Block Summary Questions Flashcards
An elderly patient who mobilises with a ZF and suffers from CHF, COPD and type 2 diabetes presents to A and E and is found to have a displaced intracapsular hip fracture, what definitive treatment should be given and why?
hip hemi-arthroplasty
displaced fracture- unstable, and intracapsular- high risk of AN to femoral head, but patient unfit for a THR- longer op, higher risk of general complications, as requires more than 1 walking stick to mobilise, and has several co-morbidities.
a patient presents with a grossly deformed and swollen ankle in A and E, and is placed into a plaster backslab. Why is this used rather than a full plaster cast?
in order to allow swelling to reduce and not increase the pressure
methods to reduce ankle swelling before ORIF?
ankle elevation above the level of the heart
ice- ensure covered well so as not to burn the skin
apply a plaster backslab
rest the limb
a patient admitted with an ankle fracture, which has been stabilised in a plaster backslab, complains now of pain which is disproportionate to his injury. What 2 important management steps must take place?
removal of the plaster backslab
dermatofasciotomy
initial investigations to be undertaken in a patient following ABCDE assessment in A and E after a suspected significantly unstable fracture of both the right tibia and fibula?
FBC Us and Es clotting studies group and save plain X-ray of the right leg (and ankle?)
must assess NV status- palpate pulses and test sensation
standard ankle radiograph views?
AP
lateral
mortise- not a true AP, but optimises view of ankle joint- 30 degree oblique projection facing plane of inferior tibiofibular joint, this is best view to show tibiofibular joint separation (diastasis), and allows full visualisation of medial and lateral joint spaces.
mechanism of injury in skiers thumb/ thumb UCL acute injury?
hyperabduction or extension of thumb at the MCPJ
indications for a hinged TKR?
may be used in revision surgery or severe arthritis, have longer stem to allow for more secure fixaton into bone cavity
may be necessary if weakness of main knee ligaments, major bone loss due to arthritis or fracture, or major knee deformity
approximate healing time for surgical neck fractures (2 part fractures) of humerus?
6-8 weeks
but recovery takes months
shoulder stiffness generally occurs if shoulder immobilised for more than 2 weeks
why might a broad arm sling be used instead of a collar and cuff for a proximal humeral fracture?
if impacted fracture and don’t want disimpaction
union more likely with an impacted fracture
most common causative organism in prosthetic joint infections?
staphylococcus aureus
presentation of skiers thumb?
pain at ulnar aspect of thumb MCPJ
tment of skiers thumb?
nonoperative- immobilisation for 4-6wks- thumb spica splint
operative- ligament repair or reconstruction if significant instability
4 leg compartments?
anterior
lateral
superficial posterior
deep posterior
how can compartment syndrome be tested for in a patient?
needle manometry to measure intracompartmental pressure
passive hyperextension of the toes or fingers- increased pain in calf or forearm, as ischaemic muscle highly sensitive to stretch
note that aggressive IV fluid therapy required in treatment as myoglobinuria may follow fasciotomy and cause renal failure
why may a pulse still be felt in compartment syndrome?
ischaemia occurs at the capillary level
important blood test in suspected bone malignancy?
bone profile- Ca2+, phosphate, ALP, albumin
or
just Ca2+
rate of failure of a TKR?*
chance of failure in the 1st 10 years is 1% per annum cumulative
2 ways to distinguish between vascular claudication and spinal claudication?
spinal- relieved by leaning forward, vascular- just by rest
spinal- pain same or better when walking uphill, worse in vascular claudication
most common long bone fracture?
tibial shaft
along with supracondylar fractures these types of fractures most likely to cause compartment syndrome
mechanism of tibial shaft fracture?
low energy fracture pattern- indirect trauma, result of torsional injury, fibula fracture at different level
high energy pattern- direct forces, significant comminution, fibula fracture at same level, significant soft tissue injury
what tibial fracture is associated with a posterior malleolar fracture?
spiral fracture through distal 1/3 of tibia
symptoms of ptnt presenting with a mid-shaft tibial fracture, and what must be examined?
pain, inability to WB
NV status, status of compartments- palpation, passive movements of toes, pulse and sensation, intracompartmental pressure measurement if indicated
inspect soft tissue envelope for open fracture, contusions, blisters
recommended radiographs in suspected mid-shaft tibial fracture?
full length AP and lateral views of tibia
AP and lateral views of ipsilateral knee and ankle
indications for CT scan in midshaft tibial fracture?
