cortext week 5 Flashcards
what is Elective surgery?
scheduled non-emergency operations, normally once conservative treatment fails
what does conservative treatment involve
rest, lifestyle changes, physic, orthoses, mobility aids, splints, injections, medical treatments
who can these patients be referred on to?
rheumatology, podiatrist, physio, OT, neuro, orthotics, interventional radiologists
what are some common elective surgical procedure in orthopaedics?
arthritis, soft tissue inflammatory problems (tendonitis, tendon rupture), correction of deformity, nerve compression, joint instability, joint contractures, chronic infection, tumour
what are the surgical strategies for managing arthritic joint?
arthroplasty/joint replacement.
osteotomy
arthrodesis
excision/resection arthroplasty.
arthroplasty meaning
reshaping of joint, synonymous with replacement
what is a hemiarthroplasty
replace half of a joint
most successful arthroplasty/joint replacement
hip and knee
common arthroplasty/joint replacement
hip, knee, glenohumeral, elbow, ankle, 1st MCP of big toe, MCP of hands and wrist.
what materials can joint replacements be made from?
stainless steel, cobalt chrome, ceramic, titanium alloy, polyethlyne
what are the possible surface interaction in arthroplasty/joint replacement?
metal-polyethylene - mainly
metal-metal, ceramic/eramic, ceramic-polyethylene
why do arthroplasty/joint replacement fail?
due to loosening (due to wear particles produce inflammatory response or due to high stress).
or breakage of components
or fracture leading to protruding replacement
what do metal particles from joint replacement cause over time? what does this lead to?
inflammatory granuloma (AKA pseudotumour) which leads to bone and muscle necrosis
what do polyethylene particles from joint replacement cause over time? what does this lead to?
inflammatory response in bone with subsequent bone reabsorption (osteolysis) leading to loosening
why do ceramic fail over time?
shatter with fatigue due to brittle nature
what happens once arthroplasty/joint replacement fails?
joint revision
what is involved in a joint revision?
removal of old components and insert new ones.
inc risk of complication, inc difficult of surgery and poorer outcomes in joint revision
complications of surgery
deep infection, recurrent dislocation, neuromuscular injury, PE, medical complication (MI, renal failure, chest infections…)
how to treat deep infection if diagnoses early (2-3 weeks)
washout + debridement + prolonged antibiotic (6 weeks) to salvage.
50% success rate
how to treat deep infection if diagnosed late (>3 weeks)
biofilm has formed (stops IS and antibiotics working effectively) so remove everything and patient has no joint for 6 weeks + parental antibiotics. Then joint revision.
90% effective but stiffness and overall function usually compromised
what are the early local complication of of joint replacement surgery
infection, dislocation, fracture, instability, leg length discrepancy, nerve injury, bleeding, arterial injury, DVT
what are the early general complication of of joint replacement surgery
hypovolaemia, shock, acute renal failure, MI, ARDS, PE, chest infection, urine infection (0.2% chance of death)
what are the late local complication of of joint replacement surgery
infection (haemaotgenous), loosening, fracture, pseudotumour formation, implant breakage
what is excision/resection Arthroplasty?
removal of bone and cartilage form one or both sides of the joint. Disabling for larger joints bur log surgery for smaller joint
when is excision/resection Arthroplasty indicated?
1st CMC inhand, Kellas porceedure for Hallux Valgus, occasionally used after failure of hip/shoulder replacement
what is arthrodesis?
surgical stiffening/fusion of joint in a position of function; the remaining hyaline cartilage or bone is removed and the joint is stabilised resulting in bony union (like all fracture healing) and fusion.
when is arthrodesis used?
good at reducing pain but also reduced funciton in larger joints and increases pressure on surronding joints (causing OA).
good for end-stage ankle, wrist and 1st MTP of foot (halls rigidus) arthritis
osteotomy
surgical realignment of bone. corrects deformity and redistribute load across arthritis joint(from disease to non-disased area); used for early arthritis of hip/knee
examples of soft tissue problems
include tendonopathies (tears and ruptures), enthesopathies (inflamed tendon origin or where it inserts into bone), cartilage tears, labour tears, inflamed nurse, tenosynovitis, capulsitis + non-infective fasciitis.
