orthopaedics/acute Flashcards
1
Q
causes of lower back pain
A
non-specific muscular neoplastic Facet joint Spinal stenosis Ankylosing spondylitis Peripheral arterial disease
2
Q
characteristics of facet joint pain
A
May be acute or chronic
Pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse on extension of the back
3
Q
characteristics of spinal stenosis
A
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
4
Q
characteristics of ankylosing spondylitis
A
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
5
Q
characteristics of peripheral arterial disease
A
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
6
Q
Ankle injury: Ottawa rules
A
The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
inability to walk four weight bearing steps immediately after the injury and in the emergency department
There are also Ottawa rules available for both foot and knee injuries
7
Q
causes/risk factors for osteoporosis
A
Advancing age and female sex and significant risk factors for osteoporosis. Prevalence of osteoporosis increases from 2% at 50 years to more than 25% at 80 years in women.
There are many other risk factors and secondary causes of osteoporosis. We'll start by looking at the most 'important' ones - these are risk factors that are used by major risk assessment tools such as FRAX: history of glucocorticoid use rheumatoid arthritis alcohol excess history of parental hip fracture low body mass index current smoking
Other risk factors sedentary lifestyle premature menopause Caucasians and Asians endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus multiple myeloma, lymphoma gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. Coeliac's), gastrectomy, liver disease chronic kidney disease osteogenesis imperfecta, homocystinuria
Medications that may worsen osteoporosis (other than glucocorticoids): long term heparin therapy proton pump inhibitors glitazones aromatase inhibitors e.g. anastrozole
8
Q
investigations for a secondary cause of osteoporosis
A
If a patient is diagnosed with osteoporosis or has a fragility fracture further investigations may be warranted. NOGG recommend testing for the following reasons:
exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma);
identify the cause of osteoporosis and contributory factors;
assess the risk of subsequent fractures;
select the most appropriate form of treatment
The following investigations are recommended by NOGG:
History and physical examination
Blood cell count, sedimentation rate or C-reactive protein, serum calcium,
albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases
Thyroid function tests
Bone densitometry ( DXA)
Other procedures, if indicated
Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging
Protein immunoelectrophoresis and urinary Bence-Jones proteins
25OHD
PTH
Serum testosterone, SHBG, FSH, LH (in men),
Serum prolactin
24 hour urinary cortisol/dexamethasone suppression test
Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
Isotope bone scan
Markers of bone turnover, when available
Urinary calcium excretion
So from the first list we should order the following bloods as a minimum for all patients: full blood count urea and electrolytes liver function tests bone profile CRP thyroid function tests
9
Q
what is a straight leg raise test
A
The straight leg raise, also called Lasègue’s sign, Lasègue test or Lazarević’s sign, is a test done during the physical examination to determine whether a patient with low back pain has an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve).
With the patient lying down on his or her back on an examination table or exam floor, the examiner lifts the patient’s leg while the knee is straight.
A variation is to lift the leg while the patient is sitting.[1] However, this reduces the sensitivity of the test.[2]
In order to make this test more specific, the ankle can be dorsiflexed and the cervical spine flexed. This increases the stretching of the nerve root and dura.
If the patient experiences sciatic pain when the straight leg is at an angle of between 30 and 70 degrees, then the test is positive and a herniated disc is likely to be the cause of the pain.[3]
A meta-analysis reported the accuracy as:[4]
sensitivity 91%
specificity 26%
If raising the opposite leg causes pain (cross or contralateral straight leg raising):
sensitivity 29%
specificity 88%
10
Q
general features of a prolapsed lumbar disc
A
A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.
Features
leg pain usually worse than back
pain often worse when sitting
11
Q
L3 nerve root compression
A
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
12
Q
L4 nerve root compression
A
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
13
Q
L5 nerve root compression
A
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
14
Q
S1 nerve root compression
A
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
15
Q
management of a likely prolapsed lumbar disc
A
Management
similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises
if symptoms persist then referral for consideration of MRI is appropriate
16
Q
what is Chondromalacia patellae
A
Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy
17
Q
Osgood-Schlatter disease
tibial apophysitis
A
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
18
Q
Osteochondritis dissecans
A
Pain after exercise
Intermittent swelling and locking
19
Q
Patellar subluxation
A
Medial knee pain due to lateral subluxation of the patella
Knee may give way
20
Q
Patellar tendonitis
A
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
21
Q
what is Lateral epicondylitis
A
Lateral epicondylitis typically follows unaccustomed activity such as house painting or playing tennis (‘tennis elbow’). It is most common in people aged 45-55 years and typically affects the dominant arm.
Features
pain and tenderness localised to the lateral epicondyle
pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
Management options: advice on avoiding muscle overload simple analgesia steroid injection physiotherapy
22
Q
what is Trigger finger
A
Trigger finger is a common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes ‘stuck’ and cannot pass smoothly through the pulley.
Associations* (idiopathic in the majority)
more common in women than men
rheumatoid arthritis
diabetes mellitus
Features
more common in the thumb, middle, or ring finger
initially stiffness and snapping (‘trigger’) when extending a flexed digit
a nodule may be felt at the base of the affected finger
Management
steroid injection is successful in the majority of patients. A finger splint may be applied afterwards
surgery should be reserved for patients who have not responded to steroid injections
*there is scanty evidence to support a link with repetitive use
23
Q
what is Talipes equinovarus
A
Talipes equinovarus, or club foot, describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.
Talipes equinovarus is twice as common in males than females and has an incidence of 1 per 1,000 births. Around 50% of cases are bilateral.
Most commonly idiopathic. Associations include: spina bifida cerebral palsy Edward's syndrome (trisomy 18) oligohydramnios arthrogryposis
The diagnosis is clinical (the deformity is not passively correctable) and imaging is not normally needed.
