Principles Flashcards
What is the most common type of intimate partner violence?
What is the most common type of physical abuse?
Emotional abuse most common: 30.5%
Physical abuse 2nd most common: 8.5%
Sexual abuse: 3.3%
Of physical abuse:
Head/neck trauma most common
Orthopaedic injuries second most comon (sprains, fractures, dislocations, foot injuries)
Grafting of burns should take place within what time frame?
Within 5 days
In the aging population, what should the training regimen involve?
resistance
endurance
balance
flexibility
What addidtional specieis do you have to cover for in fresh and saltwater contaminated open fractures?
Fresh
Aeromonas hydrophilia (G-)
Vibrio
Salt
Clostridia (tetanus)
Vibrio
Virchow’s triad
Venous stasis
Hypercoaguable state
Endothelial injury
What is the major arterial supply to gastrocs flap
Sural artery (for both medial and lateral)
What is the term to define a loss of function resulting from an anatomic or physiologic derangement
Impairment
What is the best route and dosing for postop analgesics in a morbidly obese individual?
IV patient controlled analgesia (PCA) based on ideal body weight (not actual)
Avoid subcutaneous/submuscular (poor blood supply –> increased infectiion risk)
What anesthetics have an effect on neuromonitoring?
inhalational - affects both SSEP and MEP
neuromuscular blockage: MEPs only
What is the immune response when transplanting fresh articular cartilage allograft?
There is none, even when unmatched
There is once you start adding in cells, like BM aspirate
Mechanism of Tocilizuab
IL-6 antagonist
Do acidic or alkaline burns penetrate deeper?
Alkali
List 4 ways to optimize intra-operative cultures
No pre-op antibiotics
Bone and Soft Tissue Samples
>= 5 samples
Hold cultures for 10-14 days
toughness
amount of energy per unit volume a material can absorb before failure
= area under the stress/strain curve
units: joules/m3
When does braking time return to normal after:
knee arthroscopy
Surgical management of ankle fracture
After initiation of weight bearing following major lower extremity fracture?
knee arthroscopy: 4 weeks
Surgical management of ankle fracture: 9 weeks
After initiation of weight bearing following major lower extremity fracture: 6 weeks
Stress Strain curve: Yeild strength
amount of stress necessary to produce a specific amount of permanent deformation
Can a person drive with a simple forearm cast?
Yes (JAAOS 2013)
But not if the elbow is immobilized
What percentage of patietns in fracture clinic have been victims of intimate partner violence:
Overall:
this year:
Specifically for this visit:?
Overall: 33% (1 in 3)
this year: 15% (1 in 6)
Specifically for this visit: 2% (1 in 50)
Consequences of paralytic ileus (6)
abdominal pain
malnutrition
prolonged hospital stay
hospital readmission
bowel perforation
death
Define neuropraxia
Disruption of myelin sheath only, causing focal conduction block
No wallerian degeneration
full recovery expected
Higher Young’s modulus means what?
Young’s modulus of elasticity
Higher Young’s modulus = A stiffer material = more ability to resist deformation
What percentage of women presenting to ER with injuries are a result of domestic violence?
Up to 35%
What immunoglobulin does rheumatoid factor target?
IgG
It is an IgM that targets the Fc portion of IgG
Criteria for Bisphosphonate Related Fractures
Major
- None or minimal trauma (fall from standin or less)
- Originates from lateral cortex & is transverse or short oblique in nature
- If complete, fracture extends through both cortices and may be associated with a medial spike (incomplete fractures only involve lateral cortex)
- Fracture is noncomminuted or minimally comminuted
- Localized periosteal or endosteal thickening of the latearl cortex is present at the fracture site (beaking or flaring)
Minor
- Generalized increase in cortical thickness of the femoral diphaysis
- Unilateral or bilateral prodromal sx (thigh pain)
- Bilateral incomplete or complete femoral diphyseal fractures
- Delayed fracture healing
Need 4/5 major. NO minor (they are just associations)
2013 American Society for Bone Mineral Task Force, as per JAAOS 2015
Ideal candidate for fresh osteochondral allograft?
Young (<25)
Symptoms < 1 year
They have better results and higher return to sport
2 muscles innervated by axillary nerve
Deltoid
teres minor
Ways to optimize for bone healing?
