T&O (General Principles) Flashcards
State the three principles of Fracture Management
Reduce
Hold
Rehabilitate
What is Reduction?
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)
What is ‘Hold’
Term for immobilising a fracture
When might traction be required with the ‘Hold’ principle
If muscular pull is particularly strong it may naturally displace the fracture
Commonly required for #NOF, Pelvic and Femoral Fractures
Give two principles of Splints/Plasters
- 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
What is Rehabilitation?
Intensive phsiotherapy required by most patients
What are the X-Ray features of OA?
L - Loss of joint space
O - Osteophytes
S - Subchondral Cysts
S - Subchondral Sclerosis
How do intra-articular steroids work for OA?
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
Describe three surgical managements of OA
Osteotomy - Bone is cut to change its alignment
Arthrodesis - Fusing the joint to prevent movement and pain
Arthroplasty - Replacement or reconstruction of a joint
What is an Open Fracture?
When there is a direct communication between the fracture and the external environment
(Usually through the skin, pelvic ones may be through vagina/rectum)
State the two types of Open Fractures
In to Out - Broken bone has punctured and broken through the skin
Out to In - Penetrating injury also caused fracture
What is the Gustilo-Anderson classification of Open Fractures?
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
Give 4 principles of management of Open Fractures
- 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
What is Compartment Syndrome?
Critical pressure increase in a non distensible fascial compartment
Causes include: High energy trauma/Crush Injury/DVT/Tight Casts
Describe three features of Compartment Syndrome pathophysiology
- 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
Give 4 clinical features of Compartment Syndrome
- Paraesthesia
- Severe Pain (Disproportionate to injury)
- Affected area may feel tense
- Arterial insufficiency stage - 6P’s
Compartment Syndrome is typically a clinical diagnosis, but suggest two possible investigations
- Upward trending CK levels
- Intracompartmental pressure monitor (>40mmHg diagnostic)
Give 3 principles of management for Compartment Syndrome
- Pre Op (High Flow O2, IV Crystalloid Fluids, IV Opioid Analgesia)
- Fasciotomy
- Monitor Renal Function (Rhabdomyolysis, Reperfusion Syndrome)
Define Septic Arthritis
Infection of a joint (can be prosthetic or natural)
Can cause irreversible damage to articular cartilage leading to severe OA
Describe the three modes of infection in Septic Arthritis
Bacteraemia (UTI, Pneumonia)
Direct Inoculation
Spreading from adjacent Osteomyelitis
Give 4 causative organisms of Septic Arthritis
S.Aureus
Streptococci
N.Gonorrhoea
Salmonella
State four risk factors of Septic Arthritis
Age>80
DM
IVDU
Joint Prosthesis
How would Septic Arthritis present?
- 60% have fever
- Single swollen joint causing severe pain
- Often joint is rigid and patient is unable to weight bear
Give four investigations for Septic Arthritis
- Routine Bloods
- Blood Cultures (atleast 2 different samples)
- Joint Aspiration PRE Abx
- XRay
How is Septic Arthritis managed?
- Extensive Antibiotics (atleast 6 weeks with the first two being IV)
- Extensive Surgical Irrigation and Debridement
What is Osteomyelitis?
Infection of the bone that causes progressive inflammatory destruction and formation of new bone
Can be acute or chronic
Describe the three mechanisms of infective spread causing Osteomyelitis
- Haematogenous
- Direct Inoculation with normal vascularity
- Contiguous spread with poor vascularity (eg Diabetic
Foot)
Describe the pathophysiology of Osteomyelitis in five steps
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)
Describe the clinical features of Osteomyelitis
- Low grade pyrexia
- Severe Pain (may be worse at night) (except in diabetic patients)
What is Pott’s Disease?
Infection of vertebral body and intervertebral discs with Mycobacterium Tuberculosis, normally affecting thoracolumbar region
Back Pain/Low Grade Fever
Investigate with MRI
What is the definitive investigation of Osteomyelitis?
MRI
How is Osteomyelitis managed?
- Long term IV antibiotics (atleast 4 weeks)
- If evidence of deterioration - curettage of affected area
Give two complications of Osteomyleitis
Growth disturbances in Children due to premature epiphyseal closure
Chronic Osteomyelitis
Name 5 common primary tumours that metastasise to bone
Thyroid
Lung
Breast
Kidney
Prostate
Give 3 risk factors for Bone Tumours
Genetic (RB1, P53)
Previous Radiation Exposure
Benign Bone Conditions (Pagets, Fibrous Dysplasia)
Give two presenting features of a Primary Bone Tumour
- Pain (worse at night)
- Fracture without trauma
Name four benign Primary Bone Tumours
Osteoid Osteoma
Osteochondroma
Chondroma
Benign Osteoclastoma
Where do Osteoid Osteomas and Osteochondromas normally form?
Metaphyses of bones
Name three malignant Primary Bone Tumours
Osteosarcoma
Ewing’s Sarcoma
Chondrosarcoma
Osteosarcoma is the most common malignant bone tumour, describe the bimodal age distribution
- 10 to 14
- > 65
How would Osteosarcomas appear on an X-Ray?
Medullary and Cortical Bone Destruction
How are Osteosarcomas managed?
Aggressive surgical resection and chemotherapy to prevent metastases?
What is Ewing’s Sarcoma?
A paediatric malignancy of poorly differentiated neurectodermal cells commonly affecting the diaphyses of long bones
How does Ewing’s Sarcoma present on an X-Ray?
Onion Skin
What is the staging system for bone tumours?
Enneking
Which one of the clinical signs is most strongly suggestive of Acute Compartment Syndrome?
Passive Stretch of Muscle Belly initiating pain
