Skin, soft tissue, bone Flashcards
Cellulitis pathogens and antibiotic treatment
Staph aureus
Strep pyogenes
Staph epidermidis
Empiracle antibiotics:
Di/flucloxacillin for staph aureus, strep pyogenes. And/or phenoxymethylpenicillin for strep progenies
Cephalexin if hypersensitive to penicillin
Cellulitis investigations
Often none are needed but:
- MCS if purulent wound exudate present
- blood cultures if haemodynamically unstable/severe cellulitis/lack of response to empiric therapy
- CT or MRI if necrotising fasciitis suspected
- USS to rule out DVT
58yo man presents with bilateral red swollen legs (non-pitting).
No response to oral cephalexin
Non-elevated WCC and CRP. NO evidence DVT on USS.
Diagnosis?
Management
Chronic Lymphedema
Manage w:
Gentle resistance training, compression bandaging, massage, meticulous skin and nail care to prevent risk of secondary cellulitis
Risk factors for cellulitis
Peripheral oedema Lymphatic stasis Trauma IVDU Ulcers Wounds Tinea pedis
Red swollen skin
Differentials
Cellulitis or erysipelas
Chronic Lymphedema
Acute contact dermatitis
Gout/pseudogout
Definition of osteoporosis
Decreased bone mass and micro architectural deterioration leading to increase in bone fragility and susceptibility to fracture
Bone mineral density >=2.5SD below the peak bone mass for young adults
( T-score <= -2.5)
Definition of osteopenia
Bone mineral density with T-score between -1 and -2.5
Cause of primary osteoporosis
Post-menopausal women have less oestrogen which results in resorption>mineralisation
Older men have less testosterone (to be converted to oestrogen)
Causes of secondary osteoporosis
Bone marrow disorders (MM, lymphoma, leukaemia)
Endocrine (Cushings, hyperparathyroid, hyperthyroid, diabetes)
Drugs (steroids, androgen deprivation therapy, aromatase inhibitors)
Rheum: RA, SLE, ankylosing spondylitis
Clinical features of OA
Asymptomatic
Height loss
Fractures (hip, vertebrae, humerus, wrist)
Backache (assoc w fractures)
Management of osteoporosis
Ca supplements
Vitamin D
Bisphosphonates
Surgery in extreme cases
Investigations for osteoporosis
DXA scan (bone scan) Lateral spine x ray looking for crush fractures
Bloods: FBE, ESR, UEC, Ca, Vitamin D, TFT
What is osteomalacia and what are common causes?
Vitamin D deficiency leading to soft bones
CKD or CLD
Dietary deficiency of vitamin D
Decr UV exposure
Malabsorption
What is Paget’s disease of the bone?
A metabolic disease characterised by excessive bone destruction and repair (excessive osteoclast activity)
SX of PAget’s disease
Asymptomatic
Bone pain
Skeletal deformity
High output congestive cardiac failure
Ca, Ph, ALP (from bone turnover) for
Osteoporosis
Osteomalacia
Paget’s
Osteoporosis: all normal
Osteomalacia: low Ca and Ph, incr ALP
Paget’s: normal Ca and Ph, incr ALP
Treatment of Paget’s
SX: analgesia
Vit D, Ca, exercise
Bisphosphonates and surgery if needed (fractures, deformity, degenerative change)
Plain film findings of osteomyelitis
Soft tissue swelling Lytic bone destruction (seen 10-12 days after onset) Periosteal reaction (formation of new bone in response)
Treatment acute osteomyelitis
IV antibiotics (empirical and then adjust based on blood and aspirate cultures)
Surgery for abscess
Causes of septic joint
Haematogenous spread
