Orthopaedics Flashcards
(193 cards)
1
Q
what are the non-surgical management methods for fracture fixation?
A
external coaptation
conservative
2
Q
what are the surgical management methods for fracture fixation?
A
pin and wire
external skeletal fixation
plate and screw
3
Q
what are the principles of fracture fixation?
A
return the patient to normal function as soon as possible
create circumstances which allow bone healing to be optimal
4
Q
what are the potential advantages of non-surgical management?
A
reduce/avoid anaesthesia
avoid need for open surgical approach
cheaper materials
cheaper overall? (may end in surgery anyway)
5
Q
what are the potential disadvantages of non-surgical management?
A
fracture disease
insufficient stability, leading to delayed/non-union
malunion
cast sores, ischaemia
6
Q
what are the principles of conservative fracture management?
A
surrounding soft tissue provides sufficient stability to keep bones aligned whilst healing
minimise movement whilst healing - restrict exercise, prevent weight-bearing
7
Q
which fractures are suitable for conservative management?
A
selected fractures of pelvis, scapula or vertebra
stable, minimally displaced fractures
8
Q
how long do fractures typically take to heal with conservative management?
A
4-6 weeks
possibly less in younger animals
9
Q
what can be used to prevent weight bearing on scapular fractures?
A
carpal flexion bandage
velpeau sling
10
Q
what information needs to be given to owners of animals undergoing conservative fracture management?
A
cage size and contents prevention of boredom nursing care decubitus ulcer prevention provide non-slip rugs and ramps
11
Q
what is external coaptation?
A
compressive forces transmitted to bones by means of interposed soft tissues
12
Q
which joints must be immobilised in external coaptation?
A
immobilise joint above and below fracture
this principle extends to all joints distal to the fracture to avoid foot swelling
13
Q
which fractures are suitable for coaptation?
A
fractures distal to elbow or stifle
stable fractures
50% overlap of fracture fragments on orthogonal radiographs
fracture of one bone of a 2 bone segment (e.g. radius and ulna)
2 or fewer metatarsal/metacarpal fractures
14
Q
what is the first layer of a cast?
A
‘stockinette’
double layer, long enough for overlap top and bottom
hold taut so doesn’t ruck up
15
Q
what is the second layer of cast?
A
primary layer - soffban water-repellant, conformable bandage 1-2 50% overlap layers not too much padding over bony prominences allow excess top and bottom for overlap
16
Q
what is the third layer of cast?
A
cast material - fibreglass impregnated polyurethane
lightweight, comfortable, waterproof, radiolucent, fast setting
wear gloves!
17
Q
how do you apply the cast material?
A
immerse in water and squeeze 6 times
apply under a little tension
average of 6 layers (3 up and downs) - more at bends
avoid wrinkles
18
Q
what should you do once the cast material has set? why?
A
bivalve using a cast saw while dog still sedated/under GA
for ease of removal if problems or if another vet does not have a cast saw
19
Q
what should you do with the cast once it has been bivalved?
A
secure it firmly using strips of non-stretchy tape (zinc oxide tape)
20
Q
how do you protect against sharp ends of cast?
A
fold over sofban and stockinette - apply extra padding as necessary to avoid sharp edges
reinforce foot area with extra tape (wears through)
21
Q
what is the final layer of cast?
A
outer protective layer - vetrap (cohesive bandage)
22
Q
what final check should be done once the cast is in place?
A
make sure toenails and central pads are visible but not protruding
23
Q
why is the complication rate of external coaptation high?
A
inappropriate case selection
owner compliance
difficulties in management
24
Q
what is the most common complication of external coapation?