intra-articular fracture extension or suspicion of joint involvement
ankle for distal 1/3 spiral fracture to exclude posterior malleolar fracture
define compartment syndrome
raised pressure within an enclosed fascial space, leading to localised tissue ischemia
type of injury at high risk of compartment syndrome?
crushing injury
causes of compartment syndrome?
bone fracture
reperfusion injury after prolonged ischaemia e.g. in ptnt with critical limb ischaemia who undergoes bypass grafting
compression from tight bandage
burns
prolonged compression in comatose, unprotected patient
importance of postoperative splintage after dermatofasciotomy for compartment syndrome?
splint limb in neutral, or functional, position, espec. if any muscle damage has occurred as contractures may then develop
what do spiral fractures of the tibia and fibula usually result from?
violent twisting injuries in contact sports, e.g. rotational stress applied to foot
nonoperative approach to non-displaced tibial shaft fracture?
closed reduction and stabilisation with above knee POP and split cast
convert to functional brace at 4 weeks
operative approach to displaced tibial shaft fractures?
IM nailing
percutaneous locking plate if inadequate fixation with IM nailing, but if long plate can place superficial peroneal nerve at risk- sensation to dorsum of foot except 1st webspace between hallux and 2nd toe.
IM nailing superior to external fixation as reduced malalignment, quicker time to WB and decreased further surgeries
potential complications of tibial shaft fracture?
compartment syndrome popliteal artery injury peroneal nerve injury- sensation loss and footdrop fat embolism non-union, mal-union infection gangrene skin loss osteomyelitis arthritis amputation
tment of undisplaced proximal or fibular shaft fractures?
analgesia and elevation, support in tubigrip or padded bandage
below knee POP and crutches if unable to WB
tment of a Masionneuve fracture?
prox fibular fracture following ankle injury, often MM fracture
will require surgery and short NWB cast for 6 weeks
difference between a dislocation and a subluxation of a joint?
dislocation= complete loss of congruity between articulating surfaces of a joint subluxation= partial dislocation, in which the articulating surfaces of a joint are no longer congruous but loss of contact is incomplete.
define a ligament sprain
an incomplete teat of a ligament or complex of ligaments responsible for joint stability
what is a dislocation the commonest result of?
indirect violence
name given to stress fracture of 2nd metatarsal?
march fracture- due to its frequency in army recruits
characteristics of greenstick fractures?
buckling of bone on opposite side to causal force as bone less brittle in a child
minimal tearing of soft tissues and surrounding periosteum
where in the body are compression/crush fractures common?
vertebral bodies- due to flexion injuries
heels- following fall from a height
union usually rapid if deformity accepted
common examples of avulsion fractures resulting from sudden muscle contraction?
base of 5th MT=Jones fracture- peroneus brevis
upper pole of patella-quadriceps
tibial tuberosity-quadriceps
lesser trochanter-iliopsoas
importance of correcting irregularities when a fracture is intra-articular?
if persist, may cause secondary OA
why can a fracture close to a joint cause stiffness?
involvement of muscles and tendons which can become bound down by callus
common complications of a fracture-dislocation?
stiffness
avasuclar necrosis
why is it important to visualise both ends of a fractured bone on a radiograph?
look for axial rotation
how can the diagnosis of a hairline fracture help to be confirmed?
CT scan
redo plain X-ray 2 weeks later
types of 5th metatarsal fractures?**
avulsion fracture of base- occurs with contraction of peroneus brevis, and in inversion injuries
jones fracture- fracture of 5th MT between metaphysis and diaphysis
nerve root for finger flexors (distal phalanx of middle finger)?
C8
nerve root for little finger abduction?
T1
upper limb max total motor score?
50 (25 R and 25 L, 5 for each)
what is a muscle function grading of 5?
normal active movement, full ROM against gravity and full resistance in a muscle specific position expected from an otherwise unimpaired person
what is a muscle function grading of 4?
active movement, full ROM against gravity and moderate resistance in a muscle specific position
what is a muscle function grading of 3?
active movement, full ROM against gravity but not resistance
what is a muscle function grading of 2?
active movement, full ROM with gravity eliminated
what is a muscle function grading of 1?
palpable or visible muscle contraction
what is a muscle function grading of 0?
total paralysis
why might muscle function grading be NT (not testable)?
immobilisation
severe pain such that ptnt cannot be graded
limb amputation
contracture of >50% of range of motion
what is a muscle function grading of 5*?
normal active movement, full ROM against gravity and sufficient resistance to be considered normal if identified inhibiting factors e.g. pain, disuse, were not present.