Staph aureus Neisseria gonorrhoea (if sexually active)
Risk factors for septic joint
Age >80 DM RA Prosthetic joint Recent joint surgery skin infection/ulcer IVDU intra-articular injections (steroids)
Treatment septic joint
IV antibiotics
Small joints: serial needle aspirates until sterile
Large joints: surgical washout
5 Ps of compartment sydrome
Pain Pallor (late finding) Paraesthesia Paralysis (late finding) Pulselessness (late finding)
treatment compartment syndrome
Non-operative: remove any dressings and elevate limb
Operative: urgent fasciotomy followed by wound closure +/- necrotic tissue debridement
Describing a fracture (6)
- Where
- Integrity of skin/soft tissue (simple/complex/open/closed)
- Angle (transverse/spiral/oblique/comminuted/semgmental)
- Pattern of fracture (non-displaced/non-displaced/distracted/angulated/impacted/rotated/shortened)
- Pathological fracture
- Complications (malunion/nonunion i.e. failed bone healing)
Indications for open reduction
NO CAST □ Non union □ Open fracture □ NV compromise □ Intra-articular fracture □ Salter-Haris 3,4,5 □ Polytrauma
treatment of fractures
ABCs: primary and secondary survey
AMPLE history
Analgesia
Imaging
Splint
Reduction (open/closed) and stabilisation (external/internal) with follow up assessment of NV status and imaging
Will need anaesthetic +/- muscle relaxant
Rehabilitation to avoid stiffness and regain function
+/- Tetanus shot if open fracture
Complications of fractures
Early vs Late
Early Local
- Compartment syndrome
- Neurological injury
- Vascular injury
- Infection
Early Systemic
- Sepsis
- DVT/PE
- ARDS secondary to fat embolus
- Haemmhoragic shock
Late
- Non union/mal union
- AVN
- Osteomyelitis
- Heterotrophic ossification
- Post-traumatic OA
- Joint stiffness/adhesive capsulitis
Hill Sachs lesion
Refers to cortical depression in posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim
Bankart lesion
Refers to avulsion of the anterior glenoid labrum from the glenoid rim
Claviclar fracture -where does this normally occur?
Complications?
Lateral 2/3s
Pneumothorax
AC joint dislocation
Treatment septic arthritis
Surgical washout and deep specimens for culture and susceptibility testing
+IV antibiotics
SSX red hot painful swollen joint
Septic arthritis
Septic bursitis
Gout/pseudogout
Haemarthrosis
Cellulitis
Underlying osteomyelitis
MX necrotising fasciitis
§ Empiracle antibiotics
□ Meropenem
□ Vancomycin
□ Clindamycin
§ Referral to plastics and taken to theatre for mutliple surgical debridements (if muscle and fascia are necrotic)
§ Long hospitalisation and recovery (residual tissue defects and scarring)
What is osteosarcoma?
Who gets it?
Primary malignant neoplasm of the bone
Common in adolescent males
Secondary to paget’s disease of the bone
HX of chemo or radiotherapy
What is the Gustilon-Anderson classification used for?
What are the levels?
For open fractures
1: <1cm (closed with sutures)
2: 1-10cm (closed w sutures/graft)
3a-c: >10cm, will require free flaps to close (c has vascular injury)
Post-Op orders following internal fracture reduction and debridement
Fluids, IV antibiotics, Intranasal O2 Bed rest Elevate 4 hourly 'foot obs' via nurses Pulses - cap return, movement, sensation, temperature.
How could you anaesthetise the arm for reduction of a colles fracture?
