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MBBS - Year 1 > Clinical skills - Fractures and Dislocations > Flashcards

Clinical skills - Fractures and Dislocations Flashcards

1
Q

Fracture management

A

Reduce
Retain
Rehab

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2
Q

Fracture management - reduce

A

Closed reduction by applying a splint
Closed reduction by traction
Closed reduction by manipulation
Open reduction if closed reduction fails but not in all

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3
Q

Fracture management - retain

A 
Maintain reduction until fracture heals 
Traction 
Plaster 
Splints 
Gravity in huumeral fractures 
Internal fixation - screws, plates, tension bands, intramedulllary devices
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4
Q

Fracture management - rehab

A

Restore to orig. status before the injury

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5
Q

Principles of DCO

A

Control of bleeding
Arterial repair, decompressing tension, pneumothorax and fasciotomy for compartment syndrome
Provisional fracture stability w/ external fixation

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6
Q

When is decompression fasciotomy considered

A

Taken more than 6 hrs to restore arterial supply to the limb
Extensive distal injury including burns
Significant venous damage

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7
Q

Pelvic binder

A

Emergency management
Pelvic binder over greater trochanters
Binding both legs together
Flexing hips by inserting a pillow under the knees

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8
Q

Pelvis packing

A

Double pelvic external fixators applied first to stabilise pelvis then a laparotomy is performed, and the pelvis is packed. External fixator may be left in situ for 3 months

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9
Q

Acute compartment syndrome

A

Rise in pressure within a closed space resulting in ischaemia of the components
Most common in lower limb, forearm, thigh

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10
Q

Ischaemia

A

Inadeqaute blood supply

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11
Q

Fasciotomy

A

Long cannula inserted into anterior compartment, under anaesthesia and once a certain pressure is made along w/ other clinical signs, patient is taken to operate - all compartments released

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12
Q

Early long bone stabilisation leads to reduced:

A 
ARDS 
Pneumonia 
Ventilator days 
ITU days 
Hosp days 
Systemic infection
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13
Q

Treatment of open fractures

A

Photography
Cover w/ antiseptic dressing
Abx and splint the limbs - antitetanic when indicated
Theatre within 6 hrs for definitive survey
Debridement
Wound is vigorously irrigated w/ warm isotonic saline where appropriate
Stabilisation w/ external fixator

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14
Q

Debridement

A

Dead and damaged tissue excised

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15
Q

Signs of dead tissue

A

Doesn’t contract when pinched w/ forceps

Isn’t red and shiny

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16
Q

What happens few days after an open fracture is treated

A

Wound reinspected and covered w/ muscle and skin graft

Occasionally external factor is replaced w/ intrameduallary nail

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17
Q

Fracture definition

A

A soft tissue envelope in which there happens to be a break in cortex which exists from the opposite cortex

