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Conference 6/11/2020

Week 11 of virtual conference is here. Good work last week during the Research Symposium, much kudos to all who had research projects as well as a strong showing representing our EM residency! The Research Symposium also featured keynote speaker Dr Velma Scantlebury, an African American pioneer in the field of transplant surgery – read more here https://en.wikipedia.org/wiki/Velma_Scantlebury. She addressed healthcare inequalities and racial disparities in medicine, key topics for our times.

Also

Due to social distancing in the COVID Era, we had to forego our usual MEDWars this year, but we did a co-virtual MEDWars with UTSW and played some fun games, with a mix of pop culture and medical trivia. We had a strong showing from both UTSW @DallasEMed and @FTWorthEM. Congrats to the winners!

Also

Congratulations to Dr Vithalani for being named MedStar’s New Medical Director! Dr Vithalani has been acting as interim director currently.

Onto business..


Here is an article from EMDOCS about open fractures. http://www.emdocs.net/open-fractures-pearls-and-pitfalls/

Open fractures pearls:

Classification
The grading system for open fractures is the Gustilo-Anderson classification. It is based on the size of the skin defect and degree of soft tissue injury and contamination.2

Type I – Laceration is <1cm and there is no evidence of contamination

Type II – Laceration >1cm with moderate contamination

Type III

  • A: severe soft tissue injury highly contaminated (5-10%)
  • B: severe soft tissue injury, massive contamination, bone is exposed, and there is periosteal stripping (10-50%)
  • C: same as IIIB but with an arterial injury requiring repair (25-50%)


Antibiotics: Gustilo-Anderson types I-II should be treated with a first generation cephalosporin (ie Ancef), with the addition of an aminoglycoside (ie gentamycin) for type III fractures. (If allergic Clindamycin or Vancomycin). If there is any concern for clostridial exposure (e.g. farm injuries), the recommendation is to add Penicillin G Or Pip/Tazo (Zosyn). Some have been using Ceftriaxone for open fracture management as well, which is supported in literature. (3)

There is some disagreement in orthopedics literature about timing for ORIF and washout. Some sources say <6 hrs some say >6 hours is appropriate. There hasn’t been shown to have increased risk of infection with delayed washout but this is dependent on the wound contamination. Obviously a discussion with orthopedics regarding this is needed and their early involvement is key.

Next

Check out this article on knee injuries http://foamcast.org/2015/01/12/episode-22-the-knee/

It covers topics on – what to do with a knee dislocation and how to evaluate and address septic arthritis.


Next


Here is a Rosh Review Question for you to review:

A 27-year-old woman presents with severe left knee pain after an MVC where she was the front passenger. She states her knee hit the dashboard. An X-ray of the patient’s knee is shown below. After quick bedside reduction, the physical examination reveals swelling of the knee and an Ankle-Brachial Index (ABI) of 0.8. What do you do next?

A. Discharge home
B. Observation and repeat ABI
C. Obtain angiography or CTA
D. Splint and elevation

Answer

C. Obtain Angiography. This patient presents with a knee dislocation and signs of a popliteal artery injury requiring angiography for diagnosis. A knee dislocation refers to a dislocation of the tibia in relation to the femur and not a patellofemoral dislocation. A tibiofemoral dislocation is a limb-threatening emergency due to the high rate of popliteal artery injury. The neurovascular bundle (popliteal artery, popliteal vein and common peroneal nerve) runs posteriorly in the popliteal fossa. The popliteal artery is tethered to the femur and tibia by a fibrous tunnel and is inherently immobile making it susceptible to injury during dislocation. Knee dislocations typically occur in major trauma. An MVC where the knee strikes the dashboard is a common scenario. The dislocation is usually clinically obvious and should be emergently reduced regardless of the presence of confirmatory X-rays. The leg should rapidly be assessed for any “hard” signs of vascular injury including an absence of pulse, limb ischemia, rapidly expanding hematoma, the presence of a bruit or thrill and pulsatile bleeding. Neurologic status should also be assessed prior to and after reduction. After reduction, all patients should have ankle-brachial index (ABI) performed. A normal ABI is > 0.9. Any patient with an ABI less than this should be further investigated for a popliteal injury with angiography. Splint and elevation (D) may be appropriate once a vascular injury is ruled out. The patient should not be discharged home (A) with an abnormal ABI. Observation and repeat ABI (B) is indicated if the initial ABI is normal.

Next

Check out this article on DontforgettheBubbles regarding “how to interpret a knee xray

That’s it for now, see you at conference this week.

References

  1. 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. J Bone Joint Surg Am. 1976;58(4):453-8.
  2. Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. Lippincott Williams & Wilkins; 2010.
  3. Saveli, Carla C., et al. “The role of prophylactic antibiotics in open fractures in an era of community-acquired methicillin-resistant Staphylococcus aureus.” Orthopedics (Online)8 (2011): 611.


Images
Courtesy of Rosh Review https://www.roshreview.com/
@OwenBeard – Unsplash
@SamuelPeriera – Unsplash

Stefan Meyering DO, FAAEM

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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