Skeletal System Shannon Carroll, MD Suresh Agarwal, MD.

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Skeletal System

Shannon Carroll, MDSuresh Agarwal, MD

Skeletal System

• Common Skeletal System Pathology encountered in Critical Care

• Complications of Skeletal Injury

Skull

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Skull Fractures

4 Major Types

• Linear

• Depressed

• Diastatic

• Basilar

Linear Skull Fracture

• Most common type

• Over Lateral Convexities

• Over squamous area of temporal bone

– Damage to middle meningeal artery

– Epidural Hematoma

www.hawaii.edu/medicine/pediatrics/pemxray/v5c09h2.jpg

Depressed Skull Fracture

• Displaced bone fragments pushed into the cranial vault

• From blunt force by object with small surface area

• Often damages underlying brain tissue

• Complex = dura mater torn

• Contamination/Infection

• Often require surgery

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Diastatic Skull Fracture

• Fracture causes widening of suture

• Most commonly seen in infants and small children

• Seen in adults along the lambdoid suture

Pirouzmand F, Muhajarine N. Craniofac Surg. 2008 Jan;19(1):27-36. Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. img.medscape.com/pi/emed/ckb/radiology/336139-343764-9928.jpg

Basilar Skull Fracture

• From blunt force to the forehead or occiput

• Usually anterior

– Often involves cribriform plate

– Disruption of olfactory nerves

• Posterior

– Through petrous bone and internal auditory canal

– Disruption of the vestibulocochlear nerve and facial nerves

• CSF otorrhea/rhinorrhea

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Basilar Skull Fracture

Raccoon Eyes

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Battle’s Sign

Vertebral Injuries

• Vertebral Column forms the Axial Skeleton

• Among All Trauma Patients

– 4.3% Cervical Spine Injury

– 6.3% Thoracolumbar Spine Injury

– 1.3% Spinal Cord Injury

www.eorthopod.com/images/ContentImages/spine/spine_thoracic/anatomy/thoracic_spine_anatomy01.jpg

Vertebral Injuries

7 Mechanisms of Injury

• Flexion – compression

• Axial compression

• Flexion – distraction

• Hyperextension

• Rotation

• Shear

• Avulsion

Cervical Spine Injuries

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spine.jpg

Cervical Spine Injuries

• 25% Occiput to C2

• 75% C3 to C7

• Occipto-cervical subluxation

– Rare

– Usually fatal

• Fractures of the Atlas

– Pain

– Decreased mobility

• Atlanto-axial dislocation

– High risk of neurologic deficit www.springerlink.com/content/26ghau7p5nmpcjle/

Fractures of the Odontoid

• Apical ligament avulsion fracture

• Stable

• Minimal if any external support

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1299.jpg


• Waist of the odontoid

• Unstable

• Requires reduction or translation and angulation

• Requires stabilization

– Surgical

– Halo vest img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1267150-

1299.jpg


• Extends below the waist into the body of C2

• Best treated with a halo vest

• 15% incidence of nonunion with other immobilization

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Thoracolumbar Spine Injuries

• L1 fracture 16%

• Spondylolisthesis

– Subluxation or Slip of one vertebral body on another

– Most common in lumbar spine

– Treatment

• Conservative management

• Fusion www.webinique.com/images/lumbar_spondylolisthesis_grades.

jpg

Spinal Instability

• Disruption of anatomic components, motion or supportive elements

• Excessive or abnormal spinal motion

• 3 Column Model

– In thoracolumbar spine

– Instability = Injury to 2 or 3 columns

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Spinal Instability

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• 50% Loss of Vertebral Body Height

• Angulation > 20%

• Compression Fractures

• Burst Fractures

Non-operative Management of Spinal Injuries

• Stable injuries

• No neurologic deficits

• Immobilization

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Spinal Immobilization

• C– spine

– Head halter

– Tongs

– Halo

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MEDIUM_IMAGE.jpg

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Spinal Immobilization

• T– and L– spine

– Bedrest

– Log rolling

– Rigid brace

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http://www.optecusa.com/product/custom-tlso-salo

Operative Management of Spinal Injuries

• Spinal Fusion

– Pedicle screws and rods

• Vertebroplasty

• Kyphoplasty

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Ch15_Carpentry_Folder/Ch15_Images/

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www.vancouverspinedoctor.com/images/balloon_kyphoplasty.jpg

Cervical Spine Clearance

The NEXUS Clinical Criteria

1. Tenderness at the posterior midline of the cervical spine

2. Focal neurologic deficit

3. Decreased level of alertness

4. Evidence of intoxication

5. Clinically apparent pain that might distract the patient from the pain of a cervical spine injury

– Any of the above -> increased risk for cervical spine injury -> requires radiographic evaluation

– Sensitivity: 99.6%

– NPV: 99.9%

– Specificity: 12.9%

– PPV: 2.7%

Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set ofclinical criteria to rule out injury to the cervical spine in patients

with blunt trauma. National Emergency X-Radiography UtilizationStudy Group. N Engl J Med. 2000;343:94 –99.

