elective surgery and general trauma Flashcards
what sort of conditions are treated with elective surgery
non-emergency
‘cold’ MSK conditions
examples of conservative treatment
lifestyle advice
rest
physio
orthoses
mobility aids
medical treatments
when should surgical management be considered
when there is an appropriate surgical solution and when conservative measures have not controlled the patient’s symptoms
surgical strategies for the management of an arthritic joint
arthroplasty/joint replacement
excision or resection arthroplasty
arthrodesis
osteotomy
arthroplasty can include
joint replacement
removal of a diseased joint
replacement of one half of a joint is known as
hemiarthroplasty
the most successful joint replacements are
hip and knee
joint replacements can be made of
stainless steel
cobalt chrome
titanium alloy
polyethylene
ceramic
metal particles from joint replacement can cause
inflammatory granuloma (pseudotumour) which can cause bone and muscle necrosis
polyethylene partciles for joint replacement can cause
an inflammatory response in bone with subsequent bone resorption (osteolysis)
results of revision joint replacement
complications rates are higher
functional outcomes are poorer
patient satisfaction is less
serious complications of joint replacement
deep infection
recurrent dislocation
neurovascular injury
pulmonary embolism
renal failure/MI/chest infection
early local complications of joint replacement
infection
dislocation
instability
fracture
leg length discrepancy
nerve injury
bleeding
arterial injury/ischaemia/DVT
early general complications
hypovolaemia
shock
acute renal failure
MI/ARDS/PE
chest infection
urine infection
late local complications
infection (haematogenous spread)
loosening
fracture
implant breakage
psuedotumour formation
management of a fulminant infection diagnosed 2-3 weeks post joint replacement
surgical washout and debridement
prolonged parenteral antibiotics (6 weeks)
why is the artificial joint generally not salvageable if an infection presents more than 3 weeks after the replacement
infecting bacteria adhere to the foreign surfaces and form a biofilm
management of fulminant infection more than 3 weeks after joint replacement
removal of all foreign material
parenteral antibiotics
revision replacement once the infection is under control (6 weeks)
excision or resection arthroplasty involves
the removal of bone and cartilage of one or both sides of a joint
excision arthroplasty is most effective in large joints
true/false
false
its better in smaller joints such as the carpometacarpal joints of the hand
what is arthrodesis
surgical stiffening or fusion of a joint in a position of function
pros and cons of arthrodesis
pros
good at alleviating pain
cons
limited function, may increase pressure on surrounding joints,
arthrodesis is a good treatment for
ankle arthritis
wrist arthritis
arthritis of the first MTPJ
what is osteotomy
surgical realignment of a bone
what can osteotomy be used for
deformity correction
redistribution of load across an arthritic joint
osteotomy can be used in early arthritis of the
knee and hip
examples of tendonopathies
tears
ruptures
what is an enthesopathy
inflammation of a tendinous origin from or insertion into bone
the vast majority of soft tissue inflammatory problems can be treated with
rest
analgesia
anti-inflammatory medications
tendons in which areas are suitable for injection of steroid
rotator cuff
elbow
non-weight bearing joints
why should steroid injections be avoided in cases such as achilles tendonitis
substantial risk of tendon rupture
decompression surgery for soft tissue problems generally involves
making more space for the affected tissue
synovectomy can be performed for
extensor tendons of the wrist in RA
inflammation of the tibialis posterior tendon to prevent rupture
majot tendon tears may require
splintage (achilles)
surgical repair (quadriceps/patellar tendon)
tendon transfer (tibialis posterior, EPL)
meniscal tears in the knee can be treated with ________ if the pain fails to settle or if there are mechanical problems
arthroscopic removal
what is joint instabilty
abnromal motion of a joint (rotation or translation) resulting in subluxation or dislocation with pain and/or giving way
instability can be caused by
previous injury
ligamentous laxity
examples of anatomic variation that predispose to patellofemoral instability
shallow trochlea of distal femur
femoral neck anteversion
genu valgum
most cases of joint instability can be treated with
physiotherapy to strengthen the surrounding muscles
splints/calipers/braces
soft tissue procedures for instability
ligament tightening/advancement
ligament reconstruction using a tendon graft
soft tissue reattachment
bony procedures for instability
fusion (severe ligamentous laxtiy eg ehlers-danlos)
osteotomy (skeletal predispostion)
angular deformity of the long bones of the lower limb may result in
early arthritis of the ankle or knee
how can a shorter limb be lengthened
using an external fixator
why would severe scolioisis require surgery
cosmesis
wheelchair posture
restrictive respiratory defect
most commn sites of peripheral nerve compression
median nerve at the wrist (carpal tunnel)
ulnar nerve at the elbow (cubital tunnel)
spinal nerve roots may become compressed by
disc material
bony osteophytes
non-surgical management of contractures
splintage
physion
baclofen (skeletal muscle relaxant)
