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case 25- physiology 2 Flashcards

1
Q

Nutritional frailty

A

Common in vulnerable older adults.
Sudden weight loss and loss of muscle mass and strength
Loss of physiological reserve

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2
Q

Medication side effects that affect nutritional status

A 
Appetite changes
Nausea
Dry mouth
Changes in taste/smell
GI effects
Glucose levels
Organ system toicity
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3
Q

Decrease in calorific requirements in the elderly

A

Decreased body mass and decreased activity levels and decreased BMR reduce calorie requirements

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4
Q

Micro/macro requirements in the elderly

A

Requirement for micro/macronutrients doesn’t really change but absorption might be less efficient due to multimorbidity so might actually need more

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5
Q

Assessing nutritional status

A

Nutritional screening should be used to identify any individuals at risk of malnutrition

When should it be done- On admission and at regular intervals
In the community should be done in care homes on admission and monthly and annually if >75 and living at home

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5
Q

Assessing nutritional status

A

Nutritional screening should be used to identify any individuals at risk of malnutrition

When should it be done- On admission and at regular intervals
In the community should be done in care homes on admission and monthly and annually if >75 and living at home

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6
Q

Assessing nutritional status- methods

A 
BMI
Skin fold thickness - % body fat
Body circumference
Waist-hip ration
MUST - malnutrition universal screening tool
Functional assessment
Biochemical tests
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7
Q

MUST

A

Find out if low, medium or high risk of malnutrition
Management after MUST - special diet? local policy, treat underlying condition - advice on food choices, eating/drinking
Record presence of obesity

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8
Q

Functional and Biochemical tests for malnutrition

A

Functional- Grip strength, overall muscle strength

Biochemical- Blood index, Anaemia, Total lymphocyte count, Serum protein

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9
Q

Clinical features of neck of femur fracture

A

Shortened
Abducted
Externally rotated
Flexed

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10
Q

Retrograde blood flow

A 
Blood goes from peripheral areas back to heart
3 bones in body
- head of femur
- talus
- scaphoid

More prone to avascular necrosis

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11
Q

NOF fracture classification

A

Intracapsular - degree of displacement
Extracapsular - number of parts and displacement
Open or closed
Orientation

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12
Q

Displaced and undisplaced fracture

A

Displaced- bone ends are out of normal alignement

Undisplaced- the bone is without angulation or separation

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13
Q

Haematomas in healing

A

Part of healthy process of healing - contains growth and healing factors
Not present in intracapsular fractures

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14
Q

Gardens classification of intracapsular ligaments

A

Based on degree of displacement of bony trabeculae
Relates to risk of vascular disruption and healing
Treatment determined by these factors
Purely based off AP views of pelvis

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15
Q

Different classifications in Gardens classification

A

A - incomplete, vagus impacted, non displaced
B - complete, non displaced
C - complete, partially displaced
D - complete, fully displaced

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16
Q

Pauwels classification of fracture

A

Angle of fracture line

More angle means more vertical, more shear force, less chance of healing

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17
Q

Classification of fracture based on location

A

Intracapsular

  • subcapital (just below head)
  • transcervical (neck of femur)
  • base of neck

Extracapsular

  • intertrochanteric
  • subtrochanteric
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18
Q

Fracture fixation

A

Young age
Undisplayed/reducible
Extracapsular

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19
Q

Arthroplasty- replaced

A

Surgical repair or replacement of a joint

  • elderly/poor bone quality
  • displaced
  • intracapsular
  • presence of arthritis
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20
Q

Fixation devices

A

Dynamic hip screw
Cannulated screw
Intramedullary nail

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21
Q

Types of arthroplasty

A

Hemiarthroplasty - Austin Moore and Thompson

Total hip replacement

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22
Q

Fracture healing

A

Need a good blood supply
Mechanical stability
Can heal directly or indirectly

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23
Q

Direct healing

A

Bony fragments are fixed together with compression
No callus formation
Bone ends are joined and healed by osteoblast and osteoclast activity

