Trauma Flashcards
Abx prophylaxis
1 - Gustillo grade I injuries?
2- Grade 2?
3 - Grade 3?
Grade I/II : 1st gen cephalosporin
Grade III: cephalosporin + amino glycoside
Add PCN for farm injuries or bowel contamination (clostridium)
Class I shock (% blood loss/mL)?
Class II-% loss and sx?
Class III?
Class IV?
Class I: 15%, <750 mL
Class II: 15-30%, 750-1500 mL, HR increases, Tx w/ fluid
Class III: 30-40%, 1500-2000 mL, HR >120, deceased BP, urine decreased, decreased pH, Tx with fluid AND blood
Class IV: >40%, >2000 mL, >140 BPM, negligible urine, lethargic/coma, tx w/ fluid and blood
Adequate resuscitation markers - Lactate? gastric mucosal pH? base deficit?
Serum lactate: <2.5 mmol/L
Gastric mucosal pH: >7.3
Base deficit: -2 to +2
Highest risk of viral transmission following blood trasfusion - Hep C, Hep B, HIV?
Hep B - 1 : 205,000
Hep C - 1: 1.8 million
HIV - 1 : 1.9 million
Indications for DCO?
GCS <8 Bilateral femoral fx Multiple injuries with severe pelvic/abdominal trauma and hemorrhagic shock Pulmonary contusions Hypothermia <35 C Head injury IL6 over 500 pg/dL
What is acute inflammatory window after trauma?
2 to 5 days after injury, surge of inflammatory markers
Parameters for Early Appropriate Care?
Lactate <4.0 mol/L
ph > 7.3
Base excess > -5.5
Try to fix spine/pelvis/femur/tab w/in 36 hours
Adults or children have a more robust inflammatory response after trauma? What system affected first for each?
Adults more robust initial inflammatory response
Adults: Pulmonary
Children: dampened initial, then affects all organs simultaneously
Low velocity vs high velocity GSW (m/s, type of Gustillo injury)
Low velocity: <350 m/s or <2000 ft/s (handguns); Gustillo I or II
High velocity: >600 m/s or >2000 ft/s, Gustillo Type III; assault rifles/hunting rifles
Indications for surgery after GSW
Articular involvement unstable fx Presentation >8 hrs after GSW Tendon involvement Superficial fragment in palm or sole
Retained bullet in lumbar spine w/o neuro deficits and perforated bowel - Tx?
IV broad spectrum abx for 7 days
% increase with: 1- Syme 2- BKA (long vs short) 3- Vascular BKA 4: AKA
Syme: 15% BKA long: 10% BKA short: 40% Vascular BKA: 40% AKA: 68% trauma, 100% vascular
Wound healing after amp - good prognosis?
TcPO2 >30
ABI >0.45
Total lymphocyte count >1500
Albumin > 3.0 g/dL
Treatment for post amputation neuroma? Phantom limb pain
Neuralgia: Target muscle regeneration (TMR)
Phantom pain: mirror therapy
Contraindications to HBOT
History of COPD - blebs
Hx of bleomycin Tx - pneumonitis
Pneumothorax
Insulin pump - malfunction or deformation of device under pressure
After BKA, removal of dog ears damages what arteries for flap?
Sural and saphenous arteries
Hip fx mortality at 1 month and 1 year
1 month: 6%
1 year: 30%
Hip fx pt with head injury, ISS >25, hip fx and requires intubation in trauma bay. What is greatest risk of mortality at 1 year?
Intubation: in hospital 10%, 1 year 79% morality
Head injury 1 year 51%
hip fx: 6% and 30%
ISS: 73% at one year
Block to use to decrease opioid usage, delirium and length of stay for hip fx?
Fascia iliaca block
muscles of anterior leg compartment? Nerve? Vessel?
Tib ant, EHL, EDL, PT
Nerve: Deep peroneal
Vessels: Anterior tib vessels
Lateral leg muscles? Nerve?
Peroneus longus and brevis
Nerve: Superficial peroneal
Deep posterior leg muscles? Nerve? Vessels?
Popliteus, FHL, FDL, Posterior tib
Nerve: Tibial nerve
Vessel: posterior tib vessel
Superficial posterior leg muscles? Nerve?
Gastroc, soleus, plantaris
Nerve: Medial sural cutaneous nerve
Position of foot for least pressure in leg compartments while in cast?
Resting platarflexion
30-50% less pressure
Signs of pediatric compartment syndrome?
Analgesia requirements, agitation, anxiety
Saline load test for knee: 95% sensitivity? 99%?
95%: 155 mL
99: 175 mL
Tx of gonococcal septic arthritis?