Provide mechanical stability and a favorable biologic environment
Tobacco cessation
glycemic control
nutritional optimization
- Vit D deficiency
management of metabolic and endocrine abnormalities
- thyroid
- parathyroid
- central hypogonadism
What is the only anticoagulation prophylaxis recommended by AAOS in all risks groups undergoing THA or TKA?
Pneumatic compression devices
Mixing what 2 metals has the highest risk of galvanic corrosion?
316L stainles steel and cobalt chromium (Co-Cr)
Nerve repair of what nerve has the best and the worst outcomes
Best: radial
Worst: peroneal
The following nerves had excellent recovery potential:
- the radial, musculocutaneous, and femoral nerves.
The following nerves had moderate recovery potential:
- the median, ulnar, and tibial nerves.
The following nerve had poor recovery potential:
- the peroneal nerve.
Name the 3 main triggers of bone erosion in RA:
Synovitis
Anti-citrullinated protein antibodies (Anti-CCP)
RANKL
What do you have to do post-op medication-wise in patient with CRF
Specifially analgesia, abx, DVT prophylaxis
Narcotics:
decrease dose
Hydromorphone: reduce to 25% and titrate
Morphine: none (max short term only)
Anticoagulatns:
Unfractionated heparin, warfarin, ASA, clopidogrel, argatroban OK - no dose adjustment
No: LMWH, fondaparinux, dabigatran
Antibiotics
Ancef:1-2g IV q24
Describe updated CANMEDS
Medical Expert
Professional
Communicator
Collborator
Leader
Health advocate
Scholar
(no more Manager)
Hysteresis
Energy dissipation
characteristic of viscoelastic materials
the loading curve does not follow the unloading curve
the difference between the two curve is the energy that is disspitated
In relation to TB arthropathy.
What is Phemister’s Triad?
Juxta-articular osteopenia/osteoporosis
Peripheral osseous erosions
Gradual narrowing of joint space
What medication combined with MTX makes it more effective against RA?
Doxycycline
Components of WHO pre op sign in
Before induction of anesthesia
Plastic deformation
irreversible changes in shape to a material due to a load
material DOES NOT return to original shape when load is removed
Salt water open fracture. Treatment?
doxycycline and ceftazidime, or a fluoroquinolone
Mechanism of Etanercept:
TNF-alpha inhibitor
2 dDx for erosive arthritis
Inflammatory arthritis
TB - always think TB & ask about foreign travel
Kid steps on a nail at a cottage.
what is your initial magagement?
Tetanus
I&D in ER
No need for abx - tell them to return if any signs/symptoms
FYI: remember NEVER to give cipro to a kid - risk of tendon rupture
After contaminated needle stick, risk of:
HIV
Hep B
Hep C
HIV: 0.3%
Hep B: 37-62% (good thing we got our shots)
Hep C: 0.5-1.8%
2 factors/cytkines that promote differentiation into osteoclasts:
RANKL (releaesd by osteoblasts), M-CSF
Peroneus brevis flaps are good for:
distal 1/3 coverage leg
small defects only
Characteristics of an abused patient
Change in affect
Constantly seeking partner approval
Finding excuses to stay in treatment facility for prolonged period of time
Repeated visits to the emergency department
Significant time missed at work or decreased productivity at work
Define ICER
Incremental cost effectiveness ratio
Determines which intervention is more cost effective in a patient population
Define health utility
Reflects a patient’s preference for a particular health state or health-related outcome in a single index number between 0 (death) & 1(perfect health)
When can a patient drive after THA?
4-6 weeks
Who should be screened for intimate partner violence?
Who should screen?
All women in a fracture clinic
Screening should be done by an IPV coordinator
(Sprague & Bhandari 2013)
Define axonotmesis
Disruption of myelin sheath and axon
Endoneurium is intact
leads to conduction block with wallerian degeneration
Managment of Anti-TNFa inhibitors perioperatively
Etanercept: discontinue 1-2 weeks prior, restart when wound is healed (2 weeks)
Rituximab: discontinue 2 months prior
All other: discontinue 1 month prior
Complications of transfusion (especially massive transfusion)
thrombocytopenia
coagulation factor depletion
stored blood contains all coag factors except V and VIII
DIC consequence of delayed or inadequate resus
oxygenic affinity changes
Hypocalcemia
side effects of hypocalcemia ® tetany, hypotension, arrhythmias
hyperkalemia
not a problem unless very large amounts of blood given quickly
acid / base disturbances
hypothermia (frozed PRBCs – warmed to room temp)
leads to tendency to cardiac dysrhymthmias
ARDS/TRALI
What antihypertensives should you hold preop?
