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
Describing a fracture (6)
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)
26
Indications for open reduction
``` NO CAST □ Non union □ Open fracture □ NV compromise □ Intra-articular fracture □ Salter-Haris 3,4,5 □ Polytrauma ```
27
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
28
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
29
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
30
Bankart lesion
Refers to avulsion of the anterior glenoid labrum from the glenoid rim
31
Claviclar fracture -where does this normally occur? | Complications?
Lateral 2/3s Pneumothorax AC joint dislocation
32
Treatment septic arthritis
Surgical washout and deep specimens for culture and susceptibility testing +IV antibiotics 
33
SSX red hot painful swollen joint
Septic arthritis Septic bursitis Gout/pseudogout Haemarthrosis Cellulitis Underlying osteomyelitis
34
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)
35
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
36
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)
37
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. ```
38
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)
39
Define OA
Degenerative arthritis - gradual wear and tear of hyaline CARTILAGE resulting in joint pain, stiffness and functional limitation
40
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
41
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 ```
42
X-ray changes for OA
LOSS: Loss of joint space Osteophytes Subchondral cysts Subarticular sclerosis
43
X ray changes RA
Jutra-articular osteopenia Soft tissue swelling Joint deformity Loss of joint space
44
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
45
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)
46
Complications of OA
``` Functional decline Joint effusion Spinal stenosis (with cervical/lumbar OA) GI bleed (NSAIDs) ```
47
Back pain - DDX
1. MSK (includes OA) 2. Fractures 3. Infection (discitis, osteomyelitis) RED FLAG conditions: 4. AAA (referred) 5. Malignancy - primary or spinal mets 6. Epidural abscess or hematoma 7. Spinal cord compression (disc prolapse, osteophytes) causing neurological deficit or cauda equina syndrome
48
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
49
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
50
Risk factors for RA
Genetics | Smoking
51
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
52
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
53
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
54
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)
55
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
56
Steroids - side effects
``` Weight gain Osteoporosis AVN Cataracts, glaucoma PUD Infection Easy bruising Acne HTN, HLDaemia Hypokalaemia, hyperglycaemia Mood swings ```
57
Steroids - side effects
``` Weight gain Osteoporosis AVN Cataracts, glaucoma PUD Infection Easy bruising Acne HTN, HLDaemia Hypokalaemia, hyperglycaemia Mood swings ```
58
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.
59
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.
60
Investigations for diagnosed osteosarcoma (discovered on x-ray)
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
What is a crush fracture?
Assoc w comminution with great damage to surrounding soft tissue. Heavy object falling on limb.
62
What is a greenstick fracture?
○ Greenstick - bone breaks on one side only with the other side in tact. Common in children.
63
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.
64
Fracture healing: the 4 steps
1. Haematoma formation 2. Soft callous formation 3. Hard callous formation 4. Bone remodelling
65
FNOF - how will the leg be oriented?
Externally oriented with shortening of leg
66
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 ```
67
Immediate MX of an open fracture (10 steps)
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
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
69
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
70
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
71
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
72
Risk of crush injury
infection and tissue necrosis
73
Risk of shear injury
Tissue iscahemic necrosis from vascular compromise
74
Risk of puncture wound Management
Risk deep infection Cleaning is difficult - needs to be excised and irrigated. IV antibiotics
75
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)
76
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
77
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
78
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)