botox injections
indications for surgery in joint contractures
fixed or resistant contrature
surgical treatment of joint contracture
tendon lengthening
tendon transfer
release or lengthening of tight soft tissues
bony procedures (osteotomy, arthrodesis)
what is osteomyelitis
infection of bone including compact and spongy bone as well as the bone marrow
how can pathogens infect bone in osteomyelitis
penetrating trauma
surgery
haematogenous spread
bacteraemia
risk factors for OM
immunosuppression
chronic disease
extremes of age
pathophysiology of OM
enzymes from leukocytes cause local osteolysis and pus forms which impairs local blood flow
a dead fragment of bone (sequestrum) can form and break off
new bone will form around the area of necrosis (involucrum)
what is a sequestrum
a fragment of dead bone formed in OM that can break off
what is an involucrum
new bone formed around the area of necrosis in OM
acute OM in the absence of surgery usually occurs in which age group
children
(also in immunosuppressed adults, but less likely)
why are children more prone to acute OM
the metaphyses of the long bones contain abundant tortuous vessels with sluggish flow which can reult in accumulation of bacteria and infection spreads towards the epiphysis
in neonates/infants some metaphyses are IA, which means that infection can
spread into the joint and cause septic arthritis
what is the consequence of loose periosteum in infants with OM
an abscess can extend widely along the subperiosteal space
what is brodie’s abscess
a subacute OM, with insidious onset where the boner reacts by walling off the abscess with a thin rim of sclerotic bone
chronic OM develops from
an untreated acute OM
chronic OM may be associated with
involucrum
sequestrum
chronic OM in adults tends to affect which part of the skeleton
axial skeleton (spine/pelvis)
peripheral chronic OM can be caused by
previous open fracture
internal fixation
TB can cause chronic OM
true/false
true
through haematogenous spread from primary lung infection
the most common causative organism of OM is
staph aureus
superficial OM affect
the outer surface of the bone
how is OM classified
superficial (outer surface of bone)
medullary
localised (cortex and medullary bone)
diffuse (infection results in skeletal instability)
acute OM treatment
antibiotics IV
abscess requires surgical drainage
surgical removal of infected bones and washout may be required
why is antibiotic therapy alone not sufficient in treating chronic OM
the infection may be suppressed but lie dormant and resurface at a later date
chronic OM treatment
surgery to gain deep tissue cultures, remove sequestrum and excise any infected/non-viable bone
IV antibiotics
why can a sequestrum not be treated with antibiotics
no blood supply
advantages of external fixation for stabilisation after debridement surgery in OM
limb can be lengthened
risk factros for OM of the spine
poorly controlled diabetics
IV drug users
immunocompromised patients
commonest location of spinal OM
lumbar spine
spinal OM presentation
insidious onset back pain which is constant and unremitting
paraspinal muscle spasm
spinal tenderness
fever/systemic upset
complications of spinal OM
cuada equina syndrome is below L1
paravertebral or epidural abscess
kyphosis/vertebra plana (flat vertebra) due to vertebral weakness
spinal OM investigations
MRI
blood cultures
CT guided biopsy for tissue cultures
ECHO (consider endocarditis)
treatment of spinal OM
high dose IV antibiotics
debridement, stabilisation and fusion of vertebrae if no response to antibiotics
complications of prosthetic joint infection
pain
poor function
recurrent sepsis
chronic discharging sinus formation
implant loosening
a deep infection in a fracture increases the risk of
OM and non-union
common viurlent organisms which produce an early prosthetic infection include
staph aureus
gram negative bacillia eg coliforms
organism associated with late onset haematogenous infection of prosthetic joints include
staph aureus
beta haemolytic strep
enterobacter
for orthopaedic infections the treatment is generally
surgical rather than antibiotics
why should antibiotics not be given until a surgical decision has been made when treating an orthopaedic infection
antibiotics can interfere with the bacteriological tissue cultures and the causative organism may not be identified from surgical debridement
initial management of major trauma
ABCDE
save life and prevent serious complications ahead of preventing pin and loss of function from fractures or dislocations
early death after major trauma can be caused by
airway compromise
severe head injury
severe chest injury
interneal organ rupture
fractures associated with major blood loss (pelvis, femur)
what is primary bone healing
the bone bridges the gap with new bone from osteoblasts
when does primary bone healing occur
when there is minimal fracture gap
hairline fractures and fractures that are fixed with compression screws and plates
what is secondary bone healing
the space between the bones is toobig for primary healing so a sort of scaffold is formed while new bone forms around it
re-order the stages of secondary bone healing
- osteoblasts lay down bone matric (collagen type 1) (enchondral ossification)
- haematoma occurs with inflammation from damaged tissues
- calcium mineralisation produces immature woven bone (hard callus)