what do soft tissue injuries occur?
degenerative tears, injuries, overuse, inflammatory conditions (RA), drugs (steroid, quinolone), chronic disease (renal failure). many are idiopathic
treatment of soft tissue injuries.
rest, analgesia, anti-inflmmatory markers (majority).
refractory cases → surgical debridgement or decompression.
how to treat major tendon tears
splintage (achilles), surgical repair (quads and patellar tendons, maybe achilles), or don transfere (tib post or extensor polices longus)
when is synovectomy used in soft tissue injuries
entire tendon of wrist in RA or inflamed tibial posterior to prevent rupture
how are cartilage/meniscal tears treated?
conservative and then arthroscopic removal (or occasionally repair) if plan to settle fails or locking/catching occurs.
labrum of acetabulum or glenoid tears treatment
resected or repaired
tendon problems
steroid injections (except achilles + extensor of knee)
what is joint instability
an abnormal motion in the joint → subluxation/dislocation with pain/giving way
commonly unstable joints
kne ligament, subluxation/dislocation of shoulder/patella. frequent giving way of ankle causing instability, spinal instability.
why does instability occur?
due to injury, lax ligaments, predisposing anatomy (genu valgum; femoral neck anteversions; shallow trochlea) or disease process (RA, polio)
treatment for joint instability [conservative]
physio (inc surrounding muscle strength and inc proprioception) + splints/calipes/braces for additional support
treatment for joint instability (surgical)
soft tissue procedures (ligament tightening, reconstruction, reattachment).
bony proceedures (used is significant ligamentous laxities (EDS, Marfan’s) osteotomy (patellar), arthrodesis (spine)).
why correct deformities?
improve function, cosmesis, reduced arthritis risk.
what can deformities occur
congential, developmental, acquired or idiopathic
what are congenital deformites and how are they best treated
complex bone and soft tissue surgery (sometimes amputation is best)
angular deformities of long bones treatment
need growth plate manipulation or osteotomy (or Early OA occurs)
leg length discrepancy treatment
shorten or lengthen one limb
foot deformities treatment
pressure problems with footwear so do osteotomy,arthrodesis, soft tissue procedure + joint excision used
why correct spinal deformities?
surgery if cosmesis/inc wheelchair sitting/fix restrictive lung disease
nerve decompression why is it indicated
use as peripheral nerves can be trapped at various sites (carpal/cubital tunnels). decompression surgery relieves symptoms
used in spinal nerve roots as can be compromised by disc material or bony osteophytes causing a ridiculopathy → spinal decompression or discectomy
joint contractures why do they occur?
neuromuscular disease, spacicity (e.g.:stroke), soft tissue imbalance, arthritis, injury, fibrosing disease (dupuyren’s), disuse, burns
treatment of joint contractures
may be passively correctible or need splintage, physio, medications (botox, baclofen) to receive spasticity.
surgery for fixed/resistant contractures - tendon lengthening/transfer/release or lengthening of soft tissues or bony procedures (osteotomy, arthrodesis)
orthopaedic infections
infected bursitis, arm or leg abscess, wound infections may require surgery (esp if abscess has formed). Bone and joint infection (septic arthritis is emergency)
osteomyelitis (OM) what is it?
infection of bone (inc compact and spongey bone as well as bone marrow)
what causes OM
bacterial infection (occasionally fungus)
where do the organisms come from to cause OM
direct injury, surgery, haematogenous or bacteria at different site (different pathogens = different loads(amount) and virulence).
who does OM commonly affect
young, elderly, immunocompromised, chronic disease sufferers
pathogenesis of OM
once infected → enzyme from leukocyte cause local osteolysis and pus formation → impairs blood flow → reduced infection eradication.
what is a sequestrum and what can happen to it in OM
Sequestrum is a dead fragment of bone that can form and break off; once sequestrum once its present then need more than antibiotics to treat
what is an involucrum?
