Week 3 Flashcards
_______________ is the most common arthropathy and is a leading cause of pain and disability in the Western world.
Osteoarthritis (OA)
Osteoarthritis (OA) is a condition characterised by the ______________ and _____________ of the underlying bone.
progressive loss of articular cartilage
remodelling
Osteoarthritis is traditionally thought of as a ‘_____________’ disease which occurs as we age.
wear and tear
The pathogenesis of Osteoarthritis involves a __________ of _______ and remodelling of bone due to an active response of ____________ in the articular cartilage and the inflammatory cells in the surrounding tissues.
degradation; cartilage
chondrocytes
In osteoarthritis
The release of enzymes from these cells break down ________ and _________, destroying the articular cartilage. The exposure of the underlying subchondral bone results in ___________, followed by reactive remodelling changes that lead to the formation of _______ and _________________.
The joint space is ———————- over time.
collagen and proteoglycans
sclerosis
osteophytes; subchondral bone cysts
progressively lost
Risk factors for primary OA include ___________,_________,__________, and __________
obesity, advancing age, female gender, and manual labour occupations.
Clinical features of OA include _________ and __________ , worsened with _________* and relieved by ______.
pain and stiffness in joints
activity; rest
_______ in OA tends to worsen throughout the day, whereas ________ tends to improve.
Pain
stiffness
Prolonged OA results in ________ and a _______________.
deformity
reduced range of movement
On examination in OA, inspect for deformity; there are some common characteristic findings depending on the joint affected, such as __________ (swelling of PIPJs) or ____________ (swelling of DIPJs) in the hands, and _____________ deformity or varus malalignment in the knees.
Bouchard nodes
Heberden nodes
fixed flexion
Joint stiffness and pain that improves with activity is characteristically seen in ___________ arthropathies (e.g. ________________
inflammatory
rheumatoid arthritis
Osteomyelitis is defined as ________________, either _______ or ________.
an infection of bone
acute or chronic
Osteomyelitis In adults, the _________ are the most commonly affected bones, whilst in children, __________ are more commonly affected.
vertebrae
long bones
Most cases of osteomyelitis are ________ and ________ in origin, however it can also be _————- and rarely can even be __________ in origin.
acute and bacterial
chronic; fungal
Osteomyelitis can be caused by 3 main routes:
—————————— spread
_________________ into the bone (e.g. following _____________)
_________ spread from _____________ (e.g. adjacent _____________)
Haematogenous
Direct inoculation of micro-organisms ; an open fracture
Direct; nearby infection ; septic arthritis
The most common causative organisms for osteomyelitis include _________ (most common), —————- , Enterobacteur spp.,___________,______________ (especially in intravenous drug users), and __________ (especially in patients with sickle cell disease)
S. aureus
Streptococci
H. Influnzae ; P. aeruginosa
Salmonella spp.
In chronic cases of osteomyelitis , the infection can lead to —————- of the affected bone, resulting in _________ and __________ of the surrounding bone.
devascularisation
necrosis; resorption
In chronic osteomyelitis, after devascularization of the dead bone, it leads to a “ _________ ” piece of dead bone, termed a ___________, which acts as a __________ for infection (and cannot be penetrated by antibiotics, as it is ————-).
floating; sequestrum
reservoir; avascular
In chronic osteomyelitis, An ____________ can also form, following the sequestrum formation, whereby the region becomes ________ in a _________ of ___________ bone.
involucrum
encased; thick sheath
new periosteal
Risk factors for developing osteomyelitis include —————-, ___________ (such as long term steroid treatment or AIDS), _______________ or_____________
diabetes mellitus
immunosuppression
alcohol excess, or intravenous drug use.
Osteomyelitis and the Diabetic Foot
______ infections occur frequently in diabetic patients, these infections are often due to minor trauma, but due to a combination of _________ and _________ disease, infection often develops quickly and can initially go unnoticed.