Management*
in recent years there has been a move away from surgical intervention to more conservative methods such as the Ponseti method
the Ponseti method consists of manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks. An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic
night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%
*reference: BMJ 2010; 340:c355: Current management of clubfoot. Bridgens J, Kiely N
24
Q
what happens in radial nerve palsy
A
This man has ‘Saturday night palsy’ caused by compression of the radial nerve against the humeral shaft, possibly due to sleeping on a hard chair with his hand draped over the back
Overview
arises from the posterior cord of the brachial plexus (C5-8)
Motor to extensor muscles (forearm, wrist, fingers, thumb)
Sensory to
dorsal aspect of lateral 3 1/2 fingers
however, only small area between the dorsal aspect of the 1st and 2nd metacarpals is unique to the radial nerve
Patterns of damage
wrist drop
sensory loss to small area between the dorsal aspect of the 1st and 2nd metacarpals
Axillary damage
as above
paralysis of triceps
25
what happens in ulnar nerve palsy
Overview
arises from medial cord of brachial plexus (C8, T1)
```
Motor to
medial two lumbricals
aDductor pollicis
interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris
```
Sensory to
medial 1 1/2 fingers (palmar and dorsal aspects)
Patterns of damage
Damage at wrist
'claw hand' - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits
wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals)
wasting and paralysis of hypothenar muscles
sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects)
Damage at elbow
as above (however, ulnar paradox - clawing is more severe in distal lesions)
radial deviation of wrist
26
features of Cubital tunnel syndrome
Due to the compression of the ulnar nerve.
Features
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
27
what is Olecranon bursitis
Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.
28
what happens in Radial tunnel syndrome
Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.
Features
symptoms are similar to lateral epicondylitis making it difficult to diagnose
however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
symptoms may be worsened by extending the elbow and pronating the forearm
29
what happens in Medial epicondylitis (golfer's elbow)
Features
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
30
what happens in Median nerve palsy
Overview
arises from lateral and medial cords of the brachial plexus (C6-8, T1)
Motor to (LOAF)
Lateral two lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
the above three form the thenar eminence muscles
also supplies flexor muscles of the forearm
Sensory to
palmar aspect of lateral (radial) 3 1/2 fingers
Patterns of damage
Damage at wrist
e.g. carpal tunnel syndrome
paralysis and wasting of thenar eminence muscles
sensory loss to palmar aspect of lateral (radial) 3 1/2 fingers
Damage at elbow, as above plus:
unable to pronate forearm
weak wrist flexion
ulnar deviation of wrist
Anterior interosseous nerve (branch of median nerve)
leaves just below the elbow
results in loss of pronation of forearm and weakness of long flexors of thumb and index finger
31
8 potential causes of hip pain in adults
```
Osteoarthritis
Inflammatory arthritis
Referred lumbar spine pain
Greater trochanteric pain syndrome (Trochanteric bursitis)
Meralgia paraesthetica
Avascular necrosis
Pubic symphysis dysfunction
Transient idiopathic osteoporosis
```
32
features of hip Osteoarthritis
Pain exacerbated by exercise and relieved by rest
Reduction in internal rotation is often the first sign
Age, obesity and previous joint problems are risk factors
33
features of hip Inflammatory arthritis
Pain in the morning
Systemic features
Raised inflammatory markers
34
features of hip Referred lumbar spine pain
Femoral nerve compression may cause referred pain in the hip
Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
35
features of hip Greater trochanteric pain syndrome (Trochanteric bursitis)
Due to repeated movement of the fibroelastic iliotibial band
Pain and tenderness over the lateral side of thigh
Most common in women aged 50-70 years
36
features of hip Meralgia paraesthetica
Caused by compression of lateral cutaneous nerve of thigh
| Typically burning sensation over antero-lateral aspect of thigh
37
features of hip Avascular necrosis
Symptoms may be of gradual or sudden onset
| May follow high dose steroid therapy or previous hip fracture of dislocation
38
features of Pubic symphysis dysfunction
Common in pregnancy
Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
39
features of hip Transient idiopathic osteoporosis
An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
40
name the rotator cuff muscles and role
SItS - small t for teres minor
Supraspinatus - aBDucts arm before deltoid
Most commonly injured
Infraspinatus - Rotates arm laterally
teres minor - aDDucts & rotates arm laterally
Subscapularis - aDDuct & rotates arm medially
41
what happens in Carpal tunnel syndrome
Carpal tunnel syndrome is caused by compression of median nerve in the carpal tunnel.
History
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may 'ascend' proximally
patient shakes his hand to obtain relief, classically at night
Examination
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel's sign: tapping causes paraesthesia
Phalen's sign: flexion of wrist causes symptoms
```
Causes
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
```
Electrophysiology
motor + sensory: prolongation of the action potential
Treatment
corticosteroid injection
wrist splints at night
surgical decompression (flexor retinaculum division)
42
what is Morton's neuroma
Morton's neuroma is a benign neuroma affecting the intermetatarsal plantar nerve, most commonly in the third inter-metatarsophalangeal space. The female to male ratio is around 4:1.
Features
forefoot pain, most commonly in the third inter-metatarsophalangeal space
worse on walking. May be described as a shooting or burning pain. Patients may feel they have a pebble in their shoe
Mulder's click: one hand tries to hold the neuroma between the finger and thumb. The other hand squeezes the metatarsals together. A click may be heard as the neuroma moves between the metatarsal heads
there may be loss of sensation distally in the toes
Diagnosis is usually clinical although ultrasound may be helpful in confirming the diagnosis
Management
avoid high-heels
metatarsal pad
CKS recommends referral if symptoms persist for > 3 months despite footwear modifications and the use of metatarsal pads
orthotists may give the patient a metatarsal dome orthotic
other secondary care options include corticosteroid injection and neurectomy of the involved interdigital nerve and neuroma
43
what happens in Common peroneal nerve lesion
The sciatic nerve divides into the tibial and common peroneal nerves. Injury often occurs at the neck of the fibula
The most characteristic feature of a common peroneal nerve lesion is foot drop
Other features include:
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
44
a scar centered over the greater trochanter extending over the buttock could indicate what
previous hip replacement
45
commonest cause of a fixed flexion deformity in the hip
capsular fibrosis and osteophytes in osteoarthritis. seen as the angle between the bed and the thigh in thomas' test.
46
what muscle/nerve is deficient in a winged scapula
the serrates anterior and the long thoracic nerve of bell. c5,6,7 keeps the wings from going to heaven.
47
what is craniocleidodysostosis
increadibly rare. inherited disorder can result in absence of the clavicles and the patient will be able to bring both shoulders into the midline.
