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Surgery block (Y3) > Trauma and orthopaedics (7): General > Flashcards

Trauma and orthopaedics (7): General Flashcards

1
Q

OA is characterised by

A

progressive loss of articular cartilage and remodelling of the underlying bone.

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2
Q

causes of OA

A
  • Degradation of cartilage and remodelling of bone due to an active response of chondrocytes in the articular cartilage and the inflammatory cells in the surrounding tissues.
  • The release of enzymes from these cells break down collagen and proteoglycans, destroying the articular cartilage.
  • The exposure of the underlying subchondral bone results in sclerosis, followed by reactive remodelling changes that lead to the formation of osteophytes and subchondral bone cysts.
  • The joint space is progressively lost over time.
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3
Q

RF for OA

A

obesity, advancing age, female gender, and manual labour occupations.

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4
Q

most common joints affected by OA

A
  • small joints of hands and feet
  • hip
  • knee
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5
Q

presentation of OA

A
  • insidius
  • chronic
  • gradually worsening
  • pain and stiffness worsened with activity
  • relived by rest
  • joint deformity
  • reduced range of meovement
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6
Q

characteristic signs of OA

A
  • Bouchard nodes (swelling of PIPJs) or
  • Heberden nodes (swelling of DIPJs) in the hands
  • Fixed flexion deformity or varus malalignment in the knees.

Feel for crepitus throughout the range of movement. Movement of the joint is generally reduced and painful.

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7
Q

investigation for OA

A

primarily a clinical diagnosis

  • blood tests to exclude inflammatory or infective causes
  • X-ray - to confirm diagnosis and exclude fractures
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8
Q

X-ray findings of OA

A

LOSS

  • Loss of joint space
  • Osteophytes
  • Subchondral cysts
  • Subchondral sclerosis
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9
Q

conservative management of OA

A

weight loss

physio (strengthening exercise)

local heat/ice packs

joint supports

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10
Q

medical management of OA

A

Paracetamol and topical NSAIDs are the mainstay of most medical management for OA, alongside the conservative measures.

+- steroid injection (typically mixed with local anaesthetic)

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11
Q

surgical management of OA

A

surgical management choice will depend on the site affected. Options include:

  • Osteotomy
  • Arthrodesis (joint fusion)
  • Arthroplasty
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12
Q

general complications after orthopaedic surgery

A
  • malunion/ nonunion
  • Nerve dysfunction
  • infection (open fracture)
  • secondary osteoarthritis
  • fat embolism
  • VTE
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13
Q

how long do artifical joints last

A

more than 10-15 years. However, they may be affected by loosening, wear and dislocation.

Some patients may require further surgery and replacement of the artificial joint at some point.

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14
Q

other options than joint replacement

A

analgesia, steroid injections and physiotherapy.

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15
Q

indication of joint replacement

A

Osteoarthritis is the most common indication for an elective joint replacement. It is not usually performed until symptoms are severe and not manageable with conservative treatments.

Joints may also require replacement for:

  • Fractures
  • Septic arthritis
  • Osteonecrosis
  • Bone tumours
  • Rheumatoid arthritis
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16
Q

options for joint replacement

A
  • Total joint replacement – replacing both articular surfaces of the joint
  • Hemiarthroplasty – replacing half of the joint (e.g., the head of the femur in the hip joint)
  • Partial joint resurfacing – replacing part of the joint surfaces (e.g., only the medial joint surfaces of the knee)
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17
Q

total hip replacement (THR) method

A

Usually, a lateral incision over the outer aspect of the hip is used. The hip joint is dislocated (separated) to give access to both articular surfaces.

The head of the femur is removed. A metal or ceramic replacement head of femur, on a metal stem, is used to replace it. The stem can either be cemented into the shaft of the femur or carefully pushed into the shaft to make a tight enough fit to hold it securely in place. Uncementedstems have a rough surface that holds them tightly in place.

The acetabulum (socket) of the pelvis is hollowed out and replaced by a metal socket, which is cemented or screwed into place. A spacer is used between the new head and socket to complete the new artificial joint.

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18
Q

Total Knee Replacement

A

Usually, a vertical, anterior incision is made down the front of the knee. The patella is rotated out of the way to allow access to the knee joint.

The articular surfaces (the cartilage and some of the bone) of the femurand tibia are removed. A new metal surface replaces these. They can be either cemented or pushed tightly into place.

A spacer is added between the new articular surfaces of the femur and tibia to complete the new artificial joint.

