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MD2 > Skin, soft tissue, bone > Flashcards

Skin, soft tissue, bone Flashcards

1
Q

Cellulitis pathogens and antibiotic treatment

A

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

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2
Q

Cellulitis investigations

A

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
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3
Q

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

A

Chronic Lymphedema

Manage w:
Gentle resistance training, compression bandaging, massage, meticulous skin and nail care to prevent risk of secondary cellulitis

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4
Q

Risk factors for cellulitis

A 
Peripheral oedema
Lymphatic stasis 
Trauma
IVDU
Ulcers
Wounds
Tinea pedis
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5
Q

Red swollen skin

Differentials

A

Cellulitis or erysipelas
Chronic Lymphedema
Acute contact dermatitis
Gout/pseudogout

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6
Q

Definition of osteoporosis

A

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)

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7
Q

Definition of osteopenia

A

Bone mineral density with T-score between -1 and -2.5

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8
Q

Cause of primary osteoporosis

A

Post-menopausal women have less oestrogen which results in resorption>mineralisation

Older men have less testosterone (to be converted to oestrogen)

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9
Q

Causes of secondary osteoporosis

A

Bone marrow disorders (MM, lymphoma, leukaemia)

Endocrine (Cushings, hyperparathyroid, hyperthyroid, diabetes)

Drugs (steroids, androgen deprivation therapy, aromatase inhibitors)

Rheum: RA, SLE, ankylosing spondylitis

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10
Q

Clinical features of OA

A

Asymptomatic
Height loss
Fractures (hip, vertebrae, humerus, wrist)
Backache (assoc w fractures)

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11
Q

Management of osteoporosis

A

Ca supplements
Vitamin D
Bisphosphonates

Surgery in extreme cases

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12
Q

Investigations for osteoporosis

A 
DXA scan (bone scan)
Lateral spine x ray looking for crush fractures

Bloods: FBE, ESR, UEC, Ca, Vitamin D, TFT

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13
Q

What is osteomalacia and what are common causes?

A

Vitamin D deficiency leading to soft bones

CKD or CLD
Dietary deficiency of vitamin D
Decr UV exposure
Malabsorption

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14
Q

What is Paget’s disease of the bone?

A

A metabolic disease characterised by excessive bone destruction and repair (excessive osteoclast activity)

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15
Q

SX of PAget’s disease

A

Asymptomatic
Bone pain
Skeletal deformity
High output congestive cardiac failure

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16
Q

Ca, Ph, ALP (from bone turnover) for

Osteoporosis
Osteomalacia
Paget’s

A

Osteoporosis: all normal

Osteomalacia: low Ca and Ph, incr ALP

Paget’s: normal Ca and Ph, incr ALP

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17
Q

Treatment of Paget’s

A

SX: analgesia

Vit D, Ca, exercise

Bisphosphonates and surgery if needed (fractures, deformity, degenerative change)

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18
Q

Plain film findings of osteomyelitis

A 
Soft tissue swelling
Lytic bone destruction (seen 10-12 days after onset)
Periosteal reaction (formation of new bone in response)
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19
Q

Treatment acute osteomyelitis

A

IV antibiotics (empirical and then adjust based on blood and aspirate cultures)

Surgery for abscess

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20
Q

Causes of septic joint

A

Haematogenous spread

Staph aureus
Neisseria gonorrhoea (if sexually active)
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21
Q

Risk factors for septic joint

A 
Age >80
DM
RA
Prosthetic joint
Recent joint surgery
skin infection/ulcer
IVDU
intra-articular injections (steroids)
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22
Q

Treatment septic joint

A

IV antibiotics

Small joints: serial needle aspirates until sterile

Large joints: surgical washout

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23
Q

5 Ps of compartment sydrome

A 
Pain
Pallor (late finding)
Paraesthesia
Paralysis (late finding)
Pulselessness (late finding)
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24
Q

treatment compartment syndrome

A

Non-operative: remove any dressings and elevate limb

Operative: urgent fasciotomy followed by wound closure +/- necrotic tissue debridement