__________ infection can therefore increase the risk of osteomyelitis developing.
Foot
neuropathy; small vessel
Soft tissue
It is important to suspect osteomyelitis in any diabetic patient with a ________ or __________ infection. Any suspected case should have an MRI scan to confirm the diagnosis.
deep or chronic foot
Clinical Features of osteomyelitis
Patients will usually present with ___________* in the affected region and associated _____________________.
severe pain
low grade pyrexia
Clinical features of osteomyelitis
Pain is (constant or intermittent?) and can be worse at ________. Cases may present with non-specific symptoms or possibly with a previous history of recent trauma.
On examination, the site will be ________, with potential overlying ________ and ________. If the lower limb is affected, the patient may be unable to __________.
Ensure you examine for potential sources of the infection, such as _______________________ from intravenous drug use, cellulitic areas, penetrating wounds, or stigmata of concurrent infection in another body system.
Constant ; night
tender; swelling and erythema
weight bear
pock marks or sinuses
The main differentials for suspected cases of osteomyelitis include _____________, _________ injuries (including soft tissue injury or fractures), and primary or secondary bone tumours.
septic arthritis
traumatic
Potts disease is an infection of the ________ and ____________ by _____________.
Patients will present with __________ +/- neurological features, with associated _________ and non-specific infective symptoms.
vertebral body; intervertebral disc
Mycobacterium tuberculosis
back pain; low grade fever
Pott’s disease
The infection will initially start in the __________ before spreading to the —————- regions, typically affecting the ______________ region of the spine.
intervertebral disc
para-discal
thoraco-lumbar
Pott’s disease
_____________ is the gold-standard investigation for suspected cases. Most cases will require a prolonged course of anti-TB medication, however surgical intervention may be required for abscess drainage in the case of extensive spinal destruction.
MRI imaging
Management of osteomyelitis
If the patient is clinically well, patients will require ___—-term ——————- therapy (>4 weeks), tailored to any cultures available or otherwise following local antimicrobial protocols. This is usually the mainstay of treatment for osteomyelitis, with no surgical intervention is needed.
However, in cases where the patient clinically deteriorates or imaging shows progressive bone destruction, then surgical management may be required. At this stage, _______________ of the infected bone is required, ensuring any samples are sent for culture and sensitivity. In severe or chronic cases, large debridements and complex reconstruction may be needed.
long; intravenous antibiotic
surgical debridement
Complications of osteomyelitis
Poorly managed acute osteomyelitis may lead to ______ and even mortality. Associated _________ or soft tissue infections may occur.
Children may develop ______ disturbances as a result of _____________. _______________ is rarely required in modern practice.
Recurrence of infection can occur, often associated with premature cessation of antibiotics. Chronic osteomyelitis can occur in immunocompromised patient, under-treated patients, or virulent or resistant organisms.
sepsis; septic arthritis
Growth; premature physeal closure
Amputation
Chronic Osteomyelitis
Patients with chronic osteomyelitis will present with localised ongoing ________ and non-specific infection symptoms (e.g. malaise or lethargy). There may be a draining sinus tract and they may have difficulties in mobility.
bone pain
Septic arthritis refers to the ______________. It requires a _____ index of suspicion and can affect both ________ and _____________.
infection of a joint
high
native and prosthetic joints
The main causative organisms that lead to septic arthritis are __________ (most common in adults), __________ spp., _______ (more common in sexually active patients), and _________ (especially in those with sickle cell disease).
