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Medicine Year 2 (Bear) > Week 218 - Fractured Hip > Flashcards

Week 218 - Fractured Hip Flashcards

1
Q

Week 218

What does bone “do”?

A

– Provide structural support for the body
– Protect vital organs
– Act as a home for bone marrow
– Provide a reservoir for minerals (eg calcium)

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2
Q

Week 218

NEED TO GO OVER BONE BIOLOGY, ROLE OF VIT D and its SUBSTITUTES, HOW DEPOSITION IS CAUSED, ROLE OF PTH ETC

A

to do

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3
Q

Week 218

What is an Osteoclast, and what is its role?

A

An Osteoclast is a type of bone cell theat resorbs bone tissue.

Osteoclasts are regulated by several hormones, including** parathyroid hormone** (PTH) from the parathyroid gland, calcitonin from the thyroid gland, and growth factor interleukin 6 (IL-6). This last hormone, IL-6, is one of the factors in the disease osteoporosis, which is an imbalance between bone resorption and bone formation.

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4
Q

Week 218

What is the role of Parathyroid Hormone (PTH) in bone remodelling?

A

PTH enhances the release of calcium from the large reservoir contained in the bones.Bone resorption is the normal destruction of bone by osteoclasts, which are indirectly stimulated by PTH.

PTH also enhances active reabsorption of calcium and magnesium from distal tubules and the thick ascending limb or the kidney, and absorbtion of Calcium from the Small Intestine.

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5
Q

Week 218

What is the role of Calcitonin in bone remodelling?

A

Calcitonin acts to reduce blood calcium (Ca2+), opposing the effects of parathyroid hormone (PTH).

Specific effects in bone:

  • *Inhibits osteoclast** activity in bones.
  • *Stimulates osteoblastic** activity in bones.
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6
Q

Week 218

In very basic terms - what is the difference between Trabecular and Cortical bone?

A

Trabecular bone is the “Scaffolding”, and Cortical bone is the “Cover”.

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7
Q

Week 218

Define Osteoporosis.

A

“Systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk”

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8
Q

Week 218

Deficiency of which sex hormone is a risk factor for Osteoporosis?

A

Oestrogen.

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9
Q

Week 218

How is Osteoporosis usually diagnosed?

A

Osteoporosis is usually diagnosed with a DEXA Scan (Dual Energy X-Ray Absorpitometry).

The diagnosis is based on a measurement of Bone Mass Density (BMD) in g/cm2.

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10
Q

Week 218

With reagrds to the measurement of Bone Mass Density in Osteoporosis, what is meant by the “Z” score?

A 
#standard deviations from age and
gender-matched mean
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11
Q

Week 218

With regards to the measurement of Bone Mass Density in Osteoporosis, what is meant by the “T” score?

A 
#standard deviations from gendermatched
young adult mean
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12
Q

Week 218

With regards to the measurement of Bone Mass Density in Osteoporosis, what is the classification of disease, with relation to the T score?

A

0 to -1 = normal

  • *-1 to -2.5 = osteopenia**
  • 2.5 below = osteoporosis
  • 2.5 and below with fracture = severe osteoporosis
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13
Q

Week 218

Name two drugs that increase bone formation.

A

– Teriparatide
– Strontium Ranelate

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14
Q

Week 218

Name two drugs that decrease bone resorption.

A
  • Bisphoshonates
    – RANK Ligand inhibitors (Denosumab)
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15
Q

Week 218

Name some Biphosponates, and state what effect they have.

A

– Alendronic acid, Risedronate, zolendronic acid, ibandronate
– Inhibit osteoclasts

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16
Q

Week 218

What type of drug is Denosumab? What does it do?

A

Denosumab is a RANK Ligand inhibitor

Prevents osteoclast differentiation, activation and survival
– ‘Biological’ drug – humanised antibody
– Subcutaneous injection every 6 months
– Side effects

Rarely ONJ, atypical fracture
– Often given with calcium and vitamin D supplement

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17
Q

Week 218

What is Teriparatide, and how does it work?

A

This is a Recombinant human parathyroid hormone
• Normally PTH causes bone loss
• BUT given in pulses
– Increases bone production (anabolic)
– Increases BMD

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18
Q

Week 218

What is the common term given to the condition Osteomalacia?

A

Rickets

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19
Q

Week 218

What are the actions of Vitamin D?

A

– Maintain calcium homeostasis
– Maintain bone health
– Increase Ca2+ from the gut
– Increase phosphate absorption from gut
– Osteoclast function / maturation

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20
Q

Week 218

What is the effect of a Vitamin D Deficiency on bone density?