new bone that forms around the area of necrosis
why is s.aureus particularly difficult to eradicate in OM
because it can infect intra-cellularly → difficult to eradicate
who does acute OM commonly affect?
kids (or IC adults)
why are children at greater risk of acute OM
have abundant tortuous vessels with sluggish flow in the long bone → bacteria accumulate and spread to epiphysis.
also children have loosely applied periosteum so infection/abscess extend widely along subperioteal space.
where are common places for acute OM
proximal femur and humerus, radial head and ankle are common → spread to joint space → septic arthritis.
what is a brodie’s abscess?
children can develop - subacute, insidious onset of OM with walled thin sclerotic bone
what can hide Chronic OM
antibiotics, for years hidden then reactivates causing localised pain; inflammatory and systemic upset and possible sinus formation
causes of chronic OM
axial (spine and pelvis) in adults with haematogenous spread from pulmonary/urinary infections or infection from discitis.
can also be due to open fracture/internal fixation.
can be due to acute untreated OM, may be associated sequestrum and/or involucrum.
TB can also cause chronic OM (esp if from lung infection)
causative organism for OM in newborns (less than 4 months)
s.aureus, enterobacter, group A+B strep
causative organism for OM in child (4month-4 years)
s.aureus, group A strep, HiB (reduced due to vaccine), enterobacter.
causative organism for OM in child/adolescent (4-adult)
s.aureus, group A strep, enterobacter, H.inflenzae
causative organism for OM in adult
s.aureus, occasionally enterobacter or strep.
causative organism for OM in sickle cell anaemia patients
s.aureus comments still but salmonella fairly common and unique to sickle cell patients
classification on OM
superficial, medullary, localised, diffuse.
treatment of acute OM
IV antibiotic ‘best guess organism’ for acute OM unless abscess formed then drain.
If fails to resolve then second line antibiotics or surgery to obtain culture samples, move infected bone and washout infected area.
treatment of chronic OM
cannot be eradicated by antibiotics alone (acute infection may be suppressed by not removed).
surgery to get cultures, remove sequestrum, excise infected/non-viable bone (debridement). Not that samples from discharging sinuses won’t accurately reflex infection.
if debridement causes instability then internal/external fixation.
other strategies are bone grafting and local antibiotic delivery system., potentially plastic surgeon if skin/soft tissue coverage not sufficient to cover bone.
IV antibiotic prolonged (6 weeks)
what is the advantage with using external fixation?
bone can be lengthened.
who is at risk of OM of the spine?
poorly conrtolled diabetics, IVDU, IC.
OM can complicate spinal surgery
where does OM in spine occur commonly
lumbar commonest, although anywhere possible.
PC of OM in spine
insidious onset of back pain (constant and unremitting). also paraspinal muscle spasm, spinal tenderness +/- fever/systemic upset. severe cases may have neurological deficit. can get kyphosis or flat back (vertebrae plana)
investigating OM of spine
MRI shows extent of infection and abscess formation.
blood cultures may indicate causative organism (usually s.aureus - including MRSA. Atypical in IC)
Also check for endocarditis via blood, exam, ECHO.
treatment of OM of spine
IV antibiotics after CT guided biopsy to obtain tissue culture; antibiotics required for months.
monitored by examination and CRP levels
around 50% of patients go on to have spontaneous fusion and resolution.
surgery
when is surgery indicated in spine OM
surgery is indicated if progressive verbal collapse or progressive neurological deficits or no response to antibiotics or inability to obtain cultures
what does surgery involve in spinal OM
debridement, stabilise and fusion of adjacent vertebrae
what precautions are taken to reduce infection of orthopaedic surgical implants
perioperative antibiotics, special air flow, sterile procedure (of tools), anti-septic technique.
still 1% infection rate
why does infection of orthopaedic surgical implants occur?
from patients skin,
from patients hair follicle bacteria.
from skin cells of theatre staff
also haematogenous spread at a later stage
what can cause bacteria to thrive in surgery
haematoma
what does a deep infection incase patients risk of?
