MSK and Trauma

Question 1

What is included in the primary survey?

Answer 1

Airway with c-spine protection
Breathing with adequate oxygenation
Circulation with hemorrhage control
Disability - What injuries are we observing that are obvious to the naked eye
Exposure/Environment - Fully undress the patient

Question 2

First step in shock therapy for hypovolemic shock

Answer 2

IV Crystalloids

Question 3

What are the components of the Secondary Survey?

Answer 3

History
Physical exam: Head to toe
Complete neurologic exam
Special diagnostic tests
Re-evaluation

Question 4

When do you start the secondary survey?

Answer 4

After:
The primary survey is complete
ABCDE’s are reassessed
Vital functions are returning to normal

Question 5

Symptoms and exam findings of hypovolemic shock

Answer 5

AMS, anxiety
Cold, diaphoretic skin
Tachycardia
Tachypnea, shallow respirations
Hypotension
Decreased urinary output

Question 6

Treatment of hypovolemic shock

Answer 6

Fluid resucitation
–LR rather than NS because of Na
–Don’t worry about the volume. If they end up in heart failure, that’s fine. You can fix that with medicines.
–Monitor response
–Prevent hypothermia - pRBC are refrigerated

pRBC:FFP - 1:1 ratio
If infusing a lot of blood products, watch the K and Ca - can result in hyperK and hypo Ca

Question 7

What is a battle sign indicative of?

Answer 7

Basilar skull fracture

Likely need surgery and ppx antibx

Question 8

What is the Monro-Kellie Doctrine

Answer 8

There is only so much room in the skull so if something presses on the brain, CSF or venous volume will decrease

If there is no venous return from the brain, the brain will become hypoxic

Question 9

Cause of epidural hematoma

Answer 9

Often associated with skull fracture

Middle meningeal artery tear

Question 10

Clinical presentation of epidural hematoma

Answer 10

Initial LOC, followed by lucid interval, followed by vomiting and rapid decompensation to LOC

Can be rapidly fatal - needs evacuation and bone flap

Question 11

Causes of subdural hematoma

Answer 11

Venous tear/brain laceration

Question 12

When do you interfere with subdural hematoma

Answer 12

If >5mm of midline shift, recommend rapid surgical evacuation

Question 13

Below what GCS should intubation be considered?

Answer 13

GCS of 8 and below should likely be intubated because the LOC could get worse

Question 14

Why is Mannitol used in brain injury?

Answer 14

Creates an osmotic gradient that stalls cerebral swelling

Question 15

What is the best type of imaging for facial fracture?

Answer 15

Non contrast CT Face

Question 16

What is a LeFort Fracture?

Answer 16

The LeFort fracture is the most concerning of the maxillofacial fractures

Involves the maxilla and/or skull base

“Dish face”

Question 17

Management of trauma to the neck

Answer 17

Unless the impaled object is acting like a lever or definitely obstructing the airway, DO NOT REMOVE IT!

If there is bleeding, compression one side of the neck - low threshold to intubate

If the injury is strangulation/hanging:
–Apply a hard collar
–Assess for hoarseness (suggests injury to the larynx/hyoid bone)
–Assess for crepitus - trachea is no longer intact
–Obtain CT c-spine and CTA head and neck

Question 18

What is Horner’s Syndrome

Answer 18

Damage to the sympathetic trunk (nerve fibers running from the base of the skull to the coccyx).

Caused by carotid dissection or direct injury to the bundle of nerve fibers

Symptoms occur on the same side as the lesion of the sympathetic trunk:
-Miosis - constriction of the pupil
-Ptosis
-Anhydrosis - decrease in sweating

Question 19

What is L’hermittes Sign?

Answer 19

Elicited with the neck flexed and causes an electrical sensation that runs down the back and into the limbs. Generally uncomfortable.

Indicates possible MS and compression of the spinal cord in the neck from cervical spondylosis, disc herniation, tumor and Arnold-Chiari malformation

Question 20

What are the NEXUS criteria

Answer 20

Scale utilized to rule out the need for imaging for neck injuries

If all are negative, no need for x-ray of the neck:
-There is no posterior or midline cervical tenderness
-There is no evidence of intoxication
-The pt is A&Ox3
-There is no focal neurological deficit
-There are no painful distracting injuries

Question 21

What is a Jefferson fracture?

Answer 21

Burst fracture of C1

Question 22

What is a teardrop fracture?

Answer 22

Fracture that disrupts ant/post ligament and bone
Very unstable

Question 23

Lower back pain - red flags

Answer 23

Recent significant trauma or mild trauma with pain disproportionate to history/exam
Age >50
Unexplained weight loss
Unexplained fever/immunosuppression
History of cancer
IVDU
Osteoporosis
Prolonged use of glucocorticoids
Focal neurologic deficit or truly disabling symptoms
Duration greater than 6 weeks

Question 24

Neurogenic Shock: Causes, symptoms, treatment

Answer 24

Can occur in a spinal cord injury at or above level of T6

Is a syndrome of autonomic dysfunction
–bradycardia and hypotension
–Peripheral vasodilation causing hypothermia

Treatment goals:
–SBP >90 - use dopamine
–HR >80
–Keep warm, give warmed IVF
–Immobilize
–Insert foley, acute urinary retention is common

Treat with methylprednisolone and consult

Question 25

Treatment for cauda equina

Answer 25

Dexamethasone 10mg IV and consult neurosurgery for possible decompression surgery

