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phase iii orthopaedics > ortho eopt revision > Flashcards

ortho eopt revision Flashcards

1
Q

define open fracture

A

fracture or its hematoma that communicates with the external environment

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2
Q

classification for open fractures

A

gustilo anderson classification

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3
Q

what is gustilo I

A 
size: wound < 1 cm
minimal ST damage
mild contaimination 
low impact 
risk of amputation: 5%
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4
Q

what is gustilo II

A 
size: wound 1-10cm
moderate ST injury, no flap or avulsion 
moderate contamination
moderate commintion 
risk of amputation: 10%
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5
Q

what is gustilo III

A

size; wound > 10cm
extensive ST injury
significant contamination
high impact

IIIA:
adequate ST coverage of bone
risk of amputation: 20%

IIIB:
inadequate ST coverage
risk of amputation: 30%

IIIC:
arterial injury (regardless of wound size)
prophylactic faciotomy
risk of amputation: >40%

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6
Q

management of open fracture

A

1) primary survey (ABCDE, remove gross debris, tro open fracture, escalate to consultant)
2) check neurovascular status + apply direct pressure on bleeding wound
3) early management (analgesia according to WHO pain ladder, splint fracture)
4) AMPLE + XR + photograph wound
5) prepare for EOT (antibx = 1st gen cephalosporin cephalaxin +/- gentamycin for GIII, tetanus, nbm)
6) debridement + wound culture
7) repair vascular injuries + amputate crush injuries
8) remove comminuted fragments
9) dilute bacterial load with 10L saline
10) reduce, maintain & stabilise
11) 48h later: relook operation (repeat I&D? wound cover)
12) 4-6 weeks: bone graft

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7
Q

bone complications of open fractures

A

1) OM
2) arthritis
3) malunion
4) delayed union
5) non union: SPLINTS
6) AVN

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8
Q

causes of nonunion

A

SPLINTS

1) soft tissue interposition
2) position of reduction
3) location
4) infection
5) nutrition
6) tumor
7) severity of injury

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9
Q

regional complications of open fractures

A

1) neurovascular injury
2) ST blisters/fracture blisters (haemorrhagic/non)
3) complex regional pain syndrome
4) heterotopic ossification
5) joint stiffness
6) compartment syndrome (after wound closure)
7) surgical site infection

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10
Q

complications of compartment syndrome

A

1) rhabdomyolysis
2) volksmann ischaemic contracture
3) permanent functional impairment

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11
Q

systemic complications of open fracture

A

1) hypovolemic shock
2) fat embolisation
3) DVT/PE
4) MODS
5) ARDS

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12
Q

position of fragments in femoral shaft fracture of proximal 1/3 or midshaft

A

proximal: flexed, abducted, externally rotated (iliopsoas @ lesser trochanter, gluteus medius/minimus @ greater troch)
distal: adducted

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13
Q

position of fragmenst in distal 1/3 femoral shaft fracture

A

proximal: adducted
distal: flexed (gastroc)

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14
Q

management of femoral shaft fracture in infant

A

1-2 weeks: gallow’s traction

3-4 weeks: hip spica

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15
Q

management of femoral shaft fracture in child

A

3-4 weeks: traction
- child < 12kg : gallow’s traction
- older children: thomas’s splint + pearson knee attachment
6 weeks: hip spica

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16
Q

management of femoral shaft fracture in adolescent

A

traction + spica followed by ORIF + plate/screws (if reduction unsatisfactory)

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17
Q

management of femoral shaft fracture in adults

A

1) thomas splint at scene
2) ABCDEs of trauma
3) analgesia
4) manipulation & reduction with conscious sedation
5) hold with traction with thomas’ splint
6) intramedullary nail within 24h (ext fixation if open fracture)
7) early mobilisation