ACE-I
ARB
Components of WHO Sign out
Before patient leaves OR
Best test for RA
Anti-CCP
Most sensitive and specific
Stress
intensity of an internal force
= force/area
units: Pascal’s (Pa) or N/m2
What test is diagnostic for hypophosphatasia?
Increased urine phosphoethanolamine
What material is the most susceptible to crevice corrision?
316L stainless steel
Best way to size fresh osteochondral allograft for the knee?
AP x-ray
(MRI are worse)
ARDS criteria
- acute, meaning onset over 1 week or less
- bilateral opacities consistent with pulmonary edema must be present and may be detected on CT or chest radiograph
- PF ratio
- “must not be fully explained by cardiac failure or fluid overload,” in the physician’s best estimation using available information — an “objective assessment“ (e.g. echocardiogram) should be performed in most cases if there is no clear cause such as trauma or sepsis.
(Berlin criteria)
Name a common location of fretting corrision
Head neck junction in THA
Important aspects of consent
Capacity
Disclosure (of material risks and benefits)
Demonstrate Understanding (synthesize, ask good questions)
Voluntary
Indications for thoracotomy in ATLS
Hemothorax >1500mL initially
Hemothorax >200-300mL/hr
Penetrating injury with PEA
Formula for absolute risk reduction
ARR = control event rate - treatment event rate
Sleep apnea has what effect post-op?
Increased complications, including
in hospital mortality
PE
wound hematoma/seroma
Can be diagnosed with STOP BANG (see pic)
JAAOS 2014
How does TXA work?
inhibits fibrinolysis via inhibition of activation of plasminogen
What is a thixotropic fluid?
It’s viscosity decreases with increase rate of movement (ie with increasing shear)
Sorry..it was on an exam
List 4 occupational hazards to the pregnant or lactating woman in the orthopaedic OR:
Radiation exposure
Physical stress
Blood borne pathogens (HIV, HCV, HBV)
Harmful chemical (PMMA, inhalational anesthestics)
Treatment of CRPS
1st line:
Gentle PT, stretching
Medications: NSAIDs, anti-depressants, alpha blockers, CCBS, antidepressants, anticonvulsants, GABA agonists
Nerve stimulation: type II only
Operative
Surgical sympathectomy
Indicated in failed nonoperative management
The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant
The bending rigidity of a solid cylindrical pin is related to the fourth power of the pin’s radius. The bending rigidity of the implant shown in Figure A is proportional to what power of the measured radius of the implant
Bleeding risk in patients with Chronic renal fialure?
INcreased ris of BOTH bleeding and thrombosis
5 poor prognostic indicators in nerve injuries
Old >54
Proximal nerve injury
- At level of wrist, 50% good recovery
Graft >7cm
War injuryBlast:
- Large zone of injury or heavily contaminated
Surgery delayed >18 months
Fasiculations: a sign of upper or lower motor neuron lesion?
Lower
List 4 principles of treating fractures through burned skin
If fracture needs OR:
Definitive treatment ideal
Through alternate skin incision if possible
If incision must be through burn, must do this within 48hrs
If >48hrs (tissue will be colonized):
- Ex-fix (until wounds healed)
- Splint (until wounds healed)
- ORIF at the same time of wound debridement and skin grafting
How long is the consolidation phase of distraction osteogenesis technique?
2x transport
5 ways to decrease risk of injury with a tourniquet:
Time:
< 2 hours generally safe
Deflation time: The more the better (at least 30 mins)
Pressure
<200 mmHg in UE (or 50 above sBP)
<250mmHg in LE (or 100 above sBP)
Best is to measure Limb Occlusion Pressure using commercially available devices
Shape
Wide
Conical
Other
Not using a tourniquet
Having 2 cuffs and alternating between them
Well padded
Post-op, what adjustment to post-op pain control will redheads need ?
Higher dosing
What levels of MAP and PaO2 are protective in spinal surgery/post spinal trauma?
MAP > 85mmHg
PaO2 > 60mmHg
3 main cytokines in RA
TNF-alpha, IL-1, IL-6
After frostbite, administration of what drug has been shown to decrease rates of amputation?
Tissue plasminogen activator
Thought that thrombosis after re-warming leads to necrosis/amputation
What is the most common cause of OM?
