Spinal/Extremity Trauma

A 53-year-old woman presents to the ED 6 hrs after sustaining a shotgun injury to her left lower extremity. Her vital signs are stable. On exam, there are no identifiable pulses in her foot, and she has reduced capillary refill. She has a comminuted fracture of the tibia and fibula. She reports some tingling in her foot. In addition to irrigation and debridement in the operating room, what is your recommendation?

• Posterior splint with packing of the open wound and reexploration in 24 hours

• Primary amputation

• Application of an external fixator with mobilization of a muscle flap for tissue coverage

• Application of an external fixator

• Revascularization with synthetic conduit

Answer explanation

Using the Mangled Extremity Severity Score (MESS), the patient has 8 points for age over 50 years, transient hypotension, pulseless limb ischemia (doubled for >6 hours), and a low energy civilian gunshot wound.

>7 should be considered for primary amputation

10+ consider above-knee amputation

27-year-old man sustained multiple gunshot wounds to the left lower extremity and abdomen. He has a massive transfusion requirement from a superficial femoral artery injury. Damage control laparotomy is performed for a colon injury. He additionally has an open, comminuted midshaft fracture of the femur that is grossly contaminated. A shunt is used to restore flow to the distal superficial femoral artery. What additional intervention should be performed?

• Gluteal fasciotomy

• Systemic anticoagulation

• Above-knee amputation

• External fixation

Answer explanation

reduce and immobilize this severe fracture and also facilitate control of his emergency intra-abdominal concerns.

33M presents after his leg was ran over by a car. He is hemodynamically stable. No open wounds or gross bony deformity, but you note a nonexpanding popliteal hematoma. (ABI) in the injured limb is 0.85. What is the most appropriate next step in management?

• CTA

• Plain film imaging of the tibia/fibula and knee joint

• Operative exploration

• Admission for observation and neurovascular checks

Answer explanation

Hard vs Soft vascular injury signs

Hard signs: pulsatile bleeding, distal limb ischemia or lack of pulses, pulsatile or expanding hematoma, or bruit/thrill in the vessel.

Soft signs: nonpulsatile hematoma, reduced distal pulses, signs of nerve injury, and orthopedic trauma with likely concomitant vascular injury > require further imaging before intervention.

Calculate the ABI: right arm 119/85, left arm 112/82, right ankle 108/85, and left ankle 104/80.

Answer explanation

The ABI is calculated by dividing the systolic blood pressure (SBP) in the injured extremity by the greatest brachial SBP of the upper extremities, regardless of laterality.

Patient with a 2-cm laceration at the interphalangeal (IP) joint of the right thumb 2 days ago. He is unable to flex the IP joint in his thumb. Ideally, when should his tendon repair take place?

• within a few days from injury

• within 1 week

• within 2 weeks

• within 4 weeks

Answer explanation

The sooner the better: less chance of needing a tendon graft, and less retraction of the proximal stump away from the injury site.

30-year-old patient is brought to the ED after a MVC. Alert and awake with stable vitals but report that they cannot feel or move their left arm. What is the most appropriate next step?

• Chest XRay

• CT of c-spine

• MRI c-spine

• EMG

Answer explanation

a chest x-ray is most helpful in identifying associated injuries, including clavicular and rib fractures

then get imaging of the cervical spine, and electromyography

A 33-year-old patient presents to the ED after an MVC and reports abdominal and low back pain. HR is 110 beats/min, and BP is 145/90 mm Hg. The patient's abdomen and lumbar spine are exquisitely tender on exam, and they have decreased strength in their lower extremities. CT reveals a Chance fracture, as demonstrated in the image below, as well as free intraperitoneal air. What is the next step in management?

• Emergency exploratory laparotomy

• MRI of the lumbar spine

• Emergency open reduction and internal fixation of the spine

• Mass transfusion protocol

Answer explanation

Chance fractures are thought to be caused by excessive flexion and distraction of the lumbar vertebrae from a high-riding seat belt. Coexisting abdominal injuries are relatively common. In this patient with a tender abdomen and free air on imaging, one must suspect hollow viscous perforation, which requires immediate surgical intervention. This takes priority over operative stabilization of the spine.

Match the following neuromuscular injuries

• long thoracic nerve

• Carpal tunnel syndrome

• median nerve

• Hip dislocation

• radial nerve

• Knee Dislocation

• sciatic nerve

• Winged Scapula

• popliteal artery or common peroneal nerv

• Humeral shaft fracture

Label

a

b

c

d

e

f

Musculocutaneous

Radial

Axillary Nerve

Ulnar Nerve

Thorocodorsal

Median Nerve

Thoracic outlet syndrome is compression of the brachial plexus, subclavian artery, or subclavian vein where these structures pass between the first rib and ______ muscle(s).

Answer explanation

subclavian artery and brachial plexus runs between the anterior and MIDDLE scalenes, where the nerve may get pinched in neurogenic thoracic outlet syndrome