T&O III Flashcards
A 62-year-old female with marked osteoarthritis presents with nodes over the distal interphalangeal joint of her right index and ring fingers.
Heberden’s node
Heberden’s nodes occur at the distal interphalangeal joints in familial generalised osteoarthritis.
Bouchard’s nodes occur at proximal interphalangeal joints.
The square thumb deformity which is also seen in osteoarthritis of the hand results from a deformity of the thumb carpometacarpal joint.
A 54-year-old female with rheumatoid arthritis presents with a deformity of her right middle finger in which there is flexion at the proximal interphalangeal joint and extension at the distal interphalangeal joint.
Boutonnière lesion
Rheumatoid arthritis results in synovitis of the metacarpophalangeal joints with filling of the hollow between metacarpal heads when the fingers are flexed and synovial swelling of the extensor tendon sheaths. Tendons may rupture producing a boutonnière deformity. (The central slip of the extensor expansion detaches from its insertion at the base of the middle phalanx. This allows the two slips to fall sideways and the proximal interphalangeal joint to protrude between the two, producing the characteristic deformity).
A swan neck deformity occurs by flexion at the metacarpophalangeal joint, proximal interphalangeal joint extension and flexion at the distal interphalangeal joint.
A 41-year-old woman had a lump at the base of the distal phalanx of the left middle finger excised by the GP. The lump has rapidly recurred.
Ganglion
Ganglions occur most frequently on the dorsum of the wrist or foot but occasionally are related to the long flexor tendons in the palm or the peroneal tendons at the ankle.
At operation a tense unilocular cyst is seen communicating with the synovial membrane of a joint or a tendon sheath. They probably result from a leakage of synovial fluid with secondary fibrous encapsulation.
Recurrence is high (approximately 30%) following surgical excision.
Elective resection of Crohn’s leaving 40 cm of small bowel.
Long term total parenteral nutrition (TPN)
Adequate quantities of amino acids, glucose, fat, minerals and vitamins produce a hypertonic solution. Therefore it is necessary to infuse this solution through a central venous line rather than a peripheral line.
Complications of TPN include
Phlebitis Thrombosis Pneumothorax Haemothorax Air embolism Arterial damage Septicaemia. A good selection criterion is required based on a nutritional assessment.
At laparotomy a resection of 30 cm of ischaemic large and small bowel are resected.
Normal diet
The small intestine is 4 m long and perfectly adequate nutrition can be maintained after half has been resected. Long-term survival has been recorded if 45 cm of jejunum is left intact along with the duodenum and colon. Less than 45 cm of intact jejunum and the patient will develop short bowel syndrome (progressive malnutrition) and will require long term intravenous feeding. Malabsorption of vitamin B12 and bile salts occurs when greater than 50 cm of the terminal ileum has been resected.
Pancreatectomy for multiple endocrine tumours.
Oral diet with supplemental exocrine enzymes
Following resection of the entire pancreas the patient will lose exocrine enzymatic function and will develop steatorrhoea. These patients require frequent nutritional assessment and support if necessary. They also require life long supplementation of exocrine enzymes, for example, creon.
Burns patients.
Please select the most appropriate answer from the given list for his fluid requirements in the first 24 hours.
Head, neck, back and buttocks
(Head and neck) 9% + (back and buttocks) 18% = 27%:
27 x 70 x 4 = 7.5 l
When a burn occurs it is important to estimate the extent and depth of the burns. The simplest way to estimate the extent of a burn for an adult is the rule of nines.
In this rule
The arms account for 9% Legs 18% Perineum 1% Head 9% Front of torso 18% Back of torso 18% of the total body surface area.
Note that this rule tends to be less accurate in children, as the head is comparatively larger than the rest of the body.
Burns patients
Please select the most appropriate answer from the given list for his fluid requirements in the first 24 hours.
Right circumferential leg and perineum
(Leg) 18% + (perineum) 1% = 19%:
19 x 70 x 4 = 5.3 l
The depth of a burn is determined as partial thickness (spares the dermis) to full thickness (epidermis and dermis destroyed). Burns of less than 10% can be treated orally with salt containing fluids.
