OSCE Stations- Surgery

Question 1

What do you need to go through with fractures in terms of how to present?

Answer 1

The demographics
Whether it is AP/lateral/oblique

Whether it is a closed or open fracture

Where the fracture is (metaphysis, diaphysis, epiphysis, intra articular)

Whether the fracture is displaced or non displaced

Question 2

What signs would you expect in hip fractures?

Answer 2

Short and externally rotated leg

Question 3

What Ix would you do for hip fractures?

Answer 3

Need to find out why they fell- ECG, bloods, CXR (need to see if respiratory reserve is good enough for surgery), echo if HF
G andS, cross match

Question 4

What does non comminuted mean?

Answer 4

It means bones are in little parts

Question 5

What is the line that can help you identify NOF fractures?

Answer 5

Shentons

Question 6

What are the risk factors for NOFs?

Answer 6

Age 
Osteporosis 
Low musclem ass
Steroids
Smoking 
Alcohol

Question 7

What can hip fractures be categorised as?

Answer 7

Can be categorised as either intra or extra capsular depending on the location

Anything above the intertrochanteric line= intracapsular

Anything below the intertrochanteric line=
Extracapsular

Question 8

What are the two types of extra-capsular fractures?

Answer 8

Subtrochanteric

Intertrochanteric

Question 9

Why is intracapsular fracture worse than extracapsular fracture?

Answer 9

Disruption of the reticular blood supply (medial and lateral circumflex arteries may be damaged) leads to avascular necrosis of the head of femur.

Question 10

What is the garden classification?

Answer 10

This is for intra capsular NOF fractures, it is useful to guide management

Garden 1= incomplete fracture
Minimally displaced

Garden 2= complete fracture non displaced

Garden 3= complete fracture,
Partially displaced

Garden 4= complete fracture, completely displaced

Question 11

How do you treat intracapsular fractures?

Answer 11

1,2 screw
3,4 austin moore

This means that in garden 1/2 fractures internal fixation is used with screws

However if garden 3/4 hemi or total hip replacements are done

(In young fit patients urgent reduction and internal fixation is often attempted first)

Question 12

Who would you do a THR in?

Answer 12

NICE guidelines state that you do a THR in…

1) someone who is able to walk independently out of doors with no more than the use of a stick AND
2) are not cognitively impaired

AND

3) are medically fit for anaesthesia and the procedure

Question 13

How do you manage extracapsular hip fractures?

Answer 13

Intertrochonateric- DHS/IM nail

Subtrochanteric- IM nail

Question 14

What is the post op management for NOF fractures?

Answer 14

Post op PT/OT are key helping pts mobilise and get home safely

Delirium is common post and pre op and should be screened for

Look out for chest infections and urinary tract infections are also relatively common. Less often op site haematoma or op site infections may be seen

Pts are at increased risk of DVT and PE following hip fracture and surgical fixation, normally prophylactic dose LMWH is started 6-12 hours post op, this will usually be continued got a month
TED stockings and intermittent pneumatic compression may be used

Question 15

After a hip fracture when should you encourage mobilisation?

Answer 15

Patients should be encouraged to mobilise the day after surgery. Early mobilisation helps reduce the risk of blood clots, chest infections and deconditioning. Patients should have daily physiotherapy as an inpatient and a plan for community support at discharge.

Patients home situation should be reviewed and a re-ablement package instituted as needed to (ideally) return the patient to their home or care home.

Question 16

What are bisphosphonates used for?

Answer 16

They are used to reduce the risk of hip and spine fractures in osteoporosis, they may also be used at different doses to treat pagets disease of the bone

Question 17

How should your patient take bisphosphonates?

Answer 17

Take it on an empty stomach with a glass or two of plain tap water
Don’t eat or drink anything other than tap water or take any other medication or supplements for at least 30 minutes afterwards, this is to ensure the medication is effectively absorbed

You will beed to stay upright for up to an hour afterwards to prevent the medication flowing back from your stomach and causing heartburn

You shouldn’t lie down after taking bisphosphonate until after you have eaten

Question 18

What are the SES of bisphosphonates?

Answer 18

Osteonecrosis of the jaw
Abdominal discomfort
Oesophageal irritation
Dermatological reactions

Question 19

What is a T score?

Answer 19

A T score is used to categorise bone mineral density. It refers to the standard deviation above or below the normal bone mineral density for a young patient of the same gender with peak bone mass

Normal > or equal to 1
Osteopenia

Question 20

What is a Z score?

Answer 20

The standard deviation above or below the normal BMD for the patients age

Question 21

What is compartment syndrome?

Answer 21

A particular complication that may occur following fractures (or following ischaemia reperfusion injury in vascular patients)

It is characterised by raised pressure within a closed anatomical space

The raised pressure within the compartment will eventually compromims tissue perfusion resulting in necrosis.

Question 22

What are the twi main fractures compartment syndrome occurs in?

Answer 22

Supracondylar fractures

Tibial shift injuries

Question 23

What are the features of compartent syndrome?

Answer 23

Pain, especially on movement (even passive)- excessive use of breakthrough analgesia should raise suspicion for compartment syndrome

Parasthesiae

Pallor may be present

Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise

Paralysis of the muscle group may occur

PRESENCE of pulse does not rule out compartment syndrome!!

Question 24

How is compartment syndrome diagnosed?

Answer 24

A diagnosis is made by measurement of intracompartmental measurements

Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic

Question 25

What is the treatment of compartment syndrome?

Answer 25

This is essentially prompt and extensive fasciotomies
In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
Death of muscle groups may occur within 4-6 hours

Question 26

How do you treat DVT?

Answer 26

Do the wells score, if DVT likely= 2+ or more
DVT unlikely= 1 point or less

If DVT is likely then a proximal leg US should be carried out within 4 hours

If a DVT is ‘unlikely’ (1 point or less)
perform a D-dimer test
this should be done within 4 hours. If not, interim therapeutic anticoagulation should be given until the result is available
if the result is negative then DVT is unlikely and alternative diagnoses should be considered
if the result is positive then a proximal leg vein ultrasound scan should be carried out within 4 hours
if a proximal leg vein ultrasound scan cannot be carried out within 4 hours interim therapeutic anticoagulation should be administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)

Anticoagulant of choice now=DOACS

if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the patient has antiphospholipid syndrome (specifically ‘triple positive’ in the guidance) then LMWH followed by a VKA should be used

Question 27

What is refeeding syndrome?

Answer 27

Metabolic abnormalities which occur on feeding a person following a period of starvation (after surgery)
The metabolic consequences include….

Hypophosphataemia 
Hypokalaemia 
Hypoomagnesadmia (may peecede to torsades de pointes) 
Abnormal fluid balance 
May lead to organ failure

Question 28

What are the risks of re feeding syndrome?

Answer 28

NICE produced guidelines in 2006 on nutritional support. Refeeding syndrome may avoided by identifying patients at a high-risk of developing refeeding syndrome:

Patients are considered high-risk if one or more of the following:
BMI < 16 kg/m2
unintentional weight loss >15% over 3-6 months
little nutritional intake > 10 days
hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

If two or more of the following:
BMI < 18.5 kg/m2
unintentional weight loss > 10% over 3-6 months
little nutritional intake > 5 days
history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids

NICE recommend that if a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.