Trauma and orthopaedics Flashcards
What is the most likely bacterial cause of septic arthritis? (1)
Most common location
Staphylococcus aureus
Knee
What fluids will you send for culture in septic arthritis (2)
Synovial fluid culture
Blood culture (most common cause is hematogenous spread)
Name 2 inflammatory markers raised along with the WCC in septic arthritis
ESR, CRP
Outline immediate management plan in septic arthritis
Analgesia
Take blood and fluid cultures BEFORE empirical antibiotics
IV antibiotics: flucloxacillin or clindamycin if allergic for 4-6 weeks
What would be the role of orthopaedics do in septic arthritis (1)
Joint aspiration / wash out to decompress joint
What other organism should be considered in septic arthritis if a metal prosthesis was in situ in the joint
Staphylococcus epidermis
Give 2 risk factors for developing septic arthritis (2)
Penetrating injury
Immunocompromised
Infections elsewhere e.g. gonococcal
Diabetes
Most likely cause of septic arthritis in sexually active patient (1)
Neisseria gonorrhoea (gonococcus)
Name 4 rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Where does the supraspinatus attach to the humerus? (1)
Greater tubercle
What muscle takes over abduction of the arm after the supraspinatus initiates movement (first 10-15 degrees) (1)
Deltoid 15-90
(Trapezius 90-180)
What 2 muscles are innervated by the accessory nerve? (2)
Teres minor
Deltoid
What 2 methods are used to image the supraspinatus and to assess whether any labral tears are present? (2)
MRI and ultrasound
ABCDE approach: RTA, spinal board with collar, blocks and tape immobilising his cervical spine, snoring-like sound from airway
a) What manoeuvre should you perform initially? (1)
b) What adjunct is available to help manage the patient’s airway? (1)
a) Jaw thrust
(presume cervical spine is unstable so do not perform head tilt-chin lift)
b) Oropharyngeal airway (Guedel)
(nasopharyngeal cannot be used as there is a possibility of basal skull fracture)
ABCDE approach
What can you do improve a patient’s ‘breathing’
Oxygen 15L non-rebreathe mask
ABCDE approach
Tachycardiac, hypotensive, no obvious site of bleeding
a) Give 2 initial steps you would take to manage his circulatory problems (2)
b) What 4 urgent blood tests would you request at this point (4)
a) Insert two wide-bore cannulae, IV 0.9% normal saline bolus
b) FBC, U&E, cross-match, clotting
Below what GCS is the airway at risk of not being maintained?
< 8
ABCDE approach
a) Name 2 images you would request in a trauma series (2)
b) What 2 forms of complex imaging would allow you to fully assess the extent of the injuries (2)
a) chest, pelvic and cervical X-ray
b) CT head and adbomen
Hyper-resonant percussion and tracheal deviation most likely diagnosis (1)
Tension pneumothorax
Management of pneumothorax
a) minimal symptoms
b) symptoms but not high-risk
c) high-risk characteristics (haemodynamic compromise, >50)
a) conservative care
b) needle aspiration (wide-bore cannula into the 2nd intercostal space mid-clavicular line), if unsuccessful then chest drain
c) chest drain (triangle of safety)
Massive haemothorax
a) Percussion sound (1)
b) Acute management (1)
a) Dull percussion
b) Wide-bore chest drain (tube thoracosotomy)
3cm laceration entering the chest wall around the 6th intercostal space, give 2 structures that could be damaged (2)
liver, heart
Initial imaging test for haemothorax (1)
Chest X-ray
Test for integrity of anterior cruciate ligament (1)
Anterior drawer test
Test for integrity of posterior cruciate ligament (1)
Posterior drawer test
Describe how you test the collateral ligaments of the knee (2)
Flexion of the knee to 20 degrees, one hand holds the ankle and one stabilises the femur
Knee joint stressed in abduction to test the MCL and adduction to test the LCL
a) what is the unhappy triad? (1)
b) why is it so commonly damaged? (1)
a)
1. anterior cruciate ligament
2. medial collateral ligament
3. medial meniscus
b) tightly adheres to the MCL
What test may be positive with a meniscal tear? (1)
McMurray’s test
What imaging can be used to assess the damage to the medial meniscus? (1)
MRI
Where can an autograft be taken from if the ACL is to be reconstructed (1)
Patella tendon
Hamstring tendon
Quadriceps tendon
Which cruciate ligament is seen attaching anteriorly to the tibial plateu? (1)
ACL
What position will the leg be in in a NOF? (2)
externally rotated and shortened
If X-rays are inconclusive, give an alternative imaging method which may be used to confirm a fractured neck of the femur?