Cervical Spine Clearance Algorithm

Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.


Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical

spine injuries following trauma. 2009.


Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for

identifying cervicalspine injuries following trauma. 2009.


Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines

for identifying cervicalspine injuries following trauma. 2009.

Chest Wall

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Rib Fractures

• Overall mortality = 12%

• High-Energy Injuries:

– 1st or 2nd rib fractures

– Multiple rib fractures

– Scapula Fracture

• Rib Fractures in the Elderly (>65)

– 2 – 5 x greater risk of morbidity/mortality

– 19% Increase in mortality per rib fx

– 27% Increase in pneumoniaimage.wetpaint.com/image/1/

XOMgDfktBYZImgBWx3Xc2g171569/GW537H600

Rib Fractures

• Treatment = Analgesia

– PCA

– Rib Blocks

– Epidural

– Intercostal/ IntrapleuralCatheter

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Flail Chest

• 2 ribs fractured in 2 locations

• Significant morbidity from underlying pulmonary contusions

• “Pendelluft”

• Treatment:

– Supplemental O2

– Analgesia

– Pulmonary Toilet

– ?Endotracheal Intubation

– ?Surgical Stabilizationupload.wikimedia.org/wikipedia/

commons/3/39/Flail_chest_mechaincs.jpg

Paradoxical Motion

Surgical Stabilization

• Studies suggest

– Quickly restores normal chest wall mechanics

– Less pain

– Decreased mortality

– Decreased mechanical ventilation needs

– Shorter hospital stays

– Decreased long term morbidity

www.acuteinnovations.com/files/ribloc-overview1.20090316-

1712.jpg

Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib

fractures. Chest 124:295S

Suggested Indication for Surgical Treatment of Rib Fractures

• Flail chest

• Reduction of pain and

• disability

• Chest wall deformity/defect

• Symptomatic rib fracture non-union

• Thoracotomy for other indications

Raminder Nirula1, Jose J. Diaz Jr.2, Donald D. Trunkey3 and John C. Mayberry3. Rib

Fracture Repair: Indications, Technical Issues, and Future Directions. World Journal

of Surgery 2009; 33(1): 14-22

Sternal Fractures

• “Steering Wheel Syndrome”

• Possible Associated Injury = Blunt Cardiac Injury

• Most Common Associated Injuries:

– Rib fractures

– Long bone fractures

– Head injuries

• Treatment:

– Rest

– Analgesia

– Monitor for EKG changes

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Scapula Fractures

• From high energy trauma

• Rarely occur as an isolated injury

• Management:

– Sling

– Pendulum exercises at 3 weeks

– Strengthening at 6 weeks

www.eorthopod.com/sites/default/files/images/

adult_shoulder_fx_type_scapular_blade.jpg

Indications for Surgical Repair of Scapula Fractures

• If it is one of multiple shoulder fractures

• Displaced fracture of the glenoid neck

• Displaced fracture of the glenoid fossa

• Significant disruption of superior shoulder suspensory complex

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Clavicle Fracture

• Classification

– Proximal (rare)

– Central (80%)

– Distal

• Risk of Nonunion (highest in distal fractures)

• Treatment:

– Sling

– Pendulum exercises at 2 to 3 weeks

– Avoidance of heavy activity x 8 weeks

www.drdavidduckworth.com.au/css/images/clavicle-side.jpg

Clavicle Fractures

• Indications for surgical fixation:

– Distal clavicle

– Middle clavicle with >2cm of shortening

– Open

– Symptomatic Nonunions

– Associated neurovascular injury

– Complex injuries of the shoulder

• Surgical Procedure

– Screw and Plate Fixation

– Intramedullary implants

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Pelvis

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Pelvic Fractures

• Most Common Etiologies

– Motorcycle collisions

– Pedestrian v. Motor vehicle

– Fall > 15 feet

– Motor vehicle collision

• Mortality

– 7-14%

– 30% w/ severe or open fractures

– Most deaths due to other traumatic causes

• Concomitant Injuries in >90% of patients with pelvic fractures

• Most deaths due to:

