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Pestana Review Surgery

Head Trauma:
- Epidural hematoma, good prognosis if emergent craniotomy w/in first few
hours, fatal otherwise.
o Sx = trauma, initial LOC, lucid interval, gradual coma, fixed dilated
pupil on IL side, CL hemiparesis
- Subdural hematoma may present similarly to epidural, but have more severe
trauma mechanism
o Check CT scan, head + spine b/c of severity of injury. Needs emergent
craniotomy if midline shift but poor prognosis, otherwise medical
- Chronic subdural have trauma several weeks prior, gradual decline of MS,
elderly b/c of increased space and tension on bridging veins
o Tx is surgical decompression w/ craniotomy good improvement post
- Basilar skull fx = rhinorrhea, otorhhea, battles sign, raccoon sign
o CT scan of head and C-spine, neurosurgery, abx
- Neuro bleeding cannot cause shock
- Abd GSW and shock try to do ex lap immediately for control of bleeding +
concurrent IVF and blood administration
- Someone w/ GSW to abd + chest + shock could be hypovolemic b/c of
blood loss in GSW but also tamponade or tension PTX given chest injury, look
for CVP (high in last + resp findings of PTX)
- Tamponade is clinical dx if shock + distended neck veins w/out resp
signs/tracheal deviation do pericardial window, no imaging. If + do
o If location of wound really suggests tamponade may do thoractomy
right away
- No CXR for tension PTX do needle decompression then CT
- CP + distended neck veins + shock w/out trauma suggests cardiogenic shock
- no fluid resuscitation
- Vasomotor shock = anaphylaxis or spinal anesthesia/transection get low
CVP but warm and flushed patient
o Tx w/ vasoconstrictors, fluids OK too
Chest Trauma:
- Simple traumatic PTX if HDS can get CXR before CT placement
- For HTX, if HDS and not a massive amount of blood (1500 initiall, 600ml in 6
hours) then dont need surgery, just CT, low pressure lung parenchymal bleed
will stop on its own
o If large amount of initial blood or a lot in the preceeding hours then
could be arterial bleed from IC vessels do thoracotomy to ligate.
- Hemo-pneumothorax: dull to percussion at base, hyperresonat at apex, airfluid level on CXR
o Tx is CT, sx only if large amount of blood
- Tension PTX no CXR CT right away (needle decompression first), later CXR
to r/out widened mediastinum.
- Flail chest suggests high risk for other injuries
o MGMT is for pulm contusion fluid restriction, diuretics, colloid rather
than crystalloid fluids, resp support (intubation, PEEP)

Pulm contusion may show up later (day 2), see white on out
imaging + resp deterioration
o If other injuries mean they require OR/resp/intubation should place b/l
CT due to high risk of developing tension PTX during PP breathing
- Sternal fracture means high risk for myocardial contustion or aortic rupture
o Contustion: EKG, enzymes
o Aorta: CTA, TEE
- Diaphragmatic rupture get decreased breath sounds on one side but no
tympanic changes, would see bowel in chest
o Always on left
o Treatment is surgical repair from the abdomen
- Aortic rupture: hidden injury, may initially be stable as hematoma is forming,
be suspicious if have fx of hard-to-break bone like 1 st rib, sternum, or scapula
o See widened mediastinum on CXR
o Dx is arteriogram
o Tx is surgery
- Traumatic rupture of the trachea of major bronchus subQ air, CXR shows air
in tissues, confirm dx and level of injury w/ bronchoscopy, then surgical repair
Abdominal Trauma:
- Patient w/ HDIS but no scalp lac, normal CXR, normal pelvis think blood in
o Shock is loss of 25-30%, approx 1.5 L, would see in neck, CXR, pelvis,
or long bones if fx
o If suspect abd bleeding and stable CT
o If suspect abd bleeding and unstable FAST or peritoneal lavage
o CT w/ ruptured spleen if stable serial exam and CT, if unstable exlap
- All abd GSW go to surgery for exlap, even if stable
o Prep for surgery bladder catheter, big bore venous line, broad
spectrum abx
o Belly begins at nipple but chest does not end at nipple
So if patient with GSW below nipple line needs w/u for
penetrating chest wound (CXR, CT) + exlap
- Most bleeding in abd comes from liver, most clinically significant bleeding site
comes from the spleen
o Think if lower rib fx on left + shocky VS
o Diagnostics: if stable/responds to fluids then CT, may follow w/ serial
o if still unstable then FAST/lavage
If + FAST/lavage then exlap
Always try to save spleen before removing
If remove, need vaccinations
- Unstable + peritoneal signs = exlap
o Peritoneal signs can be from blood (VS) or hollow viscera contents
Urologic Trauma
- Hallmark is blood in urine gross hematuria in setting of trauma needs to be
worked up
o Microhematuria only needs w/u in peds b/c could be congenital
(incidental, not due to trauma)