3rd gen cephalosporin (ceftriaxone), PCN and tetracyclines not effective 2/2 resistance
Types of Necrotizing fasciitis: Type 1? Type 2? Type 3? Type 4?
Type 1: Polymicrobial, most common 80-90%, seen in DM, cancer
Type 2: Monomicrobrial (GAS), 5% cases, seen in healthy patients
Type 3: Marine vibrio vulnificus, marine exposure
Type 4: MRSA
LRINEC scoring system
Score >6 92% of nec fasc CRP >150 = 4 pts WBC <15 = 0, 15-25 = 1, 25+ =2 Hb >13.5 = 0, 11-13.5 =1, <11 = 2 Na <135 = 2 Cr >141 = 2 Glucose >10 (mmol/L) = 1
Abx tx for nec fasc?
Generally polymicrobial PCN Aminoglycoside Metronidazole Clindamycin
Cierny-Mader classification for osteomyelitis (Anatomic location and host)
Anatomic location
Stage 1: Medullary
Stage 2: Superficial/cortical
Stage 3: Localized (medullary and cortical)
Stage 4: Diffuse (entire bone w/ bone loss)
Host type
Type A: normal
Type B: Compromised
Type C: Tx worse than infection
Def of sequestrum and involucrum?
Sequestrum: Devitalized bone that serves as infxn nidus
Involucrum: New bone around area of bony necrosis
How does VAC improve wound bed?
Decreases after load in capillary bed
Dilates arterioles - proliferation of granulation tissue
Removes interstitial fluid (contain inhibitory factors that suppress formation of fibroblasts, vascular endothelial cells)
Eliminates superficial purulence (Reduces anaerobic colonization
Removal excess fluid - maintains osmotic gradient
Biofilm process - 2 stages
Step 1: Adhesion, regulated by adhesions
After several bacteria attached –> step 2 –> quorum sensing/cell to cell communication
Allows maturation of biofilm and expression of genes that activate virulence factors
Preganglionic brachial plexus injuries - definition? Symptoms/signs?
Avulsion proximal to DRG - involves CNS - no regen
Horner’s syndrome - sympathetic chain disruption
Winged scapula medially - loss of serrates (long thoracic n), rhomboids (dorsal scapular n)
Motor deficits - flail ext
Sensory intact
Normal histamine test - C8-T1 sympathetic ganglion
EMG shows loss of innervation of cervical paraspinals
Postganglionic brachial plexus findings?
Involves peripheral nervous system - better prog
Sensory deficits
EMG shows maintained innervation of cervical paraspinals
Abnormal histmine test - redness and wheal but NO flare
Horner’s syndrome - Symptoms? When does happen after BPI? Which level?
Drooping of eyelid, pupillary constriction, anhidrosis
Happens ~3 days after injury
Disruption of sympathetic chain at c8 and/or T1 root avulsions
When to do immediate (<1 wk) surgical exploration of BPI?
Sharp penetrating trauma (except GSW)
Iatrogenic
Open injuries
Expanding hematoma or vascular injury
What is an Oberlin transfer?
Ulnar nerve used for upper trunk injury for biceps fxn
% femoral neck fx ass’d w/ femoral shaft fx?
6-9%
Mortality rate at 1 year after femoral neck fx? 2 year mortality in pts with renal failure?
1 year: 30%
2 year in pt w/ chronic renal failure: 45%
Major blood supply to femoral head in adult?
Medial femoral circumflex artery –> lateral epiphyseal artery
Anterior/inferior head from lateral femoral circumflex
Rate of osteonecrosis after hip fx? risk factors? Tx of osteonecrosis?
10-45%
Increased w/ increased initial displacement, non anatomic reduction
Tx: young pt: FVFG vs THA
Older: Hemi vs THA
Nonunion after hip fx rate? Risk factor? Tx?
5-30%
Increased w/ increased displacement, varies malreduction
Tx: valgus intertroch osteotomy (vertical fx to horizontal –> decreases shear)
FVFG (young pt w/ viable fem head)
Arthroplasty
Revision ORIF
When do hip fx fixation methods fail? Percentages of failure after fixation vs arthroplasty?
Most fail in first 2 years
Fixation 45%
Arthroplasty 8%
Higher failure after hip fx with cannulated screws or sliding hip screw?
Cannulated screws have HIGHER REOPERATION rates (not higher implant failure)
Esp for displaced, basicervical and current smokers
When do failure rates stabilize after hip fx operation?
ORIF/fixation and arthroplasty level off at 2 years, then no difference in ongoing failure rates
Risk factors for mortality after hip fx?
