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Musculoskeletal > Perioperative Management of Fx Pt > Flashcards

Perioperative Management of Fx Pt Flashcards

1
Q

Define triage

A

A system of sorting patients according to need when resources are insufficient for all to be treated

Rapid identification and prioritization of the most serious problems followed by those less serious, so that life saving treatments may be administered

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2
Q

What are the overarching triage categories?

A

I -Catastrophic patients

Must receive therapy immediately (cardiac arrest, airway obstruction)

II - Critical patients

Therapy in minutes to an hour (bleeding, mult injuries)

III - Serious patients

Therapy within a few hours (blunt trauma, open wounds, burns)

IV - Pressing patients

Therapy within 12-24h

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3
Q

What are the triage categories for skeletal trauma?

A

I - Critical patients; immediate therapy (open fractures)

II - Semicritical patients; therapy in 2-5d

III - Noncritical; treatment within several days

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4
Q

What is assessed during the primary survey?

A

Level of safety (biting animals, infectious disease, blood in mouth, etc.)

Level of consciousness

  • Alert and oriented
  • Depressed but responsive to voice and vision
  • Responsive to pain only
  • Unresponsive

ABCs - airway, breathing, circulation

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5
Q

What is assessed during the secondary survey?

A 
Airway
Cardiovascular
Respiratory
Abdomen
Spine
Head
Pelvis
Limbs
Arteries (veins)
Nerves
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6
Q

Define closed fracture

A

The fracture does not communicate to the outside; no environmental contamination

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7
Q

Define open fracture

A

The fracture communicates to the external environment; has environmental contamination (5-10% of fractures)

  • Usually associated with high-energy trauma
  • Commonly seen in bones with little soft tissue coverage
  • Classified according to mechanism of puncture and severity of soft tissue injury
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8
Q

What are the areas of possible open fracture?

A 
Below stifle
Below elbow
Mandible
All contaminated
Complication potential
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9
Q

How are open fractures placed into categories?

A

According to origin and degree of soft-tissue injury

Alerts surgeon to complexity and magnitude of possible soft-tissue problems

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10
Q

Describe a type I open fracture (4 points)

A

The skin is penetrated from the inside out by a sharp bone fragment

Low energy force

Bone fragment usually retracts under the skin and is no longer visible

Wound is less than 1cm in the proximity of the fracture; mild soft tissue injury

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11
Q

Define a type II open fracture (4 points)

A

Wounding of the skin occurs from the outside in; Variably sized skin wound that communicates with the fracture. There is moderate soft tissue damage, more than grade I. Fracture is minimally comminuted

Higher energy force than grade I

Skin wound larger than 1cm

Foreign material may be carried into the wound at the time of injury or later

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12
Q

Describe a type III open fracture (4 points)

A

Extensive skin, SQ tissue, and muscle injury from the outside is present

Bone is usually fragmented due to a high-energy injury, with or without skin loss. Severe comminution

High-energy trauma

  • High velocity bullet wounds
  • Shear type injuries (HBC, partial amputation)
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13
Q

Describe a type III a open fracture

A

No major reconstructive procedure (flap, graft) needed to cover bone or wound

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14
Q

Describe a type III b open fracture

A

Reconstructive procedure required

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15
Q

Describe a type III c open fracture

A

Major arterial injury requiring repair

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16
Q

Describe a type IV open fracture

A

Amputation or near limb amputation; there is severe soft tissue damage and neurovascular injury present

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17
Q

How should a telephone assessment be conducted?

A

Calm owner

Ensure owner safety

Aim to stop hemorrhage and prevent contamination

Proper immobilization important - body board for spinal trauma; splint for fractures distal to the elbow or stifle. Do not allow the limb to dangle freely

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18
Q

What should one look for in a patient with a fracture?

A 
Swelling (hemorrhage, edema)
Bruising
Abnormal motion
Angular change
Crepitus (SQ emphysema, bony fracture)
Tenderness or pain
Re-examine unconscious patients when mentally alert
Rectal exam important
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19
Q

What are some possible fracture and soft-tissue damages?

A 
Contamination (foreign debris)
Damage to underlying neurovascular structures
Soft tissue damage (depth and width)
Motor and sensory function
Perfusion (Doppler US)
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20
Q

What is the most common stabilization method in a pt with a fracture?

A

Robert-Jones bandage

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21
Q

T/F: thoracic radiographs are often indicated in ots with a fracture

A

True

22
Q

How should one sedate a pt with a fracture?

A

Opioids are good for orthopedic pain, minimal cardiorespiratory depression, and are REVERSIBLE

23
Q

T/F: If not careful, a clinician may make a closed fracture an open fracture

A

True

24
Q

What is the first step in initial management of a fracture?

A

Cover open fractures immediately

  • Sterile dressing
  • Prevent nosocomial infection
  • Control hemorrhage
  • Prevent desiccation of bone and soft tissues
25
Q

What should be done immediately after covering an open fracture?

