Ortho- Trauma

Front 1

C-spine injury

Back 1

-assume C-spine injury in any pt with multisystem trauma: esp with AMS or blunt injury above clavicle
-neck should be immobilized until all aspects of c-spine studied

Front 2

eval of spine

Back 2

-examine from occiput to sacrum (logroll)
-inspect for bruising
-palpate for deformity of step off
-neuro exam (motor, sensory, reflexeS)
-rectal exam (bulbocavernosis reflex) - tells u if they are in spinal shock if you dont see the reflex

Front 3

radiographs of cspine

Back 3

-lateral spine: base of skull to T1
-AP, open mouth odontoid views
-flexion/extension views
-CT

Front 4

radiographs of T/L spine

Back 4

-AP and lateral views
-Must be obtained for any patient with multiple trauma, especially to the trunk
-Must be obtained in presence of C-Spine injury

Front 5

fixing fractures...

Back 5

-helps pts survive!
-helps with nursing care

Front 6

trauma pts

Back 6

-treat pt efficiently to avoid D's
Destitute
Divorced
Drug Dependent
Depressed

Front 7

fracture

Back 7

-the loss of continuity in the substance of the bone
-Fx = break = busted
from: crush, tapping, penetrating, gunshot (high vs low velocity)

Front 8

indirect trauma

Back 8

-traction or tensions: transverse fxs
-angulation: tension side fails first; transverse or transverse with butterfly fragment
-rotational: spiral fx
-compression

Front 9

high energy fxs

Back 9

1. open fxs (exception: outside trauma)
2. comminution
3. segmental (broken in more than 1 place)

Front 10

pathologic fxs

Back 10

-bone weakened by: metabolic, malignancy
-be suspicious fx with trivial trauma
-metastasis vs primary tumor

Front 11

pathologic fxs- be prepared in OR

Back 11

-blood availabe
-send specimen
-protect entire bone with implant

Front 12

metastatic bone tumors

Back 12

1. prostate
2. breast
3. kidney
4. thyroid
5. lung

Front 13

pediatric fxs

Back 13

-greater healing potential
-heals more rapidly
-thicker periosteum
-bones more pliable: greenstick fxs
-tremendous remodeling potential: most <10 yo

Front 14

Physeal fxs- Salter fxs

Back 14

I: epiphysis separates from metaphysis thru growth plate
II: thru metaphysis
III: thru growth plate and into joint
IV: through metaphysis, growth plate and into joint
V: complete crush of growth plate

Front 15

describing fxs

Back 15

-very impt!
-start with brief hx, age of pts, mechanism of injury, brief PMH include surgical and wound healing pertinent conditions: DM, smoking, obesity, bleeding diathesis, PVD
-descrive soft tissues: open or closed, compartments soft or tense
-describe fx
-neurovascular status

Front 16

soft tissue status

Back 16

-simple bone fx can become complex b/c soft tissue injury
-must be described

Front 17

describe the fracture

Back 17

1. Location:
-anatomic area
-1/3 bone
-metaphyseal/diaphyseal
2. Pattern:
-intra/extra-articular (in joint?)
-comminuted (multiple pieces)
-spiral
-transverse

Front 18

stages of fx healing

Back 18

1. inflammation
2. Repair
3. Soft callus: ~3wks, fragments no longer free moving
4. hard callus

Front 19

remodeling

Back 19

-replacement woven bone with lamellar bone
-occurs for yrs after fx healing
-Follow Wolffs law: bone placed in areas most stress

Front 20

diaphyseal fx

Back 20

-piece all fragments together like puzzle? -NO
-fragments with soft tissue are living pieces of bone
-fragments without soft tissue are dead bone
-restore length
-restore alignment
-restore rotation

Front 21

Articular fracture

Back 21

-Anatomic reduction: needed to prevent post-traumatic arthritis

Front 22

Traction

Back 22

-place pin in proximal tibia or distal femur
-add weight to pin via pulleys: keeps fx out to length
-Benefits: minimally invasive
-Disadva: poort control of fragments, long hospital stay, decubitus ulcers, labor intensive

Front 23

Traction role today

Back 23

-pediatric femur fxs
-temporizing

Front 24

Cast

Back 24

-minimally invasive, minimally stripping, better control of fragments
-complications: pressure sores, muscle atrophy
-must immobilize joint above and below
-can get stiffness and compartment syndrome

Front 25

External fixator

Back 25

-grab bone above and below fx with pins
-connect pins together externally with bars and clamps
-minimally invasive, better control of fragments, quick
-Disadvant: pin tract infxs, pts hate them