A

Low Vitamin D leads to reduced Calcium absorption from the gut. This in turn leads to low Serum Calcium, and a subsequent increase in the release of PTH from the parathyroid glands. PTH causes Calcium resorption from bone, which in turn reduces bone mineralisation (creates “sort bones”).

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21
Q

Week 218

Name some causes of Vitamin D Deficiency.

A
  • Inadequate sunglight
  • Inadequate diet
  • Malabsorbtion
  • Medication
  • Abnormal metabolism of vit D (Renal or Hepatic disease)
  • Hypophosphataemia
  • 1-alpha hydroxylase deficiency (rare)
  • congenital vitamin d resistance (rare)
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22
Q

Week 218

What is Rickets?

A

Rickets is a condition that affects bone development in children. It causes the bones to become soft and weak, which can lead to bone deformities.

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23
Q

Week 218

What is Osteomalacia? What are the clinical signs of this disease?

A

Osteomalacia is the softening of the bones caused by defective bone mineralization secondary to inadequate amounts of available** phosphorus and calcium**, or because of overactive resorption of calcium from the bone as a result of hyperparathyroidism (which causes hypercalcemia, in contrast to other aetiologies). Osteomalacia in children is known as rickets.

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24
Q

Week 218

In a Vitamin D deficient patient, what would you expect from the following tests:

  • Serum 25(OH) Vitamin D
  • Serum PTH
  • Serum calcium
  • Serum phosphate
  • Alkaline phosphatase
A

Serum 25(OH) Vitamin D - LOW
Serum PTH - INCREASED
Serum calcium - LOW/NORMAL
Serum phosphate - LOW
Alkaline phosphatase - INCREASED