Staph aureus in all age groups and demographics (including IVDU)
What percentage of women have been abused in the last 12 months?
2013 PRAISE - Lancet/Multinational Study: 1/6
2011 PRAISE - JBJS Ontario Only, smaller study = 1/3
So I would say 1/6, bigger study.
** Should say IPV rather than abuse. IPV includes physical, emotional and sexual.
What does the OTA & American College of Chest Physicians recommend as anticoagulation prophylaxis?
LMWH
(JAAOS is wishy washy)
General principles of delivering bad news/news of complication:
Sit down 1 on 1 with patient
Find a quiet, non-rushed environment
Turn off pager and cell phone
Tell them what happened
Tell them what we will do:
- a. to correct the patient’s problem
- b. to ensure that this will not happen again (patient’s want to hear this)
Ask if they have any questions
T/F:
Most people lose weight after THA/TKA
False
Most people DO NOT lose weight after TKA
So the idea that we give people a TJA to help them lose weight is bullshit
Classificaiton of CRPS
Type I: CRPS without demostrable neve lesion
most common
Type II: CRPS with evidence of obvious nerve damage
For optimal wound healing, albumin should be:
>3.0g/dL
Nerve repair spiel
I will aim for a tension free repair in a clean wound bed
Name 5 local and 5 systemic manifestations of using a tourniquet
Local
Post-operative swelling and stiffness
Delay in recovery of muscle power
compression neurapraxia
wound hematoma
Wound infection
Direct vascular injury
Bone and soft-tissue necrosis
Compartment syndrome
Systemic:
increased VP
arterial hypertension
cardiorespiratory decompensation
Cerebral infarction (CVA)
Alterations in acid-base balance
Rhabdomyolysis
DVT (controversial)
Contraindications to hyperbaric oxygen therapy
Chemo or radiation therapy
- pressure-sensitive implanted medical device:
- defibrillator, pacemaker, dorsal column stimulator, insulin pump
- Undrained pneumothorax
Define neurontmesis
Complete disruption of the nerve, including disruption of endoneurium
No recovery unless surgial repair performed
After burns, what level of urine output should be maintained?
at least 2mL/kg/hr
(for 70kg man: 140mL/hr)
What medication has been shown to increase skeletal muscle regeneration and decrease fibrosis (in animal models)
Angiotension II Receptor blockers (Losartan)
What do you do after identifying a medical error?
Offer an apology to family/patient
Provide full disclosure (explain what happened)
Accept responsibility
Offer corrective steps to prevent recurrence
Document fully
Call CMPA
(an apology is NOT the same as accepting blame. You are sorry for what happened, not for doing something bad)
Define a neurologic level in SCI
Lowest level with normal sensation and 3/5 power
So the lowest normal level
If there is a lesion at L3, it would be an L2 level
In other words, an L2 level means everything below L3 is messed
What is the additional energy expediture for the following:
Transtibial amputation
Long transtibial amputation
Transfemoral amputation
Transtibial amputation: 25%
Long transtibial amputation: 10%
Transfemoral amputation: 65%
Name the CanMeds Components
Professional
Health advocate
Medical expert
Manager
Scholar
Communicator
Collaborate
“Please Help Me Memorize Stupid Canmeds Crap”
Who should be listed as an author on a research paper?
Each author should have participated sufficiently in the work, including:
Conception or design, or analysis and interpretation of data, or both
Drafting the article or revising it for critically important intellectual content
Final approval of the version to be published
*participation solely in the collection of data does not justify authorship (ie can’t be in it if you let your patient’s take part)
Mortality rate of fat emboli syndrome?
15%
Contraindications to primary closure in open fracture
- Inadequate debridement
- Gross contamination
- Farm related or freshwater immersion injuries
- Delay in treatment >12 hours
- Delay in antibiotic administration
Describe Brooker Classification
Classification for HO
class I: represents islands of bone w/in soft tissues about hip
class II: inclues bone spurs in pelvis or proximal end of femur leaving at least 1 cm between the opposing bone surfaces;
class III: represents bone spurs that extend from pelvis or the proximal end of femur, which reduce the space between the opposing bone surfaces to less than 1 cm;
class IV: indicates radiographic ankylosis of the hip;
Classic radiographic findings with TB arthorpathy?
Phemister’s triad
juxta-articular osteopaenia/osteoporosis
peripheral osseous erosions
gradual narrowing of joint space
*Major dDx of inflammatory arthritis - always ask