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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
Q

Soft tissue

A 
Skin 
Muscles 
Blood vessels 
Nerves 
Tendons and ligaments 
Fascia
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26
Q

Reading an x-ray

A 
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
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27
Q

Angulation

A

Valgus
Parallel
Varus

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28
Q

Valgus angualtion

A

Apex medial

Distal limb away from midline

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29
Q

Parallel angulation

A

No angulation

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30
Q

Varus angulation

A

Apex lateral

Distal limb towards midline

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31
Q

Types of femoral neck or hip fractures

A

Sub trochanteric - reduce and fix w/ dynamic hip screw
Trochanteric - IM nail
Sub-capital/ intracapsular - requires replacement
Management depends on blood supply

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32
Q

Salter Harris

A

Classification of fractures in regards to epiphysis

Straight 
Above 
beLow
Through - metaphysis and epiphysis 
cRushed
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33
Q

Dislocation

A

No articulation between joints when there is usually one

Neurovascular status is esp important

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34
Q

AMPLE history

A 
A - allergies 
M - medications 
P - past medical history 
L - last meal 
E - event
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35
Q

Bone healing

A

Fracture
Haemotoma
Cartilage
Replaced by lamellar woven immature bone
Remodelling bone - NSAIDs switch off infl process, so may delay bone healing

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36
Q

Growth and differentiation factors

A 
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)
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37
Q

Growth and differentiation factors process

A

Stem –> Proliferation, Migration –> Differentiation –> Matrix production, Vascularisation

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38
Q

Growth and differentiation factors in proliferation and migration

A

TGF - b
FGF
IGF
PDGF

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39
Q

Growth and differentiation factors in differentiation

A

BMP

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40
Q

Growth and differentiation factors in matrix production and vascularisation

A

TGF-b
BMP
FGF

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41
Q

Valid consent

A

Voluntary
Informed
Capacity

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42
Q

Valid consent - voluntary

A

Patient must be free to agree to refuse treatment

Consent should be obtained without coercion or duress

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43
Q

Valid consent - informed

A

The procedure must be explained in simple language

Complications and ‘material risks’ should be discussed - consequences

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44
Q

Valid consent - capacity

A

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

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45
Q

Types of consent

A

Implied
Oral
Written

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46
Q

Implied consent

A

The patient presenting to clinic to be examined

The arm offered for venepuncture

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47
Q

Oral consent

A

Verbal conversation gaining permission

Often formalised after the encounter w/ documentation in the notes

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48
Q

Written point

A

Pre-emptive
Involved
Best supported in law

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49
Q

Treatment without consent

A

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

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50
Q

FBC

A

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

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51
Q

Characteristics of erythrocytes

A 
Normocytic 
Macrocytic 
Microcytic 
Normochromic 
Hyperchromic 
Hypochromic
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52
Q

Normocytic

A

Normal cell size

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53
Q

Macrocytic

A

Larger than normal cell size

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54
Q

Microcytic

A

Smaller than normal cell size

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55
Q

Normochromic

A

Normal Hb content

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56
Q

Hyperchromic

A

Red cell saturated w/ Hb

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57
Q

Hypochromic

A

RBC w/ diminished Hb

58
Q

Types of WBC

A 
Neutrophils 
Lymphocyte 
Monocytes
Eosinophils 
Basophils
59
Q

Lymphocytes

A 
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
Q

Function of monocytes

A

Phagocytosis

61
Q

Function of eosinophils

A

Protect against irritants/ allergies

62
Q

Basophils

A

Become mast cells in allergic reactions and release histamines

63
Q

Bone marrow failure

A 
Anaemia - lack of RBC's 
Leucopoenia - lack of WBC's
Thrombocytopaemia - lack of platelets
Pancytopenia - all 3 together 
Caused by drugs or disease
64
Q

Liver function tests

A

Aminotransferases
Alanine aminotransferases (ALT)
Alkaline phosphatase

65
Q

Aminotransferases

A

Enzymes present in liver cells which leak into blood when damaged

66
Q

ALT

A

Raised in acute liver damage, injury to skeletal muscle

67
Q

Alanine phosphatase

A

From bone or liver
In liver - often indicated mechanical blockage
Elevated in disease w/ osteoblastic activity