48
heberdens and bouchards which is which
heberdens in DIPJs bouchards pipj
49
9 types of fracture
transverse
oblique
spiral
comminuted (multifragment)
avulsion
compression (cancellous bone e.g. vertebrae)
stress fracture
greenstick - seen in children, cortex buckles on one side.
pathological - osteoporosis is a common cause
50
when bones break, the fragments often move relative to each other due to the trauma, gravity and muscle tension. give 4 terms and define
1 - impaction - the fragments are driven into one another to cause shortening. may appear hyper dense on radiograph.
2 - angulation - one fragment is angulated relative to another, describe the distal fragment relative to the proximal. e.g. varus valgus angulation. if untreated can lead to permanent deformity. described in degrees
3 - lateral displacement/translation - as it sounds. described in terms of percentage opposed.
4 - rotation - as it sounds. likely in degrees.
51
what is dislocation
complete loss of congruity of the articulating surfaces of a joint and implies disruption of the capsule and soft tissues. cf subluxation. can be associated with fracture e.g. fracture dislocation.
52
the 4 Rs of fracture management
resuscitation
reduction
restriction = stabilisation
rehabilitation
53
methods of reduction
1 - manipulation usually under a LA or GA. pull distal fragment in line with the bone to disimpact, the deformity may need to be exaggerated, then reposition anatomically.
2 - traction - when contraction forces of large muscles need to be overcome e.g. in femur fractures. skin or skeletal traction. in skin traction, adhesive tape and bandages are applied to the skin, in skeletal a pin is placed through the bone distal to the fracture. in both cases the limb is pulled usually via a pulley by a weight.
3 - open reduction - after failure of other methods usually. referred to as ORIF. open reduction, internal fixation. esp used in intraarticular fractures.
54
methods of restriction
1 - non-rigid methods of support - slings and elastic supports e.g. tubigrip
2 - plaster fixation - pop. there is a risk of compartment syndrome in the first 24-48 hrs so usually just a back slab is applied. this can later be completed by application of further layers.
3- functional bracing - the joints are left free to move and the shafts of bone are supported by cast segments joined by hinges to allow movement in one plane. most widely used for femoral or tibial fractures. usually applied after the bone has begun to unite so full cast first
4 - continuous traction - skin or skeletal
5 - external fixator - fragments held in place by pins through the skin into the bones. the bins are joined together externally. need to educate PT about pin site hygene, infection not uncommon.
6 - internal fixation - as expected.
55
what does immobility do to your muscles
often quoted that about 50% of muscle mass can be lost in 2 weeks.
56
what happens in compartment syndrome
pressure rises within fascial compartment around a muscle this compromises blood flow to the muscle by compressing blood vessels. ischaemia results and after several hours, necrosis starts. once infarcted the muscle is replaced by fibrous tissue leading to contracture = volkmann's ischaemic contracture.
compartmetnt syndrome can occur in a plaster cast that is too tight. classical symptoms are pain out of proportion to the clinical findings. the earliest sign is pain on passive stretching of the muscles.
early treatment = elevate limb, remove all bandages and split the cast but don't remove. if this fails then remove the cast, get help, is it progresses a fasciotomy may be necessary to alleviate the pressure.
57
palsies resulting from fracture or dislocation of: shoulder dislocation, shaft of humerus fracture, elbow dislocation , hip dislocation, knee dislocation, fracture of neck of fibula
- axillary nerve palsy
- radial nerve,
- ulnar nerve,
- sciatic nerve
- common peroneal nerve
- common peroneal nerve.
58
the two types of non-union
hypertrophic - bone ends look rounded like elephant feet, dense and sclerotic.can make a pseudo joint.
atrophic non-union - looks osteopenic. likely due to poor blood supply
59
3 common sites of avascular necrosis
the head of femur, the scaphoid and the talus. the bones become soft and deformed causing pain stiffness and osteoarthritis. sclerosis on X-ray but symptoms appear first.
60
how are intracapsular hip fractures classified
by the garden classification
garden 1 and 2 are undisplaced, garden 3 and 4 are displaced. grey scale, hard to diff 1 from 2 and 3 from 4.
61
what is a colles' fracture
an extraarticular fracture of the distal radius within an inch and a half of the joint. the displacement of the distal fragment is dorsal with radial shift and impaction. it is caused by a fall on to an outstretched hand and are most common in the osteoporotic.
produces a dinner fork like deformity.
62
what are the principle aims of reduction
to restore the length and to correct the angulation to allow for optimum function and minimal deformity.
63
diagnosis of a scaphoid fracture
often from hx and pain in the snuffbox as it can appear normal on an X-ray but you are obliged to treat.
64
what vessel is at risk in a distal humerus fracture
the brachial artery. check neuromuscular, reduction can make the radial pulse return.
65
what area does the axillary nerve supply
the regimental patch area. so test this area in a shoulder dislocation before and after reduction to check its not impinged.
66
what is a common long term problem with shoulder dislocation
recurrent instability. the older the PT is at time of injury the lower the chances of instability. PTs under the age of 20 have a recurrance rate of about 90%.
67
what triad of injuries can occur in the knee following severe rational injury
anterior cruciate, medial meniscus, medial collateral lig. the triad of o'donoghue.
68
joint swelling haemarthrosis vs effusion hx
```
haem = immediate swelling = fractures and torn cruciates
effusion = overnight swelling = meniscal tear or other ligaments.
```
69
4 cardinal knee symptoms
pain, locking, swelling and giving way
locking = cannot fully extend due to mechanical obstruction e.g. meniscal tear
giving way = instability e.g. torn acl.
locking and effusion and joint line tenderness = meniscal tear.
70
management of an acutely swollen ortho knee with no apparent fractures
```
RICE
rest
ice packs
compression or splintage
elevation
```
after the swelling has subsided it should be reexamined.
71
xray changes in OA
```
narrowing of joint space
osteophytes
subchondral sclerosis
subchondral bone cysts
bony destruction and deformity later on.
```
72
OA management
largely conservative
- analgesia
- weight loss
- avoid exacerbating activities
- increasing rest
- walking aids
- physio
surgical intervention in severe cases. e.g. washout. osteotomy, arthrodesis
73
which muscles does the median nerve supply in the hand?
