R2 LOCO2 Flashcards
How much blood loss is possible from the first 2hrs from
Tibia / fibula region [1]
Femur region [1]
Pelvic region [1]
Possible blood loss within the first 2 hours
tibia/fibia= 500ml
femur= 500ml
pelvic= 2000ml
Open pelvic fracture bleeds are commonly caused by damage to which structures? [3]
- Posterior pelvic venous plexus (85%)
- Bleeding from trabecular bone
- < 10 % is arterial source
Define the damage the occurs in each of the following:
neuropraxia
axonotemsis
Neurotmesis
- Neurapraxia: no axonal discontinuity
- Axonotmesis: axoplasmic disruption endoneural sheath intact
- Neurotmesis: axon disrupted loss of tubules, support cells destroyed
Define what is meant by a degloving injury [1]
avulsions or detachment of the skin and subcutaneous tissue from the underlying muscle and fascia secondary to a sudden shearing force applied to the skin surface
Define crush injury [1] and crush syndrome [1]
Crush injury:
* Injury caused as a result of direct physical crushing of the muscles due to something heavy.
Crush syndrome:
* Also termed rhabdomyolysis, involves a series of metabolic changes produced due to an injury of the skeletal muscles of such a severity as to cause a disruption of cellular integrity and release of its contents into the circulation.
Which organ may speficcally be damaged in soft tissue injury [1]
Kidney damage
What type of reduction would you use for a Colles fracture? [1]
Closed reduction (alignment without angulation) with a splint
What are absoulte indications for operative treatment? [5]
- Displaced intra-articular fractures
- Open fractures
- Fractures with vascular injury or compartment syndrome
- Pathological fractures
- Non-unions
What are current relative indications for operative treatment? [4]
- Loss of position with closed method
- Poor functional result with non-anatomical reduction
- Displaced fractures with poor blood supply
- Economic and medical indications
Healing time
Define what clinical union is [1]
Define what radiological union [1]
Clinical union:
* the bones move as one and can be tender when stressed
Radiological union:
* Bridging callus formation
* Fracture line is often still present
* Remodelling
State the healing time for
:)
What is an early [1] and late [3] complication to bone from trauma?
Early:
* infection: osteomyelitis
Late:
* Non-union
* Mal-union
* AVN
What is are early [4] and late [3] complication to soft tissue from trauma?
Early:
* Plaster sores
* Infection
* Neurovascular injury
* Compartment syndrome
Late:
* Tendon rupture
* Nerve compression
* Volkmann contracture
Define volkman contracture [1]
Volkmann contracture is a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm.
The condition is also called Volkmann ischemic contracture.
What triad of things are you looking for with a fat embolism? [3]
Lung involement: causes hypoxaemia
Brain involvement: fat droplets get lodged in white matter in brain
Petachie: droplets get stuck in vessels and cause haemorrhage
Tx for fat embolism? [3]
Fluids
O2
Albumin
What are the 6Ps of compartment syndrome? [6]
Which one is early? [1] and which is late? [1]
Pale
Pulseless
Parenthesis: first stage
Pain
Paralysis: late stage
Polar
What pressures are normal in compartment? [1]
What are elevated [1] and emergency [1] pressures in a compartment?
Why are these clinically significant? [2]
Normal 0-10mmHg
Elevated 20-30mmHg: venous flow compromised
Emergency 30+ mmHg: arterial flow compromised
What delta pressures would be a definite indication [1] and relative indication for a fasciotomy? [2]
< 20mmHg = definite indication for a fasciotomy
< 30mmHg = relative indication for a fasciotomy
Apart from increases in delta pressures, name two indications for a fasciotomy [2]
- Interruption of arterial perfusion for 4 or more hours
- Clinical signs of acute compartment syndrome
Biggest cause of mortality in septic arthritis is
Staphylococcus aureus
Streptococci spp.
Clostridium sp
Neisseria gonorrhoea
Escherichia coli
Biggest cause of mortality in septic arthritis is
Staphylococcus aureus
Septic arthritis
What investigations would you conduct to diagnose? [5]
- Elevated ESR
- Children: neutrophilia
- Synovial fluid analysis: yellow & cloudy; lumpy & purelent
- Gram stain positive: due to Staphylococcus aureus being the most common
- Blood culture positive
How would a S. aureus infection appear in culture? [1]
Appears as grape like clusters, on trypticase soy agar plate produces yellow pigment: staphlyoxanthin
Describe how septic arthritis joint (synovial) fluid examination would present [4]
Turbid or purulent
Leukocytes >50,000/mm3, pred. neutrophils
Gram stain positive in one-third
< 25mg/dL glucose (much lower than serum)
How does mycobacterial infection cause radiological changes? [4]
Joint space narrowing
Effusion
Erosions
Cyst formation
Describe radiological changes seen in septic athritis patients? [4]
May see soft tissue swelling
Joint capsule distension
Destructive changes seen after at least 2 weeks
* Erosion of articular surface
* Associated soft tissue swelling
Why does acute blood born osteomyelitis affect children? [2]
Have a very rich blood supply to the bones, especially the metaphyseal ends of the long bones as this is where the growth plate is
The capillary loops near the metaphysis have slow flow/sluggish flow due to a rich blood supply here, meaning they are more at risk for bacterial invasion of the bone from the blood here
Describe how osteomyelitis causes abscesses to grow
- Bacteria enters the bone, it commonly lodges just below the epiphyseal growth plate
- Bone produces new bone around the bacterial infection to try and wall off and contain the bacteria in one location, however it walls it off yet this cannot be accessed by antibiotics as it is walled off.
