Trauma 1 Flashcards
What is stage 3 shock?
EBL
HR
BP
RR
When you’re unstable - RULE of 3s
EBL = 30% blood volume (2000cc)
HR >130
BP decreased (can’t compensate)
RR 30
Resus with cystalloid and blood
Whats the ratio of blood products for an MTE? What is an adverse reaction of giving pRBC
1:1:1
RBC:platelets:FFP
pRBC w/ citrate (preservative) - cause hypoCa
Describe stable vs unstable values for:
Lactate
pH
Base deficit
NORMAL
Lactate <2.5
pH > 7.2
Base deficit < -5.5
ABNORMAL
Lactate >4
pH <7.2
Base deficit > -6
What is a time goal for femur fracture fixation if concomitant abdominal injury?
> 12hrs - if appropriate
1 study that shows >50% risk reduction of complications when femur definitively fixed >12hrs from severe abdominal injury present
Is organ failure after trauma faster for kids or adults
Kids
What is independently associated w/ complications in poly trauma pt w/ pelvis frx
Severe chest injury
List the GA classification + abx required
1 = <1cm
- Cephalosporin
2 = <10cm
- “ “
3 = >10cm, significant periosteal stripping even with small wound
- “ “ + aminoglycoside / OR 3rd gen cephalosporin alone (ceftriaxone)
3A = primary closure
3B = flap
3C = vascular injury requiring repair
3 most important interventions for decreasing infection with open fractures
TIMING IV abx
Time to thorough I&D (not time to definitive surgery)
Time to transfer to a definitive trauma center (LEAP/Pollak data!)
What is goal for ST coverage for open frx
<7 days - longer is associated w/ infx
Increase by 16% per day after this
What abx do you add to open frx prophylaxis for:
1. Water contamination
2. Farm contents or bowel/ischemia
- Quinolone
- Penicillin
Findings of FLOW
No benefit pulse lavage (increased cost)
High reop if you use soap (vs saline alone)
AKA saline on gravity!!!
What are the options for bone defects in open frx
<5cm
5-10cm
>10cm
<5cm - autograft +/- Masquelet
5-10cm - graft or transport
>10cm - bone transport (1mm/day)
What was the initial finding for LEAP at 2 years - amp vs salvage?
How did the finding hold at 7 years?
2 yrs
No difference in functional outcomes
No diff return to work
Salvage had more
- Complications
- Reop / readmission
7yrs - no difference again, both groups worsened
Aka clinical outcomes more related to social/personal/economic resources that injury management
What is the metabolic changes for the following amp levels
- Syme
- BKA vs short BKA
- AKA
- Syme 15%
- BKA 10%
vs short BKA 40% - AKA 70%
Through knee worse than AKA
What is the rate of MRSA in ortho trauma pts
3%
Think not that common in the world, so shouldn’t be in wounds initially
Compartment pressure dx for compartment syndrome
Measured pressure within 30mmHg of DBP
Nerve at risk with dual vs single incision lower leg compartment release
Single = CPN
Dual = SPN
3 thigh compartments
Lateral = quads
Medial = adductors
Posterior = hamstrings
How many foot compartments are there? 2 options for release
9 compartments
Single medial vs 2 dorsal incisions
Wound vacs - what is the data for:
- Open tibias
- Post fasciotomy
- At risk wounds (calc, pilon, etc)
- STSG
- Open tibias = less infx
- Post fasciotomy = better wound perfusion
- At risk wounds (calc, pilon, etc) = less infection and wound breakdown
- STSG = NO diff in healing, more $$
What factor is most important when considering surgical treatment of bullet wounds
Low vs high velocity bullet
E = M V^2
Low velocity can leave alone
High velocity - treat like open frx, serial debridement
OTA recs for DVT (pre-PCLOT)
- Initial DVT choice
- Mechanical DVT?
- Duration of AC?
- IVC filters?
- Which fractures may not need AC?
- Initial DVT choice = LMWH (enoxaparin) within 24h of MSK injury
NOW PCLOT ASA 81 BID - Mechanical DVT? YES strong rec
- Duration of AC? unclear, limited data
- IVC filters? Against unless PE/DVT on appropriate prophylaxis strong rec
- Which fractures may not need AC?
Below knee and able to mobilize
No diff for Lovenox vs placebo RCT
What is the mechanism of action/reversal if applicable
ASA
Warfarin
Heparin
Xabans
Dabigatran
ASA - irreversible thromboxane A2 on platelets
Warfarin - vit K antagonist
- Reverse vit K, FFP
Heparin - increase AT3 (indirect thrombin inhibition)
- Heparin faster onset that LMWH bc also inhibits X1 and IIa
- Reverse heparin w/ protamine
Xabans - factor Xa inhibitor
- Eliquis (apixaban), Xarelto (rivaroxaban)
Dabigatran - direct thrombin inhibitors
Major criteria for dx fat embolism syndrome / trt
Hypoxia (PaO2<60) - presents as:
- CNS confusion
- Petechial rash
- Pulm edema
Trt = ventilation support (aka nothing)
Diagnose ARDS
Bilateral CXR infiltrates
Less lung compliance
PaO2/FiO2 < 200
How should you position a pregnant patient if need surgery
Left lat decub - prevent aorta/IVC compression
What is the most injury domestic violence? RFs?
