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elective surgery and general trauma Flashcards

1
Q

what sort of conditions are treated with elective surgery

A

non-emergency

‘cold’ MSK conditions

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2
Q

examples of conservative treatment

A

lifestyle advice

rest

physio

orthoses

mobility aids

medical treatments

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3
Q

when should surgical management be considered

A

when there is an appropriate surgical solution and when conservative measures have not controlled the patient’s symptoms

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4
Q

surgical strategies for the management of an arthritic joint

A

arthroplasty/joint replacement

excision or resection arthroplasty

arthrodesis

osteotomy

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5
Q

arthroplasty can include

A

joint replacement

removal of a diseased joint

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6
Q

replacement of one half of a joint is known as

A

hemiarthroplasty

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7
Q

the most successful joint replacements are

A

hip and knee

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8
Q

joint replacements can be made of

A

stainless steel

cobalt chrome

titanium alloy

polyethylene

ceramic

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9
Q

metal particles from joint replacement can cause

A

inflammatory granuloma (pseudotumour) which can cause bone and muscle necrosis

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10
Q

polyethylene partciles for joint replacement can cause

A

an inflammatory response in bone with subsequent bone resorption (osteolysis)

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11
Q

results of revision joint replacement

A

complications rates are higher

functional outcomes are poorer

patient satisfaction is less

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12
Q

serious complications of joint replacement

A

deep infection

recurrent dislocation

neurovascular injury

pulmonary embolism

renal failure/MI/chest infection

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13
Q

early local complications of joint replacement

A

infection

dislocation

instability

fracture

leg length discrepancy

nerve injury

bleeding

arterial injury/ischaemia/DVT

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14
Q

early general complications

A

hypovolaemia

shock

acute renal failure

MI/ARDS/PE

chest infection

urine infection

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15
Q

late local complications

A

infection (haematogenous spread)

loosening

fracture

implant breakage

psuedotumour formation

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16
Q
A
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17
Q

management of a fulminant infection diagnosed 2-3 weeks post joint replacement

A

surgical washout and debridement

prolonged parenteral antibiotics (6 weeks)

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18
Q

why is the artificial joint generally not salvageable if an infection presents more than 3 weeks after the replacement

A

infecting bacteria adhere to the foreign surfaces and form a biofilm

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19
Q

management of fulminant infection more than 3 weeks after joint replacement

A

removal of all foreign material

parenteral antibiotics

revision replacement once the infection is under control (6 weeks)

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20
Q

excision or resection arthroplasty involves

A

the removal of bone and cartilage of one or both sides of a joint

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21
Q

excision arthroplasty is most effective in large joints

true/false

A

false

its better in smaller joints such as the carpometacarpal joints of the hand

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22
Q

what is arthrodesis

A

surgical stiffening or fusion of a joint in a position of function

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23
Q

pros and cons of arthrodesis

A

pros

good at alleviating pain

cons

limited function, may increase pressure on surrounding joints,

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24
Q

arthrodesis is a good treatment for

A

ankle arthritis

wrist arthritis

arthritis of the first MTPJ

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25
Q

what is osteotomy

A

surgical realignment of a bone

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26
Q

what can osteotomy be used for

A

deformity correction

redistribution of load across an arthritic joint

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27
Q

osteotomy can be used in early arthritis of the

A

knee and hip

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28
Q

examples of tendonopathies

A

tears

ruptures

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29
Q

what is an enthesopathy

A

inflammation of a tendinous origin from or insertion into bone

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30
Q

the vast majority of soft tissue inflammatory problems can be treated with

A

rest

analgesia

anti-inflammatory medications

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31
Q

tendons in which areas are suitable for injection of steroid

A

rotator cuff

elbow

non-weight bearing joints

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32
Q

why should steroid injections be avoided in cases such as achilles tendonitis

A

substantial risk of tendon rupture

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33
Q

decompression surgery for soft tissue problems generally involves

A

making more space for the affected tissue

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34
Q

synovectomy can be performed for

A

extensor tendons of the wrist in RA

inflammation of the tibialis posterior tendon to prevent rupture

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35
Q

majot tendon tears may require

A

splintage (achilles)

surgical repair (quadriceps/patellar tendon)

tendon transfer (tibialis posterior, EPL)

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36
Q

meniscal tears in the knee can be treated with ________ if the pain fails to settle or if there are mechanical problems