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25
Week 218 What is **Pagets** Disease?
Paget disease of bone is a **chronic disorder** that can result in enlarged and misshapen bones. Paget's is caused by the **excessive breakdown and formation of bone**, followed by disorganized bone remodelling. This causes affected bone to **weaken**, resulting in **pain**, misshapen bones, **fractures** and **arthritis** in the joints near the affected bones.
26
Week 218 What is the first **manifestation** of **Pagets** disease?
The first manifestation of Paget's disease is usually an **elevated alkaline phosphatase** in the blood. Overall, the most **common symptom is bone pain**.
27
Week 218 What is the difference between **Monostotic** or **Polyostotic** Pagets disease?
Monostotic - affects one bone Polyostotic - Affects many bones
28
Week 218 Which clinical (blood/urine) results would be definitive of **Pagets** Disease?
**_ Blood tests_** • **High alkaline phosphatase** (NB. liver disease) • Normal calcium, vitamin D, PTH, phosphate – **Urinary hydroxyproline** increased – **Isotope bone scan** – increase uptake
29
Week 218 Which **class of drug** is used to treat **Pagets** disease? Can you give any **examples**?
**Bisphosphonates.** _Examples:_ **Risedronate** **Zolendronate**
30
Week 218 Which **conditions** are indicated by the following sets of **results**?
This is VERY likely to be an EMQ type question. Learn it.
31
Week 218 What effect does a **decrease** in plasma **calcium** have on **plasma CaHPO4** absorption?
Plasma CaHPO4 absorption increases when there is a decrease in plasma Calcium.
32
Week 218 **UV light** converts 7- dehydrocholesterol to \_\_\_\_\_\_.
Cholecalciferol
33
Week 218 Cholecalciferol is converted **in the liver** to \_\_\_\_\_\_\_
25- Cholecalciferol
34
Week 218 **Without** the effect of **PTH**, what is 25-cholecalciferol converted to in the **Kidneys**?
24,25 D variants.
35
Week 218 In the **presence of PTH**, what is 25-Cholecalciferol converted to in **the kidneys**?
Calcitriol.
36
Week 218 What is the **hormonal response** to **hypophosphataemia**?
**Increased Calcitriol**, leading to **decreased PTH**, leading to a **decrease** in **bone** calcium resorption, an **increase** in intestinal **phosphate absorption**, and a **decrease** in **phosphate excretion** from the urine.
37
Week 218 Which disease is related to a problem with bone density and strength?
Osteoporosis.
38
Week 218 Which disease is related to a problem with bone mineralisation?
Osteomalacia
39
Week 218 Which disease is related to a disorder of bone formation?
Pagets
40
41
Week 218 What is the **Berg** balance scale?
A Formal assessment of balance, often used in the provision of elderly care.
42
Week 218 What is the "**TUG**" test?
This is the "**timed get up and go**" test. It's used when assessing an elderly patients ability to mobilise.
43
Week 218 Which blood measurement is taken as the **level of Vitamin D** in the body?
25-OHD
44
Week 218 A patient on the ward has some blood tests done. Their **25-OHD** (Vitamin D levels) are **80nmol/l**. Is this an acceptable level? What does it show?
Anything **over 75 nmol/L** shows their on bloody good form. This patient is **HEALTHY**!
45
Week 218 A patient on the ward has some blood tests done. Their **25-OHD** (Vitamin D levels) are **48 nmol/l**. Is this an acceptable level? What does it show?
Anything under 50nmol/L indicates that Vitamin D supplementation is needed. (*They also probably need to stop staring at computer screens in the library revising, and actually go outside where this is thing called the SUN*.)
46
Week 218 A patient on the ward has some blood tests done. Their **25-OHD** (Vitamin D levels) are **23 nmol/l**. Is this an acceptable level? What does it show?
**This is not good.** _\< 25nmol/l means that **Calciferol** is indicated_ (**high risk** of **rickets** and **osteomalacia**). Daily recommendations of **400IU(10g) per day only** sufficient to prevent rickets.
47
Week 218 According to *Saunders et al.,* most hip fractures of the elderly occur **where**?
In care homes.
48
Week 218 Bone density is a ____ indicator of fractures in individuals.
Bone density is a **poor **indicator of fractures in individuals.
49
Week 218 The DIPART trial looked at what?
Vitamin D consumption in individuals.
50
Week 218 Is **poor vidual acuity** a risk factor for falls?
YES. There is a large body of evidence to support this.
51
Week 218 What is the **Hayflick limit**?
The Hayflick limit (or Hayflick phenomenon) is **the number of times a normal human cell population will divide until cell division stops**. Empirical evidence shows that the **telomeres associated with each cell's DNA will get slightly shorter with each new cell division** until they shorten to a critical length.
52
Week 218 Define "**Fracture**".
‘A loss of continuity of the substance of a bone due to physical force’
53
Week 218 Define "**Dislocation**"
"Complete loss of contact between articulating surfaces of a joint".
54
Week 218 What is meant by the term "**Sublaxation**"?
This is similar to dislocation. There is some contact between articulating surfaces, but **they are no longer congruous**.
55
Week 218 What are the **four** stages of **Fracture repair** (regeneration)?
–Inflammation –soft callus –hard callus –remodelling
56
Week 218 What are the **advantages** and **disadvantages** (to healing) of **fracture fixation** (i.e. a metal plate)?
