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Year 4 - MSK ANNA > MSK - Trauma > Flashcards

MSK - Trauma Flashcards

1
Q

What are the four most common locations for haemorrhage in an A&E patient assessment?

A
  1. Chest
  2. Abdomen
  3. Pelvis
  4. Fractured long bones
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2
Q

What 3 imaging scans are common as part of an ATLS assessment?

A
  1. CXR
  2. PXR
  3. FAST scan - check for internal bleeding
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3
Q

What is a pathological fracture?

A

A fracture through an abnormal bone

  • e.g. a fracture through the bone of a patient with: osteoporosis; primary or secondary tumours; infection; medications
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4
Q

PCA (Patient controlled analgesia) is the practice of patient’s self administering small IV bolus doses of IV opiods. This is most effective when the button is pressed at the onset of symptoms and not at peak pain (as less drug is required and blood levels of opiod remain below threshold for adverse effects).

Which opiods are most commonly used for PCA?

A
  1. Morphine
  2. Pethidine
  3. Fentanyl (may be preferred in pts with renal failure as it is a shorter acting opiod and thus accumulation in pts system is less likely - pt will press button less frequently)
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5
Q

Which of the following are true about morphine?

  1. It is subject to extensive first-pass metabolism
  2. Its primary actions of therapeutic value are analgesia and sedation
  3. It works predominantly through its action on Kappa-receptors
  4. Is more potent than buprenorphine
  5. Is broken down in the liver through conjugation with glucuronic acid
A

1, 2 and 5

  • It is subject to extensive first-pass metabolism
  • Its primary actions of therapeutic value are analgesia and sedation
  • Is broken down in the liver through conjugation with glucuronic acid
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6
Q

Post reduction and stabilisation of tibial fracture, the pts limb is tense with mottling of toes and severe pain on passive stretch.

What could be the cause?

A

Compartment Syndrome

  • Pain that isn’t responding to analgesia should make you think compartment syndrome
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7
Q

Describe Compartment Syndrome

A

Compartment Syndrome is when the pressure within a fascial compartment exceeds the perfusion pressure of the vascular system within the compartment, causing ischaemia of the tissues within the compartment.

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8
Q

What are the 2 main fractures associated with compartment syndrome?

A
  1. Supracondylar fracture
  2. Tibial shaft fracture
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9
Q

What steps do you take when you suspect a patient has compartment syndrome?

A
  1. History
  2. Examine the neurovascular status of the limb for signs of compartment syndrome
  3. Review analgesia
  4. Release any dressings/casts which may be causing external compression
  5. Position limb at level of the heart
  6. If patient doesn’t respond to analgesia –> contact senior as emergency fasciotomy may be needed
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10
Q

What time period defines ‘delayed union’ i.e. failure of a fracture to reach bony union?

A

Failure at 6 months post injury = delayed union

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11
Q

What protocol / steps might you following when

describing a fracture on x-ray?

A
  1. Site of fracture (which bone and which part of the bone)
  2. Type of fracture (Transverse, oblique, spiral)
  3. Simple or comminuted
  4. Displaced or not
  5. Angulated or not
  6. Is the bone of normal consistency or not (e.g. osteoporosis causing pathological fracture)
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12
Q

Describe this X-ray

A

This is an AP of the right humerus. There is a simple transverse fracture of the midshaft of the right humerus, which is displaced medially and angulated by 40 degrees medially. There are no signs of pathological fracture.

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13
Q

Describe this X-ray

A

This is an AP and lateral x-ray of the left tibia and fibula. There is a comminuted spiral fracture of the midshaft of the tibia and fibula. It is completely displaced laterally and anteriorly with no angulation. There are no signs of a pathological fracture.

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14
Q

Describe this X-ray

A

This is a transverse fracture of the midshaft of the left collar bone. It is displaced but not angulated and has occurred through normal bone.

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15
Q

What do the following descriptions of nerve injuries mean?

  1. Neuropraxia
  2. Axonotmesis
  3. Neurotmesis
A
  1. Neuropraxia = reversible conduction block due to mild injury to nerve (compression / ischaemia)
  2. Axonotmesis = disruption to the myelin sheath and the axon but endoneurium still intact
  3. Neurotmesis = complete nerve division and disruption of the endoneurium
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16
Q

The common peroneal nerve splits into superficial and deep branches - what does each supply?

A
  • Superficial = motor for lateral compartment of lower leg
  • Deep = motor for anterior compartment of lower leg

Common peroneal also = sensation over lateral lower leg + dorsum of foot (majority)

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17
Q

What are the WHO (1992) definitions of osteopenia and osteoporosis?

A
  • Osteopenia = Bone mineral density that lies 1 standard deviation or more below the average value for a young healthy person of the same race and sex as the patient
  • Osteoporosis = Bone mineral density that lies 2.5 standard deviation or more below the average value for a young healthy person of the same race and sex as the patient
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18
Q

What is the most accurate clinical sign of Compartment Syndrome?