- macrophages and osteoclasts remove debris and resorb the bone ends
- remodelling occurs with organisation along lines of stress into lamellar bone
- chondroblasts form cartilage (soft callus)
- granulation tissue forms from fibroblasts and new blood vessels
- fracture occurs
when is the soft callus normally formed
by the 2nd-3rd week
how long does the hard callus take to form
6-12 weeks
what does secondary bone healing require
good blood supply for oxygen
nutrients
stem cells
a little movement or stress
risk factors for atrophic non-union
lack of blood supply
no movement
too big a fracture gap
tissue trapped in the fracture gap
what causes hypertrophic non-union
excessive movement at the fracture site
why does excessive movement at the fracture site cause hypertrophic non-union
there is abundant hard callus formation but too much movement doesn’t give the fracture a chance to bridge the gap
what are the five basic fracture patterns
transverse fracture
oblique fracture
spiral fracture
comminuted fracture
segmental fracture
how do transverse fractures occur
with pure bending force where the cortex on one side fails in compression and the cortex on the other side in tension
complications of transverse fractures
may angulate or result in rotational malalignment
how do oblique fractures occur
with a shearing force eg fall from height, deceleration
oblique fracture complications
tend to shorten
may angulate
how do spiral fractures occur
torsional forces (twisting)
spiral fracture complications
unstable to rotational forces
may angulate
what are comminuted fractures
fractures with 3 or more fragments
how do comminuted fractures occur
high energy injury (or poor bone quality)
comminuted fracture complications
substantial soft tissue swelling
periosteal damage
reduced blood supply to fracture site
very unstable
what is a segmental fracture
a bone that is fractured in two separate places
what is the diaphysis
the shaft of the bone
intra-articular fractures have a greater risk of
stiffness
pain
post traumatic OA
what is displacement
the direction of translation of the distal fragment
100% displacement is referred to as an ________ fracture
off-ended
what is angulation
the direction in which the distal fragment points towards and the degree of this deformity
residual displacement or angulation can lead to
deformity
loss of function
abnormal pressure on joints leading to post traumatic OA
clinical signs of a fracture
localised bony tenderness
swelling
deformity
crepitus (bone ends grating with an unstable fracture)
what is a tomogram
a moving xray
used to take images of complex bones
when would a CT be used to diagnose a fracture
complex bone (vertebrae, pelvis, calcaneus, scapular glenoid)
determine the degreeof articular damage
help surgical planning for IA fractures
when would an MRI by used in investigating a fracture
to detect occult fractures if there is clinical suspicion but a normal xray
technetium bone scans can be used to detect
stress fractures
initial management of a long bone fracture
analgesia (IV morphine)
splintage/immobilisation
investigation
in what situations should a fracture be reduced before radiographs are taken
fracture is obviously grossly displaced
obvious fracture dislocation
risk of skin damage from excessive pressure
undisplaced, minimally displaced and minimally angulated fractures which are stable are usaully treated with
a period of splintage or immobilisation
if a fracture is displaced or angulated it requires
reduction under anaesthetic
unstable fractures may need to be treated with
surgical stabilisation
pins/screws/plates etc
what is ORIF
open reduction and internal fixation
what is the goal of ORIF
anatomic reduction and rigid fixation leading to primary bone healing
when should ORIF be avoided
soft tissue are very swollen
blood supply to fracture site is tenuous
if it may cause extensive blood loss (femoral shaft)
what are the potential complications of external fixation
pin site infection
loosening
how should compartment syndrome be managed
fasciotomy
early local complications of fractures
compartment syndrome
vascular injury with ischaemia
nerve compression injury
skin necrosis
early systemic complications of fractures
hypovolaemia
fat embolism
shock
ARDS
acute renal failure
SIRS
MODS
late local complications of fractures
stiffness
loss of function
chronic regional pain syndrome
infection
non-union/mal-union
Vlokmann’s ischaemic contracture
post traumatic OA
DVT
late systemic complications of fractures
pulmonary embolism
what is compartment syndrome
swelling inside a fascial compartment
compartment syndrome pathogenesis
swelling from inflammatory process/bleeding compresses the venous system
blood can’t get out of the compartment
causes secondary ischaemia as the arterial supply can’t reach the muscle
signs of compartment syndrome
increased pain on passive stretching of the involved muscle(s)
severe pain outwith the anticipated severity of the clincial context
what is Volkmann’s contracture
ischaemic muscle that has been allowed to necrose resulting in fibrotic contracture
knee dislocation risks injury to which artery
popliteal
paediatric supracondylar fracture risks injury of which artery
brachial artery
shoulder trauma can damage which artery
axillary artery
what is ‘degloving’
avulsion of the skin from its underlying blood vessels
normally as a result of a shearing force injury
why do fracture blisters form