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18
Q

general complications of femoral shaft fracture

A

1) haemorrhage
2) shock
3) fat embolism
4) ARDS
5) MODS
6) DIVC

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19
Q

early complications of femoral shaft fracture

A

1) vascular injury: femoral artery

2) neurological injury: sciatic nerve

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20
Q

late complications of femoral shaft fractures

A

1) thromboembolism
2) fat embolism
3) infection
4) delayed union/non-union
5) malunion
6) joint stiffness (joint injury or ST adhesion)

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21
Q

types of proximal femur fractures

A

1) neck of femur
2) intertrochanteric
3) subtrochanteric

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22
Q

types of neck of femur fractures

A

1) subcapital
2) transcervical
3) basicervical

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23
Q

risk factors for proximal femur fractures

A

1) non modifiable
- old age
- F
- early menopause
- nulliparity
- family history or personal history of fractures

2) modifiable
- factors increasing risk of falls
- factors reducing bone strength (osteoporosis, steroids/smoking/alc, hypo/hyperthyroidism, physical immobility, pathological bone conditions, chronic liver/kidney conditions)

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24
Q

bruising suggestive of intra or extra capsular proximal femoral fracture?

A

extra capsular

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25
Q

classification for neck of femur fractures

A

garden’s classification

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26
Q

garden’s classification

A

type 1: incomplete impacted fracture
type 2: complete fracture, not displaced
type 3: complete fracture, moderately displaced (head in varus, internally rotated, abducted; distal externally rotated)
type 4: complete fracture, severely displaced

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27
Q

management of NOF fracture in <60

A

undisplaced: hip spica
displaced: m&r > internal fixation (cancellous screws)

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28
Q

management of NOF fracture in > 60

A

undisplaced

  • 65: cancellous screw
  • 90: hemiarthroplasty

displaced

  • hemiarthroplasty
  • THR
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29
Q

why is internal fixation contraindicated in displaced NOF fracture of old (>60)

A

risk of AVN + nonunion

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30
Q

general complications of NOF fracture

A

1) thromboembolism
2) pneumonia
3) bed sores
4) uti

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31
Q

fracture related complications of NOF fracture

A

1) AVN of femoral head (NOF fracture can sever both nutrient artery + retinacular artery, leaving ligamentum teres vessels insufficient)

2) nonunion (SPLINTS)
- <50: bone graft across fracture
- >50: hemiarthroplasty or THR

3) secondary OA

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32
Q

management for intertrochanteric or subtrochanteric fractures

A

m&r under anaesthesia + internal fixation with PFNA

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33
Q

causes of hip dislocation

A

1) septic arthritis
2) muscle imbalance
3) trauma
4) post THR (THR unstable in flexion, adduction, internal rotation)

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34
Q

mechanism of injury of posterior hip dislocation

A

dash board injury

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35
Q

associated injuries with posterior hip dislocation

A

1) PCL injury
2) posterior wall of acetabulum
3) femoral fracture
4) sciatic nerve injury

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36
Q

signs of posterior hip dislocation

A

1) shortened limb

2) hip adducted, internally rotated and flexed

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37
Q

management of posterior hip dislocation

A

m&R with bigelow’s maneuver

  • relax muscles w conscious sedation (IV fentanyl/GA/spinal)
  • stabilise pelvis
  • flex + upward traction + abduct + externally rotate
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38
Q

signs of anterior hip dislocation

A

abduction + external rotation + flexion of hip

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39
Q

management of anterior hip dislocation

A

m&r with barlow’s maneuver

  • relax muscles
  • stabilise pelvis
  • flex + downward pressure + adduct + internally rotate
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40
Q

complications of hip dislocation

A

1) early
- fractures
- vascular injury

2) late
- avn of femoral head
- myositis ossificans
- coxa magna
- recurrent dislocations
- secondary OA (cartilage injury + intraarticular loose bodies)

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41
Q

differential diagnosis of hip pain

A

1) referred pain
- discogenic (sciatic nerve)

2) joint disorders
- septic arthritis
- oa
- ra
- perthe’s disease
- slipped capital femoral epiphysis
- osteonecrosis