- Probably use IV regional block (apply double tourniquet on arm, butterfly in back of hand, inject prilocaine)
- Prilocine can cause cardiac arrest if gets into systemic circulation, which is why you use a double tourniquet (so if one deflates, you have a backup)
Define OA
Degenerative arthritis - gradual wear and tear of hyaline CARTILAGE resulting in joint pain, stiffness and functional limitation
Clinical features of OA
Pain and crepitus, worst during use/at end of day and relieved by rest and panadol
Weight gain (pain limits exercise)
NO systemic SX or signs of inflammation (not hot/red)
Exam: Decr ROM, Heberden’s (DIP) and Bouchard’s (PIP) nodes
Common sites: hands (DIP, PIP, CMC), hip, knee, lumbar and cervical spine
Risk factors for OA
Old age Obesity (joint loading and low level inflammation) Female Fam HX, genes Diabetes (ineffective repair, AGEs) Trauma, physical/manual occupation
X-ray changes for OA
LOSS:
Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis
X ray changes RA
Jutra-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space
Management OA
Exercise
Weight loss if overweight
PT and OT (aids, splints, cane, brace)
Analgesia: paracetamol
+/- NSAIDs (topical or oral +PPI)
(+/- intraarticular steroid or hyaluronic acid injections)
Joint replacement (hips, knees) for severe disabling OA
Investigating OA
Exclude other causes (inflammatory, soft tissue, periarticular)
Bloods: Rh factor, ANA
Xray
+/- MRI (spinal OA for ?nerve compression and r/o AVN)
Synovial fluid analysis if an acute flare up with effusion (r/o inflammation)
Complications of OA
Functional decline Joint effusion Spinal stenosis (with cervical/lumbar OA) GI bleed (NSAIDs)
Back pain - DDX
- MSK (includes OA)
- Fractures
- Infection (discitis, osteomyelitis)
RED FLAG conditions:
- AAA (referred)
- Malignancy - primary or spinal mets
- Epidural abscess or hematoma
- Spinal cord compression (disc prolapse, osteophytes) causing neurological deficit or cauda equina syndrome
Define RA:
Autoimmune inflammatory disorder primarily attacking the joint and leading to decr ROM and deformity, but may also affect the lungs, heart and RBCs
Pathophys of RA
Chronic inflammation INITIALLY INVOLVING SYNOVIAL membrane and progressing to erode the cartilage and underlying bone.
- Inflammation and tethering of tendons
- Thickening of joint capsule
Risk factors for RA
Genetics
Smoking
Clinical features of RA
Symmetrical involvement of joints (MCP, PIP, IP, wrist, shoulder, knee, cervical spine)
Deformed joints
Hot, red, swollen, painful, Stiff joints
-Worse in the morning, after rest or prolonged inactivity
- Better with gentle movement
+/- low grade fever, lethargy, fatigue, anaemia
Extra articular manifestations of RA
Anaemia of chronic disease
Skin: Rh nodules
Lungs: fibrosis, granulomatous nodules, pleural effusions
Heart: Pericarditis, pericardial effusion, incr risk PVD, MI, Stroke
Eyes: Sjogrens
Deformities of RA
Ulnar deviation Boutonniere deformity (flexion PIP, extension DIP) Swan neck (extension PIP, flexion DIP) Z thumb (subluxation and fixed flexion of MCP, hyperextension of IP)
Claw, hammer and mallet toes
Investigations for suspected RA
Bloods: Rh factor, Anti-CCP
-FBE, ESR, CRP
X-ray may be normal at onset (U/S or MRI to detect early changes)
Management of RA
Lifestyle: exercise, diet, education
- PT and OT
- NSAIDs and corticosteroids (oral or intra-articular) + paracetamol
-DMARDs (methotrexate + folate first line)
Surgery for structural joint damage
Steroids - side effects
Weight gain Osteoporosis AVN Cataracts, glaucoma PUD Infection Easy bruising Acne HTN, HLDaemia Hypokalaemia, hyperglycaemia Mood swings
Steroids - side effects
Weight gain Osteoporosis AVN Cataracts, glaucoma PUD Infection Easy bruising Acne HTN, HLDaemia Hypokalaemia, hyperglycaemia Mood swings
Role of the parathyroid gland
Secretes PTH in response to low Ca
PTH acts to increase bone formation: PTH acts on bone to release Ca and Ph. Also on kidneys to retain Ca and form calcitriol (1-25vitD), which acts on the gut to increase absorption of Ca.
14 year old girl with 3 month history of increasing pain in R knee.
