Ortho basics Flashcards
Describe the structure of bone
- Cortical bone on outside: hard, mechanical function
- Cancellous bone inside: porous, holds marrow
Diaphysis (shaft)
Epiphysis (head)
Metaphysis (between growth plate + diaphysis)
Describe the 3 main types of fracture (in terms of aetiology) and give examples
- Traumatic eg. FOOSH, high speed RTA
- Stress eg. sports/running
- Pathological eg. osteoporosis compression #, tumours
Describe the imaging needing in suspected fracture
- Plain radiographs
- 2 views: AP and lateral +/- extras eg Mortise
- Also xray of joints above + below injury
Describe the different patterns of fractures
- Transverse
- Oblique
- Spiral
- Compression
- Greenstick
- Avulsion
- Comminuted
Describe how to report a fracture xray
- Patient details
- Fracture pattern: simple/comminuted, transverse, oblique, spiral
- Anatomical location: bone + part of bone
- Intra or extra articular
- Deformity: translation, angulation (varus, valgus)
- Soft tissues: open/closed, NV status
- Specific type eg. Colles, Smiths
Describe the stages of fracture healing
- Reactive phase: up to 48 hours. Haematoma formation -> inflammatory cell recruitment
- Reparative phase: 2 days - 2 weeks. Callus formation (proliferation of blasts) -> consolidation of woven bone
- Remodelling phase: 1 wk - 7 years. Remodelling of lamellar bone to cope w forces.
Describe fracture healing time
3 weeks: child, upper limb, metaphyseal, closed Prolonging factors (double time): adult, lower limb, diaphyseal, open
Describe the basics of fracture management
4 Rs: resus, reduction, restriction, rehab
- Resus: follow ATLS, assess for injuries + neurovascular status, stabilise -> imaging
- Reduction: for displaced fractures. Manipulation (closed reduction), traction, open reduction
- Restriction: eg non-rigid (slings), POP, ext/int fixation
- Rehab: physio, OT
Describe the specific management for open fractures
6 As:
- Analgesia: morphine + metoclopramide
- Assess: NV status, injuries
- Antiseptic: irrigation, cover with betadine-soaked dressing
- Alignment: align + splint
- Anti-tetanus
- Antibiotics: fluclox + penpen OR co-amox
Describe the complications of fractures
General: Trauma complications: -Pain, bleeding, shock Complications of surgery + anaesthesia Post-op complications: DVT, pneumonia, PE, infection
Specific:
Immediate: neurovascular damage
Early: compartment syn, infection
Late: problems with union, AVN, growth disturbance, OA
Describe compartment syndrome
A condition that occurs following fracture/trauma to a limb, in which pressure rises in a single compartment. Without treatment, this can compromise blood flow to the compartment and cause muscle death (when compartment P > capillary P)
Describe the presentation of compartment syndrome
PAIN
+/- reduced/absent pulses
-Warm, red, swollen limb
Describe the management of compartment syndrome
Conservative:
- Elevation
- Remove splint/bandages/POP
Medical:
-Analgesia
Surgical:
-Fasciotomy
What are some problems with fracture union?
Delayed union: ^ time to unite
Non-union: failure to unite
-Can be hypertrophic or atrophic
Malunion
What are some causes of delayed/non-union?
5 Is:
- Ischaemia
- Infection
- Interfragmentary strain
- Interposition of tissue between fragments
- Intercurrent disease eg. malnutrition
Which bones are most susceptible to avascular necrosis?
Femoral head
Scaphoid
Talus
Describe the presentation of osteoarthritis
Painful joints, typically large joints in lower limbs (knee, hip) and hands (DIPs, PIPs, 1st CMC)
- Stiffness + pain worse on exercise/at end of day
- Relieved by rest
- Decreased range of movement
- Deformities
Describe the signs of osteoarthritis on radiograph
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Describe the important features to ask on history in OA
- Pain: when? Rest, night, exertion
- Stiffness
- Any sensation of locking, giving way
- Disability: stairs, walking distance
- Treatments
- Other joints affected
-Previous Hx of trauma, infection
Describe the basic management of OA
Conservative:
-Physio, exercise modification
Medical:
- Analgesia: topical/systemic NSAIDs
- Steroid injections
Surgical:
-Arthroplasty: TKR, PKR
Describe the difference between total and partial knee replacement
Partial: replacement of one compartment (knee has 3). Suitable if only 1 has disease but this is small number of people. Less invasive, better recovery time
Total: replacement of all compartments. More frequently done. More invasive, longer recovery
Describe the presentation of septic arthritis
Acute, painful joint. Often knee/hip
- Hot, red, swollen, tender, decreased ROM, holding joint in position + unable to weight bear
- Fever, systemically unwell
Which pathogens commonly cause septic arthritis?
Staph aureus + Streptococci almost always
+ Neisseria gonorrhae, E coli, Salmonella, TB
Name some risk factors for septic arthritis
Problems with the joint:
- Artificial joint/previous joint replacement
- Pre-existing joint disease: OA, RA
- Steroid injections
Patient characteristics:
- Immunosuppression: HIV, DM, steroids
- IVDU
Describe the investigations for septic arthritis
Any swollen acutely painful joint should be considered SA until proven otherwise:
- After history and examination
- Bloods: FBC, CRP, U+Es, LFTs, VBG, culture
- Joint aspiration for MC+S
- Imaging: Xray
Describe the management of septic arthritis
If prosthetic -> refer to ortho straight
If septic: A to E approach
Otherwise:
-History, examination, investigations (joint aspiration is also therapeutic- aspirate til dry)
-Analgesia: paracetamol, NSAIDs
-IV fluids
-IV antibiotics (cont 2 weeks -> PO for 4 weeks)
Surgical if not responsive: washout, debridement
Describe the presentation of osteomyelitis
May be acute or chronic presentation
Pain, swelling, warm, tender bone (sometimes no localising signs)
Fever + systemically unwell
Describe the risk factors for osteomyelitis
Abnormal anatomy:
- Previous surgeries
- Penetrating injury
Abnormal host immune system:
- Immunosuppresion: HIV, DM, alcohol, elderly, IVDU
- Sickle cell
What are the common causative organisms in osteomyelitis?
Staph aureus + Streptococci most common
+ E coli, Klebsiella, etc
Describe the investigations for osteomyelitis
- After history and examination
- Wound swab (eg infected diabetic ulcer)
- Bloods: FBC, CRP, U+Es, VBG, culture
- Imaging: Xray, MRI
- Bone biopsy rarely done
Describe the management of osteomyelitis
Acute osteomyelitis:
- Analgesia, IV fluids
- IV ABx -> PO (total 6 weeks)
- Surgical opinion re: debridement
Chronic:
- ABx will not cure chronic once bone has become necrotic
- Surgical management is necessary: debridement + excision, fixation etc