3) bone
- fracture
- dislocation

4) periarticular disorders
- hernia
- iliotibial band tendinitis
- trochanteric bursitis
- LN
- PID
- gluteal muscle strain
- SI pathology

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42
Q

risk factors for avascular necrosis of hip

A

main: FRACTURE, DIABETES, ALCOHOL ABUSE, STEROIDS, IDIOPATHIC

V: haemoglobinopathies (e.g. sickle cell)
I - septic arthritis
T - fracture/dislocation
A - SLE, RA
M - alcohol abuse > hyperlipidemia, obesity, smoking, caisson’s disease, gaucher’s disease, cushing’s disease
I - steroids
N - malignant infiltration (leukemia/lymphoma)
C - perthes, scfe, factor v leiden

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43
Q

pathophysiology of avascular necrosis

A

1) metabolic factors
2) local factors
- arterial supply interruption/vascular damage
- venous stasis/occlusion
- capillary compression (2ndary to marrow swelling)

> increase interosseous pressure > ischaemia

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44
Q

most reliable modality in picking up AVN

A

MRI
T1: low density area (edema)
T2: double line sign
- high intensity inner line: reparative granulation tissue
- low intensity peripheral line: sclerotic bone

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45
Q

staging system for avascular necrosis of hip

A

ficat arlat (mri + xr + clinical)

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46
Q

ficat arlat stage 0

A

preclinical: at risk

normal imaging

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47
Q

ficat arlat stage 1

A

preradiographic: bone death within 48h without structural changes
- s/s: pain

xr+ ct = normal
mri = edema
bone scan = increased uptake

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48
Q

ficat arlat stage 2

A

precollapse: repair and early structural failure
- s/s: pain, stiffness

xr = sclerosis + cyst formation
mri = geographic defect
bone scan = increased uptake

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49
Q

ficat arlat stage 3

A

collapse: major structural collapse of necrostic bone
- s/s: pain, stiffness, limping

xr = crescent sign + flattening of femoral head 
mri = crescent sign + cortical collapse
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50
Q

management for ficat arlat stage 1 and 2

A

1) conservative
- non pharmacological: bed rest, physiotherapy, splintage, weight relief (crutches)
- pharmacological: NSAIDs, bisphosphonates

2) surgical
- core decompression + bone grafting (indication: avn from venous stasis/marrow edema)

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51
Q

management for ficat arlat stage 3

A

surgical

  • femoral head resurfacing
  • hemiarthroplasty
  • transtrochanteric rotational osteotomy
  • realignment osteotomy
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52
Q

ficat arlat stage 4

A

osteoarthritis: articular destruction
- s/s: v painful, stiffness, limp

xr = LOSS
mri = 2ndary degenerative changes
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53
Q

management for ficat arlat stage 4

A

surgical

  • resurfacing arthroplasty
  • THR
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54
Q

differentials for hip pain in child <3 yo

A

1) infection
2) trauma
3) toddler’s fracture (1-4)

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55
Q

differentials for hip pain in child 3-7 yo

A

1) transient synovitis (3-10)
2) inflammatory/septic arthritis
3) growing pain (4-5 + puberty)
4) leukemia (4-10)

56
Q

differentials for hip pain in child 7-10 yo

A

1) perthes disease (4-8)

2) transient synovitis

57
Q

differentials for hip pain in >10 yo

A

1) SCFE (15)

2) growing pains

58
Q

differentials for painless limb length discrepancy

A

1) bone
- femur vs tibial shortening

2) joint
- DDH

3) generalised
- muscle hypertrophy on one side

4) physiological
- metatarsal adductus
- tibial torsion
- femoral anteversion
- flat foot

59
Q

definition of developmental dysplasia of hip

A

disorder of abnormal development resulting in dysplasia, subluxation and possible dislocation of hip secondary to capsular laxity & mechanical instability

60
Q

epidemiology of DDH (F/M + L/R)