– Head Injury

– Non-pelvic hemorrhage

– Lung Injury

– Thromboembolic Events

– MSOF

Pelvic Fractures

• Mean transfusion requirement = 8 units of packed red blood cells

• Minimize blood loss from pelvic fractures

– Early re-approximation and stabilization• Bed Sheet

• Splint

• Clamp

• External Fixation

– Angiography• Pelvic arterial disruption is

source of hemorrhage 3 – 20%

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Pelvic Compression Fracture Vectors

• Lateral Compression

• Anterior-Posterior Compression

• Vertical Shear

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Lateral Compression Fracture

• Impact to lateral side of pelvic ring

• Shortens diameter across pelvis/decreases volume of pelvis

• Little risk of vascular or ligamentous injury

www.eorthopod.com/content/adult-pelvis-fractures-types

Anterior-Posterior Compression Fractures

• “Open Book”

• Mechanisms:

– Direct Impact to the Iliac Spines

– Transmitted through the femurs

• Can have ligamentous injury without fracture

• Increases diameter/volume of pelvis

• Significant risk of bleeding

• Unstable

www.eorthopod.com/sites/default/files/images/adult_pelvis_fx_causes06.jpg

Vertical Shear Pelvic Fractures

• Mechanism: Fall/Jump landing on straight leg

• Disruption of ligaments:

– Symphyseal

– Sacrospinous

– Sacrotuberous

– SI

– Increases Diameter/Volume of Pelvis

• Less bleeding than A-P fractures, but still significant risk

www.eorthopod.com/content/adult-pelvis-fractures-types

Upper Extremity

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Shoulder Fractures/Dislocations

• Acromioclavicular dislocation

– “Shoulder Separation”

– Mechanism: fall onto acromion

– Involved ligaments:• Acromioclavicular ligament

• Coracoclavicular ligament

– Complications:• Risk of Brachial Plexus Injury

• Risk of Subclavian Vessel Injury

– Treatment: Sling

www.jurewitz.com/upload/shoulder_acromioclavicular_separ

ation_intro01.jpg

Shoulder Fractures/Dislocations

• Floating Shoulder

– Glenoid neck fracture + Clavicle fracture

– Glenohumeral joint without attachment to the rest of the skeleton

– Usually requires surgical fixation of one of the elements (clavicle)

Low CK, Lam AWM. Results of fixation of clavicle alone in managing floating shoulder. Singapore Med .

2000;4(19):452-453.

Shoulder dislocation

• Anterior (85-95%)

– Risk of axillary nerve injury

– Treatment: Closed Reduction

• Posterior

– Mechanisms: Seizures, Electrocution

– Risk of axillary artery injury


http://www.sports-injury-info.com/image-files/shoulder-dislocation.jpg

www.eorthopod.com/images/ContentImages/shoulder/shoulder_dislocation/shoulder_dislocation_anatomy12.jpg

Humerus FracturesProximal Humerus Fractures

• Concomitant injuries:

– Rotator cuff injuries

– Shoulder dislocation

• Risk of peripheral nerve injuries

• Risk of axillary artery injury

• Nondisplaced Fractures

– Sling for a short period

– Early Range Of Motion

• Displaced Fractures

– With impaction of humeral head: Nonop

– Most 2 Part Fractures: Closed reduction w/ percutaneous fixation

– Most 3 Part Fractures: ORIF

www.shouldersurgeon.com/graphics/

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Humerus Fractures

• Midshaft Humerus Fractures

– Radial Nerve Injury• 12% of Humeral Shaft Fractures

• with fractures of the distal 1/3 of the Humerus

• Runs in the spiral groove

• 70% resolve w/ conservative management

• Splint wrist and digits

– Nondisplaced: Sling

– Displaced: • Reduction with long arm cast for gravity traction

• Fracture Brace

• Plate and Screw Fixation

• Intramedullary Nailing

www.eorthopod.com/sites/default/files/images/adult_humeral_fx_brace.jpg

Humerus Fractures

Supracondylar Humerus Fractures

• Almost always require ORIF

• Volkmann’s Contracture

– Supracondylar Humerus Fracture

– Anterior interosseus artery is occluded

– After reduction, perfussion is restored

– Reperfussion injury leads to Flexor Compartment Syndrome

www.unboundedmedicine.com/wp-content/Volkman.jpg

Elbow Fractures/Dislocations

• “Terrible Triad of the Elbow”