A
soft tissue injury - ischaemic injury
mild dermatitis to avascular necrosis
25
what structural complications can arise from external coaptation?
may heal with rotation, angulation and/or shortening
may be functional or non-functional depending on degree/severity
26
how does fracture disease occur?
occurs during the time necessary for the bone to heal and is a result of fracture management
27
what can result from fracture disease?
joint stiffness
muscle atrophy
osteoporosis
muscle contracture and fibrosis
28
how can fracture disease be avoided?
aim for a rapid return to weight-bearing
avoid unnecessary immobilisation of joints by external coaptation
consider other options that cause less fracture disease e.g. ESF or internal fixation
29
what is the nurses role in surgical fracture repair?
analgesia provision and patient care prior to surgery
aseptic surgical prep
equipment gathering and setup for theatre
trolley assistant for surgery
post-operative care of the patient
discharging patient to owner
30
what trolley setup can make fracture surgery easier?
tidy instruments with handles all in same direction
separate tray for sharps
needles separate
commonly used instruments in separate tray
31
what type of drape is used in fracture surgery?
adhesive drape (opsite/loban)
32
is the foot clipped for fracture surgery?
only if directly involved in surgery - must always be covered regardless
33
what is fracture reduction?
the process of replacing the fracture segments in their original anatomical position
34
which injuries are suitable for closed fracture reduction?
recent/stable fractures
| lower limb fractures - less soft tissue, easier to reduce and palpate
35
which methods are used for closed fracture reduction?
traction and counter-traction
manipulation
bending
36
what is the main barrier in open fracture reduction?
overcoming muscle contraction
37
h
38
how can we overcome muscle contraction during open fracture reduction?
levers (Hohmann retractors)
bone holders
muscle relaxants
39
why aren't muscle relaxants always used to overcome muscle contraction?
often don't respond well as the tissue is inflamed
40
what is toggling?
bending the fracture 180° to engage the ends, then straightening the limb in order to position the bone straight for stabilisation
41
which fractures are suitable for toggling?
transverse fractures
42
what types of implants are used in fracture repair?
```
pins
wire
screws
external skeletal fixation
plate and screws
```
43
can intramedullary pins be used alone?
rarely - do not prevent rotation at the fracture site
44
what are intramedullary pins often combined with?
plate or ESF
45
when are intramedullary pins used alone?
metacarpal/metatarsal repair - splinted by other bones
46
what are the complications with using intramedullary pins?
length - too long/short and won't stabilise fracture effectively + difficult to retrieve
too long will result in seroma formation
loosening and migration
fracture non-union
47
what is an interlocking nail? why is it used?
stainless steel pin used as intramedullary pin - locked in place using screws/bolts
prevents rotation and axial collapse
48
what materials are bone plates/screws made out of?
stainless steel or titanium alloy
49
what is the function of bone plates?
compression of bone fragments
50
what is the effect of bone compression?
friction - increases stability
primary bone healing
load-sharing between bone and implants
51
what is bridging fixation?
plate is used to shore up/support fragments in unreconstructable fractures
uses a larger plate
52
what are the different uses for bone screws?
combination with a plate or interlocking nail
used in isolation for fractures of cancellous bone (never for diaphyseal)
53
why aren't bone screws ever used in isolation for diaphyseal fractures?
slower healing and greater forces through bone
54
what different types of bone screws are there?
locking screws
self tapping
non-self tapping
55
what are the functions of a bone screw?
secure a plate to a bone to support a fracture during healing
to compress fragments together in lag fashion to enable rapid healing without a callus
56
where is it important to avoid callus formation?
in fractures close to a joint
57
how should you treat an articular fracture?
open reduction and internal fixation
compression
perfect reduction
maintenance of joint mobility
58
when are smooth bone pins used?
rarely as don't hold bone well
| sometimes used if very small pin required
59
what types of threaded pins are there?
negative (Ellis) or positive (Imex) profile
end threaded (positive or negative)
centrally threaded (positive only)
interface pins (roughened to help stick to putty)
60
when is putty used?
to replace bars and clamps
61
what is the advantage of using stainless steel/carbon connecting bars?
reusable
62
what are the disadvantages of using stainless steel/carbon connecting bars?
heavy (carbon light)
| all clamps need to be in a straight line
63
what are the advantages of using acrylic/putty?
light
no limit to pin size/closeness
no protruding pin ends which might irritate
64
what is the disadvantage of using acrylic/putty?
removal is more difficult
65
what are clamps used for?
connecting pins to bars
66
what are the advantages of using clamps?
reusable if not deformed
| makes adjustments and pin removal easier
67
what are the disadvantages of using clamps?
limit to pin and bar size
| need to be constructed correctly
68
what is a tied-in IM pin?
the IM pin is left long and connected to the ESF via a separate connecting bar or by bending the bar
69
what is the advantage of using a tied in IM pin?
