Presby - Pre/post Op Management, Surgical Principles

Front 1

Pre-op note consists of:

Back 1

-32 yo AAF presents for surgical correction of her painful bunion left foot. condition has not resolved with conservative therapy.
-PMH: IDDM, HTN
-Meds/Allergies
-SH
-Sx H
-Labs
-Foot xrays
-chest xray; no active lung dz
-ECG; normal sinus rhythm
-Impression: HAV deformity left foot
-Plan; pt cleared for procedure as per Dr X, consent signed

Front 2

Post op note consists of

Back 2

-SAPPPA HEMI PC
-surgeon
-assistant
-preop dx
-post op dx
-procedure
-anesthesia (general, spinal, local)
-hemostasis (mmHg, time)
-estmated blood loss
-materials (suture, drains, fixation)
-injectables (abx, lidocaine)
-pathology (bone, soft tissue, foriegn)
-complications
-condition (stable, fair)

Front 3

Post Op / Admission Orders

Back 3

ADC VANDILMAX
-Admit to service of Dr...
-Diagnosis
-Condition (stable)
-Vitals (i.e monitor vitals q shift as per floor protocol)
-Activity (i.e bedrest)
-Nursing (elevate left leg)
-Diet
-Ins/Outs (fluid maintentance)
-Labs
-Meds
-Ancillary personell (PT, Socialwork)
-Xrays

Front 4

Inpatient Progress Note

Back 4

Date, Time
S-
O-
A-
P-

Front 5

exampled of Subjective part of inpatient Progress note

Back 5

-pt visited at bedside, offers no complaints. pt denies SOB, chest pain, cough, calf/thigh pain. Good appetite. -N/V, -abd pain, +void, + BM

Front 6

what is the normal temperature range

Back 6

97-99.5 F

Front 7

what can trigger malignant hyperthermia (temp >100)

Back 7

-inhalation agents such as ether, halothane, enflurane
-NM blockers like succinylcholine
-stress

Front 8

symptoms of malignant hyperthermia

Back 8

-first sign is arrythmias
-masseter muscle spasm
-rapidly rising temp
-tachycardia
-hyperhydrosis
-metabolic and respiratory acidosis
-dark, mottled skin
-hyperkalemia leading to cardiac dysarythmias
-elevated CPK levels
-myoglobin release

Front 9

treatment of malignant hyperthermia

Back 9

-stop anesthesia
-hyperventilate with 100% O2
-correct the acidosis
-cool the patient
-dantrolene

Front 10

what is dantrolene

Back 10

-muscle relaxant that prevents the release of calcium

Front 11

what is the pneumonic for post op fever causes

Back 11

-Wind, Walk, Water, Wound, Wonder Drugs
-Wind (12-24 hrs postop); atelectasis, pneumonia
-Walk (24hrs); thrombophelbitis, PE
-Water(48hrs); UTI
-Wound (72hrs); post op wound infection
-Wonder Drugs; drug fever

Front 12

what should Hct/Hb be for elective sx to take place

Back 12

Hct >40%
Hbg >10 gm

Front 13

what should be given to pts before a transfusion

Back 13

-50mg benadryl and 650mg Tylenol

Front 14

what lab test do you use to determine platelet deficiency

Back 14

-platelet count
100,000-400,00

Front 15

what lab test do you use to determine platelet fxn

Back 15

-bleeding time

Front 16

what factors does PT lab test evaluate

Back 16

2,5,7,10

Front 17

what factors does PTT lab test evaluate

Back 17

5,8,10,11,12

Front 18

mild to moderate HTN is not a significant risk for sx if the BP is...

Back 18

-if the distolic BP is stable and <110 mmHg

Front 19

in what direction should you prep an area for anesthesia injection

Back 19

-distal to proximal

Front 20

where do you enter for a Popliteal block and how much LA do you use

Back 20

-2 inches above the popliteal skin crease, medial to teh biceps femoris tendon(lateral tendon)
-30-40 cc's

Front 21

Common peroneal nerve block; where do you enter and how much LA do you use

Back 21

-it is very superficial nerve, so palpate the fibular head and enter lateral adn 2 cm distal to fibular head
-3-6 cc's

Front 22

why would you do a common peroneal nerve block

Back 22

-diagnostic for asessing spastic peroneal muscles or for stress inversion xrays for lateral ankle instability

Front 23

list the nerves blocked in an ankle block

Back 23

(5)
-posterior tibial
-superficial peroneal (int/medial dorsal cutaneous)
-deep peroneal
-saphenous
-sural

Front 24

what nerves are blocked with a mayo block

Back 24

-deep peroneal
-1st proper digital branch of medial dorsal cutaneous
-first proper digital nerve of MPN
-second proper digital nerve od MPN

Front 25

what nerves are blocked with a hallux block

Back 25

-first proper digital branch of the medial dorsal cutaneous and first proper digital nerve of the MPN
-deep peroneal proper digital branch to the hallux and 2nd proper digital branch of the MPN

Front 26

what do osteoclasts do; be specific

Back 26

-large cells located in the tip of the cutting cone which dissolves bone matrix and forms canals through existing bone
-responsible for new bone formation

Front 27

what is osteoid

Back 27

-non calcified organic matrix formed by osteoblasts
-contains collagen and proteoglycans
-osteoid becomes bone via mineralization

Front 28

mineralization

Back 28

-process in which osteoid becomes bone
-osteoid is deposited with crystalline hydroxyapatite to form bone

Front 29

what is woven bone

Back 29

-type of bone that forms healing bone callus
-disordered array of collagen fibrils
-eventually remodels to form lamellar bone

