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Millers > Trauma 1 > Flashcards

Trauma 1 Flashcards

1
Q

What is stage 3 shock?
EBL
HR
BP
RR

A

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

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2
Q

Whats the ratio of blood products for an MTE? What is an adverse reaction of giving pRBC

A

1:1:1
RBC:platelets:FFP

pRBC w/ citrate (preservative) - cause hypoCa

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3
Q

Describe stable vs unstable values for:
Lactate
pH
Base deficit

A

NORMAL
Lactate <2.5
pH > 7.2
Base deficit < -5.5

ABNORMAL
Lactate >4
pH <7.2
Base deficit > -6

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4
Q

What is a time goal for femur fracture fixation if concomitant abdominal injury?

A

> 12hrs - if appropriate

1 study that shows >50% risk reduction of complications when femur definitively fixed >12hrs from severe abdominal injury present

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5
Q

Is organ failure after trauma faster for kids or adults

A

Kids

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6
Q

What is independently associated w/ complications in poly trauma pt w/ pelvis frx

A

Severe chest injury

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7
Q

List the GA classification + abx required

A

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

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8
Q

3 most important interventions for decreasing infection with open fractures

A

TIMING IV abx
Time to thorough I&D (not time to definitive surgery)
Time to transfer to a definitive trauma center (LEAP/Pollak data!)

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9
Q

What is goal for ST coverage for open frx

A

<7 days - longer is associated w/ infx

Increase by 16% per day after this

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10
Q

What abx do you add to open frx prophylaxis for:
1. Water contamination
2. Farm contents or bowel/ischemia

A
  1. Quinolone
  2. Penicillin
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11
Q

Findings of FLOW

A

No benefit pulse lavage (increased cost)
High reop if you use soap (vs saline alone)

AKA saline on gravity!!!

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12
Q

What are the options for bone defects in open frx
<5cm
5-10cm
>10cm

A

<5cm - autograft +/- Masquelet
5-10cm - graft or transport
>10cm - bone transport (1mm/day)

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13
Q

What was the initial finding for LEAP at 2 years - amp vs salvage?
How did the finding hold at 7 years?

A

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

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14
Q

What is the metabolic changes for the following amp levels
- Syme
- BKA vs short BKA
- AKA

A
  • Syme 15%
  • BKA 10%
    vs short BKA 40%
  • AKA 70%

Through knee worse than AKA

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15
Q

What is the rate of MRSA in ortho trauma pts

A

3%
Think not that common in the world, so shouldn’t be in wounds initially

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16
Q

Compartment pressure dx for compartment syndrome

A

Measured pressure within 30mmHg of DBP

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17
Q

Nerve at risk with dual vs single incision lower leg compartment release

A

Single = CPN
Dual = SPN

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18
Q

3 thigh compartments

A

Lateral = quads
Medial = adductors
Posterior = hamstrings

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19
Q

How many foot compartments are there? 2 options for release

A

9 compartments
Single medial vs 2 dorsal incisions

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20
Q

Wound vacs - what is the data for:
- Open tibias
- Post fasciotomy
- At risk wounds (calc, pilon, etc)
- STSG

A
  • 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 $$
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21
Q

What factor is most important when considering surgical treatment of bullet wounds

A

Low vs high velocity bullet
E = M V^2

Low velocity can leave alone
High velocity - treat like open frx, serial debridement

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22
Q

OTA recs for DVT (pre-PCLOT)
- Initial DVT choice
- Mechanical DVT?
- Duration of AC?
- IVC filters?
- Which fractures may not need AC?

A
  • 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
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23
Q

What is the mechanism of action/reversal if applicable
ASA
Warfarin
Heparin
Xabans
Dabigatran

A

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

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24
Q

Major criteria for dx fat embolism syndrome / trt

A

Hypoxia (PaO2<60) - presents as:
- CNS confusion
- Petechial rash
- Pulm edema

Trt = ventilation support (aka nothing)

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25
Q

Diagnose ARDS

A

Bilateral CXR infiltrates
Less lung compliance
PaO2/FiO2 < 200

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26
Q

How should you position a pregnant patient if need surgery

A

Left lat decub - prevent aorta/IVC compression

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27
Q

What is the most injury domestic violence? RFs?

A

Facial frx

RF
- F
- 19-29
- Pregnant
NOT race or SE status

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28
Q

What are the 2 main posterior SI joint ligaments

A

Sacrotuberous - resist vertical shear (ischium to sacrum)
Sacrospinous - resist ER because more horizontal

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29
Q

Tile classification pelvis

A

A = stable frx (avulsions)
B = rotationally unstable (IR/ER)
C = rotation + vertically unstable

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30
Q

What is the Young Burgess classification pelvis
Does this classification predict mortality?

A

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

31
Q

Associated injuries for
LC 1/2
LC 3
APC 3
Vertical shear

A

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

32
Q

Describe an inlet vs outlet XR

A

Inlet = true ring XR, sacrum flat
Outlet = sacrum vertical

33
Q

What do you see on obturator outlet XR

A

Supra acetabular pins (“LC-2 screw”)
- Sup-inf placement
- Are you out of the joint

34
Q

What do you see on a teardrop XR? What is a teardrop XR?

A

Teardrop = OO w/ more outlet
Start point for supra acetabula screws

35
Q

What are the Judet XRs? What do you see on each?

A

Iliac oblique = IOWA
- Wall anterior
- Post col

Obturator oblique
- Post wall
- Ant col

36
Q

What do you use an obturator inlet XR for

A

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”

37
Q

What do you use an obturator outlet XR for?

