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Medicine year 2 semester 2 > case 25- physiology 2 > Flashcards

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
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

25
Q

Indirect healing

A

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
Q

Stages of fracture healing

A
  1. haematoma formation
  2. fibrocartilaginous callus formation
  3. bony callus formation
  4. bone remodelling
27
Q

Haematoma formation

A

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
Q

Soft callus formation

A

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
Q

Hard callus formation

A

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
Q

Remodelling process

A

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
Q

Primary bone healing

A

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
Q

Fracture callus

A

Temporary formation of fibroblasts and chondroblasts at the site of bone fracture where the bone heals

33
Q

What affects bone healing

A

Diet
Diabetes
Nicotine
Medications- biphosphates, steroids NSAIDs

34
Q

Secondary bone healing

A

Endochondral healing
Periosteal healing occurs via formation of a callus
Callus undergoes mineralisation and remodels to form bone tissue
Relative stability

35
Q

Post menopausal osteoporosis treatment

A

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
Q

Osteoporosis in postmenopausal women

A

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
Q

Oral biphosphonate

A

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
Q

IV biphosphonate

A

Ibandronic acid, zoledronic acid, denosumagb, raloxifene

Alternative if intolerant of oral biphosphonate or contraindicated

39
Q

Teriparatide

A

Treatment limited to 24 months
Reserved for post menopausal women - severe osteoporosis
High risk of vertebral fracture

40
Q

Useful investigations in the diagnosis of bone disease

A 
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
Q

BMD screening

A

> -1 - normal

< -1 or >-2.5 osteopenia

42
Q

Foot print changes from 6 months to adulthood

A

Starts much flatter and ends with a high medial arch

43
Q

Medial longitudinal foot arch

A

Begins at the calcaneus, rises to the talus, then descends through the navicular, cuneiforms, and the head of the first three metatarsals

44
Q

Lateral longitudinal arch

A

Composed of the calcaneus, talus, cuboid, and the fourth and fifth metatarsals
L and flatter than the medial longitudinal arch.

45
Q

Transverse arch

A

Arch over the top of the foot

Cuboid, cuneiforms, base of 5 metatarsals and heads of metatarsals

46
Q

Locomotion- walking cycle

A
  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
Q

Double support

A

When both feet are in contact with the ground at the same time

48
Q

Gait changes with age

A

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
Q

Double stance increasing with age

A

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
Q

Diplegic gait

A

Seen in people with cerebral palsy
Spasticity in limbs, usually lower
Abnormally narrow base
Drag both legs, scraping toes

51
Q

Hemiplegic gait

A

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
Q

Trendelenburg gait

A

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
Q

Ataxic/cerebellar gait

A

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
Q

Neuropathic gait

A

Foot drop

Many causes including perineal nerve palsy, Charvot-Marie-Tooth disease

55
Q

Parkinsonian gait

A 
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
Q

FRAX score

A

Tool to predict the chances of developing another fracture

If FRAX is high, need to find ways of decreasing the incidence of fracture

57
Q

What is included in a FRAX assessment

A 
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
Q

What does the FRAX score tell you

A

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
Q

How to use FRAX clinically

A

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
Q

Clinical implications associated with ageing

A

Polypharmacy
Multimorbidity
Non specific presentations - more complex appointments
Problems with communication

61
Q

Health issues associated with ageing

A 
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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