Front 30

what is lamellar bone

Back 30

-highly organized bone laid down in congruent layers with paralell collagen fibrils

Front 31

list the stages of bone healing and how long each lasts

Back 31

-Inflammation(day1-4);intial hematoma and necrosis of bone margins
-induction(unknown duration); callus develops from hematoma
-soft callus(day4-4wks);clinical union w/elimination of motion across site
-hard callus (4wks-4mths); callus converted to mature lamellar bone
-remodeling(4mths-2yrs)

Front 32

healing that occurs when bone fragments are immobilized and callus formation is absent

Back 32

-primary (direct healing)
-example is a plate

Front 33

what type of healing occurs when a bone isnt immobilized

Back 33

-secondary healing; motion allows for additional hemorrhage favoring fibrocartilage thus callus formation

Front 34

how will a fracture show up on Tc-99m bone scan at 1 week, 4 weeks and 2 years

Back 34

-week1-4; DIFFUSE uptake at fx site and areas of bone
-week 4-12; BIPHASIC pattern with uptake localized more to bone ends
-week 12-2yrs; coalescence stage with focal uptake at fx site only

Front 35

list the 3 types of vascular (hypertrophic) non unions and describe them

Back 35

-elephant foot (heavy callus formation)
-horse foot (mildy hypertrophic with poor callus formation)
-oligotrophic (no hypertrophy or callus formation)

Front 36

what causes a elephant foot to form

Back 36

-unstable fixation and premature WB

Front 37

what causes a horses foot to form

Back 37

-moderately unstable fixation

Front 38

what causes a oligotrophic non union

Back 38

-results from displacement of fracture or fixation w/o direct apposition of fragements

Front 39

what size gap can be healed with electrical stimulation

Back 39

-can be used as long as the gap isnt more then 1/2 the diameter of the bone involved
-or less then 1 cm

Front 40

how long does bone healing with electric stim take

Back 40

3-6 months

Front 41

why does anemia delay wound healing

Back 41

-hemoglobin less then 10gm/dl with a hematocrit less hten 33% is considered inadequate tissue oxygen supply for proper healing

Front 42

what is accuzyme?

Back 42

papain-urea debriding agent
-only digests non-viable tissue
-pt may complain of buring sensation

Front 43

List the 4 goals of AO (some german word for internal fixation)

Back 43

1. anatomic reduction
2. preservation of blood supply
3. stable internal fixation
4. early active mobilization

Front 44

what is the neutral axis of bone

Back 44

-when bone is loaded, a compression side and a tension side develops; the axis w/o tension or compression is the neutral axis

Front 45

is a plate placed on the tension or compression side of a bone and why

Back 45

-plates can withstand tension, but not bending
-so place the plate on the tension side

Front 46

what is the pitch of a screw

Back 46

the distance between threads

Front 47

which has a tighter pitch; cancellous screw or cortical

Back 47

-cortical, making it more suitable for cortical bone

Front 48

define a lag screw

Back 48

-screw whose threads dont engage hte near cortex or one that doesnt have "near" threads

Front 49

list the sequence of cortical screw insertion

Back 49

1. glide hole (overdrill)
2. thread the hole (underdrill)
3. countersink
4. measure depth
5. tap(make thread pattern) and insert screw

Front 50

what type of bone are cancellous screws meant for

Back 50

-designed for soft metaphyseal and epiphyseal bone

Front 51

3 conditions must exist for a screw to function as a lag (create compression across two sites)

Back 51

1. the near cortex must have a glide hole
2. the far surface must be threaded
3. when tighthened, the screw head must contact the near surface of the cortex to comrpess the fragments

Front 52

what is a trephine tip

Back 52

self cutting tip

Front 53

how is a cannulated screw used

Back 53

-designed to minimize complications assoc. with screw insertion
-k wire is used to achieve reduction and intr-op xray is taken to confirm placement
-k wire then serves as a guide

Front 54

how long after screw removal have fx across the screw been documented

Back 54

-11 months after removal
-so pts should be in a cast for 3-4 weeks after removal

Front 55

name 3 ways that plates can function

Back 55

-interfragmentary compression
-butressing
-neutralization
-plate can perform more then 1 fxn at a time

Front 56

these plates can be T, L, spoon or cloverleaf shaped

Back 56

-butress plates

Front 57

what do butress plates do

Back 57

-applied to a fracture site to prevent shift of the fragments under load

Front 58

LC-DCP

Back 58

-low contact dynamic compression plate
-minimizes the disruption of the blood supply under the plate

Front 59

Herbert Bone screw

Back 59

-headless screw allows for insertion of the screw through articular cartilage
-used for osteochondral fragments, met osteotomies, akin osteotomy

Front 60

Reese arthrodesis screw

Back 60

-screw with clockwise threads proximally and counter clockwise thereads distally and smooth portion in the middle
-designed to create greater compression across arthrodesis site

Front 61

complications of k wires and steinman pins

Back 61

-skin protrusion as a site of pin tract infection
-loosening causing necrosis
-migration and motion (less with threaded wires)

Front 62

complication of staples in bone

Back 62

-cortical shattering
-distraction of fracture ends
-fx displacement on insertion of staple

Front 63

if you are suturing in an infected wound, which type of suture should you use

Back 63

-monofilament

Front 64

swaged needle

Back 64

-this is the most common needle type
-suture is directly attached to the needle (eyeless)

Front 65

Ethilon, Surgilon, Ethibond, Dacron, Prolene, Surgilene

Back 65

synthetic non absorbable

Front 66

Dexon, Vicryl, PDS, Maxon and Monocryl

Back 66

Synthetic absorbable