Blood at meatus urthreal injury, needs retrograde urethrogram, dont

insert foley!
Posterior urethral injury may have high riding prostate and
sensation to void but unable
Tx is to get suprapubic and delay repair x 6 months
Anterior urethral injury needs repair right away
o Blood in urine bladder or kidney
Bladder dx with retrograde cystogram
Extraperitoneal place foley
Intraperitoneal surgical repair + suprapubic foley
Kidney almost always no surgery
Rare sequalae is AV fistula leading to CHF
- Scrotal hematoma needs surgery only if testicle is ruptured (sonogram)
- Penile fracture occurs only when penis is erect get fx of tunica albuginea or
corpora cavernosa needs emergency sx
- Chemical (alkaline worse than acid) needs massive amounts of irrigation
started ASAP
- High voltage electrical burns always worse than looks, may need massive
o Concern for myoglobinuria + RF TONs of fluids, osm diuretics,
alkalinization of urine
- Concern for resp burns if soot around mouth or in mouth, concern if
flame/chemical in enclosed space
o Dx w/ bronch + blood gases
o Tx w/ resp support
- Circumfrential burns bad b/c cut off blood supply when develop edema
o MGMT w/ serial monitoring of pulses
o If s/s of compromised circulation due escharotomies
- Scalding burns in children think abuse
- Third degree burns:
o White/leathery in adults
o Bright red in children
- Extent of burns rule of 9s
o Arms and head are 9 each, trunk is 4 9s, each leg is 2 9s
o Babies have big heads, get 2 9s for head and 3 b/t both legs
- Fluid requirement in burns
o 4 cc/kg/% burned mL of LR, want in first 8 hours
o Really are just adjusting to desired UOP and CVP
UOP want 1-2 ml/kg/hour
Keep CVP below 15-20
o Will see lots o UOP day 3 after burn edema reabsorbed and massive
o For babies 20 ml/kg/h if >20% burn
- Other burn:
o Tetanus
o Silver sulfadizine or mafenide acetate for deper
o Triple abx for near eyes/face b/c silver irritating

NG suction first 1-2 days then intense nutritional support (high cal,
high N2)
o If no regeneration in 2-3 weeks then graft
Early excision and grafting if 3rd degree and localized (under 20%)

*Human bites (cut on knuckle) need specialized orthopedic car including

surgical exploration
Pediatric Orthopedics
- Hip disorders:
o Developmental dysplasia: uneven gluteal folds, easy post dislocation
w/ jerk +click then snapping relocation
Tx is abduction splinting (no xray)
o Legg-Calve-Perthes disease: age 6, avascular necrosis of capital
femoraly epiphysis, get gradual limping + hip/knee pain + decreased
Dx w/ XRAY
Tx is contain femoral head w/in the acetabulum by casting and
o Slipped capital femoral epiphysis: chubby teen, groin/knee pain,
limping, foot turns towards other when dangling
Dx w/ XRAY
Needs ortho sx
o Septic hip toddler w/ recent febrile illness who then refuses to move
the hip
- Acute heme OM: febrile illness then localized bone pain w/o hx of trauma
wont see on XRAY for 2 weeks need MRI + abx
- Genu varum bowlegs, is nml up to age 3, then blunt dz
- Genu valgus knock knee, nml b/t 4-8
- Osgood-Schlatter dz teens w/ pain over tibial tubercle worse w/ contraction
of quads RICE tx, if no response then ortho for casting
- Club foot casting then sx at 9-12 months if no improvement
- Scoliosis is adolescent girls T spine tx if severe or issues w/ pulm function.
May progress until skeletal maturity is reached 80% at onset of menses
- Kids remodel super fast, may not need same degree of angulation you require
w/ adults
- Supracondylar fractures of the humerus from hyperextension when falling on
hand w/ arm extended issue is vascular and nerve injuries leading to
Volkmann contracture need to monitor median nerve and brachial artery
- Growth plate fractures can close reduction if fx does not cross the epiphyses
or growth plate and does not involve the joint if does then need precise
aligment w/ open reduction and internal fixation
- Primary malignant bone tumors seen in young persons while older it is
metastatic disease
- Osteogenic sarcoma is most common, seen in 10-25 y/o, subburst pattern on
- Ewing sarcoma in younger children age 5-15 see onion skinning