Hypovolaemic shock tends to occur when burns affect more than 10% of the total body surface area. The degree of shock is proportional to the total area burned and the depth.
Burns of 10-30% require intravenous fluids and burns greater than 30% require a rapid infusion.
Burns patients
Please select the most appropriate answer from the given list for his fluid requirements in the first 24 hours.
Left circumferential arm and neck
2-3 crystalloid
(Arm) 9% + (neck) 1% = 10%:
10 x 70 x 4 = 2.8 l
Fluid requirements are dictated by pulse, blood pressure, urine output and central venous pressure. A number of formulae are used, but in general the fluid requirement in the first 24 hours is calculated by percentage burn multiplied by body weight multiplied by 4.
There is little difference between colloid and crystalloid in the first 24 hours. Blood is usually not required in the first 24 hours.
In hypovolaemic shock which of the following is true?
(Please select 1 option)
A narrowed pulse pressure indicates significant blood loss
Anuria (less than 17 ml/hr) occurs early
Haematocrit and haemoglobin are good indicators of estimated blood loss
Tachycardia and lowered blood pressure are early manifestations
Vasodilatation is an early response to blood loss
A narrowed pulse pressure indicates significant blood loss
Haemorrhage is the commonest cause of shock and post injury death in the trauma patient, and the only method of stopping on-going losses and stabilising the patient may be surgical. Therefore early surgical review is vital, along with early identification of shock itself.
Early circulatory changes are compensatory and include tachycardia and cutaneous vasoconstriction.
As the amount of blood loss increases and tissue perfusion further decreases, urine output is reduced and so eventually is the patient’s level of conciousness.
Significant reduction in blood pressure is a relatively late manifestation and a narrowed pulse pressure is an indicator of significant blood loss. Unfortunately haemoglobin and haematocrit are unreliable in estimating acute blood loss, and should not be used for diagnosing shock as they may only show minimal acute decrease in massive blood loss.
Oliguria is defined as a urine output of less than 17 ml/hr or more practically less than 400 mls in 24 hours. Oliguria only occurs when 30-40% of the circulating volume (class III haemorrhage) has been lost.
Anuria is defined as a urine output of less than 50 mls in 24 hours and only occurs when greater than 40% of the circulating volume has been lost.
Which of the following are true of tracheostomy?
(Please select 1 option)
Bleeding should be managed by deflating the cuff and removing the tube
Cuffed tubes should be used in children under 8-years-old
It is usually required to wean from a prolonged period of mechanical ventilation
Open procedure involves division of the thyroid isthmus and vertical incision between the third, fourth and fifth tracheal rings
Removal requires a FiO2
It is usually required to wean from a prolonged period of mechanical ventilation
There are numerous indications for the formation of a tracheostomy.
These include:
The upper airway obstruction
To facilitate airway suction
To decrease the work of breathing and to allow weaning from mechanical ventilation.
Once the decision has been made to go ahead, a tracheostomy may be performed percutaneously or openly.
When using the open method, a midline incision is made and the thyroid isthmus divided and ligated and a vertical incision made between the second, third and fourth tracheal rings (as the formation of windows and flaps increases the risk of stenosis), and the cuff inflated.
However, in children, cuffed tubes should be avoided due to the risk of tracheal stenosis and mucosal ulceration.
Bleeding from the tracheotomy wound is also a recognised complication and best treated by not deflating the cuff or removing the tube - as they help to tamponade the bleeding - but by giving oxygen, ventilating the patient, and gaining IV access, whilst calling for help.
Criteria for the removal are that the patient is able to maintain their own airway and ventilate adequately. Indicators of this are a low inspired oxygen concentration, adequate carbon dioxide elimination, minimal sputum production and that the patient is not heavily sedated and able to co-operate!
Which of the following is true of congenital torticollis?
(Please select 1 option)
Appears after the third month of birth
Facial asymmetry is a common presentation
Physiotherapy is ineffective in the early stages
The ear is nearer the shoulder on the normal side
Tilt and rotation of the head to the same side of swelling
Facial asymmetry is a common presentation
Congenital torticollis develops as a result of birth injury to the sternocleidomastoid muscle.