A

Pain in suspected region is exacerbated by passive stretch

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19
Q

Which area of the body and which compartment are most likely to be affected by compartment syndrome?

A

Anterior compartment of the lower leg

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20
Q

If a diagnosis of compartment syndrome is made in the lower leg, what is the first course of action?

A

Immediate fasciotomy of all 4 compartments of the lower leg

  1. Anterior
  2. Lateral
  3. Deep posterior
  4. Superficial posterior
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21
Q

When is the discharge plan for a patient with a # started?

A

As soon as the patient is admitted

  • This is because speedy intervention and discharge is associated with improved mobility and avoidence of complications
22
Q

What factors delay bone healing?

A
  • HIV
  • Diabetes mellitus
  • Vitamin D deficiency
  • Protein malnourishment
  • Hypercalcaemia associated with ↑ bone resorption e.g. hyperparathyroidism
  • Nicotine (smoking)
  • Medications:
    • Bisphosphonates (cause of osteoporotic fractures with long term use)
    • Systemic steroids
    • NSAIDs
    • Quinolones (type of Abx)
23
Q

What criteria should make you regard a surgical aptient or patients with trauma as being at an increased risk of VTE?

A
  • Surgical procedure with a total anaesthetic and surgical time of > 90 mins or 60 minutes if the surgery involves the pelvis or lower limb
  • Acute surgical admission with inflammatory or intra-abdominal condition
  • Expected significant reduction in mobility
  • Or if the patient has one of the following risk factors:
    • Active cancer or cancer treatment
    • Age over 60 years
    • Dehydration
    • Obesity (body mass index [BMI] over 30 kg/m2 )
    • 1 or more significant medical morbidities (heart disease, endocrine or respiratory pathologies, acute infectious disease etc.)
    • Personal history or first-degree relative with a history of VTE
    • Use of hormone replacement therapy
    • Use of oestrogen-containing contraceptive therapy
    • Varicose veins with phlebitis
24
Q

What are some important allergies to consider for a pre-op surgical patient?

A
  1. Abx
  2. Latex
  3. Iodine
  4. Chlorhexidine (antiseptic)
  5. Aneasthesia
  6. Analgesics
25
Q

If a patient has a fall from standing (i.e. low energy injury) which results in a #, what medical condition should you assume they have until proven otherwise?

A

Osteoporosis

  • Can be tested for via DEXA scan - T-score > 2.5 for a healthy young person of the same race and sex
26
Q

What are the 5 main cancers that metastasise to bone?

A
  1. Thyroid
  2. Breast
  3. Lung
  4. Renal
  5. Prostate
27
Q

Subtrochanteric fractures (from lesser trochanter to 5 cm distal) are associated with what 2 groups of patients?

A
  • Usually occur in young patients via high-energy mechanism
  • Can occur in elderly in low-energy mechanism –> often as pathological atypical femur fracture
    • Bisphosphonates = risk factor for atypical femur fractures e.g. subtrochanteric
28
Q

What is the typical presentation of a # Neck of Femur (NoF)?

A

Affected leg is shortened, externally rotated and abducted

29
Q

You suspect a patient has a # of NoF, what is an examination would support this?

A
  1. Straight leg raise –> most patients will be unable
  2. Leg roll maneuver –> pain on internal + external rotation (this is often due to haemorrhage into the capsule)
  3. Groin pain when axial load is applied to affected extremity
30
Q

Describe the major arteries of the neck of the femur?

A

Femoral head has 3 sources of arterial supply:

  • Extracapsular arterial ring:
    • Medial circumflex femoral artery (main supply to head) from profunda femoris (deep artery of the thigh
    • Lateral circumflex femoral artery - gives off 3 branches:
      • Descending
      • Transverse
      • Ascending (joins with MCFA to produce arterial ring)
  • Ascending cervical branches - given off the extracapsular ring
  • Artery to the ligamentum teres - from obturator artery
    • Supplies perifoveal area
31
Q

Which 3 bones are commonly at risk of avascular necrosis due to fracture?

A
  1. Head of Femur
  2. Waist of Scaphoid
  3. Neck of Talus
32
Q

Draw the proximal end of a femur. Name and draw lines where common fractures can occur.

A

Intracapsular:

  • Subcaptial
  • Transcervical
  • Basicervical

Extracapsular:

  • Intertrochanteric
  • Pertrochanteric
  • Subtrochanteric
33
Q

What type of fracture of the femur commonly poses risk of avascular necrosis of the head of the femur?

A

Intracapsular frature (displaced more likely to cause necrosis)

  • The reason for this is that fracture + displacement in this region often damages the blood supply to the head of the femur –> avascular necrosis
34
Q

If a patient suffers an intracapsular fracture with no displacement (i.e. unlikely that blood vessels to head are damaged) - how long should the patient be followed up on to monitor if avascular necrosis occurs?

