মুখ্য Dr. Pestana’s Surgery Notes: Top 180 Vignettes for the Surgical Wards

Dr. Pestana’s Surgery Notes: Top 180 Vignettes for the Surgical Wards

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Celebrated by medical students for over a decade, Kaplan's pocket-sized Dr. Pestana's Surgery Notes is the highest-yield surgery review for the the shelf and USMLE Step 2 CK exams.

Designed for portable prep, Dr. Pestana's Surgery Notes fits perfectly in your lab coat so you can refresh your knowledge in between cases.

The Best Review
Concise high-yield review of core surgery material
180 up-to-date vignettes for self-testing
15 brief essays examining selected diagnostic and therapeutic tools from a surgical perspective
NEW essay topics: intravenous fluid therapy, surgical infections, and fluid needs in children
NEW illustrated chapter on bariatric surgery
NEW introduction with guidance for addressing regional variations in medical practice on National Board questions
Expert Guidance
Revised and fully up-to-date content from distinguished surgery instructor Dr. Carlos Pestana
For over a decade, Dr. Pestana's Surgery Notes has helped med students excel on the surgery shelf exam and USMLE Step 2 CK
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Dr. Pestana’s Surgery Notes: Top 180 Vignettes for the Surgical Wards

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Dr. Pestana’s Surgery Notes

Top 180 Vignettes for the Surgical
Carlos Pestana, MD, PhD

Table of Contents
Dr. Pestana’s Surgery Notes 2018
Title Page
About the Author
For Test Changes or Late-Breaking Developments
For Questions or Feedback About This Book
Section I: Surgery Review
Chapter 1: Trauma
Initial Survey (the ABCs)
A Review from Head to Toe
Bites and Stings
Chapter 2: Orthopedics
Disorders in Children
General Orthopedics
Chapter 3: Pre-Op and Post-Op Care
Preoperative Assessment
Postoperative Complications
Chapter 4: General Surgery
Diseases of the Gastrointestinal System
Diseases of the Breast
Diseases of the Endocrine System.
Surgical Hypertension.
Chapter 5: Pediatric Surgery
Birth Through the First 24 Hours
A Few Days Old Through the First Two Months of Life
Later in Infancy
Chapter 6: Cardiothoracic Surgery
Congenital Heart Problems
Acquired Heart Disease
The Lung
Chapter 7: Vascular Surgery
Vascular Surgery
Chapter 8: Skin Surgery

Skin Surgery
Chapter 9: Ophthalmology
Chapter 10: Otolaryngology (ENT)
Neck Masses
Other Tumors
Pediatric ENT
ENT Emergencies and Miscellaneous
Chapter 11: Neurosurgery
Differential Diagnosis Based on Patient History
Vascular Occlusive Disease
Brain Tumors
Pain Syndromes
Chapter 12: Urology
Urologic Emergencies
Congenital Urologic Disease
Retention and Incontinence
Chapter 13: Bariatric Surgery
Bariatric Surgery
Chapter 14: Organ Transplantation
Organ Transplantation
Section II: Practice Questions
Answers and Links

USMLE® is a joint program of the Federation of State Medical Boards of the United States and the
National Board of Medical Examiners, neither of which sponsors or endorses this product.
This publication is designed to provide accurate information in regard to the subject matter covered
as of its publication date, with the understanding that knowledge and best practice constantly
evolve. The publisher is not engaged in rendering medical, l; egal, accounting, or other professional
service. If medical or legal advice or other expert assistance is required, the services of a competent
professional should be sought. This publication is not intended for use in clinical practice or the
delivery of medical care. To the fullest extent of the law, neither the Publisher nor the Editors
assume any liability for any injury and/or damage to persons or property arising out of or related to
any use of the material contained in this book.
© 2018, 2017, 2015, 2013 by Carlos Pestana, MD, PhD
Published by Kaplan Publishing, a division of Kaplan, Inc.
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New York, NY 10017
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ISBN: 978-1-5062-3592-9
Kaplan Publishing books are available at special quantity discounts to use for sales promotions,
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About the Author
Carlos Pestana, MD, PhD, is currently an emeritus professor of surgery at
the University of Texas Medical School at San Antonio. A native of the
Canary Islands, Spain, Dr. Pestana graduated from medical school in
Mexico City, ranking #1 in his class, and subsequently received a doctorate
in surgery from the University of Minnesota, in conjunction with a 5-year
surgical residency at the Mayo Clinic. Throughout his career, he has
received over 40 teaching awards and prizes at the local, state, and
national levels, including among the latter the Alpha Omega Alpha
Distinguished Professor Award from the Association of American Medical
Colleges, and the National Golden Apple from the American Medical
Student Association.
In the late 1980s and early 1990s, Dr. Pestana was a member of the
Comprehensive Part II Committee of the National Board of Medical
Examiners, which designed what is now the clinical component of the
Licensure Examination (Step 2 of the USMLE®), and he also served for 8
years as a member-at-large of the National Boards.

For Test Changes or Late-Breaking
The material in this book is up-to-date at the time of publication. However,
the Federation of State Medical Boards (FSMB) and the National Board of
Medical Examiners (NBME) may have instituted changes in the test after
this book was published. Be sure to carefully read the materials you receive
when you register for the test. If there are any important late-breaking
developments—or any changes or corrections to the Kaplan test
preparation materials in this book—we will post that information online at

For Questions or Feedback About This
Contact us at booksupport@kaplan.com.

The front cover says “Surgery Notes.” Your curiosity is aroused: “I always
wanted to know how an appendectomy is done. Let me look inside and
find out.” You will not encounter that information. Surgeons obviously
have to know that, but this little book was written for medical students and
physicians preparing to take a licensure exam. For those purposes, you
have to understand surgical diseases—to know when to operate and which
procedure is indicated—but not exactly the technical steps.
Surgeons themselves recognize that the most important thing they do is to
choose the who and when and what, rather than the how. Although
surgeons take great pride in providing flawless execution, which is of
course terribly important, they dismiss it out of hand with the classic joke:
“You could teach a monkey how to operate.”
But before we leave the operating room, let’s look at what goes on in there
with a brief historical perspective.
By around 1910, virtually all our surgical armamentarium had been
developed, mostly in Western Europe. The last two areas, open-heart
surgery and transplantation, were added around the mid-1900s. As they
pertained to the two major body cavities, the abdomen and the chest, they
were approached via large incisions. That “open” route provided good
exposure, allowing the surgeon and assistants to use normal hand
motions. Not only could they see what they were doing, but they also could
feel the structures being dissected. Stones could be palpated, pulsations
detected. When unexpected bleeding arose, direct pressure could instantly
stanch it while additional help was summoned. It worked.
But it worked at a price—paid by the patient, as a true story from my days
at the Mayo Clinic illustrates. Dr. C. W. Mayo, with his retinue of residents,

students, and nurses, was making rounds on a postoperative patient.
Pointing to the long, recently sutured abdominal incision, Dr. Mayo praised
the virtues of generous access. “Make them big,” he said. “They heal from
side to side, and not from end to end.”
At which point the patient interjected, “Yes, but they hurt from end to end.”
Indeed they did. And a laparotomy was not the worst. The traditional
approach to the chest, a posterolateral thoracotomy, was the most painful
incision that could be inflicted on a human being. Every breath afterward
was pure agony.
Unknown to the patients, and mostly ignored by the physicians, was the
other cost of those big cuts: They were destructive. The vast majority of
metabolic response to trauma often came from the incision itself rather
than from what was done inside.
The stage was thus set for the revolution that began in the second half of
the 20th century and continues to this day: minimally invasive surgery.
Consider the example of laparoscopic surgery: Carbon dioxide is insufflated
into the abdomen to make room to conduct the procedure. A thin tube
with a TV camera and a light source—a laparoscope—is introduced through
a tiny incision, and the area to be worked on appears on a TV screen.
Additional probes are then added through other ports to do the actual
operation, with scissors, staplers, cautery tips, and so on, at the working
end of those long sticks. Moving these ingenious instruments requires
complex, unnatural motions both to position the tip and to activate the
various functions—requiring the surgeon and assistants to master new
skills of hand-eye coordination.
There is no palpatory input, the image is two-dimensional, and if anything
goes wrong the belly has to be opened. In planning for a laparoscopic
procedure, it is made clear to the patient that old-fashioned open surgery
is the standard. Every effort will be made to complete everything with
minimally invasive techniques, but converting to open is not a

complication, an error, or an untoward outcome. It is simply the prudent
thing to do if needed.
Proprietary developments have improved the basic procedures. More
sophisticated setups allow three-dimensional images, with robotic surgery
representing the most expensive and elaborate end of the spectrum. In the
latter, the surgeon sits at a console wearing gloves that transmit all the
hand motions to a tiny robot that has been previously introduced into the
patient. In contrast with the forced, awkward motions of laparoscopic
surgery, the surgeon uses enhanced natural movements. The robot, for
instance, can rotate more than a human hand can. That little device can
twist and turn in every desirable way. Like magic.
But even there, surgeon and patient are in the same room. The little robots
can do wonders, but human intervention may become necessary if
unexpected problems arise.
In the field of vascular surgery, thoracotomies and laparotomies are
nowadays often replaced by endovascular procedures, in which a stent is
introduced via the femoral artery and then advanced under x-ray guidance
and fixed in the location where a major vessel needs to be repaired.
Let’s leave the operating room for now, and direct our attention to the
contents of these surgery notes. For several decades, I ran a course at the
San Antonio medical school that prepared our students to function in the
surgical wards and confront their exams. To facilitate those tasks, I wrote a
pocket manual for them—a humble, homemade product, distributed at no
cost. Somehow, that booklet was posted on the Internet, and to my
delighted surprise students all over the nation were downloading and
praising it. That was the forerunner of this little book, currently enhanced
by the editorial input of Kaplan, and regularly updated.
This is not a substitute for learning “on the job.” Your professors, your
residents, and your patients will be your best teachers, along with the
library, standard textbooks, and your computer. (You just need to

remember one word: “Google.”) But the clerkship does not expose you to
every surgical disease, and there will be times when you need a quick
answer. Keep my notes in your white coat, with the lab slips and the
granola bars. There is a lot of information in there.
To prove that, let me address an issue that I have never seen covered in any
publication or medical school lecture. Surgery is an art, more than a
science. There are multiple ways to diagnose and treat patients: regional
variations, institutional preferences, evolving criteria. Students are
bewildered when they read two different books and are given different
advice. They want to know which is the correct answer for the exam.
Let me share a little secret with you. The design features of National Board
exams stipulate that any given question can have only one correct answer.
The distractors obviously have to be believable, but none of them can be
true. Thus, if you read in one book that Disease A should be managed with
Therapy X, while another text recommended Therapy Y, you have to
remember both therapies. One of them will appear on an item dealing with
Disease A—but not both. It’s against the rules.
Now let’s move to a more sophisticated level of examination, requiring
greater discrimination on the exam candidate’s part. Here, a prohibition
applies to the particular patient described in the stem of the vignette (i.e.,
it is not a blanket no-no), and the answer options offer both Therapy X and
Therapy Y as the right way to take care of “Patient Q.” Does this mean that
the National Board of Medical Examiners has made a mistake? No, it does
not. Their quality control is awesome. Rather, it signifies that this particular
individual has an additional problem precluding the use of one of the
proposed answers.
Let’s look at an actual example. Go to the back of this book and read
question 53. It describes a dissecting aneurysm of the ascending aorta,
which can be diagnosed with a sonogram, an MRI, or a CT angiogram. Two
of those appear to be correct answers. But the patient in question has a
creatinine of 4, indicative of severe kidney disease. Her renal function

would be wiped out by the intravenous dye needed to do the CT angio.
That would not be good. You have to pick MRI for her.
Which brings us to a little review of those practice questions at the end of
the book.

