Acute MSK / MSK emergencies

Question 1

Compartment syndrome.

a) Causes
b) Signs and symptoms
c) To diagnose
d) Management
e) How many compartments in upper limb?

Answer 1

a) Crush injury, tight bandaging/casting, broken bones (supracondylar and tibial shaft especially), burns
b) PAIN!! and increased on extension of affected muscle compartment (e.g. foot dorsiflexion if leg affected)

c) Intracompartmental pressure measurement:
- >20 abnormal
- >40 abnormal

d) Urgent surgical decompression via open fasciotomy
e) 4

Question 2

CES.

a) Causes
b) Presentation
c) Management

Answer 2

a) Disc herniation, malignant compression, fracture, abscess, haematoma
b) Back pain, bilateral leg weakness / sciatica, bowel/ bladder/ sexual dysfunction, saddle anaesthesia

c) - Urgent MRI spine
- Call spinal surgeons
- Surgical decompression
- Dexamethasone?

Question 3

Fat emboli.
a) Generally post…? (pathogenesis)

b) Prevention

Answer 3

a) Long bone fractures: the yellow marrow in the diaphysis is exposed and damaged
b) Early traction

Question 4

Fracture description.

AABCS

Answer 4

Adequacy
Alignment
Bones - OLD ACID (Open/closed, location, degree of fracture, articular involvement/angulation, communion, intrinsic bone quality, displacement/rotation)
Cartilage
Soft tissue

NB. Angulation - varus or valgus

Question 5

Open fracture management

a) Non-surgical
b) Surgical

Answer 5

a) - Clean and cover
- Analgesia
- Check neurovascular status (if impaired require urgent surgery)
- IV access
- Take bloods
- IV fluids/ transfusion
- IV ABx (co-amox)
- Tetanus booster
- XR imaging

b) - Reduce and splint
- Surgical debridement
- Later- fixation

Question 6

Hot, swollen joint: differentials

a) Monoarthritis
b) Oligoarthritis
c) Polyarthrtitis

Answer 6

a) Septic, gout, pseudogout
b) RA, reactive arthritis
c) RA, psoriatic, polyseptic arthritis (gonococcal)

Question 7

Septic arthritis: management

Answer 7

• IV Abx (fluclox)
• Bloods - sepsis 6 (FBC, CRP, cultures), urate
• Joint aspiration - gram stain, cell count, crystal analysis, MCS
• XR/ MRI
• Surgical washout if necessary

Question 8

Fracture.

a) stages of healing
b) drugs to avoid during acute healing stages

Answer 8

a) - Inflammation: ruptured blood vessels results in a haematoma and release of inflammatory cytokines (days)
- Formation of soft callus: haematoma becomes organised and is infiltrated by fibrovascular tissue, which forms initial spongy bone, which is still tender and liable to re-fracture; needs immobilising (days - weeks)
- Formation of hard callus: soft callus is replaced by hard callus over period of weeks; should be non-tender and able to move/weight bear (~ 6 weeks post-injury)
- Remodelling: gradual replacement of hard callus by strong cortical bone (months - years)

b) Bisphosphonates, NSAIDs, steroids and other immunosuppressives, quinolones

Question 9

Fracture management principles (3)

Answer 9

Reduce – Hold – Rehabilitate

Question 10

Fracture reduction.

a) What is it?
b) Why is it done?
c) How is it done?

Answer 10

a) Restoring the anatomical alignment of a fracture or dislocation of the deformed limb
b) Allows for bleeding tamponade and relief of pressure on surrounding structures (eg. nerves, vessels)

c) - requires analgesia (ideally a local/regional nerve block)
- usually performed ‘closed’ in ED; however, may be performed ‘open’ in theatre
- may or may not involve traction

Question 11

Fracture immobilisation.

a) Methods
b) Casting principles
c) Further management

Answer 11

a) Methods:
- Splinting (eg. Thomas splint for femoral shaft #)
- Plaster cast
- Surgical

b) - Initially only back-slab, not circumferential (allows swelling to occur)
- Not too tight - prevents compartment syndrome
- Should cover joint below the fracture (and also joint above if there is axial instability - prevents bone turning on its long axis)

c) - Decide whether suitable for weight-bearing or not
- VTE given
- Advice on compartment syndrome

Question 12

Fracture rehabilitation.

Answer 12

Physiotherapy.

• Ensure unaffected and non-immobilised joints are kept moving to avoid joint stiffness
• Once there is fracture union (usually after ~ 6 weeks), the affected bones should be stressed within limits to allow for strengthening
• Strengthen surrounding muscles

Occupational therapy.
- May need aids/devices to assist with ADLs

Question 13

Osteomyelitis.

a) Most common site and spread in children
b) Risk factors
c) Presentation
d) Investigations
e) Management - acute vs. chronic

Answer 13

a) - Haematogenous (systemic infection) or direct (trauma, surgery)
- Metaphysis of long bones (eg tibia, femur, humerus).
- Usually staph aureus

b) IVDU, trauma, fracture, prosthesis, SCD, diabetes, septic arthritis/cellulitis, sepsis, old age, debilitation, haemodialysis

c) Fever, painful limb, tender, non-weight bearing (if legs)
- (usually acute)

d) - Bloods: FBC, CRP, blood cultures
- Imaging: MRI (gold standard)*

*XR may not show changes for ~ 1 week (patchy osteopenia, periosteal reaction, necrosis, etc.)

e) - Surgical debridement and ABx in all cases
- ABx - IV for 2 weeks, then consider switching to oral
- Acute non-MRSA: Fluclox + fusidic acid (4 - 6 weeks)
- Acute MRSA: Vancomycin + fusidic acid (4 - 6 weeks)
- Chronic: 12 weeks ABx + removal (12 weeks)
- Treatment guided by cultures, clinical findings and inflammatory markers

Question 14

Post-fracture complications

Answer 14

Short-term: Haemorrhage, Ischaemia, Infection

Long-term: Arthritis

Question 15

Types of fracture.

Answer 15

• Stable fracture: The broken ends of the bone line up and are barely out of place.
• Open, compound fracture: Breaks the skin (need ABx)
• Transverse fracture: horizontal fracture line.
• Oblique fracture: an angled pattern.
• Spiral fracture
• Green-stick (in kids)
• Comminuted fracture: three or more pieces.