Front 26

external fixator role today

Back 26

-pediatric
-critically ill
-tempoizing

Front 27

plates and screws

Back 27

-grab bone above and below fx with screws connected to metal plate
-excellent control of fragments
-rigid construct
-disadv: large exposure

Front 28

intramedullary nail

Back 28

-metal rod placed inside meduallry canal of bone
-Screws through bone and rod grabbing above and below fracture site
-minimally invasive
-Excellent union rates with low rates of infection for diaphyseal fractures
-disadva: difficult to obtain adequate fixation for extremely distal fxs; reaming to place nail can lead to emboli

Front 29

open fx

Back 29

-disruption of the soft tissue such that bone is exposed to the external environment
-may see fat droplets draining
-concerns: osteomyelitis, limb loss

Front 30

open fx tx

Back 30

-needs prompt tx
-irrigation and debridement to prevent infx
-remove devitalized bone
-abx
-stabilization
-soft tissue coverage

Front 31

vascular injuries

Back 31

-may result in bleeding or ischemia
-blood loss may lead to hypovolemic shock
-open fxs: loss greater thn expected
-fxs of femur: up to 3 units blood loss
-pelvic fxs: up to 6 units
-may be limb threatening injury

Front 32

vascular injury diagnosis

Back 32

-Primary signs: brisk bleeding, expanding hematoma, abnml pulses-
-Seconday signs: bruit, thrill, pallor, dec refill, coolness, dec sensation, weakness
-BP/dopple exam
-Angiogram:whenever dx is in doubt

Front 33

Gustilo classification

Back 33

1: wound <1cm, low E
2. Wound 1-10 cm
3. A extensive periosteal stripping
B needs free flap
C arterial injuy requireing repair

Front 34

vascular injury tx

Back 34

-identify and tx before irreversible ischemia develops
-control bleeding (direct P)
-do not explore/clamp vessels in ER
-correct hypovolemia and gross deformity
-restoration within 4-6 hrs essential

Front 35

traumatic amputation

Back 35

-severe open fxs represent partial amputations
-hemostasis and wound care are priorities
-early decision whether limb is salvageable
1- status of pt
2-level of amputation
3-condition of amputated part/stump

Front 36

traumatic amputation tx

Back 36

-bulky sterile dresing to stump
-tetanus, abx
-transport to replantation center
-amuptated part: clean, wrap in sterile towel moistened with saline, place in sterile sealed bag, place bag in cooling chest with crushed ice and water
-DO NOT allow part to freeze

Front 37

compartment syndrome

Back 37

-swelling in leg due to fx causes pressure higher than perfusion P
-tissue w/out perfusion die
-potential limb loss
-more likely in tibia than femur
-tx is faciotomy

Front 38

compartment syndrome dx

Back 38

1. pain out of proportion
2. tense swelling
3. neurologic changes
4. loss of pulses
5. measure pressure

Front 39

joint dislocations

Back 39

-need prompt reduction
-longer wait, more difficult reduction is
-ideally reduced within 6 hrs (critical for hip and talus- avascular necrosis)

Front 40

proximal femoral fxs

Back 40

1. subtrochanteric fx
2. intertrochanteric fx
3. peritrochanteric fx
4. femoral neck fx
-potential disruption of bl supply to femoral head
-avascular necrosis

Front 41

femoral neck fx- fix or replace?

Back 41

Nondisplaced fx fis:
-capsule potentially intact
-cannulated screws, DHS
Displaced fx:
-likely disruption of bl supply
-younger pt attempt PRIF
-older pt: prosthetic replacement - bipolar or total hip

Front 42

Arthroplasty Hip- Cemented

Back 42

-implant glued into femur with bone cement
-immediate stability
-good for pts poor bone quality
-rarely used in young pts

Front 43

Arthroplasty hip- Ingrowth

Back 43

-Porous metal
-bone grow into metal
-need stability of implant for bone to ingrow

Front 44

Dislocation

Back 44

-arthroplasties potentially can dislocate
-Only thing holding stem reduced is geometry and soft tissue tension

Front 45

peritrochanteric fxs

Back 45

-blood supply to femoral head intact
-preserve hip
-ope reduction internal fixation

Front 46

Hip fxs

Back 46

-know preoperative ambulatory status
-pts usually lose level of function
-most will get operated on

Front 47

Damage control

Back 47

1. control hemorrhage
2. revascularize
3. release compartments
4. debride and irrigate
5. stabilize fxs