General Orthopedic

Question 1

What are the general principles of fracture management?

Answer 1

‘Reduce – Hold – Rehabilitate’

Resuscitate

Question 2

What does reduction entail? How is this done?

Answer 2

• Tamponade of bleeding at the fracture site
• Reduction in the traction on the surrounding soft tissues, in turn reducing swelling
• Reduction in the traction on the traversing nerves, in turn reducing the risk of neuropraxia
• Reduction of pressures on traversing blood vessels, restoring any affected blood supply
• How? requires analgesia - entanox

Question 3

What does ‘hold’ entail?

Answer 3

• Immobilising a fracture
• Consider whether traction is needed
• How? Simple splints or plaster casts. first 2-weeks, plasters are not circumferential
• Prevent compartment syndrome: They must have an area which is only covered by the overlying dressing, to allow the fracture to swell
• ? Axial instability: the plaster should cross both the joint above and below
• Clinical requirements:
  
  • Weight bearing limb
  • Thromboprophylaxis

Question 4

What does rehabilitate involve?

Answer 4

• Intensive period of physiotherapy following fracture management
• Remember that many fractures occur in frailty and render the patient with an inability to weight bear or use an arm, having profound effects on their ability to cope at hom

Question 5

What are the features of OA?

Answer 5

• Loss of joint space
• Remodelling of bone
• Subchondral sclerosis
• Bone cysts
• Osteophytes

Question 6

How is OA treated?

Answer 6

• Conservative:
  
  • ​Joint protection, emphasising the importance of strengthening and exercise, weight loss.
  • Local heat or ice packs, joint supports, and physiotherapy
• Medical:
  
  • Simple analgesics and topical NSAIDs
  • Intra-articular steroid injections + mixed with local anaesthetic: ‘steroid flare’ where pt sx can worsen for a few days after
• Surgical
  
  • Osteotomy
  • Arthrodesis (joint fusion)
  • Arthroplasty

Question 7

How are open fractures assessed and managed?

Answer 7

Assessment

• ABCDE + Initial resuscitation
• Blood: FBC, UE, clotting screen, G+S
• Check neurovascular status
• Plain film radiograph
• Need for plastic surgery input identified early

Management

• Urgent realignment and splinting
• Broad-spectrum antibiotic cover: co-amoxiclav
• Tetanus vaccination: if the patient is not fully up-to-date with their vaccination
• Photograph the wound
• Remove any gross debris + saline wash

Question 8

What is compartment syndrome?

Answer 8

• Typically occurs following high-energy trauma, crush injuries, or fractures that cause vascular injury
• Fascial compartments are closed and cannot be distended; so any fluid that is deposited therein will cause an increase in the intra-compartmental pressure.
• As pressure increase, the veins will be compressed.
• This increases the hydrostatic pressure within them, causing fluid to move down its gradient and out of the veins in to the compartment.
• This increases the intra-compartmental pressure further.
• Traversing nerves are compressed. This causes a sensory +/- motor deficit in the distal distribution.
• Paraesthesia
• Lastly, as the intra-compartmental pressure reaches the diastolic blood pressure, the arterial inflow will be compromised, leading to ischaemia (a cool, pale, pulseless and paralysed distal limb). This is a late sign of missed compartment syndrome.

Question 9

How is compartment syndrome investigated and managed?

Answer 9

• Investigations: intra-compartmental pressure monitor + creatine kinase (CK)
• Management:
  
  • Conservative: Keep the limb at a neutral level, high flow oxygen, IV fluid resuscitation (BP control) , Remove all dressings / splints / casts
  • Analgesia: IV morphine
• Surgery: urgent fasciotomies; skin incisions are left open and a re-look is planned for 24-48 hours
• Monitor renal function: rhabdomyolysis

Question 10

How is osteomyelitis diagnosed (gold standard test)?

Answer 10

Culture from bone biopsy at debridement + MRI imaging

Question 11

What RFs pre dispose someone to Septic Arthritis?

Answer 11

• Age >80yrs
• Any pre-existing joint disease (e.g. rheumatoid arthritis)
• Diabetes mellitus or immunosuppression
• Chronic renal failure
• Hip or knee joint prosthesis
• Intravenous drug use

Question 12

How is septic arthritis investigated?

Answer 12

• Bloods: FBC, UE, CRP, ESR, urate
• Joint aspiration before Abx
• Imaging: Radiograph, CT or MRI (if further infection suspected)

Question 13

How is septic arthritis managed?

Answer 13

• Sepsis 6
• Long term Abx (>6 weeks + IVI for 2 weeks)
  
  • Flucloxacillin 1g/6h IV - Staph Aureus
  • Vancomycin 1g/12h IV - MRSA
  • Cefotaxime 1g/8h IV - gonococcal/ gram-ve
  • IV Abx 2 weeks, 2-4 weeks PO
• Irrigation and debridemenent of infected areas

Question 14

What pre disposes you more to bone cancer?

Answer 14

• Genetic association:
  
  • ​RB1(familial retinoblastoma) and p53 (Li Fraumeni syndrome)- osteosarcomas
  • Mutations to TSC1 andTSC2 mutation (tuberous sclerosis)
• Previous exposure to radiation or alkylating agents in chemotherapy
• Benign bone conditions, such as Paget’s disease and fibrous dysplasia (osteosarcoma)
• Metastatic spread: renal, thyroid, lung, prostate

Question 15

Which cancers are most likely to metatasise to bone?

Answer 15

renal, thyroid, lung, prostate

Question 16

What is a ‘red flag’ symptom of bone cancer?

Answer 16

Pain. This is typically not associated with movement and is worse at night (often deemed a

Question 17

What staging system is used for bone cancer?

Answer 17

Enneking staging system