An exam question, from the exam writer’s perspective, is designed to
conceal the important diagnostic clues among a mass of information that
is not particularly relevant to that specific case, thus testing the ability of
the well-informed examinee to instantly separate the wheat from the chaff.
The typical exam question always starts with age and gender, followed by
present complaint, past history, physical exam, and lab or imaging studies.
Each of those “chapters” includes standard data, whether relevant or not.
For instance, the vital signs are always given: temperature, pulse rate,
blood pressure, height, and weight. In a trauma patient who is in shock, the
pulse rate and blood pressure are extremely important. In a woman with a
breast mass, they are not. Personal habits are irrelevant in deciding
whether somebody has a brain tumor, but would be virtually diagnostic in
someone with a neck mass.
By contrast, the questions in this book are primarily designed for
content review, and are abbreviated versions of the longer, ritualized
format of the actual USMLE or shelf exam questions. They are not cluttered
with vital signs or other facts that will not help. Rather, these questions
contain only the key combination of facts that should be immediately
recognized by an astute clinician.
A preface typically ends with words of thanks to those who helped with the
text. My gratitude extends first of all to my readers, who, by accepting the
three previous editions, made this fourth one possible. Then hats off to the
faculty at the San Antonio medical school. They helped me teach the

surgery course for many years, and they still keep me on my toes. But I
mentioned something about regional and institutional preferences, which
make this discipline an art rather than a science. So, let me recognize the
coast-to-coast contributions of the Kaplan Medical faculty: Dr. Adil
Farooqui of Los Angeles; Dr. Mark Nolan Hill of Chicago; and Dr. Ted A.
James of Burlington, Vermont.
Carlos Pestana, MD, PhD
San Antonio, Texas

Section I


Chapter 1

Initial Survey (the ABCs)
An airway is present if the patient is conscious and speaking in a normal
tone of voice. The airway will soon be lost if there is an expanding
hematoma or emphysema in the neck. An airway should be secured before
the situation becomes critical.
An airway is also needed if the patient is unconscious (with a Glasgow
Coma Scale of 8 or under) or his breathing is noisy or gurgly, if severe
inhalation injury (breathing smoke) has occurred, or if it is necessary to
connect the patient to a respirator. If an indication for securing an airway
exists in a patient with potential cervical spine injury, the airway has to be
secured before dealing with the cervical spine injury.
An airway is most commonly inserted by orotracheal intubation, under
direct vision with the use of a laryngoscope, assisted in the awake patient
by rapid induction with monitoring of pulse oxymetry, or less commonly
with the help of topical anesthesia. In the presence of a cervical spine
injury, orotracheal intubation can still be done if the head is secured and
not moved. Another option in that setting is nasotracheal intubation over a
fiber optic bronchoscope.

The use of a fiberoptic bronchoscope is mandatory when securing an
airway if there is subcutaneous emphysema in the neck, which is a sign of
major traumatic disruption of the tracheobronchial tree.
If for any reason (laryngospasm, severe maxillofacial injuries, an impacted
foreign body that cannot be dislodged, etc.) intubation cannot be done in
the usual manner and we are running out of time, a cricothyroidotomy
may become necessary. It is the quickest and safest way to temporarily
gain access before the patient sustains anoxic injury. Because of the
potential need for future laryngeal reconstruction, however, we are
reluctant to do it before the age of 12.

Hearing breath sounds on both sides of the chest and having satisfactory
pulse oximetry establishes that breathing is okay.

Clinical signs of shock include low blood pressure (BP) (under
90 mm Hg systolic), fast feeble pulse, and low urinary output (under 0.5
mL/kg/h) in a patient who is pale, cold, shivering, sweating, thirsty, and
In the trauma setting, shock is caused by either bleeding (hypovolemichemorrhagic, by far the most common cause), pericardial tamponade, or
tension pneumothorax. For either of the last two to occur, there must be
trauma to the chest (blunt or penetrating). In shock caused by bleeding,
the central venous pressure (CVP) is low (empty veins clinically). In both
pericardial tamponade and tension pneumothorax, CVP is high (big
distended head and neck veins clinically). In pericardial tamponade there
is no respiratory distress. In tension pneumothorax there is severe

respiratory distress, one side of the chest has no breath sounds and is
hyperresonant to percussion, and the mediastinum is displaced to the
opposite side (tracheal deviation).
The treatment of hemorrhagic shock in the urban setting (big trauma
center nearby), with penetrating injuries that will require surgery anyway,
starts with the surgical intervention to stop the bleeding, and volume
replacement takes place afterward. In all other settings, volume
replacement is the first step, starting with about 2 L of Ringer lactate
(without sugar), followed by packed red cells, fresh frozen plasma, and
platelet packs, in a 1-1-1 ratio, until urinary output reaches 0.5 to 2
mL/kg/h, while not exceeding CVP of 15 mm Hg.

Massive Bleeding
Uncontrolled massive bleeding is lethal, and so is untreated
hemorrhagic shock. In the usual civilian setting, where one single
patient arrives with a visible source of bleeding to an ER staffed by
tons of people, that bleeding is best controlled with local pressure.
A gloved finger pushes and occludes the lacerated vessel until it can
be repaired.
In the military setting, where 10 soldiers may be blown up by a
roadside bomb and there is only one medic to look after them, the
obvious life-savers are tourniquets. The same is true in massive
civilian casualties. When terrorists deploy explosives that maim
dozens of people lined up watching a parade, the first responders
also have to resort to tourniquets as they sort out and transport the
Once bleeding is controlled, hemorrhagic shock, if present, has to
be dealt with. The obvious final therapy for lost whole blood, is
whole blood. The military often can do that. All soldiers have been
typed, are certified not to have blood-borne diseases, and are

typically willing to donate blood to their injured comrades. But in
the civilian world we can’t ask for whole blood. Blood is a scarce
resource, and blood banks break it down into components to make
more efficient use of it. If we want whole blood, we have to
reconstitute it by the 1-1-1 expedient already mentioned.

Preferred route of fluid resuscitation in the trauma setting is 2 peripheral
IV lines, 16-gauge. If they cannot be inserted, percutaneous femoral vein
catheter or saphenous vein cut-downs are alternatives. In children under 6
years of age, intraosseus cannulation of the proximal tibia is the alternate
Management of pericardial tamponade is based on clinical diagnosis (do
not order x-rays—if diagnosis is unclear choose sonogram), and centered
on prompt evacuation of the pericardial sac (by pericardiocentesis, tube,
pericardial window, or open thoracotomy). Fluid and blood administration
while evacuation is being set up is helpful.
Management of tension pneumothorax is also based on clinical diagnosis
(do not order x-rays or wait for blood gases). Start with big needle or big IV
catheter into the affected pleural space. Follow with chest tube connected
to underwater seal (both inserted high in the anterior chest wall).

Brief detour: Shock in the nontrauma setting
Shock can be hypovolemic, from bleeding or other massive fluid loss
(burns, pancreatitis, severe diarrhea). The classical clinical signs of shock
will include a low CVP. Treat the cause, and replace the volume.
Intrinsic cardiogenic shock can happen with massive infarction or
fulminating myocarditis. In this case the clinical signs will come with a high
CVP, a key identifying feature. Treat with circulatory support.

Vasomotor shock is seen in anaphylactic reactions and high spinal cord
transection or high spinal anesthetic. Circulatory collapse occurs in
flushed, “pink and warm” patient. CVP is low. Pharmacologic treatment to
restore peripheral resistance is the main therapy (vasopressors). Additional
fluids will help.
Septic shock includes all three components. Early on, low peripheral
resistance and high cardiac output predominate. Later, cardiogenic and
hypovolemic features are seen. In addition to antibiotics, the initial
treatment often includes a steroid bolus. Patients who respond beautifully
at first but then suffer a relapse might not have septic shock at all, but
rather adrenal insufficiency. It is not common, but you will look very
smart if you make that diagnosis.

A Review from Head to Toe
Penetrating head trauma as a rule requires surgical intervention and
repair of the damage.
Linear skull fractures are left alone if they are closed (no overlying
wound). Open fractures require wound closure. If comminuted or
depressed, they have to be treated in the operating room (OR).
Anyone with head trauma who has become unconscious gets a
computed tomography (CT) scan to look for intracranial hematomas. If
negative and neurologically intact, they can go home if the family will wake
them up frequently during the next 24 hours to make sure they are not
going into coma.
Signs of a fracture affecting the base of the skull include raccoon eyes,
rhinorrhea, and otorrhea or ecchymosis behind the ear. Expectant
management is the rule. From our perspective, the significance of a base of
the skull fracture is that it indicates that the patient sustained very severe
head trauma, and thus it requires that we assess the integrity of the
cervical spine. This is best done with CT scan, usually as an extension of the
scan that is done for the head. Remember also that nasal endotracheal
intubation should be avoided in these patients.
Neurologic damage from trauma can be caused by 3 components: the
initial blow, the subsequent development of a hematoma that displaces
the midline structures, and the later development of increased intracranial
pressure (ICP). There is no treatment for the first, surgery can relieve the
second, and medical measures can prevent or minimize the third.

Acute epidural hematoma occurs with modest trauma to the side of the
head and has classic sequence of trauma, unconsciousness, lucid interval
(with completely asymptomatic patient who returns to his previous
activity), gradual lapsing into coma again, fixed dilated pupil (90% of the
time on the side of the hematoma), and contralateral hemiparesis with
decerebrate posture. CT scan shows biconvex, lens-shaped hematoma.
Emergency craniotomy produces dramatic cure. Because every patient
who has been unconscious gets CT scan, the full-blown picture with the
fixed pupil and the contralateral hemiparesis is seldom seen.
Acute subdural hematoma has the same sequence, but the trauma is
much bigger, the patient is usually much sicker (not fully awake and
asymptomatic at any point), and the neurologic damage is severe (because
of the initial blow). CT scan will show semilunar, crescent-shaped
hematoma. If midline structures are deviated, craniotomy will help, but
prognosis is bad. If there is no deviation, therapy is centered on preventing
further damage from subsequent increased ICP. Do ICP monitoring, elevate
head, hyperventilate, avoid fluid overload, and give mannitol or
furosemide. Do not diurese to the point of lowering systemic arterial
pressure. (Brain perfusion = arterial pressure — intracranial pressure.)
Hyperventilation is recommended when there are signs of herniation, and
the goal is a PCO2 of 35. Sedation and hypothermia have been used to
decrease brain activity and oxygen demand. Hypothermia is currently
suggested as a better option to reduce oxygen demand. As an interesting
aside, we will encounter the topic of increased intracranial pressure again
when we review brain tumors. We treat that problem with high-dose
steroids, rather than in the way we have just detailed in cases of trauma.
Diffuse axonal injury occurs in more severe trauma. CT scan shows diffuse
blurring of the gray-white matter interface and multiple small punctate
hemorrhages. Without hematoma there is no role for surgery. Therapy is
directed at preventing further damage from increased ICP.