Male (37% at 1 yr vs 28%)
Older age
Increased comorbidities
What does Timed Up and Go (TUG) determine? Times at 4 days postop and 3 wks?
Need for walking aid
NOT independence of ADLs
4 days 58 sec (1 min)
3 wks 26 sec (30 sec)
Times above these predict need for walking aid at 2 years
Performing a valgus producing osteotomy for femoral neck nonunion. Currently at 40 degrees from horizontal, place pin at 130 degrees with planned 20 degree osteotomy. What angle for side plate?
150 deg
Guide insertion (130) + osteotomy (20) = side plate angle
Side plates available in 130 deg to 150 degrees
Risk for AVN after hip fx in young vs old? Men vs women?
Higher in those <60 (20%) vs 60-80 (12.5%) vs 80+ (2.5%)
Women 11% vs men 5%
When does mortality risk return to baseline after fem neck fx?
After 1 year returns to that of normal, age-matched controls
FRAX score factors?
Bone density of FEMORAL NECK (not spine)
Current smoking hx
Hx of parental hip fx
prior personal hx of fx before age 50
What other fx increases risk of hip fx at one year?
Proximal humerus fx
Risk factors for increased mortality after intertroch fx?
Male gender (25-30%) vs female (20%) Intertroch (vs FNF) Age >85 comorbidities ASA III and IV
Stable vs unstable intertroch?
Stable - intact posteromedial cortex (resists medial compressive loads when reduced)
Unstable - fx will fall into varus Posteromedial comminution Thin lateral wall (<20 mm suggests postop lateral wall fx) Reverse obliquity Subtract extension
What test to get with isolated greater trochanter hip fx?
MRI - eval for intertroch extension
4 hole vs 2 hole SHS for intertroch fx - which is better?
No difference clinically or biomechanically
Most common failure after intertroch implant fixation?
Implant failure and cutout
Risk factors for increased postop infection after tibia plateau ORIF?
OR time >3 hours
Open fx
Indications for clavicle operative intervention (absolute and relative)
ABSOLUTE indications: Open fx Displaced with skin tenting Subclavian artery/vein injury Floating shoulder Symptomatic nonunion/malunion
Relative indications Displaced with >2cm of shortening Bilateral clavicles BPI Polytrauma
Risk factors for nonunion of clavicle fx treated nonop?
Comminution >100% displacement >2cm shortening Elderly Female Lateral 1/3 fx (11% vs 4.5% midshaft)
Outcome of displaced mid shaft clavicle fx with >2cm shortening treated nonop?
1-5% nonunion
Decreased shoulder strength and endurance
Superior vs anteroinferior plating for clavicle fx: which is higher load to failure? Lower risk of neurovascular injury? Lower removal of deltoid?
Higher load to failure: Superior plating
Lower rate neurovasc injury? anteroinferior plating
Lower removal of deltoid attachment: Superior plating
Advantages of plating clavicle?
Improved results for fx >2cm shortening or 100% displacement
Improved functional outcomes and less pain w/ overhead
Faster time to union (16 wks vs 28 wks)
Decreased symptomatic maluinon rate
Better cosmoses
increased shoulder strength/endurance
Definition of clavicle malunion
Shortening > 3cm
Angulation >30 degrees
Translation >1 cm
% of clavicle plates that require removal?
30%
Nonop vs op clavicle fx: constant shoulder scores and DASH scores?
Improved in operative group at all time points
Operative indications for scapula fx?
Open fx
Loss of RC fun
coracoid w/ >1 cm displacement
Glenopolar angle <22 degrees
GH instability
displacement or >25% joint surface (instability)
>5mm glenoid articular step off
Scapular neck:
>1cm medial displacement
>40 degrees
Most common ass’d injury w/ scapula fx?
Rib fx
How to treat humerus nonunion?
Compression plating +/- bone graft (4.5 plate)
Superior to IMN
Where does radial nerve cross humeral diaphysis from: medial epicondyle? lateral epicondyle? Radiocapitellar joint?
Medial epicondyle: 20 cm proximal
Lateral epicondyle: 14 cm proximal
Radiocapitellar joint: 10 cm
Medial collateral ligament of elbow - origin and insertion? what does it restrain? when is it tight?
Anterior bundle originates from distal medial epicondyle, inserts onto sublime tubercle
Restrain to valgus (30-120 deg)
Tight in pronation
Lateral collateral ligament of elbow - origin and insertion? what does it restrain? when is it tight?