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25
Q

Describing a fracture (6)

A
  1. Where
  2. Integrity of skin/soft tissue (simple/complex/open/closed)
  3. Angle (transverse/spiral/oblique/comminuted/semgmental)
  4. Pattern of fracture (non-displaced/non-displaced/distracted/angulated/impacted/rotated/shortened)
  5. Pathological fracture
  6. Complications (malunion/nonunion i.e. failed bone healing)
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26
Q

Indications for open reduction

A 
NO CAST
□ Non union
□ Open fracture
□ NV compromise
□ Intra-articular fracture
□ Salter-Haris 3,4,5
□ Polytrauma
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27
Q

treatment of fractures

A

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

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28
Q

Complications of fractures

Early vs Late

A

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
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29
Q

Hill Sachs lesion

A

Refers to cortical depression in posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim

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30
Q

Bankart lesion

A

Refers to avulsion of the anterior glenoid labrum from the glenoid rim

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31
Q

Claviclar fracture -where does this normally occur?

Complications?

A

Lateral 2/3s

Pneumothorax
AC joint dislocation

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32
Q

Treatment septic arthritis

A

Surgical washout and deep specimens for culture and susceptibility testing
+IV antibiotics

33
Q

SSX red hot painful swollen joint

A

Septic arthritis
Septic bursitis
Gout/pseudogout
Haemarthrosis

Cellulitis
Underlying osteomyelitis

34
Q

MX necrotising fasciitis

A

§ 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)

35
Q

What is osteosarcoma?

Who gets it?

A

Primary malignant neoplasm of the bone

Common in adolescent males
Secondary to paget’s disease of the bone
HX of chemo or radiotherapy

36
Q

What is the Gustilon-Anderson classification used for?

What are the levels?

A

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)

37
Q

Post-Op orders following internal fracture reduction and debridement

A 
Fluids, IV antibiotics, Intranasal O2
Bed rest
Elevate
4 hourly 'foot obs' via nurses 
Pulses - cap return, movement, sensation, temperature.
38
Q

How could you anaesthetise the arm for reduction of a colles fracture?

A
  • 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)
39
Q

Define OA

A

Degenerative arthritis - gradual wear and tear of hyaline CARTILAGE resulting in joint pain, stiffness and functional limitation

40
Q

Clinical features of OA

A

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

41
Q

Risk factors for OA

A 
Old age
Obesity (joint loading and low level inflammation)
Female
Fam HX, genes 
Diabetes (ineffective repair, AGEs)
Trauma, physical/manual occupation
42
Q

X-ray changes for OA

A

LOSS:

Loss of joint space
Osteophytes
Subchondral cysts
Subarticular sclerosis

43
Q

X ray changes RA

A

Jutra-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space

44
Q

Management OA

A

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

45
Q

Investigating OA

A

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)

46
Q

Complications of OA

A 
Functional decline
Joint effusion
Spinal stenosis (with cervical/lumbar OA)
GI bleed (NSAIDs)
47
Q

Back pain - DDX

A
  1. MSK (includes OA)
  2. Fractures
  3. Infection (discitis, osteomyelitis)

RED FLAG conditions:

  1. AAA (referred)
  2. Malignancy - primary or spinal mets
  3. Epidural abscess or hematoma
  4. Spinal cord compression (disc prolapse, osteophytes) causing neurological deficit or cauda equina syndrome
48
Q

Define RA:

A

Autoimmune inflammatory disorder primarily attacking the joint and leading to decr ROM and deformity, but may also affect the lungs, heart and RBCs

49
Q

Pathophys of RA

A

Chronic inflammation INITIALLY INVOLVING SYNOVIAL membrane and progressing to erode the cartilage and underlying bone.