inflammatory exudates lift the epidermis of the skin (like a burn)
signs of fracture healing
resolution of pain and function
absence of point tenderness
no local oedema
resolutin of movement at fracture site
signs of non-union
ongoing pain
ongoing oedema
movement at fracture site
what is the slowest healing bone
tibia
what is delayed union
a fracture that hasn’t healed in the expected time
fractures that are prone to non-uniondue to poor blood supply
scaphoid waist
distal clavicle
subtrochanteric fractures of the femur
should prophylactic anticoagulation (eg LMWH) be given to fracture patients
patients at risk of DVT etc
which fractures are prone to developing AVN
femoral neck
scaphoid
talus
treatment of AVN
often requires THR (femoral neck) or arthrodesis (scaphoid/talus)
what is an open fracture
a fracture where the skin has been broken
two types of open fracture
inside-out: fragment of fractured bone breaks through the skin
outside-in: laceration of skin or penetrating injury
main complication of open fractures
infection
how can infection complicate the healing of a fracture
can lead to non-union
factors the increase the risk of infection of a fracture
higher energy injury
amount of contamination
delay of appropriate treatment
problems with wound closure
initial managment of open fracture (A&E)
IV broad spectrum antibiotics (fluclox, gent and met)
sterile or antispetic dressing sshould be applied to prevent further contamination before splintage
surgical management of open fracture
debridement
reduction and fixation
why does devitalised tissue need to be removed when managing an open fracture
because it is de-vascularised it won’t be reached by antibiotics and may harbour infection
main complication of haematoma in open fractures
acts as a culture medium and may cause necrosis
delayed union is more common in open fractures
true/false
true
they are often higher energy
why are open fracutres normally treated with internal/external fixation rather than a plaster cast
because frequent wound inspecions are required
which tissues will not take a skin graft
bare tendon
bone
exposed metalwork
fat may not due to poor vascularisation
name a group of people that often have a delayed presentation of dislocation
alcoholics
delayed presentation of dislocation increases the risk of
requiring open reduction
recurrent instability
name two conditions that result in hypermobility
ehlers-danlos
marfan’s
injuries associated with dislocations include
tendon tears
nerve injury
vascular injury
compartment syndrome
rapid resisted contraction of a muscle may result in
muscle tear
RICE stands for
rest
ice
compression
elevation
acute onset of a severely painful, hot, swollen and tender joint with severe pain on any movement are the typical presenting features of
septic arthritis
in most cases of septic arthritis, the invading pathogens spread to the joint via…
the blood
from an infection of adjacent tissues
septic arthritis is common in adults
true/false
false
it is relatively uncommon in adults but should always be excluded with any unexplained acute monoarthritis
why is septic arthritis considered an emergency
bacterial infection can irreversibly damage hyaline cartilage within days
groups most commonly affected by septic arthritis
the young
the old
PWIDs
immunocompromised patients
the most common pathogen in septic arthritis is adults is
staph aureus
the most common cause of septic arthirtis is the old, PWIDs and the seriousy ill
E coli
investigation of septic arthritis
joint aspiration to confirm diagnosis and identify causative pathogen
managment of septic arthritis
surgical washout via open surgery or arthroscopic techniques
IV antibioitics if not surgery (children)
carpal tunnel syndrome is caused by compession of the
median nerve
cubital tunnel syndrome is caused by compression of the
ulnar nerve
which of the following tendon tears is commonly surgically repaired to optimise function
hip adductor
achilles tendon
patellar tendon
long head of biceps
patellar tendon
occurs when bone is exposed to a shearing force eg fall from height, deceleraton
oblique fracture
occur due to torsional forces acting on the bone
spiral fracture
occur when a pure bending force is applied to the bone
transvere fracture
what is the chief indication for performing hip and knee joint arthroplasty
improve range of movement
increase strength
improve function
pain
pain
which of the following fractures has higher rates of non-union due to a retrograde blood supply and avascularity of the bone
waist of scaphoid fractures
supracondylar fractures
proximal humeral fractures
waist of scaphoid
which tendon tear is commonly managed conservatively
hip adductor tendon
patellar tendon
long head of biceps
quadriceps tendon
long head of biceps
poor grip strength post distal radial fracture is asociated with loss of extension/flexion at the wrist joint
extension
the wrist needs at least 10 degrees of extension for full grip strength
distal radial fractures which result in a volar angulation will cause
impairment of grip
a glasogw coma score of less than ___ implies loss of airway control
8
a tibial osteotomy may be considered as an alternative surgical option to joint replacement for knee arthrtitis is the young patient
true/false
true
what is allodynia and what is it a sign of
sensitvity to stimuli not normally painful
chronic regional pain syndrome