MRI
What system is used to classify intracapsular femoral neck fractures? (1)
Garden classification system
Name 2 arterial supplies to the head of the femur (2)
Cervical vessels in the joint capsule
Artery of the ligamentum teres
Intramedullary vessels
What complication may occur if the blood supply to the head of the femur is disrupted by an intracapsular fracture
Avascular necrosis
Operative procedure: displaced intracapsular fracture where there are concerns that the blood supply has been disrupted
Arthroplasty (hemi or total)
hemiarthroplasty if poor mobility before / significantly co-morbid otherwise total
Operative procedure: Undisplaced intracapsular fracture with blood supply intact
Internal fixation (nails or screws)
Name 1 blood test to perform before surgery
FBC, U&E, cross-match, clotting
a) What bone is fractured in a Colles’ fracture
b) What part of the bone is fractured
c) What displacement
a) Radius
b) Distal
c) Dorsal displacement
Dinner fork Deformity
Approximately how long does a Colles’ fracture take to heal?
6-8 weeks
Define an open fracture
communication between the fracture and the outside world
What system is used to classify open fractures?
gustilo and anderson classification system
Give 4 components of managing an open fracture
Fluid resuscitation
Assessment of neurovascular status
Sterile cover
Broad-spectrum antibiotics
Tetanus prophylaxis
Excruciating pain in posterior aspect of lower leg exacerbated by dorsiflexion of the foot
a) likely diagnosis
b) surgical management
a) Compartment syndrome
b) Urgent decompression via open fasciotomy
Apart from compartment syndrome, give 2 complications of open fracture
Wound infection
Tetanus infection
Osteomyelitis
Nerve damage
Vascular damage
Sepsis
DVT
Death
a) What is the termination of the spinal cord known as?
b) at what vertebral level does it occur in adults
c) at what vertrebral level does it occur in newborns
a) conus medullaris
b) L2-L3
c) L4-L5
What are two possible causes of cauda equina syndrome
Herniated disc (most common)
Spinal trauma
Spinal tumour e.g. mets
Spinal abscess
Give 2 lower motor neurone signs
Fasiculations
Hypotonia
Hyporeflexia
Muscle wasting
*Cauda equina is lower motor neurone which is why you get bilateral hyporeflexia
What is the preferred imaging modality in suspected cauda equina
Lumbar MRI spine
a) What is the definitive management of cauda equina
b) Give 1 potential complication if left untreated
urgent surgical decompression
paralysis, sensory abnormalities, bladder dysfunction, bowel dysfunction, sexual dysfunction
What gender is more at risk of developing osteoarthritis
Female
Give 2 features that may be found on examination of OA knee
Tenderness, derangement, swelling, pain on movement, crepitus
What are the swellings at DIPJ affected by osteoarthritis called?
Heberden’s nodes
What are the 4 changes typically seen on X-ray of a joint affected by OA?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
a) Give 2 pieces of lifestyle advice for OA
b) give 2 reasons to consider joint arthroplasty
a) weight loss, regular exercise
b) reduced QOL, symptoms not responding to non-surgical
2 features of the pain a/w carpal tunnel syndrome
Worse at night
Gradually worsening
Intermittent
Relieved by shaking hand
Nerve affected in carpal tunnel syndrome and nerve roots
Median
C6-T1
Why is sensation usually preserved over the palm in CTS
Palmar cutaneous branch of median nerve does not pass through the CT
T scores for osteopenia and osteoporosis
1 to 2.5 = osteopenia
> 2.5 = osteoporosis
Give 3 symptoms/signs of cauda equina
Urinary retention
Lower limb weakness
Bowel dyfunction e.g. incontinence
Bilateral hyporeflexia
Sudden onset bilateral sciatica
Sudden onset bilateral neurological symptoms (weakness, tingling)
Saddle paraesthesia
Compartment syndrome features
Acute compartment syndrome presents with the 5 P’s:
P – Pain “disproportionate” to the underlying injury, worsened by passive stretching of the muscles
P – Paresthesia
P – Pale or pink
P – Pressure (high) / swollen
P – Paralysis (a late and worrying feature)
NOTE: pulselessness is NOT a feature and would indicate acute limb ischaemia