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19
Q

before joint replacement surgery

A
  • X-rays
  • CT or MRI scans may be required for a more detailed assessment
  • Pre-operative assessment (pre-op)
  • Consent for surgery
  • Bloods (including group and save and crossmatching of blood)
  • Medication changes if needed (e.g., temporarily stopping anticoagulation)
  • Venous thromboembolism assessment
  • Fasting immediately before surgery
  • The limb will be marked with the patient awake to ensure the operation is performed on the correct joint
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20
Q

joint replacement surgery requires either

A

general anaesthetic or spinal anaesthetics

prophylactic Abx

Tranexamic acid to minimise blood loss

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21
Q

after joint replacement surgeyr

A
  • Analgesia
  • Physiotherapy to guide when and how to mobilise
  • VTE prophylaxis
  • Post-operative x-rays
  • Post-operative full blood count (to check for anaemia)
  • Monitoring for complications (e.g., deep vein thrombosis or infection)
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22
Q

VTE prophylaxis

A

LMWH for:

  • 28 days post elective hip replacement
  • 14 days post elective knee replacement

Other measures that may be used for VTE prophylaxis after joint replacement surgery are:

  • Aspirin
  • DOACs (e.g., rivaroxaban)
  • Anti-embolism stockings
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23
Q

risk of joint replacement

A
  • Risks of the anaesthetic
  • Pain
  • Bleeding
  • Infection – infection of the prosthesis can be highly problematic (see below)
  • Damage to nearby structures (e.g., nerves or arteries)
  • Stiffness or restricted range of motion in the joint
  • Joint dislocation
  • Loosening
  • Fracture during the procedure
  • Venous thromboembolism (DVT or PE)
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24
Q

most common organism which causes prosthetic joint infection

A

staphylococcus areus

Risk factors for prosthetic joint infection are:

  • Prolonged operative time
  • Obesity
  • Diabetes

Symptoms include:

  • Fever
  • Pain
  • Swelling
  • Erythema
  • Increased warmth
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25
Q

Compartment syndrome

A

is where the pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment.

26
Q

Fascial compartments involve m

A

muscles, nerves and blood vessels surrounded by fascia. Fascia is a sheet of strong, fibrous connective tissue that encases the contents of the compartment. It is not able to stretch or expand.

27
Q

compartment syndrome can be classified as

A

acute or chronic

28
Q

Acute compartment syndrome

A

is usually associated with an acute injury, where bleeding or tissue swelling (oedema) associated with the injury increases the pressure within the compartment.

29
Q

presentation of acute compartment syndrome

A

Acute compartment syndrome most often affects one of the fascial compartments in the legs, but it can also affect the forearm, feet, thigh and buttocks.

It usually presents after an acute injury, particularly:

  • Bone fractures
  • Crush injuries

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
  • P – Pressure (high)
  • P – Paralysis (a late and worrying feature)
30
Q

what is not a feature of compartment syndrome

A

Note that pulseless is not a feature, differentiating it from acute limb ischaemia. The pulses may remain intact depending on which compartment is affected.

31
Q

key characteristic of compartment syndrome

A

Disproportionate pain is a key characteristic of compartment syndrome. The pain is so severe that pain medications are not effective. If you see a patient with disproportionate pain after an injury in your exams, the diagnosis is probably compartment syndrome.

32
Q

investigation for compartment syndrome

A

Needle manometry

  • Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
  • Compartment syndrome will typically not show any pathology on an x-ray
33
Q

initial management of compartment syndrome

A
  • Escalating to the orthopaedic registrar or consultant
  • Removing any external dressings or bandages
  • Elevating the leg to heart level
  • Maintaining good blood pressure (avoiding hypotension)
34
Q

definitive management of acute compartment syndrome

A

Emergency fasciotomy

35
Q

Emergency fasciotomy

A

ASAP

involves a surgical operation to cut through the fascia, down the entire length of the compartment, and release the pressure. The compartment is explored to identify and debride any necrotic muscle tissue. The wound is left open and covered with a dressing.

36
Q

after fasciotomy

A
  • repeated trips back to theatre to explore for necrotic tissue which needs debridement
  • as swelling improved wound can be gradually closed- several weeks
  • skin graft may be required
37
Q

Osteomyelitis

A

refers to inflammation in a bone and bone marrow, usually caused by bacterial infection.

can be acute or chronic

38
Q

most common mode of infection for osteomylitis

A

Haematogenous spread

39
Q

other Mode of infection for osteomyelitis

A

direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation.