o Metastatic: lytic is breast, blastic is prostate
Path fx may be presentation
o MM get punched out lytic lesions + bence jones in urine + Ig in blood
o Soft tissue sarcomas are firm + fixed to surrounding structures
Mets to lung but not lmph nodes
General Adult Orthopedics
- Need two views 90 from one antoher + one join above and below
- Anterior dislocation of shoulder most common hold arm close to body but
located outwards
- Posterior shoulder dislocations from sz w/ massive contractions hold arm
close to body and IR, need axiallary or scapular XRAY views to detect
- Colles fracture: old lady, FOOSH, dinner fork, dorsally distplaced and
angulated distal radius fractures
- Monteggia/nightstick fracture is from blow to ulnar get diaphyseal fracture
of the proximal ulna
- Galeazzi fx is mirror of monteggia but of the raidus
- Metacrapl neck fx (4/5th) from closed fist hitting wall tx depends on degree
of angulation/displacement mild do closed reduction w/ ulnar gutter
- Hip fracture leg is shortned and ER
- Femoral neck fx need replacement of femoral head to prevent avascular
- Intertrochanteric fx less tenuous blood supply open reduction + internal
- Femoral shaft fx need intramedullary rod fixation high risk for clot b/c of
- Collateral ligament injuries from sideways blow to knee valgus stress hurts
medial, varus stress hurts lateral
- ACL more common than PCL do anterior drawer or Lachmans
- Meniscal tears do MRI get pop/click
- May get ACL, MCL, and MM together
- Tibial stress fractures xrays may be normal, do cast and repeat xray in 2
- Leg fx of tibia/fibula concern for compartment syndrome
- Rupture of achilles tendon do equinis position casting or sx
- Back pain
o Lumbar disk herniation L4/L5 or L5/S1 vague aching pain then
sudden neurogenic pain worse when coughing, sneezing, defecating,
+ straight leg raising tx is bed rest pain injections sx if neuro
o Cauda equine bladder retention, flaccid rectal spinchter, perineal
saddle anesthesias needs emergent decompression
o Ankylosing spondylitis young men, chornic back pain and morning
stiffiness wrose w/ rest, better w/ activity bamboo spine HLA-b27
o Metastatic malignancy progressive BP worse at night and unrelieved
by rest or positional changes + weight loss lytic women blastic men
- Leg Ulcers:
o DM ulcers: pressure points (heel, tips of toes, metatarsal head) , get
b/c of neuropathy, fail to heal b/c of microvascular dz

Arterial insuffiency tip of toes poor granulation in base other s/s of

AS dz like absent pulses, trophic changes, rest pain, claudication
doppler for pressure gradient (if not is microvascular dz and not
o Venous stasis ulcers from chronically edematous, inducated, and
hyperpigmented skin w/ granulating bed frequent ceulluitis support
stockings, ace bandages, unna boot
o Marjoin ulcer is SCC of skin that develops w/in chronic leg ulcer seen
w/ untreated third degree burns or chornic draining sinuses from osteo
get ulcer w/ heaped up dedges need wide local excision and skin
- Foot pain:
o Plantar fasciitis bone spur hurts but lots of us have them w/out pain
o Morton neuroma inflammation of the common digital nerve in the
third interspace b/t the 3rd and 4th toes- get palpable and tender spot,
can be from high heeled shoes/pointed boots analgesics and better
shoes surg
Orthopedic Emergencies:
- Compartment syndrome most commonly in lower leg and forearm
prolonged ischemia, reperfusion, crush, fracture w/ closed reduction is mst
common. Pai w/ passive extension.
- Pain under cast should remove cast and inspect
- Open fx need OR for cleaning and reduction w/in 6 hours
- Posterior dislocation of hip head on collision w/ knees up leg is shortned
and INTERNALLY rotated needs emergency reduction b/c of tenuous blood
supply of the femoral head + avascular nercosis potential
- Gas gangrene see w/ penetrating deep dirty wounds need debridement and
hyperbaric oxygen
- NV injuries:
o Radial nerve in oblique fractures of the middle to distal thirds of the
humerusm cant dorsiflex/extend wrist can resolve w/ reduction, if
not entrapped and needs OR
o Popliteal injuries w/ posterior dislocation of the knee, if delayed
restoration of flow need prophylactic fasciotomy
- Think of hidden injuries if: direction of force, fall from height landing on feet
(LT spine), head on automobile collisions, facial fractures/closed head think cspine.
Hand Probszzz
- Carpal tunnel women w/ repetitive hadn motion numbness in median nerve
distribution, particularly at night clinical dx or XRAY splint and NSAIDs if
need sx to nerve conduction studies
- Trigger finger also women flexed finger, painful snap to extend injections
before surgery considered
- De Quervain tenosynovitis from forced wrist flexion and thumb extension
pain with fist + ulnar deviation is radial side of wrist splint + NSAIDs +
steroid injections
- Dupuytren contracture older men of Norwegian descent get contraction of
the palm of hand and palmar fascial nodules can be felt may need surgery