Chronic subdural hematoma occurs in the very old or in severe alcoholics.
A shrunken brain is rattled around the head by minor trauma, tearing
venous sinuses. Over several days or weeks, mental function deteriorates
as hematoma forms. CT scan is diagnostic, and surgical evacuation
provides dramatic cure.
Hypovolemic shock cannot happen from intracranial bleeding. There
isn’t enough space inside the head for the amount of blood loss needed to
produce shock. Look for another source.

Penetrating trauma to the neck leads to surgical exploration in all cases
where there is an expanding hematoma, deteriorating vital signs, or clear
signs of esophageal or tracheal injury (coughing or spitting up blood). A
strong tradition of surgical exploration for all gunshot wounds of the
middle zone of the neck (regardless of symptoms) is giving way to a more
selective approach.
More selective approaches in other settings include the following: for
gunshot wounds to the upper zone, arteriographic diagnosis and
management is preferred; for gunshot wounds to the base of the neck,
arteriography, esophagogram (water-soluble, followed by barium if
negative), esophagoscopy, and bronchoscopy before surgery help decide
the specific surgical approach.
Stab wounds to the upper and middle zones in asymptomatic patients can
be safely observed.
In all patients with severe blunt trauma to the neck, the integrity of the
cervical spine has to be ascertained. If there are neurologic deficits, the
need to radiologically exam the neck with a CT scan of the cervical spine is
obvious, but it also has to be done in neurologically intact patients who
have pain to local palpation over the cervical spine. In the emergency

department setting, CT scan is the best way to assess the status of the
cervical spine. If a CT of the head is ordered secondary to head trauma, this
scan can be extended to include the neck.

Complete transection is unlikely to be on the exam because it is too easy:
Nothing works (sensory or motor) below the lesion.
Hemisection (Brown-Séquard) is typically from clean-cut injury (knife
blade) and has paralysis and loss of proprioception distal to the injury on
the injury side and loss of pain perception distal to the injury on the other
Anterior cord syndrome is typically seen in burst fractures of the vertebral
bodies. There is loss of motor function and loss of pain and temperature
sensation on both sides distal to the injury, with preservation of vibratory
and positional sense.
Central cord syndrome occurs in the elderly with forced hyperextension of
the neck (rear-end collision). There is paralysis and burning pain in the
upper extremities, with preservation of most functions in the lower
Management: Precise diagnosis of cord injury is best done with magnetic
resonance imaging (MRI; CT is easier to do if we only have to look at the
bone). The use of corticosteroids immediately after the injury is no longer
recommended. Further surgical management is too specialized for our
level of review.


Rib fracture can be deadly in the elderly, because of progression of pain →
hypoventilation → atelectasis → pneumonia. Treat with local nerve block
and epidural catheter.
Plain pneumothorax results from penetrating trauma (which could be the
jagged edge of a broken rib or any of the more common penetrating
weapons). There is moderate shortness of breath, and one side of the
thorax has no breath sounds and is hyperresonant to percussion. Get chest
x-ray, place chest tube (upper, anterior), and connect to underwater seal.
Hemothorax happens the same way, but affected side will be dull to
percussion. It is diagnosed by chest x-ray. Blood needs to be evacuated to
prevent development of empyema, thus chest tube (placed low) is needed,
but surgery to stop the bleeding is seldom required. The lung is the usual
bleeding source, and it will stop by itself (low pressure system). If we get
1,500 mL or more of blood when the chest tube is inserted (or more than
600 mL is collected in the ensuing 6 hours), we realize that a systemic
vessel is lacerated. This is typically an intercostal artery, and video-assisted
thoracotomy will be needed to control the bleeding.
In severe blunt trauma to the chest there may be obvious injuries, plus
hidden injuries. The latter have to be monitored for (blood gases and chest
x-ray to detect developing pulmonary contusion; cardiac enzymes
[troponins] and electrocardiogram [EKG] to detect myocardial contusion)
or actively sought at the outset (traumatic transection of the aorta).
Sucking chest wounds are obvious from physical exam, as there is a flap
that sucks air with inspiration and closes during expiration. Untreated, it
will lead to deadly tension pneumothorax. First aid is with occlusive
dressing that allows air out (taped on 3 sides) but not in.
Flail chest occurs with multiple rib fractures that allow a segment of the
chest wall to cave in during inspiration and bulge out during expiration
(paradoxic breathing). The real problem is the underlying pulmonary
contusion. Contused lung is very sensitive to fluid overload, thus treatment

includes fluid restriction and use of diuretics. Pulmonary dysfunction may
develop, thus blood gases have to be monitored. If a respirator is needed,
bilateral chest tubes are advisable to prevent tension pneumothorax from
developing (the multiple broken ribs may have punctured the lung). To get
a flail chest big trauma is required, thus traumatic transection of the aorta
must be actively sought.
Pulmonary contusion can show up right away after chest trauma, with
deteriorating blood gases and “white out” of the lungs on chest x-ray, or it
can appear up to 48 hours later (thus it is one of those hidden injuries that
has to be monitored for). Treatment as detailed above for flail chest.
Myocardial contusion should be suspected in sternal fractures. EKG
monitoring will detect it. Troponins are quite specific. Treatment is focused
on the complications, such as arrhythmias.
Traumatic rupture of the diaphragm shows up with bowel in the chest
(by physical exam and x-rays), always on the left side. All suspicious cases
should be evaluated with laparoscopy. Surgical repair is typically done
from the abdomen.
Traumatic rupture of the aorta is the ultimate “hidden injury.” It happens
at the junction of the arch and the descending aorta, requires big
deceleration injury, and is totally asymptomatic until the hematoma
contained by the adventitia blows up and kills the patient. Suspicion
should be triggered by the mechanism of injury (knowing that the patient
suffered severe deceleration injury) or by the presence of fractures in chest
bones that are “very hard to break”: first rib, scapula, or sternum, or by the
presence of wide mediastinum. Noninvasive diagnostic tests include:
transesophageal echocardiography, spiral CT scan, or MRI angiography. In
the trauma setting, the most practical of these is the spiral CT scan, which
is enhanced by intravenous dye, and thus is also known as CT angio. As in
other areas of vascular surgery, repair of these is now done, whenever
possible, with endovascular prosthesis rather than open thoracotomy.

Traumatic rupture of the trachea or major bronchus is suggested by
developing subcutaneous emphysema in the upper chest and lower neck,
or by a large “air leak” from a chest tube. Chest x-ray confirms the presence
of air in the tissues, and fiberoptic bronchoscopy identifies the lesion and
allows intubation to secure an airway beyond the lesion. Surgical repair
Differential diagnosis of subcutaneous emphysema also includes
rupture of the esophagus (but the usual setting is after endoscopy) and
tension pneumothorax (but in the latter the other findings—shock and
respiratory distress—are far more alarming and deadly).
Air embolism should be suspected when sudden death occurs in a chest
trauma patient who is intubated and on a respirator. It also happens when
the subclavian vein is opened to the air (supraclavicular node biopsies,
central venous line placement, CVP lines that become disconnected), also
leading to sudden collapse and cardiac arrest. Immediate management
includes cardiac massage, with the patient positioned with the left side
down. Prevention includes the Trendelenburg position when the great
veins at the base of the neck are to be entered.
Fat embolism may be seen in multiple trauma patients with several long
bone fractures. They develop petechial rashes in the axillae and neck;
present with fever, tachycardia, and low platelet count; and eventually
become a full-blown picture of respiratory distress with hypoxemia and
bilateral patchy infiltrates on chest x-ray. Treatment is respiratory support
using a respirator. Rarely, fat droplets may reach the brain, producing
unexpected coma. A “star-field pattern” on MRI is diagnostic. Spontaneous
resolution is possible, and thus one should not rush to declare irreversible
damage and withdraw further care.


Gunshot wounds to the abdomen require exploratory laparotomy for
repair of intraabdominal injuries (not necessarily to “remove the bullet”).
Any entrance or exit wound below the level of the nipple line is considered
to involve the abdomen. In very select cases of abdominal trauma due to
low caliber gunshot wounds involving the right upper quadrant,
conservative therapy may be used if the patient is properly monitored with
close follow-up of clinical signs and serial abdominal CT scans.
Stab wounds allow a more individualized approach. If it is clear that
penetration has occurred (protruding viscera), exploratory laparotomy is
mandatory. The same is true if hemodynamic instability or signs of
peritoneal irritation develop. In the absence of the above, digital
exploration of the wound in the ER (gentle insertion of gloved finger) and
observation may be sufficient. If digital exploration is equivocal, a CT scan
is diagnostic.
Blunt trauma to the abdomen requires exploratory laparotomy if signs of
peritoneal irritation (an acute abdomen) develop. Otherwise, in blunt
trauma one must determine whether there are internal injuries, whether
there is bleeding into the peritoneal cavity, and whether the bleeding is
likely to stop by itself or will require surgical intervention. The finding that
triggers such investigation is the presence of signs of internal bleeding
(patient going into shock, with low CVP, with no obvious external source of
blood loss).
Signs of internal bleeding in a patient with blunt trauma include a drop
in blood pressure, with fast thready pulse, low CVP, and low urinary output,
in a cold, pale, anxious patient who is shivering, thirsty, and perspiring
profusely. Those signs of shock occur when 25–30% of blood volume is
acutely lost (about 1,500 mL in the average size adult), and thus there are
few places within the body where such large amounts of blood could hide.
It cannot do it in the head (a much smaller amount would produce lethal
neurologic damage by compression and displacement of the brain). The
neck could accommodate a large hematoma, but gross deformity would be

obvious on physical exam. Blood in the pericardial sac would lead to
pericardial tamponade. The pleural cavities could easily accommodate
several liters of blood, with relatively few local symptoms, but that blood
could not hide from an x-ray machine (a few hundred milliliters show up on
chest x-ray). By virtue of their size, the arms and lower legs would also
show gross deformity if they were the site of a 1,500-mL hematoma. That
leaves the abdomen, thighs (secondary to femur fractures), and pelvis (in
pelvic fractures) as the only 3 places where 1,500 mL of blood could “hide”
in a blunt trauma patient who has developed shock. The femurs and pelvis
are always checked for fractures in the initial survey of the trauma patient
(by physical exam, with x-rays if needed). So, the multiple trauma patient
who has a normal chest x-ray and no evidence of pelvic or femur fracture
has to be suspected of intraabdominal bleeding when he or she goes into
hypovolemic shock for no obvious reason. This has to be proven, because
the blood loss might have been to the outside, rather than internal.
The diagnosis of intraabdominal bleeding can be made most accurately
with CT scan. CT will show the presence of blood, will show the injury from
where the blood is coming (most frequently liver or spleen), and will even
give an idea of how bad that injury is. In conjunction with the patient’s
response to fluid administration, it allows a decision to be made for surgery
or expectant therapy. The patient with minor internal injuries who
responds promptly to fluid resuscitation does not need surgery. The
patient with major injuries and vital signs that do not improve with fluid
resuscitation will require surgery. Even though fast CT scanners are
available in Level I trauma centers, it is imperative that the patient be
hemodynamically stable so that pictures can be taken without all the
commotion of continuing resuscitation efforts.
The diagnosis of intraabdominal bleeding in the patient who is
hemodynamically unstable has to be made quickly in the ER or OR, at the
same time that resuscitation efforts are under way. This is best done with a
limited sonogram, known by the acronym FAST (Focused Abdominal