A

F>M= 6:1

L (60%) > R

61
Q

risk factors for DDH

A

1) family history - joint laxity/shallow acetabulum

2) intrauterine malpositioning
- first born
- oligomenorrhea
- fibroids
- large baby/small mother
- breech delivery

3) post natal posture
- carrying baby with hip and knee fully extended

62
Q

diagnosis for DDH in newborns

A

positive barlow’s + ortolani

u/s earliest at 6 weeks for high risk cases

63
Q

why cant you ultrasound newborns at birth for DDH

A

maternal hormones facilitate emergence from birth canal > laxity of joint > inaccurate reading

64
Q

diagnosis for DDH in child > 4 mths

A

clinical signs + XR

  • positive trendelenburg test
  • galleazi’s test - femoral shortening
  • barlow’s test - aDduct; dislocatability
  • ortolani’s test - aBduct; reducibility
65
Q

radiological findings for >4mth for DDH

A

XR

  • shallow + sharply sloping roof of acetabulum
  • femoral head: small + underdeveloped + posterosuperiorly dislocated
  • shenton’s line broken
  • perkin’s line: epiphysis not medial
  • hilgenreiner’s line: epiphysis not inferior
  • acetabular index (N: <30)
  • van rosen’s line = hip abducted > femoral shafts should point towards acetabulum
  • medial gap: larger gap = larger possibility for dislocation
66
Q

management of DDH in 0-6mth old

A

reducible: pavlik’s harness

irreducible : adductor tenotomy (closed reduction + hip spica)

67
Q

management of DDH in 6-18 mth old

A

closed reduction + MUA

  • successful reduction: hip spica + abduction splint
  • unsuccessful reduction: open reduction (femoral derotating + shortening) > hip spica
68
Q

management of DDH beyond 18 mths

A

salter osteotomy

- redirection of acetabulum so its roof covers femoral head both anteriorly and superiorly

69
Q

complications of unreduced DDH

A

1) partial dislocation + pseudoarthrosis
- progressive deformity, disability + secondary OA

2) complete dislocation
- trendenlenburg gait > scoliosis

3) bilateral dislocaiton
- waddling gait > lordosis

70
Q

commonest cause of hip pain in children

A

transient synovitis

71
Q

postulated cause of transient synovitis

A

URTI/pharyngitis/bronchitis/otitis media

72
Q

signs of transient synovitis

A
  • most sensitive test: log roll > involuntary muscle guarding of one site
  • antalgic gait
  • tenderness on palpation
  • mild restriction of ROM
73
Q

investigations for transient synovitis

A

1) imaging
a. u/s joint effusion - TRO septic arthritis(infection less likely if effusion observed)
b. xr - no changes

2) lab
- WBC, CRP (tro septic arthritis), esr

74
Q

management for transient synovitis

A

conservative

  • nonpharma: heat, massage, bed rest
  • pharma: NSAIDs (naproxen/ibuprofen)
75
Q

risk factors of septic arthritis in children

A

1) prematurity
2) caesarian section
3) h/o invasive procedures

76
Q

mechanism of septic arthritis

A

1) direct innoculation
2) haematogenous seeding (URTI precedes 80% of cases)
3) extension from adjacent bone (OM)
- neonates may have transphyseal vessels that allow spread into joint

77
Q

joints with intra articular metaphysis

A

hip, shoulder, elbow, ankle

78
Q

most common pathogen in septic arthritis

A

s. aureus

79
Q

position of comfort in septic arthritis

A

FABER

80
Q

progression of inflammatory markers in septic arthritis

A

fever > crp > esr > refusal to weight bear > wbc

81
Q

investigations for septic arthritis

A

1) imaging
- AP + frog leg pelvis XR: widening of joint space (significant pus), subluxation/dislocation of femur
- U/S
- screen contralateral hip in neonate
- guide joint aspiration

2) lab
- FBC: wbc, esr, crp
- hip aspirate - wbc, gram stain + c/s

82
Q

management of septic arthritis in children

A

1) conservative (rarely indicated)
- IV antibiotics (adolescent n.gonorrhea may be amenable to large dose penicillin without surgical debridement for NON HIP joint

