2. AJM Sheets:
• Trauma is another area that is often highlighted
during the interview process. This section first
details a trauma-specific work-up, and then goes
through some specific traumatic conditions. In
terms of the interview, you generally will be
expected to work-up, diagnose and classify based
on radiographs, CTs and MRIs. While you should
certainly have an understanding of treatment
interventions and protocols, this will probably be
less emphasized than diagnosis and classification.
• A lot of these classifications are very visual (and I
don’t have room for that in 100 pages), so I’ve tried
to include a lot of specific references with pictures
of the classifications (mostly to McGlamry’s and
Gumann’s texts).I’ve also tried to include a lot of
references to “classic” articles and review articles.
Textbooks with good trauma information for
additional reading include specific ones (Gumann’s,
Scurran’s, Rang’s, etc), but also general ones
(McGlamry’s, Myerson’s, Hansen’s, etc).
3. AJM Sheets:
• I said that while I was studying for the Diabetic Foot
Infection work-up, I tried to learn as much as possible on
the topic and really tried to “wow” the attendings at the
interview. However, my strategy was different when
dealing with trauma and the specific surgical work-ups.
Here I tried to demonstrate “competence” as opposed to
“mastery” of the material. With specific surgeries, you’re
really not supposed to have strong, pre-formed opinions
as a student or as an intern. That’s what your residency is
for; developing surgical opinions. If you already know
what to do in every surgical situation, then what’s the
point of doing a residency? So while on externships and
at the interview, you should really try to walk a fine line
between:
• 1. Displaying competence in knowledge of the baseline
material
• 2. Displaying that you still have a lot to learn, and that you
are eager to learn it
4. AJM Sheet:
Trauma
Work-up
• The Trauma Work-up is very similar to the
regular patient work-up, but with a few
things added. You still need to go through
the CC, HPI, PMH, PSH, Meds, Allergies, SH,
FH, ROS and complete physical exam in that
order. In addition, there are three other
topics that you need to address on every
trauma patient for every work-up:
6. ABCDE’s of
the Primary
Survey
• Airway: Three common forms of airway
obstruction are cervical spine injury, swollen
tongue and facial fracture.
• Breathing: Note how this is different from an
established airway. Someone can have an
airway, but still not breathing.
• Circulation: Assess vascular status in all four
extremities. Two large-bore (18-gauge) IV’s
should be started immediately if fluid
replacement is considered necessary.
7. ABCDE’s of
the Primary
Survey
• Deficits (Neurological): There are two ways
to assess this.
• AVPU→ Alert, responds to Verbal stimuli,
responds to Painful stimuli, Unresponsive
• Glasgow Coma Scale
• Based upon three criteria:
• Eye opening,
• Verbal response,
• Motor response.
• Based on scale of 0-15 (higher score indicating a
better prognosis)
• 13+ associated with a good prognosis;
• 7- associated with a poor prognosis.
• Exposure: Complete exposure of the patient
to evaluate further, unknown damage. (Take
the clothes off)
8. Tetanus
Status
• Clostridium tetani is a racquet-shaped gram-
positive bacillus. It releases an exotoxin
causing a pre-sympathetic blockade.
• Triad of tetanus symptoms:
• Trismus,
• Risus Sardonicus, and
• Aphagia.
• Characteristics of a tetanus-prone wound:
• greater than 6 hours old,
• clinical signs of infection,
• deep,
• devitalized tissue,
• contamination,
• traumatic mechanism of injury, etc.
9.
10. NPO status
• All trauma patients are potential surgical
candidates, so get this information for the weenie
anesthesiologists (Always remember that lunch is
for doctors, not for surgeons; while coffee breaks
and crossword puzzles are for anesthesiologists).
• Traditional guidelines recommend:
• Nothing by mouth after midnight the night before
elective surgery.
• Nothing by mouth within 6-8 hours of any type of
surgery.