Sonogram for Trauma). The test simply confirms that the belly is full of
blood, and prompt laparotomy will ensue. (FAST has already displaced the
older, invasive, diagnostic peritoneal lavage.)
A ruptured spleen is the most common source of significant
intraabdominal bleeding in blunt abdominal trauma. (If all patients are
counted—significant and insignificant—the liver is a more common
source.) Often there are additional diagnostic hints, such as fractures of
lower ribs on the left side. Given the immunologic function of the spleen,
every effort will be made to repair it rather than remove it—particularly in
children. If removal is unavoidable (truly smashed to pieces, or there are
many other life-threatening injuries that preclude the use of operative time
for repair), postoperative immunization against encapsulated bacteria is
mandatory (Pneumococcus, Haemophilus influenza B, and
Intraoperative development of coagulopathy during prolonged
abdominal surgery for multiple trauma with multiple transfusions is
treated empirically with platelet packs and fresh-frozen plasma,
approximately 10 units of each. If in addition to coagulopathy there is
hypothermia and acidosis, the laparotomy has to be promptly terminated,
with packing of bleeding surfaces and temporary closure. The operation
can be resumed later when the patient has been warmed and the
coagulopathy treated.
The abdominal compartment syndrome occurs when lots of fluids and
blood have been given during the course of prolonged laparotomies, so
that by the time of closure all the tissues are swollen and the abdominal
wound cannot be closed without undue tension. In those cases, a
temporary cover is placed over the abdominal contents, either an
absorbable mesh (that can later be grafted over) or nonabsorbable plastic
to be removed at a later date when closure might be possible. This
syndrome may not be evident until the second postoperative day in a
patient on whom closure was done; who subsequently goes on to develop

distention, with the sutures cutting through the tissues, hypoxia secondary
to inability to breathe, and renal failure from the pressure on the vena
cava. In that setting, the abdomen must be opened and a temporary cover
Damage control laparotomy has become the standard concept that now
guides management of the severely traumatized patient, who is subject to
consumption coagulopathy, hypothermia, and the abdominal
compartment syndrome. These patients can now be identified ahead of
time, as surgeons have gained experience with their management. The
operation is designed, up front, to be brief. Clamp all the bleeders,
temporarily occlude damaged viscera, clean up all the contamination, and
get out of there. Then do the rest of the resuscitation, and at a later date go
back in and finish the job.

Pelvic hematomas are typically left alone if they are not expanding.
In any pelvic fracture, associated injuries have to be ruled out. These
include rectum (do rectal exam and proctoscopy) and bladder (more about
that later) in both sexes; and vagina in women (do pelvic exam); or urethra
in men (do retrograde urethrogram).
Pelvic fractures can be the site of significant, potentially deadly
hemorrhage. We realize that is happening when we see signs of
hypovolemic shock in a trauma patient who has a pelvic fracture with a
big hematoma, and no evidence of bleeding anywhere else. This
problem does not have a surgical solution. The site of blood loss is often
inaccessible and not amenable to clamping or electrocoagulation. We
rely instead on two things: immobilizing the pelvis as best we can,
and angiographic management. We do the first with binding or

external fixation and the second with embolization of either specific
bleeding arteries or of internal iliacs to minimize venous bleeding.

The hallmark of urologic injuries is blood in the urine in someone who
has sustained penetrating or blunt abdominal trauma. Gross hematuria in
that setting must be investigated with appropriate studies.
Penetrating urologic injuries are as a rule surgically explored and
Blunt urologic injuries may affect the kidney, in which case the associated
injuries tend to be lower rib fractures. If they affect the bladder or urethra,
the usual associated injury is pelvic fracture.
Urethral injury occurs almost exclusively in men, is typically associated
with a pelvic fracture, and may present with blood at the meatus. More
complete clinical picture might include a scrotal hematoma, for posterior
injuries the sensation of wanting to void but not being able to do it, and a
“high-riding” prostate on rectal exam. The key issue in any of those is that a
Foley catheter should not be inserted (it might compound an existing
injury), but a retrograde urethrogram should be done instead. If by chance
someone had attempted to pass a Foley catheter and met resistance, that
would be another diagnostic clue suggesting urethral injury.
Bladder injuries can occur in either sex, are usually associated with pelvic
fracture, and are diagnosed by retrograde cystogram. The x-ray study must
include postvoid films, to see extraperitoneal leaks at the base of the
bladder that might be obscured by the bladder full of dye. If the latter are
found, they can be treated simply by placing a Foley catheter. For
intraperitoneal leaks, surgical repair is done and protected with a
suprapubic cystostomy.

Renal injuries secondary to blunt trauma are usually associated with
lower rib fractures. They are assessed by CT scan, and most of the time can
be managed without surgical intervention. A rare but fascinating potential
sequela of injuries affecting the renal pedicle is the development of an
arteriovenous fistula leading to congestive heart failure. Should renal
artery stenosis develop after trauma, renovascular hypertension is another
potential sequela.
Scrotal hematomas can attain alarming size but typically do not need
specific intervention unless the testicle is ruptured. The latter can be
assessed with sonogram.
Fracture of the penis (fracture of the corpora cavernosa, fracture of the
tunica albuginea) occurs to an erect penis, typically as an accident during
vigorous intercourse (with woman on top). There is sudden pain and
development of a large penile shaft hematoma, with a normal-appearing
glans. Frequently, the true history will be concealed by an embarrassed
patient who concocts a cover story (the toilet seat lid fell on him, or some
such thing). Emergency surgical repair is required. If not done, impotence
will ensue as arteriovenous shunts will develop.

In penetrating injuries of the extremities, the main issue is whether a
vascular injury has occurred or not. Anatomic location provides the first
clue. When there are no major vessels in the vicinity of the injury tract, only
tetanus prophylaxis and cleaning of the wound is required. If the
penetration is near major vessels and the patient is asymptomatic, Doppler
studies or CT angio are done. If there is an obvious vascular injury (absent
distal pulses, expanding hematoma), surgical exploration and repair are

Combined injuries of arteries, nerves, and bone obviously need repair,
but they pose the challenge of which one to do first. The usual sequence is
to stabilize the bone first, then do the delicate vascular repair (which would
be otherwise disrupted by the rough handling needed to put together a
bone), and leave the nerve for last.
A fasciotomy should be added because the prolonged ischemia could lead
to a compartment syndrome.
High-velocity gunshot wounds (military or big-game hunting rifles)
produce a large cone of tissue destruction that requires extensive
debridements and potential amputations.
Crushing injuries of the extremities pose the hazard of hyperkalemia,
myoglobinemia, myoglobinuria, and renal failure, as well as potential
development of compartment syndrome. For the first, vigorous fluid
administration, osmotic diuretics, and alkalinization of the urine are good
preventive measures. For the latter, a fasciotomy may be required.

Chemical burns require massive irrigation to remove the offending agent.
Alkaline burns (Liquid Plumr, Drano) are worse than acid burns (battery
acid). Irrigation must begin as soon as possible at the site where the injury
occurred (tap water, shower). Do not “play chemist” and attempt to
neutralize the agent.
High-voltage electrical burns are always deeper and worse than they
appear to be. Massive debridements or amputations may be required.
Additional concerns include myoglobinemia-myoglobinuria-renal failure
(give plenty of fluids and osmotic diuretics like mannitol, and alkalinize the
urine), orthopedic injuries secondary to massive muscle contractions
(posterior dislocation of the shoulder, compression fractures of vertebral
bodies), and late development of cataracts and demyelinization
Respiratory burns (inhalation injuries) occur with flame burns in an
enclosed space (a burning building, car, plane) and are chemical injuries
caused by smoke inhalation. Burns around the mouth or soot inside the
throat are suggestive clues. Diagnosis is confirmed with fiberoptic
bronchoscopy, but the key issue is whether respiratory support (a
respirator) is needed or not, and blood gases are best to make that
determination. Intubation should be done if there is any concern about
adequacy of the airway. The level of carboxyhemoglobin must be
monitored. If elevated, 100% oxygen will shorten its half-life.
Circumferential burns of the extremities can lead to cutoff of the blood
supply as edema accumulates underneath the unyielding eschar. In
circumferential burns of the chest, a similar mechanical problem may

interfere with breathing. Escharotomies (done at the bedside, with no need
for anesthesia) will provide immediate relief.
Scalding burns in children should always raise the suspicion of child
abuse, particularly if the pattern of the burn does not fit the description of
the event given by the parents. A classic example is burns of both buttocks,
which are typically produced by holding a small child by arms and legs, and
dunking him into boiling water.
Fluid replacement in the severely burned patient is the most critical,
life-saving component of the management of extensive thermal burns.
Underneath a deep burn, a lot of fluid accumulates. This is essentially
plasma that has been temporarily lost from the circulating space and
trapped at the burn site. In extensive burns, this internal shift of fluids is
enormous and, if untreated, leads to hypovolemic shock and death. Thus,
large infusions of intravenous fluids are required.
Complicated formulas were devised to estimate how much fluid would be
needed. They multiplied the weight of the patient in kilograms by the
extent of the burn as a percentage of body surface (capped at 50%; beyond
that there is no further fluid loss). The involved body surface was
calculated by the “rule of 9s,” assigning 9% of body surface to the head and
to each upper extremity, double that to each lower extremity, and 4 times
that much to the trunk. The product was then multiplied by another
number, empirically arrived at, ranging between 4 and 6, depending on the
specific formula. That final calculation gave us milliliters of Ringer lactate
that were meant to be infused most rapidly in the first 8 hours, tapering
afterwards, and supplemented by a couple of liters of D5W every day and, if
desired, by colloids on the second day. The expectation was that no fluids
would be needed by the third day, when the plasma trapped in the burn
edema would be reabsorbed and a large diuresis would ensue.
In reality, most of these complicated calculations and instructions were
never carried out: As soon as hourly urinary output was available, the
therapy was fine-tuned based on the patient’s response, aiming for an