2) surgical (*)
- urgent surgical I&D + IV antibiotics
- traction in abduction until infection resolves

83
Q

complications of septic arthritis in children

A

1) growth disturbance
- LLD
2) femoral head destruction/deformity
3) AVN

84
Q

common organisms + septic arthritis antibiotic treatment in <3mth

A

1st gen cephalosporin

organisms: group B strep, s. aureus, gram neg bacilli

85
Q

common organisms + septic arthritis antibiotic treatment in 3mth -5 years

A

2nd or 3rd gen cephalosporin

organisms: s. aureus, kingella, s.pneumoniae, group A strep, h.influenzae

86
Q

common organisms + septic arthritis antibiotic treatment in 5-12 years

A

1st generation cephalosporin

organism: s. aureus

87
Q

common organisms + septic arthritis antibiotic treatment in 12-18 years

A

2nd or 3rd gen cephalosporin

organisms: n.gonorrhea, s.aureus

88
Q

define perthes disease

A

idiopathic avascular necrosis of proximal femoral epiphysis in children

89
Q

epidemiology of perthes (F/M + L/R)

A

M>F = 4:1

L=R

90
Q

pathology of perthes disease

A

trauma/nonspecific synovitis > effusion in hip joint > pressure on lateral epiphyseal vessels in retinacula > AVN

91
Q

name the classification for stages of perthes disease

A

waldenstrom classification

92
Q

stages of perthes disease

A

1) initial
2) fragmentation
3) reossification
4) healing or remodelling

93
Q

stage 1 of perthes disease

A

initial

  • smaller sclerotic epiphysis
  • medial joint space widening
94
Q

stage 2 of perthes disease

A

fragmentation

  • crescent sign: subchondral lucent line
  • result of revascularization process with bone resorption producing collapse with subsequent patchy density and lucencies
95
Q

stage 3 of perthes disease

A

reossification

- new bone appearance

96
Q

stage 4 of perthes disease

A

healing or remodelling

- femoral head remodels until skeletal maturity

97
Q

prognostic classification for perthes disease

A

catteral classification

98
Q

grade 1 catteral classificaiton

A

involves anterior portion of epiphysis only
no collapse or sequestrum

prognosis: revascularisaiton may be complete without bone collapse

99
Q

grade 2 catteral classification

A

<50% epiphyseal involvement with sequestrum

prognosis: bony collapse inevitable

100
Q

grade 3 catteral classification

A

75% epiphyseal involvement with collapse and sequestrum

prognosis:
- bony collapse inevitable
- poor prognosis

101
Q

grade 4 catteral classification

A

whole epiphyseal involvement

prognosis
- bony collapse inevitable

102
Q

management of perthes disease

A

1) conservative (children < 8yo)
- observation + activity limitation + physiotherapy

2) surgical
- varus osteotomy of femur
- innominate osteotomy of pelvis

103
Q

most common cause of hip pain in adolescents

A

slipped capital femoral epiphysis

104
Q

risk factors of SCFE

A
  • obesity
  • acetabular retroversion + femoral retroversion
  • precocious puberty
105
Q

what conditions is SCFE associated with

A

1) endocrinopathies (bilateral SCFE)
- hypothyroidism
- hypogonadism (physeal fusion)
- hypopituitarism
- growth hormone disturbance (bone growth)

2) down’s syndrome
3) h/o trauma (30%)

106
Q

pathophysiology of SCFE

A

stress fracture through hypertrophic zone of epiphyseal growth plate

  • metaphysis translates anteriorly and externally rotates
  • epiphysis remains in acetabulum
  • AVN
  • chondrolysis > early onset OA
107
Q

signs of SCFE

A
  • coxa vara
  • shortened limb + externally rotated + fixed
    = limited abduction + internal rotation
  • pain on movement
108
Q

complications of SCFE

A

1) AVN
2) contralateral hip SCFE (most common complication after unilateral surgical fixation)
3) coxa vara deformity
4) chondrolysis > 2ndary OA