S. aureus; Streptococcus
Gonorrhoea; Salmonella
Septic arthritis
Bacteria will ‘seed’ to the joint from a —————- (e.g. recent cellulitis, UTI, chest infection), a direct inoculation, or spreading from _____________.
bacteraemia
adjacent osteomyelitis
Septic arthritis can cause irreversible articular cartilage damage leading to severe ____________.
osteoarthritis
Risk Factors
The main risk factors for developing septic arthritis are increasing _____, any ___________ disease (e.g. rheumatoid arthritis), diabetes mellitus or immunosuppression, chronic kidney disease, hip or knee joint ___________, or intravenous drug use
age; pre-existing joint
prosthesis
Clinical Features of septic arthritis
Patients will most commonly present with a __________ joint causing severe pain. ________ will be in around 60% of affected individuals (although its absence should not rule out septic arthritis).
single swollen; Pyrexia
Clinical features of septic arthritis
On examination, the joint will appear ________,_________, and _______, causing pain on ___________ movements. An effusion may also be evident.
red, swollen, and warm
active and passive
Clinical features of septic arthritis
Often the joint is ______ and the patient will not tolerate any passive movement at all, and will be unable to weight bear. Symptoms are more florid and obvious in ______ joint injection; in _______ joint infections, the features can be more subtle.
rigid
native
prosthetic
The main complications of septic arthritis are ________ and _________
osteoarthritis and osteomyelitis.
A Marjolin ulcer is a _____________ malignancy that arises in the setting of _____________ skin, _____________ scars, and _____________ wound
cutaneous malignancy
previously injured skin
longstanding scars
chronic wound
Traditionally the metabolic response to injury is divided into an initial period of catabolism followed by an anabolic phase of repair and tissue healing.
The catabolic phase begins at the time of injury and is characterised by _______volaemia, decreased __________, reduced _______, ________ and ————.
hypo
basal metabolic rate
cardiac output
hypothermia and lactic acidosis
The main physiological role of this catabolic phase is to ————- and ________________ and thus maximise sur- vival chances for future recovery.
conserve both circulating volume and energy stores
A series of neurohormonal responses accompany these catabolic phase efects and trigger a _________________________, where body stores are mobilised for recovery and repair.
systemic infammatory response syndrome (SIRS)
The catabolic efects of metabolic response to injury include muscle _______, weight ——— and hyper___________ , which themselves increase the risk of complications, especially _________.
breakdown; loss
glycaemia
sepsis
‘__________ ’ perioperative care helps to preserve homeostasis following elective surgery
Stress-free
Shock is a systemic state of _______________ that is inadequate for ________________.
With insufcient delivery of _________ and ___________ , cells switch from _________ to ————— metabolism. If perfusion is not restored in a timely fashion, cell death ensues.
low tissue perfusion
normal cellular respiration
oxygen and glucose
aerobic to anaerobic
Ischaemic cell death releases ________ into the circula- tion, leading to systemic __________ and (acidosis or alkalosis?) , as well as further damage to molecules that systemically activate the ________ and _________ system.
potassium
hyperkalaemia and acidosis
immune; coagulation
Systemic response to shock
CVS- _________
Respiratory-_____________
Renal-____________
Endocrine -___________
Widespread vasoconstriction
Compensatory respiratory alkalosis
Reduced urine output, further vasoconstriction
Activated RAAS system
Non-haemorrhagic causes include _________, excessive fuid loss due to ________,_________,_________ , evaporation or ‘ ___________ ’, where fuid is lost into the _____________ and _________ , as for example in bowel obstruction or pancreatitis.
dehydration
vomiting, diarrhoea, urinary loss
third-spacing
gastrointestinal tract and interstitial spaces
In anaphylaxis shock , vasodilatation is due to _________, while in high spinal cord injury there is failure of ___________ and adequate ___________ (neurogenic shock).
histamine release
sympathetic outfow and adequate vascular tone
Multiple organ failure is defned as —————————————
two or more failed organ systems.
Effects of organ failure
● Cardiac: ___________ failure
● Lung: ________________
● Kidney: ___________
● Liver: _________ and ________
● Brain: _________ and _____________
Cardiovascular
Acute respiratory distress syndrome
Acute renal insuffciency
Liver failure and coagulopathy
Cerebral swelling and dysfunction
In general, loss of around _____% of the circulating blood volume is within normal compensatory mechanisms.
Blood pressure is usually well maintained and only falls after ________% of circulating volume has been lost.