**_Advantage:_** Modifies **MECHANICS** of fracture healing (direct bone healing, restructuring of bone). **_Disadvantage:_** Dispersal of **fracture haematoma** alters the **biology** of fracture healing, almost always **adversely**.
57
Week 218. What does this image show?
This shows a failed fracture implant. The implant has failed before the fracture could heal.
58
Week 218 What is **Myositis ossificans**?
This is **calcified soft tissue near a joint**, restricting movements.
59
Week 218 Following a car accident 2 weeks ago, in which he **broke his left femur**, a man present so to A and E with confusion, respiratory distress and a petechial rash across his legs and chest. What do you suspect has caused this?
The cause of this is likely to be a** Fat Embolism**. Fat globules can form in lung parenchyma and peripheral circulation **after long bone fracture or other major trauma**.
60
Week 218 What is **compartment syndrome**?
**Muscle swelling within a closed osseo-fascial compartment, **with increased pressure leading to capillary ischaemia and death of both muscle and nerve cells.
61
Week 218 What is meant by the term "**Malunion**"?
This is the term used to describe a **fracture that has united, but in a poor position**. There may be shortening, angulation, displacement and/or rotation.
62
Week 218 What does the phrase "**Delayed Union**" refer to?
A delayed union refers to a situation **in which a bone union (from a fracture) fails to occur within the expected time**. X-Ray may show abnormal bone resorption, or a poor quality callus.
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Week 218 What is meant by the term "**Hypertrophic non-union**"?
This is a **poorly healing fracture**. The bone ends are viable, and have a good blood supply, but their is **inadequate stability**. The treatment is to **achieve stability**, in order to allow union.
64
Week 218 What is meant by the term "**Atrophic non - union**"?
**This is a non healed fracture. There is no evidence of cellular activity**, bone ends may be narrow and porotic. Treating this is difficult, and may require removal of fibrous bone ends.
65
Week 218 What is meant by the term "**Avascular Necrosis**"?
This is **bone death** due to **blood supply disruption**. Revascularisation takes 6-18 months. The affected bone will be soft, and distorted in shape.
66
Week 218 What is Osteitis?
Infection of a bone.
67
Week 218 What is meant by the term "**Pathological Fracture**"?
"A fracture occurring following minimal stress through abnormal bone"
68
Week 218 Whqat is a "**greenstick fracture**"?
A greenstick fracture occurs when a **bone bends and cracks, instead of breaking completely into separate pieces.** This type of broken bone most commonly occurs in children because their bones are softer and more flexible than are the bones of adults.
69
Week 218 What is a "**Salter Harris Fracture**"?
Salter-Harris fractures are **epiphyseal plate fractures** and are common and important as they **can result in premature closure and therefore limb shortening and abnormal growth**.
70
Week 218 What is a Smith's Fracture?
This is when you fracture the distal radial head, causing posterior displacement of the hand, typically after reaching to "catch your fall".
71
Week 218 What is a "**Collies Fracture**"?
This is a fracture of the radial head (rare), causing anterior displacement of the hand.
72
Week 218 What is the **name given** to this type of injury?
This is a Salter Harris fracture.
73
Week 218 What is the **name given** to this injury?
This is a Salter Harris fracture.
74
Week 218 What is the **name given** to this type of injury?
This is a Femoral Neck Fracture
75
Week 218 What is the name given to this type of fracture?
This is an **intraarticular** fracture.
76
Week 218 What is the name of this injury?
This is fracture of the pubic ramus.
77
Week 218 What is the name given to this injury?
This is a sub trochenteric neck of femur fracture.
78
Week 218 Which muscles cause **flexion** at the **knee**?
* Semi tend * Semi memb * Biceps fem
79
Week 218 Which peripheral nerve supplies the **knee flexors**?
The Tibial portion of the Sciatic Nerve
80
Week 218 Which peripheral nerve supplies the **Quadriceps**?
The Femoral Nerve.
81
Week 218 What is the **root origin** of the **Sciatic** nerve?
The Nerve root origin of the Sciatic nerve: L4-S3.
82
Week 218 Which muscles of the thigh are supplied by the **Femoral** nerve?
* Sartorius * Iliacus * Vastus Lateralis * Rectus Femoris * Vastus Medialis * Vastus Intermedius
83
Week 218 Which muscles cause **plantar flexion of the ankle**?
* Gastrocnemeus * Soleus * Flexor hallucis and digitalis longus * Tibialis posterior
84
Week 218 Which muscles cause **dorsiflexion of the ankle**?
* Tibia anterior * Extensor hallucis * Digitalis longus * Peroneus Tertius
85
Week 218 Which muscles cause **inversion of the ankle**?
* Tibia posterior * Flexor dig long * Tibia anterior * Extensor hal long
86
Week 218 Which muscles cause **Eversion of the ankle**?
* Peroneus longus * Peroneus brevis * Extensor digitalis longus
87
Week 218 Learn these bad boys!
88
Week 218 Which nerve root supplies **Plantar flexion of the ankle**?
s1
89
Week 218 Which nerve root supplies **dorsiflexion of the ankle**?
l4/5
90
Week 218 Which nerve root supplies **muscles of inversion of the ankle**?
l4
91
Week 218 Which nerve root supplies **muscles of eversion of the ankle**?
s1
92
Week 218 Which **nerve** supplies the **Short head biceps femoris, and the sup. and deep Peroneal muscles** of the leg?