• These strict guidelines are in the process of
changing however, particularly with regard to
allowing the ingestion of small amounts of clear
liquids up to the time of surgery. If interested,
please read:
[Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane
Database Syst Rev. 2003; (4): CD004423.]
[Murphy GS, et al. The effect of a new NPO policy on operating room utilization. J Clin Anesth. 2000 Feb;
12(1): 48-51.]
12. Types of
Shock:
Hypovolemic: most common; defined as the
acute loss of circulating blood. Treatment is
aggressive fluid replacement.
Cardiogenic: induced by myocardial
dysfunction.
Neurogenic: secondary to decreased
sympathetic tone from head and spinal cord
injuries.
Septic: shock secondary to infection.
• Goal of Treatment: restore organ perfusion.
14. 1. OPEN
FRACTURES
• Note that 30% of lower extremity open
fractures are associated with polytrauma.
• Mainstays of treatment: Aggressive incision and
drainage with copious lavage.
• It is generally recommended to never primarily
close an open fracture until devitalized
soft tissue has demarcated.
• This certainly isn’t always the case in practice. In
fact, the Ortho Trauma services at many
hospitals across the country routinely primarily
closes open fractures following I&D with ORIF.
• Follow traditional tetanus guidelines as listed on
the previous page.
15. Gustilo-Anderson Classification of Open Fractures [Gustilo RB, Anderson JT. Prevention of
infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.
JBJS-Am. 1976; 58(4): 453-8.]
16. Rank and
Thompson
Classification
Based on 4 criteria’s:
• TIDY WOUND: Surgical incision, laceration
• UNTIDY WOUND: Crush, avulsion, abrasion
• WOUND WITH TISSUE LOSS: Excision, burn,
ulcer, avulsion
• INFECTED WOUND:
• Established (cellulitis, lymphangitis, abscess,
burn, vasculitis)
• Incipient (burn, contaminated wound, abrasion)
17. Mangled
Extremity Severity
Score (MESS)
based on 4
criteria (score
points)
Skeletal / Soft-tissue injury
• (1) Low energy (stab; simple fracture; pistol gunshot wound)
• (2) Medium energy (open or multiple fractures, dislocation)
• (3) High energy (high speed MVA or rifle GSW)
• (4) Very high energy (high speed trauma + gross contamination)
Limb ischemia
• (1) Pulse reduced or absent but perfusion normal*
• (2) Pulseless; paresthesias, diminished capillary refill*
• (3) Cool, paralyzed, insensate, numb*
Shock
• (0) Systolic BP always > 90 mm Hg
• (1) Hypotensive transiently
• (2) Persistent hypotension
Age (years)
• (0) < 30
• (1) 30-50
• (2) > 50
18. Mangled
Extremity Severity
Score (MESS)
based on 4
criteria (score
points)
• * A (score) of 7+ = an increased likelihood of
amputation.
• * (Score) doubled for ischemia > 6 hours
• * Based on a (score) from 1-11 with a higher score
leading to an increased incidence of amputation.
• Gustilo-Anderson Classification of Open Fractures [Gustilo RB, Anderson
JT. Prevention of infection in the treatment of one thousand and twenty-
five open fractures of long bones: retrospective and prospective analyses.
JBJS-Am. 1976; 58(4): 453-8.]
• Review Paper for IIIa-IIIb sepsis rates: GustiloRB; MerkowRL; Templeman.
Current Concepts review. The management of open fractures. J Bone Joint
Surg[Am], 72:299-304, 1990 Feb
• Amputation Rates from: Gustilo1987 paper [Helfet DL, et al. Limb salvage
versus amputation. Preliminary results of the Mangled Extremity Severity
Score. CORR 1990; 256: 80-6.]
• [Bosse MJ, et al. A prospective evaluation of the clinical utility of the
lower-extremity injury-severity scores. JBJS-Am 2001; 83(1): 3-14.]
19. 2.COMPARTMENT
SYNDROME
First described by Volkmann. Myerson has good articles/chapters
on this topic.
Limb-threatening and life-threatening condition.
