Surgery B - Hip fracture, soft tissue infection and compartment syndrome Flashcards
What is the blood supply to femoral head?
- 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
which important anastomoses contributes to blood supply of femoral head?
- anastomosis with inferior gluteal artery
- can be dominant vessel supplying the femoral head
State three different types of hip fracture?
- femoral neck fracture
- intertrochanteric fracture
- subtrochanteric fracture
what type of healing does the femoral neck fracture have and why?
- poor healing
- femoral neck intracapsular
- lacks periosteal layer so callus formation limited
- disruption of blood supply
what is the intertrochanteric area made from?
- dense trabecular bone
what might be seen on clinical examination of neck of femur fracture?
- painful, shortened and externally rotated limb
- due to unopposed action of hip abductors and short rotators
differential diagnoses for neck of femur fracture?
- pubic rami fracture
- pelvic fracture
- acetabular fracture
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?
- rhabdomyolysis: muscle breakdown biproducts can cause abnormal kidney function
- pmh of AF, possibly on blood thinners, banged head. sus of intracranial bleed
- COPD and previous breast cancer: could be on meds promoting o.porosis.
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?
- assess head injury
- IV access, blood tests as patient is likely to be dehydrated and in pain
- surgery within 36hrs
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:
Gas gangrene
cellulitis
necrotizing fascitis
impetigo
erysipelas
myositis
cutaneous anthrax
what is myelodysplasia?
- type of blood cancer affecting bone marrow
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
gas gangrene
what investigation would confirm presence of gas gangrene?
- culture of infected tissue
- identified clostridium
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)
necrotizing fasciitis
what differentiating investigation would be done for necrotizing fasciitis?
- skin biopsy
- LRINEC score
which condition has the following signs and symptoms?
- patchy distribution with superficial blistering
- with or without bullae
- with crusting and erythema
- may have pruritus
impetigo
what differentiating investigations would confirm impetigo?
- culture of infected tissue
- would identify staphylococcus aureus or strep pyogenes
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
erysipelas
- more superficial then cellulitis
- more clearly delineated borders compared with cellulitis
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
cutaneous anthrax
what organisms are suspected in causing necrotizing soft tissue infection?
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
management of gas gangrene?
a) antibiotics
- meropenem, clindamycin. vancomycin
b) shock and resus
c) hyperbaric oxygen
d) surgical debridement
an example of a broad spectrum antibiotic effective against G+ve, G-ve and anaerobic bacteria
meropenem
what is the principle management of open fractures?
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