A

arthroscopic removal

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37
Q

what is joint instabilty

A

abnromal motion of a joint (rotation or translation) resulting in subluxation or dislocation with pain and/or giving way

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38
Q

instability can be caused by

A

previous injury

ligamentous laxity

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39
Q

examples of anatomic variation that predispose to patellofemoral instability

A

shallow trochlea of distal femur

femoral neck anteversion

genu valgum

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40
Q

most cases of joint instability can be treated with

A

physiotherapy to strengthen the surrounding muscles

splints/calipers/braces

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41
Q

soft tissue procedures for instability

A

ligament tightening/advancement

ligament reconstruction using a tendon graft

soft tissue reattachment

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42
Q

bony procedures for instability

A

fusion (severe ligamentous laxtiy eg ehlers-danlos)

osteotomy (skeletal predispostion)

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43
Q

angular deformity of the long bones of the lower limb may result in

A

early arthritis of the ankle or knee

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44
Q

how can a shorter limb be lengthened

A

using an external fixator

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45
Q

why would severe scolioisis require surgery

A

cosmesis

wheelchair posture

restrictive respiratory defect

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46
Q

most commn sites of peripheral nerve compression

A

median nerve at the wrist (carpal tunnel)

ulnar nerve at the elbow (cubital tunnel)

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47
Q

spinal nerve roots may become compressed by

A

disc material

bony osteophytes

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48
Q

non-surgical management of contractures

A

splintage

physion

baclofen (skeletal muscle relaxant)

botox injections

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49
Q

indications for surgery in joint contractures

A

fixed or resistant contrature

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50
Q

surgical treatment of joint contracture

A

tendon lengthening

tendon transfer

release or lengthening of tight soft tissues

bony procedures (osteotomy, arthrodesis)

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51
Q

what is osteomyelitis

A

infection of bone including compact and spongy bone as well as the bone marrow

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52
Q

how can pathogens infect bone in osteomyelitis

A

penetrating trauma

surgery

haematogenous spread

bacteraemia

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53
Q

risk factors for OM

A

immunosuppression

chronic disease

extremes of age

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54
Q

pathophysiology of OM

A

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)

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55
Q

what is a sequestrum

A

a fragment of dead bone formed in OM that can break off

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56
Q

what is an involucrum

A

new bone formed around the area of necrosis in OM

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57
Q

acute OM in the absence of surgery usually occurs in which age group

A

children

(also in immunosuppressed adults, but less likely)

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58
Q

why are children more prone to acute OM

A

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

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59
Q

in neonates/infants some metaphyses are IA, which means that infection can

A

spread into the joint and cause septic arthritis

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60
Q

what is the consequence of loose periosteum in infants with OM

A

an abscess can extend widely along the subperiosteal space

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61
Q

what is brodie’s abscess

A

a subacute OM, with insidious onset where the boner reacts by walling off the abscess with a thin rim of sclerotic bone

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62
Q

chronic OM develops from

A

an untreated acute OM

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63
Q

chronic OM may be associated with

A

involucrum

sequestrum

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64
Q

chronic OM in adults tends to affect which part of the skeleton

A

axial skeleton (spine/pelvis)

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65
Q

peripheral chronic OM can be caused by

A

previous open fracture

internal fixation

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66
Q

TB can cause chronic OM

true/false

A

true

through haematogenous spread from primary lung infection

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67
Q

the most common causative organism of OM is

A

staph aureus

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68
Q

superficial OM affect

A

the outer surface of the bone

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69
Q

how is OM classified

A

superficial (outer surface of bone)

medullary

localised (cortex and medullary bone)

diffuse (infection results in skeletal instability)

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70
Q

acute OM treatment

A

antibiotics IV

abscess requires surgical drainage

surgical removal of infected bones and washout may be required

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71
Q

why is antibiotic therapy alone not sufficient in treating chronic OM

A

the infection may be suppressed but lie dormant and resurface at a later date

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72
Q
A
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73
Q

chronic OM treatment

A

surgery to gain deep tissue cultures, remove sequestrum and excise any infected/non-viable bone

IV antibiotics

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74
Q

why can a sequestrum not be treated with antibiotics

A

no blood supply

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75
Q

advantages of external fixation for stabilisation after debridement surgery in OM