68
Q

RhF

A

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
Q

Anti-CCP antibodies

A

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
Q

ANA (Anti-Nuclear Antibodies)

A

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
Q

ENA

A

Extracted nuclear antibodies

Spp antibodies formed against diff aspects of the cell

72
Q

ANCA

A

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
Q

Causes of physical disability

A

Congenital conditions
Acquired illness
Trauma

74
Q

Classification of fractures

A 
Closed fractures 
Open/ compound fractures 
Comminuted
Displaced 
Angulated 
Impacted - pressure on 1 or 2 crushed together
75
Q

Pathological fractures

A

Low impact

Bone cancer
Osteoporosis
Paget’s disease; osteoclasts function > osteoblasts

76
Q

1’ bone cancer

A

Starts in the bone

77
Q

2’ bone cancer

A

Starts in the breast, kidney, bladder etc and travels to bone

78
Q

Green stick fractures

A

One side of the bone is broken and the other side is only bent
Only occurs in children

79
Q

Systemic factors affecting healing

A

Age - decreased osteoblasts
Nutrition - vit D and Ca
Systemic diseases
Corticosteroids - asthma, RA, IBS

80
Q

Cushing’s disease

A

Adrenal glands stop working due to corticosteroid therapy so no longer producing hormones —> brittle bones

81
Q

FOOSH

A

Fall On Outstreched Hand

82
Q

Non-traumatic dislocations are usually ..

A

Recurrent and follow initial trauma

Once you dislocate your shoulder, you become prone to again as the ligaments stretch

83
Q

What suggests a compound fracture

A

Portruding bone or break in skin

84
Q

Neurovascular assessment

A

Sensation
Capillary refill
Distal pulse (beyond fracture site)

85
Q

Pre hospital treatment of fractures

A

Splint - immobilise
Sling
Elevation

86
Q

DVT

A

Deep Vein Thrombosis

87
Q

PE

A

Pulmonary Embolism

Increased risk due to being immobile

88
Q

Fat embolism

A

Fat released from inside of bone into blood

89
Q

Who needs an X-ray

A 
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
Q

Why are children an at risk group concerning fractures

A

Poor historians
Difficult to examine
Cannot mentally isolate pain

91
Q

Local variables affecting fracture healing

A 
Type of bone 
Degree of trauma 
Vascular injury 
Degree of immobilisation 
Separation of bone ends 
Infection
92
Q

How does type of bone affect fracture healing

A

Cancellous bone heals faster than cortical bone

93
Q

How does degree of trauma affect fracture healing

A

Severely comminuted injuries w/ extensive soft tissue damage heal poorly

94
Q

How does vascular injury affect fracture healing

A

Inadequate blood supply impairs healing

95
Q

How does degree of immobilisation affect healing

A

The fracture site must be immobilised for vascular ingrowth and bone healing to occur

96
Q

How does separation of bone ends affect fracture healing

A

Normal apposition of fracture fragments is needed for union to occur

97
Q

Immediate complications of fractures

A

Pain, bleeding and shock, neuromuscular compromises

Acute compartment syndrome

98
Q

Medium term complications of fractures

A 
Infection 
Wound problems, cast problems e.g too tight 
Deformity, shortening 
Mal-union
DVT/ PE/ chest infections, op related 
Fat embolism
99
Q

Long term complications of fractures

A

Non-union, avascular necrosis, osteomyelitis
OA
Loss of function
Socioeconomic implications, psychological

100
Q

Sublaxation

A

When the bones in a joint become partially displaced OR partial dislocation of a joint

101
Q

Ottawa ankle rules

A

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
Q

Ottawa foot rules

A

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
Q

Ottowa knee rules

A 
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
Q

Bony injury non suspected - Ottawa -ve

A

Advice to patient on duration of healing
Advice on keeping gently mobile
Analgesia
RICE

105
Q

RICE

A

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
Q

Services offered to fracture and non-fracture patients

A

Physio
Occupational Therapy
Social support
Psychological support

107
Q

Common MSK injuries seen in primary care

A

Back and ankle strains and sprains
Meniscal tear of knee –> may require MRI to diagnose
Rotator cuff tear of shoulder
Overuse injuries

