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CSI > falls > Flashcards

falls Flashcards

1
Q

what is the proximal femur characterised by?

A

head and neck and 2 large projections referred to as the greater and lesser trochanters residing on the superior shaft

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2
Q

what does the shaft of the femur bear?

A

the greater and lesser trochanter, providing attachment for muscle that articulate the hip

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3
Q

what is the inter-trochanteric line?

A

resides on the anterior surface along the junction of the femoral neck and shaft traversing between the two trochanters

it demarcates the inferior attachments of the hip capsule

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4
Q

what does the hip capsule contain?

A

the acetabular notch which is spanned by the transverse acetabular ligament, the fossa contains fibro-fatty tissue, thus the articular surface is a horseshoe shape to minimise contact stress with the acetabulum

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5
Q

what is the hip capsule deepened by?

A

rim of cartilage known as the acetabular labrum

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6
Q

what are the head of the femur and acetabular notch connected by?

A

ligamentum teres from the transverse acetabular ligament and the fovea of the femoral head

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7
Q

what does the hip capsule contain that perfuses through the femoral head?

A

retinacular vessels

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8
Q

what are retinacular vessels branches of?

A

medial and lateral circumflex femoral arteries that extend to the head of the femur within the retinacular folds of the synovial membrane, penetrating the capsule of the hip joint at the intertrochanteric line (intracapsular)

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9
Q

what are retinacular vessels?

A

branches of the medial and lateral circumflex femoral arteries that extend to the head of the femur within the retinacular folds of the synovial membrane, penetrating the capsule of the hip joint at the intertrochanteric line (Intracapsular).

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10
Q

what can intracapsular fractures lead to?

A

intracapsular fractures lead to a significant disruption to the vasculature of the femoral head and neck leading to avascular necrosis.

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11
Q

what do femoral neck fracture interrupt blood supply to?

A

femoral head that is predominantly supplied by the extracapsular arterial ring formed by the branches of the medial and lateral circumflex femoral arteries around the base of the femoral neck.

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12
Q

what do intrascapular features disrupt?

A

penetrating retinacular arteries that supply the femoral head, ultimately manifesting as necrosis.

the foveal artery via the ligamentum teres contributes to supplying the femoral head.

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13
Q

what are the types of femoral fractures?

A
  • Intracapsular - fractures Above the inter-trochanteric line
  • Extracapsular – fractures Below the intertrochanteric line
  • Subcapital - fracture line that passes across the femoral head-neck junction → Highest risk of developing necrosis of the femoral head. Most common type of intrascapular fracture.
  • Transcervical - fracture line passes through the mid-portion of the femoral neck.
  • Basicervical - fracture line passes across the base of neck → Lowest risk of avascular femoral head necrosis.
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14
Q

What type of intracapsular fracture has greater risks of avascular necrosis?

A

Subcapital fracture along the head-neck junction (this type is also the most common).

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15
Q

describe Garden Classification Stage I

A

undisplaced, incomplete fracture, valgus impacted

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16
Q

describe Garden Classification Stage II

A

undisplaced, complete fracture, no disturbance of the medial traveculae

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17
Q

describe Garden Classification Stage III

A

partially displaced, complete fracture, femoral head tilts into varus position causing its medial trabeculae to be out of line with the pelvic trabeculae

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18
Q

describe Garden Classification Stage IV

A

completely displaced, complete fracture, femoral head aligned in the acetabulum; medial trabeculae are in line with the pelvic trabeculae

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19
Q

which type is there a minimal displacement in?

A

type I and II → therefore there is a lessened risk to the disruption of femoral head blood supply.

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20
Q

which type is there a significant disruption of femoral head blood supply?

A

Type III and IV fracture displacement cause significant disruption to the femoral retinacular supply.

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21
Q

what are neurological aetiologies of fragility fractures and falls?

A
  • confusion
  • CI
  • depression
  • poor vision, balance and co-ordination
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22
Q

what are neuromuscular aetiologies of fragility fractures and falls?

A
  • muscle weakness
  • gait disorder (e.g. parkinson’s hemiplegia, cerebellar disease, antalgic, normal pressure, hydrocephalus, proximal myopathy)
  • peripheral neuropathy including sensory ataxia, foot drop
  • arthritis and joint disorders
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23
Q

what are cardiovascular aetiologies of fragility fractures and falls?

A
  • syncope
  • arrythmias
  • orthostatic hypotension
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24
Q

what are environmental aetiologies of fragility fractures and falls?

A
  • home hazards
  • inappropriate footwear
  • insufficient home modifications
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25
Q

what are chemical aetiologies of fragility fractures and falls?

A
  • polypharmacy (5+)
  • particular drug culprits
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26
Q

what is a fragility fracture?

A

fracture that is attributed to low energy mechanical forces and trauma. These forces have been quantified to be equivalent to a fall from a standing height or less.

27
Q

define osteoporosis

A

reduction in BMD and bone mass, resulting in bones that are liable to fracture.

infection, injury and synovitis can cause localised osteoporosis

generalised osteoporosis is common in the elderly and typically proceeds menopause

28
Q

how can you diagnose fragility fractures?