A

Iliac crest pins
Vertical look at the crest

38
Q

What are the pros/cons for supra acetabular vs crest pins for pelvic ex fix? XRs you need for each

A

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

39
Q

What 2 risks with supra-tab pins

A

30% LFCN palsy (from compression on outside when sitting) - also see with the in-fix
9% HO

40
Q

What plate for anterior ring

A

Always 4-6 hole, never 2

41
Q

Iliosacral screws - nerve at risk

A

L5 > S1
Iliac cortical density shows you L5
- Lateral XR
- Stay behind the ICD

42
Q

Why look for sacral dysmorphism

A

S1 likely hard to use
S2 easier

43
Q

What are the 3 zones of sacral frx

A

1 = lateral to foramen
- Neuro rare
- If displaced, can be unstable

2 = foramen
- Neuro = uniL radiculopathy

3 = involves canal
- bilateral radiculopathy or cauda!!

44
Q

Diagnose:
- Kyphotic sacrum on sag CT
- Bilateral sacral rfx
- Paradoxical inlet XR (what does this mean)

A

Spinopelvic dissociation

Paradoxical inlet = you can see S1 on the AP pelvis

45
Q

How do you fix spinopelvic dissociation

A

Triangular osteosynthesis

Iliosacral screw
Unilateral lumbopelvic fixation

46
Q

Which bladder injuries do you have to fix with pelvic frx

A

Intraperitoneal - look for contrast in bladder tracking up into abdomen

47
Q

Best XR for vertical shear

A

Outlet

48
Q

How treat medial physeal clavicle fractures (vs SC joint dislocation)

A

Physeal frx
- Posterior can observe because remodeling occurs

49
Q

Absolute indications ORIF clavicle

A

Open / threatened skin
Vascular injury
Scapulothoracic dissociation being treated operatively

50
Q

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

A

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

51
Q

ORIF clavicles
- Which construct is less symptomatic hardware
- Which construct is best to resisting rotational forces
- Which construct is best to resisting bending forces

A

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

52
Q

What is the benefit of AC joint reconstruction

A

CONTROVERSIAL

Cots - no lasting clinical advantage
Metanalysis - earlier return to work, worse cosmesis with OR

53
Q

Indications for scapula frx ORIF

A

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

54
Q

Associated injury scapulothoacic dissociation

A

Neurologic injury - most common, 1ary det outcome
Subclavian rupture - why you’ll DIE, always get CTA

55
Q

Imaging findings for scapulothoracic dissociation

A

Distance between medial border of scapulae on CXR wide
Distracted clavicle fracture
SC or AC separation

56
Q

What is metaphyseal extension a predictor for non op treatment prox hum frx - what are the numbers

A

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

57
Q

What was finding of PROFHER for displaced 2 part fractures

A

No sig diff between op/non op 2yrs

58
Q

For deltoid split, how far down is the axillary nerve off the edge of the acromion

A

4-7cm

59
Q

Most common complication of ORIF prox hum frx

A

Screw cut out (fixed angle in bad bone)
Also 2/2 AVN

Some suggest strong calcar screw to prevent this

60
Q

Op vs non op algorithm for the test
- GT frx
- 2 pt prox hum
- 3+ prox hum: young vs old

A

GT >5mm displaced = op
2 pt prox hum = nonop everyone
3+ prox hum young = ORIF
“ “ old = RSA (vs nonop if sick)

61
Q

What is the distance from top of the pec tedon to the top of articular head

A

5.5cm

62
Q

Acceptable alignment parameters nonop humeral shaft frx

A

20 deg A/P
30deg V/V
15deg malrotation
3cm short

63
Q

CI bracing for hum shaft frx

A

BMI too high
NM injury

NOT comminution

64
Q

What are 2 risks of using IMN for humeral shaft frx

What structures are at risk with the distal locking bolts

A
  1. Higher rates shoulder stiffness…. duh
  2. 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

65
Q

Humerus approaches:

  • Anterior: which muscle has dual innervation
  • Lateral: what nerve at risk
  • Posterior: what structure limits extension proximally
A

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

66
Q

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

A

EMG 6wks
6ish mo minimum nonop

BR 1st to return

67
Q

What is the advantage to parallel vs orthogonal plating distal hum frx

A

BIOMECH STUDIES ONLY

Parallel plates = increased torsional stiffness

68
Q

What is the Milch classification distal hum condyle frx

A

Medial or lateral condyles - doesn’t matter

1: Trochlea intact
2: Frx through trochlea

Think like an articular frx, anything displaced needs OR

69
Q

Structure at risk if your olecranon tension band wires push out anterior

A

AIN

70
Q

Name 2 lateral approaches to elbow

A

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

71
Q

What is an Essex Lopresti? What must you address in OR?

A

IO membrane disruption
Need to create length stability - either ORIF or replace radial head

72
Q

3 parts of MCL

A

Post bundle - what you can resect to get more flexion
Ant bundle *** most impt
Transverse ligament

73
Q

Name parts of the lateral elbow ligamentous complex

A

Annular
LUCL
Radial colat

74
Q

What structures are disrupted?

Valgus laxity in supination
vs
Valgus laxity in pronation

A

Supination: LUCL +/- MCL
- splint in pronation

Pronation: proven MCL disruption
- splint in supination

Pronation will only improve PL instability when the MCL is intact

Millers (29 decks)

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