- Can cause bone to die
Common consequences of osetomeylitis? [2]
Rare consequences of osetomeylitis? [2]
Common:
* Local bone loss
* Persistent drainage through sinuses
Rare
* Squamous cell carcinoma
* Amyloidosis
Risk factors for osteomyelitis? [6]
Age
Malnutrition
Impairment of local vascular blood supply:
* Diabetes mellitus
* Venous stasis
* Radiation fibrosis (radiation therapy damaging blood vessels)
* Sickle cell disease (due to crisis)
Describe how you diagnose osteomyelitis [4]
How does it appear on ultrasound? [2]
(same as SA)
Local non-specific pain
Elevated neutrophil count (< 50% of cases)
Elevated ESR
Ultrasound:
* Cortical thinning
* Inflamation
* Periosteal lifiting: abscess lifting it off
How do you treat chronic osteomyelitis? [5]
Puncture drainage if abscessed
Surgical debridement
Reconstruct bone (allograft/ autograft)
Antibiotics (4-6wks, at least 2 IV):
* Vancomyocin cement beads
* Flucoxallin (gram +ve)
* Clindamycin
* Piperacillin
* Ciprofloxacilin
How do you investigate for chronic osteomyelitis? [3]
MRI:
* Bone scintigraphy if MRI not available or suspicion of multifocal osteomyelitis - radiation that shows reactive bone
- Bone biopsy
- Blood samples
- Radiography
Describe treatment of chronic osteomyeltis [5]
Puncture drainage if abscess identified
Reconstruct bone (allograft or autograft)
Surgical debridement to remove dead bone
Antibiotics for 4-6 weeks (at least 2wks IV):
* vancomycin cement beads: dissolve and give steady supply of vancomycin
Bone graft (& muscle graft)
Which antibiotics would you give for chronic osteomyelitis [1]
Vancomycin cement beads
Why does joint infection occur when giving prosthetic bone / joint replacements occur? [2]
Where does it occur? [2]
Occurs in osseous tissue adjacent to prosthesis:
* bone cement interface
* bone contiguous with prosthesis (cementless devices)
Results from:
* local inoculation at surgery or post-op spread from wound sepsis
* haematogenous spread
Management of infections that have occurred from joint replacement infections? [2]
Removal of prosthesis, antibiotics for 6wks, re-implantation of new prosthesis 4 weeks after removal - 90%+ success
Long term suppressive antibiotics
Name an organism that cause septic arthritis for each organism type of bacteria
Gram positive cocci [1]
Gram positive bacilli [1]
Gram negative cocci: [1]
Gram negative bacilli [1]
Gram positive cocci: staphylococcus aureus
Gram positive bacilli: clostridium sp
Gram negative cocci: Neisseria gonorrhoea
Gram negative bacilli: Escherichia coli, pseudomonas aeruginosa, haemophilus influenza
In which joints is reactive arthritis most common in? [2]
How does it differ from septic arhritis? [1]
knees, ankles and feet
completely sterile: no bacteria or virus, and normally clears up in a couple days.
What is sequestrum in chronic osteomyelitis? [1]
What is Involucrum in chronic osteomyelitis? [1]
Sequestrum: fragment of necrosed bone that has become separated from surrounding tissue
Involucrum: covering or sheath that contains a sequestrum of bone
Which of the following is a fibrous ligament
achilles ligament
deltoid ligament
spring ligament
patella ligament
spring ligament
Which of the following is associated with enthesitis
RA
OA
Ankylosing sponditlitis
Gout
Which of the following is associated with enthesitis
RA
OA
Ankylosing sponditlitis
Gout
Unloading by temporary paralysis is most beneficial for which type of tendons?
Long tendons that undergo tendon-bone healing
Short tendons that undergo tendon-bone healing
Long tendons that undergo flexor tendon healing
Short tendons that undergo flexor tendon healing
Short tendons that undergo tendon-bone healing
Which IL is specifically associated with enthesitis?
IL-1
IL-6
IL-8
IL-10
IL-23
IL-23
Vincular arteries supply
Ligaments
Enthesis
Tendons
Perimysium
Tendons
Name the condition for pain at the tendon at the arrow [1]
De Quervain’s tenosynovitis
Name the condition for this tendon condition [1]
Trigger finger
Which drug class is used for ankylosing spondylitis enthesitis? [1]
Anti-TNF treatment
Corticosteroid injection
Sulfasalazine
Methotrexate
Anti-TNF treatment
Discoid lesions are assoicated with
Ankylosing spondylitis
Systemic lupus erythematosus
Dermatomyositis
Scleroderma
SLE
Jaccoud arthropathy is a deforming non-erosive arthropathy characterized by ulnar deviation of the 2nd to 5th fingers with metacarpophalangeal joint subluxation.
Which of the following is it associated with
Belimubab inhibits BAFF (B cell activating factor). It is used to treat
Ankylosing spondylitis
Systemic lupus erythematosus
Dermatomyositis
Scleroderma
Rheumatoid arthritis
Systemic lupus erythematosus
A characterisitic of [] arthritis is that it can be moved back into the correct position. What is this arthritis called? [1]
Jaccoud arthritis
What pathology is depicted here? [1]
Trigger finger
Superficial and deep flexor tendons with local tenosynovitis at the metacarpal head subsequently develop localised nodal formation on the tendon, distal to the pulley (Fig. 1). The A1 pulley is the most frequently involved ligament in trigger finger.
Which of the following is most commonly involved ligament in trigger finger?
A1 pulley
A2 pulley
A3 pulley
A4 pulley
A5 pulley
A1 pulley