• Perfusion pressure falls below tissue pressure in a closed
anatomic space.
• As Intra-compartmental pressure rises, venous pressure rises.
• When venous pressure is higher than CPP, capillaries collapse.
• Oxygen delivery stops!
• Hypoxic injury causes cells to release vasoactivesubstances
(eg, histamine, serotonin), which increase endothelial
permeability.
• Capillaries allow continued fluid loss, which increases tissue
pressure and advances injury.
• Nerve conduction slows, tissue pH falls due to anaerobic
metabolism, surrounding tissue suffers further damage, and
muscle tissue suffers necrosis, releasing myoglobin
• The end result is loss of the extremity and, possibly, the loss of
life.
20. 2.COMPARTMENT
SYNDROME
If left untreated → rise in compartment
pressures → Muscle Ischemia → Muscle
Necrosis → Rhabdomyolysis
• Tissue Necrosis
• Permanent functional impairment.
• Renal failure and death.
Sequelae
• Rigid toe contractures
• Cavus Deformity
• Equinus
• Paralysis
• Sensory Neuropathy
• Gangrene
21. Clinical Signs can
be vague
• “Pain out of Proportion”
• DilaudidTest
• “Absent Pulses”
• Pulses can be absent or present!!!!!
• NOTE in the foot, DP and PT are palpable
because they are extra-compartmental.
• “Decreased Sensation”
• Epicritic pathways diminished
ALWAYS BE AWARE THAT COMPARTMENT
SYNDROME IS A CLINICAL DIAGNOSIS!
22. 7 P’s of
Compartment
Syndrome
• Pain out of proportion and not
controlled by analgesics
• Paralysis
• Pain with passive dorsiflexion of the
toes
• Pulselessness
• Paresthesia
• Pressure
• Pallor
23. How many
compartments
are there?
The foot has anywhere from 3-11 compartments depending on
who you read:
1. Intermetatarsal Compartments X 4: Contains the interossei
muscles
2. Medial Compartment: Abductor Hallucis
3. Lateral Compartment: Abductor digiti minimi
4. Superficial Central Compartment: FDB
5. Deep Central Compartment: Adductor Hallucis
6. Calcaneal Compartment: Quadratus Plantae
• Compartment Syndrome
• First described by Volkmann. Myerson has good articles/chapters on this topic.
• [Perry MD, Manoli A. Foot compartment syndrome. Orthop Clin North Am. 2001 Jan; 32(1):
103-11.]
• [Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin
Orthop Relat Res. 1993 May: 142-50.]
• Results when interstitial pressure exceedscapillary hydrostatic pressure, so the
microcirculation shuts down.
• The foot has anywhere from 3-11 compartments depending on who you read:
1. Intermetatarsal Compartments X 4: Contains the interossei muscles
2. Medial Compartment: Abductor Hallucis
3. Lateral Compartment: Abductor digiti minimi
4. Superficial Central Compartment: FDB
5. Deep Central Compartment: Adductor Hallucis
6. Calcaneal Compartment: Quadratus Plantae and lateral plantar artery
7. Dorsal Compartment: EHB and EDB
24.
25. Diagnosis
• Normal compartment pressure? 0-5mm Hg
• When do you start getting worried? 20-
30mm Hg
• When do you consider surgical intervention?
>30-40mm Hg
• How is diagnosis made? Wick or slit catheter
to measure compartment pressures.
26. Whiteside
Theory
• Delta-p (𝝙P) is a measure of perfusion
pressure (diastolic blood pressure minus
intra-compartmental pressure)
• DBP – CP > 30 = 😄
• DBP – CP < 30= COMPARTMENT
SYNDROME
• A Delta p of < 30 mm Hg means that the
patient is at risk for compartment
syndrome.
27. Treatment
• Decompression via fasciotomy, debridement of
necrotic tissue, copious lavage and
delayed closure
• Incision approaches: Consider dorsal vs. medial
approaches
• Fulkerson Method
• Needle through each intermetatarsal space
(four).