40
Q

organism which causes osteomyelitis

A

Staphylococcus aureus

41
Q

RF for osteomyelitis

A

The key risk factors for developing osteomyelitis are:

  • Open fractures
  • Orthopaedic operations, particularly with prosthetic joints
    • BIG PROBLEM
  • Diabetes, particularly with diabetic foot ulcers
  • Peripheral arterial disease
  • IV drug use
  • Immunosuppression
42
Q

The typical presentation of osteomyelitis is with

A
  • Fever
  • Pain and tenderness
  • Erythema
  • Swelling

The presentation of osteomyelitis can be quite non-specific, with generalised symptoms of infection such as fever, lethargy, nausea and muscle aches.

43
Q

investigations for osteomyelitis

A

MRI best for establishing diagnosis (x-ray only shows later signs)

blood tests (WBC, CRP, blood culture)

bone culture

44
Q

management of osteomyelitis

A

Management involves a combination of:

  • Surgical debridement of the infected bone and tissues
  • Antibiotic therapy
45
Q

antibiotic therapy for osteomyelitis

A
  • 6 weeks of flucloxacillin, possibly with rifampicin or fusidic acidadded for the first 2 weeks

alternative to penicillin

  • Clindamycin in penicillin allergy
  • Vancomycin or teicoplanin when treating MRSA
46
Q

antibiotic for chronic osteomyelitis

A

Usually requires 3 months or more of antibiotics.

Osteomyelitis associated with prosthetic joints (e.g., a hip replacement) may require complete revision surgery to replace the prosthesis.

47
Q

sarcomas

A

Sarcomas are cancers originating in the muscles, bones or other types of connective tissue

48
Q

bone sarcoma

A
  • Osteosarcoma – the most common form of bone cancer
  • Chondrosarcoma – cancer originating from the cartilage
  • Ewing sarcoma – a form of bone and soft tissue cancer most often affecting children and young adults
49
Q

soft tissue sarcoma

A
  • Rhabdomyosarcoma – originating from skeletal muscle
  • Leiomyosarcoma – originating from smooth muscle cancer
  • Liposarcoma – originating from adipose (fat) tissue)
50
Q

presenation of sarcoma

A

depends on location and size

  • A soft tissue lump, particularly if growing, painful or large
  • Bone swelling
  • Persistent bone pain
51
Q

investigations of sarcoma

A
  • X-ray for bony lumps
  • US for soft tissue
  • CT or MRI for better visualisation
  • biospy
52
Q

staging of sarcoma

A

TNM

53
Q

most common location for sarcoma to metastasis to

A

lungs

54
Q

Sarcoma treatment

A

will depend on the type, location, size and stage of the sarcoma. This may involve:

  • Surgery (surgical resection is the preferred treatment)
  • Radiotherapy
  • Chemotherapy
  • Palliative care
55
Q

septic arthritis

A

refers to the infection of a joint.

It requires a high index of suspicion and can affect both native and prosthetic joints.

56
Q

main causative organism of septic arthritis

A

S. aureus (most common in adults),

Neisseria gonorrhoea (more common in sexually active patients)

Salmonella (especially in those with sickle cell disease).

57
Q

mode of infection of septic arthritis

A
  • haematogenous spread e.g. recent cellulitis, UTI, chest infection
  • direct inoculation e.g. via adjacent osteomyelitis
58
Q

complications of septic arthritis

A
  • full blown sepsis
  • irreversible cartilage damage leading to OA
  • osteomyelitis
59
Q

RF for SA

A
  • pre-existing joint disease e.g. RA
  • DM or immunosuppression
  • CKD
  • joint prosthesis
  • IVDU
60
Q

presentation of SA

A
  • single swollen joint, red and warm
  • severe pin
  • pyrexia
  • unable to weight bear
61
Q

investigations for SA

A
  • routine bloods (FBC, CRP, urate, blood cultures (at least two separate samples)
  • joit aspiration and fluid analysis (gram stain and culture)
    • preferably joint sample sent prior to starting antibiotics (unless pt septic)
62
Q

management of septic arthritis

A
  • Sepsis 6
    • antibiotics administered for 4-6 weeks
  • infected native joints- irrigation and debridement (washout) in theatre
  • prosthetic joint- washout and then revision surgery of joint

Surgery block (Y3) (38 decks)

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