A

limb can be lengthened

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76
Q

risk factros for OM of the spine

A

poorly controlled diabetics

IV drug users

immunocompromised patients

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77
Q

commonest location of spinal OM

A

lumbar spine

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78
Q

spinal OM presentation

A

insidious onset back pain which is constant and unremitting

paraspinal muscle spasm

spinal tenderness

fever/systemic upset

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79
Q

complications of spinal OM

A

cuada equina syndrome is below L1

paravertebral or epidural abscess

kyphosis/vertebra plana (flat vertebra) due to vertebral weakness

80
Q

spinal OM investigations

A

MRI

blood cultures

CT guided biopsy for tissue cultures

ECHO (consider endocarditis)

81
Q

treatment of spinal OM

A

high dose IV antibiotics

debridement, stabilisation and fusion of vertebrae if no response to antibiotics

82
Q

complications of prosthetic joint infection

A

pain

poor function

recurrent sepsis

chronic discharging sinus formation

implant loosening

83
Q

a deep infection in a fracture increases the risk of

A

OM and non-union

84
Q

common viurlent organisms which produce an early prosthetic infection include

A

staph aureus

gram negative bacillia eg coliforms

85
Q

organism associated with late onset haematogenous infection of prosthetic joints include

A

staph aureus

beta haemolytic strep

enterobacter

86
Q

for orthopaedic infections the treatment is generally

A

surgical rather than antibiotics

87
Q

why should antibiotics not be given until a surgical decision has been made when treating an orthopaedic infection

A

antibiotics can interfere with the bacteriological tissue cultures and the causative organism may not be identified from surgical debridement

88
Q

initial management of major trauma

A

ABCDE

save life and prevent serious complications ahead of preventing pin and loss of function from fractures or dislocations

89
Q

early death after major trauma can be caused by

A

airway compromise

severe head injury

severe chest injury

interneal organ rupture

fractures associated with major blood loss (pelvis, femur)

90
Q

what is primary bone healing

A

the bone bridges the gap with new bone from osteoblasts

91
Q

when does primary bone healing occur

A

when there is minimal fracture gap

hairline fractures and fractures that are fixed with compression screws and plates

92
Q

what is secondary bone healing

A

the space between the bones is toobig for primary healing so a sort of scaffold is formed while new bone forms around it

93
Q

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
A
94
Q

when is the soft callus normally formed

A

by the 2nd-3rd week

95
Q

how long does the hard callus take to form

A

6-12 weeks

96
Q

what does secondary bone healing require

A

good blood supply for oxygen

nutrients

stem cells

a little movement or stress

97
Q

risk factors for atrophic non-union

A

lack of blood supply

no movement

too big a fracture gap

tissue trapped in the fracture gap

98
Q

what causes hypertrophic non-union

A

excessive movement at the fracture site

99
Q

why does excessive movement at the fracture site cause hypertrophic non-union

A

there is abundant hard callus formation but too much movement doesn’t give the fracture a chance to bridge the gap

100
Q

what are the five basic fracture patterns

A

transverse fracture

oblique fracture

spiral fracture

comminuted fracture

segmental fracture

101
Q

how do transverse fractures occur

A

with pure bending force where the cortex on one side fails in compression and the cortex on the other side in tension

102
Q

complications of transverse fractures

A

may angulate or result in rotational malalignment

103
Q

how do oblique fractures occur

A

with a shearing force eg fall from height, deceleration

104
Q

oblique fracture complications

A

tend to shorten

may angulate

105
Q

how do spiral fractures occur

A

torsional forces (twisting)

106
Q

spiral fracture complications

A

unstable to rotational forces

may angulate

107
Q

what are comminuted fractures

A

fractures with 3 or more fragments

108
Q

how do comminuted fractures occur

A

high energy injury (or poor bone quality)

109
Q

comminuted fracture complications

A

substantial soft tissue swelling

periosteal damage

reduced blood supply to fracture site

very unstable

110
Q

what is a segmental fracture

A

a bone that is fractured in two separate places

111
Q

what is the diaphysis

A

the shaft of the bone

112
Q

intra-articular fractures have a greater risk of

A

stiffness

pain

post traumatic OA

113
Q

what is displacement

A

the direction of translation of the distal fragment

114
Q

100% displacement is referred to as an ________ fracture

A

off-ended

115
Q

what is angulation

A

the direction in which the distal fragment points towards and the degree of this deformity