```
LOAF
lumbricals (first 2)
opponens pollicis
abductor pollicis
flexor pollicis brevis
```
problems = carpal tunnel syn. dd = cervical rib or cervical spondylosis involving c6 and c7
74
cause of dupuytren's contracture
fibrosis and thickening of the palmar fascia
commoner in men and later in life.
unknown aetiolgy but can be inherited in an autosomal dominant manner.
```
associations:
alcohol
drugs such as phenytoin
cirrhosis
diabetes
```
75
what's a ganglion in ortho
a cystic swelling commonly seen on the dorm of the wrist and can interfere with wearing a watch.
exact origin debated but probably a cystic mucoid degeneration of the joint capsule or tendon sheath.
painless lump but can be painful
can disappear spontaneously.
smooth and fluctuant and can be fixed to deep structures.
can be aspirated or excised.
DD = lipoma, fibroma, sebaceous cyst.
76
how are epiphyseal fractures classified?
by the salter-harris classification. from grade 1 to 5.
X-rays in children are difficult to interpret, as the growth plate is often confused for a fracture. If there is damage to the growth plate (physis — see section on bone tumours for a discussion on the physis), abnormal growth may result. Injuries at the epiphyseal end of long bones of children can be categorised according to the Salter–Harris classification into five types (Figure 15.4). The results of these injuries depend on the injury pattern and the management at the time of injury. Type I tend to do well, whereas Type V do badly.
If a fracture goes through the epiphyseal plate (e.g. Salter–Harris I), provided good reduction is achieved there may be normal growth. Small amounts of displacement are often acceptable in children’s fractures, since they tend to remodel (especially in the plane of movement) as the child grows. The worst fractures are the ones where a growth plate injury, such as a crush, is missed at the time of the injury (e.g. Salter–Harris V) and are not picked up until growth is distorted. Many fractures in children can be treated by manipulation under anaesthetic and then immobilisation in plaster. Intra-articular epiphyseal injuries require anatomical reduction and are usually treated by ORIF.
77
how are undisplaced intracapsular hip fractures managed
Undisplaced intracapsular fractures are often impacted and would unite if left alone, although the aim nowadays is usually to mobilise such patients as soon as possible to avoid the complications of prolonged bed rest. Also, about a third of these fractures will go on to displace if not fixed. In most cases, therefore, the fracture is stabilised at operation, usu- ally by the insertion of parallel screws through the neck and into the head to hold it in position.
78
how are displaced intracapsular hip fractures managed
Displaced intracapsular fractures will not usually unite without reduc- tion and because of the disrupted blood supply to the head of the femur, many such patients go on to develop AVN. The management of these frac- tures involves an operation to reduce the fracture and hold it in position with screws; however, if you follow the patients up over the next few months many of them will still have pain and require a second operation (due to AVN of the femoral head). For this reason, in the elderly many surgeons would recommend excising the femoral head and replacing it with a pros- thesis (hemiarthroplasty, or half-a-hip replacement) at the initial operation.
There are many types of prostheses available. The Thompson and Austin–Moore prostheses have been around for decades. With hemi- arthroplasties the false head is large and articulates directly with the patient’s acetabulum.
The Austin–Moore (Figure 15.7b) is an example of an uncemented prosthesis, the Thompson or JRI are examples of cemented prostheses. Nowadays bipolar hemi-arthroplasties are available, where a small head isfitted inside a larger head that sits in the acetabulum.
Theoretically, there is reduced wear on the acetabulum due to sharing of the articulation between the small head and the large head and between the large head and the patient’s acetabulum.
In the younger patient (aged less than 65) you need to consider the long-term outcome. The disruption to the blood supply is dependent on the severity of the initial trauma, but early reduction may prevent subse- quent AVN. Ideally, you want to preserve the patient’s own joint for as long as possible. Therefore, all intracapsular fractures in the young should be booked for theatre as an emergency and undergo reduction and haveinternal fixation (usually with screws). Young patients should be followed up in the out-patient clinic for at least 2 years and if they develop AVN, could be considered for a total hip replacement at a later date.
79
how are extra capsular hip fractures described and managed
Extracapsular fractures can be described as basicervical, intertrochanteric or subtrochanteric, depending on the relationship to the trochanters.
Extracapsular fractures do not carry the same risk of AVN and if mini- mally displaced, could be managed nonoperatively. Again, however, most orthopaedic surgeons advocate early mobilisation and it is not possible to mobilise easily if the hip is fractured and unstable, hence we tend to fix these fractures. Fixing these fractures will also help to reduce the amount of pain.
The standard operation nowadays for these fractures is the insertion of a dynamic hip screw (DHS). In this procedure the patient is placed on a spe- cial ‘fracture’ table and the foot is placed into a traction boot. A closed reduc- tion is performed (whereby traction is applied to the leg, under image intensifier control, to reduce the fracture). An incision is made over the greater trochanter and a screw is inserted into the femoral head under image intensifier control. A plate attaches to the DHS and rests along the shaft of the femur, to which it is fixed by screws. The angle between the plate and the screw is 135, which is the usual angle between the neck and the shaft in most people (note: different angles are available to cover anatomical variants).
These fractures have a natural tendency to collapse and so the screw can slide along the plate to accommodate this. The screw can slide but cannot rotate. The sliding movement of the screw on the plate explains why the hip screw is ‘dynamic’. This type of collapse is a good thing as it leads to a more stable construct.
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Radius and Ulna Shaft fractures management and names
Due to the anatomy, isolated fractures of the shafts of either of these bones are uncommon, and if they are seen one should always suspect an associ- ated dislocation at either the proximal or the distal radioulnar joint. These fracture dislocations are known by their Italian eponyms and are common questions in exams, so they are worth remembering.
A fracture of the ulna shaft with dislocation of the radial head is called a Monteggia fracture (the radial head should normally lie in front of the capitellum). A Galleazzi fracture is a fracture of the radial shaft with a dislocation of the distal (or inferior) radioulnar joint (Figure 15.9).
These fractures are unstable and are usually treated by ORIF in adults. In children the fracture is usually manipulated under anaesthetic (if displaced) and treated in an above elbow plater.