complications - OM, non-healing #, pain, sepsis, poor function, implant loosening
what are the likely infecting organisms in an early prosthetic infection
s.aureus or G-ive bacteria (coliforms)
what are the likely infecting organisms in an late prosthetic infection
s.epidermis + enterococcus = low grade virulence and are often diagnoses late (1 year later)
treatment of prosthetic joint infection
surgery rather than antibiotics.
antibiotics should NOT be given until decision regarding surgery has been made [as may interfere with biopsy culture and causative organism may not be identified by surgical debridement]
what does trauma involve
, dislocations, laceration and penetrating injuries of upper/lower limbs.
many specialties.
when should trauma be preferred to plastic surgeons/vascular surgeon
major vascular injury or concern regarding skin/soft tissue coverage of wound and peripheral nerve division
management of major trauma
with high energy injuries → save life + prevent serious system complications → then prevent pain + LOF
in golden hour why does death occur?
early death due to: airway compression, severe head injuries, severe chest injuries, internal organ rupture and # with associated blood loss. - prevention: rapid care,
later deaths due to: sepsis and MODS. needs high quality care/surgical care.
what are the ATLS guidelines?
advanced life support guidelines
primary and secondary surgery (vital function quickly assessed, then head to toe survey)
primary survey of ALTS what needs done?
primary survey: ABCDE + GCS + trauma series of dryas depending on injuries + FBC + UandE’s + blood grouping
secondary survey of ALTS what needs done?
once primary survey complete and patient is stable; head to toe exam + full Hx.
polytrauma
where > 1 long bone is injured.
or where one # is associated with significant chest/abdo trauma (early stabilisation of # is key)
why do # occur and describe the different ways they can be classified
due to direct/indirect trauma (twist/bending force).
can be partial or complete.
also high (RTA, gunshot, blast, fall from height) and low energy (fall, trip, sports).
pathological # is due to very low enegry suggestig underlying pathology
What are the two ways # healing can occur?
primary - this occurs where there is minimal fracture, (hairline fracture when fixed with screws/plates)
secondary - majority, gap at # site needs to be filled to act as scaffold for new bone.
what is the secondary # healing process
Involves inflamation response with recruiting pluropotenial Stem Cells which differentiate into cells during the healing process. (inflamed, soft then hard callus then remodelling)
what is the primary # healing process
simply bridges new gap with osteocytes.
detailed process of secondary # healing.
→ haematoma occurs with inflammation from damaged tissue → macrophages + osteoclasts remove debris → granulation tissue forms from fibroblasts and new blood vessels→ chondroblasts form cartilage (soft callus) → osteoclasts lay down new bone martin (collagen type 1) =endochondrial ossification → calcium mineralisation produces immature woven bone (hard callus) → remodelling with organisation along lines of stress into lamellar bone (good as causes inc blood flow, more compact bone).
when are the soft and hard callus’s formed by
soft = formed by 2-3 weeks
hard = 6-12 weeks to appear
secondary bone healing requires what?
blood supply (o2, nutrients, stem cells) + little movements/stress → otherwise get atopic non-union
what causes impairment in the healing process of #
smoking (reduced healing process due to vasospasm), chronic ill health, vascular absence, malnutrition.
what are the 5 # patterns?
transverse, oblique, spiral, comminuted, segmental.
draw them
cause of transverse #
pure bending force; may not shorten but may angulate /rotationally malalign.
cause of oblique #
shearing force; can shorten or angulate; fixed with intramedullary screws
cause of spiral #
torsional force; interfragmental screws; unstable to rotational forces bu can also angulate
cause of segmental #
bone is fractured in two places; very unstable → long rods/plates to fix
cause of comminuted #
fracture of 3 or more fragments; soft tissue swelling + periosteum damage + reduced blood supply → surgically stabilised as very unstable
how to describe a fracture?
bone
#pattern
where on bone can be proximal, middle, distal (1/3rd)
type of bone involved (diaphysial, epiphyseal, metaphyseal?)
intra/extra-articular?
displacement (of distal to proximal) can be anteriorly, posteriorly, laterally or medially displaced + reference degree of displacement (25%, 50%, 100%…)
angulation (measure in degrees of distal aspect to lateral aspect down longitude of bone)
what does management of # depend on?
site? is position satisfactory? (due to fracture pattern and degree of initial displacement)
what does 100% displacement of # mean?
off-ended #
what does residual angulation and IA put patient at risk of post-#?
