subs shelf study 2/8/17 Flashcards
define open fracture
communicates with outside world
bone can break skin…
or can get bullet shot…
fracture patterns from low to high energy
and mechanism
Avulsion – tensile Spiral – torsion Transverse – bending Oblique – bending with compression Segmental/Comminuted – combined
define segond fracture
Segond fracture is an avulsion fracture of the knee that involves the lateral aspect of the tibial plateau and is very frequently (~75% of cases) associated with disruption of the anterior cruciate ligament (ACL
bending with compression causes what kind of fracture
oblique fracture
define segmental fracture
several large bone fragments separate from the main body of a fractured bon
compartment syndrome = no blood in or no blood out?
no blood out
-veins compress first
most sensitive exam finding for compartment syndrome
pain out of proportion for exam
and pain w PASSIVE STRETCH
-less sensitive are pallor pulseless poikilothermia paresthesias
common fracture locations causing vascular injury
clavicle - subclavian
supracondylar (peds) - brachia
knee dislocation - popliteal
which is more common in ortho fx / disloc… vascular or nerve inj
nerve
nerve injury = physiologic disruption called
neuropraxia
nerve injury w axonal disruption but intact epineurium called
axonotmesis
nerve transection called
neurotmesis
common nerve injuries in ortho
- humeral shaft fracture - radial nerve - wrist drop
- knee dislocation - peroneal nerve - foot drop
- hip dislocation - sciatic nerve, peroneal division
common sites of heterotopic ossification in ortho
brachialis - distal humerus fracture
quadriceps - contusion
hip abductors - surgical dissection
weakest structures most prone to ortho injury according to age
peds - physes
adults - ligaments
elderly - bone
define degloving
A degloving injury is a type of avulsion in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply
define mechanism of stress fracture
Repetitive loading below endurance limit
additional injury to rule out if scapular fracture from big fall
pneumothorax
phases of bone healing
vascular
metabolic (4-6 wks post fx)
mechanical (remodeling under stress…bone needs Some stress to heal… don’t give Too much stability)
orthopedic emergencies
Compartment syndrome
Dislocations of major joints
Fractures with vascular injury
Open fractures
class of drugs that most commonly contributes to fracture nonunion
nsaids
need inflammation to heal…
why ortho traction after trauma
to keep muscles from shortening and making reduction difficult
how to treat infected hardware once glycocalyx forms
id org and give approp abx
REMOVE hardawre when fx healed… once glycocalyx forms you will never be rid of it so take it out
when does ligamentum teres stop supplying blood to femoral head
about age 4
according to Dr. Kessler
why fix clavicle fracture with tibial fracture
for crutch use
otherwise in most cases clavicle fractures are not fixed
“shoulder separation” refers to what joint
glycocalyx
conoid and trapezoid ligaments attach…
clavicle to coracoid
Distal humerus fracture risk this nerve
ulnar nerve palsy w Distal humerus fx
(radial with humeral shaft,
axillary with humeral neck)
dinner fork deformity aka
colles fx
(distal forearm
bones predisposed to avn
femoral neck fx
talar neck fx
proximal humerus fx
ortho treatment for complex regional pain syndrome
extensive physical therapy…
tf
swelling and erythema can be symptoms of complex regional pain syndrom
t Abnormal sympathetic tone Pain Stiffness Swelling Erythema etc...