Felon is abscess at pulp of finger tip fever throbbing can lead to tissue
necrosis so needs drainage
- Gamekeepers thumb is injury of ulnar collateral ligament from forced
hyperextension of the thumb casting
- Jersey finger grab jersey get when flexed finger is forcefully extended splinting
- Mallet finger extended finger is forefully flexed splinting
- Traumatically amputated digits surgically reattached
Pre-Op Assessment:
- EF less than 35% - 75-85% periop MI risk
- Goldmans index: JVD, recent MI, PVCs, other than sinus, emergency sx, >70,
aortic stenosis, poor medical conditions, surgery w/in the chest or abdomen
- JVD indicating CHF is worst, followed by recent MI
- Smokng compromised ventilation measure FEV1 cessation for 8 weeks
and IS therapy prior to surgery
- Hepatic: high bili, low albumin, high PT, ascites, and encephalopathy
- Severe nutritional depletion : loss of 20% of body weight, serum albumin
below 3, anergy to skin antigens, serum transferrin level less than 200 2-5
days of TPN helpful
- Diabetic risk is absolute CI to sx
Post-Op Complications:
- Fever:
o High fever immediately post op think malignant hyperthermia (also w/
metabolic acidosis and hyperCa do dantrolene and O2) or bacteremia
(like if instrumentation in the urinary tract, do blood culures x 3 abx)
o Usual 101-103 range:
Atelectasis POD 1
Deep thrombophlebitis POD 5
Wound infection POD7
Deep abscess POD 10-15
- Chest Pain:
o MI: during 2/2 hypotension, 2-3 days post op, much higher mortality
risk than non post op MI cant use tPA but do angioplasty + stenting
o PE: POD 7 hypoxemia, hypocapneia, resp alkalosis CTA, JVD, heparin
+ IVC filter if repeats
Prevent by preventing DVT TEDS on all those w/ LE fx + AC if
>40, pelvic or leg fx, venous injury, femoral venous catheter,
prolonged anticipated immobilization
o Other pulm: aspiration (why NPO, lavage w/ bronchoscopy,
bronchodilators and resp support)
o IO Tension PTX difficult to ventilate can decompress through the
diaphragm or anterior chest
- Disorientation/Coma:
o Hypoxia is first thing to suspect check abg and give supplemental O2,
may be 2/2 sepsis
o ARDS b/l pulm infiltrates w/out evidenve of CHF tx w/ carefell PEEP
o Delirum tremens give IV 5% ethanol in 5% dextrose or benzos

Hyponatremia if lots of non-isotonic (sodium free like D5W) in post op

patient with high ADH levels (triggered 2/2 trauma) tx w/ ? small
amounts of hypertonic saline and osmotic diuretics
o Hypernatremia large, unreplaced H20 loss sx damage to the post
pit w/ unrecognized diabetes insipidus need to rapidly replace fluid
but cushion tonicity w/ D51/2 or 1/3 NS
o Ammonium intox in cirrhotic patient
Urinary complications:
o Post op retention common do cath in 6 hours, if need to do 3 do
indwelling cather
o Zero OP mechanical issue
o Low UOP (less than 0.5 ml/kg/hr)
Dehydrated imp w/ bolus challenge, also excretion of Na is low
(less than 10-20 or fraction less than 1)
RF no imp w/ bolus challenge are not conserving Na so see
>40 and FeNa>1
Abdominal distension:
o Paralyatic ileus both small and large bowel, bowel sounds absent,
first few days post op, mild distension, no pain
o Early mechanical SBO b/c of adhesions, think if paralytic ileus not
resolving at 5-7 days, see dilated SB and air fluid w/ no gas in colon,
confirm T point with CT, need to sx
o Oglive is paralytic ileus of large bowel seen in sedentary patients
following non-abd surgery (femur) get abd distension, and see
massively dilated colon. Need to r/o mechanical obs before giving IV
o Dehiscence is seen around POD5 get pink colored fluid that is from
peritoneum bind and care for it, nonemergent sx later to prevent
ventral hernia.
o Evisercation abd contents rush out - em sx
o Wound infections POD7
o Fistulas of GI tract cause sepsis if not draining or if draining then
fluid/electrolyte loss, nutritional depletion, and skin erosion and
digestion of belly wall
Support, should heal if no FETIIDS FB, epithelization, tumor,
infection, IBD, irradiated tissue, distal obstruction, or steroids.
o Hypernatremia: lots of water loss (or other hypotonic fluids) I L for
every 3 above 140
Slow get adapt and no CNS issues, fast get CNS issues
Need to correct volume quickly but NOT tonicity b/c leads to
cerebral edema correct w/ D5 NS