A

quantitative digital radiography and DEXA scans

29
Q

explain the pathogenesis of osteoporosis

A

there is bone remodelling imbalance

bone resorption > bone formation

RANKL and RANK are mediators of osteoclast activity:

  1. RANKL are produced by activated osteoblastic cells
  2. binds to cognate RANK receptor to activate intracellular pathway (NF kappa beta) - results in induction of osteoclastogenic genes
  3. activation of osteoclasts
  4. osteoclasts resorb bone
30
Q

what is osteoclast activity regulated by?

A

PTH, calcitonin and calctriol: all dependent on serum calcium concentrations

31
Q

what are the three risk factors of osteoporosis?

A
  1. low calcium
  2. low oestrogen
  3. drugs including glucocorticoids (decrease calcium absorption, heparin and L-thyroxine)
32
Q

what are fragility fracture common sites?

A

Distal radius (Colle’s fractures are common in patients with osteoporosis)

Proximal femur (Subcapital fracture on left femoral head) - Extends from junction of head-neck; most common intracapsular fracture.

Vertebral (Osteoporotic fractures on 8th and 10th thoracic vertebrae). Sagittal T2 spinal MRI and fish vertebrae at T12.

33
Q

list some pathophysiological signs of fracture in bone

A
  • fewer trabeculae within cancellous bone
  • osteons in cortical bone undergo thinning
  • widened haversian canals
34
Q

what are DEXA scans?

A

dual energy X-ray absorptiometry is a technique which enables the direct determination of bone mass at these skeletal locations.

Transmission of two different energy beams through the body. Dual energy photon absorptiometry uses a cathode ray X-ray tube to produce X-ray beams.

  • Detectors measure the resultant incident intensity of the X-ray beam, calculating the difference between the two beams
  • Based on the variation in the difference, the bone density can be detected.
35
Q

Outline how DEXA can be used in the diagnosis of osteoporosis.

A

Diagnosis of osteoporosis is based on measurement of the BMD using DEXA

  • BMD results are reported as a comparison matched healthy adult→T-score.
  • These scores are expressed in standard deviations.

T-score parameters

  • Osteoporosis: T score ≥2.5
  • Osteopenia: T score -1.0 ≤ 𝑻 < -2.5
36
Q

Who is T-score criteria used for?

A

T-score criteria is used for post- menopausal women and men aged 50+ years.

37
Q

What are the functions of oestrogen?

A

Oestrogen prevents bone loss through the inhibition of osteoclastic bone resorption.

Oestrogen indirectly causes increased production of TGF-B that enhances osteoclast apoptosis.

In the absence of oestrogen, T-cells promote osteoclast recruitment and prolonged survival of IL-1 and IL-6. IL-6 promotes osteoclast recruitment.

38
Q

Relationship of osteoporotic and hip fractures to age and gender?

A

The incidences of osteoporotic fractures in both genders increase with age.

  • This upward trajectory is more prominent in females, rising earlier in post-menopausal women.
  • Hip fractures proceed later and increase exponentially beyond 65 years in females.
39
Q

Explain the Mechanostat theory.

A
  • Explain the Mechanostat theory.A regulatory mechanism in bone that senses changes in mechanical demands exerted on it, and thus stimulating adjustments in its architecture to
    accommodate the habitual load.
    • Postulated that below a certain threshold of mechanical use, bone is resorbed (Osteoclast activity).
    • Above threshold → Bone formation occurs (Osteoblast activity)
40
Q

What is Wolff’s Law?

A

States that bone grows and remodels in response to forces that are exerted onto it. Placing specific stress in specific directions stimulate osteocyte activity. Osteocyte apoptosis occurs during disuse.

41
Q

What is sarcopenia?

A

Sarcopenia is a syndrome characterised by progressive and generalised loss of skeletal muscle, mass and strength.

  • Correlation with physical disability, low BMD and falls.
  • There is a loss in lean body mass (Muscle), however fat mass is preserved, leading to sarcopenic obesity.
42
Q

How are the majority of hip fractures treated?

A

The majority of hip fractures are treated surgically unless there are significant co-morbidities restricting surgical interventions.

43
Q

What are the NICE guidelines for the management of hip fractures?

A

Recommend surgery to be performed on the day of, or the day after admission.

  • Enable patients to fully weight bear (without restriction) in the immediate postoperative period.
  • Obtain orthopaedic opinion immediately
  • Conduct pre-operative investigations and assessments
  • Assess mental capacity – Delirium.
44
Q

What does supportive management of a hip fracture include?

A
  • Analgesia: Paracetamol, codeine
  • Fluid management
  • Fracture stabilisation
  • Traction
  • Bed rest
  • Restricted mobilisation
45
Q

What investigative measures can be done for hip fractures?

A
  • Plain radiographs Identify, site, type and displacement of fracture.
  • FBC- To identify whether appropriate for perfusion during surgery.
  • Urea, electrolytes & glucose
  • ECG – To identify any arrythmias or myocardial infarction.
  • Renal function
46
Q

What are the disadvantages of doing surgery to treat a hip fracture?