Facial frx
RF
- F
- 19-29
- Pregnant
NOT race or SE status
What are the 2 main posterior SI joint ligaments
Sacrotuberous - resist vertical shear (ischium to sacrum)
Sacrospinous - resist ER because more horizontal
Tile classification pelvis
A = stable frx (avulsions)
B = rotationally unstable (IR/ER)
C = rotation + vertically unstable
What is the Young Burgess classification pelvis
Does this classification predict mortality?
LC - IR forces
LC 1 - ramus frx, incomplete vs complete sacral frx (complete = 1.5)
2 - crescent ilium frx
3 - LC with CL ER = windswept pelvis
APC - ant-post or ER forces
AP 1 <2.5 opening
2 >2.5cm (open book) - anterior SI torn, hinging on the intact post SI lig
3 - everything torn, vertical and rotation unstable
Vertical shear
Does not directly predict mortality
Unstable patterns have higher mortality risk than stable
Associated injuries for
LC 1/2
LC 3
APC 3
Vertical shear
LC 1/2 - brain
LC 3 - bowel injury
APC 3 - shock (vascular), ARDS
Vertical shear - shock (vascular)
Vascular injuries - think about angio, embolization
- Superior glut MOST COMMON
- Obturator - 2nd most common for LC
- Internal pudendal, if injured bilaterally impotence
Describe an inlet vs outlet XR
Inlet = true ring XR, sacrum flat
Outlet = sacrum vertical
What do you see on obturator outlet XR
Supra acetabular pins (“LC-2 screw”)
- Sup-inf placement
- Are you out of the joint
What do you see on a teardrop XR? What is a teardrop XR?
Teardrop = OO w/ more outlet
Start point for supra acetabula screws
What are the Judet XRs? What do you see on each?
Iliac oblique = IOWA
- Wall anterior
- Post col
Obturator oblique
- Post wall
- Ant col
What do you use an obturator inlet XR for
Looking down the iliac wing
See if pins are contained in the ilium
“See passage of screws through supra-acetabular corridor from AIIS to PSIS”
What do you use an obturator outlet XR for?
Iliac crest pins
Vertical look at the crest
What are the pros/cons for supra acetabular vs crest pins for pelvic ex fix? XRs you need for each
Crest - less C arm dependent, potentially weaker bone
- Obturator inlet XR make sure in the wing
Supra-tab - strong bone
- Teardrop for starting point (OO)
- OI to see down the wing and make sure contained in ilium
- iliac oblique to keep the pin out of the hip joint and sciatic notch
What 2 risks with supra-tab pins
30% LFCN palsy (from compression on outside when sitting) - also see with the in-fix
9% HO
What plate for anterior ring
Always 4-6 hole, never 2
Iliosacral screws - nerve at risk
L5 > S1
Iliac cortical density shows you L5
- Lateral XR
- Stay behind the ICD
Why look for sacral dysmorphism
S1 likely hard to use
S2 easier
What are the 3 zones of sacral frx
1 = lateral to foramen
- Neuro rare
- If displaced, can be unstable
2 = foramen
- Neuro = uniL radiculopathy
3 = involves canal
- bilateral radiculopathy or cauda!!
Diagnose:
- Kyphotic sacrum on sag CT
- Bilateral sacral rfx
- Paradoxical inlet XR (what does this mean)
Spinopelvic dissociation
Paradoxical inlet = you can see S1 on the AP pelvis
How do you fix spinopelvic dissociation
Triangular osteosynthesis
Iliosacral screw
Unilateral lumbopelvic fixation
Which bladder injuries do you have to fix with pelvic frx
Intraperitoneal - look for contrast in bladder tracking up into abdomen
Best XR for vertical shear
Outlet
How treat medial physeal clavicle fractures (vs SC joint dislocation)
Physeal frx
- Posterior can observe because remodeling occurs
Absolute indications ORIF clavicle
Open / threatened skin
Vascular injury
Scapulothoracic dissociation being treated operatively
RF clavicle nonunion
Nonunion rate for nonop clavicles?
What is the NNT surgically for displaced clavicle fractures to prevent nonunion?