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18
Q

What kind of fracture does a twisting force produce

A

Spiral fracture w/ a long fracture line OR

Oblique fracture w/ short fracture line

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19
Q

What kind of fracture does a bending force produce

A

Transverse fracture w/ a third small fragment - bending wedge

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20
Q

What kind of fracture does a high energy force produce

A

Comminuted fracture w/ lots of fragments

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21
Q

Personality of fractures

A

Good
Bad
Ugly

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22
Q

Good fractures

A

Heal well

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23
Q

Bad fractures

A

Difficult to heal and have little chance of OA

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24
Q

Ugly fractures

A

Difficult to manage w/ a high chance of developing OA

All pelvic fractures are bad or ugly

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25
Soft tissue
``` Skin Muscles Blood vessels Nerves Tendons and ligaments Fascia ```
26
Reading an x-ray
``` Read name of patient Confirm dob on patients wrist band Read hosp no. Find out date of X-ray Note part of region, right or left Look for whether standing or weight bearing X-rays ```
27
Angulation
Valgus Parallel Varus
28
Valgus angualtion
Apex medial | Distal limb away from midline
29
Parallel angulation
No angulation
30
Varus angulation
Apex lateral | Distal limb towards midline
31
Types of femoral neck or hip fractures
Sub trochanteric - reduce and fix w/ dynamic hip screw Trochanteric - IM nail Sub-capital/ intracapsular - requires replacement Management depends on blood supply
32
Salter Harris
Classification of fractures in regards to epiphysis ``` Straight Above beLow Through - metaphysis and epiphysis cRushed ```
33
Dislocation
No articulation between joints when there is usually one | Neurovascular status is esp important
34
AMPLE history
``` A - allergies M - medications P - past medical history L - last meal E - event ```
35
Bone healing
Fracture Haemotoma Cartilage Replaced by lamellar woven immature bone Remodelling bone - NSAIDs switch off infl process, so may delay bone healing
36
Growth and differentiation factors
``` Transforming Growth Factor (TGF-b) Bone Morphogenetic Proteins (BMPs) Fibroblast Growth Proteins (FGF-1,2) Insulin-Like Growth Factor (IGF-1) Platelet - Derived Growth Factor (PDGF) ```
37
Growth and differentiation factors process
Stem --> Proliferation, Migration --> Differentiation --> Matrix production, Vascularisation
38
Growth and differentiation factors in proliferation and migration
TGF - b FGF IGF PDGF
39
Growth and differentiation factors in differentiation
BMP
40
Growth and differentiation factors in matrix production and vascularisation
TGF-b BMP FGF
41
Valid consent
Voluntary Informed Capacity
42
Valid consent - voluntary
Patient must be free to agree to refuse treatment | Consent should be obtained without coercion or duress
43
Valid consent - informed
The procedure must be explained in simple language | Complications and 'material risks' should be discussed - consequences
44
Valid consent - capacity
Must understand the relevant info provided Be able to retain the info Be able to weigh up the pros of cons of the treatment proposed Be able to communicate
45
Types of consent
Implied Oral Written
46
Implied consent
The patient presenting to clinic to be examined | The arm offered for venepuncture
47
Oral consent
Verbal conversation gaining permission | Often formalised after the encounter w/ documentation in the notes
48
Written point
Pre-emptive Involved Best supported in law
49
Treatment without consent
Emergency situation to save life Waiting for another professional would be detrimental to patient Risk to public health Severely ill and living in unhygienic conditions
50
FBC
Full blood count Establishes total no. of RBC/s, WBC's & platelets. These cells develop in active bone marrow - ends of long bones e.g. humerus
51
Characteristics of erythrocytes
``` Normocytic Macrocytic Microcytic Normochromic Hyperchromic Hypochromic ```
52
Normocytic
Normal cell size
53
Macrocytic
Larger than normal cell size
54
Microcytic
Smaller than normal cell size
55
Normochromic
Normal Hb content
56
Hyperchromic
Red cell saturated w/ Hb
57
Hypochromic
RBC w/ diminished Hb
58
Types of WBC
``` Neutrophils Lymphocyte Monocytes Eosinophils Basophils ```
59
Lymphocytes
``` Produce antibodies (B) or directly attack foreign cells (T) May be raised in viral infection, chronic bacterial illness e.g. TB Low in those w/ lupus ```
60
Function of monocytes
Phagocytosis
61
Function of eosinophils
Protect against irritants/ allergies