A

Check viability of the limb - may need to reduce fracture

  • Color and temperature
  • Distal pulses
  • Bleeding from cut nail bed
  • Motor and sensory function - re-evaluate once swelling subsides
  • Splint limb to prevent further soft-tissue damage
26
Q

How should rads be acquired?

A

Proper positioning with at least two orthogonal views

  • Completely evaluate fracture
  • Plan repair
  • May need rads of contralateral bone

Adequate sedation or anesthesia

Adequate analgesia

Good quality diagnostic images necessary
- Defer until patient is stable. Exception for spinal or cranial trauma (CNS rather than musculoskeletal trauma)

27
Q

T/F: most animals presenting to the ER fall between class I and II

A

False; most are between class III and IV

28
Q

What are the most common complications of an open fracture?

A

Delayed union
Non-union
Infection

29
Q

T/F: if any instability in a limb is felt, the area should be clipped to check for an open fracture

A

True

30
Q

T/F: NSAIDs are an ideal choice for analgesia in trauma patients

A

False; NSAIDs are filtered via the kidneys and not ideal in patients with possibly compromised kidneys

31
Q

T/F: Analgesia selection for the trauma patient is the same for every patient

A

False; selection is based on signalment, physical exam findings, and laboratory analysis

32
Q

T/F: analgesia is part of the anesthetic protocol

A

True

33
Q

What forms of analgesia are available for trauma patients?

A 
General anesthesia
Epidural analgesia
Local blocks
Opioids
NSAIDs
34
Q

T/F: It is important to use lube when shaving open wounds

A

True

35
Q

When should cultures of an open fracture be taken?

A

AFTER initial flushing and debridement (make sure what’s there is from there)

Take aerobic and anaerobic cultures

36
Q

Why are systemic antibiotics indicated in cases of open fracture?

A 
Environmental contamination (usually Staph, sometimes Strep, E. coli, Pseudomonas, Proteus, Klebsiella)
Use broad spectrum!*
37
Q

How should an open fracture wound be flushed?

A

.05-.1% chlorhexidine sol’n
Sterile saline sol’n or LRS under high pressure
Copious lavage
18-20g needle + 35mL syringe
Best to perform at time of formal debridement

38
Q

Debridement guidelines

A
  • Do not remove bone fragments that are firmly attached to soft tissue
  • Only debride obviously necrotic and avascular tissue, including devascularized bone
  • Remove dirt and foreign debris
    Be conservative with the skin
    Wet-to-dry dressing (use for continued debridement)
  • Appropriate bandage/splint
  • Appropriate pain management
  • Avoid premature wound closure as infection and wound dehiscence is a common complication
39
Q

What is a Robert-Jones Bandage?

A

A soft padded bandage with three layers

  • Padding layer: cotton or cast padding (1-3 1lb rolls for 25kg dog)
  • Pressure layer: elastic roll or conforming gauze
  • Protective layer: Vetrap

Extremely bulky so as to immobilize

40
Q

When is a Robert-Jones Bandage indicated?

A

Fractures or dislocations at or distal to the elbow and stifle
Provides temporary support of a fracture through immobilization, while maintaining even compression over the entire limb

41
Q

What is a Modified Robert-Jones Bandage?

A

Same 3 layers as R-J Bandage with tape stirrups underneath
Less bulky
With or without splint

42
Q

When is a Modified R-J Bandage indicated?

A

Cases where compression is needed to reduce soft tissue swelling but rigid stability is not needed

43
Q

T/F: When applying each layer of a bandage, the material should overlap 50% on each rotation

A

True

44
Q

T/F: Cast padding and gauze should not be visible past the Vetrap

A

False; want padding and gauze to protrude to minimize tension of vetrap on limb

45
Q

In a R-J bandage, one only needs to be able to see the tips of the pads of digits ___

A

3 and 4

46
Q

A Modified RJ bandage should use ___ layers

A

6-10

47
Q

One pass = ___ layers

A

2

48
Q

T/f: Subsequent layers in a bandage should extend past previous layers

A

False!

49
Q

When are splinted bandages used?

A

When weight bearing is needed and as an ancillary support to internal fixators

50
Q

What factors will influence a client’s choice of treatment for their pet?

A 
Degree of fracture
Cost of treatment
Severity of any other injuries
Prognosis
Quality of life
Complications
Postoperative management
51
Q

What is the current prophylactic antibiotic of choice and how is it administered?

A

Cefazolin 22mg/kg
IV 30-60min prior to incision
Repeat every 90 min
Discontinue at end of Sx

52
Q

Bandaging tips

A
  • Cast padding will rip before wrapped too tightly
  • Wrap should be cranial to caudal medially and caudal to cranial laterally to minimize supination
  • Wrap distal to proximal

Musculoskeletal (7 decks)

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