116
Q

residual displacement or angulation can lead to

A

deformity

loss of function

abnormal pressure on joints leading to post traumatic OA

117
Q

clinical signs of a fracture

A

localised bony tenderness

swelling

deformity

crepitus (bone ends grating with an unstable fracture)

118
Q

what is a tomogram

A

a moving xray

used to take images of complex bones

119
Q

when would a CT be used to diagnose a fracture

A

complex bone (vertebrae, pelvis, calcaneus, scapular glenoid)

determine the degreeof articular damage

help surgical planning for IA fractures

120
Q

when would an MRI by used in investigating a fracture

A

to detect occult fractures if there is clinical suspicion but a normal xray

121
Q

technetium bone scans can be used to detect

A
122
Q

stress fractures

A
123
Q

initial management of a long bone fracture

A

analgesia (IV morphine)

splintage/immobilisation

investigation

124
Q

in what situations should a fracture be reduced before radiographs are taken

A

fracture is obviously grossly displaced

obvious fracture dislocation

risk of skin damage from excessive pressure

125
Q

undisplaced, minimally displaced and minimally angulated fractures which are stable are usaully treated with

A

a period of splintage or immobilisation

126
Q

if a fracture is displaced or angulated it requires

A

reduction under anaesthetic

127
Q

unstable fractures may need to be treated with

A

surgical stabilisation

pins/screws/plates etc

128
Q

what is ORIF

A

open reduction and internal fixation

129
Q

what is the goal of ORIF

A

anatomic reduction and rigid fixation leading to primary bone healing

130
Q

when should ORIF be avoided

A

soft tissue are very swollen

blood supply to fracture site is tenuous

if it may cause extensive blood loss (femoral shaft)

131
Q

what are the potential complications of external fixation

A

pin site infection

loosening

132
Q

how should compartment syndrome be managed

A

fasciotomy

133
Q

early local complications of fractures

A

compartment syndrome

vascular injury with ischaemia

nerve compression injury

skin necrosis

134
Q

early systemic complications of fractures

A

hypovolaemia

fat embolism

shock

ARDS

acute renal failure

SIRS

MODS

135
Q

late local complications of fractures

A

stiffness

loss of function

chronic regional pain syndrome

infection

non-union/mal-union

Vlokmann’s ischaemic contracture

post traumatic OA

DVT

136
Q

late systemic complications of fractures

A

pulmonary embolism

137
Q

what is compartment syndrome

A

swelling inside a fascial compartment

138
Q

compartment syndrome pathogenesis

A

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

139
Q

signs of compartment syndrome

A

increased pain on passive stretching of the involved muscle(s)

severe pain outwith the anticipated severity of the clincial context

140
Q

what is Volkmann’s contracture

A

ischaemic muscle that has been allowed to necrose resulting in fibrotic contracture

141
Q

knee dislocation risks injury to which artery

A

popliteal

142
Q

paediatric supracondylar fracture risks injury of which artery

A

brachial artery

143
Q

shoulder trauma can damage which artery

A

axillary artery

144
Q

what is ‘degloving’

A

avulsion of the skin from its underlying blood vessels

normally as a result of a shearing force injury

145
Q

why do fracture blisters form

A

inflammatory exudates lift the epidermis of the skin (like a burn)

146
Q

signs of fracture healing

A

resolution of pain and function

absence of point tenderness

no local oedema

resolutin of movement at fracture site

147
Q

signs of non-union

A

ongoing pain

ongoing oedema

movement at fracture site

148
Q

what is the slowest healing bone

A

tibia

149
Q

what is delayed union

A

a fracture that hasn’t healed in the expected time

150
Q

fractures that are prone to non-uniondue to poor blood supply

A

scaphoid waist

distal clavicle

subtrochanteric fractures of the femur

151
Q
A
152
Q

should prophylactic anticoagulation (eg LMWH) be given to fracture patients

A

patients at risk of DVT etc

153
Q

which fractures are prone to developing AVN

A

femoral neck

scaphoid

talus

154
Q

treatment of AVN

A

often requires THR (femoral neck) or arthrodesis (scaphoid/talus)