109
Q

management of SCFE

A

operative

- percutaneous insitu fixation w single cannulated screw

110
Q

why is maniputlation contraindicated in SCFE

A

increased risk of AVN

111
Q

relevant history to be taken from patient presenting to the ED with open fracture

A

AMPLE

1) allergies
2) medications: anticoagulants, cardiovascular medication, insulin
3) past medical and surgical history
4) last meal: time of last meal to decide whether interventions needed for safe surgical intervention

5) events/environment surrounding injury
- circumstances that the injury took place
(vehicle/people involved, speed collided vehicles moving at, location of injury)
- what measures have been taken during the transfer

112
Q

how would you manage a patient in shock post TKR?

A

1) alert on call team + senior on duty
2) STAT ECG and cardiac enzymes to evaluate for AMI
3) check knee drain for excessive blood loss + input and output charts for decreased urinary output

if decreased output:

1) order STAT FBC to check for excessive blood loss and guide management
2) renal panel for acute kidney injury
3) lactate and ABG to assess for lactic acidosis > severity of shock
4) GXM if patient require blood transfusion

if investigations point towards cardiogenic cause

1) inform on call cardiology team
2) aspirin, nitrates, analgesia according to WHO pain ladder
3) arrange for urgent PCI

if investigations rule out cardiogenic cause

  • IV fluid resuscitation, blood transfusion if Hb < 7g/dL
  • direct pressure on wound if active bleeding
113
Q

possible causes of shock post TKR

A

1) cardiogenic shock (any risk factors?)

2) hypotensive shock from bleeding

114
Q

principles of management in operating theatre for open fractures

A

1) aggressive debridement of necrotic tissue and extensive irrigation
2) fractures stabilisation (open reduction, internal/external fixation)
3) soft tissue coverage and wound closure
4) antibiotic beads placement in open dirty wounds

115
Q

why is sensation over thenar eminence spared in carpal tunnel?

A

palmar cutaneous branch of the median nerve travels superficial to the flexor retinaculum

116
Q

aetiologies of carpal tunnel syndrome

A

1) anatomical
- traumatic carpal fractures/dislocation
- tenosynovitis secondary to repeated hand movements (occupational work factors like awkward hand positions, hand arm vibration during construction work)

2) physiological
- fluid imbalances: pregnancy, menopause, cardiac/renal failure, obesity, hypothyroid, amyloidosis
- inflammatory: RA, GA
- metabolic: gout
- neuropathic: dm, alcoholism
- endocrine: hypothyroidism

3) idiotpathic!

117
Q

causes of tardy ulnar nerve palsy

A

1) medial and lateral condylar fractures

2) monteggia fracture

118
Q

limb attitude post proximal femoral fracture

A

flexed, abducted, externally rotated

119
Q

limb attitude post posterior dislocation of hip

A

flexed, adducted, internally rotated

120
Q

limb attitude post anterior dislocation of hip

A

flexed, abducted, externally rotated

121
Q

describe management of intertrochanteric/subtrochanteric fracture in 80 year old lady

A

1) pre op:
- analgesic according to WHO pain ladder
- management of co morbidities

2) operative
- PFN

3) post operative
- dvt prophylaxis
- early mobilisation

122
Q

why is fracture fixation preferred choice of treatment in intertrochanteric/subtrochanteric fractures (rather than hip replacement) ?