• Laterally through space plantar to fifth
metatarsal..
• Medially 4cm inferior to medial malleolus.
• Take pressures at medial compartment and
then at calcaneus compartment.
• Medial Arch through FDB.
28. Complications
• Permanent loss of function with structural
deformity (Volkmann contractures),
myoneural necrosis, sensory loss, chronic
pain
[Perry MD, Manoli A. Foot compartment syndrome. Orthop Clin North Am. 2001 Jan; 32(1):
103-11.]
[Myerson M, Manoli A. Compartment syndromes of the foot after calcaneal fractures. Clin
Orthop Relat Res. 1993 May: 142-50.]
29. 3.Gas Gangrene
• Medical & surgical emergency. Known as
“clostridial myonecrosis”. Bacterial infection
that produces gas in tissues. IDSA defines as
infection caused by clostridium species.
Immunocompromised, diabetic, malignant
disease are at greater risk . It is often
associated with mixed aerobic/anaerobic
bacteria. Gradual progression with better
prognosis if diagnosed early. More common
than clostridial gas gangrene
30. 3.Gas Gangrene
• Gram + bacilli,
• Anaerobic organisms which survive in tissue
only with low oxygen, toxins destroy cell wall
leading to necrosis.
• Dirty wound with dead muscle, area of
major trauma or surgery, or complication of
thermal burns
• Clostridium perfringens 90%
• Clostridium novyi 4%
• Clostridium septicum 2%
• Clostridium histolyticum
34. 3.GasGangrene:
Blood Draw
Positive result directly related to amount of
blood drawn
• 3 vials of 10 ml each
• Taken from 2 separate sites (two vials one
site, one vial the other site)
• Positive if 2 or more vials are positive for
common skin flora, or one vial positive for
uncommon organisms (such as yeasts,
anaerobic cocci, etc)
35. 3.GasGangrene:
Treatment
• It is a surgical emergency. Patient needs to be
scheduled for emergent Incision and Drainage.
Debridement and excision with possible
amputation Consent patient for the worst
because you don’t know what you will find in
the OR and surgical plans can change to save
patient’s life.
• Start IV Antibiotics, start broad and then tailor
when cultures return
• HBO therapy can be used in Diabetic foot
infections as an adjunct treatment for recovery
phase but you will hardly see this because of
conflicting studies.
• One I&D is never enough. If you see no further
signs of infection, application of wound vac is
adequate with aggressive wound care.
36. 4. Necrotizing
Fasciitis Work up
• Necrotizing fasciitis is a life-threatening
infection that spreads along soft tissue
planes with a mortality rate of 32%.
Mortality correlates with time to surgical
intervention.
• Risk factors include immune suppression,
diabetes, AIDS, cancer, bacterial
introduction, IV drug use, insect bites, skin
abrasions, abdominal and perineal surgery.
37. 4. Necrotizing
Fasciitis
Associated conditions usually include cellulitis.
However, overlying cellulitis may or may not
be present.
• Early Findings: localized abscess or cellulitis
with rapid progression minimal swelling, no
trauma or discoloration
• Late findings: severe pain, high fever, chills
and rigors, tachycardia
38. 4. Necrotizing
Fasciitis:
Physical exam
would usually
show
• Skin bullae
• Discoloration
• Ischemic patches
• Cutaneous gangrene
• Swelling, edema
• Dermal induration and erythema
• Subcutaneous emphysema (gas producing
organisms)
39. 4. Necrotizing
Fasciitis:
Treatment
• Emergency radical debridement with broad-
spectrum IV antibiotics whenever suspicion
for necrotizing fasciitis
• Liquefied Subcutaneous Fat
• Dishwater Pus
• Muscle Necrosis
• Venous Thrombosis
• Technique hemodynamic monitoring with
systemic resuscitation is critical. hyperbaric
oxygen chamber if anaerobic organism
identified
• Initial antibiotics: Start empirically with
penicillin, clindamycin, metronidazole, and
an aminoglycoside
41. Definitive
antibiotics
• Penicillin G
• for strep or clostridium
• Imipenem or doripenem or meropenem
• for polymicrobial
• Add vancomycin or daptomycin
• if MRSA suspected
43. Gun Shot
Wounds
• High velocity GSWs are characterized by
speeds >2500 ft/s. This is significant because
high velocity GSWs have a tendency to yaw
and tumble leading to increased cavitation.