IM pin can't migrate/loosen - increases stability of the whole structure
70
which bones are prone to avulsion fractures?
```
olecranon
greater trochanter
medial malleolus
acromion of scapula
os calcaneus
tibial tuberosity
```
71
what is the tension band wire principle?
active distracting forces are counteracted and converted into compressive forces
72
what is the role of the surgical assistant during fracture repair surgery?
managing the surgical table and passing instruments correctly
assisting with surgical retraction and haemostasis
ensuring that diagnostic samples are not lost and transferred appropriately to sample pots
keeping bone graft safe and reminding the surgeon to use it
keeping count of surgical swabs
running a continuous suture and cutting sutures
73
how should you pass instruments to the surgeon?
in a decisive manner
tip of instrument visible and handles placed in surgeons waiting hand in proper position for use
don't reach behind a member of the sterile team
74
what should be carried out post-op?
post-op x-rays
| discussion of physio
75
what information should be given to the owners post-op?
cage rest information
timeframe of when weight-bearing should occur
suture removal information
buster collar info
prognosis
warn about possibility of premature closure of growth plate in young animals
76
what complications might occur post-op?
fracture instability
loosening
breakage
delayed or non-union
77
what should owners be looking out for post-op?
```
lameness
change in limb use
change in shape
swelling
discharge
```
78
what is the purpose of orthopaedic first aid?
to minimise injury and future disability
| to keep the patient alive in serious cases
79
what are the 3 aims of orthopaedic first aid?
preserve life
prevent suffering
prevent deterioration
80
what is triage of the trauma patient?
a methodical initial assessment to rapidly identify the major life threatening injuries
81
what do we check in triage of the trauma patient?
```
airway
breathing
circulation
external haemorrhage
CNS function
```
82
what possible oral/skull reasons could there be for a patient having difficulty breathing following trauma
head trauma/fractures (skull, maxillary)
blood clots
ruptured trachea
83
how do you assess the airway during the primary survey/what are we checking for?
```
check mouth for obstruction (blood clot, foreign body)
nostril blockages
tongue swollen/lacerated
hard palate split
swelling around larynx
```
84
how do we check breathing during the primary survey?
breathing rate/effort/adequacy
85
what might have occurred if a cat has blood around nose, excess saliva, and inability to close the mouth
fractured jaw
86
how can we check circulation during the primary survey?
```
mm colour
CRT
heart/pulse rates, pulse quality
rectal temperature
peripheral pulses and temperature
```
87
what are the symptoms of mild shock?
mild tachycardia and tachypnoea
darker pink mm
CRT <1 second
normal mentation and BP
88
what are the signs of early decompensated shock?
```
tachycardia and tachypnoea
pale mm
slow CRT
weak pulse
poor mentation
hypotension
```
89
what what point of shock should we give the patient fluids?
early decompensated
90
what are the signs of late decompensated shock?
```
bradycardia
absent CRT
severe hypotension
cheyne stokes breathing
death
```
91
when should we assume RTA patients have severe injury?
until proven otherwise
92
how should we transport recumbent RTA patients?
on an improvised stretcher
93
what is a secondary survey?
thorough check of body systems if primary survey ok/patient stabilised
94
what does A CRASH PLAN stand for?
A - airway - nose/larynx/neck/thoracic inlet
```
C- cardiovascular (CRT, pulse, BP)
R - respiratory (chest wall, lungs)
A - abdomen (diaphragm, inguinal, flank, paracostal)
S - spine
H - head (eyes/ears/mouth/teeth/tongue)
```
P - pelvis (rectum, perineum, scrotum, vulva)
L - limbs
A - arteries and veins
N - nerves (cranial and peripheral)
95
when is the secondary survey performed?
only after successful resuscitation and stabilisation of life-threatening injuries is the history taken and the thorough physical examination performed
96
what are the main signs of orthopaedic injury?
recumbency/severe lameness
limb wounds with pain/swelling
deformity
abnormal mobility/instability of limb
crepitation (due to bone-bone contact)
97
what is a luxation?
dislocation
| complete disruption of normal relationship between articular surfaces of a joint
98
what are the major types of orthopaedic injury?
fractures
luxations
subluxations
wounds penetrating joints
tendon lacerations/avulsions
ligament strains
muscle lacerations
(all soft tissue injuries)
99
what is a fracture?
a disruption in the cortical continuity of a bone - can be complete or incomplete
100
what is an incomplete fracture?
not across full bone, only one cortex affected
| seen in young animals due to flexibility of bone
101
what is sub-luxation?
partial disruption of relationship between articular surfaces of a joint
102
why is water soluble jelly used in management of open contaminated wounds?
to protect wound and prevent hair falling in while clipping
103
which order should be used in management of open contaminated wounds?