If a fracture of the forearm is being treated in plaster, then it should be left in the most stable position. Fractures of the proximal radius and ulna are said to be the most stable in supination, distal fractures are said to be the most stable in pronation, and fractures of the midshaft are said to be the most stable in neutral. For example, a midshaft radial fracture is plas- tered with the hand in neutral (midpronation). The plaster is extended above the elbow to prevent any supination or pronation.
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what vessel is commonly damaged in supracondylar fractures of the humerus
The distal fragment usually displaces backwards and the sharp edge of the proximal humerus may compress or injure the brachial artery which lies just in front of it (Figure 15.10).
The key to management is first to ensure no neurovascular damage results and second to restore the anatomy to prevent long-term malunion.
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damage that occurs in a shoulder dislocation
Almost all cases of dislocation of the shoulder are anterior dislocations (95%). Dislocation is usually caused by direct trauma or falling on to the hand where the humerus is driven forward tearing the capsule of the joint. Often the glenoid labrum is pulled off anteriorly, and this is called a Bankart lesion. If the humeral head impacts against the relatively hard anterior glenoid a defect can occur on the superior surface of the humeral head called a Hill Sachs lesion. This occurs in 35–40% of anterior dislo- cations. A Hill Sachs lesion may destabilise the glenohumeral joint and predispose to further dislocation.
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typical presentation and management of a dislocated shoulder
The patient presents in severe pain, reluctant to allow any examina- tion of the shoulder. The normal curved contour of the shoulder may be lost and may appear square. The arm is supported by the opposite hand. It is vital that you examine for any distal neurovascular deficit, espe- cially of the axillary nerve, which can be damaged during the disloca- tion. The axillary nerve supplies a small egg-shaped patch of skin over the insertion of the deltoid and should be tested and the findings docu- mented both before and after reduction (the axillary nerve also supplies the deltoid but clearly the muscle is difficult to assess whilst the shoul- der is dislocated).
X-rays should be an AP and a trans-scapular view (in the line of the body of the scapula) to see in which direction the humeral head has gone in relation to the glenoid, i.e. anterior or posterior.
Reduction is usually performed under sedation in the casualty depart- ment. One method has the patient in the supine position with the arm abducted and an assistant applying countertraction to the body (maybe with a towel held around the patient’s chest under the axilla). The head can be guided gently back into the socket.
An alternative is to have the patient prone with the arm hanging attached to some weights to apply traction (Kocher’s method can slice off the articular cartilage and cause a fracture of the greater tuberosity and so is not recommended). If these methods fail then reduction is usually easy to achieve with some muscle relaxant in theatre.
The arm can then be rested in a sling for about 3–4 weeks, after which physiotherapy rehabilitation can begin.
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what happens in Osteochondritis Dissecans
A piece of bone and its overlying articular cartilage may fall (dissect) off and into the joint space due to repeated minor stresses. The commonest site is the knee, with pain, swelling and limitation of movement. X-rays may show a loose body or a crater on the articular surface of the medial femoral condyle of the femur from which the fragment has fallen off.
Treatment depends on the size of the defect and the symptoms it causes. The options range from taking a ‘wait and see’ policy to surgery, which could include drilling, osteochondral autografting or autologous chondro- cyte implantation. No good prospective randomised long-term trial results have been published to allow patients to make a really informed decision. A large defect will ultimately progress and lead to OA.
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DD for primary benign bone tumours
Aneurysmal bone cysts (ABCs). These are bone cysts that are expansile (hence their name). They usually affect those under the age of 30 and present with pain. On an MRI they display the pathognomonic sign of multiple fluid levels. Treatment of symptomatic bone cysts is usually to curette out the cyst and fill with bone graft.
Bone cysts (also called simple bone cysts or unicameral or solitary bone cysts). Most of these occur in the proximal humerus and femur, again in young patients. They are usually asymptomatic but if they take up a large amount of the width of the bone, they can fracture. If they do fracture, a bit of the cortex can fall into the cyst, which gives the classical ‘fallen fragment sign’.
Chondroma (also known as enchondromas). These are benign tumours, which can be single or multiple (Ollier’s disease). If multiple and asso- ciated with soft tissue haemangiomas, there is another syndrome called Maffucci’s syndrome, which we only mention for MCQ purposes as you are unlikely to ever see one. Chondromas or enchondromas are the most common benign cystic lesions of the phalanges but can affect other long bones. In patients over 40 it is important to exclude a chon- drosarcoma, into which a chondroma can (rarely) develop.
Fibrous cortical defect (also called nonossifying fibroma). These are common and have been reported to be seen incidentally on X-ray in up to 20% of children. They usually spontaneously regress, however, and so are rarely seen after the age of 30. They are nonpainful and benign defects of the cortex, as the name suggests, and usually affect the metaphasis of long bones. They should be left alone.
Fibrous dysplasia. This is a condition whereby bits of the bone (usually long bones) are replaced by fibrous tissue. It can be monostotic (localised) or polyostotic (generalised). Monostotic is more common (approximately 70–80%). In monostotic fibrous dysplasia a solitary segment is affected and the cause is unknown. It is usually picked up incidentally on X-ray, although it can present as a pathological fracture with pain.
In polyostotic fibrous dysplasia (20–30%) several bones are affected and it usually presents with progressive deformity (where the bones bend or enlarge), pain and pathological fracture. The classical X-ray appearance is described as a ground glass or smokey appearance. It has been questioned whether the Elephant Man had fibrous dysplasia, although most believe he had neurofibromatosis or Proteus syndrome.
There is a rare condition, worth a mention for a multiple choice exam and that is McCune–Albright syndrome, where polyostotic fibrous dysplasia occurs in association with pigmentation of the skin (café au lait spots) and, in females, precocious puberty.
Giant cell tumour (GCT). These are sometimes called osteoclastomas and are of unknown origin, although there are multinuclear giant cells under the microscope, giving them their name. They occur in young adults, but always after fusion of the growth plate. If the growth plate is still open, discard this diagnosis. They are usually around the knee (in the lower end of the femur or upper tibia) and always abut the artic- ular surface. They are usually considered benign neoplasms, although some can be locally aggressive and some metastasise.