62
Basophils
Become mast cells in allergic reactions and release histamines
63
Bone marrow failure
``` Anaemia - lack of RBC's Leucopoenia - lack of WBC's Thrombocytopaemia - lack of platelets Pancytopenia - all 3 together Caused by drugs or disease ```
64
Liver function tests
Aminotransferases Alanine aminotransferases (ALT) Alkaline phosphatase
65
Aminotransferases
Enzymes present in liver cells which leak into blood when damaged
66
ALT
Raised in acute liver damage, injury to skeletal muscle
67
Alanine phosphatase
From bone or liver In liver - often indicated mechanical blockage Elevated in disease w/ osteoblastic activity
68
RhF
High in RhA, infections, malignancy, family history of RA, lung fibrosis, lupus Prevalence increases w/ age Found in 80% patients w/ RhA - predicts poor prognosis, radiological progression and extra-articular manifestation Doesn't correlate w/ disease activity
69
Anti-CCP antibodies
Anti-citrullated protein antigens found in inflamed synovium Most spp antibody in RhA Can be found early on Predicts some patients w/ aggressive/ erosive disease 40% sero-ve patients are anti CCP+ Very early DMARD intervention in anti-CCP +ve infl arthritis delays progression to RA
70
ANA (Anti-Nuclear Antibodies)
Group of antibodies found in 5% of normal individuals Only important in those w/ symptoms Screening test for connective tissue diseases e.g. SLE, systemic sclerosis ENA
71
ENA
Extracted nuclear antibodies | Spp antibodies formed against diff aspects of the cell
72
ANCA
Antibodies directed against cytoplasmic antigens in human neutrophils C-ANCA (cytoplasmic, PR3) P-ANCA (perinuclear, MPO) Associated w/ some primary forms of vasculitis Can change over time and associated w/ disease activity
73
Causes of physical disability
Congenital conditions Acquired illness Trauma
74
Classification of fractures
``` Closed fractures Open/ compound fractures Comminuted Displaced Angulated Impacted - pressure on 1 or 2 crushed together ```
75
Pathological fractures
Low impact Bone cancer Osteoporosis Paget's disease; osteoclasts function > osteoblasts
76
1' bone cancer
Starts in the bone
77
2' bone cancer
Starts in the breast, kidney, bladder etc and travels to bone
78
Green stick fractures
One side of the bone is broken and the other side is only bent Only occurs in children
79
Systemic factors affecting healing
Age - decreased osteoblasts Nutrition - vit D and Ca Systemic diseases Corticosteroids - asthma, RA, IBS
80
Cushing's disease
Adrenal glands stop working due to corticosteroid therapy so no longer producing hormones ---> brittle bones
81
FOOSH
Fall On Outstreched Hand
82
Non-traumatic dislocations are usually ..
Recurrent and follow initial trauma | Once you dislocate your shoulder, you become prone to again as the ligaments stretch
83
What suggests a compound fracture
Portruding bone or break in skin
84
Neurovascular assessment
Sensation Capillary refill Distal pulse (beyond fracture site)
85
Pre hospital treatment of fractures
Splint - immobilise Sling Elevation
86
DVT
Deep Vein Thrombosis
87
PE
Pulmonary Embolism | Increased risk due to being immobile
88
Fat embolism
Fat released from inside of bone into blood
89
Who needs an X-ray
``` Trauma hx Pain (severe) Loss of function e.g. inability to weight bear Deformity Crepitus, swelling and tenderness At risk group i.e. children and elderly ```
90
Why are children an at risk group concerning fractures
Poor historians Difficult to examine Cannot mentally isolate pain
91
Local variables affecting fracture healing
``` Type of bone Degree of trauma Vascular injury Degree of immobilisation Separation of bone ends Infection ```
92
How does type of bone affect fracture healing
Cancellous bone heals faster than cortical bone
93
How does degree of trauma affect fracture healing
Severely comminuted injuries w/ extensive soft tissue damage heal poorly
94
How does vascular injury affect fracture healing
Inadequate blood supply impairs healing
95
How does degree of immobilisation affect healing
The fracture site must be immobilised for vascular ingrowth and bone healing to occur
96
How does separation of bone ends affect fracture healing
Normal apposition of fracture fragments is needed for union to occur
97
Immediate complications of fractures
Pain, bleeding and shock, neuromuscular compromises | Acute compartment syndrome
98
Medium term complications of fractures
``` Infection Wound problems, cast problems e.g too tight Deformity, shortening Mal-union DVT/ PE/ chest infections, op related Fat embolism ```
99
Long term complications of fractures
Non-union, avascular necrosis, osteomyelitis OA Loss of function Socioeconomic implications, psychological
100
Sublaxation
When the bones in a joint become partially displaced OR partial dislocation of a joint