  • Inflammation and tethering of tendons
  • Thickening of joint capsule
50
Q

Risk factors for RA

A

Genetics

Smoking

51
Q

Clinical features of RA

A

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

52
Q

Extra articular manifestations of RA

A

Anaemia of chronic disease

Skin: Rh nodules

Lungs: fibrosis, granulomatous nodules, pleural effusions

Heart: Pericarditis, pericardial effusion, incr risk PVD, MI, Stroke

Eyes: Sjogrens

53
Q

Deformities of RA

A 
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

54
Q

Investigations for suspected RA

A

Bloods: Rh factor, Anti-CCP
-FBE, ESR, CRP

X-ray may be normal at onset (U/S or MRI to detect early changes)

55
Q

Management of RA

A

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

56
Q

Steroids - side effects

A 
Weight gain
Osteoporosis
AVN
Cataracts, glaucoma
PUD
Infection 
Easy bruising
Acne
HTN, HLDaemia
Hypokalaemia, hyperglycaemia
Mood swings
57
Q

Steroids - side effects

A 
Weight gain
Osteoporosis
AVN
Cataracts, glaucoma
PUD
Infection 
Easy bruising
Acne
HTN, HLDaemia
Hypokalaemia, hyperglycaemia
Mood swings
58
Q

Role of the parathyroid gland

A

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.

59
Q

14 year old girl with 3 month history of increasing pain in R knee.

Give 3 likely DDX

A

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.

60
Q

Investigations for diagnosed osteosarcoma (discovered on x-ray)

A
  1. 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.
  2. CT - see if can excise tumour (if it is in at most 2 msucle compartments)
61
Q

What is a crush fracture?

A

Assoc w comminution with great damage to surrounding soft tissue. Heavy object falling on limb.

62
Q

What is a greenstick fracture?

A

○ Greenstick - bone breaks on one side only with the other side in tact. Common in children.

63
Q

What is a hairline fracture?

A

○ Hairline - disruption of crystalline matrix partial disruption of collagen matrix, and periosteum is intact. Least fracture that you can get.

64
Q

Fracture healing: the 4 steps

A
  1. Haematoma formation
  2. Soft callous formation
  3. Hard callous formation
  4. Bone remodelling
65
Q

FNOF - how will the leg be oriented?

A

Externally oriented with shortening of leg

66
Q

What does the Garden classification refer to?

A 
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
67
Q

Immediate MX of an open fracture (10 steps)

A
  1. Take pics
  2. IM analgesia
  3. Copious wash w large amount of normal saline
  4. Reduction to protect soft tissue and NV structures
  5. Dress w sterile gauze soaked in NS and antiseptic
  6. Immobilise w splints
  7. IV antibiotics
  8. Tetanus
  9. Imaging
  10. refer to ortho
68
Q

With what neural pathology do you get a “claw hand”

A

Ulnar and Median Nerve - results in extensors working unopposed.

Extensors extend the MCP joint and flex the IP joints

69
Q

Aspects of hand injury exam

A

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
70
Q

When might you suspect tenosynovitis and what is this?

A

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

71
Q

What is froment’s test

A

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

72
Q

Risk of crush injury

A

infection and tissue necrosis

73
Q

Risk of shear injury

A

Tissue iscahemic necrosis from vascular compromise

74
Q

Risk of puncture wound

Management

A

Risk deep infection

Cleaning is difficult - needs to be excised and irrigated.

IV antibiotics

75
Q

Management of basic hand injuries

A

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)

76
Q

MX for hand wound located over a joint

A

Aggressive surgical treatment: debridement, irrigation, Antibx

Risk if septic arthritis which causes permanent cartilage loss and joint destruction

77
Q

What sort of hand injuries always get referred onto plastics (NOT sutured up in ED)

A

Open punch injury (ex: tooth to knuckle)

Animal bite

Wound over joint

Amputation

Tenosynovitis

Necrotising infections

78
Q

Basic principles of wound management

A

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)

MD2 (16 decks)

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