108
Q

Overuse injuries

A

Bursitis - foot, hip, elbow
Tendonitis - shoulder, Achilles’ tendon
Plantar fasciitis - under the foot

109
Q

Diazepam

A

Used to treat back and ankle strain and sprains

110
Q

WHO analgesic ladder

A

Step 1 - simple analgesia
Step 2 - moderate analgesia
Step 3 - strong analgesia

111
Q

Step 1 of WHO analgesic ladder

A

Non -opioid, mild pain, plus minus adjuvants

112
Q

Step 2 of WHO analgesic ladder

A

Weak opioid, moderate pain plus minus non-opioids and adjuvants

113
Q

Step 3 of WHO analgesic ladder

A

Strong opioid, severe pain plus minus non-opioid

114
Q

Non-opioids (OTC)

A

Ibuprofen or another NSAIDs
Paracetomol (acetominophen)
Aspirin

115
Q

Weak opioids

A

Codeine
Tramadol –> synergy w/ paracetamol
Low dose or morphine

116
Q

Strong opioids

A 
Morphine 
Fentanyl 
Oxycodone 
Hydromorphone
Buphenophine

Consider prophylactic laxatives to avoid constipation

117
Q

Adjuvants

A 
Antidepressants 
Anticonvulsants 
Antispasmodic
Muscle relaxant 
Biphosphonate 
Corticostroids
118
Q

Can you combine drugs of the same class

A

No but combing an opioid and a non-opioid is effective

Time doses of drug half-life, not when pain recurs

119
Q

Ibuprofen dosage

120
Q

Ibuprofen side effects

A

GI ulceration
Cardiac arrhythmias
Renal toxicity

121
Q

Cocodamol dosage

A

500 mg paracetamol and 8 mg codeine (15-30mg when prescribed)
1 or 2 tablets QDS

122
Q

Cocodamol side effects

A 
Constipation
Nausea
Drowsiness 
Dependence/ addiction 
Confusion
123
Q

Naproxen dosage

A

500 mg BDS
Stronger than ibuprofen, replacement (NSAID)
Opioid based

124
Q

Side effects of morphine

A

Constipation
Nausea and vomiting
Drowsiness

125
Q

Ways to administer med

A 
Orally 
Patch 
Nasally 
Suppository 
Rectally 
IV 
Buccally 
Intra-articular 
Intramuscularly
Sub lingual
Via a pessary (intravaginal)
Topically
126
Q

Common ENA

A 
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
Q

Colles’ fracture

A

Fracture of distal radius with dorsal angulation

128
Q

Smith’s fracture

A

Fracture of distal radius with palmar angulation

Caused by a FOOSH

129
Q

Jones’ fracture

A

Fracture at base of 5th metatarsal

130
Q

Boxer’s fracture

A

Fracture at head of 5th MCP with palmar angulation

Result of ruching person or wall

131
Q

Scaphoid fractures

A

Quite common but easily missed
Pain in anatomical snuffbox
Can be caused by FOOSH
Can lead to AVN

132
Q

Buckle fracture of radius/ulna

A

Look for angulation of cortex

133
Q

Radial head fracture

A

Easily missed as may require several views to identify

134
Q

What is Garden classification used for

A

Femoral neck fractures

135
Q

Garden classification - Stage I

A

Incomplete fracture of the neck (so-called abducted or impacted)

136
Q

Garden classification - Stage II

A

Complete without displacements

137
Q

Garden classification - Stage III

A

Complete with partial displacement. Fragments are still connected by posterior retinacular attachment and there is malalignment of the femoral trabeculae

138
Q

Garden classification - Stage IV

A

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
Q

Immediate post-op complication after hip replacement surgery

A

Pulmonary embolism

140
Q

Complications of shoulder dislocation and fractures

A

OA
Capsulitis
Chronic instability
Axillary nerve palsy

141
Q

Complication of fractures involving growth plates

A

Growth arrest

MBBS - Year 1 (93 decks)

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