock Bilateral total knee replacement Rheumatoid arthritis Intramedullary instrumentation ```

Answer 31

``` Major: - Petechia - Hypoxemia - CNS depression - Pulmonary edema Minor: - Tachycardia - Hyperthermia - Retinal fat emboli - Urinary fat globules - ↓platelets/Hct - ↑sed rate - Fat globules present in sputum ```

Answer 32

``` Early recognition Reversing contributing factors (hypovolemia) Fracture stabilization Aggressive pulmonary support Pharmacologic therapy SUPPORTIVE ```

Answer 33

Major cause death following LE trauma or surgery DVT 40-80% ortho patients w/o prophylaxis PE 28% w/o prophylaxis Thromboprophylaxis based on risk factor identification Risk factors - previous hip fracture, advanced age, immobility, previous DVT, cancer, pre-existing hypercoagulable state

Answer 34

``` Subcutaneous emphysema Pneumomediastinum Tension pneumothorax Irrigation 3-5L - Compare fluid in & out - Large volumes → volume overload, CHF, pulmonary edema, or hyponatremia (sterile water) ```