Osteochondromas. These are the commonest tumours of the bone. They are cartilage-capped exostoses that continue to grow as the bone grows (if multiple they may be part of a condition known as hereditary multiple exostoses). They usually present as a bony lump and appear on an X-ray as an abnormal outgrowth of bone — either finger-like or cauliflower-shaped projections (often they look smaller on an X-ray than the size to touch, because the cartilage does not show up). If there are symptoms they should be excised, and if they change in size after skele- tal maturity, then this suggests possible malignancy (chondrosarcoma).
Osteoid Osteoma. These are benign tumours that do not become malig- nant. They are small and usually occur in those under 30, most commonly in the tibia or femur. They appear on the X-ray as a small radiolucent area (the nidus) surrounded by dense sclerosis and are hot spots on a bone scan. The main symptom is pain which characteristically responds to aspirin (but then again so do a lot of things). If left alone they may disap- pear spontaneously, but if the pain persists excision of the nidus should be undertaken, usually with instant resolution of symptoms. Large osteoid osteomas have been referred to as osteoblastomas although they behave much like ABCs and if seen usually relate to the spine. We will not say any more as it is simply too rare for us to worry about.
A mnemonic to remember the list is ABC FFG OO, if you are so inclined.
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DD of primary malignant bone tumours
Osteosarcomas. These occur in males more than in females, and usu- ally in adolescents (although there is a second peak in those over 50, due to malignant change in Paget’s disease). The commonest sites are around the knee or proximal humerus. Osteosarcomas usually occur in the metaphysis and are locally invasive, spreading distally via the blood (often to the lung). The main symptom is pain, especially at night, and there may be local tenderness. X-rays show a metaphyseal, translucent and destructive lesion. The tumour expands through the cortex, caus- ing it to be raised, and a triangle of new bone is produced in the angle where the periosteum separates from the shaft called Codman’s trian- gle. Eventually, it breaks through the cortex into the surrounding soft tissues, causing streaks of calcification within them (the ‘sun-ray’appearance).
Treatment usually involves chemotherapy and resection, which may mean amputation or wide local excision using an allograft or prostheses. About 60% survive 5 years.
Ewing’s sarcomas. These are rare malignant tumours arising from the bone marrow, usually in young patients. Most of them occur in the dia- physis of long bones (in contrast to osteosarcomas which tend to be metaphyseal). Again, they present with a painful swelling, although because the lump is usually warm and tender they are occasionally diagnosed as having osteomyelitis. X-rays show a destructive lesion, sometimes with several layers of periosteal new bone around the lesion (called an ‘onion skin’ appearance). Treatment is usually chemother- apy, followed by surgical excision if possible.
Chondrosarcomas. These usually affect the middle-aged to elderly age group and are found in the pelvis or the proximal end of the long bones. There are two types: one arises from the surface of the bone (sometimes in the cartilage-covered cap of an osteochondroma) and the other arises within the medulla of the bone, often as a chondroma that either becomes malignant or has in fact been a slow-growing malignancy all the time. X-rays show an expanding radiolucent lesion with characteristic flecks of calcification. Treatment is by excision or, if necessary, amputation, since chondrosarcomas tend to metastasise late. Five-year survival is about 50%.
To summarise, if the patient is young (less than 30) always consider osteosarcoma or Ewing’s sarcoma in your differential. In older patients (i.e. 40) think of chondrosarcoma, myeloma and mets.
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secondary bone tumours - which and where?
Cancers that commonly metastasise to bone include breast, thyroid, renal, bronchus and prostate (not necessarily in this order, but it often helps to remember them by the mnemonic ‘Bone Tumours are Rarely Bony Primaries’). The majority of metastases are lytic lesions, with the excep- tion of prostate, which is usually osteosclerotic (however, breast and thy- roid are sometimes osteosclerotic). They metastasise to bone that contains red marrow, otherwise known as the axial skeleton (spine, pelvis, ribs and the proximal end of the long bones). Secondary tumours may cause local pain or present as a pathological fracture. Pathological fractures are best treated by internal fixation, as they tend not to heal. By the time there are multiple bony secondaries the prognosis is poor and treatment is likely to be palliative. Radiotherapy is often used to treat local bone pain.
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Development dysplasia of the hip
Often picked up on newborn examination
Barlow's test, Ortolani's test are positive
Unequal skin folds/leg length
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Transient synovitis (irritable hip
Typical age group = 2-10 years
Acute hip pain associated with viral infection
Commonest cause of hip pain in children
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Perthes disease
Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head
Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral
Features
hip pain: develops progressively over a few weeks
limp
stiffness and reduced range of hip movement
x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening
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Slipped upper femoral epiphysis
Typical age group = 10-15 years
More common in obese children and boys
Displacement of the femoral head epiphysis postero-inferiorly
Bilateral slip in 20% of cases
May present acutely following trauma or more commonly with chronic, persistent symptoms
Features
knee or distal thigh pain is common
loss of internal rotation of the leg in flexion
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Juvenile idiopathic arthritis (JIA)
Preferred to the older term juvenile chronic arthritis, describes arthritis occurring in someone who is less than 16 years old that lasts for more than three months. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA
Features of pauciarticular JIA
joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
limp
ANA may be positive in JIA - associated with anterior uveitis
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Septic arthritis
Acute hip pain associated with systemic upset e.g. pyrexia. Inability/severe limitation of affected joint
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Spinal cord compression
Spinal cord compression is an oncological emergency and affects up to 5% of cancer patients. Extradural compression accounts for the majority of cases, usually due to vertebral body metastases. It is more common in patients with lung, breast and prostate cancer
Features
back pain - the earliest and most common symptom - may be worse on lying down and coughing
lower limb weakness
sensory changes: sensory loss and numbness
neurological signs depend on the level of the lesion. Lesions above L1 usually result in upper motor neuron signs in the legs and a sensory level. Lesions below L1 usually cause lower motor neuron signs in the legs and perianal numbness. Tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
Management
high-dose oral dexamethasone
urgent oncological assessment for consideration of radiotherapy or surgery
95
if someone is drunk, aggressive and abusinve verbally in A and E what should you do?
call security and or the police to ensure the safety of others. you should also try to rule out an organic cause (alcohol intox doesn't count, delerium does)
96
what are the rules around a policeman asking for a PT blood sample for etoh testing if they are unconscious?
police reform act 2002
can request a sample but can only be collected by a forensic medical examiner (police surgeon) to be tested later if the PT gives consent.