```
give analgesia and antibiotics therapy ASAP
apply water soluble jelly
clip
flush
debride
bandage
```
104
what equipment is required for management of open contaminated wounds?
```
water soluble jelly
clippers
fluids for flush
scalpel to debride necrotic tissue
bandage for stabilisation
```
105
what is involved in first aid for open fractures/luxations?
treat as for laceration
apply sterile hydrogel to exposed articular cartilage and/or bone
support dress the injured limb, attempting to restore normal anatomy
106
should patients undergoing orthopaedic first aid be cage confined?
yes - unless only minor injuries
| confinement will help prevent further injury through restricting movement
107
can we attempt to reduce luxations/fractures in the conscious patient?
no - too painful
108
can we attempt to stabilise proximal limb injuries in the conscious patient?
no - only below stifle/elbow
| not possible with external coaptation, must be internal repair
109
why is it not possible to stabilise proximal limb injuries with external coaptation?
muscle will stabilise these joints
| difficult to support joints above and below
110
what are orthogonal radiograph views?
views at 90° to each other
111
what else can be done while the patient is under GA for radiography?
wound care
splint/bandage application
reduction of luxation/fracture (if simple transverse fracture)
112
when might it be possible to support dress a limb in reduction/near reduction?
some distal injuries with torn ligaments and tissues resulting in marked laxity
113
how can you dress unstable fractures to support them?
use soft padding, then splinting material
| then conform and outer protective layer
114
what splinting materials are available?
fibreglass resin - activated by water (5 min to harden)
orthoboard - plasticised cardboard, mould in hot water
thermoplastic - heat in water/use heat gun
plaster of paris - activated by water (long time to set)
115
what are the 4 layers of bandaging?
dressing - wet to dry/cotton wool (melolin/absorban)
sofban (water repellent)/swabs
conforming layer
vet wrap
116
what are the functions of a bandage?
protection
support for fracture/luxation/pre and post-surgery
pressure (haemostasis/swelling control)
immobilisation
117
where are support dressings useful in first aid?
stabilisation of distal limb only - support joint proximal and distal to injury
118
what are some of the different shapes of splint?
green gutter
tongue depressor
custom made splint using cast material
119
what does a robert jones bandage achieve?
immobilisation of fracture/luxation
control swelling and oedema
comfort
120
how do we provide first aid for bleeding?
treat as for laceration
apply a sterile contact layer, then generous padding using an absorbent layer (cotton robert jones)
apply pressure 30 mins-1hour for arterial bleed
121
what is hip dysplasia?
a developmental disease where laxity develops in the joint capsule, which allows hips to subluxate
122
what is the aetiology of hip dysplasia?
combo of genetics, size (larger breeds), diet, exercise
123
what is the common signalment associated with hip dysplasia?
mainly affects large/giant breed dogs (can affect small breeds and cats)
124
how does hip dysplasia manifest in young dogs (4-12 months)?
laxity
125
how does hip dysplasia manifest in adult dogs?
osteoarthritis
126
what can be seen with gait analysis of an animal with hip dysplasia?
short strides, stiffness, clunking of hips
lateral swaying
bunny hopping
adducted hindlimbs
127
what can be seen on orthopaedic examination of an animal with hip dysplasia?
pain on hip extension
clunking
hindlimb muscle atrophy
crepitus
128
what can be seen on an x-ray of an animal with hip dysplasia?
hip subluxation
acetabular remodelling
osteophytes
129
what x-ray position should be used for suspected hip dysplasia?
ventrodorsal extended - very important for hips to be straight
130
which test can be used to confirm hip dysplasia?