hourly urinary output of 1 or 2 mL/kg/h, while avoiding CVP over 15 mm Hg.
Furthermore, those detailed formulas too often failed to provide accurate
numbers. As a result, they have been mostly abandoned in favor of a
simpler approach in which fluid infusion is begun at an arbitrary,
predetermined rate and then adjusted as needed.
An appropriate predetermined rate of fluid infusion in the adult is to
start at 1,000 mL/h of Ringer lactate (without sugar) on anyone whose
burns exceed 20% of body surface, and then adjust as needed to produce
the desired urinary output. (Sugar is avoided in the Ringer lactate so as not
to induce an osmotic diuresis from glycosuria, which would invalidate the
meaning of the hourly urinary output.)
Estimation of fluid needs in burned babies differs from the adult in
several measures. Babies have bigger heads and smaller legs; thus the
“rule of 9s” for them assigns two 9s to the head, and both legs share a total
of three 9s instead of four. In determining what is third-degree, we should
remember that in babies those areas look deep bright red (rather than the
leathery, dry, gray appearance in the adult). Babies need proportionally
more fluid than the adult. An appropriate rate of initial fluid administration
is 20 mL/kg/h if the burn exceeds 20% of body surface, to be subsequently
fine-tuned in response to urinary output.
Other aspects of burn care include tetanus prophylaxis, cleaning of the
burn areas, and use of topical agents. The standard topical agent is silver
sulfadiazine. If deep penetration is desired (thick eschar, cartilage),
mafenide acetate is the choice (do not use it everywhere else; it hurts and it
can produce acidosis). Burns near the eyes are covered with triple
antibiotic ointment (silver sulfadiazine is irritating to the eyes). In the early
period, all pain medication is given intravenously. After an initial day or two
of NG suction, intensive nutritional support is provided, preferably via the
gut, with high-calorie/high-nitrogen diets. After 2 or 3 weeks of wound care
and general support, the burned areas that have not regenerated are
grafted. Rehabilitation starts on day one.

The concept of early excision and grafting is used whenever possible to
save costs and minimize pain, suffering, and complications. It implies
removal in the OR (on day one) of the burned areas, with immediate skin
grafting. This can be done only for fairly limited burns (under 20%) that are
obviously third-degree, but the experts are extending the concept to highly
selected patients with more extensive burns. On an exam question, you can
expect the candidate for early excision and grafting to have a very limited

Bites and Stings
Tetanus prophylaxis and wound care are required for all bites.
Dog bites are considered provoked if the dog was petted while eating or
otherwise teased. No rabies prophylaxis is required, other than observation
of the dog for developing signs of rabies. Because bites to the face are very
close to the brain, it might be prudent to start immunization and then
discontinue it if observation of the dog is reassuring.
Unprovoked dog bites or bites from wild animals raise the issue of
potential rabies. If the animal is available, it can be killed and the brain
examined for signs of rabies. Otherwise, rabies prophylaxis is mandatory
(immunoglobulin plus vaccine).
Snakebites by crotalids (rattlesnakes) do not necessarily result in
envenomation, even if the snake is poisonous (up to 30% of bitten patients
are not envenomated). The most reliable signs of envenomation are severe
local pain, swelling, and discoloration developing within 30 minutes of the
bite. If present, draw blood for typing and crossmatch (they cannot be
done later if needed), coagulation studies, and liver and renal function.
Treatment is based on antivenin. The currently preferred agent for
crotalids is CROFAB, of which several vials are usually needed.
Antivenin dosage relates to size of the envenomation, not size of the
patient (children get the same dosages as adults). Surgical excision of the
bite site or fasciotomy are very rarely needed. The only valid first aid is to
splint the extremity during transportation. All the first aid measures that
you learned at boy scouts are wrong. Do not make cruciate cuts, suck out
venom, wrap with ice, or apply a tourniquet.

Brightly colored coral snakes have a neurotoxin that needs to be promptly
neutralized with specific antivenin. Don’t wait for signs of envenomation.
True coral snakes are identified by the mnemonic “Red on yellow, kill a
fellow,” meaning that red rings and yellow rings touch each other.
Harmless brightly colored imitators have black rings separating yellow and
Bee stings kill many more people in the United States than snakebites
because of an anaphylactic reaction. Wheezing and rash may occur, and
hypotension when present is caused by vasomotor shock (“pink and
warm” shock). Epinephrine is the drug of choice (0.3 to 0.5 mL of 1:1,000
solution). The stingers should be removed without squeezing them.
Black widow spiders are black, with a red hourglass on their belly. Bitten
patients get nausea, vomiting, and severe generalized muscle cramps. The
antidote is IV calcium gluconate. Muscle relaxants also help.
Brown recluse spider bites are often not recognized at the time. By the
next day a skin ulcer develops, with necrotic center and a surrounding halo
of erythema. Dapsone is helpful. Surgical excision may be needed but
should be delayed until the full extent of the damage is evident (as much as
one week). Skin grafting may be needed.
Human bites are bacteriologically the dirtiest bite one can get. They
require extensive irrigation and debridement (in the OR). A classic human
bite is the sharp cut over the knuckles on someone who punched someone
else in the mouth and was cut by the teeth of the victim. They often show
up in the ER with a cover story but should be recognized because they need
specialized orthopedic care.

Surgical Infections
Infections often occur as an aftermath of the violation of the
integrity of the human body, such as trauma. They obviously can
also occur as a consequence of disease—for instance, perforation of

the colon with subsequent spillage of bacteria into the peritoneal
cavity. Many general principles apply to both situations. Let us
review them.
When harmful organisms invade our tissues, the ultimate outcome
depends on the balance between the virulence of the bugs and the
robustness of the body’s natural defenses. The principal factor on
the side of the invaders is their number; a wound sustained on a
battlefield, for instance, starts with a huge inoculum. The second
factor in microbes’ favor is time. Bacteria in an environment with
ideal nutrients, humidity, and temperature multiply at an
astonishing speed. Thus, what might begin as a minor
contamination—such as a stab wound in a clean setting—will
eventually become a real problem if not promptly treated. The
“magic” time for that undesirable development is around 6 hours.
On the side of patient, the main defense is the richness of the blood
supply at the site of the battle. Well-supplied sites like the face and
the soft tissues of the oral cavity get infected very rarely. At the
other end of the spectrum are bones, cartilage, and previously
irradiated tissues. The bugs typically win there, sometimes helped
by systemic conditions like an immunosuppressed state or
So, what can we do to help the patient? Bearing in mind what we
have reviewed so far, several strategies should be obvious.
Let’s start with time: Don’t allow those evil bugs to multiply inside
the human victim. An individual with a perforated colon or a broken
femur sticking out of a dirty wound deserves priority in the
scheduling of available operating rooms. Simple mechanical
cleansing in the OR will diminish the number of invaders. The first
order of business is elimination of foreign material and dead tissue,
along with massive irrigation: Dilution is the solution to the
problem of pollution.

Next, let’s look at blood supply: Given its importance, wouldn’t it be
nice to increase it to tilt the balance in favor of the patient? We can
do it with an old trick that is cheap and easy to apply. Consider
subcutaneous tissue, another poorly irrigated area of the body. If
we close a heavily contaminated wound, that fatty layer will
predictably become an abscess. But if we leave it open, the healing
process covers that exposed fat with granulation tissue, which is
made up of vascular buds.
Medical students are often bewildered at the end of an operation
for a perforated colon when the surgeon tells the chief resident,
“Leave the wound open.” They have visions of bowel spilling out
and flies landing for a drink of blood. What the chief is actually
communicating is “Close everything up to and including the fascia,
but leave the subcutaneous tissue and skin open.” Several days
later, when granulation tissue is well established, we can close that
wound with impunity.
More recently, we have discovered another way to keep wounds
clean: suction. Constant, gentle suction applied by patented
mechanical devices has become a common adjuvant in the
management of these patients.
What about antibiotics? Aren’t they our most potent weapons to kill
Yes, antibiotics have a role, but they are not a substitute for the
universally applicable measures already discussed. There is no
“universal” antibiotic—no single drug or drug combination that can
wipe out all harmful bugs. It is beyond the scope of this little book
to engage in a detailed discussion of antibiotic choices: More than
150 options are available, and mastery of that topic requires a 2year fellowship beyond basic residency training. We will just
mention a couple of examples.

Colonic contents represent one end the spectrum, requiring a
combination of agents to cover gram-positive, gram-negative, and
anaerobic organisms. Some practitioners use ciprofloxacin and
metronidazole in the management of lower GI injury or disease,
while some prefer piperacillin and tazobactam and others include
imipenem. Skin flora, on the other hand, is typically handled with a
single drug. When you first venture into the operating room for a
clean, elective case, you will find that surgeons want the patient to
have good blood levels of cefazolin during the operation. To ensure
this, they administer it 2 hours prior to making the incision.
Many of the rituals of surgery are, in fact, based on the principles
that we have just discussed. Because morning hours are very busy
in the surgical suite, we used to shave the operating area the night
before. No longer. Razor blades can nick the skin and allow bacteria
in. Given 12 hours in a warm, moist, nutrient-rich environment,
what do those little creatures do? You know: They multiply like
crazy. So, now we get rid of the hair just before we prep the area—
and we do it with clippers.

Chapter 2

Disorders in Children
Developmental dysplasia of the hip runs in families and ideally should be
diagnosed right after birth. Children have uneven gluteal folds, and
physical examination of the hips shows that they can be easily dislocated
posteriorly with a jerk and a “click,” and returned to normal with a
“snapping.” If signs are equivocal, sonogram is diagnostic (do not order xrays; the hip is not calcified in the newborn). Treatment is abduction
splinting with Pavlik harness for about 6 months.
Hip pathology in children may show up with hip pain, or it may show up
with knee pain.
Legg-Calvé-Perthes disease (avascular necrosis of the capital femoral
epiphysis) occurs around age 6, with insidious development of limping,
decreased hip motion, and hip (or knee) pain. Kids walk with an antalgic
gait, and passive motion of the hip is guarded. Diagnosis is provided by AP
and lateral hip x-rays. Treatment is controversial, usually containing the
femoral head within the acetabulum by casting and crutches.
Slipped capital femoral epiphysis is an orthopedic emergency. The
typical patient is a chubby (or lanky) boy, around age 13. They complain of

groin (or knee) pain and are noted to be limping. When they sit with the
legs dangling, the sole of the foot on the affected side points toward the
other foot. On physical exam there is limited hip motion, and as the hip is
flexed the thigh goes into external rotation and cannot be rotated
internally. X-rays are diagnostic, and surgical treatment pins the femoral
head back in place.
Septic hip is another orthopedic emergency. It is seen in little toddlers who
have had a febrile illness and then refuse to move the hip. They hold the leg
with the hip flexed, in slight abduction and external rotation, and do not let
anybody try to move it passively. They have elevated sedimentation rate.
Diagnosis is made by aspiration of the hip under general anesthesia, and
further open drainage is done if pus is obtained.