when to sling vs fix shoulder disloc
usually sling
fix wide displacement, open fx, associated fx (ipsilateral or lower extremity… crutches)
manage proximal humerus fx
sling rom if simple minimal displacement
orif if displaced
hemiarthroplasty if comminuted
ligaments of clavicle shoulder joint
acromioclavicular ligament
conoid and trapezoid ligaments (coraco-clavicular ligaments)
treat shoulder dislocation
closed reduction
2-3 weeks immobilized
early rehab
surgery for athletes / high demand young pts
nerves at risk in supracondylar humerus fracture
AIN
Ulnar
manage supracondylar humerus fracture
immediate referral to orthopod (neurovascular risk)
-for closed reduction, percutaneous pinning, and 4-6 wks casting
3 phases of wound healing
few days (inflammation 4-6 days) few weeks (proliferation 4-24 days) few months-years (remodeling 21 days - 2 years)
bacterial load of wound infection
10^5
less than that just contamination
why not do elevtive surgery on a smoker
impaired wound healing (nicotine vasoconstricts and CO… poisons… reduced oxygen)
eg nose job will just necrose their face
tf
keloid = hypertrophic scar
FFFF
keloid is Outside borders or original injury, w preference for darker skin, usualy recur if excised (excision typically deferred for 12-24 mos)
-hypertrophic scar is Within borders of orignial injury w no skin preference, usually improve with excision if pain or contractures (excision typically deferred for 12-24 mos)
(both from excessive inflammation, disorganized collagen deposition, too much tension, secondary intension
healing by primary vs secondary intention
primary (closed) - edges brought together, no tissue loss
secondary (open)- edges not brought together, left open
cover cat or dog bite for infection
augmentin (amox clav)
for pasteurella multocida
BUT coag neg staph (epi, saphro) still most likely to cause infection of any skin wound
*can close dog bite, abx optional
*never close cat bite, always abx (deeper puncture)
treat dog vs cat bite
dog - can loosely close, abx optional
cat - Never close (deep puncture, can heal superficially and not deep and more likely to get infected), Always abx (augmentin to cover pasteurella multocida… and coag neg staph skin)
best finger to lose
actually index finger
… just for pointing… don’t want to lose thumb… ring and pinkie for power grip…
what is an unna boot
4 layer dressing for compression
bug in human bites
eg fight bight from punching teeth
eikinella corrodens (anaerobic) -need to be washed out
what limbs can you replant vs not
can replant UE forearm and below
NEVER lower extremity…
which needs debridemnt, wet or dry gangrene`
wet
dry is stable… needs vascular surgery to get flow back to it…
common site for venous stasis ulcer
what venous problems involved
medial malleolus
-venous htn and venous valvular incompetence
reconstructive ladder
secondary intention primary closure skin graft local flap regional flap free flap (not local, completely disconnected / transplanted)
difference graft vs flap
graft has no blood supply
flap does
acetic acid household item
vinegar
how are resting tension lines oriented compared to muscles
perpendicular to contraction
so perpendicular to fibers
e.g. crows feet orbicularis oris
what is a wet to dry dressing
moist gauze applied - saline, acetic acid (vinegar) for contaminated wound or clean, dakins solution (bleach) for necrotic or infected
allowed to dry and then changed
stages of skin graft incorporation
day 1-2 plasmatic imbibition - drinking plasma by passive absorption
day 3-4 inosculation - cut capillaries in graft find recipient bed vessels
day 5 - capillary ingrowth
major risks to grafts
fluid - hematoma/seroma
infection
shear force
full thickness skin graft donor sites
supraclavicular - for face grafts
groin - for most other full thickness grafts
forearm…
full versus split skin graft dermis primary contraction secondary contraction take rate cosmesis
full - all epidermis and Dermis, more primary contraction (as soon as removed - has all dermal elements / myofibroblasts, more elastin), less secondary contraction (as graft heals), lower take rate, better cosmesis (better for face)
split - some dermis, less primary, more secondary, higher take, worse cosmesis
split thickness skin graft donor sites
thigh buttock back
best cartilage graft donor sites
ear (concha - hollow next to canal)
rib
nasal septum
why do fat transplants work
aspirated fat has stem cells that allow transfer and take in new recipient site
primary vs secondary skin graft contraction
primary - as soon as taken out of body (full thickness with dermis - more elastin and myofibroblasts…)
secondary - occurs as graft heals in new site (split thickness, less thick more secondary contraction…)
best mgmt of pressure ulcers
PREVENTION
duration of sustained pressure for pressure ulcer to develop
2 hours sustained pressure
flap classification
based on blood supply type 1 - single vascular pedicle type 2 - dominant and minor pedicles type 3 - 2 dominant pedicles type 4 - segmental type 5 - segmental and dominant
golden rule of LE wound reconstruction
upper 1/3 - gastroc flap
middle 1/3 - soleus flap
lower 1/3 (ankle) - free flap
best cream for simple burns
silvadene
erythema without skin breaks is what type of burn
first degree
burn eschar around chest causes what? requires what?
