Week 5 - MSK Elective Surgery and General Trauma Formative

Question 1

What term is defined as ‘an inspiratory noise caused by airway obstruction’?

Answer 1

Stridor Signs of airway obstruction include noisy breathing, gurgling, stridor and agitation from hypoxia and hypercapnoea. A patient who is able to speak has control of a clear airway.

Question 2

Nerve injury may accompany an open ofrclosed injury with out without fracture of bones or dislocation of a joint. Some injuries are characteristically associated with particular nerve injuries. State the nerve most at risk in each mechanism or type of injury * Anterior dislocation of the shoulder * Humeral shaft fracture * Colles (distal radial) fracture

Answer 2

Anterior dislocation of the shoulder - axillary nerve Humeral shaft fracture - radial nerve Colles (distal radial) fracture - median nerve

Question 3

Peripheral nerves may become compressed by surrounding structures and this can produce symptoms, such as decreased or abnormal senation or muscle weakness, due to nerve disfunction. State the correct nerves at risk of compression at he following anatomic sites in the upper limb: * Carpal tunnel * Cubital tunnel

Answer 3

Carpal tunnel - median nerve Cubital tunnel - ulnar nerve 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 (carpal tunnel syndrome) and the ulnar nerve at the elbow (cubital tunnel syndrome). Symptoms can be improved by nerve decompression surgery.

Question 4

Nerve injuries can be associated with fractures / dislocations. Functional recovery from these injuries is often good but time to recovery varies upon the type of injury sustained to the nerve vessel. State the injury relating to the definition. * A complete transection of a nerve requiring surgical repair for any chance of recovery of function. * A temporary conduction defect from compression or stretch and resolve over time with full recovery * Nerve injury sustained due to compression or stretch or from a higher degree of force with death of the long nerve cell axons distal to the point of injury die.

Answer 4

Neurotmesis - A complete transection of a nerve requiring surgical repair for any chance of recovery of function

Neurapraxia - A temporary conduction defect from compression or stretch and resolve over time with full recovery

Axontmesis - Nerve injury sustained due to compression or stretch or from a higher degree of force with death of the long nerve cell axons distal to the point of injury die.

Question 5

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Answer 5

Compartment syndrome is serious condition and an orthopaedic emergency and when suspected it requires prompt review, diagnosis and treatment. Muscle ischaemia is manifested by severe pain and pressure rises can also compress nerves resulting in paraesthesiae and sensory loss. The cardinal clinical sign is increased pain on passive stretching of the involved muscle and pain out of proprtion with clinical features.

Question 6

Malunion: Fractures of the distal radius that heal in a poor position (a malunion) may result in impaired grip strength. Is this associated impairment associated with loss of extension or flexion at the wrist joint post injury? Select one: * a. Extension * b. Flexion

Answer 6

The correct answer is loss of wrist extension is associated with poor grip strength post distal radial fracture. The wrist needs at least 10 degrees of extension for full grip strength.

Question 7

True or false: Acute osteomyeltis, in the absence of previous surgery, is more common in children than adults. Select one: True False

Answer 7

True

Question 8

True or false: A tibial osteotomy may be considered as an alternative surgical option to joint replacement for knee arthritis in the young patient. Select one: True False

Answer 8

TRUE - Osteotomy is surgical realignment of a bone which can be used for deformity correction or to redistribute load across an arthritic joint. This surgery is a useful aternative to knee replacement arthroplasty, especially in the young patient, as evidence suggests that * (1) Young patients often have greater functional demands than a knee replacement offers, and * (2) the life-span of a joint replacement is related to how much it is used and it, therefore, wears out more quickly in young patients.

Question 9

The Glasgow Coma Scale is a tool used to assign a numerical value to a patient’s neurological function. Both the actual value and the trend is valuable in assessing a patient. What score (or below) on the GCS implies a loss of airway control and should prompt the treating doctor to perform airway manoevres? Select one: * 0 * 3 * 6 * 8 * 10

Answer 9

A Glasgow Coma Score (GCS) of 8 or less implies loss of airway control and the first aid manoevre of chin‐lift, jaw thrust corrects this.

Question 10

Whilst vascular injuries are uncommon in trauma, the consequences can be significant. Certain injuries have a higher risk of concomitant vascular injury. State the injured artery at particular risk of injury for each: * Knee dislocation * Shoulder dislocation * Paediatric supracondylar fracture

Answer 10

Knee dislocation - popliteal artery Shoulder dislocation - axillary artery Paediatric supracondylar fracture - brachial artery

Question 11

The primary survey consists of the ABCDE evaluation: * Airway management with cervical spine control * Breathing & ventilation * Circulation & bleeding control * Disability (neurological evaluation) * Exposure & environmental control When performing the primary survery, a quick run-through of these assessments is done in order and any issues are noted. Management of any issues noted are then dealt with simultaneously once the run-through is complete. T OR F ?