Acute hematogenous osteomyelitis is also seen in little kids who have
had a febrile illness, but it shows up with severe localized pain in a bone
(and no history of trauma to that bone). X-rays will not show anything for a
couple of weeks. MRI gives prompt diagnosis. Treat with antibiotics.
Genu varum (bowlegs) is normal up to the age of 3. No treatment is
needed. Persistent varus beyond age 3 is most commonly Blount disease (a
disturbance of the medial proximal tibial growth plate), for which surgery
can be done.
Genu valgus (knock-knee) is normal between ages 4 and 8. No treatment
is needed.
Osgood-Schlatter disease (osteochondrosis of the tibial tubercle) is
seen in teenagers with persistent pain right over the tibial tubercle, which
is aggravated by contraction of the quadriceps. Physical exam shows
localized pain right over the tibial tubercle, and there is no knee swelling.
First responders use conservative management, as suggested by the

mnemonic RICE: rest, ice, compression, and elevation. If such measures are
unsuccessful, these patients are referred to an orthopedic surgeon, who at
most would use an extension or cylinder cast for 4 to 6 weeks.
Club foot (talipes equinovarus) is seen at birth. Both feet are turned
inward, and there is plantar flexion of the ankle, inversion of the foot,
adduction of the forefoot, and internal rotation of the tibia. Serial plaster
casts started in the neonatal period provide sequential correction starting
with the adducted forefoot, then the hindfoot varus, and last the equinus.
Often Achilles tenotomy and part-time, long-term use of braces are added.
Those who do not respond to casting require surgery, typically done
between the ages of 9 and 12 months.
Scoliosis is seen primarily in adolescent girls, whose thoracic spines are
curved toward the right. The most sensitive screening finding is to look at
the girl from behind while she bends forward, a hump will be noted over
her right thorax. The deformity progresses until skeletal maturity is
reached (at the onset of menses skeletal maturity is about 80%). In
addition to the cosmetic deformity, severe cases develop decreased
pulmonary function. Bracing is used to arrest progression; severe cases
may need surgery.

Remodeling occurs to an astonishing degree in children’s fractures, thus
degrees of angulation that would be unacceptable in the adult may be
okay when these fractures are reduced and immobilized. Also, the healing
process is much faster than in the adult. The only areas where children
have special problems include supracondylar fractures of the humerus and
fractures of any bone that involve the growth plate.
Supracondylar fractures of the humerus occur with hyperextension of
the elbow in a child who falls on the hand, with the arm extended. Vascular

or nerve injuries can easily occur, and they could lead to Volkmann
contracture. Although they can be treated with the appropriate casting or
traction (and seldom need surgery), they require careful monitoring of
vascular and nerve integrity, and vigilance regarding development of a
compartment syndrome.
Fractures that involve the growth plate can be treated by closed
reduction if the epiphyses and growth plate are displaced laterally from the
metaphysis but are in one piece (i.e., the fracture does not cross the
epiphyses or growth plate and does not involve the joint). If the growth
plate is in 2 pieces, the very precise alignment provided by open reduction
and internal fixation will be required. Otherwise, growth will occur
unevenly, resulting in deformity of the extremity.

Primary malignant bone tumors are diseases of young people. They
complain of persistent low-grade pain, present for several months. The xray appearance includes invasion of the adjacent soft tissues, a “sunburst”
pattern, and periosteal “onion skinning.” Treatment is highly specialized,
best left to the experts.
Osteogenic sarcoma is the most common primary malignant bone tumor.
It is seen in ages 10–25, usually around the knee (lower femur or upper
tibia). A typical “sunburst” pattern is often described on x-rays.
Ewing sarcoma is the second most common; it affects younger children
(5–15), and it grows in the diaphyses of long bones. A typical “onion
skinning”–type pattern is often seen on x-rays.

Most malignant bone tumors in adults are metastatic, from the breast in
women (lytic lesions), from prostate in men (blastic lesions). Localized pain
is an early finding. X-rays can be diagnostic, CT scans give more
information, and MRI is even better. Sometimes lytic lesions show up with
pathologic fracture (i.e., fracture precipitated by events that would not
justify it, such as lifting a bag of groceries).
Multiple myeloma is seen in old men, with fatigue, anemia, and localized
pain at specific places on several bones. X-rays are diagnostic, showing
multiple punched-out lytic lesions. They also have Bence-Jones protein in
the urine and abnormal immunoglobulins in the blood, best shown by

serum immunoelectrophoresis. It is treated with chemotherapy.
Thalidomide can be used in the event that chemotherapy fails.
Soft tissue sarcomas have relentless growth (several months) of soft
tissue mass anywhere in the body. They are firm, fixed to surrounding
structures. They metastasize to lungs but not to lymph nodes. MRIs may
help diagnose malignancy (but not specific type). Incisional biopsy should
be done by the expert who is going to do the treatment, which includes
very wide local excision, radiation, and chemotherapy.

General Orthopedics
X-rays for suspected fractures should always include two views at 90° to
one another and always include the joints above and below the broken
bone. If the mechanism of injury suggests it, other x-rays should be taken
of the bones that are “in the line of force,” which might also be broken (for
instance, the lumbar spine when somebody falls from a height and lands
on—and breaks—his feet).
As a general rule, broken bones that are not badly displaced or angulated
or that can be satisfactorily aligned by external manipulation can be
immobilized in a cast (“closed reduction”). Broken bones that are severely
displaced or angulated or that cannot be aligned easily require surgical
intervention to reduce and fix the fracture (“open reduction and internal
Clavicular fractures are typically at the junction of middle and distal
thirds. The traditional treatment is a figure-of-eight device that, by pulling
back on both shoulders, aligns the bone. Wearing a sling is more
comfortable and also works well. If very precise outcome is desired for
cosmetic reasons, open reduction and internal fixation can be done.
Anterior dislocation of the shoulder is by far the most common shoulder
dislocation. Patients hold the arm close to their body but rotated outward
as if they were going to shake hands. There may be numbness in a small
area over the deltoid, from stretching of the axillary nerve. AP and lateral xrays are diagnostic. Some patients develop recurrent dislocations with
minimal trauma.

Posterior shoulder dislocation is rare and occurs after massive
uncoordinated muscle contractions, such as epileptic seizure or electrical
burn. The arm is held in the usual protective position (close to the body,
internally rotated). Regular x-rays can easily miss it; axillary views or
scapular lateral views are needed.
Colles fracture results from fall on an outstretched hand, often in old
osteoporotic women. The deformed and painful wrist looks like a “dinner
fork.” The main lesion is a dorsally displaced, dorsally angulated fracture of
the distal radius. Treat with close reduction and long arm cast.
Monteggia fracture results from direct blow to the ulna (such as on a
raised protective arm hit by a nightstick). There is diaphyseal fracture of
the proximal ulna, with anterior dislocation of the radial head.
Galeazzi fracture is the mirror image of the previous one: the distal third
of the radius gets the direct blow and has the fracture, and there is dorsal
dislocation of the distal radioulnar joint. In both of these, the broken bone
often requires open reduction and internal fixation, whereas the dislocated
one is typically handled with closed reduction.
Fracture of the scaphoid (carpal navicular) affects a young adult who
falls on an outstretched hand. Patient complains of wrist pain. Physical
exam shows localized tenderness to palpation over the anatomic snuffbox.
In undisplaced fractures, x-rays are usually negative, but thumb spica cast
is indicated just with the history and physical findings. X-rays will show the
fracture 3 weeks later. If original x-rays show displaced and angulated
fracture, open reduction and internal fixation are needed. Scaphoid
fractures are notorious for a very high rate of nonunion.
Metacarpal neck fractures (typically the fourth or fifth, or both) happen
when a closed fist hits a hard surface (like a wall). The hand is swollen and
tender, and x-rays are diagnostic. Treatment depends on the degree of
angulation, displacement, or rotary malalignment: closed reduction and

ulnar gutter splint for the mild ones; Kirschner wire or plate fixation for the
bad ones.
Hip fractures typically happen to the old who sustain a fall. The hip hurts,
and the patient’s position in the stretcher is classic: The affected leg is
shortened and externally rotated. Specific treatment depends on specific
location (as shown by x-rays).
Femoral neck fractures, particularly if displaced, compromise the very
tenuous blood supply of the femoral head. Faster healing and earlier
mobilization can be achieved by replacing the femoral head with a
Intertrochanteric fractures are less likely to lead to avascular necrosis
and are usually treated with open reduction and internal fixation. The
unavoidable immobilization that ensues poses a very high risk for deep
venous thrombosis and pulmonary emboli, thus post-op anticoagulation is
Femoral shaft fractures are often treated with intramedullary rod fixation.
If bilateral and comminuted, they may produce enough internal blood loss
to lead to shock (external fixation may help while the patient is stabilized).
If they are open, they are an orthopedic emergency, requiring OR cleaning
and closure within 6 hours. If multiple, they may lead to the fat embolism
Knee injuries typically produce swelling of the knee (knee pain without
swelling is unlikely to be a serious knee injury). Swelling of the knee has
been described as “the poor man’s MRI,” a reference to its clinical
reliability, and to the fact that MRI is the best highly technological way to
look inside the knee.
Collateral ligament injuries are usually sustained in a sideways blow to
the knee (a common sports injury). Medial blows disrupt the lateral
ligaments, and vice versa. The knee will be swollen and show localized pain
by direct palpation on the affected side. With the knee flexed 30°, passive

abduction or adduction will produce pain on the torn ligaments and allow
further displacement than the normal leg. Abduction demonstrates the
medial injuries (valgus stress test), whereas adduction diagnoses the
lateral injuries (varus stress test). Isolated injuries are treated with a hinged
cast. When several ligaments are torn, surgical repair is preferred.
Anterior cruciate ligament injuries are more common than posterior
ones. There is severe knee swelling and pain. With the knee flexed 90°, the
leg can be pulled anteriorly, like a drawer being opened (anterior drawer
test). A similar finding can be elicited with the knee flexed at 20° by
grasping the thigh with one hand, and pulling the leg with the other
(Lachman test). Posterior cruciate ligament injuries produce the opposite
findings. MRIs are diagnostic. Sedentary patients may be treated with
immobilization and rehabilitation, whereas athletes require surgical
reconstruction. Almost all cruciate injuries are sports-related and require
Meniscal tears are difficult to diagnose clinically and on x-rays, but are
beautifully shown on MRI. Patients often have protracted pain and swelling
after a knee injury, and they may describe catching and locking that limit
knee motion, and a “click” when the knee is forcefully extended. Repair is
done, trying to save as much meniscus as possible. Complete
meniscectomy leads to late development of degenerative arthritis.
Injuries to the medial meniscus, the medial collateral, and the anterior
cruciate often occur simultaneously.
Tibial stress fractures are seen in young men subjected to forced
marches. There is tenderness to palpation over a very specific point on the
bone, but x-rays are initially normal. Treat with a cast and repeat the x-rays
in 2 weeks. Non–weight bearing (crutches) is another option.
Leg fractures involving the tibia and fibula are often seen when a
pedestrian is hit by a car. Physical exam shows angulation; x-rays are
diagnostic. Casting takes care of the ones that are easily reduced;

intramedullary nailing is needed for the ones that cannot be aligned. The
lower leg (along with the forearm) is one of the most common locations for
development of the compartment syndrome. Increasing pain after a long
leg cast has been applied requires immediate removal of the cast and
appropriate assessment.
Rupture of the Achilles tendon is seen in out-of-shape middle-aged men
who subject themselves to severe strain (tennis, for instance). As they plant
the foot and change direction, a loud popping noise is heard (like a rifle
shot), and they fall clutching the ankle. Limited plantarflexion is still
possible; but pain, swelling, and limping bring them to the doctor.
Palpation of the tendon reveals a gap. Casting in equinus position allows
healing in several months; surgery achieves quicker cure.
Fractures of the ankle occur when falling on an inverted or everted foot.
In either case, both malleoli break. AP, lateral, and mortise x-rays are
diagnostic. Open reduction and internal fixation is needed if the fragments
are displaced.

