Week 5 - B - Elective Surgery (2) - soft tissue and osteomyelitis

Question 1

Which drug should not be given in tendonitis?

Answer 1

Ciprofloxacin - fluoroquniolones

Question 2

What do the vast majority of soft tissue inflammatory problems settle with?

Answer 2

The vast majority of soft tissue inflammatory problems settle with RICE:

* rest, ice, compression and elevation

Also can alleviate with analgesia and antiinflammatory medications if appropriate.

Question 3

Some tendons and entheses are amenable to injection of steroid around the tendon (eg rotator cuff, tennis albow) whilst in others there is substantial risk of tendon rupture

What are exmaples that are at high risk of tendon rupture if a steroid injection was given?

Answer 3

Extensor tendonitis (extensor mechanism of the knee) and Achilles tendonitis

Question 4

What is used in the knee examination to test the extensor mechanism function is intact?

Answer 4

Carry out a straight leg raise - lock knee and raise leg

Question 5

What is tennis and golfers elbow?

Answer 5

Tennis elbow - lateral epidcondylitis - where the extensor mechanism of the arm insert

Golfer’s elbow - medial epicondylitis where the flexor muscles of the arm insert

Question 6

What can be performed for the extensor tendons of the wrist in rheumatoid arthritis or for inflammation of the tibialis posterior tendon to prevent rupture?

Answer 6

Synovectomy

Synovectomy is a procedure where the synovial tissue surrounding a joint is removed.

This procedure is typically recommended to provide relief from a condition in which the synovial membrane or the joint lining becomes inflamed and irritated and is not controlled by medication alone.

Question 7

Instability is abnormal motion of a joint (rotation or translation) resulting in subluxation or dislocation with pain and/or giving way. What are common examples of instability?

Answer 7

Common examples are knee ligament instability and shoulder instability and patellar instability

Question 8

Most cases of joint instability can be managed with what to strengthen up surrounding muscles and to improve proprioception ?

Answer 8

Can be managed with physiotherapy

Splints, calipers or braces may provide additional support

Question 9

Cases of significant ligamentous laxity causes soft tissue procedures to be unlikely to work

Name 2 types of significant ligamentous laxity conditions?

Answer 9

This would be Ehler’s Danlos and Marfan’s

Question 10

What is the mutation in Marfan’s disease?

Answer 10

Mutation in the fibrillin gene which is essential for the elastic fibres in elastin in connective tissues

Question 11

What is the abnormal formation of elastin and collagen sometimes caused by in Ehler’s Danlos syndrome?

Answer 11

Mutation in type V collagen

Question 12

Leg length discrepancies can be corrected by either shortening the longer limb or lengthening the short limb using a special external fixator What is this fixator known as?

Answer 12

Ilizarov technique

Question 13

What is ilizarov technique?

Answer 13

This is an external fixation technique used to lenghten or shorten limb lengths

Question 14

Peripheral nerves can be trapped at various sites in the upper and lower limbs with the most common sites being the median nerve at the wrist and the ulnar nerve at the elbow What are the syndromes of these nerve compressions known as and what can treatment be?

Answer 14

Median nerve compression at wrist - carpal tunnel syndrome

Ulnar nerve compression at elbow - cubital tunnel syndrome

They can both be treated by decompression surgery

Question 15

Spinal nerve roots can be compressed by disc material or bony osteophytes causing a radiculopathy which may require spinal decompression or discectomy. What is the herniated part in a disc prolapse?

Answer 15

Herniated gelatinous nucleus polposus

Question 16

An acute osteomyelitis in the absence of recent surgery usually occurs in children, however immunocompromised adults can also be affected. What two other groups of people are more predisposed to osteomyelitis?

Answer 16

Poorly controlled diabetics

Those who are intravenous drug abusers (PWID)

Question 17

What is the most common cause of osteomyelitis? What can also cause it in sickle cell anaemia patients?

Answer 17

Most common cause is staph aureus infection

Can also be caused by salmonella in sickle cell anaemia patients

Question 18

Once infected, enzymes from leucocytes cause local osteolysis and pus forms which impairs local blood flow making the infection very difficult to eradicate

What is the dead fragment of bone which can break of in osteomyleitis known as?

Answer 18

Sequestrum can break off

Question 19

Osteomyleitis and septic arthritis can often present similarly

Which has pain also at rest as well as movements?

Answer 19

Septic arthritis is also associated with pain at rest

Question 20

Where is the red swelling in spetic arthritis? Where is the red swelling in osteomyelitis?

Answer 20

Spetic arthritis - over the joint involved

Osteomyelitis - swelling occurs over the area of bone involved

Question 21

How is the diagnosis of osteomyelitis carried out?

Answer 21

Diagnosis of osteomyelitis carried out by:

MRI is the best imaging modality for establishing the diagnosis of osteomyelitis as it can demonstrate bone marrow oedema, confirm the presence of abscesses and delineate extraosseous disease spread

CT guided bone biopsy - gold standard for pathogen identification and if diagnosis still remains uncertain

Question 22

If frank pus is aspirated, the clinical picture fits with obvious septic arthritis or a positive Gram stain is found, the treatment is usually surgical washout either via open surgery or using arthroscopic techniques.

What is probably the better technique to reduce the bacterial load in the joint?

Answer 22

Open washout of the joint is probably best

Question 23

What is the antibiotic usually given in septic arthritis?

Answer 23

This would be IV flucloxacillin after open washout