It can present from the second week of birth as a swelling within the sternocleidomastoid muscle.
Once the swelling subsides there is subsequent fibrosis resulting in a tilt of the head towards the affected side and rotation of the neck to the opposite side. Therefore the ear on the affected side is nearer the shoulder. Thus, congenital torticollis causes the head to tilt downwards towards the affected side and the face to turn away from the affected side.1 These are the normal actions of contraction of the muscle.
Facial asymmetry is a common clinical presentation.
In the early stages physiotherapy to lengthen the muscle is beneficial.
If the condition persists, surgical treatment in the form of division and release of the muscle at its lower end may be required.
Regarding metastases, which of the following statements is correct?
(Please select 1 option)
Due to colon cancer are the commonest cause of bone metastases in women
Due to prostate cancer are predominately osteolytic lesions
Early in the disease process can be seen on plain radiographs
To the bone develop a pathological fracture in 10% of patients
To the bone occur in less than 5% of patients with malignant disease
To the bone develop a pathological fracture in 10% of patients
Bone metastases occur in up to 30% of patients with malignancy.
The commonest tumours causing bone metastases are
Breast (35%) Prostate (30%) Bronchus (10%) Kidney (5%) Thyroid (2%). They usually present with
Bone pain A lump Pathological fracture Hypercalcaemia Cord compression. Ten percent of patients with bone metastases will develop a pathological fracture.
Radiological changes usually occur late and bone scintigraphy is the most sensitive investigation available to detect metastatic spread.
Most metastases are osteolytic but some tumours, particularly prostate carcinoma, can cause osteosclerotic lesions.
Which of the following regarding eponymous fractures is correct?
(Please select 1 option)
Bennett’s fracture involves the distal ulna
Colles’ fracture involves the proximal radius
Galeazzi’s fracture involves the radial shaft and dislocation of the proximal radioulnar joint
Monteggia’s fracture involves the proximal ulna and anterior dislocation of the head of the radius
Pott’s fracture is a general term applied to fractures around the knee
Monteggia’s fracture involves the proximal ulna and anterior dislocation of the head of the radius
A Bennett’s fracture is an intra-articular fracture of the base of the first metacarpal.
A Galeazzi’s fracture involves the radial shaft with dislocation of the distal radioulnar joint.
Monteggia’s fracture is an angulated fracture at the junction of the proximal and middle third of ulna accompanied by anterior dislocation of the radial head.
A Pott’s fracture is a general term applied to fractures around the ankle.
Regarding osteosarcoma, which of the following statements is correct?
(Please select 1 option)
Affects the epiphyses of long bones
Can result in pulmonary metastases via haematogenous spread
Is exclusively a disease of adolescence and early adult life
Is most commonly seen around the hip
On x ray shows a ‘sunburst’ appearance due to bony involvement
Can result in pulmonary metastases via haematogenous spread
Osteosarcomas affect the metaphyses of long bones.
They are most commonly seen around the knee and in the proximal humerus.
They often occur in young adults but are also seen in the elderly in association with Paget’s disease. They usually present as bone pain and a palpable lump.
x Ray shows periosteal elevation (Codman’s triangle) and a ‘sunburst’ appearance due to soft tissue involvement.
Early haematogenous spread occurs and the five year survival rate is approximately 50%
Regarding club-foot (talipes equinovarus [TEV]) deformity in a newborn, which of the following statements is true?
(Please select 1 option)
Has a higher incidence in babies delivered head first
Is more common in Chinese than other races
Is most commonly ‘postural’ in origin
Needs open reduction in most instances
Occurs in association with spina bifida cystica only if there is accompanying hydrocephalus
Is most commonly ‘postural’ in origin
Postural talipes is most common and can be passively corrected.
Spina bifida cystica refers to meningocoele and myelomeningocoele; these are associated with other skeletal deformities but not hydrocephalus.
It is more common in Polynesians rather than Caucasians, and not in Chinese.