The compartment syndrome occurs most frequently in the forearm or
lower leg. Precipitating events include prolonged ischemia followed by
reperfusion, crushing injuries, or other types of trauma. In the lower leg, by
far the most common cause is a fracture with closed reduction. The patient
has pain and limited use of the extremity. The compartment feels very tight
and tender to palpation. The most reliable physical finding is excruciating
pain with passive extension. Pulses may be normal. Emergency fasciotomy
is required for treatment.
Pain under a cast is always handled by removing the cast and examining
the limb.

Open fractures (the broken bone sticking out through a wound) require
cleaning in the OR and suitable reduction within 6 hours from the time of
the injury.
Posterior dislocation of the hip occurs when the femur is driven
backward, such as in a head-on car collision where the knees hit the
dashboard. The patient has hip pain and lies in the stretcher with the leg
shortened, adducted, and internally rotated (in a broken hip the leg is also
shortened, but it is externally rotated). Because of the tenuous blood
supply of the femoral head, emergency reduction is needed to avoid
avascular necrosis.
Gas gangrene occurs with deep, penetrating, dirty wounds (stepping on a
rusty nail, with lots of mud or manure). In about 3 days the patient is
extremely sick, looking toxic and moribund. The affected site is tender,
swollen, discolored, and has gas crepitation. Treatment includes penicillin
and clindamycin, extensive emergency surgical debridement, and
hyperbaric oxygen.
Other galloping soft tissue infections are seen primarily in
immunocompromised patients (diabetics, AIDS patients), the most
common being synergistic bacterial gangrene and necrotizing fasciitis.
Patients debilitated by extensive burns or widespread trauma may suffer
fulminating fungal infections. The most feared of these is mucormycosis, in
which the affected areas turn black; diagnosis is confirmed by tissue
biopsy. All of these conditions require repeated, massive surgical excisions
of dead tissue in addition to appropriate antibiotics (broad spectrum for
synergistic bacterial gangrene and necrotizing fasciitis, IV amphotericin B
for mucormycosis).

Associated neurovascular injuries
The radial nerve can be injured in oblique fractures of the middle to distal
thirds of the humerus. If the patient comes in unable to dorsiflex (extend)

the wrist and regains function when the fracture is reduced and the arm is
placed on a hanging cast or coaptation sling, no surgical exploration is
needed. However, if nerve paralysis develops or remains after reduction,
the nerve is entrapped and surgery has to be done.
Popliteal artery injuries can occur in posterior dislocations of the knee.
Attention to the integrity of pulses, Doppler studies, or CT angio, are key
issues. Prompt reduction will minimize vascular compromise. Delayed
restoration of flow requires prophylactic fasciotomy.

Injury patterns—the second, hidden fracture
The direction of force that produces an obvious injury may produce
another one that is less obvious and needs to be sought.
Falls from a height landing on the feet may have obvious foot or leg
fractures. Fractures of the lumbar or thoracic spine may be less obvious,
and must be looked for.
Head-on automobile collisions may produce obvious injuries in the face,
head, and torso; but if the knees hit the dashboard the femoral heads may
be driven backward into the pelvis or out of the acetabulum.
Facial fractures and closed head injuries should always prompt
evaluation of the cervical spine.

Carpal tunnel syndrome occurs mostly in women who do repetitive hand
work (such as typing). They complain about numbness and tingling in their
hands, particularly at night, and in the distribution of the median nerve
(radial 31⁄2 fingers). The symptoms can be reproduced by hanging the hand
limply for a few minutes, or by tapping, percussing or pressing the median
nerve over the carpal tunnel. Initial treatment is splints and anti-

inflammatory agents. If unsuccessful, electro-diagnostic studies of nerve
conduction are done to justify the need for surgery. Endoscopic release is
the currently favored operation.
Trigger finger also favors women. Patients wake up in the middle of the
night with a finger acutely flexed, and they are unable to extend it unless
they pull it with the other hand. When they do so, there is a painful “snap.”
Steroid injection is the first line of therapy; surgery is the treatment of last
De Quervain tenosynovitis is seen in young mothers who, as they carry
their baby, force their hand into wrist flexion and thumb extension to hold
the baby’s head. They complain of pain along the radial side of the wrist
and the first dorsal compartment. On physical exam the pain can be
reproduced by asking her to hold her thumb inside her closed fist, then
forcing the wrist into ulnar deviation. Splint and antiinflammatory agents
can help, but steroid injection is best. Surgery is rarely needed.
Dupuytren contracture occurs in older men of Norwegian ancestry. There
is contracture of the palm of the hand, and palmar fascial nodules can be
felt. Steroids or collagenase injections can be helpful. If not, surgery may
be needed when the hand can no longer be placed flat on a table.
Felon is an abscess in the pulp of a fingertip, caused by a neglected
penetrating injury. Patients complain of throbbing pain and have all the
classic findings of an abscess, including fever. Because the pulp is a closed
space with multiple fascial trabecula, pressure can build up and lead to
tissue necrosis; thus surgical drainage must be urgently done.
Gamekeeper thumb is an injury of the ulnar collateral ligament sustained
by forced hyperextension of the thumb (historically suffered by
gamekeepers when they killed rabbits by dislocating their necks with a
violent blow with the extended thumb—nowadays seen as a skiing injury
when the thumb gets stuck in the snow or the ski strap during a fall). On
physical exam there is collateral laxity at the thumb-metacarpophalangeal

joint, and if untreated it can be dysfunctional and painful, and lead to
arthritis. Casting is usually done.
Jersey finger is an injury to the flexor tendon sustained when the flexed
finger is forcefully extended (as in someone unsuccessfully grabbing a
running person by the jersey). When making a fist, the distal phalanx of the
injured finger does not flex with the others.
Mallet finger is the reverse of the previous one. The extended finger is
forcefully flexed (a common volleyball injury), and the extensor tendon is
ruptured. The tip of the affected finger remains flexed when the hand is
extended, resembling a mallet. For both of these injuries, splinting is
usually the first line of treatment.
Traumatically amputated digits are surgically reattached whenever
possible. The amputated digit should be cleaned with sterile saline,
wrapped in a saline-moistened gauze, placed in a sealed plastic bag, and
the bag placed on a bed of ice. The digit should not be placed in antiseptic
solutions or alcohol, should not be put on dry ice, and should not be
allowed to freeze. With the use of electric nerve stimulation to preserve
muscular function, entire amputated extremities can be reattached.

Lumbar disk herniation occurs almost exclusively at L4–L5 or L5–S1. The
peak age incidence is 45–46. Patients often describe several months of
vague aching pain (the “discogenic pain” produced by pressure on the
anterior spinal ligament) before they have the sudden onset of the
“neurogenic pain” precipitated by an event like attempting to lift a heavy
object. The latter is extremely severe, “like an electrical shock that shoots
down the leg” (exiting on the side of the big toe in L4–L5, or the side of the
little toe in L5–S1), and it is exacerbated by coughing, sneezing, or
defecating (if the pain is not exacerbated by those activities, the problem is

not a herniated disk). Patients cannot ambulate, and they hold the affected
leg flexed. Straight leg-raising test gives excruciating pain. MRI confirms the
diagnosis. Spontaneous resolution is the rule, as the body reabsorbs the
extruded disc. This process used to be very inconvenient for the patient,
requiring 3 weeks of strict bed rest. The advent of pain control specialists,
who perform nerve blocks under radiological guidance, has made the
recovery period much easier. Surgical intervention is needed if neurologic
deficits are progressing (progressive muscle weakness), and emergency
intervention is required if there is a cauda equina syndrome.
The cauda equina syndrome (distended bladder, flaccid rectal sphincter,
perineal saddle anesthesia) is a surgical emergency requiring immediate
Ankylosing spondylitis is seen in young men in their 30s or early 40s who
complain of chronic back pain and morning stiffness. The pain is worse at
rest, and improves with activity. Symptoms are progressive, and x-rays
eventually show a “bamboo spine.” Antiinflammatory agents and physical
therapy are used. Many of these patients have the HLA B-27 antigen, which
is also associated with uveitis and inflammatory bowel disease.
Metastatic malignancy should be suspected in the elderly who have
progressive back pain that is worse at night and unrelieved by rest or
positional changes. Weight loss is often an additional finding. If advanced,
x-rays will show the lesions (in women, lytic breast cancer metastases at
the pedicles; in men, blastic metastases are from the prostate). At a higher
cost, MRI is the best diagnostic tool.

Diabetic ulcers are typically indolent and located at pressure points (heel,
metatarsal head, tip of toes). They start because of the neuropathy, and
they fail to heal because of the microvascular disease. Theoretically they

can be healed with good control of the diabetes and by keeping them clean
with the leg elevated for many weeks or months. In reality they often get
worse and lead to amputations.
Ulcers from arterial insufficiency are usually as far away from the heart
as they can be: at the tip of the toes. They look dirty, with a pale base
devoid of granulation tissue. The patient has other manifestations of
arteriosclerotic occlusive disease (absent pulses, trophic changes,
claudication or rest pain). Workup begins with Doppler studies looking for a
pressure gradient (if there isn’t one, there is microvascular disease not
amenable to surgical therapy). Then CT angio, MRI angio or arteriograms,
and surgical revascularization or angioplasty and stents.
In the evaluation of chronic foot ulcers, a workup is often done for both
diabetes and arteriosclerotic occlusive disease, inasmuch as both
problems often coexist in the same patient.
Venous stasis ulcers develop in chronically edematous, indurated, and
hyperpigmented skin above the medial malleolus. The ulcer is painless,
with granulating bed. The patient has varicose veins and suffers from
frequent bouts of cellulitis. Duplex scan is useful in the workup. Treatment
revolves around physical support to keep the veins empty, best done with
support stockings measured to fit the patient. Surgery may be required
(vein stripping, grafting of the ulcer); endovascular ablation with laser or
radiofrequency may also be used.
Marjolin ulcer is a squamous cell carcinoma of the skin developing in a
chronic leg ulcer. The classic setting is one of many years of healing and
breaking down, such as seen in untreated third-degree burns that
underwent spontaneous healing, or in chronic draining sinuses secondary
to osteomyelitis. A dirty-looking, deeper ulcer develops at the site, with
heaped up tissue growth around the edges. Biopsy is diagnostic. Wide local
excision and skin grafting are done.