IA- inc risk of pain, stiffness and post-trauma OA
angulation = deformity, LOF, abnormal joint pressure, early OA
PC of #
localised bony (marked) swelling+pain, not diffuse mild tenderness, swelling, deformity, crepitus (from ends of bone grinding)
what is the investigation for a lower limb able to bear weight or injured
x-ray
how to assess injured limb
open/closed? digital neurovascular status. watch for compartment syndrome and assess skin status/soft tissue envelope
what to look for in digital neurovascular status
pulse, cap refill, temp, colour, sensation, motor power
how to investigate #
X-ray (with AP and lateral views at least) CT MRI technetium bone scan tonogram
when would oblique views be necessary in x-raying #
scaphoid, acetabulum, tibial plateau
when is tonogram done?
(moving x-ray) for mandibular #
why is a CT useful in investigating #?
assess complex bone # (pelvis, vertebrae, scapular gleaned, calcaneus)
can help determine degree of articular damage
can help with surgical planning
why is a MRI useful in investigating #?
detect occult #
why is a technetium bone scan useful in investigating #?
detect stress # (hip, femur, tibia, fibula, 2nd Metataral) as these may fail to show up on X-rays into hard callus appears
what is an occult # and what are commonest?
where X-ray is normal but clinical suspicion is high
usually scaphoid, hip
management of long bone # (early)
clinical assessment; analgesia (IV morphine); splintage/immobilisation; investigate (usually x-rays)
what can be used for splintage?
temporary plaster slab (AKA back slab), a sling, an arthesis, a thomas splint (for femoral shaft #)
when would a # be reduced before X-rays?
obvious displacement
obvious dislocation
risk of skin damage
what does definitive management depend on?
bone, location of #, # pattern, position of #, stability of #, open/closed, associated injuries, neurovascular status, age, skin/soft tissue envelope, functional status of patient, co-morbidities
angulate/displaced # treatment
MUA, → closed reduction,→ cast application do may X-rays to ensure no LOF
unstable # treatment
surgical stabilisation (pins, screws, plates, wires, nails, external fixation)
untable extra-articular disphseal # treatment
ORIF → primary bone healing
what is ORIF
open reduction and internal fixation
IA #
anatomical reduction + rigid fixation → if too severe then arthrodesis/TJR
complications 4 types?
early and late, local and systemic
what are the early local complications of a #?
compartment syndrome, vascular injury with ischemia, nerve compression/injury, skin necrosis
what are the early systemic complications of a #?
hypovolaemia, fat embolism, shock, ARDS, acute renal failure, SIRS, MODS, death
what are the late local complications of a #?
stiffness, LOF, infection, chronic regional pain syndrome (CRPS), non-union/mal-union, volkmann’s ischemic contracture, post-traumatic OA, DVT
what are the late systemic complications of a #?
PE
why does volkmann’s ischemic contracture occur?
compartment syndomre not treated quick enough → LOF +ischemia
compartment syndrome pathogenesis
inc pressure → ischemia +nerve damage → inc pain on passive stretching of muscles + pain disproportionate to injury (keep upping morphine) → fascioctomy
what are the 3 types of nerve injury?
neuropraxic, axonotmesis, neurotmesis
what is neuropraxic nerve injury?
temporary conduction deficit from compression/stretch → resolves fully (in 28 days)
what is axonotmesis?
sustained compression/stretch from greater force → recovery variable as sometimes sensation/full motor power not regained → nerve conduction studies afterwards predict recovery
what is neurotmesis
complete transection, rare in closed injuries usually if penetration (outward-in or inward-out) → needs surgery → recovery variable
what treatment can be help if axonotmesis/neurotmesis recovery is poor?