155
Q

what is an open fracture

A

a fracture where the skin has been broken

156
Q

two types of open fracture

A

inside-out: fragment of fractured bone breaks through the skin

outside-in: laceration of skin or penetrating injury

157
Q

main complication of open fractures

A

infection

158
Q

how can infection complicate the healing of a fracture

A

can lead to non-union

159
Q

factors the increase the risk of infection of a fracture

A

higher energy injury

amount of contamination

delay of appropriate treatment

problems with wound closure

160
Q

initial managment of open fracture (A&E)

A

IV broad spectrum antibiotics (fluclox, gent and met)

sterile or antispetic dressing sshould be applied to prevent further contamination before splintage

161
Q

surgical management of open fracture

A

debridement

reduction and fixation

162
Q

why does devitalised tissue need to be removed when managing an open fracture

A

because it is de-vascularised it won’t be reached by antibiotics and may harbour infection

163
Q

main complication of haematoma in open fractures

A

acts as a culture medium and may cause necrosis

164
Q

delayed union is more common in open fractures

true/false

A

true

they are often higher energy

165
Q

why are open fracutres normally treated with internal/external fixation rather than a plaster cast

A

because frequent wound inspecions are required

166
Q

which tissues will not take a skin graft

A

bare tendon

bone

exposed metalwork

fat may not due to poor vascularisation

167
Q

name a group of people that often have a delayed presentation of dislocation

A

alcoholics

168
Q

delayed presentation of dislocation increases the risk of

A

requiring open reduction

recurrent instability

169
Q

name two conditions that result in hypermobility

A

ehlers-danlos

marfan’s

170
Q

injuries associated with dislocations include

A

tendon tears

nerve injury

vascular injury

compartment syndrome

171
Q

rapid resisted contraction of a muscle may result in

A

muscle tear

172
Q

RICE stands for

A

rest

ice

compression

elevation

173
Q

acute onset of a severely painful, hot, swollen and tender joint with severe pain on any movement are the typical presenting features of

A

septic arthritis

174
Q

in most cases of septic arthritis, the invading pathogens spread to the joint via…

A

the blood

from an infection of adjacent tissues

175
Q

septic arthritis is common in adults

true/false

A

false

it is relatively uncommon in adults but should always be excluded with any unexplained acute monoarthritis

176
Q

why is septic arthritis considered an emergency

A

bacterial infection can irreversibly damage hyaline cartilage within days

177
Q

groups most commonly affected by septic arthritis

A

the young

the old

PWIDs

immunocompromised patients

178
Q

the most common pathogen in septic arthritis is adults is

A

staph aureus

179
Q

the most common cause of septic arthirtis is the old, PWIDs and the seriousy ill

A

E coli

180
Q

investigation of septic arthritis

A

joint aspiration to confirm diagnosis and identify causative pathogen

181
Q

managment of septic arthritis

A

surgical washout via open surgery or arthroscopic techniques

IV antibioitics if not surgery (children)

182
Q

carpal tunnel syndrome is caused by compession of the

A

median nerve

183
Q

cubital tunnel syndrome is caused by compression of the

A

ulnar nerve

184
Q

which of the following tendon tears is commonly surgically repaired to optimise function

hip adductor

achilles tendon

patellar tendon

long head of biceps

A

patellar tendon

185
Q

occurs when bone is exposed to a shearing force eg fall from height, deceleraton

A

oblique fracture

186
Q

occur due to torsional forces acting on the bone

A

spiral fracture

187
Q

occur when a pure bending force is applied to the bone

A

transvere fracture

188
Q

what is the chief indication for performing hip and knee joint arthroplasty

improve range of movement

increase strength

improve function

pain

A

pain

189
Q
A
190
Q

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

A

waist of scaphoid

191
Q

which tendon tear is commonly managed conservatively

hip adductor tendon

patellar tendon

long head of biceps

quadriceps tendon

A

long head of biceps

192
Q

poor grip strength post distal radial fracture is asociated with loss of extension/flexion at the wrist joint

A

extension

the wrist needs at least 10 degrees of extension for full grip strength

193
Q

distal radial fractures which result in a volar angulation will cause

A

impairment of grip

194
Q

a glasogw coma score of less than ___ implies loss of airway control

A

8

195
Q

a tibial osteotomy may be considered as an alternative surgical option to joint replacement for knee arthrtitis is the young patient

true/false

A

true

196
Q

what is allodynia and what is it a sign of

A

sensitvity to stimuli not normally painful

chronic regional pain syndrome

cortext (6 decks)

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