– Elbow dislocation + Radial Head Fx+ Coranoid Process of the Ulna Fx

– Requires surgery with repair or reconstruction

• Nursemaid’s Elbow

– Subluxation of Radius at Elbow

– Cause: Traction to an extended, pronated arm

– Tx: Closed Reduction

s3.beckshome.com/20060625-Nursemaids-Elbow.jpg

Forearm Fractures

• Monteggia Fracture

– Proximal Ulna Fracture + Radial Head Dislocation

– Treatment ORIF

• Galezzi Fracture-Dislocation

– Complex disruption of the distal radioulnar joint + Unstable radius fracture

– Surgical repair is almost always necessary

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Forearm Fractures

• Night-stick Fracture

– Isolated Ulnar Shaft Fracture

– Nondisplaced: Long arm cast for short period, then functional bracing

– Displaced: Compression Plating

• Colles Fracture

– Fall on outstretched, extended wrist

– Distal Radius Fracture


• Greenstick fracture

– Partially through bone

– Opposite side of bone bent

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Scaphoid Fracture

• ½ of all isolated carpal bone fractures

• Fracture locations:

– Waist (75%)

– Proximal Pole (20%)

– Distal Pole (5%)

– Blood supply from the ligaments at the distal pole

• Snuff Box tenderness

• Risk of Avascular Necrosis

• Operative Repair

– Open Screw Placement

– Percutaneous Screw Placement

• Cast to elbow

patientsites.com/media/img/1225/wrist_scaphoid_fracture_intro01.jpg

Finger/Thumb Fractures

• Rolando fracture

– T- or Y-shaped

– Thumb metacarpal base

– Difficult to manage

• Phalangeal fractures

– Usual treatment: Buddy taping or splint immobilization

– Intra-articular invovlement:

• Closed reduction

• Fixation with percutaneous screws

• Fixation with Kirschner wires

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Lower Extremity

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Femur Fracture

• Present in about 15% of seriously injured trauma patients

• 8-10% Bilateral

• Mortality

– Unilateral = 10-12%• 20% in patients > 65 years old

– Bilateral = 26-33%

– 90% due to concomitant injuries

• Decreased complications with surgical fixation within 24 hours

Hip Fractures

• 50% over 85years

– 6 month mortality of 20%

• Preoperative Management of Unstable Fxs

– Buck’s Traction

– Skeletal Tractionwww.lancastergeneralcollege.edu/content/upload/

AssetMgmt/images/College/conferences/Ortho_Traction_in_OrthopedicCare.pdf

Hip Fractures

Femoral Neck Fractures

• Intracapsular

– High risk of Avascular Necrosis and Nonunion

– Intracapsular hematoma also may compromise perfusion

– Surgical emergency in young people

– Treatments:

• Internal fixation

• Hip arthroplasty

• Extracapsular

– Dynamic Hip Screw (DHS)

– Early weight bearing/Rehabwww.orthomeditec.com/images/

dynamichipscrew.jpg

Hip Fractures

• Trochanteric Fractures

– More stable than femoral neck fractures

– Require ORIF• Early Ambulation/Rehab

• Subtrochanteric Fractures

– High risk of failure of surgical fixation

– Treatments:• ORIF

• Closed Reduction and Intramedullary Nailing

• Indirect reduction with blade-plate /screw-plate fixation

Hip Dislocations

• Reduction within 6 to 8 hours is crucial

• Posterior (85-95%)

– Leg internally rotated and adducted

– Risk of sciatic nerve injury


• Anterior

– Leg externally rotated and abducted

– Risk of femoral artery injury

– Treatment: Closed Reduction i21.photobucket.com/albums/b286/flagady15/Bones/hip-fig1.jpg

chestofbooks.com/health/anatomy/Human-Body-Construction/images/Fig-515-Posterior-luxation-of-

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Femoral Shaft Fractures

• Blood loss up to 1500 – 2000cc

• Important to reduce fracture and maintain alignment early

• Closed Reduction and Reamed, Interlocking Intramedullary Nail

• Ex-fix with Intramedullary Nail

– Days 5 to 10

• Associated Complications:

– Fat Embolism Syndrome

– Acute Lung Injury/ARDS

nyic.stemlegal.com/wp-content/uploads/2009/01/femur-nailing.jpg

Patella Fractures

• Mechanism: Direct blow to flexed knee

• Nondisplaced: Long leg cast

• Comminuted:

– Open reduction and internal fixation

• Lag screws

• Tension Banding

– Partial or total Patellectomy

www.cahnlitigation.com/toetheslab/images/Post%20Images/fracture_of_patella_2.JPG

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MyPortalFiles?

