1. Trauma Board Review Part II
Dr. Grumpy

2. Disclosure Drug rep dinners STC Linezolid Ertapenem Keppra
Levofloxacin
Cardene
STC

3. Topics
C-spine trauma
Pediatric trauma
Pelvic trauma

4. 6yoM. Rear-seated passenger in a moderate-speed MV crash
6yoM. Rear-seated passenger in a moderate-speed MV crash. “legs were numb” immediately following, but symptoms resolved in 30 min. Normal exam. Normal radiographs. Correct statement
Needs urgent MRI.
Discharge with close f/u as long as his exam remains normal during a 4-hr observation.
Flexion-extension radiographs should be performed to rule out any ligamentous injury.
CT scan of the C-spine should be performed to assess for surrounding soft tissue swelling.

5. Spinal Cord Injuries Central Cord Syndrome Brown Sequard Syndrome
Hyperextension injury
Upper ext weaker than lower ext
Brown Sequard Syndrome
Penetrating – hemisection of spinal cord
Loss of ipsilateral motor, position, vibration
Contralateral loss of pain and temp below level of injury

6. Spinal Cord Injuries Anterior Cord Syndrome Cauda Equina
Flexion of cervical spine
Bilateral paralysis of arms and legs equally
Due to arterial occlusion, disruption blood flow to spinal cord
Cauda Equina
Distal sacral roots - peripheral nerve injury
Variable motor/sensory loss in LE, sciatica, bowel/bladder dysfunction, saddle anesthesia

7. Spinal Cord Injuries Spinal Shock (misnomer)
Partial or complete injury
Areflexia, loss of sensation, flaccid paralysis below level of lesion
Flaccid bladder and loss of rectal tone

8. 16 yo football player c/o neck pain s/o “speared” another player with helmet. Paramedics immobilized his neck on scene. Neurologically intact. Which cervical spine injury is most likely?
Bilateral facet dislocation
Hangman fracture
Jefferson fracture
Odontoid fracture
Teardrop fracture

9. C-Spine Fxs Jefferson fx (unstable) Hangman fx (unstable)
Axial loading force
C1 burst fx
Hangman fx (unstable)
Hyperextension (hanging)
Located in pedicles of C2, with C2 displacing anteriorly on C3
Head on MVC
Associated with prevertebral swelling and cause respiratory obstruction

10. C-Spine Fxs Odontoid fx Teardrop fx (unstable)
Type I – tip superiorly. Ligaments intact and stable fx
Type II – junction of odontoid and body
Most common
Type III – superior portion of C2 at base of odontoid
Teardrop fx (unstable)
Extreme flexion
Complete disruption of all ligamentous structures at the level of injury
Unstable

11. Flexion Injuries Simple wedge fx Clay shoveler’s fx
Associated with post ligament disruption
Clay shoveler’s fx
Avulsion of spinous process of lower vertebrae  stable
Atlantooccipital and atlantoaxial dislocation w/ fx
High instability and mortality
Bilateral facet dislocation w/ fx

12. Extension Injuries Ant arch of atlas avulsion fx – unstable
Post arch of atlas fx
Compression. Look for other fxs.
Extension teardrop fx
Most common at C2. Unstable

13. Atlanto-occipital Joint Injury
Severe flexion/extension
Disruption of all ligaments between occiput and atlas.
Death usually immediately from stretching of brainstem
Cervical traction absolutely contraindicated

14. Atlanto-occipital Joint Injury
Very difficult to diagnose (CT 84% sens)
Basion-dens distance > 12mm
Posterior dens axial line > 12mm posterior or > 4mm anterior to basion

15. Power Calculation
BC/AD < 1 normal

16. Atlanto-axial Joint Injury
Disruption of transverse ligament
Extremely unstable

17. Which is classified as low probability of C-spine injury?
21yoM, no neck tenderness, intoxicated after MVC
24yo, no neck tenderness and LLE weakness, pedestrian struck by motor vehicle
32yoF, no neck tenderness, through-and-through lip laceration after MVC
48yoM, no neck tenderness and R shoulder dislocation s/p falling from scaffolding
82yoF, no neck tenderness and a L femoral neck fx s/p fall

18. Nexus No midline tenderness No pain with neck movement
No distracting injury
Long Bone Fracture (Most common DPI)
Visceral Injury Necessitating surgical consultation
Large laceration, degloving injury, or crush injury
Large Burns
Any injury producing acute functional impairment
No Neurodeficit
No Alcohol or Drugs
No Altered Mental Status 

19. CCR Dangerous mechanism Fall from > 3ft or 5 stairs
Axial load to head
MVC >100km/hr
Collision with motorized recreational vehicle
Bicycle collision

20. Pediatric Head Trauma Can bleed enough intracranially for hypotension
Vomiting, seizures, LOC are all poor in sensitivity and specificity
Scalp hematoma is indication

21. 2yo s/p struck by car after running out into the street
2yo s/p struck by car after running out into the street. Most likely thoracic injury?
Aortic dissection
Commotio cordis
Esophageal rupture
Pulmonary contusion
Rib fractures

22. Pediatric Chest Trauma
Compliant chest walls and ribs relatively resistant to fracture  forces transmitted to internal structures
Pulmonary contusions
Commotio cordis
Relatively mild blow to the chest (boards usually pitched baseball)  ventricular fibrillation
No structural damage to the heart
Death usually instantaneous, and successful resuscitation is uncommon.

23. 8 yoM s/p hit a car door while riding bike
8 yoM s/p hit a car door while riding bike. Crying and c/o abdominal pain. Vital signs age appropriate, abrasion across his epigastrium, and diffuse tenderness w/o rebound or guarding. Amylase 220. UA 2-5 RBCs PHF. Which of the following is correct?
Despite a nl abd CT, the child could have pancreatic injury and should be admitted for observation.
An IV pyelogram should be performed for evaluation of hematuria.
The bowel is the most commonly injured organ following this mechanism.
Duodenal hematoma is unlikely if a repeat exam reveals no abdominal tenderness.