Give 3 likely DDX
Long history of chronic pain, think 3 diagnostic categories
DDX
• Malignancy (most serious although not most common) - osteosarcoma more likely in 14 year old girl
• Severe infection (osteomyelitis)
• Psychogenic - conversion syndrome
○ Exclude first 2 before diagnosing the third one.
Investigations for diagnosed osteosarcoma (discovered on x-ray)
- Biopsy -> Histological staging (stage 1 confined to bone; stage 2 have left the bony compartment; stage 3 have gone to lymphatics; stage 4 have metastasised)
- Osteosarcoma gernally always stage 4. - CT - see if can excise tumour (if it is in at most 2 msucle compartments)
What is a crush fracture?
Assoc w comminution with great damage to surrounding soft tissue. Heavy object falling on limb.
What is a greenstick fracture?
○ Greenstick - bone breaks on one side only with the other side in tact. Common in children.
What is a hairline fracture?
○ Hairline - disruption of crystalline matrix partial disruption of collagen matrix, and periosteum is intact. Least fracture that you can get.
Fracture healing: the 4 steps
- Haematoma formation
- Soft callous formation
- Hard callous formation
- Bone remodelling
FNOF - how will the leg be oriented?
Externally oriented with shortening of leg
What does the Garden classification refer to?
FNOF - refers to completeness of fracture and level of displacement 1 - incomplete fracture 2-complete w no displacement 3-complete w partial displacement 4- complete displacement
Immediate MX of an open fracture (10 steps)
- Take pics
- IM analgesia
- Copious wash w large amount of normal saline
- Reduction to protect soft tissue and NV structures
- Dress w sterile gauze soaked in NS and antiseptic
- Immobilise w splints
- IV antibiotics
- Tetanus
- Imaging
- refer to ortho
With what neural pathology do you get a “claw hand”
Ulnar and Median Nerve - results in extensors working unopposed.
Extensors extend the MCP joint and flex the IP joints
Aspects of hand injury exam
Assess:
-Blood supply (radial and ulnar pulses; colour; temp; cap refill)
- Nerves (radial, ulnar, median sensory and motor)
- Tendons (FDP passive and active; FDS-hold down other fingers)
- Bones/joints
When might you suspect tenosynovitis and what is this?
Infection of tendon sheath, may occur with penetrating injury of the tendon sheath
Suspect if a digit is out of the normal finger ‘cascade’ (slightly more extended than the others when relaxed)
Swollen, red, tender digit
What is froment’s test
Test ulnar nerve motor.
To perform the test, a patient is asked to hold an object, usually a flat object such as a piece of paper, between their thumb and index finger (pinch grip). The examiner then attempts to pull the object out of the subject’s hands.
Positive test - patient w ulnar nerve palsy will flex their thumb (median) in order to hold into the paper
Risk of crush injury
infection and tissue necrosis
Risk of shear injury
Tissue iscahemic necrosis from vascular compromise
Risk of puncture wound
Management
Risk deep infection
Cleaning is difficult - needs to be excised and irrigated.
IV antibiotics
Management of basic hand injuries
Clean wound
RICE: Compression, Rest (splint in position of function), Elevation, Ice
Antibiotics, Tetanus
Analgesia
Refer to plastics if suspect deep/penetrating injury (tendon/NV/joint)
MX for hand wound located over a joint
Aggressive surgical treatment: debridement, irrigation, Antibx
Risk if septic arthritis which causes permanent cartilage loss and joint destruction
What sort of hand injuries always get referred onto plastics (NOT sutured up in ED)
Open punch injury (ex: tooth to knuckle)
Animal bite
Wound over joint
Amputation
Tenosynovitis
Necrotising infections
Basic principles of wound management
Assess wound and patient
Wound swab for MCS -> sensitivities for ABx
Tetanus prophylaxis
Debridement (remove dead tissue and foreign matter) + Lavage/wash out
Wound closure
Dressings (+/- silver containing to reduce infection)