101
Ottawa ankle rules
A series of ankle x-ray films is required only if there is any pain in malleolar zone and any of these findings Bone tenderness at posterior edge or tip of lateral malleolus Inability to weight bear - immediately and in emergency dept
102
Ottawa foot rules
A series of foot x-ray films is only required if there is any pain in mid-foot zone and any off these findings: Bone tenderness at base of 5th metatarsal Bone tenderness at Navicular Inability to weight bear
103
Ottowa knee rules
``` A series of knee x-ray films is only required for knee injury patients w/ any of these findings: Age 55+ Isolated tenderness of patella Tenderness at head of fibula Inability to flex to 90 degrees Inability to weight bear ```
104
Bony injury non suspected - Ottawa -ve
Advice to patient on duration of healing Advice on keeping gently mobile Analgesia RICE
105
RICE
Rest - rest for 48 hrs Ice - 20 mins at a time, 4-8x daily Compression - helps reduce swelling Elevate - 6-10 inches above heart
106
Services offered to fracture and non-fracture patients
Physio Occupational Therapy Social support Psychological support
107
Common MSK injuries seen in primary care
Back and ankle strains and sprains Meniscal tear of knee --> may require MRI to diagnose Rotator cuff tear of shoulder Overuse injuries
108
Overuse injuries
Bursitis - foot, hip, elbow Tendonitis - shoulder, Achilles' tendon Plantar fasciitis - under the foot
109
Diazepam
Used to treat back and ankle strain and sprains
110
WHO analgesic ladder
Step 1 - simple analgesia Step 2 - moderate analgesia Step 3 - strong analgesia
111
Step 1 of WHO analgesic ladder
Non -opioid, mild pain, plus minus adjuvants
112
Step 2 of WHO analgesic ladder
Weak opioid, moderate pain plus minus non-opioids and adjuvants
113
Step 3 of WHO analgesic ladder
Strong opioid, severe pain plus minus non-opioid
114
Non-opioids (OTC)
Ibuprofen or another NSAIDs Paracetomol (acetominophen) Aspirin
115
Weak opioids
Codeine Tramadol --> synergy w/ paracetamol Low dose or morphine
116
Strong opioids
``` Morphine Fentanyl Oxycodone Hydromorphone Buphenophine ``` Consider prophylactic laxatives to avoid constipation
117
Adjuvants
``` Antidepressants Anticonvulsants Antispasmodic Muscle relaxant Biphosphonate Corticostroids ```
118
Can you combine drugs of the same class
No but combing an opioid and a non-opioid is effective | Time doses of drug half-life, not when pain recurs
119
Ibuprofen dosage
400mg TDS
120
Ibuprofen side effects
GI ulceration Cardiac arrhythmias Renal toxicity
121
Cocodamol dosage
500 mg paracetamol and 8 mg codeine (15-30mg when prescribed) 1 or 2 tablets QDS
122
Cocodamol side effects
``` Constipation Nausea Drowsiness Dependence/ addiction Confusion ```
123
Naproxen dosage
500 mg BDS Stronger than ibuprofen, replacement (NSAID) Opioid based
124
Side effects of morphine
Constipation Nausea and vomiting Drowsiness
125
Ways to administer med
``` Orally Patch Nasally Suppository Rectally IV Buccally Intra-articular Intramuscularly Sub lingual Via a pessary (intravaginal) Topically ```
126
Common ENA
``` antiRo: Sjogren’s and cutaneous lupus antiLa: Sjogren’s and cutaneous lupus Ds DNA: SLE Scl 70: limited systemic sclerosis Anti-centromere: CREST JO-1: polymyositis ```
127
Colles' fracture
Fracture of distal radius with dorsal angulation
128
Smith's fracture
Fracture of distal radius with palmar angulation | Caused by a FOOSH
129
Jones' fracture
Fracture at base of 5th metatarsal
130
Boxer's fracture
Fracture at head of 5th MCP with palmar angulation | Result of ruching person or wall
131
Scaphoid fractures
Quite common but easily missed Pain in anatomical snuffbox Can be caused by FOOSH Can lead to AVN
132
Buckle fracture of radius/ulna
Look for angulation of cortex
133
Radial head fracture
Easily missed as may require several views to identify
134
What is Garden classification used for
Femoral neck fractures
135
Garden classification - Stage I
Incomplete fracture of the neck (so-called abducted or impacted)
136
Garden classification - Stage II
Complete without displacements
137
Garden classification - Stage III
Complete with partial displacement. Fragments are still connected by posterior retinacular attachment and there is malalignment of the femoral trabeculae
138
Garden classification - Stage IV
A complete femoral neck fracture with full displacement, the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned.
139
Immediate post-op complication after hip replacement surgery
Pulmonary embolism
140
Complications of shoulder dislocation and fractures
OA Capsulitis Chronic instability Axillary nerve palsy
141
Complication of fractures involving growth plates
Growth arrest

MBBS - Year 1 (93 decks)

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