CORTEXT: Elective and Trauma Surgery Flashcards
4 main strategies for surgical management of an arthritic joint?
arthroplasty
excision
arthrodesis
osteotomy
what is an excision arthroplasty?
removal of a diseased joint
what materials can joint replacements consist of?
stainless steel cobalt chrome titanium alloy polyethylene ceramic
why do joint replacements fail?
wear particles produce an inflammatory response after time causing loosening OR breakage of the replacement components
what actually is a pseudotumour?
an inflammatory granuloma that causes muscle and bone necrosis
what material tends to cause pseudotumours?
metal
what material causes osteolysis?
polytethylene
what is osteolysis?
bone resorption which causes loosening
treatment for an early fulminant infection after surgery?
surgical washout
debridement
parenteral antibiotic therapy for 6 wks
what is a late presentation of a surgical complication?
infection from haematogenous spread loosening fracture implant breakage pseudotumour formation
is excision/resection arthroplasty good for small or large joints?
small
what is an arthrodesis?
surgical stiffening or fusion of a joint in a position of function
how is arthrodesis done?
removal of hyaline cartilage and sunchondral bone allowing bony union
what conditions are good for arthrodesis?
end stage ankle arthritis
wrist arthritis
hallux rigidus (arthritis of 1st MTPJ)
conditions that should be treated with osteotomy?
early arthritis of hip and knee
mainstay of treatment for soft tissue inflammatory disorders?
NSAIDs
rest
analgesia
what conditions can have a steroid injection around the tendon?
rotator cuff injury
tennis elbow
what areas are a no-go for steroid injection and why?
achilles tendon
extensor mechanism of knee
as risk of tendon rupture
what should you do if the mainstay of treatment for soft tissue injury doesnt work?
surgical debridement
decompression
what conditions benefit from a synovectomy?
RA of the extensor tendons of the wrist
inflammation of the tibialis posterior
main surgical treatment for achilles rupture?
splintage
what conditions are best for a tendon transfer?
tibialis posterior
extensor pollicis longus
treatment for meniscal tears in the knee?
arthroscopic removal
what condition is ligament reconstruction using a tendon graft useful?
ACL reconstruction
what condition is a soft tissue reattachment useful?
shoulder instability
why is osteomyelitis so difficult to eradicate?
enzymes from leukocytes cause local osteolysis and then pus forms which impairs local blood flow = less wbc’s
most common cause of acute osteomyelitis in adults?
surgery
who gets acute osteomyelitis in absence of surgery?
immunocompromised
children
why do you get a chronic osteomyelitis?
untreated acute osteomyelitis
where does haematogenous spread come from in chronic osteomyelitis?
spine
pelvis
infected intervertebral disc
clinical presentation of chronic OM?
localised pain
inflam
systemic upset
sinus formation
microbiological causes of OM in newborns?
s aureus
enterobacter
group a/b strep
microbiological causes of OM in children and toddlers?
staph aureus
group a strep
haemophilus influenzae
enterobacter
microbiological causes of OM in children over 4 and teenagers?
s aureus
group a strep
enterobacter
haemophilus influenzae
microbiological causes of OM in adults?
staph aureus mainly
most common bacteria causing OM in sickle cell patients?
s aureus
treatment for OM?
antibiotics AND surgery
who is at risk of OM of the spine?
poorly controlled diabetics
IV drug users
immunocompromised patients
most common area of the spine to be affected by OA?
lumbar spine
clinical presentation of spine OM?
insidious onset back pain which is constant and unremitting paraspinal miuscle spasm spinal tenderness fever systemic upset
what type of abscesses can form in spinal OM?
epidural abscess
paravertebral abscess
investigations for OM?
MRI for abscesses
blood cultures
CT guided biopsy
most common cause of OM?
staph aureus
differential diagnosis of OM?
endocarditis
surgical treatment of OM?
debridement
stabilisation
fusion of adjacent vertebrae
what is the risk from a haematoma?
acts like a medium for bacterial growth
what bacteria would you suspect in an early prosthetic infection?
staph aureus
gram negative bacilli
what bacteria would you suspect in a low grade prosthetic infection?
staph epidermidis
enterococcus
what bacteria would you suspect in a late onset prosthetic infection?
staph aureus
beta haemolytic strep
enterobacter
what conditions could have caused a death soon but not immediately after a trauma injury?
MODS
sepsis
what glasgow coma score indicates loss of airway control?
8 or less
signs of pneumothorax on ABCDE examination?
deviated trachea to opposite side respiratory distress tachycardia hypotension neck veins distended no air entry on affected side
minimum accepted urine output?
30ml/hr
first symptom of hypovolaemia?
tachycardia
examination findings of cardiac tamponade?
muffled heart sounds
distended neck veins
how to diagnose cardiac tamponade?
ECHO
investigations for abdominal bleeding?
US scan
CT scan
diagnostic peritoneal lavage
what are the “trauma x rays” performed after a primary trauma?
spine
pelvis
lateral c spine
are fractures more often direct or indirect?
indirect
what fracture gap does there need to be for a bone to heal via primary healing?
<1mm
how does bone heal in primary bone healing?
osteoblasts bridge the gap
how does secondary bone healing work?
inflammatory response with recruitment of macrophages, osteoclasts, granulation tissue, chondroblasts and remodelling
what does granulation tissue do for a fracture?
forms fibroblasts and new blood vessels
what collagen is laid down by osteoblasts in endochondral ossification?
type 1
what does calcium mineralisation of bone produce?
woven bone (hard callus)
how long does it take for the soft callus stage of fracture healing to start?
2-3 weeks
how long does it take for the hard callus stage of fracture healing to start?