15
30–40
Resuscitation is very diferent if patients are actively bleeding or if they are not bleeding. In patients who are bleeding, the priority is to __________. In patients who are not bleeding, the priority shifts to _________________ (correcting the shock state).
stop bleeding
normalising end-organ perfusion
Forms of Haemorrhage
_________ and ________ haemorrhage
___________,__________, and _____________ haemorrhage
_________ and _________ haemorrhage
Revealed and concealed
Primary, reactionary and secondary
Surgical and non-surgical
Primary haemorrhage is haemorrhage occurring _________ as a result of ___________
Reactionary haemorrhage is ________ haemorrhage (within _________)
Secondary haemorrhage is due to ___________ of a vessel. It usually occurs ________ after injury
immediately; an injury (or surgery).
delayed; 24 hours
sloughing of the wall; 7–14 days
Reactionary haemorrhage is usually due to _______________ by resuscitation, _____________ and __________. Reactionary haemorrhage may also be due to technical failure, such as ——————
dislodgement of a clot
normalisation of blood pressure
vasodilatation
slippage of a ligature.
Secondary haemorrhage is precipitated by factors such as ________, ______ necrosis (such as from a _______) or malignancy.
infection
pressure
drain
Surgical and non-surgical haemorrhage
Surgical haemorrhage is due to a _________ and is ———————- (eg ________) or other techniques such as angioembolisation.
Non-surgical haemorrhage is general bleeding from __________ and _________ due to __________ and cannot be ___________ (except packing). Treatment requires correction of the coagulation abnormalities.
direct injury
amenable to surgical control (e.g. suture ligation)
raw surfaces and mucous membranes
coagulopathy; stopped by surgical means
There are four main groups of hospital acquired infections (HAIs) : __________ infections , __________ infections , _________ and _________
respiratory
urinary tract
bacteremia
SSIs
A major SSI is defned as a wound that either __________________________ or needs a __________________________
discharges signifcant quantities of pus spontaneously
secondary procedure to drain it
Abscesses need _________
Antibiotics are indicated if the abscess cavity is ___________________
drainage
not left open to drain freely
An open abscess cavity heals by ___________ intention
secondary
Cellulitis and lymphangitis
● (Suppurative or Non-suppurative?) , (poorly or well?) localised
● Commonly caused by streptococci, staphylococci or clostridia
● Blood cultures are often ______tive
Non-suppurative; poorly
nega
Gas gangrene
● Caused by _________________
● ______ and _______ are characteristic
● ______________ patients are most at risk
● ___________________ is essential when performing amputations to remove dead tissue
Clostridium perfringens
Gas and smell
Immunocompromised
Antibiotic prophylaxis
Bacteraemia
● Common after _____________
● Dangerous if the patient has a _________, which can become
infected
● May be associated with systemic organ failure
anastomotic breakdown
prosthesis
SIRS is Presence of two out of three of the following:
● __________ or _________
● Tachycardia (>____/min, no β-blockers) or tachypnoea (>___/min)
●___________ > ___ × 109/litre or <___ × 109/litre
Hyperthermia (>38°C) or hypothermia (<36°C)
90; 20
White cell count; 12; 4
Sepsis is SIRS with a _________________
documented source of infection
General principle in a musculoskeletal examination ??
Look
Feel
Move
Inversion- movement of the ______ that directs the _______ ————
Eversion- movement of the ______ that directs the _______ ————
Foot; Sole ; Medially
Foot; sole; laterally
Assessment of hyper mobility can be done with _________ score but not by that only
Beighton
The spinal column consists of ______ vertebrae with ____ intervertebral discs.
33
23
The fulcrum of the foot is??
The talus
Causes of pes planus(________)
● Normal variant
●_________ syndrome, e.g. ______ syndrome
● Tarsal coalition – rigid and painful _______
● Tibial posterior dysfunction
Flat foot
Hyperlaxity; Marfan’s
fat foot
Causes of pes cavus
●________ anomalies, e.g. ______
● Hereditary sensorimotor neuropathies, such as ____________ disease
● ________ foot (e.g. neuropathic foot)
● Post-compartment syndrome (e.g. Volkmann’s ischaemic
contracture)
Spinal; spina bifda
Charcot– Marie–Tooth
Charcot
Bony sequestrum represents a segment of _______ bone that is separated from _________ by __________.