97
how are patients triaged in a and e
by the national triage scale
category 1 = cases like cardiac arrests, emergency
2 = 5-10minutes max before being seen by doc
3 = 1hr
4 = 2hr
5 = 4hr max, often sent to minors/walk ins.
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content of SBAR for any communication referral of a patient
s - situation - identify yourself and where you are calling from
- identify patient by name and give reason for report
- describe your concern
B - background - Pt reason for admission
- explain significant PMHx
- PT background e.g. admission diagnosis, lab results, diagnostic results etc
A - assessment - vitals
- clinical impression and concerns
R - explain what you need - be specific about request and timeframe.
- make suggestions
- clarify expectations
99
which deaths should be reported to the coroner
all a and e deaths.
any suspicious death and to the police
any deaths related to accident, suicide, employment, or recent detention in police or prison custody.
anyone who is concerned about the cause of a death can inform a coroner about it but in most cases it will be reported by a doctor or the police.
a coroner is a doctor or lawyer responsible for investigating deaths in particular situations, they also arrange for a post mortem in necessary. an inquest is a legal enquiry into the causes and circumstances of death.
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what happens in a major incident where lots of patients might be sent and overwhelm the normal capacity of a hospital a and e
every hospital has a major incident plan when normal resources are unable to cope and special arrangeents are needed. it usually has action cards with bullet points on what action an F1 F2 etc needs to take in such an event. as soon as info is relied from ambulance control that a major incident has been declaired the department should start putting the plan in to action to prepare.
all patients should be labelled with a unique number
a MERIT (mobile medical team) should be sent from a nearby hospital that is not receiving the casualties of the major incident.
the decision to receive these patients is made by senior officials at ambulance control or police service, not the hospital itself.
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if someone comes in with a red itchy rash after a possible precipitant but no signs of resp compromise and no anaphylaxis, what likely is it and what do you do
sounds like an urticarial reaction, an IgE mediated hypersensitivity that is similar to anaphylaxis.
if they are stable then first line Rx is antihistamines.
give oral steroids and antihistamines for 3 days. no need for 24 hour observation which is only indicated in anaphylaxis.
- send to an allergy specialist if they don't know what the allergen is.
102
what's the difference between all the different hypersensitivity reactions
type 1 - immediate, allergies and anaphylaxis. IgE
type 2 - IgG and IgM cytotoxic. may be involved in anaphylactoid.
type 3 - immune complex IgG or IgM.
type 4 - t cell mediated
type 5 - part of the type 2 reaction mediated by IgG or IgM complement. certain autoimmune diseases fall in to this category. e.g. graves and myasthenia gravis.
103
if over 60 and has a few bloody stools with mucus and lower abdo pain what are the most common causes
1 - most common is diverticular disease
2 - angiodysplasia is the 2nd. variable presentation from asymptomatic to frank malaena or haematochezia (fresh or altered blood)
3 - ischaeic colitis - usually have left lower abdo pain with loose stools and blood
4 - colonic chrons - colitis with bloody diarrhoea, abdo pain and systemic features such as fever and tachycardia.
5 - colonic malignancy
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basics of DKA management
rehydration and insulin therapy are the mainstays.
1L normal saline in 30 mins.
500ml saline every 30 mins with K added, titrated to serum potassium levels. check via ABG initially.
105
management of hyperkalaemia
1 - treat underlying causes
2- review medications
3- if mild then polystyrene sultanate resin e.g. Calcium resonium 15g/8h PO - binds K in the gut, brings levels down over a few days. can give as enema if vomiting.
4 - if evidence of myocardial excitability (do an ECG) or levels over 6.5mmol/l then get help and treat as an emergency.
a - stabilise cardiac membrane with 10ml 10% calcium gluconate over 10 mins
b - drive K into cells with 10 units act rapid in 50ml 20% glucose
c - if dehydrated give a fluid challenge, smaller vol if impaired
d- reassess, refer to renal team early
106
management of hypokalaemia
if less than 2.5mmol/L need to treat as emergency. NB it will exacerbate digoxin toxicity
1 - if mild, e.g. over 2.5 and no symptoms then give oral K e.g. Sando-K 2tabs/8hr
2 - if severe, less than 2.5 and/or symptomatic give IV K not more than 20mmol/hr, not more concentrated than 40mmol/L. never ever give as a stat bolus.
107
what are rhonchi
Rhonchi are coarse rattling respiratory sounds somewhat like snoring, usually caused by secretions in bronchial airways.
108
what happens to an ABG if you accidentally expose it to air
pH rises, CO2 reduces.
109
what happens to an ABG if you leave it for a while
decreases O2, increases CO2, decreases pH as metabolism continues.
110
what happens if you are giving a blood transfusion and someone has an urticarial reaction -
be careful to differentiate from anaphylaxis, more like a rash and itch but no issues breathing or cardiovascular compromise.
slow or stop the transfusion and give IV or oral chlorphenamine.
111
oxygen conc given by a hudson mask
50-60% at a rate of 5-8L/min
112
oxygen conc given by nasal specs
2l = 28%
4 l = 35%
6 l = 45%
113
what is the TIMI score
In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making.
114
acute management of a primary pneumothorax
1- SOB and or rim of air over 2cm on CXR?
if no - consider discharge
if yes go to step 2
2 - aspirate.
if successful consider discharge
if not, got to step 3
3 - consider repeat aspiration.
if successful consider discharge
if not, insert a chest drain
115
acute management of a secondary pneumothorax
1 - SOB and over 50years AND rim of air over 2cm on CXR?
if yes, insert a chest drain
if no, aspirate. if that fails then insert a chest drain, if it is successful then admit for 24hours.
116
classification of different degrees of blood loss
class 1 - under 750 ml lost. 0-15%. no change in BP or RR, tacky but below 100. thirsty
class 2 - 750-1500ml - 15-30% raised diastolic BP not systolic. HR 100-120 normal RR anxious
class 3 - 1500-2000 ml 30-40% reduce BP, HR 120 thready, RR over 20, changed mental state is drowsy
class 4 - over 2 litres over 40% very low BP/unrecordable. HR over 120 and thready RR over 20. drowsy confused or unconscious.