24. Pediatric Abdominal Trauma
Pancreatic trauma often missed on CT and presents later
Spleen > liver >> bowel
Duodenal hematoma needs observation

25. Traumatic Pancreatitis
Clinical: mild epigastric tenderness, resolve in early stages of injury, then increased severity w/I 6 hrs when pancreatic enzymes begin irritating the peritoneum, which may become superinfected and produce retroperitoneal abscess.
CT scan can’t exclude blunt pancreatic, diaphragmatic, or bowel injury.
Serum amylase is normal in up to 37% of pts with pancreatic injury
Rapid deceleration or severe crush injury

26. Pediatric Vascular AccessIO
Medial tibia (unless fx)
Fluid resuscitation, blood, medications
Complications (rare)
Growth plate injury
Compartment syndrome
Fluid leakage
Fat emboli
Osteomyelitis

27. Child Abuse Injury inconsistent with history, delay in treatment
Abuser
Young age
Increased stress
Unemployed
History of Abuse
Substance abuse
Boyfriend

28. Child Abuse
Burns
Contact
Immersion
Stocking glove
Cigarette

29. Child Abuse
Contusions
Buttocks
Genitalia
Neck
Face
Low back

30. Child Abuse
Shaken Baby Syndrome: diffuse cerebral injury with edema, retinal hemorrhages, poor prognosis
Suspicious fractures
Any < 1 years
Rib (posterior)
Skull, spine, sternum
Bilateral/multiple various stages of healing
Long bone
Metaphyseal

31. Child Abuse
Head injury
Subdural
Cerebral
SAH
Shaken baby syndrome

32. 25yoM s/p hit by car. You are assigned the task of checking the pelvis.
Push down on the greater trochanters
Push down on the iliac crest
Squeeze together on the iliac crest
Squeeze and rock the greater trochanters

37. Pt. has unstable pelvis and binder is applied
Pt. has unstable pelvis and binder is applied. Persistently hypotensive s/p 2 units of blood. FAST, DPA, CXR all negative. Next action?
ED thoracotomy
Repeat FAST/DPA
OR Laparotomy
Angiography
Pack

38. Angio ready in 15 minutes. Well resuscitated. Intubated
Angio ready in 15 minutes. Well resuscitated. Intubated. Surgical medical student wants to put in foley so he can check it off on his list. You…
Make the senior surgeon assist
Get a coude catheter
Insist on urology resident for insertion
Rudely stop the medical student

39. GU trauma Signs of GU trauma somewhere – hematuria Urethral injury
Perineal ecchymosis
Unable to urinate
Blood at meatus
High-riding/absent prostate
Blood in scrotum/scrotal hematoma
Obvious penile trauma
Pelvic fracture Dx
Retrograde urethrogram
Do not blindly put foley (unless you’re really skilled) – partial tear into complete disruption Tx
Foley over wire. Foley in for 2 weeks.
Suprapubic catheter placement and surgical repair.
Posterior urethral injury from blunt trauma

40. Normal urethrogram

41. Urethral tear

42. Which of the following statements regarding lightning injuries is correct?
A. Aggressive fluid loading is indicated.
B. Fetal death is common in pregnant victims.
C. Lower extremity paralysis is rare.
D. Rhabdomyolysis is a frequent complication.
E. Tympanic membranes usually are normal.

43. ANSWER: B
A. Aggressive fluid loading is indicated. Overly aggressive fluid admin may worsen cerebral edema.
B. Fetal death is common in pregnant victims. (50% fetal mortality rate).
C. Lower extremity paralysis is rare. 2/3 p/w LE paralysis and 1/3 with UE paralysis.
D. Rhabdomyolysis is a frequent complication. Rhabdomyolysis occurs in only 6% of pts.
E. Tympanic membranes usually are normal. More than 50% of lightening injury victims have perforated TMs.

44. Lightning
Electrical and most lightning burns have an entrance and exit point
Death usually secondary to cardiac arrest, lightening causes massive countershock and produces asystole.
Burns are superficial, deep muscle damage rare.
Cataracts are common and may occur immediately or develop up to 2 yrs after incident.
Secondary injuries: ruptured TMs, spinal fractures at multiple levels, bilateral scapular fractures, internal organ injuries, long-bone fractures, intracranial bleeding, seizures, cardiac arrhythmias, and cardiac arrest.

45. Which does not need burn unit?
4yo, 10% BSA superficial partial-thickness burns to arms after pulling a pan of boiling water off a stove
12yo 26% BSA superficial partial-thickness burns to chest and arms from setting a blanket on fire
38yo 3% BSA full-thickness burn to his hand from a mechanical injury
42yo, DM, 5% BSA superficial partial-thickness burns to her feet from scalding bathtub water
75yo, 5% BSA superficial partial-thickness burn to back from a heating pad

46. Burn Unit Criteria Major Moderate Minor
Partial-thickness burns > 25% BSA in 10-50yo
Partial-thickness burns >20% BSA in <10yo or >50yo
Full-thickness >10% BSA
Burns in hand, face, feet, perineum, cross major joints or circumferential burns
Burns with inhalation injury, fxs/other trauma, electrical burns
Burns in infants, elderly or poor-risk
Moderate
Partial-thickness 15-25% BSA in 10-60yo
Partial-thickness 10-20% <10yo or >50yo
Full-thickness < 10% BSA
Minor
Partial-thickenes < 15% BSA 10-50yo
Partial-thickness < 10% BSA <10yo or >50yo
Full-thickness <2% BSA

47. Burn Percentage