An involucrum denotes a layer of _______ bone that has _________; it can become perforated by tracts.
necrotic; living bone ; granulation tissue
living; formed about the dead bone
Presentation of Septic Arthritis
-children may be ______ and ______, but adults only express a _________
-usually symptoms only affecting _______
-the joint is ________ and held in a position of __________
Toxic; febrile
Low grade Fever
One joint
Swollen; comfort
Musculoskeletal pain is usually improved by ____ and aggravated by ___________.
rest
movement
A Colles fracture is a type of __________(fracture). It’s also called a (proximal or distal?) fracture with (plantar or dorsal?) angulation (an ____ward angle).
broken wrist
Distal; dorsal
up
A Colles fracture aka ______ deformity
Dinner fork
Club foot: aka ___________
knock knees : aka ________
bow- legs : ________
Talipes equinovarus
genu valgus
genu varus
CAVE-
C- __________
A- ________________
V- __________
E- ___________
midfoot cavus
forefoot adduction
hindfoot varus
hindfoot equinox
____________ stiffness in all joints, especially the hands, is a characteristic of rheumatoid arthritis, while ________ stiffness of a specific joint, such as the hip, following _________, is indicative of osteoarthritis.
Early morning generalized
short-lived ; inactivity
Muscle power can be classified according to the ____________ scale.
• M0:_________________ is visible.
• M1: __________ is visible but there is ___________ of the joint.
• M2: ________ is possible if _________
• M3: ___________ can _________ but not _______________.
• M4: Active movement can ____________ and _________
• M5: There is ______________
Medical Research Council
No active contraction
Muscle contraction; no movement
Active movement; gravity is eliminated.
Active movement; overcome gravity ; resistance applied by the examiner
overcome gravity and some resistance applied by the examiner.
full power against resistance.
ATLS(______________) protocol
Primary survey :
A-_______
B-_________
C-____________
D-______________
E-_________________
Advanced trauma life support protocol
Airway and cervical spine control
Breathing and ventilation control
Circulation and Haemorrhage/shock control
Disability of the neurologic system
Exposure and Temperature control
ATLS protocol
Secondary survey :
Detailed _______
A-_______
M-_________
P-____________
L-______________
E-_________________
Detailed __________
history
Allergies
Medication
PMH, pregnancy, period
Last meal before trauma
Events related to trauma
examination
FAST-_____________
Focused abdominal sonography in trauma
Gustillo -Anderson classification of open fracture
Grade 1-?
Grade 2-?
Grade 3-?
3a
3b
3c
Wound less than 1cm
Wound between 1-10cm with no neurovascular injury
Greater than 10cm with neuro vascular damage
No periosteal stripping
Periosteal stripping
Neuro vascular stripping
A lucid interval (LI) is the period of time between _____________ after a ________________
regaining consciousness
short period of unconsciousness
The ‘Raccoon sign’ comprises unilateral or bilateral progressive ________ associated with ________. It is also referred to as the ‘raccoon eyes’ and the ‘ _______sign. ‘
The pooling of blood around the eyes is most commonly associated with fractures of the _________________
periorbital ecchymosis; edema
panda; base of the anterior cranial fossa.
Battle Sign is defined as bruising over the _______________
mastoid process.
The Lethal Six of thoracic trauma
???
F A T T H O M
Flail chest
Airway obstruction
Tension pneumothorax
Tamponade( cardiac)
hemothorax(massive)
open pneumothorax
The hidden 6??
T-thoracic aortic disruption
T-Trancheobronchial disruption
E-Esophageal disruption
M-myocardial contusion
P-pulmonary contusion
D-diaphragmatic tear