ASIA nerve root hip flexion?
L2
ASIA nerve root knee extension?
L3
ASIA nerve root ankle DF?
L4
ASIA nerve root ankle PF?
S1
ASIA nerve root long toe extension?
L5
what is considered alongside muscle function grading of particular muscle groups in LL motor ASIA assessment?
voluntary anal contraction
how are key sensory points for ASIA classification established?
area where nerve roots do not overlap
how is sensation scored on ASIA chart?
0-2 2=normal 1=altered 0=absent NT=not testable
what is the single neurological level?
lowest segment where motor and sensory function is normal on both sides, and is the most cephalad of the sensory and motor levels determined in steps 1 and 2
what does an ASIA impairment scale (AIS) of E mean?
ptnt with a documented SCI is found to have recovered normal function on follow up
3 subgroups of type III open fractures?
IIIA: adequate soft-tissue coverage of fracture despite high-energy trauma or extensive laceration or skin flaps, more than 10 cm high energy, includes segmental or extensively comminuted fractures even if wound less than 10cm.
B: inadequate soft-tissue coverage with periosteal stripping, soft-tissue reconstruction necessary- need for free or regional soft tissue flap for coverage
C: any open fracture assoc. with vascular injury requiring repair
what score can be used to predict need for future amputation in patient with an open fracture?
mangled extremity score
a score of 7 or more is highly predictive of amputation
what score can be used to assess risk of pathological fracture in patients with metastatic bone cancer?
Mirel’s risk score
human fight bite injury common over dorsum of hand, over 3rd or 4th MCPJS, what is it therefore important to assess the integrity of?
extensor tendon function- get ptnt to extend fingers, espec, as can be overloooked with proximal tendon retraction
dog bite injuries often don’t cause fracture, what are indications for radiographs in assessing human bite injuries?
look for foreign body e.g. tooth fragment, and for fracture
tment of human bite injury?
irrigation and debridement
ABx- IV, then oral for 7 days when discharged e.g. co-amoxiclav-BS, effective against both staph and strep
how can bacteria get into a joint to cause septic arthritis?
bacteraemia
direct inoculation from trauma or surgery
contiguous spread from adjacent osteomyelitis
how might AVN of proximal scaphoid be visible on X-ray?
proximal pole bone sclerosis
why might a periosteal reaction be noted on a radiograph?
callus formation in a fracture, or a slow growing tumour- cortex thick and dense, has wavy or uniform appearance
infection, trauma, osteoid osteoma- cortex may appear lamellated, amorphous or sunburst-like.
define a bankart lesion
avulsion of the anteroinferior glenoid labrum from the glenoid
common in recurrent anterior shoulder joint instability
how long is pharmacological VTE prophylaxis continued for in orthopaedic surgery?
until ptnt no longer has significantly reduced mobility
MOA of LMWH in VTE prophylaxis in ptnts undergoing elective TKR?
inhibits factor Xa in the clotting cascade by binding to antithrombin III, inducing a conformational change in the molecule which allows it to more readily inhbit factor Xa
what condition are heal spurs associated with?
plantar fasciitis
why is septic arthritis so damaging to a joint?
causes irreversible cartilage destruction, which will cause permanent pain in the joint
most common causative organism in septic arthritis?
staphylococcus aureus
why might culture for gonococcal infection be performed in young, otherwise healthy ptnt presenting with an erythematous, painful, swollen knee joint?
may have septic arthritis caused by neisseria gonorrhoea
characteristic findings of joint aspirate in septic arthritis?
cloudy or purulent
WBC more than 50,000/L
gram staining
glucose less than 60 per cent of serum glucose
how can effects of ABx tment of septic arthritis be monitored?
serum WBC, CRP and ESR levels
operative tment required for septic arthritis?
irrigation and drainage- washout
RFs for adult osteomyelitis?
recent trauma or surgery IC patients e.g. RA, cirrhosis, splenectomy, steroid use, DM illicit IV drug use PVD peripheral neuropathy
gold standard for directing ABx therapy in osteomyelitis tment?
bone biopsy
complications of adult osteomyelitis?
persistence or extension of infection
sepsis
amputation
malignant transformation (Marjolin’s ulcer)- most commonly SCC
how is serum lactate of relevance in ptnt admission with suspected hip fracture?
serum lactate been found to be a prognostic indicator in hip fracture patient, with an elevated venous serum lactate on admission following hip trauma indicating that the patient should be identified as having a higher mortality risk and may benefit from targeted medical therapy.
