Surgery B - Hip fracture, soft tissue infection and compartment syndrome

Question 1

What is the blood supply to femoral head?

Answer 1

• main bs via lateral epiphyseal artery 4/5ths
• lateral epiphyseal artery is the terminating branch of the medial circumflex artery
• medial circumflex also gives way to posterior inferior nutrient artery 1/5ths

Question 2

which important anastomoses contributes to blood supply of femoral head?

Answer 2

• anastomosis with inferior gluteal artery

- can be dominant vessel supplying the femoral head

Question 3

State three different types of hip fracture?

Answer 3

1. femoral neck fracture
2. intertrochanteric fracture
3. subtrochanteric fracture

Question 4

what type of healing does the femoral neck fracture have and why?

Answer 4

• poor healing
• femoral neck intracapsular
• lacks periosteal layer so callus formation limited
• disruption of blood supply

Question 5

what is the intertrochanteric area made from?

Answer 5

• dense trabecular bone

Question 6

what might be seen on clinical examination of neck of femur fracture?

Answer 6

• painful, shortened and externally rotated limb

- due to unopposed action of hip abductors and short rotators

Question 7

differential diagnoses for neck of femur fracture?

Answer 7

• pubic rami fracture
• pelvic fracture
• acetabular fracture

Question 8

86 y/o female

pc: neck of femur fracture
- banged her head when she fell
- did not lose consciousness
- on floor for three hours before neighbour found her

PMH
- AF, COPD, previous breast cancer

what aspects of history cause concern and why?

Answer 8

1. rhabdomyolysis: muscle breakdown biproducts can cause abnormal kidney function
2. pmh of AF, possibly on blood thinners, banged head. sus of intracranial bleed
3. COPD and previous breast cancer: could be on meds promoting o.porosis.

Question 9

86 y/o female

pc: neck of femur fracture
- banged her head when she fell
- did not lose consciousness
- on floor for three hours before neighbour found her

PMH
- AF, COPD, previous breast cancer

how should patient be managed?

Answer 9

• assess head injury
• IV access, blood tests as patient is likely to be dehydrated and in pain
• surgery within 36hrs

Question 10

79 y/o male
pc: pain in arm

OE: mild patchy erythema over anterior aspect of arm, now has pronounced blistering extending along most of his limb

OBS
- 127bpm, 84/50mmHg, 37.8, 92% sats, 26 RR

pmh: myelodysplasia, AF

being investigated for bowel cancer.

state some differentials:

Answer 10

Gas gangrene

cellulitis

necrotizing fascitis

impetigo

erysipelas

myositis

cutaneous anthrax

Question 11

what is myelodysplasia?

Answer 11

• type of blood cancer affecting bone marrow

Question 12

which condition has the following signs and symptoms?

• rapidly progressive infection with Clostridium
• usually follows penetrating trauma or crush injury
• interruption of blood supply to affected area

Answer 12

gas gangrene

Question 13

what investigation would confirm presence of gas gangrene?

Answer 13

• culture of infected tissue

- identified clostridium

Question 14

which condition has the following signs and symptoms?

• skin inflammation and erythema
• disproportionate pain on palpation of involved area and beyond
• haemorrhagic bullae and ecchymosis (late finding)
• skin anaesthesia and skin necrosis (late finding)

Answer 14

necrotizing fasciitis

Question 15

what differentiating investigation would be done for necrotizing fasciitis?

Answer 15

• skin biopsy

- LRINEC score

Question 16

which condition has the following signs and symptoms?

• patchy distribution with superficial blistering
• with or without bullae
• with crusting and erythema
• may have pruritus

Answer 16

impetigo

Question 17

what differentiating investigations would confirm impetigo?

Answer 17

• culture of infected tissue

- would identify staphylococcus aureus or strep pyogenes

Question 18

which condition has the following signs and symptoms?

• painful bright red, tender plaque with clear margins
• in superficial upper dermis of skin extending to lymphatic vessels within the skin
• well-defined, tender, bright red rash

Answer 18

erysipelas

• more superficial then cellulitis
• more clearly delineated borders compared with cellulitis

Question 19

the following points to a diagnosis of:

History of intravenous drug use, or contact with
animals or their products (e.g. hides, wool).

Painless, pruritic papule forms 2 to 5 days after
exposure.

Lesion becomes vesicular, evolving
Vesicular fluid/blood

Gram stain and culture:
gram-positive bacilli in
short chains (Bacillus

into a necrotic black eschar with massive
surrounding oedema 24 to 36 hours later.
Regional lymphadenopathy is common

Answer 19

cutaneous anthrax

Question 20

what organisms are suspected in causing necrotizing soft tissue infection?

Answer 20

necrotizing fasciitis can be classified by its microbiology

Type 1
- polymicrobial including gram positive cocci, gram negative bacilli and anaerobes

Type 2
- group A beta haemolytic streptococci with or without staph aureus

Type 3
- clostridium species

Question 21

management of gas gangrene?

Answer 21

a) antibiotics
- meropenem, clindamycin. vancomycin

b) shock and resus
c) hyperbaric oxygen
d) surgical debridement

Question 22

an example of a broad spectrum antibiotic effective against G+ve, G-ve and anaerobic bacteria

Answer 22

meropenem

Question 23

what is the principle management of open fractures?

Answer 23

IV antibiotics ideally within 3hrs injury
- co-amoxiclav

assess vascular and neurological status of limb

saline soaked gauze to cover wound after gross contamination has been removed