expendable cuteneuos nerve graft
what nerve does a colles # most commonly injury
medial nerve compression/acute carpal tunnel
what nerve does a posterior dislocation of the hip most commonly injury
sciatic nerve injury
what nerve does a supracondylar # most commonly injury
median nerve injury
what nerve does a anterior dislocation of the shoulder most commonly injury
auxillary nerve palsy
what nerve does a humeral shaft # most commonly injury
radial neve palsy
what nerve does a “bumper injury” to lateral knee most commonly injury
common peroneal nerve (common fibular nerve) palsy
what vascular complication can occur due to #
thrombosis, haemorrage, ischemia (fat embolism)
what artery does a knee dislocation affect
popliteal artery
what artery does a supracondylar # (paediatrics) of elbow affect
brachial artery
shoulder trauma causes injury to what artery?
auxiliary artery.
pelvic trauma causes what vascular problem?
massive haemorrhage (close space by Wrapping hips in binder so less blood loss, )
what do you do if there is reduced digital coruscation in a # patient?
urgent vascular surgical review (urgent angiography)
what causes fragile skin (making soft tissue/skin problems more likely?)
RA, steroids, age
what occurs in soft tissue/skin problems post #?
devascularisation + necrosis with skin breakdown
what to do if skin is tenting/blanching?
reduced (under anaesthesia) as emergency to preserve soft tissue/skin from necrosis.
what is de-gloving?
avulsion of skin from underlying blood vessels
what does ge-gloving cause?
necrosis and skin ischemia
signs of de-gloving
skin won’t blanch on pressure and may be insensitive; underlying haematoma may be present
what soft tissue damage can occur?
bruising/swelling (more shows higher energy), fracture blisters can occur due to inflammatory exudates causing lift of epidermis
(also de-gloving, skin tenting/blanching, skin penetration due to open #)
what is classed as a healing #?
resolution of pain and function, abscess of local tenderness, no local oedema, resolution of movement at # site.
what is classed as a non-healing #?
ongoing pain, oedema and movement at # site
what is delayed union? what is a common cause?
that has not healing in expected time (infection may be cause).
do all # heal at same rate?
no. tibial take 16 weeks cast then 1 year to heal fully whereas others r much less.
what are the two types of non-union?
hypertrophic and atrophic
hypertrophic non-union. why does it occur and treatment?
instability and excess motion. (may also be due to infection)
plate ensures fix
atrophic non-union. why does it occur and treatment?
reduced blood supply, chronic disease, fracture gap. (may also be due to infection)
surgery: remove fibrous tissue, restore bleeding bone ends, restore medullary canal continuity, bone graft to stimulate bone format (and act as scaffold) + external/internal fixator with compression across fixation
what do you examine for in a patient with non-union? what is the treatment if this is the cause?
infection [CRP and bacteriological sampling]
remove and externally fixate
what are other local problems what can occur due to #?
DVT, AVN, OA, CRPS, infection, # disease
DVT due to # (who does it affect and treatment)
esp post-pelvic and major lower limb # with period of immobility
LMWH prophylaxis
what is mean by fracture disease as a complication of #?how is this treated
stiffness and weakness due to cast and #.
physio and time restores
where does AVN commonly affect and what is treatment if it occurs after #?
humeral/femoral head, talus, scaphoid.
arthrodesis or TJR
post-trauma OA risk is increased by what and how is it treated?
IA #, mal-union, lax ligament
analgesia, bracing, arthrodesis + TJR
what is CRPS and its PC?
heightened response to pain after injury
PC = pain, sensitivity, swelling, and changes in the skin
CRPS treatment
analgesia, antidepressant (amityptylene), gabapentin (anti-convulsant), steroids, physio, TENS machine, lidocaine patches, symps.nerve blocking injections
how to treat infected #
antibiotics +/- surgical washout or surgical replacement/revision surgery