venous lactate of 3mmol/L or more associated with twice the odds of death in hospital compared to matched individuals
and a 1mmol/L increase in venous lactate associated with a 1.2 increased risk of in hospital mortality
considerations in describing a distal radial fracture?
intra or extra articular
comminute or non-comminuted
displacement- radial height (normal=11mm), angle of inclination (22 degrees) and angulation (volar tilt of 11 degrees)
ulna- fracture or subluxation
presenting features of CE syndrome?
bilateral sciatica saddle anaesthesia urinary retention urinary and faecal incontinence, urinary= overflow incontinence following PNS disruption to bladder necessary for detrusor contraction lower extremity sensorimotor changes
causes of nerve root compression in CE syndrome?
disc herniation spinal stenosis tumour trauma spinal epidural haematoma epidural abscess
well known complication of spinal surgery?
DVT
causes of spinal canal narrowing in neurogenic claudication?
IV disc narrowing
osteophyte formation, degenerative vertebrae
hypertrophy of ligamentum flavum- located in posterior portion of vertebral canal, connecting adjacent laminae- located between transverse and spinous processes of vertebrae
operative surgery for spinal stenosis?
spinal decompression- laminectomy
can use an X-stop if ptnt unfit for laminectomy
non-oeprative- instructions on posture, pain analgesia e.g. NSAIDs and injection of corticosteroid and LA
examination findings in CES?
lower limb weakness, bilateral, and sens distrubances
hyporeflexia/areflexia LL
bladder enlarged
reduced or absent sensation to pinprick in S2-S4 perinanal region
reduced anal tone on PR exam
CES tment?
urgent decompression surgery within 48 hrs of onset of symptoms, laminectomy and discectomy
alternative to MRI in CES investigation in ptnt with a pacemaker?
CT myelogram
use of pharmacological VTE prophylaxis in hip fracture ptnts?
LMWH start on admission, stopped 12 hrs before surgery, and restarted 6-12 hrs post surgery
fondaparinux sodium- synthetic and selective factor Xa inhibitor, given 6hrs after surgical closure
UFH if severe renal impairment or established renal failure, same timings as LMWH
continue for 28-35 days post surgery
enoxaparin use in orthopaedic surgery?
40 mg once daily SC, initial dose 12 hrs before surgery in hip fracture ptnts, started 6-12 hrs after surgery in elective hip and knee replacements
CIs to pharmacological VTE prophylaxis?
recent haemorrhagic stroke
thrombocytopenia
active gastric or duodenal ulceration
uncontrolled hypertension- 230/120 mmHg or higher
elements of a halux valgus deformity?
lateral deviation and rotation of hallux
prominence of medial side of head of 1st metatarsal (bunion)- may also be an overlying bursa and thickened soft tissue
overcrowding of lateral toes can occur, and sometimes over-riding
4 acute presentations of shoulder pathology?
infection
injury
acute calcific tendonitis
parsonage-turner syndrome= brachial neuritis- inflammation of BP, causes sudden onset shoulder and arm pain, followed by weakness and/or numbness
what should the midline of the patella line up with in the foot?
midline of the 2nd toe
what are yellow flag signs in back pain presentation, and give examples
psychosocial factors shown to be indicative of long term chronicity and disability
e.g. social or financial problems
a negative attitude that back pain is harmful or potentially severely disabling
social withdrawal
low morale
tendency to depression
fear avoidance behaviour and reduced activity levels
an expectation that passive rather than active tment will be beneficial
in ASIA classification of SCI, how is complete and incomplete injury defined?
in terms of sacral spaing
so complete injury= no voluntary anal contraction, all S4-S5 sensory scores=0 and no deep anal pressure
otherwise injury is incomplete
what is the ASIA impairment scale if injury complete?
A
no sensory or motor function is preserved in sacral segments S4-S5
what is the ASIA impairment scale if motor injury incomplete?
B
sensory function preserved below the neurological level and includes S4-S5, no motor function preserved more than 3 levels below the motor level on either side of the body
what are AIS C and D in ASIA impairment scale classification?
if motor injury incomplete, and less than half of the key muscles below the single neurological level are graded 3 or better (3- active movement, full ROM against gravity) then AIS= C, and if more than half then AIS=D
to be either, ptnt must have voluntary anal sphincter contraction or sacral sensory sparing with sparing of motor function more than 3 levels below motor level for that side of body.
