T&O (General Principles)

Question 1

State the three principles of Fracture Management

Answer 1

Reduce
Hold
Rehabilitate

Question 2

What is Reduction?

Answer 2

Restoring the anatomical alignment of a fracture/dislocation
Normally done in a closed setting but may be open
Generally requires three people (one to reduce, one to provide countertraction, one to apply plaster)

Question 3

What is ‘Hold’

Answer 3

Term for immobilising a fracture

Question 4

When might traction be required with the ‘Hold’ principle

Answer 4

If muscular pull is particularly strong it may naturally displace the fracture
Commonly required for #NOF, Pelvic and Femoral Fractures

Question 5

Give two principles of Splints/Plasters

Answer 5

• For the first two weeks the plaster is not circumferential (allows for swelling and prevents compartment syndrome)
• If axial instability then the plaster needs to cross the joint above and below

Question 6

What is Rehabilitation?

Answer 6

Intensive phsiotherapy required by most patients

Question 7

What are the X-Ray features of OA?

Answer 7

L - Loss of joint space
O - Osteophytes
S - Subchondral Cysts
S - Subchondral Sclerosis

Question 8

How do intra-articular steroids work for OA?

Answer 8

Typically mixed with local anaesthetic which improves symptoms for a few hours
Will subsequently have a steroid flare which will worsen symptoms for a few days

Question 9

Describe three surgical managements of OA

Answer 9

Osteotomy - Bone is cut to change its alignment
Arthrodesis - Fusing the joint to prevent movement and pain
Arthroplasty - Replacement or reconstruction of a joint

Question 10

What is an Open Fracture?

Answer 10

When there is a direct communication between the fracture and the external environment
(Usually through the skin, pelvic ones may be through vagina/rectum)

Question 11

State the two types of Open Fractures

Answer 11

In to Out - Broken bone has punctured and broken through the skin
Out to In - Penetrating injury also caused fracture

Question 12

What is the Gustilo-Anderson classification of Open Fractures?

Answer 12

1 - less than 1cm wound and clean
2 - 1 to 10cm wound and clean
3a - Greater than 10cm wound and high energy
3b - Greater than 10cm wound and high energy, with significant tissue loss
3c - All injuries with vascular injury

Question 13

Give 4 principles of management of Open Fractures

Answer 13

• Involve the correct specialty (3a is Orthopaedics only, 3b involve plastics, 3c involve vascular)
• Realignment and resplinting
• Broad spectrum Abx and Tetanus
• Photograph and dress wound

Question 14

What is Compartment Syndrome?

Answer 14

Critical pressure increase in a non distensible fascial compartment
Causes include: High energy trauma/Crush Injury/DVT/Tight Casts

Question 15

Describe three features of Compartment Syndrome pathophysiology

Answer 15

• As pressure increases, veins compress increasing hydrostatic pressure, forcing fluid out further increasing pressure
• Paraesthesia as traversing nerves are compressed
• Ischaemia is Pressure is greater than diastolic

Question 16

Give 4 clinical features of Compartment Syndrome

Answer 16

• Paraesthesia
• Severe Pain (Disproportionate to injury)
• Affected area may feel tense
• Arterial insufficiency stage - 6P’s

Question 17

Compartment Syndrome is typically a clinical diagnosis, but suggest two possible investigations

Answer 17

• Upward trending CK levels

- Intracompartmental pressure monitor

Question 18

Give 3 principles of management for Compartment Syndrome

Answer 18

• Pre Op (High Flow O2, IV Crystalloid Fluids, IV Opioid Analgesia)
• Fasciotomy
• Monitor Renal Function (Rhabdomyolysis, Reperfusion Syndrome)

Question 19

Define Septic Arthritis

Answer 19

Infection of a joint (can be prosthetic or natural)

Can cause irreversible damage to articular cartilage leading to severe OA

Question 20

Describe the three modes of infection in Septic Arthritis

Answer 20

Bacteraemia (UTI, Pneumonia)
Direct Inoculation
Spreading from adjacent Osteomyelitis

Question 21

Give 4 causative organisms of Septic Arthritis

Answer 21

S.Aureus
Streptococci
N.Gonorrhoea
Salmonella

Question 22

State four risk factors of Septic Arthritis

Answer 22

Age>80
DM
IVDU
Joint Prosthesis

Question 23

How would Septic Arthritis present?