117
use of the ABCD2 scoring system
validated as a predictor of future risk of stroke in patients with TIAs in AandE.
1 - age over 60
2 - BP over 160 sys or 90 dia
3 - clinical - unilateral weakness (2 points), speech disturbance only = 1, other =0
4 - duration of symptoms- over 60 mins = 2, 10-59 = 1, less than 10 = 0.
5 - diabetes
all points = 1 unless stated. range 0-7
risk of stroke in next 48 hrs:
6-7 = 8%
4-5 = 4%
0-3 = 1%
```
indicators for hospital admission =
1 - score over 4
2 - continuing symptoms
3 - more than 4 TIAs in the past 2 weeks
4 - known neuromuscular stenosis.
5 - already on anti platelet therapy
6 - suspected cardiac emboli
7 - diagnostic uncertainty.
```
118
a PT presents having had a generalised siezure of no obvious cause and no history of seizures. how do you manage
either do an emergency CT and admit to investigate and treat r send home to be followed up by the GP.
indications for the emergency CT head:
- focal defecit
- fever
- head injury
- persistent headache
- use of anticoagulants
- history of AIDS
- prolonged post-ictal state.
119
what is Somatisation disorder
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Somatisation disorder
multiple physical SYMPTOMS present for at least 2 years
patient refuses to accept reassurance or negative test results
120
what is Hypochondrial disorder
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Hypochondrial disorder
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer
patient again refuses to accept reassurance or negative test results
121
what is Conversion disorder
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Conversion disorder
typically involves loss of motor or sensory function
the patient doesn't consciously feign the symptoms (factitious disorder) or seek material gain (malingering)
patients may be indifferent to their apparent disorder - la belle indifference - although this has not been backed up by some studies
122
what is Dissociative disorder
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Dissociative disorder
dissociation is a process of 'separating off' certain memories from normal consciousness
in contrast to conversion disorder involves psychiatric symptoms e.g. Amnesia, fugue, stupor
dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder
123
what is Munchausen's syndrome
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Munchausen's syndrome
also known as factitious disorder
the intentional production of physical or psychological symptoms
124
what is Malingering
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Malingering
fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain
125
difference between cohort and case control study
Cohort study Observational and prospective. Two (or more) are selected according to their exposure to a particular agent (e.g. medicine, toxin) and followed up to see how many develop a disease or other outcome.
The usual outcome measure is the relative risk.
Examples include Framingham Heart Study
Case-control study Observational and retrospective. Patients with a particular condition (cases) are identified and matched with controls. Data is then collected on past exposure to a possible causal agent for the condition.
The usual outcome measure is the odds ratio.
Inexpensive, produce quick results
Useful for studying rare conditions
Prone to confounding
126
what happens in Osteomalacia
Basics
normal bony tissue but decreased mineral content
rickets if when growing
osteomalacia if after epiphysis fusion
```
Types
vitamin D deficiency e.g. malabsorption, lack of sunlight, diet
renal failure
drug induced e.g. anticonvulsants
vitamin D resistant; inherited
liver disease, e.g. cirrhosis
```
Features
rickets: knock-knee, bow leg, features of hypocalcaemia
osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy
Investigation
low calcium, phosphate, 25(OH) vitamin D
raised alkaline phosphatase
x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures)
Treatment
calcium with vitamin D tablets
127
8 reversible causes of cardiac arrest in the ALS formula
hypopxia
hypovolaemia
hypo/hyperkalaemia/ metabolic
hypothermia
tension pneumothorax
tamponade cardiac
toxins
thrombosis - coronary of pulmonary
128
what is see saw breathing a sign of
along side a silent chest it is a sing of complete airway obstruction.
129
what happens if someone goes in to cardiac arrest but you dont know if they are DNACPR or not
you start CPR before clarifying their DNACPR status.
| compressions come first
130
if a PT appears to have an upper GI bleed what is a good quick test that can hlep confirm this
a PR
131
in paracetamol overdose why dont you take bloods before 4hrs?
as the drug is still being absorbed and distributed and thus the result is unreliable.
132
who is at risk of liver damage even with just a little paracetamol
enzyme inducing drugs and those likely deficient in glutathione eg people with cystic fibrosis HIV infection, an eating disorder or who are cachexic or starved.
133
when is activated charcoal used
in paracetamol overdose but only within the first hour.
134
what classifies a PE as a MASSIVE PE
a systolic BP below 90mmHg. these need urgent assessment with a view to thrombolysis as cardiac arrrest is imminent.
135
why might a PT with COPD present with an addisonian crisis?
as they are on long term steroids!! any condition in which steroids is a treatment option consider whether a drop in BP and GCS is due to an addisonian crisis.
136
thrombolysis for PE
an immediate intravenous bolus of 50 mg alteplase administered during cardiopulmonary resuscitation may be life saving
137
ALS - if someone is in the middle of CPR but the ECG changes to an organised rhythm what do you do?
unless the patient shows signs of life that are compatible with the return of spontaneous circulation you should keep going with that round of CPR before assessing.
138
what is the power of a study
The power of a study is the probability of (correctly) rejecting the null hypothesis when it is false, i.e. the probability of detecting a statistically significant difference
power = 1 - the probability of a type II error
power can be increased by increasing the sample size
139
whats the p value of a study
The p value is the probability of obtaining a result by chance at least as extreme as the one that was actually observed, assuming that the null hypothesis is true. It is therefore equal to the chance of making a type I error (see below).
140
what are Two types of errors may occur when testing the null hypothesis
Two types of errors may occur when testing the null hypothesis
type I: the null hypothesis is rejected when it is true - i.e. Showing a difference between two groups when it doesn't exist, a false positive. This is determined against a preset significance level (termed alpha). As the significance level is determined in advance the chance of making a type I error is not affected by sample size. It is however increased if the number of end-points are increased. For example if a study has 20 end-points it is likely one of these will be reached, just by chance.
type II: the null hypothesis is accepted when it is false - i.e. Failing to spot a difference when one really exists, a false negative. The probability of making a type II error is termed beta. It is determined by both sample size and alpha