ortolani test (test of hip laxity) - dog in dorsal/lateral recumbency and stifles rotated outwards
will be negative if normal or just dislocated hip
131
what are the non-surgical treatment options for hip dysplasia?
osteoarthritis management - NSAIDs, rest, hydrotherapy, diet
132
what are the surgical treatment options for hip dysplasia?
juvenile pubic symphysiodesis (young dogs)
triple/double pelvic osteotomy (young dogs)
total hip replacement
femoral head and neck excision
133
what is avascular necrosis of the femoral head?
lack of blood supply to the femoral head, causes tissue death
134
what is the aetiopathogenesis of avascular necrosis of the femoral head?
trauma
ischaemia
small breed disposition
inherited basis with an autosomal inherited gene
135
what are the clinical signs of avascular necrosis of the femoral head?
unilateral hindlimb lameness
pain on hip extension and flexion
muscle wastage
136
what will be seen on a radiograph of a dog with avascular necrosis of the femoral head?
lucent areas initially
collapse and mushrooming of the femoral head as disease progresses
137
how can avascular necrosis of the femoral head be treated?
surgery - femoral head and neck excision; total hip replacement
conservative - cage rest
138
what is the prognosis for avascular necrosis of the femoral head?
guarded - usually requires salvage surgery
139
what is slipped capital femoral epiphysis?
damaged growth plate resulting in separation of the femoral head from the femoral neck
140
what are the clinical signs of slipped capital femoral epiphysis?
lameness and hip pain
| atraumatic - often not acute onset of lameness
141
which animals are more likely to be affected by slipped capital femoral epiphysis?
young, male, neutered cats (<2 years), overweight/large breed
142
why does castration influence development of slipped capital femoral epiphysis?
castration delays growth plate fusion
143
what radiographic changes are seen with slipped capital femoral epiphysis?
radiolucent line at capital physis
separation/movement between femoral head and femoral neck
resorbtion of femoral neck
144
what is the treatment for slipped capital femoral epiphysis?
salvage surgery -
femoral head and neck excision
total hip replacement
parallel pin
145
what is the prognosis for slipped capital femoral epiphysis allowed to head spontaneously?
guarded for healing - usually do not heal and surgery is required
146
what is the pathogenesis of hip luxation?
usually traumatic (RTA, fall)
147
what is the aetiology of hip luxation?
can be seen spontaneously in dogs with hip dysplasia
148
how is the gait altered in dogs with hip luxation?
sudden onset lameness
stifle out, hock in and leg adducted
dislocated leg appears shorter
149
which direction does hip luxation usually occur in?
craniodorsally
150
what are the clinical signs of hip luxation?
variable lameness/pain/crepitus
palpation of landmarks (greater trochanter in line with iliac crest/tuber ischii)
'shorter' limb length
thumb displacement test
151
how do you carry out the thumb displacement test for hip luxation?
place thumb between tuber ischii and greater trochanter - with dislocation, thumb will stay in notch with manipulation
152
why are radiographs/CT scans essential for diagnosis of hip luxation?
physical examination and clinical signs can be complicated by the presence of fractures of the pelvis and proximal femur
153
which factors affect the method of treatment for hip luxation?
presence of pre-existing disease (hip dysplasia)
duration of luxation
concurrent orthopaedic injuries
154
what are the management options for hip luxation?
closed reduction +/- stabilisation
open reduction
salvage surgery
155
what is closed reduction of hip luxation?
manual manipulation of the femoral head back into the acetabulum
156
when should closed reduction of hip luxation never be attempted?
if:
acetabular/femoral head fractures
chronic luxations/hip dysplasia
other injuries e.g. pelvic fractures preventing reduction
evaluation of the cartilage is needed
157
what is the technique for closed reduction of hip luxation?
–Animal anaesthetised
–Assistant needed to hold on to dog or may be pulled off table
–Extend, adduct and externally rotate limb to lift femoral head over dorsal acetabular rim
–Then abduct and internally rotate to sit femoral head into the acetabulum
–Confirm reduction with two orthogonal xrays
–Ehmer sling or cage rest post reduction
158
what are the methods involved in open reduction of hip luxation?