A

~ 2 years

35
Q

What classification describes avascular necrosis of femoral head on X-ray/MRI scans?

A

Steinberg Classification

36
Q

If a patient has a DNAR, does it apply in surgical theatre?

A

No, often DNARs are ‘suspended’ in theatre as the operation itself or the anaesthesia can cause cardiac arrest and clinicians can often reverse/manage the arrest promptly and in a controlled fashion in theatre.

37
Q

What is a Mini Mental State (MMS) test scored out of?

What scores reflect differing degree of cognitive impairment?

A

MMS is scored out of 30

  • >24/30 = normal cognition
  • 19-23 = mild cognitive impairment
  • 10-18 = moderate cognitive impairment
  • ≤9 = severe cognitive impairment

N.B. score + education and age need to be accounted for as a score of 30 doesn’t rule out dementia

38
Q

What is a RESPECT form?

A

It is a Recomended Summary Plan for Emergency Care and Treatment

  • The form creates personalised recommendations for a person’s clinical care in a future emergency in which they are unable to make or express choices
39
Q

What should you offer patients with a displaced intracapsular hip #?

A

Hip replacement (total or semi arthroplasty)

40
Q

When do you offer total hip replacement rather than hemoarthroplasty in a patient with displaced intracapsular hip #?

A
  1. Were able to walk independently out of doors with no more than the use of a stick and
  2. are not cognitively impaired and
  3. are medically fit for anaesthesia and the procedure
41
Q

How do surgical interventions differ for the following hip fratures: undisplaced intracapsular, displaced intracapsular, extracapsular?

(This is assuming the patient isn’t young e.g. < 55yrs in which case intracapsular hip fractures are surgical emergencies to reduce and fixate)

A

Intracapsular:

  • Fix = internal fixation, or hemi-arthroplasty if unfit
  • Replace:
    • Young + fit i.e. < 70yrs = reduction and internal fixation (if possible)
    • Old + reduced mobility = hemiarthroplasty or total hip replacement

Extracapsular:

  • Nail = intramedullary nail
  • DHS = dynamic hip screw
42
Q

What is a Dynamic Hip Screw (DHS) and what is it used for?

A
  • A DHS is an implant for internal fixation certain hip fractures e.g. intertrochanteric #
  • It allows movement of the femoral head along the plane of the screw
  • This allows the bone to respond to dynamic stresses which encourages primary healing
43
Q

What is a bipolar hemiarthroplasty?

A

It is a partial hip replacement which involves a moving inner head inside of the larger external head.

Bipolar hemiarthroplasty:

  • Costs more than unipolar
  • Lower dislocation rate - but dislocation often requires open reduction
  • 10% revision rate in 7 years vs 20% for unipolar
  • Slightly better walking speeds and motion
  • Should be associated with less pain
44
Q

What is the mortality rate post hip # at 30 days vs 1 year?

A

30 days: ~ 8%

1 year: ~ 30%

45
Q

What are the complications of a hip replacement surgery?

A
  • Death
  • Infection:
    • Chest
    • UTI
    • Deep bone or superficial tissue (hip)
  • DVT/PE
  • Pressure sores
  • Nerve damage
  • Dislocation
  • Leg length difference
  • Non union
  • Avascular necrosis
46
Q

Which Abx are commonly used at the start of orthopeadic surgeries involving a hip # as prophylactic Abx?

A
  1. Teicoplanin i/v 600mg
  2. Gentamicin 2mg/kg at induction of anaesthesia

N.B. normal orthopaedic prophylactic abx is Flucloxacillin + gentamicin but for hip #, we skip to teicoplanin

47
Q

What 2 Abx are used prophylactically at the start of the orthopaedic surgeries listed and how does this change if pt is allergic to penicillin?

  • Primary or revision arthroplasty, open spinal surgery, other orthopaedic implant surgery, open or compound fractures
A

Not allergic to Penicillin:

  1. Flucloxacillin
  2. Gentamicin

Allergic to Penicillin:

  1. Teicoplanin
  2. Gentamicin
48
Q

What classification system can be used for hip fractures?

A

Garden System

  • Type I: Stable fracture with impaction in valgus
  • Type II: Complete fracture but undisplaced
  • Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
  • Type IV: Complete boney disruption
49
Q

Bisphosphonates are often used to ↓ blood [Ca2+] - but due to stopping bone turnover, they can put patients at risk of what?

A

Atypical femur fracture

50
Q

Due to risks associated with long-term bisphosphonate use, patients often go on ‘drug holiday’. After how many years of treatment is this considered, and for how long do they stop bisphosphonates?

A

Consider break after 5 years

Break can last 1/2 years

Year 4 - MSK ANNA (13 decks)

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