Question 26

Clinical presentation of tension pneumothorax

Answer 26

Often the result of blunt trauma Respiratory distress Shock Distended neck veins Unilateral decrease in breath sounds Hyperresonance Cyanosis (late sign)

Question 27

Clinical manifestations of rib fractures

Answer 27

Pain localized to the area of the fracture Pleuritic pain Auscultatory crepitance Flail chest: 3 or more broken ribs in 2 or more places

Question 28

Treatment of rib fx

Answer 28

Single, non-displaced: NSAIDs, spirometry Admit 3 or more rib fx or if underlying organ damage Admit flail segment Usually will heal in about 8 weeks

Question 29

Early management of extremity trauma

Answer 29

Early concerns are vascular compromise and open fractures Assess and manage vascular compromise: -Reduce fracture -Splint fracture -Assess pulses by palpation or doppler -Obtain surgical consult Manage open fractures: -Apply appropriate splint -Clean/debride -Consider time factor -Obtain ortho consult -Antibiotic/tentanus status

Question 30

Symptoms of Compartment Syndrome

Answer 30

Pain Paresthesia Pallor Paralysis Pulselessness Poikiothermia (cold)

Question 31

How to assess for rotator cuff tear

Answer 31

Weakness and pain with abduction and adduction of the shoulder Job's Strength Test - resistance of adduction - supraspinatus muscle

Question 32

Clinical features of shoulder dislocation

Answer 32

Deformity noted plus a depression at the AC joint Patient cannot move shoulder at all Most common is anterior dislocation Posterior (rare) Inferior (very rare - arm up over head)

Question 33

Different methods of shoulder reduction

Answer 33

Cunningham - Massage and shoulder shrugs Milch - rotation of the arm outward and up until it pops back in

Question 34

Clinical features of radial head fracture and treatment

Answer 34

Usually caused by FOOSH Pain laterally, held at 80 degree flexion for comfort Pain in the elbow with supination/pronation Can see a "sail sign" in an occult radial head fracture Treatment: If <2mm displaced - Sling, ice, analgesia If >2mm displaced - Sling vs ORIF If comminuted: ORIF

Question 35

Why is it important to always reduce an elbow

Answer 35

Often associated with neurovascular compromise

Question 36

Clinical features of a scaphoid fracture

Answer 36

Most common carpal fracture although difficult to see on plain films Must not be missed as the scaphoid is poorly vascularized Snuff box tenderness and MOI by FOOSH If xray negative but clinically appears to have scaphoid fx, consider CT, MRI, bone scan Immobilize with thumb spica

Question 37

Treatment of subungual hematoma

Answer 37

Xray to assess for fracture Relieve pressure by trephination

Question 38

Management of pelvic fracture

Answer 38

Fractures of the non-load bearing parts of the pelvis generally require no treatment aside from pain medicine and rest Severe fractures often require ORIF Could consider pelvic binder to stop the bleeding CT imaging preferred to find small fx

Question 39

Tibial plateau fracture: Clinical presentation, diagnostics and treatment

Answer 39

Usually present with knee effusion and inability to bear weight Concern for compartment syndrome with tibial plateau fx Get CT if high suspicion and negative XR Treatment is knee immobilizer, non-weight bearing and surgery

Question 40

Ankle Sprain: Diagnosis and treatment

Answer 40

Presentation is pain, swelling, ecchymosis Xray only indicated for point tenderness, swelling and bruising Treatment is Ace wrap, aircast, crutches, ice, elevation and NSAIDs

Question 41

Masionneuve Fracture

Answer 41

Proximal fibular fracture accompanying any kind of ankle fracture Rotational forces are transmitted up to the knee Always palpate the proximal fibula in any ankle injury and have low threshold to image the whole fibula

Question 42

Lisfranc Injury: What is it? Treatment?

Answer 42

Injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus If <2mm displaced: Strict non-weight bearing for 6 weeks If >2mm, ORIF is indicated Can cause compartment syndrome and threaten the toes

Question 43

What is a Jones Fracture and how do you treat it

Answer 43

Proximal 5th metatarsal fracture Treated with splint and crutches

Question 44

Management of traumatic pneumothorax

Answer 44

Open pneumothorax (sucking chest wound) is caused by penetrating trauma Treatment involves 3 sided dressing and placing a chest tube In tension pneumothorax - insert 14 gauge angiocath into the 2-3rd intercostal space, mid clavicular line

Question 45

Symptoms of compartment syndrome

Answer 45

Severe ischemic pain Tensely swollen Skin perfusion, arterial pulses will be normal Paresthesia Passive stretch of muscle is painful Progressive loss of sensory/motor function Repeated examinations are required to check for developing compartment syndrome

Question 46

Diagnosis of compartment syndrome

Answer 46

Use of a Stryker tonometer: Normal is 0-8mmHg Compartment syndrome: >30mmHg

Question 47

What is the perfusion pressure of a compartment (delta pressure)

Answer 47

Delta pressure = Diastolic blood pressure - intra-compartmental pressure Delta Pressure <30 - indicative of the need for fasciotomy

Question 48

What is the only type of fracture that you would give an antibiotic for?

Answer 48

Open fracture

Question 49

What is the difference between a dislocation and a subluxation?

Answer 49

Subluxation is an incomplete dislocation