The Trauma Bay

At my program, the intern takes all of the floor/ED/trauma consults during the day. Regular consults on the floor or in the ED are really not that big of a deal. I go to see the patient, look at the films, read about what I've seen and heard and then report to my chief. The trauma bay is another animal, especially if I have been called for something that requires immediate attention like a disvascular limb, dislocated joint, or open fracture. This call usually occurs after the initial primary survey has been completed but before the patient leaves the trauma bay to go to the CT scanner and get additional plain films. The patient has a portable chest x-ray, an AP pelvis and maybe a couple of other portable films of obvious deformities.

Keep in mind, I am the intern, and the trauma/EM staff, not to mention many upper level residents stop what they are doing and stare at me while I complete my evaluation, ask for things that I need and prepare whatever intervention is necessary. Meanwhile, the trauma chief is asking to take the patient to the CT scanner and the nurses are griping about keeping the patient in the trauma bay for longer than is necessary.

So, I have to balance the excitement of taking care of some blown up limb or reducing a dislocated extremity with not overstepping my bounds as an intern - and get things done in a timely manner so that the trauma team can finish their evaluation. Oh yeah, and there is a person laying on that bed with a life/limb threatening injury. We've had some interesting trauma so far, a couple of really bad open fractures, a blown off foot and a couple of dislocated hips, and I've learned a ton in that setting. Number one, I've learned how to walk into a room where anything can happen and things are changing by the second and keep my cool. When I come into the trauma bay, "I'm just the intern," is not really a great excuse. I'm the "expert" in the room and it's my job to take care of the patient. I had to tell a lady the other day that there is a chance we will have to amputate her leg. Luckily, she still has her leg - but we'll see how things go over the course of the next year, not only for the patient - but also for my education...

Approaches - Anterior Lateral Approach to the Distal Humerus

Uses

-ORIF

-Exploration of Radial Nerve

Positioning

-Supine, arm abducted 60 deg, exsanguinate limb and use tourniquet

Landmark - biceps brachii and flexion crease of elbow

Incision - curved longitudinal on lat border of biceps, start 10cm prox to flexion crease and end at flexion crease

Internervous plane - Brachialis and brachioradialis are both innervated by radial nerve - although their innervation plays a minor role in motor function

Superficial Dissection

-Subq tissues

-ID lateral border biceps and retract medially

-ID interval between brachioradialis/brachialis

Deep Dissection

-ID and stay on medial side of radial nerve

-Retract brachialis medially

Dangers

-radial nerve

-musculocutaneous nerve

Approaches - Anterior Approach to the Proximal Tibia

Uses

-IMN tibial shaft fractures

Positioning

-Fracture table: Supine, Hip flexed 60deg, knee flexed 100-120deg+traction (boot or traction pin) No tourniquet!

-Free Leg Position: Supine, remove end table, injured leg flex over side, contralateral leg in support - flexed and abducted. No tourniquet!

Landmark - inf pole of patella, medial border of patellar tendon

Incision - 5cm incision from inf pole patella to tibial tubercle - in line with medial border patellar tendon

Internervous plane - None

Superficial Dissection

-Subq tissues

-Numerous small vessels to coagulate

-Incise fascia superior to patellar tendon

Deep Dissection

-Retract patellar tendon laterally

-Expose deep infrapatellar bursa

-Determine entry point at prox end tibia at junction of ant/sup aspects of the bone

-Entry is extrasynovial

Dangers

-infrapatellar branch saphenous nerve

-popliteal vein - if supports are in popliteal fossa

-ACL insertion/ant. horn MM if nail too post

-medial=valgus

-lateral=varus

-beware cortical bone

-patellofemoral joint if knee is not flexed enough

Approaches - Posterior Approach to the Elbow

-Usually requires osteotomy

Uses

-ORIF fx’s distal humerus

-Removal loose bodies

-Non-unions

Positioning

-Diving Board

-Prone

-Tourniquet

-Arm abducted 90 degrees

-Elbow flexed over side of table

Landmark - palpate olecranon process

Incision - 5cm incision over the olecranon process that is curvilinear. Start lateral and curve it medially at olecranon

Intervervous plane - None

Superficial Dissection

-ulnar nerve as it curves post to medial epicondyle (protect)

-osteotomy 2cm from tip (v-shaped)

Deep Dissection

-Elevate tricep from back humerus

-Beware of radial nerve as is passes from post to ant through the lat intermuscular septum

Dangers

-ulnar nerve - beware traction

-median nerve - ant to distal humerus

-radial nerve - if prox extension of approach

-brachial artery - with median nerve

Approaches - Posterior Approach to the Hip

Uses

-Hemiarthroplasty

-THA, including revision

-ORIF post acetabulum

-Dependant drainage hip sepsis

-Removal loose bodies hip joint

-Pedicle bone grafting

-ORIF post. hip dislocations

Positioning

-Diving Board

-Peg Board

-True lateral

-Good padding

-Be certain you have room to move the hip

Landmark - greater troch

Incision - 10-15cm incision, curved, centered post aspect greater troch

Internervous plane - None

Superficial Dissection

-Incise fascia lata to uncover vast lateralis

-split glut max (may have some bleeding from branches sup./inf. gluteal art)

Deep Dissection

-Retract short external rotators (sup gamell, obt internus, inf gamell)

-Beware sciatic nerve, runs over SER

-Stay sutures in piriformis/obt internus tendons

-Beware quad femoris contains supply blood to hip

-Open capsule - hip exposed

-Dislocate with flexion, ext rotation and abduction

Dangers

-sciatic nerve - beware self retractors - may have two branches - beware of “small sciatic nerve”

-inf. gluteal artery - underneath piriformis = if lots bleeding, put pt. supine and tie off int. iliac artery

Approaches

One of the most important things an intern, or a senior medical student for that matter, must understand if they are going to participate in the operating room is anatomy. I was standing in the operating room today staring into a surgical wound and I begin to think 1-2 years into the future when I will be the one doing a significant portion of cases. It's amazing the background knowledge that goes into being a surgeon. That said, I have decided that, as I begin preparing for cases and studying approaches I was going to make study guides. They are fairly simple, but they point out most of the important anatomical points that an intern/medical student might get pimped on. My source is Hoppenfeld's Surgical Exposures in Orthopaedics, 3rd Ed. There is a newer edition. I should also mention that there are many other ortho exposure books available. This one just happens to be the one that I prefer.

I'll post each approach separately. I'll take feedback if you would like to give it, and I'll continue to post these as I make them. These would make good quick study guides that one could print and stick in their pocket before cases.