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Knee Dislocation

• May involve:

– Patello-femoral joint

– Tibio-femoral joint

• Usually Lateral

– Hemarthrosis or Effusion develops

– May be recurrent

– Treatment:• Closed Reduction

• Knee immobilization for 4 to 6 weeks

• Complete Knee Dislocation:

– Anterior or Posterior

– Need angiogram to assess for Popliteal Artery injury

www.ajronline.org/content/vol186/issue3/images/large/00_04_0756_04b_cmyk.jpeg

Tibia-Fibula Fractures

• Proximal and Midshaft Tibia Fractures

– High risk for compartment syndrome

• Tibial Plateau Fractures

– Nondisplaced proximal tibia fractures: hinged knee brace

– Displaced/Unstable patient: External fixator

– Deformity/Instability: Surgical Repair

www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/sundry-msk-

computer-programs/sundry-images-for-programs/3DCTS1_3DAP.jpg/image

Calcaneus Fractures

• Require tremendous force to the heal

• Frequently occur w/ spine injuries

• Nondisplaced and extra-articular: nonoperative

• Displaced and intra-articular: ORIF 2-3 weeks after injury

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Talus Fractures

• Risk of Avascular Necrosis (AVN)

– Especially if fracture is at neck of talus

– Dislocation is a surgical emergency

• Closed reduction for most

• Severely displaced: Precise reduction and fixation with Interfragmentary Screws

www.foothyperbook.com/images/hindfootTrauma/FxTalusNeck.gif

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Metatarsal Fractures

• Jones Fracture

– Mechanism: Inversion of Foot

– 5th Metatarsal

– At risk for nonunion

www.eorthopod.com/content/adult-foot-fractures-types

www.eorthopod.com/content/adult-foot-fractures-types

Complications of Extremity Fractures

• Infection

– Findings often appear 10-21 days after infection

– Most common organism = Staph. aureus

– Also common = Pseudomonas aeruginosa and Enterobacteriaceae

• Diagnosis

– Physical findings

– Constitutional symptoms

– Radiography• CT

• MRI

• 3-phase bone scan

• Radiolabeled WBC scan


• Gas Gangrene

• Necrotizing fasciitis

• Treatment:

– Early wide debridement

– Antibiotics (PCN)

• Tetanus

– Highest risk w/ farming accidents

– Treatment:• Supportive

• Debridement

• Immunization

• Antibiotics

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Osteomyelitis

• Acute Osteomyelitis

– Hematogenous Spread

– Contiguous Spread

• Subacute Osteomyelitis

• Chronic Osteomyelitis

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Diagnosis of Osteomyelitis

• Requires 2 of the 4 following criteria:

• Purulent material on aspiration of affected bone

• Bone tissue or blood culture positive

• Localized classic physical findings of bony tenderness, with overlying soft-tissue erythema or edema

• Positive radiological imaging study www.medical-look.com/diseases_images/osteomyelitis.jpg

Osteomyelitis

Most Common Organisms

• Staphylococcus aureus

• Gram negative infections (vertebral bodies)

• Pseudomonas (IVDA)

• Fungal osteomyelitis (chronicallyill/TPN)

• Salmonella osteomyelitis (Sickle Cell Disease)

• Group B streptococcus (Infants 2-4 weeks old)

• Haemophilus influenzae (6 months to 4 years old)

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Osteomyelitis

• Treatment:

• Surgical Debridement

• ? Limb Loss

• Antibiotics

– Broad Spectrum IV

– Tissue cultures to narrow

• Hyperbaric Oxygen for Refractory Osteomyelitis

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Kindwall EP. Uses of hyperbaric oxygen therapy in the 1990s. Cleve Clin J Med. Sep-Oct 1992;59(5):517-28


• Fat Embolism

– Approx. 5000 deaths per year

– Classic Triad:

• Respiratory Compromise

• Change in Mental Status

• Petechiae

– Half of all cases present only with respiratory failure

– Treatment: Supportive

img.medscape.com/pi/emed/ckb/vascular_surgery/459840-459841-

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Thromboembolism

• Virchow’s Triad:

– Hypercoagulability

– Endothelial Damage

– Venous Stasis

• More than 60% of DVTs are Asymptomatic

• PEs are the 3rd most common cause of death in trauma patients who survive past the first day

• DVT Prophylaxis:

• SCDs

• Foot pumps

– Heparin

• LMWH

• Coumadin


Compartment Syndrome

• Diagnosis primarily clinical

– Pain

– Parasthesias

– Piokylothermia

– Pulseless

– Pain with passive range of motion

• Critical Pressures:

– Compartment Pressure > 30mmHg

– Diastolic BP – Compartment Pressure < 30mmHg


• Rhabdomyolysis

– Treatment = aggressive IVF

• Avoid buildup of myoglobin in renal tubules

• Prevent hyperkalemia

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Skeletal System Shannon Carroll, MD Suresh Agarwal, MD.

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Transcript of Skeletal System Shannon Carroll, MD Suresh Agarwal, MD.