Frailty- fractures Flashcards
General approach to interpreting x-rays of large bones 1
- Check patient demographics: name, DOB, hospital number
- Comment on projections (remember 2 views are normally obtained): AP, lateral, oblique, axial
- Comment on technical adequacy: entire area of concern included, exposure (over exposed, under exposed), rotation
- Cortical margins: is there a breach or disruption of the cortex- fracture, periosteal reaction (malignancy, infection, trauma, subperiosteal haematoma)
- Bone surface/contours: irregular, erosive, osteophytes, smooth, osteochondral defect, subchondral cysts
General approach to interpreting x-rays of large bones 2
- Bone density: normal, increased (sclerotic), decreased (osteopenia), lucent- malignancy? Osteoporosis?
- Joint space- narrowed, widened, presence or absence of an effusion
- Alignment- subluxation, dislocation
- Soft tissue- swelling, laceration, presence of gas, debridement, muscle atrophy
- Artefact: foreign body, loose bony fragment, replacement, resurfacing, metalwork
Osteoarthritis classification criteria
- Grade I (doubtful): small osteophyte formation, normal joint space
- Grade II (mild): definite osteophyte formation, normal joint space
- Grade III (moderate): moderate joint space reduction
- Grade IV (severe): joint space greatly reduced, subchondral sclerosis
Shoulder x-ray AP view
Shoulder joint/glenohumeral: Articular surface between humeral head and glenoid should be parallel. Smooth arch from medial aspect of proximal humerus to lateral aspect of the scapula
Acromioclavicular joint: inferior aspect of the distal clavicle and acromion should align.
Shoulder x-ray: axial view
Patient needs to abduct arm, x-ray plate below armpit, x-ray taken from above the shoulder down towards the armpit. The humeral head should sit on the glenoid (like a golf ball sitting on a golf tee). Coracoid and acromion should point anteriorly.
Shoulder x-ray: Y view
The patient extends their upper arm and the x-ray is taken from the medial aspect of the scapula, obliquely, towards the humeral head. The coracoid, scapular spine/acromion and scapular blade form a Y shape and the humeral head should sit directly over the centre of the Y.
Anterior shoulder dislocation
- Humeral head is displaced medially and overlies the glenoid
- The articular surface between the humeral head and the glenoid is interrupted
Posterior shoulder dislocation
Lightbulb sign: fixed internal rotation of the humeral head which takes on a rounded appearance
Hip dislocation
- Posterior hip dislocation: most common- 85%
- Anterior hip dislocation: 10%
- Central hip dislocation: always associated with acetabular fracture
Approach to fracture
- Anatomy: which bone, which part of the bone, which side
- Fracture type: open/closed, transvers, oblique, spiral, comminuted
- Number of fragments
- Displacement: translation, angulation, rotation, shortening and distraction
- Joint involvement: intra or extra articular
- Associated dislocation?
- Neurovascular assessment
Assessment of fracture patient
- History: mechanism of injury, associated injuries, patient demographics, medical history
- Clinical signs: pain/tenderness, swelling, deformity, abnormal movement, crepitus, broken skin
How to manage a patient with a fracture
- IV access
- Analgesia: paracetamol, NSAID’s, Codeine, Tramadol, Morphine
- Bloods: FBC, U&E, group and save, cross match
- Resuscitation: fluids, blood components, major trauma, transfusion pack
How to manage a patient with a fracture: open and closed
- Closed fracture: assess neurovascular status, assess soft tissues, splint, back-slab
- Open fracture: assess neurovascular status, assess soft tissues, photograph open wound, dress open wound, back-slab, tetanus booster, IV antibiotics, emergency
Types of fractures
- Transverse- straight line across
- Linear- straight line up the bone
- Oblique non-displaced: at a diagnonal angle
- Oblique displaced
- Spiral- at a diagonal angle due to twisting of line
- Greenstick- normally occurs in paeds as there bones are more bendy, incomplete fracture where the bone is bent
- Comminuted- lots of crushed bone
How do fractures happen
- Trauma i.e. falls
- Fatigue/stress
- Pathalogical: tumour, bone cysts, metabolic disorders
Treatment of fractures
- Reduce: put it back in line. You should reduce before x-ray except for in the wrist
- Hold (until healed): cast or splint
- Rehabilitate
Risk factors for hip fractures
- Menopause- in the absence of HRT or Ca/ vitamin D supplementation, early menopause has increased risk
- Bone density- nutrition, exercise, race, smoking, number of children
- Pathological- unprovoked by injury
NOF: neck of femur fractures
- The affected leg is shortened, externally rotated and abducted
- Palpation of the hip produces pain
- The patient is unable to perform a straight leg raise
- Pain on gentle internal and external rotation of the affected leg (log roll test)
- Soft tissue symptoms: bruising and swelling in and around the hip area
The intertrochanteric line separates the femoral head and neck from the body
Types of neck of femur fractures
- Subcapital, transcervical and basicervical fractures are intracapsular hip injuries
- Intertrochanteric and subtrochanteric fractures don’t involve the neck of femur
NOF fracture: shentons line
- Shenton’s line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus
- Loss of contour of Shenton’s Line is a sign of a fractured neck of Femur
- Fractures of the femoral neck don’t always cause loss of shentons line
Treatment of intracapsular fractures
- Fluid resuscitation
- Analgesia
- Care of pressure area
- Fixation of fracture <24hrs: blood supply to the femoral head is disrupted, Hemiarthroplasty/ total hip replacement
- Early mobilisation
Difference between Hemiarthroplasty and total hip replacement
Hemiarthroplasty: replaces the femoral head and neck
Total hip replacement: replaces the acetabulum and hip bone
Treatment of extra-capsular fractures
- Fluid resuscitation
- Analgesia
- Care of pressure area
- Fixation of fracture <24hrs: blood supply to the femoral head is preserved, dynamic hip screw
- Early mobilisation
Colles and Smith fracture
Colles- dinner fork deformity, fracture of the distal radius with dorsal angulation and impaction of the fracture fragment. Occurs in FOOSH (outward)
Smiths- distal radius fracture with volar angulation of the distal fracture fragment. Due to falling on a flexed hand (inwards).