Answer 23

• 60% have fever
• Single swollen joint causing severe pain
• Often joint is rigid and patient is unable to weight bear

Question 24

Give four investigations for Septic Arthritis

Answer 24

• Routine Bloods
• Blood Cultures (atleast 2 different samples)
• Joint Aspiration PRE Abx
• XRay

Question 25

How is Septic Arthritis managed?

Answer 25

• Extensive Antibiotics (atleast 6 weeks with the first two being IV)
• Extensive Surgical Irrigation and Debridement

Question 26

What is Osteomyelitis?

Answer 26

Infection of the bone that causes progressive inflammatory destruction and formation of new bone
Can be acute or chronic

Question 27

Describe the three mechanisms of infective spread causing Osteomyelitis

Answer 27

• Haematogenous
• Direct Inoculation with normal vascularity
• Contiguous spread with poor vascularity (eg Diabetic
  Foot)

Question 28

Describe the pathophysiology of Osteomyelitis in five steps

Answer 28

1) Pathogen settles in a bone, creating a biofilm
2) Inflammation creates sub-periosteal reaction, lifting the periosteum from bone (appears like a tumour on the XRay)
3) No blood supply/nutrition from the periosteum devitalises it (AKA Periosteal Stripping)
4) Necrosis of bone results in Sequestrum formation (floating piece of bone - acts as a resevoir of infection)
5) Involucrum formation (AKA new bone)

Question 29

Describe the clinical features of Osteomyelitis

Answer 29

• Low grade pyrexia

- Severe Pain (may be worse at night) (except in diabetic patients)

Question 30

What is Pott’s Disease?

Answer 30

Infection of vertebral body and intervertebral discs with Mycobacterium Tuberculosis, normally affecting thoracolumbar region
Back Pain/Low Grade Fever
Investigate with MRI

Question 31

What is the definitive investigation of Osteomyelitis?

Answer 31

MRI

Question 32

How is Osteomyelitis managed?

Answer 32

• Long term IV antibiotics (atleast 4 weeks)

- If evidence of deterioration - curettage of affected area

Question 33

Give two complications of Osteomyleitis

Answer 33

Growth disturbances in Children due to premature epiphyseal closure
Chronic Osteomyelitis

Question 34

Name 5 common primary tumours that metastasise to bone

Answer 34

Thyroid
Lung
Breast
Kidney
Prostate

Question 35

Give 3 risk factors for Bone Tumours

Answer 35

Genetic (RB1, P53)
Previous Radiation Exposure
Benign Bone Conditions (Pagets, Fibrous Dysplasia)

Question 36

Give two presenting features of a Primary Bone Tumour

Answer 36

• Pain (worse at night)

- Fracture without trauma

Question 37

Name four benign Primary Bone Tumours

Answer 37

Osteoid Osteoma
Osteochondroma
Chondroma
Benign Osteoclastoma

Question 38

Where do Osteoid Osteomas and Osteochondromas normally form?

Answer 38

Metaphyses of bones

Question 39

Name three malignant Primary Bone Tumours

Answer 39

Osteosarcoma
Ewing’s Sarcoma
Chondrosarcoma

Question 40

Osteosarcoma is the most common malignant bone tumour, describe the bimodal age distribution

Answer 40

• 10 to 14

- >65

Question 41

How would Osteosarcomas appear on an X-Ray?

Answer 41

Medullary and Cortical Bone Destruction

Question 42

How are Osteosarcomas managed?

Answer 42

Aggressive surgical resection and chemotherapy to prevent metastases?

Question 43

What is Ewing’s Sarcoma?

Answer 43

A paediatric malignancy of poorly differentiated neurectodermal cells commonly affecting the diaphyses of long bones

Question 44

How does Ewing’s Sarcoma present on an X-Ray?

Answer 44

Onion Skin

Question 45

What is the staging system for bone tumours?

Answer 45

Enneking

Question 46

Which one of the clinical signs is most strongly suggestive of Acute Compartment Syndrome?

Answer 46

Passive Stretch of Muscle Belly initiating pain