Biggest comp of op management
RF
- 100% displacement
- Older
- Female
- Smoking
15% nonunion
NNT to prevent 1 nonunion = 7
Presenters conclude not cost effective for health care system
Comp = reop for sx hardware
ORIF clavicles
- Which construct is less symptomatic hardware
- Which construct is best to resisting rotational forces
- Which construct is best to resisting bending forces
Op clavicle, will likely present Q stem with 100% displacement, >2cm shortening
Ant plating = least sx hardware
Anterosup plating = resist rotational forces
Ant = resist bending forces
What is the benefit of AC joint reconstruction
CONTROVERSIAL
Cots - no lasting clinical advantage
Metanalysis - earlier return to work, worse cosmesis with OR
Indications for scapula frx ORIF
Coracoid/acromion >1cm displaced
Glenoid displaced >2-5mm (articular frx)
Glenoid frx causing GH instability
Glenopolar angle = glenoid face relation to lateral angle scaupla
- Op <20 - aka face becomes almost parallel to lat border
- Normal 30-45
Scap body angle >45 (sagittal cuts)
Lateral border displaced >2cm from rest body
Associated injury scapulothoacic dissociation
Neurologic injury - most common, 1ary det outcome
Subclavian rupture - why you’ll DIE, always get CTA
Imaging findings for scapulothoracic dissociation
Distance between medial border of scapulae on CXR wide
Distracted clavicle fracture
SC or AC separation
What is metaphyseal extension a predictor for non op treatment prox hum frx - what are the numbers
Metaph ext <8mm poor predictor
Does the head piece have metaphysis on it or not
Aka does the medial calcar stay with the articular frag or the shaft
- Stays with head (aka >8mm of extension into metaphysis) = GOOD
- Stays with shaft = bad
What was finding of PROFHER for displaced 2 part fractures
No sig diff between op/non op 2yrs
For deltoid split, how far down is the axillary nerve off the edge of the acromion
4-7cm
Most common complication of ORIF prox hum frx
Screw cut out (fixed angle in bad bone)
Also 2/2 AVN
Some suggest strong calcar screw to prevent this
Op vs non op algorithm for the test
- GT frx
- 2 pt prox hum
- 3+ prox hum: young vs old
GT >5mm displaced = op
2 pt prox hum = nonop everyone
3+ prox hum young = ORIF
“ “ old = RSA (vs nonop if sick)
What is the distance from top of the pec tedon to the top of articular head
5.5cm
Acceptable alignment parameters nonop humeral shaft frx
20 deg A/P
30deg V/V
15deg malrotation
3cm short
CI bracing for hum shaft frx
BMI too high
NM injury
NOT comminution
What are 2 risks of using IMN for humeral shaft frx
What structures are at risk with the distal locking bolts
- Higher rates shoulder stiffness…. duh
- Iatrogenic radial nerve injury
- Why people harp about opening for reduction regardless of instrumentation choice
Distal locking screws:
- Lat to med screw = radial n
- Ant to post screw = MSC
Humerus approaches:
- Anterior: which muscle has dual innervation
- Lateral: what nerve at risk
- Posterior: what structure limits extension proximally
Ant: deep interval is brachialis split
- MCNn medial
- Radial n lateral
Lat: triceps post, BR ant
- Radial n
Post: mobilize triceps off medial (not triceps split)
- Ax n limits proximal
- See ABCn and radial n directly
When do you get the EMG for radial n injury with hum shaft? How long wait to operate?
What muscle comes back first with radial n recovery
EMG 6wks
6ish mo minimum nonop
BR 1st to return
What is the advantage to parallel vs orthogonal plating distal hum frx
BIOMECH STUDIES ONLY
Parallel plates = increased torsional stiffness
What is the Milch classification distal hum condyle frx
Medial or lateral condyles - doesn’t matter
1: Trochlea intact
2: Frx through trochlea
Think like an articular frx, anything displaced needs OR
Structure at risk if your olecranon tension band wires push out anterior
AIN
Name 2 lateral approaches to elbow
kAplan = Ant
- ECRL/ECRB
- Anterior so protects LUCL
- Closer to PIN (going through supinator
- This is the answer for any radial head/neck fracture that needs fixation extension onto the shaft
Kocher
- Anconeus (radial) / ECU (PIN)
- More risk LUCL
What is an Essex Lopresti? What must you address in OR?
IO membrane disruption
Need to create length stability - either ORIF or replace radial head
3 parts of MCL
Post bundle - what you can resect to get more flexion
Ant bundle *** most impt
Transverse ligament
Name parts of the lateral elbow ligamentous complex
Annular
LUCL
Radial colat
What structures are disrupted?
Valgus laxity in supination
vs
Valgus laxity in pronation
Supination: LUCL +/- MCL
- splint in pronation
Pronation: proven MCL disruption
- splint in supination
Pronation will only improve PL instability when the MCL is intact