```
iliofemoral suture (common)
toggle
transarticular pin
prosthetic capsular repair
primary capsular repair
```
159
what is the prognosis for hip luxation?
good in 75% of cases
OA will form eventually
recurrent dislocation possible
160
what is patella luxation?
displacement of the patella from its groove in the distal femur
161
which way does the patella usually luxate?
medially
162
is patella luxation usually unilateral or bilateral?
bilateral
163
which animals are more likely to develop patella luxation?
common in small breed dogs
lateral luxation in large breed dogs
can occur in cats
164
what is the aetiology of patella luxation?
most cases are developmental and appear when young - possibly hereditary
occasionally atraumatic
165
how is the gait altered with patella luxation?
may avoid flexing or extending the stifle
| appears to walk in 'cowboy' stance with stifles flexed and a wide based stance
166
what is usually found with clinical examination of patella luxation?
stifle discomfort
patella clicks on manipulation of stifle
stifle in extension - look for patella laxity
167
what is a grade I patella luxation?
Patella normally within the groove
| Returns spontaneously when luxated manually
168
what is a grade II patella luxation?
Patella normally within the groove
| Can be luxated and will remain so when released
169
what is grade III patella luxation?
Patella normally outside the groove
| Can be manipulated back into the groove
170
what is grade IV patella luxation?
Patella normally outside the groove
| Cannot be reduced by manipulation
171
what is the most common grade of patella luxation?
grade II
172
how is patella luxation treated?
tibial tuberosity transposition - realigns the tibial tuberosity and the quadriceps line of pull with the groove
173
what is involved in post-op care for patella luxation?
consider support dressing
multimodal analgesia
strict rest initially, gradual increase in exercise after 6 weeks
174
what is the prognosis for patella luxation?
deteriorates with increasing grade of luxation
90-95% success in small dogs
significantly higher risk of failure in larger dogs (>20kg)
175
what is the most common cause of hindlimb lameness in dogs?
cranial cruciate ligament disease (CCLD)
176
what are the functions of the cranial cruciate ligament?
limit cranial drawer
limit hyperextension
limit internal rotation
177
what are the causes of cranial cruciate ligament disease?
degeneration of the ligament (common)
inflammatory arthropathy
growth abnormality (tibial plateau angle)
major trauma (uncommon)
178
which dogs are most likely to develop cranial cruciate ligament disease?
young (6m-3y)
| large breeds
179
what percentage of cranial cruciate ligament disease occurs bilaterally?
30-50%
180
what are the 2 bands of the cranial cruciate ligament?
caudolateral - only tight in extension
| craniomedial - always tight
181
which band of the cranial cruciate ligament is more susceptible to partial tears?
craniomedial band
182
how is cranial cruciate ligament disease diagnosed?
gait analysis
| physical examination - stifle pain, effusion, crepitus, medial buttress, instability
183
what are the 2 tests used to assess instability in cranial cruciate ligament disease?
cranial drawer test
| tibial thrust
184
what are the drawbacks of the cranial drawer test?
can be painful
| can be resisted in the conscious animal
185
what is the tibial thrust test?
applying pressure at the level of the hock in order to test for tibial movement against the femur
186
how is cranial cruciate ligament disease diagnosed?
straightforward cases - signalment, instability tests, painful stifle, effusion
187
how are problem cases of cranial cruciate ligament disease diagnosed?
if not DJD on radiograph or effusion
possibly partial rupture but other arthropathies are possible
consider arthrocentesis
188
how is cranial cruciate ligament disease treated?
conservative treatment
surgical - intra/extra-articular replacements (fabello-tibial sutures)
OR corrective osteotomy (TPLO)
189
what are the post-op considerations for cranial cruciate ligament disease?
opioids for 24-48 hours, NSAIDs for 10-14 days
physiotherapy is important and beneficial to recovery
must make owners aware that surgery is not a cure, only slows progression of arthritis - joint will never be normal again
190
what is the prognosis for cranial cruciate ligament disease?
complication and success rates similar between techniques
most effective is osteotomy procedures
'over the top' is least effective
full recovery can take several months
191
how often does cranial cruciate ligament disease also result in meniscal tearing?
50%
192
how are meniscal tears treated?
must perform arthrotomy during surgery - debride torn portion and leave unaffected meniscus
193
which meniscus usually tears with cranial cruciate ligament disease?
usually medial meniscus