Originates from distal lateral epicondyle and inserts onto wrist supinatorus
Stabilizes against posterolateral rotational instability (PRLI)
Tight in supination
Pt has distal humerus fx, Y-type, requiring ORIF w/ pre-existing ulnar neuropathy, unchanged after injury: parallel or orthogonal plates? Decompress nerve?
Parallel plates has greater construct rigidity
Every screw pass thru plate, each screw as long as possible, screws should interdigitate, each screw through as many articular fragments as possible
Decompress nerve (in situ) if previous Sx or if hardware comes in contact with nerve (transposition)
Describe olecranon osteotomy length of osteotomy, apex distal or proximal?
Screw direction into ulna?
Chevron osteotomy apex distal 2cm
Cancellous screw slightly MEDIAL due to various bow of primal ulna
What surfaces of humerus place plate for distal humerus fixation if using orthogonal plates?
Posterolateral and medial surfaces
How to address lack of flexion at elbow after distal humerus fx with fracture united?
Open release of posterior bundle of MCL and excision of osteophytes
Posterior capsule if nec
Long K wire for olecranon osteotomy can affect which nerve?
AIN - thumb IP flexion
Predictors of humeral head ischemia after proximal humerus fx?
<8 mm cal car length attached to articular segment
Disrputed medial hinge
Displacement >1 cm
Angulation >45 deg
NOT the same as developing AVN
What is major blood supply to humeral head?
Posterior humeral circumflex artery
Takes off more distally than anterior humeral circumflex artery
Anterior circumflex goes to anterolateral ascending branch and ARCUATE artery –> main supply to greater tuberosity
What determines if proximal humerus fx has separate “parts” for Neer classification?
Displacement >1cm
45 deg angulation
Determination of humerus plate pullout strength (measurement)
Medial + lateral combined cortical thickness >4mm
ORIF indications for proximal humerus fx
1- Greater tuberosity displaced >5 mm (impingement casting loss abduction and ER)
2- 2, 3, or 4 pt fx in young pt
3- Head splitting fx in young patient
Most common complication of ORIF of proximal humerus fx?
Screw cut out
How to prevent varus collapse in ORIF of proximal humerus fx?
Inferomedial cal car screw in osteoporotic bone
Proximal humerus fx: How far below articular surface of hemiarthoplasty should place getter tuberosity?
How to best determine height of prosthesis?
10 mm
determine height of prosthesis from superior edge of pec tendon –> 5.6 cm between top of humeral head and superior edge of pec tendon
Best predictor of successful outcome after hemiarthroplasty for proximal humerus fx?
Anatomic healing of tuberosities
Acceptable criteria for humerus alignment?
<20 deg anterior angulation
<30 deg varus/valgus
<3 cm shortening
Risk factor for nonunion in nonop tx of humerus fx?
Proximal 1/3 spiral or oblique fx patterns
Absolute Indications for ORIF for humerus fx?
Relative?
Absolute: Open fx Vascular injury Floating elbow BPI Compartment syndrome Periprosthetic humeral shaft fx at the tip of stem
Relative:
Bilateral humerus fx
Polytrauma
Path fx
Weight bearing after plate fixation of humerus fx?
Full crutch weight bearing has no effect on union
Humeral plating vs nailing - union rates? Complications? Shoulder pain? ASES scores? Nerve injury?
Union rate = no difference Complications = higher in IMN group Shoulder pain = higher in IMN group Functional shoulder scores (ASES) = SAME between two groups Nerve injury = No difference
Time point to determine nonunion for humerus fx being treating nonop?
6 weeks w/o callous on XR and fx motion
Radial nerve palsy after humerus fx - % that improve? when do they improve?
When get EMG?
Which muscle comes back first?
Which comes back last?
8-15% overall, 22% w/ distal 1/3 fx
85-90% improve
Recovery at 7 weeks with full recovery at 6 months
EMG at 3-4 months
First muscle: brachioradialis
Last muscle: extensor indicis
Transfers for radial nerve palsy?
1: PT to ECRB
2: FCR to EDC (important to maintain FCU to generate ulnarly directed flexion)
3: PL to EPL
Which nerve to identify when doing posterior approach to humerus to trace to radial nerve?
Posterior antebrachial cuteanous nerve
When to perform excision and triceps advancement for olecranon fx?
Elderly pt w/ osteoporosis
Fx <50% joint surface
Nonunions
Most common issue with ORIF after olecranon fx?
Symptomatic hardware
Safe zone for hardware placement in radial head?
90 deg from radial styloid to Lister’s tubercle
Tx of radial head fx?
Short period of immobilization and early ROM for isolated minimally displaced fx with no mech block
ORIF vs resection vs arthroplasty for >2 mm step off or mechanical block