6-12 weeks
causes of atrophic non union of a fracture?
lack of blood supply
no movement
too big a fracture gap
tissue trapped in fracture gap
causes of hypertrophic fracture gap?
excessive movement at fracture site
name the 5 main fracture patterns
transverse oblique spiral comminuted segmental
do transverse fractures of a limb cause it to shorten or rotate?
no shortening, but can rotate it
what direction do oblique fractures tend do appear like on the bone?
diagonal
how can you treat an oblique fracture?
interfragmentory screw
do oblique fractures shorten or rotate?
both
what causes a spiral fracture?
torsional forces
what are comminuted fractures?
fractures with 3 or more fragments
what type of injury typically causes a comminuted fracture?
high energy
what other pathologies may be present on the bone in a comminuted fracture?
soft tissue swelling
periosteal damage
damage blood supply to fracture site
what is a segmental fracture?
bone fractured in 2 places
how to treat a segmental fracture?
stabilisation with long rods and plates
what sites are used to describe a fracture of a long bone?
proximal, middle and distal thirds
what does an intraarticular fracture mean?
fracture extends into joint
what does an extraarticular fracture mean?
fracture that doesnt extend into the joint
is a stiff fracture more likely to be intra or extra articular?
intra
what does the position of a fracture depend on?
degree of displacement and angulation
what does displacement of a fracture mean?
the direction of translation of the distal fragment; this can be ant/post/lat/sup
what does angulation mean?
the direction in which the distal fragment points towards the degree of the deformity;
how is angulation measured?
in degrees from the longitudinal axis of the diaphysis of a long bone
what can a displacement or angulation cause?
deformity
loss of function
abnormal pressure
post traumatic OA
clinical signs of a fracture?
bony tenderness
swelling
deformity
crepitus
what should you check for on assessment of an injured limb?
open or closed injury
distal neurovascular status
compartment syndrome
status of skin and soft tissue
when would an oblique x ray view be useful?
to see complex shaped bones like scaphoid, acetabulum etc
which imaging is good for assessing the level of articular damage?
CT
what imaging is good if you suspect a fracture but x ray is normal?
MRI
when would a technetium bone scan be useful?
stress fractures
someone presents to you with a suspected fracture; what do you do first?
assessment of limb
iv morphine
splintage/immobilisation
investigation- x ray
what fractures require a thomas’ splint?
femoral shaft fractures
what characteristics does a fracture need to have to be classed as stable?
minimally displaced or not at all
minimally angulated
how would you treat a stable fracture?
period of splintage/immoblisation
rehabilitation
how would you treat an unstable fracture?
reduction under anaesthetic
closed reduction
cast application
surgical stabilisation
how would you treat an unstable extra articular diaphyseal fracture?
ORIF using plates and screws
can do external fixation but risk of infection
how should you treat a fracture with joint involvement?
joint replacement
arthrodesis
main late systemic complication of fractures?
PE
what time after a fracture would a PE occur?
several days to weeks
can occur within a day
why do you get muscle ischaemia in compartment syndrome?
pressure compresses the venous system = congestion of venous system = congestion of muscle = oxygenated arterial blood cant supply it due to congestion
clinical signs of muscle ischaemia?
increased pain on passive stretching of muscle
severe pain
swollen limb
what is volkmann’s ischaemic contracture?
necrosing ischaemic muscle causing fibrotic contracture
what vessel is in danger of being injured in a knee dislocation?
popliteal artery
how should you treat a haemorrhage from an arterial injury to the pelvis
angiographic embolisation
what is degloving?
avulsion of the skin from its underlying blood vessels
consequences of degloving?
skin ischaemia
necrosis
another word for bruising?
contusion
why do you get fracture blisters?
inflammatory exudates cause lifting of the skin epidermis
signs and symptoms of fracture healing?
resolution of pain and function
absence of point tenderness
no local oedema
resolution of movement at site of fracture
clinical signs of non-union/healing?
ongoing pain
ongoing oedema
movement at the fracture site
slowest healing bones in the body?
tibia
femoral shaft
do metaphyseal or cortical fractures take longer to heal?
cortical
what fractures is a DVT particularly common in?
pelvic
major lower limb fracture
what fractures are prone to developing AVN?
talus
scaphoid
femoral neck
what bone injuries can cause post traumatic OA?
intraarticular fracture
ligamentous instability
fracture malunion
what is complex regional pain syndrome (CRPS)?
heightened chronic pain response
clinical presentation of CRPS?
constant burning or throbbing sensitivity to previously normal stimuli chronic swelling stiffness painful movement skin colour changes
what is the differene between type 1 and 2 CRPS?
1 is a peripheral nerve injury, 2 is not
antibiotic management of an open fracture?
iv broad spectrum antibiotics
fluclox for gram +ve organisms, metronidazole for anaerobes, gentamicin for gram-ves
surgical treatment for open fractures?
internal/external fixation
debridement
what should you do if you cant close a wound properly?
skin graft
associated injuries with dislocations?
tendon tear
nerve injury
vascular injury
compartment syndrome
what complete tendon tears can be treated conservatively?
achilles tendon
rotator cuff
long head of biceps brachii
distal biceps
clinical presentation of septic arthritis?
acute onset of a severely red, hot, swollen, tender joint
severe pain on any movement
most common cause of septic arthritis?
direct injury of an object into a joint
1st, 2nd and 3rd bacterial causes of septic arthritis?
staph aureus
streptococci
haemophilus influenzae
what should be done before antibiotics are given?
aspiration under aseptic technique
what should the aspiration look like if it is septic arthritis?
pus
treatment for septic arthritis?
open washout
surgical washout