Answer 11

FALSE * This is a very important principle of the primary survey. Assessment and management is performed together for each of the domains (A, B,C, D and E). * That is, you do not move on to assessing breathing until you are happy you have control of the airway. You do not move on to assessing neurological status until you have assessed and managed circulation.

Question 12

True or false: All tendon tears require surgical repair to preserve function and allow early recovery. Select one: True False

Answer 12

False * Major tendon tears may require * splintage (often used in the treatment of Achilles tendon tears), * surgical repair (eg quadriceps or patellar tendon, occasionally Achilles tendon) * or tendon transfer (eg tibialis posterior, extensor pollicis longus), which is not usually done urgently.

Question 13

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Answer 13

Correct answer - Using scissors, split the backslab down the soft area at the front. Cut the entire length of the cast to ensure there are no tight bands left. * The cast must be split fully, top to bottom, to provide relief of pressure. If even one, small circumferential band of cast is left, there will be ongoing impairment of blood flow.

Question 14

Ligaments and tendons can be sprained (intra-substance tearing of some fibres), partially torn or completely ruptured. Some tendon ruptures are treated conservatively, whilst others are best managed with surgical repair to restore function. From the following choices, select the tendon which is commonly surgically repaired to optimize function: Select one: * a. Long head of biceps * b. Patellar tendon * c. Achilles tendon * d. Hip adductor tendon

Answer 14

Patellor tendon Complete tears of tendons fundamental for function (quadriceps tendon, patellar tendon,) require surgical repair for restoration of function

Question 15

Options * Transverse * Oblique * Spiral * Comminuted * Segmental

Answer 15

The bone is fractured in two separate places. - Segmental fracture

Occurs in childrens bones with the cortex on the tension side of the fracture failing but the cortex on the compression side of the fracture remaining intact- Greenstick fracture

Fractures with 3 or more fragments. This type of fracture is very unstable and tend to be stabilized surgically. - Comminuted fracture

Question 16

Salter-Harris fractures: The Salter-Harris classification system can be used to classify and describe children’s fractures occuring aorund the physis (growth plate). Which types of Salter-Harris fractures are intra-articular? Select one or more: * V * III * II * IV * I

Answer 16

Salter-Harris fractures III and IV are intra-articular

Question 17

True or false: Joints are anatomocially designed to be inherently stable so instability can only occur after a preceding trauma or injury. Select one: True False

Answer 17

False - Instability is abnormal motion of a joint (rotation or translation) resulting in subluxation or dislocation with pain and/or giving way. * Instability can be a consequence of an injury or can be related to ligamentous laxity. It can also be predisposed by anatomic variation (eg shallow trochlea of distal femur, femoral neck anteversion and genu valgum in patellofemoral instability) and can be due to an underlying disease process (eg cervical spine instability in rheumatoid arthritis, knee hyperextension in polio).

Question 18

Fracture healing: State whether the following statements describe primary or secondary healing * Can be associated with hypertrophic non-union when the fracture is not properly stabilised * Involves an inflammatory response and laying down af immature bone * Occurs with a fracture gap of less than 1mm * Occurs in anatomically reduced fractures fixed rigidly with plates and screws

Answer 18

Secondary healing Can be associated with hypertrophic non-union when the fracture is not properly stabilised Involves an inflammatory response and laying down of immature bone Iinflammatory response with recruitment of pluripotent stem cells) Primary healing Occurs with a fracture gap of less than 1mm Occurs in anatomically reduced fractures fixed rigidly with plates and screws

Question 19

Hip and knee joint arthroplasty is a common elective orthopaedic operation. From the list below, choose the chief indication for performing this operation. Please select only one answer: Select one: * To improve range of movement at the joint (reduce stiffness) * To increase strength at the joint * Pain * To improve function

Answer 19

Total joint arthoplasty is an excellent operation when done for the correct indication and when patients are counselled properly prior to the procedure so that they have reasonable expectations. The chief indication for arthroplasty is pain.

Question 20

What type of joint procedure is being described below? “The surgical stiffening or fusion of a joint in a position of function.”

Answer 20

Arthodesis means a surgical stiffening or fusion of a joint in a position of function. The remaining hyaline cartilage of the joint and subchondral bone is removed and the joint is stabilized resulting in bony union (like fracture healing) and fusion. * Arthrodesis is good for end stage ankle arthritis, wrist arthritis and arthritis of the first MTP joint of the foot (hallux rigidus).