The Peroneal nerve bro. The peroneal nerve.
93
Week 218 Which **nerve** supplies the **muscles of extension at the ankle**?
The Deep peroneal nerve.
94
Week 218 Which **myotome** supplies **knee flexion**?
S2
95
Week 218 **Intra-osseous blood supply** to bone is via the _____ \_\_\_\_\_.
Nutrient artery.
96
Week 218 **Extra-Osseus blood supply** to bone is via which **two** things?
Extra- Osseous supply is via: * Muscle attachments * Circular anastomoses
97
Week 218 Blood supply to the **Femoral head** is via **which vessels**?
* Via medial & lateral femoral circumflex arteries * Retinacular (subsynovial) vessels * Intra-osseous vessels * Foveal vessels
98
week 218 Where can you readily identify the **Lateral Femoral circumflex artery**?
At the **intertrochanteric** line.
99
Week 218 A Fracture **proximal** to the intertrochanteric line is known as an _____ fracture. A Fracture **distal** to the intertrochanteric line is known as an _____ fracture.
A Fracture proximal to the intertrochanteric line is known as an intracapsular fracture. A Fracture distal to the intertrochanteric line is known as an extracapsular fracture.
100
Week 218 What injury does this image show?
Central dislocation of the left hip.
101
Week 218 What is meant by the term "**Heterotopic ossification**"?
The process of bone tissue formation **outside of the skeleton**.
102
Week 218 Which **nerve** is likely to be damaged by a hip dislocation?
The Sciatic nerve. This could lead to a sciatic nerve palsy.
103
Week 218 Describe the **anatomical borders of the Femoral Triangle**.
* **Superorly**- Inguinal ligament * **Medially** - Adductor longus * **Laterally** - Sartorius * **Floor** - Ileopsoas and pectineus * **Roof** - Fascia lata,subcutaneous fat
104
Week 218 Where does the **inguinal ligament run from and to**? What goes **underneath** it? What goes **through** it?
* Runs from ASIS to PUBIC TUBERCLE * Femoral vessels go underneath it * Testicular vessels go through it
105
Week 218 What is the name given to the **vein** that runs underneath the inguinal ligament, and the femoral triangle?
The Great Saphenous Vein.
106
Week 218 Which is of greater concern - Deep or superficial venous thrombosis of the leg?
Deep.
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108
Week 218 EMQ FBK Revision How does **Warfarin** work?
Warfarin **inhibits the enzyme Vitamin K Reductase**, which prevents formation of vitamin K from oxidised vitamin K. Vitamin K is required for the reduction of Glutamic Acid to Alpha-Carboxyglutamic acid, which is a component of tissue factors 2,7,9 and 10.
109
What is Thrombocytopaenia?
A deficiency of platelets.
110
111
Week 218 Secondary osteoporosis is a disease usually found in younger women. What are the usual causes?
* Oestrogen deficiency * Glucocorticoid use/cushings (the cortisol suppresses osteoblasts and subsequent bone growth) * Hyperparathyroidism (increased PTh causes \< resorbtion).
112
Week 218 **Alendroate** and **Zolendroate** are drugs used in the management of which condition?
osteoporosis These drugs encourage osteoclast apoptosis, therefore \> bone resorbtion.
113
Week 218 Raloxifene is a drug used to treat which condition? How does it work?
Osteoporosis. This mimics oestrogen (receptor modulator) - increases osteoblastic activity.
114
Week 218 What are the causes of Osteomalacia/Rickets?
* Vit D deficiency * Abnormal Vit d metabolism (renal or hepatic disease) * Hypophosphataemia - PO4 req'd to make hydroxyapatite * Drugs - bisphosphonates (mineralisation inhibitors) * Congenital: congenital alpha-1 reducatse deficiency, Vit D resistance or Hypophosphataemic.
115
Week 218 Which enzyme, typicall associated with the liver, is produced by osteoblasts in bone mineralisation, and is commonly found to be raised in Paget's disease?
Alkaline Phosphatase (ALP)
116
Week 218 Define "Fracture"
A loss of continuity of the substance of a bone due to physical force
117
Week 218 Define "Dislocation"
A complete loss of contact between articulating surfaces of a joint
118
Week 218 Define "Subluxation"
Joint not congrous - partial dislocation.
119
Week 218 Define "Transverse fracture"
A fracture straight across a bonem, in a perpendicular plane. Usually due to bending force.
120
Week 218 Define "Spiral fracture"
A fracture usually due to torsion (twisting)
121
Week 218 Define "Comminuted fracture"
Bone shattered into multiple fragments, usually due to high enrgy crushing forces.
122
Week 218 Define "Impacted fracture"
Wedging/crushing of two fragments of same bone into eachother.
123
Week 218 Define "Compression fracture"
Collapse of a section of bone - think of a vertebral wedge.
124
Week 218 Define "Periarticular Avulsion"
Fracture at muscle attachment, due to a sudden sharp contraction - often a sports injury.
125
Week 218 Define "Greenstick fracture"
In children. "Bent bone" - due to torsion or bending.
126
Week 218 Define "Physeal fracture"
These asre fractures through the epiphyseal growth plate in children.
127
Week 218 Name the six types of hip fracture - 3 intracapsular, and 3 extracapsular
Intracapsular: * Fracture of head of femur (rare , usually in younger pts) * Fracture of neck of femur - most common in elderly * Avascular necorsis of head - often occurs in displaced fractures Extracapsular: * Trochanteric - avulsion of trochanter from femur * Intertrochanteric - elderly, rel. to osteoporosis * Subtrochanteric (high energy trauma)
128

Medicine Year 2 (Bear) (30 decks)

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