• Cavitation: Large wound is created under a
situation of negative pressure. This
• Negative pressure “sucks” outside
contaminants into the wound.
(Ordog classification for gunshot wounds)
[Holmes GB. Gunshot wounds of the foot.
CORR. 2003 Mar; (408): 86-91.]
46. Resnick
Classification
• I. Superficial/cutaneous: usually visible
without signs of infection.
• II. Subcutaneous or articular without signs of
infection.
• IIIA. Subcutaneous or articular with signs of
infection.
• IIIB. Bone penetration without signs of
infection.
• IV. Bone penetration with known
osteomyelitis.
[Resnick CD. Puncture wounds: therapeutic considerations and a
new classification. J Foot Surg. 1990 Mar-Apr; 29(2): 147-53.]
47. Patzakis
Classification
• Zone 1: Toes to met head
• (50% incidence of osteomyelitis)
• Zone 2: Midfoot
• (17% incidence of osteomyelitis)
• Zone 3: Calcaneus
• (33% incidence of osteomyelitis)
[Patzakis MJ. Wound site as a predictor of complications following deep
nail punctures of the foot. West J Med. 1989 May; 150(5): 545-7.]
48. When should a
foreign body be
removed?
• Clinical signs of infection, known
contaminated object, pain, object close to
NV elements, intra-articular
51. How large must a
glass foreign
body be to be
visible on plain
film radiography?
Does
leaden matter?
• A piece of glass, regardless of whether it is
leaden, must be >5mm to be visible
52. Wound
Microbiology
Most common gram positives responsible for
soft tissue infections:
• S aureus
• S epidermidis
• Streptococcus
Most common gram negatives responsible for
soft tissue infections:
• E coli
• Proteus
• Klebsiella
53. Treatment
• The goal of treating puncture wounds is to convert a
contaminated or dirty wound into a clean wound.
• Begin by cleansing the wound with sterile saline. If local
anesthetic is needed, perform the block proximal to the
wound. You do not want to spread the soft tissues around
the wound.
• The wound should be explored with a blunt sterile probe.
Wounds extending beyond the deep fascia must be treated
aggressively to present deep abscess formation and
possible osteomyelitis.
• Incision and drainage are required in all deep,
contaminated or infected wounds. Once aggressive
debridement is completed, the wound should then be
irrigated, preferably with pressure irrigation. Deep wound
cultures then are taken by removing deep tissue samples
and sending them for culture and sensitivity. The wound
should be packed open or closed over a drain to prevent
hematoma or establishment of an anaerobic infection.
Intraoperative radiographic techniques may be utilized,
such as triangulation or a metal grid system.
54. Treatment
Controversial issue
• If the wound has not penetrated the plantar fascia and is
clear of any foreign matter or necrotic tissues, then
observation without antibiotics is sufficient
• If the wound has penetrated deep through the plantar
fascia, the likelihood of contamination may necessitate the
use of prophylactic antibiotics
• When puncture wound occurs in a shoe, the antibiotic must
cover pseudomonas aeruginosa.
Recommend:
• Oral fluoroquinolones, such as cipro
• Late puncture wounds with abscess formation or ascending
cellulitis must be treated with IV
• Antibiotics.
• anti pseudomonal penicillinclass, such as ticarcillin and
pipercillin;
• Third generation cephalosporins, such as cefoperazone
and ceftazidine; Aminoglycosides with clindamycin
• Wound causing osteomyelitis must receive IV antibiotics x 6
weeks