Treatment of wrist fracture
- Analgesia
- Reduction
- Immobilisation
- Stable/extra-articular: cast
- Unstable/intra-articular: open reduction internal fixation (ORIF)
- Mobilisation
Early complications of fractures
- Bleeding: internal and external
- Injury to nerves, vessels, internal organs
- Compartment syndrome
- Infection
- Fracture blisters
- Pressure sores
Late complications of fractures
- Infection (osteomyelitis)
- Malunion/ non-union
- Growth disturbance
- Joint stiffness
- Complex regional pain syndrome (CRPS)
- Avascular necrosis
- Myositis ossificans
Compartment syndrome
- Emergency
- Pain-unremitting
- Early sign: excruciating pain on passive stretching of the muscle compartment
- Late sign: ischaemia
- Immediate surgical decompression: fasciotomy
- The pressure within the compartment of a leg increases restricting the blood flow to the area and potentially damaging the muscles and nearby nerves
Hip fracture management
- Garden stage I and II: stable fractures and can be treated with internal fixation (head-preservation)
- Garden stage III and IV: unstable fractures and hence treated with arthroplasty (either hemi- or toal arthroplasty)
Assessing geriatric frailty
- Linda Fried/Johns Hopkins Frailty criteria: five domains; unintentional weight loss, exhaustion, muscle weakness, slowness while walking and low levels of activity
- Rockwood frailty index: number of health deficits
- Four domains of frailty
- SHARE frailty index: five domains; fatigue, loss of appetite, grip strength, functional difficulties and physical activity
Delirium detection
CAM (confusion assessment method)
4AT
4 domains - alertness, AMT4, attention, acute change
Types of cutaneous warts
Veruca vulgaris = HPV 2 & 4
Cauliflower-like raised surface. Common in children & adolescents
Veruca plantaris = HPV 1
Soles of feet. Pain when walking?
Veruca plana = HPV 3, 20, 28
Flat warts on arms, face, forehead. Children and adolescents
Cutaneous warts treatment
Topical salicylic acid, fluorouracil 5%
May resolve spontaneously
Cryotherapy (liquid nitrogen)
You should suspect arrhythmias is:
1) Patients with syncope if: there is no warning, it occurs when lying or sitting, a cardiac history or abnormal ECG
2) Patients with falls: where there is significant injury, a cardiac history or abnormal ECG
Investigations for arrhythmias in falls and blackouts
1) A standard ECG
2) 24 hour heart rate monitor
3) Devices for monitoring over 1-4 weeks
4) An implantale device i.e. Reveal
Arrhythmias which suggest falls or syncope
1) Bradycarrdia <60bpm
2) Atrial fibrilation: absent P waves and irregular baseline
3) 2nd degree block (Mobitz II): alternate (2:1) p waves are conducted to the QRS, patient may need a pacemaker
4) Sinus pause: >2 seconds, would need a pacemaker
5) Ventricular tachycardia: regular broad complex (QRS >3 small squares) tachycardia at 150bpm
Aortic stenosis
Ejection systolic
Loudest in 2nd ICS R sternal edge
Radiates to carotids
Aortic regurgitation
Early diastolic murmur
Loudest in 4th ICS lower sternal edge with patient sat forwards in held expiration
Mitral stenosis
Mid diastolic murmur
Loudest in 5th ICS MCL
Occasionally with tapping apex beat
Mitral regurgitation
Pansystolic murmur
Loudest in 5th ICS MCL
Radiates to axilla
Pulmonary stenosis
Soft ejection systolic murmur
Loudest in 2nd ICS L sternal edge
Soft S2
Pulmonary regurgitation
Early diastolic murmur
Loudest in 2nd ICS L sternal edge
Commonly with right heart failure
Tricuspid stenosis
Mid diastolic murmur
Loudest in 4th ICS R sternal edge
JVD
Initial management for an NSTEMI
Aspirin PO 300mg STAT
Ticagrelor PO 180mg STAT
Fondaparinux SC 2.5mg STAT
Oramorph 5mg STAT
Oramorph – 5-10mg titrated to pain PRN, Max 20mg/ day, min 2hrly, for pain
Cyclizine 50mg PRN Max TDS, min 6hrly, for nausea/ vomiting
(could prescribe regular doses of Aspirin 75mg OD, Ticagrelor 90mg BD +/- bisoprolol, Ramipril, atorvastatin if you are keen and love secondary prevention)
