Surgery Flashcards
Pre-op, peri-op, post-op care Nutrition and Fluids management. Surgical emergencies
What are the 6 Ps of Acute Limb Ischaemia?
- Pain
- Pulseless
- Pallor
- Perishingly cold
- Parasthesia (which supersedes pain)
- Paralysis
N.o. 5,6 distinguish it from partial limb ischaemia (which can be treated medically first. Complete ischaemia needs revascularisation within 6 hours.
What is reperfusion injury?
Tissue damage as a result of reperfusion (vs ischaemia), due to production of free radicals
Complications of reperfusion (other than reperfusion injury)?
Reperfusion washes out byproducts of anaerobic metabolism - e.g. lactic acid - and cell lysis - e.g. K+, myoglobin. This can cause arrythmias, ARDS and acute renal failure (see below)
Cardiac arrythmias - because metabolic acidosis and hyperkalaemia
Acute renal failure: Rhabdomyolysis -> myoglobin -> acute tubular necrosis
Acute respiratory distress syndrome
Compartment syndrome - increased cap permeability + oedema = muscle swelling. Fascia restrict -> muscle necrosis. Treat with fasciotomy.
Open # Rx
6 A’s
1) Analgesia - M+M
2) Assess NV status, soft tissue, photo. Likely high energy injury, consider [head] CT.
3) Antisepsis - Wound swab, saline sterile gauze to cover
4) Alignment - reduce/splint. Reassess N+V, imaging - orthogonal, + joint above/below.
5) Antitetanus status
6) Abx - Co-amoxiclav
In theatre, debride, clean with wash-out and fixate externally.
When swelling reduced, fixate internally
Complication of an open #
Clostridium perfringens - gas gangrene + Sepsis
Debridement
Clindamycin
Open fractures are associated with high rates of morbidity and mortality
The most common fractures that are open are tibial, phalangeal, forearm, ankle, and metacarpal
Check the overlying area for skin breakdown or tissue loss
All patients with open fractures need antibiotic cover and up-to-date tetanus vaccination
Timely surgical management, with input from plastic and vascular surgery as required, will ensure optimal outcomes
Classification of an open #
Gustillo-Anderson
- <1 cm and clean
- 1-10cm and clean
3a. >10cm but high energy, but soft tissue coverage (Ortho can manage)
3b. ^ but not adequate soft tissue coverage (Need plastics)
3c. All injuries with vascular injury (Need Vascular team as well).
What is compartment syndrome?
inc. pressure in a fascial compartment
due to oedema/bleeding
can lead to muscle necrosis
Rhabdomyolysis -> Acute Tubular Necrosis
Symptoms of Compartment syndrome
Pain - even passive stretch
Parasthesia
Why is it important to remove pus from septic joint?
Pus - neutrophils
Destroy cartilage
Arthritis don’t want
Why intracapsular # matter?
Callus formation in joint not ideal
post-trauma arthritis
Types
Transverse
Oblique
Spiral
Comminuted
Avulsion
Don’t aspirate prosthetic knee joint that looks septic
no idea why
How to distinguish between transient synovitis vs septic arthritis
Kocher’s criteria
Non WB
Febrile
ESR raised >40
WBC raised >12000
Chorda equina red flags
Back pain
Saddle anaesthesia
Faecal incontinence/loss of anal tone
Urinary retention and subsequent stress incontinence
Shoulder trauma types
# Clavicle, prox humeral/humeral shaft # Dislocations - humeral and AC joint
Clavicle important points
FOOSH. Middle 3rd common site. Rx: Broad arm sling 3 weeks
Humeral shaft
Usually FOOSH, oblique and displaced….
Worry about radial nerve damage.
Rx: Collar/cuff
Definition of open #
A fracture is ‘open’ when there is a direct communication between the fracture site and the external environment. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum.
Painful arch
Subacromial impingement syndrome refers to the inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space
Presents with progressive pain in the anterior superior shoulder, typically worsening by abduction and relieved by rest
Diagnosis is a clinical one however MRI imaging can be useful to confirm the diagnosis and assess for further complications of the condition
Mainstay of management is conservative, with limited evidence advocating surgical intervention
Olecranon
Fractures of the olecranon process are relatively common fractures of the upper limb
Will often follow falling on an outstretched hand, with tenderness over the posterior aspect of the elbow and a potential palpable defect
Lateral and AP radiographs remain the mainstay of initial investigations
Management can be either operative or non-operative, heavily influenced by degree of displacement
What leads to mal/non-union
Fragments may have moved Soft tissue got in the way Too much movement Poor blood supply Infection
Rx Compartment Syndrome
Remove all bandages/splints
Lie limb flat (don’t elevate as decreases blood flow)
Monitor pressure in compartment using cathether - if difference between diastolic pressure and osteofacial compartment is less than 30mmHg, immediate decompression.
If you don’t have ^ equipment, then monitor symptoms after removal of bandaging, and if not improved 2 hours, immediate decompression
Fasciotomy. Open and leave for 2 days.
If muscle necrosis, debride
If none, then suture/skin graft
How long does it take for ischaemia to kill off muscle tissue?
4-6 hours
Why can compartment syndrome lead to renal problems?
Muscle death
Rhabdomyolysis
Acute Tubular Necrosis
Proximal humeral #
What nerve are you worried about?
TWO - Radial and (more commonly) Axillary
The axillary nerve is most commonly damaged by trauma to the shoulder or proximal humerus – such as a fracture of the humerus surgical neck.
Motor functions: Paralysis of the deltoid and teres minor muscles. This renders the patient unable to abduct the affected limb.
Sensory functions: The upper lateral cutaneous nerve of arm will be affected, resulting in loss of sensation over the regimental badge area.
Characteristic clinical signs: In long standing cases, the paralysed deltoid muscle rapidly atrophies, and the greater tuberosity can be palpated in that area.
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The radial nerve can be damaged in the axilla region by a dislocation at the shoulder joint, or a fracture of the proximal humerus. Occasionally, it is injured via excessive pressure on the nerve within the axilla (e.g. a badly fitting crutch).
Motor functions – the triceps brachii and muscles in posterior compartment are affected. The patient is unable to extend at the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist-drop.
Sensory functions – all four cutaneous branches of the radial nerve are affected. There will be a loss of sensation over the lateral and posterior arm, posterior forearm, and dorsal surface of the lateral three and a half digits.
Complications of #s
CNS ‘n’ VIV
Compartment Syndrome Nerve damage Sores - pressure and plaster Non-union Vascular injury Infection Visceral injury
Rx of anteromedial shoulder dislocation
! Axillary N injury
Analgesia Assess Radiograph Reduce Reassess Radiograph
Reduction is either traction/countertraction or modified kocker’s (ext. rota, adducted)
What are the types of non-union, and what can be done to treat?
Hypertrophic - Bone ends enlarged, so osteogenesis IS taking place, but not enough.
Functional bracing, Pulsed EM fields, Pulsed USS to stimulate along with rigid fixation
OR
Atrophic - Bone ends rounded and sclerosis present. No more osteogenesis will take place without intervention. Need to excise fibrous tissue and sclerotic edge of the bone + bone graft.