A
  • allows for early mobility and return to premorbid function
  • lower mortality rate
  • improved quality of life for patient
123
Q

investigations for frozen shoulder

A

1) XR: TRO glenohumeral arthritis, dislocation, surgical hardware
2) MRI: tro rotator cuff tear

124
Q

causes of positive trendenlenburg test

A

1) fulcrum problems: hip OA, AVN, dislocation
2) lever arm (femoral neck) problems: NOF #, coxa vara, shortening above greater trochanter
3) muscular problems: weak abductors
4) nerve problems: superior gluteal nerve or L5

125
Q

size of microfilament used in protective sensation test

A

5.07 gauge (applies 10g of force)

126
Q

investigations to order for diabetic foot

A

1) biochemical
- fbc: twc
- esr, crp
- renal panel
- HbA1C (n=4-7%, indicator of diabetic control over last 3 months
- hypocount (4-8mmol/l)
- urinanalysis: glucosuria, ketonuria (DKA), proteinuria (nephropathy)
- hb: nutritional status
- culture (blood/ulcer swab)

2) imaging
- ecg, cxr (anaesthetic fitness)
- XR foot/ankle AP + lateral
- mri (differentiate abscess from st swelling)

3) vascular assessment
- ABI/TBI
- angiogram (renal function?)

127
Q

cut off for ABI

A

normal: 1-1.2
ischaemia: <0.8
mid to mod disease: 0.5-0.9
severe disease: <0.5
critical ischaemia: <0.3

128
Q

cut off for TBI

A

normal: >0.7
ischaemia: 0.4 -0.6
critical ischaemia: <0.3

129
Q

volume of effusion tested in each of the knee effusion examinations

A

normal: <5cc
bulge test: 10-20cc
patella tap: 30-50cc
cross fluctuance: >60cc

130
Q

investigations ordered for knee OA

A

1) imaging
XR: weight bearing AP, lateral, skyline + long film to look at degree of varus/valgus deformity

2) bloods
- fbc, csr, esr (inflammatory/infection)
- renal and liver panel (if giving patients NSAIDs for LT use)

131
Q

associated fractures with ankle ligament injuries

A

1) base of 5th MT
2) lateral side of talus
3) posterior or tip of lateral and medial malleolus
4) undisplaced fibular fracture or diastasis of tibiofibular syndesmosis

132
Q

imaging to order for ligament tear

A

1) XR
- ap
- lateral
- mortise (30 deg oblique) + talar tilt test (articular surface of tibia and talus parallel?)
- any associated fractures?

133
Q

management for torn ankle ligament

A

1) grade I and II tears
- RICE
- bandage/brace > begin physio > protective weight bearing w crutches stopped when patient can walk > return to play

2) grade III
- RICE
- brace with hinged knee orthosis + crutches > physiotherapy > return to play
(previously BK cast immobilization from knee to toes in plantigrade)

3) operative repair in athletes - arthroscopic debridement or ligament reconstruction

134
Q

management of patient with diabetic ulcer

A

1) general management
a. IV antibiotics: broad spectrum (augmentin + ciprofloxacin) > culture specific antibiotics
b. maintain patient’s hydration status with IV saline + monitor intake/output charts
c. daily wound dressing with chlorhexidine, flush with H2O and saline > chlorhexidine dressing
d. elevate leg if swollen
e. diabetic chart using hypocount TDS

2) i would like to classify the ulcer according to wagner’s classificaiton to better manage the patient

135
Q

how would you classify diabetic ulcer?

A

wagner’s classifcation

136
Q

describe wagner’s classification for diabetic ulcers

A

grade 0:

  • no ulcer in high risk foot
  • conservative: education, foot wear, regular exams

grade 1:

  • superficial ulcer involving full skin thickness but no underlying tissues/no infection
  • conservative: total contact cast for offloading + walking brace + special foot wear

grade 2:

  • deep ulcer, penetrating to ligaments and muscle but no bone involvement or abscess formation
  • surgical debridement + wound care + offloading + culture specific antibiotics

grade 3:

  • deep ulcer with infection of deep tissue with pus; cellulitis, deep abscess tendinitis, OM
  • surgical debridement/partial amputation, offloading, culture specific antibiotics

grade 4:

  • forefoot gangrene
  • lower extremity amputation, vascular consultation

grade 5:

  • whole foot gangrene
  • major extremity amputation, vascular consultation

phase iii orthopaedics (6 decks)

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