Plantar fasciitis is a very common but poorly understood problem
affecting older, overweight patients who complain of disabling, sharp heel
pain every time their foot strikes the ground. The pain is worse in the
mornings. X-rays show a bony spur matching the location of the pain, and
physical exam shows exquisite tenderness to palpation over the spur. Yet
the bony spur is not the cause of the problem (many asymptomatic people
have similar spurs). Spontaneous resolution can be expected in 12–18
months, during which time symptomatic treatment is offered, and removal
of the bony spur may help.
Morton neuroma is an inflammation of the common digital nerve at the
third interspace, between the third and fourth toes. The neuroma is
palpable as a very tender spot there. The cause is typically the use of
pointed, high-heeled shoes (or pointed cowboy boots) that force the toes
to be bunched together. Conservative management includes analgesics
and more sensible shoes, but, if needed, surgical excision can be done.
Gout produces the typical swelling, redness, and exquisite pain of sudden
onset at the first metatarsal-phalangeal joint, in a middle-age obese man
with high serum uric acid. Uric acid crystals are identified in fluid from the
joint. Treatment for the acute attack is done with indomethacin and
colchicine. Allopurinol and probenicid are used for chronic control.

Chapter 3

Pre-Op and Post-Op Care
Preoperative Assessment
Ejection fraction under 35% (normal is 55%) poses prohibitive cardiac risk
for noncardiac operations. Incidence of perioperative MI is very high, and
mortality for such an event is between 55 and 90%.
Goldman’s index of cardiac risk, which dates from 1977, is no longer the
preferred method of assessing cardiac risk. Functional status, based on the
ability to cope with life’s demands, is more commonly used now. But
Goldman’s remains useful for listing all the findings that predict trouble.
They are (in descending order of importance): jugular venous distension,
recent myocardial infarction, premature ventricular contractions or any
rhythm other than sinus, age over 70, emergency surgery, aortic valvular
stenosis, poor medical condition, and surgery within the chest or
abdomen. The examination will give particular attention to the high-risk
situations that intervention can improve.
Jugular venous distention, which indicates the presence of congestive
heart failure, is the worst single finding predicting high cardiac risk. If at all
possible, treatment with ACE inhibitors, beta-blockers, digitalis, and
diuretics should precede surgery.

Recent transmural or subendocardial MI is the next worst predictor of
cardiac complications. Operative mortality within 3 months of the infarct is
40%, but it drops to 6% after 6 months. Thus deferring surgery until then is
the best course of action. If surgery is imperative sooner, admission to the
intensive care unit (ICU) the day before is recommended to “optimize
cardiac variables.”

Smoking is by far the most common cause of increased pulmonary risk,
and the problem is compromised ventilation (high PCO2, low forced
expiratory volume in 1 second [FEV1]), rather than compromised
oxygenation. The smoking history, or the presence of chronic obstructive
pulmonary disease (COPD) should lead to evaluation. Start with FEV1, and
if it is abnormal, follow with blood gases. Cessation of smoking for 8 weeks
and intensive respiratory therapy (physical therapy, expectorants,
incentive spirometry, humidified air) should precede surgery.

Two clinical findings and three laboratory values are used to predict
operative mortality in patients with liver disease: encephalopathy,
ascites, serum albumin, prothrombin time (INR), and bilirubin (only as it
reflects hepatocyte function). The presence and severity of these factors
can be combined in a variety of ways; the current favorite system is Child
class, in which class A has 10% mortality, class B 30%, and class C 80%. But
specific numbers are misleading, because so many other factors influence
the outcome. Suffice it to say that a patient in coma with huge ascites,
albumin below 2, INR twice normal, and bilirubin above 4 could not survive
a haircut, much less an operation.

Severe nutritional depletion is identified by loss of 20% of body weight
over a couple of months, serum albumin below 3, anergy to skin antigens,
or serum transferrin level of less than 200 mg/dL (or a combination of the
above). Operative risk is multiplied manyfold in those circumstances.
Surprisingly, as few as 4 or 5 days of preoperative nutritional support
(preferably via the gut) can make a big difference, and 7–10 days would be
optimal if the surgery can be deferred that long.

Diabetic coma is an absolute contraindication to surgery. Rehydration,
return of urinary output, and at least partial correction of the acidosis and
hyperglycemia have to be achieved before surgery. (If the indication for
surgery is a septic process, complete correction of all variables will be
impossible as long as the septic process is present.)

Postoperative Complications
Malignant hyperthermia develops shortly after the onset of the anesthetic
(halothane or succinylcholine). Temperature exceeds 104°F. Metabolic
acidosis and hypercalcemia also occur. A family history may exist. Treat
with IV dantrolene, 100% oxygen, correction of the acidosis, and cooling
blankets. Watch for development of myoglobinuria.
Bacteremia is seen within 30–45 minutes of invasive procedures
(instrumentation of the urinary tract is a classic example), and there are
chills and temperature spike to or exceeding 104°F. Do blood cultures
times three, start empiric antibiotics.
Although rare, severe wound pain and very high fever within hours of
surgery should alert you to the possibility of gas gangrene in the surgical
Postoperative (PO) fever in the usual range (101°–103°F) is caused
(sequentially in time) by atelectasis, pneumonia, urinary tract infection,
deep venous thrombophlebitis, wound infection, or deep abscesses.
Atelectasis is the most common source of post-op fever on the first PO
day. Rule out the other causes listed above, listen to the lungs, do chest xray, improve ventilation (deep breathing and coughing, postural drainage,
incentive spirometry). The ultimate therapy if needed is bronchoscopy.
Pneumonia will happen in about 3 days if atelectasis is not resolved. Fever
will persist. Chest x-ray will show infiltrates. Do sputum cultures, treat with
appropriate antibiotics.

Urinary tract infection typically produces fever starting on PO day 3. Work
up with urinalysis, urinary cultures. Treat with appropriate antibiotics.
Deep thrombophlebitis typically produces fever starting on PO day 5 or
thereabouts. Doppler studies of deep leg and pelvic veins is the best
diagnostic modality (physical exam is worthless). Anticoagulate with
heparin, transitioning later to warfarin.
Wound infection typically begins to produce fever on PO day 7. Physical
exam will show erythema, warmth, and tenderness. Treat with antibiotics if
there is only cellulitis; open and drain the wound if an abscess is present.
When these two cannot be easily distinguished clinically, sonogram is
Deep abscesses (like subphrenic, pelvic, or subhepatic) start producing
fever around PO days 10–15. CT scan of the appropriate body cavity is
diagnostic. Percutaneous radiologically guided drainage is therapeutic.

Perioperative myocardial infarction may occur during the operation
(triggered most commonly by hypotension), in which case it is detected by
the EKG monitor (ST depression, T-wave flattening). When it happens postop, it is typically within the first 2–3 post-op days, showing up as chest pain
only in one-third of the cases, and with the complications of the MI in the
rest. The most reliable diagnostic test is troponin. Mortality (50–90%)
greatly exceeds that of MI not associated with surgery. Treatment is
directed at the complications. Clot busters cannot be used in the
perioperative setting, but emergency angioplasty and coronary stent may
be used.
Pulmonary embolus (PE) typically happens around PO day 7 in elderly
and/or immobilized patients. The pain is pleuritic, of sudden onset, and is
accompanied by shortness of breath. The patient is anxious, diaphoretic,

and tachycardic, with prominent distended veins in the neck and forehead
(a low CVP virtually excludes the diagnosis). Arterial blood gases show
hypoxemia and hypocapnia. The standard diagnostic test is a spiral CT with
intravenous dye, commonly referred to as a CT angio. After confirming the
diagnosis, start treatment with heparinization. Add an inferior vena cava
filter (Greenfield) if PEs recur during anticoagulation or if anticoagulation is
Prevention of thromboembolism will in turn prevent PE. Sequential
compression devices can be used on anyone who does not have a lower
extremity fracture. In high risk patients, anticoagulation is indicated. Risk
factors include age >40, pelvic or leg fractures, venous injury, femoral
venous catheter, and anticipated prolonged immobilization.

Aspiration is a distinct hazard in awake intubations in combative patients
with a full stomach. It can be lethal right away, or lead to chemical injury of
the tracheobronchial tree and subsequent pulmonary failure, or secondary
pneumonia. Prevention includes NPO and antacids before induction.
Therapy starts with lavage and removal of acid and particulate matter
(with the help of bronchoscopy), followed by bronchodilators and
respiratory support.
Intraoperative tension pneumothorax can develop in patients with
traumatized lungs (recent blunt trauma with punctures by broken ribs)
once they are subjected to positive-pressure breathing. They become
progressively more difficult to “bag,” BP steadily declines and CVP steadily
rises. If the abdomen is open, quick decompression can be achieved
through the diaphragm. If not, a needle can be inserted through the
anterior chest wall into the pleural space (sneaking in under the drapes).
Formal chest tube has to be placed later.

Hypoxia is the first thing that has to be suspected when a post-op patient
gets confused and disoriented. It may be secondary to sepsis. Check blood
gases, provide respiratory support.
Adult respiratory distress syndrome (ARDS) is seen in patients with a
stormy, complicated post-op course, often complicated by sepsis as the
precipitating event. There are bilateral pulmonary infiltrates and hypoxia,
with no evidence of congestive heart failure. The centerpiece of therapy is
positive end-expiratory pressure (PEEP), taking care not to use excessive
volume. Excessive ventilatory volumes have been shown to result in
barotrauma. A source of sepsis must be sought and corrected. There is
mounting evidence that extracorporeal membrane oxygenation (ECMO) is
becoming the new standard of care for ARDS refractory to PEEP. The main
complication is intracranial bleeding, which can be minimized by using a
venovenous connection to hook up the patient to the machine.
Delirium tremens (DTs) is very common in the alcoholic whose drinking is
suddenly interrupted by surgery. About the second or third PO day they get
confused, have hallucinations, and become combative. Intravenous
benzodiazepines are the standard therapy, but alcohol is also effective. It
can be intravenous (5% alcohol in 5% dextrose), or for those on oral intake
we can actually prescribe their favorite drink.
Hyponatremia, if quickly induced by liberal administ