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24
Direct healing
Bony fragments are fixed together with compression No callus formation Bone ends are joined and healed by osteoblast and osteoclast activity
25
Indirect healing
More common Involved in endochondral and intramembranous bone healing Usually occurs with non operative fracture treatment, operative treatments where some motion occurs at the fracture site such as intramedullary nailing, external fixation and internal fixation of comminuted fractures
26
Stages of fracture healing
1. haematoma formation 2. fibrocartilaginous callus formation 3. bony callus formation 4. bone remodelling
27
Haematoma formation
1-7 days post fracutre - fracture causes soft tissue damage, disruption of blood vessels in bone and separation of small bony fragments - haematoma forms and periosteum ruptures partly - cells migrate into fracture haematoma - coagulation starts, fibrin fibres are form and stabilise haematoma
28
Soft callus formation
2-3 weeks post fracture - creation of soft callus - new blood vessels invade haematoma, decrease pain and swelling - fibroblasts derived from periosteum invade and colonise haematoma - fibroblasts produce collagen fibres (granulation tissue) - collagen fibres loosely linked to the bone fragments - cells of granulation tissue gradually differentiate to form fibrous tissue and fibrocartilage
29
Hard callus formation
3-12 weeks post fracture - endochondral ossification converts soft callus to woven bone starting at periphery and moving towards centre, further stiffening healing tissue - continues until no more inter fragmentary movements
30
Remodelling process
Takes months-years - conversion of woven bone into lamellar bone through surface erosion and osteomalacia remodelling once inter fragmentary movement ceases - fracture healing becomes complete with remodelling of medullary canal and removal of parts of external callus
31
Primary bone healing
Intramembranous healing Haversion canals form across the bone to aid healing No fracture callus forms Only occurs if edges are in close proximity Absolute stability
32
Fracture callus
Temporary formation of fibroblasts and chondroblasts at the site of bone fracture where the bone heals
33
What affects bone healing
Diet Diabetes Nicotine Medications- biphosphates, steroids NSAIDs
34
Secondary bone healing
Endochondral healing Periosteal healing occurs via formation of a callus Callus undergoes mineralisation and remodels to form bone tissue Relative stability
35
Post menopausal osteoporosis treatment
Same therapy for prevention and treatment Oral biphosphonate is first line IV biphosphonate alternative if oral biphosphonate HRT additional option if younger post menopausal woman, (adverse effects of CVD and cancer if used in older women and for long term use) Teriparatide
36
Osteoporosis in postmenopausal women
Most frequent Natural loss with ageing exacerbated Lack of oestrogen promotes bone resorption (high turnover) Most bone loss in first 10 years after menopause or oophorectomy
37
Oral biphosphonate
First line - alendrotnic acid, ridedronate sodium Antifracture efficacy Decreased occurrence of vertebral, non vertebral and hip fractures Absorbed into hydroxyapatite Induced apoptosis of osteoclasts Decreased rate of bone turnover
38
IV biphosphonate
Ibandronic acid, zoledronic acid, denosumagb, raloxifene | Alternative if intolerant of oral biphosphonate or contraindicated
39
Teriparatide
Treatment limited to 24 months Reserved for post menopausal women - severe osteoporosis High risk of vertebral fracture
40
Useful investigations in the diagnosis of bone disease
``` X-ray BMD (DEXA calcaneum screening) DEXA (dual energy xray absorptiometry) FRAX Hormone levels Quantitative CT scan Body composition analysis to detect bone loss MRI ```
41
BMD screening
> -1 - normal | < -1 or >-2.5 osteopenia
42
Foot print changes from 6 months to adulthood
Starts much flatter and ends with a high medial arch
43
Medial longitudinal foot arch
Begins at the calcaneus, rises to the talus, then descends through the navicular, cuneiforms, and the head of the first three metatarsals
44
Lateral longitudinal arch
Composed of the calcaneus, talus, cuboid, and the fourth and fifth metatarsals L and flatter than the medial longitudinal arch.
45
Transverse arch
Arch over the top of the foot | Cuboid, cuneiforms, base of 5 metatarsals and heads of metatarsals
46
Locomotion- walking cycle
1. heel contact 2. flat foot (toe down) 3. mid stance 4. heel off 5. push off 6. toe off 60% stance, 40% swing Waling involves pelvic tilt and vertebral sway
47
Double support
When both feet are in contact with the ground at the same time
48
Gait changes with age
Strength peaks in 20s and declines after 5th decade Gait speed slows Age related changes in balance - compensatory responses Age related decrease in balance and strength contribute to higher incidence of falls in older people Posture doesn't really change just with ageing, usually caused by disease Older people walk with a 5 degree greater 'toe out' - possible reduction in internal rotation of hip Gait velocity falls due to shorter steps Rhythm doesn't really change with age Double stance increases with age
49
Double stance increasing with age
20% -> 26% Decreased momentum Reduced time for swing leg to advance - shorter step length Elderly people with a fear of falling have an increased double stance time
50
Diplegic gait
Seen in people with cerebral palsy Spasticity in limbs, usually lower Abnormally narrow base Drag both legs, scraping toes
51
Hemiplegic gait
Most commonly seen in stroke Unilateral weakness on affected side causing leg drag Arm flexed, adducted and internal rotated Leg in extension with plantar flexion of the foot and toes
52
Trendelenburg gait
Drop in pelvis on non weight bearing leg Indicates hip abductor (gluteus medius and minimus) weakness on weight bearing leg Seen in muscular dystrophy
53
Ataxic/cerebellar gait
Wide base When standing still, may sway back and forth Clumsy, staggering movements Not able to walk heel-toe or in a straight line
54
Neuropathic gait
Foot drop | Many causes including perineal nerve palsy, Charvot-Marie-Tooth disease
55
Parkinsonian gait
``` Rigidity Bradykinesia Stooped head, neck forward Flexion at knees Slow, little steps - shuffling gait Difficulty initiating steps and turning Festination Loss of arm swing ```
56
FRAX score
Tool to predict the chances of developing another fracture | If FRAX is high, need to find ways of decreasing the incidence of fracture
57
What is included in a FRAX assessment
``` Age of patient Sex (females more prone to osteoporosis) Weight (too light or too heavy) Height Previous fracture Smoker Glucocorticoids Rheumatoid arthritis Osteoporosis Alcohol ```
58
What does the FRAX score tell you
10 year risk of major osteoporotic fracture and also 10 year risk percentage of hip fracture - if high risk, modify lifestyle: stop smoking/alcohol, osteoporosis scan, treatment for osteoporosis
59
How to use FRAX clinically
Treat like the patient has osteoporosis if the chance hip fracture is greater than 3% in the next 10 years and the chance of other major osteopathic fracture is greater than 20% in the next 10 years
60
Clinical implications associated with ageing
Polypharmacy Multimorbidity Non specific presentations - more complex appointments Problems with communication
61
Health issues associated with ageing
``` Sexual dysfunction - ED in men Increased risk of cancer Osteoporosis Falls Gait problems Malnutrition Dementia and parkinsons ```

Medicine year 2 semester 2 (47 decks)

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