A
  • Thromboembolism
  • UTI
  • Infection – osteomyelitis
  • Pneumonia
  • Pressure sores
  • Muscular atrophy
47
Q

Extracapsular fixation methods

A

Dynamic Hip Screw (DHS) – DHS allows fracture to ‘slide’, promoting bone healing, treat for stable intertrochanteric hip
fracture.

Intra-medullary nail to treat for subtrochanteric fracture.

48
Q

Intracapsular (Displaced) Gardens III/IV fixation methods

A

Total hip replacement – Both the acetabulum and head of femur is replaced.

Hemi-arthroplasty – Head of femur is only replaced.

N.B: Hemi-arthroplasty in patients with existing comorbidity because they aren’t adequately fit for THR

49
Q

Intracapsular (Undisplaced) Gardens I/II fixation methods

A

Cannulated hip screws (2 or 3)

Dynamic Hip Screw

50
Q

What does Zoledronic acid do?

A

Inhibition of bone resorption through inhibiting osteoclastic activity and induces osteoclast apoptosis.

51
Q

What does Raloxifene do?

A

Selective oestrogen receptor modulator and exhibits agonist characteristics to the oestrogen location.

52
Q

What does Teriparatide do?

A

Treatment is prescribed in advanced circumstance of osteoporosis, a portion a PTH, amino acid sequence 1-34 PTH mediates the osteoblast during intermittent injections.

53
Q

Outline bisphosphonates treatment

A

Alendronate inhibits osteoclast-mediated bone resorption. Attach to hydroxyapatite binding sites on superficial bone surfaces undergoing active resorption.

Bisphosphonate impairs the ability of the osteoclasts forming ruffled border, to adhere to the bony surface and produce proteins necessary for continued bone resorption.

Reduced osteoclast activity by decreasing osteoclast progenitor development, and recruitment, promotes osteoclast apoptosis.

54
Q

What is denosumab?

A

mABs that reduce osteoclast activity, and thus bone resorption. Administered to postmenopausal women as secondary prevention of osteoporosis in individuals with bisphosphonate intolerance.

55
Q

What is used to treat osteoporosis in bisphosphonate intolerant post-menopausal women?

A

Denosumab

56
Q

When is Strontium Ranelate suggested?

A

In postmenopausal women and men at a high risk of osteoporosis, SR is suggested.
There is an associated risk of MI – therefore is not administered to patients with a past medical history of CHD.

57
Q

Imaging used for osteoporosis

A
  • Plain films: X-ray of pelvis, hip, femur and knee: The entire length of the femur needs to be visualised in order to establish an entire radiographical picture to lead a suitable intervention.
  • MRI/CT: If plain films are inconclusive, conduct alternative forms of imaging to exclude occult fractures.
  • Chest X-ray: Required pre-operatively.
  • Echocardiogram: Conducted if a new murmur is auscultated in in patients with ECG abnormalities.
58
Q

What is Shenton’s line?

A

Imaginary curved line along the inferior border of the superior ramus, along the inferomedial border of the proximal femur.

It is continuous and smooth normally.

59
Q

MDT for fragility fracture management (4)

A
  1. Geriatrician
  2. PT: promotes adequate amount of movement for patient as part of strength regain.
    - Provide exercise and stretch programmes that assist with healing.
    - Muscle-strengthening exercises and balance training.
    - OTs also play a role in rehabilitation during admission and following discharge.
  3. GP: Identify FF and managing secondary prevention.

Help identify patients who are at risk, and thus implement primary preventative measures.

  1. Liaison psychiatry team: Play a role in supporting and managing patients with dementia.

Manage patients with visual and hearing impairments.

60
Q

What is delirium?

A

Acute, fluctuating change in mental status, with inattention, disorganised thinking and altered levels of consciousness.

Manifested by delusions, disorientations, hallucinations or extreme excitement.

Symptoms are infrequent - episodes vary in length.

61
Q

List some symptoms of delirium

A
  • Symptomatic patterns are sudden, worsening at specific times during the day (evening or at night).
  • Changes: State of confusion, changes in alertness (agitated), lack of concentration and easily distracted.
  • Disorientation
  • Rambling speech
  • Sleep apnoea
  • Prone to mood swings
  • Hallucinations
  • Paranoid beliefs - Delusions
62
Q

Difference between hyperactive and hypoactive delirium.

A

Hypoactive delirium: Abnormally withdrawn and sleepy

Hyperactive delirium: Abnormally alert, restless, agitated and aggressive

63
Q

Causes of delirium

A
  • Infection
  • Constipation
  • Pain
  • Analgesia
  • Polypharmacy
  • Changed environment & unfamiliarity with medical staff
  • Dehydration
  • Postoperative state
  • Visual and hearing impairments
  • Recent bereavement
64
Q

Treatment and support for patients with delirium

A

Clinicians review patient’s medication and prevent administration of drugs associated with causing delirium.

Ensure that the patient is: Free from pain, hydrated, nourished and oxygenated.

Methods:

  • Orientate Patients - 24 hr clock + calendar
  • Hearing aid and glasses
  • Avoid noise at night
  • Bring personal items, cooperate with family and friends.

CSI (9 decks)

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