respiratory distress
escharotomy
total body surface area risk for burn wound infection
^30% tbsa
primary blood supply to breast
internal mammary artery perforators
IMA perforators
benign skin lesions
- seborrheic keratosis - most common benign epithelial tumor, “stuck on”
- keratocanthoma - umbilicated dome-shaped red-tan nudule rapidly growing to average 2.5 cm within weeks
breslow depth
melanoma staging
v.75mm in situ
.76-1.5mm through bm into papillary dermis
1.6-4mm into reticular dermis
^4mm into subq
liposuction is for treatment of…
LOCALIZED adiposity
–pannus abdominoplasty for improvement of hygeine…
most common skin cancer
BCC
best way to determine tx for melanoma
FULL excisional bx to determine depth
most common benign skin tumor
sborrheic keratosis
when to repair a lip
goals
when to repair a palate
lip - 3 mos
goals - restore
palate - 9 mos
orthognathic surgery (eg of mandible to catch up after palate repair slowed growth) - 15yo ish
sensation to doral aspect of tip of index finger
median n
what should be ruled out before surgical tx of mandible fracture?
c-spine injury
check what physical exam finding when evaluating zygomatic fracture
eom - check for entrapment
what is important in repairing orbital floor fractures
reconstruct floor and walls to prevent exopthalmos
most important function of facial nerve
close eyelids
fever in viral vs bacterial pharyngitis
viral v101 not too high
^101 think bacterial
where to place needle/incision to tx peritonsiallar abscess
superior and medial to abscess, in bulge of soft palate superior and medial to abscess… toward uvula
tf
mediastinitis is a complication of bacterial tonsilitis
t
down fascial plane…
bugs in epiglottitis
BACTERIAL
H flu B HiB
(down w vaccine… but other bugs can still cause…)
function of pterygoids
open jaw
neck cyst by location
midline - thyroglossal duct cyst
(remnant from foramen cecum, near/through hyoid)
lateral - branchial cleft cyst (2nd cleft is most common)
-or salivary gland infection (Staph aureus)
malocclusionin head trauma refers to
misalignment of mandible / maxilla to one another
aka misalignment of bite
lefort fracturs are fractures of…
the maxilla (various types)
advantages vs disadvantages of cricothyrotomy for tx of airway emergency… vs tracheotomy?
hemorrhage less common
easier to identify prominent cartilage
less risk of esophageal injury
but higher risk of subglottic stenosis
which comes first, rhinitis or sinusitis
rhinitis (inflammation of nasal passageways)
then suniusitis - sinuses
ostiomeatal complex
links the frontal sinus, anterior and middle ethmoid sinuses, and the maxillary sinus to the middle meatus that allows air flow and mucociliary drainage
tf
reactive airway dz = asthma
f
reactive aireway dizease = exacerbation of lower airway problem (eg asthma) when chronic rhinosinusitis worsens… can treat by relief of rhinosinusitis to some degree instead of just treating asthma…
what bug infects w kartagener’s
pseudomonas
bugs in nose
coag neg staph
then staph a
then much less anaerobes, step pneumo, mixed
person choking, what to do
person found down, what to do
heimlich, back blow, finger sweep
jaw thrust, gauze to pull tongue forward
rinne and weber
Rinne test (mastoid process) Normal or positive if AC > BC Abnormal or negative if AC ≤ BC Weber test (forehead) If SNHL, lateralized to better hearing ear If CHL, lateralized to worse hearing ear
number 1 pathogen in otitis externa
pseudomonas
otitis media bugs
same as sinusitis bugs step pneumo hflu m catarrhalis gas (staph a rare)
kidney stone compositionby most frequent
calcium oxalate struvite calcium phosphate uric acid cysteine miscellaneous
treat kidney stone
- medical mgmt (80% will pass spontaneously with support)
- metabolic (urate or cysteine) stones always deserve a medical attempt
- lithotripsy, endoscope, laser are all surgical options…
lumbosacral myotomes
L2 - hip flexors L3L4 - knee extensors L4L5 - ankle dorsiflexors S1 - big toe extensor S4-5 ankle plantarflexor anal sphincter
key sensory dermatomes
c5 - shoulder
c6 - thumb/index
c7 - middle finger
c8 - small finger
t4 - nipple
t10 - umbilicus
l3 - medial thigh l4 - knee l5 - big toe s1 - lateral foot s4-5 perianal
