Ortho ppx

-Open fracture classification Gustilo- Anderson

-Size lac, degree soft tissue injury, contamination, vasc comp

-I: lac < 1cm, clean

-II: lac >1cm w/o extensive soft tissue

-III: lac >10 cm w extensive soft tissue injury or amp

-III A, B C

-Open fractures w/ increased incidence of infx/ osteo, vasc injury, nerve injury, compartment syndrome, VTE

-Orthopedic Trauma Association Open Fracture Classification- emerging classification system due to poor interobserver classification- Skin, muscle, contamination, bone loss- score greater than 5 add gram neg

-Goal for abx ASAP, 1-3 hours post injury by EAST guidelines

-Type I and II, Gram + only- Cefazolin 2 g Q8H

-Pts > 120kg get 3 g

-Alt clindamycin 900 mg IV Q8H

-Duration 24 hrs after closure

-Type III Gram + and –

-Cefazolin + Gentamicin or tobramycin 5mg/kg 1 time dose

-Adverse effects of aminoglycosides- Nephrotoxic- make sure adequately hydrated- Ototoxic(irreversible)

-Soil/feces contamination- Clostridium species- 4-6 million units penicillin IV q 4-6h- alt metronidazole 500 mg q 8H

-Fresh water contamination- Aeromonas- Zosyn or cefepime

-If unable can use cipro or levofloxacin

-Salt water Vibrio- Zosyn/cefepime + doxycycline (alt is cipro/levo + doxycycline)

-GSW open fx- EAST guidelines recommend to consider type 3

-Reality- low velocity (handguns) similar management to closed

-High velocity- Rifles/shotguns- similar to type III

-Recs- treat like type I or II unless contamination present. If extensive tissue damage treat like type III

Peds: Ortho/ NAT

-Le fort fractures never occur in children less than 2 due to lack of pneumatization of the sinuses

-Children less than 8- susceptible to ligamentous and growth plate C spine fx that are higher up

-Older children lower C spine fractures more common

-Posterior displaced medial clavicle fx needs CT to ensure no compression of mediastinal vessels or trachea

-Salter Harris classification

-Gartland Classification supracondylar fx- type II and III likely to require surgery

-Galeazzi

-Monteggia-

-Toddler’s Fractures- 12-94 months, low energy trauma w/ rotational force

-Subtalar joints have poor blood supply making it prone to osteonecrosis

-Chopart- separates midfoot from hindfoot- important for pronation and supination

-NAT- TEN 4 FACES P

-torso including genitals, ears, neck, frenulum, angle of the mandible, cheek, eyelid, subconjunctival hemorrhage, patterned bruising

-4- any bruising in a child less than 4 months of age

-95.6% sensitive, 87.1% specific for NAT

-Point tenderness over an unfused epiphysis concern for non-displaced salter harris- need splinting and follow up

-Nursemaids elbow- mechanism is being pulled

-Reduced by hyper-pronation or supination/flexion

-pain is usually at wrist

Tactical Medicine

-Swat developed after the Texas tower incident Aug 1, 1966

-1989 to 1990 interest began in involving medical professionals with SWAT

-Officers to learn methods of self rescue and to provide basic medical care

-TCCC- Tactical Combat Casualty Care

-Hot zone- immediate area with perpetrator- shooting back, moving casualty out of hot zone are priority

-Warm zone- potential for hostile threat, not under direct fire- Immediate care can be performed here- tourniquet, Chest seal/decompress, airway

-Cold zone- No significant threat of danger- more definitive care

-They use (S)MARCH- security, massive hemorrhage, airway, circulation, hypothermia

Nailbed Injuries and Arthrocentesis

-Indication for trephination- less than 1-2 days old, 50% or more of nail bed

-Be careful with flammable alcohols and check for acrylic nails as these are also flammable

-Nail bed laceration- digital nerve block, remove nail, repair w/ 5-0 or 6-0 absorbable sutures, replace nail into fold

-Arthrocentesis- suspicion of septic arthritis, crytal arthropathies, unexplained arthritis W/ effusion, eval of jt capsule integrity in trauma, therapeutic relief of pain/ effusion

-Contraindications: No absolute but relative include overlying cellulitis, prosthetics

– >50k WBC, >90% PMN cells indicative of septic joint