Orthopedics and Podiatry Flashcards
(122 cards)
1
Q
Orthopedics involves procedures of what?
A
Bone, joints, muscle and related soft tissue
2
Q
Podiatry is limited to the study, diagnosis and treatment of what?
A
Foot, ankle, and lower leg
3
Q
What is the largest post-operative problem after ortho procedure?
A
Pain
4
Q
What are two types of modalities (not GA) often used to control post-op pain?
A
regional and multimodal
5
Q
What is a common preoperative assessment in this patient population?
A
rheumatoid arthritis
6
Q
What is the etiology of rheumatoid arthritis?
A
chronic inflammatory process of unknown etiology
7
Q
Rheumatoid arthritis: Where does the synovitis occur?
A
cervical spine, TMJ, larynx, and pulmonary system
8
Q
What does deposition of rheumatoid nodules cause inflammation of?
A
Intervertebral discs and atlanto-occipital subluxation
9
Q
What would indicate narrowing and fixation of the glottic opening due to cricoarytenoid arthritis?
A
Hoarseness and inspiratory stridor
10
Q
Rheumatoid arthritis: how does it affect the TMJ?
A
limited opening
11
Q
Rheumatoid arthritis: if unable to open TMJ, what is the default intubation?
A
awake fiberoptic intubation
12
Q
Rheumatoid arthritis: What type of pulmonary involvement
A
pulmonary lesions (pleural effusion, intrapulmonary nodules, rheumatoid pneumocoinosis, interstitial lung dz, vasculitis, obliterative bronchiolitis, upper lobe fibrosis, pulmonary infections, bronchogenic carcinoma)
13
Q
What is one of the most challenging issues with individuals with rheumatoid arthritis?
A
Positioning issues - due to aches and pains
14
Q
Type of arthritis characterized by wearing away of cartilage by use and disease (bone on bone)
a. ) rheumatoid
b. ) osteoarthritis
A
b.) osteoarthritis
15
Q
Type of arthritis characterized by inflammation of the synovial membrane and bone erosion - not cartilage erosion.
a. ) rheumatoid
b. ) osteoarthritis
A
a.) rheumatoid
16
Q
Ankylosing spondylitis: what type of process is this (characterized by)?
A
inflammatory
17
Q
Ankylosing spondylitis: Where is the primary area affected?
A
spinal column
18
Q
Ankylosing spondylitis: Does it take significant trauma to cause injury to the spinal column?
A
No
19
Q
Ankylosing spondylitis: What other co-morbidities are also seen? List 3.
A
- conduction delays
- valve lesions
- restrictive lung disease (from spinal deformity)
20
Q
Ankylosing spondylitis: What are airway concerns with this condition? List 2.
A
- Cervical spine positioning - intubation, intraoperatively and on emergence
- TMJ mobility and distance
21
Q
Ankylosing spondylitis: What two body systems should you focus your evaluation on in your preoperative evaluation?
A
- Airway
2. Respiratory
22
Q
Ankylosing spondylitis: What type of intubation technique would you want to consider? List 2
A
- awake fiberoptic
2. nasopharyngoscope
23
Q
Osteoarthritis: What preoperative considerations would you want to consider? List 4.
A
- Activity level
- Use of NSAIDs/other pain meds
- cortisone injections
- co-morbidities of age
24
Q
What are 5 considerations for anesthetic selection for orthopedic procedures?
A
- length of procedure
- position for surgery
- body habitus
- general health
- patient acceptance
25
Pneumatic tourniquet: What should the size be?
Should cover less than or equal to 50% of the extremity
26
Pneumatic tourniquet: What needs to be placed between the patient and the tourniquet?
padding
27
Pneumatic tourniquet: What should be avoided when placing the tourniquet?
Cuff overlap
28
Pneumatic tourniquet: What needs to be done immediately before the tourniquet is inflated?
Exsanguination with Esmark elastic bandage
29
Pneumatic tourniquet: How high does the tourniquet pressure need to be?
90-100mmHg above systolic BP
30
Pneumatic tourniquet: What should the timer be set at? What is the maximum inflation time?
60min
| 120min
31
Pneumatic tourniquet: How many minutes does it take to abolish SSEPs?
30 min
32
Pneumatic tourniquet: How many minutes does pain set in?
60 min
33
Pneumatic tourniquet: How many minutes before neuropraxia?
120 min
34
Pneumatic tourniquet: Where does nerve injury usually occur in relation to placement of the tourniquet? Is it temporary or permanent?
at the edge of the tourniquet.
| sometimes permanent
35
Pneumatic tourniquet: How soon does cellular hypoxia occur?
after 2 min
36
Pneumatic tourniquet: Do cellular creatinine values increase or decrease?
decrease
37
Pneumatic tourniquet: does cellular acidosis or alkalosis occur?
acidosis
38
Pneumatic tourniquet: When does an endothelial capillary leak start?
after 2 hours
39
Pneumatic tourniquet inflation: How much blood is in a limb and "pushed" into circulation after inflation?
300-500ml
40
Pneumatic tourniquet inflation: What effect does inflation have on pulmonary and systemic pressure?
slight-moderate increase
41
Pneumatic tourniquet inflation: What type of anesthetic blunts systemic effects of the tourniquet better?
potent anesthetic vapor (vs. anesthetic technique that does not include a potent anesthetic vapor)
42
Pneumatic tourniquet deflation: What happens to temperature? permanent?
fall in core temp - transient
43
Pneumatic tourniquet deflation: Metabolic alkalosis or acidosis?
Acidosis
44
Pneumatic tourniquet deflation: Increase or decrease in MVO2
decrease
45
Pneumatic tourniquet deflation: Increase or decrease in systemic and pulmonary BP?
decrease
46
Pneumatic tourniquet deflation: Increase or decrease in ETCO2? Permanent?
increase - transient
47
Pneumatic tourniquet: When will nerve damage definitely occur?
4 hours
48
Pneumatic tourniquet: Muscle power of the extremity is reduced for how long after a three hour tourniquet time?
1 full week
49
Pneumatic tourniquet: How long does it take for the physiologic effects to resolve after one hour of tourniquet time?
20 minutes
50
What are the steps of a Bier Block? Name 10.
1. IV in arm
2. elevate arm and place tourniquet
3. wrap arm with esmark bandage tightly to distal cuff
4. Inflate distal cuff
5. Inflate proximal cuff
6. deflate distal cuff
7. put the arm down and take off esmark bandage
8. check for a pulse
9. If no pulse, give 50 mLs of 0.5% lidocaine
10. Take IV out and hold pressure for a long time
51
Bier block: After 30 min when the patient complains of tourniquet pain, what do you do?
1. inflate distal cuff
| 2. deflate proximal tourniquet
52
Most common problem that is reported with an IV regional anesthetic technique
Systemic toxicity of local anesthetic (inadequate tourniquet or equipment failure)
53
Techniques to prevent hematoma formation complication during IV regional anesthesia
Small IV
| Apply firm pressure for 2-3 min
54
IV regional anesthesia: When does engorgement occur?
With arterial inflow but no venous outflow and with significant arterial calcifications that prevent occlusion of the arteries
55
What position are orthopedic surgeries done with?
A number of different positions - depending on surgeon preference. Communicate!
56
West Lung Zones: Zone 1 - a.) ventilation b.) perfusion
a. ) high
| b. ) low
57
West Lung Zones: Zone 2 - a.) ventilation b.) perfusion
a. ) medium
| b. ) medium
58
West Lung Zones: Zone 3 - a.) ventilation b.) perfusion
a. ) low
| b. ) high
59
West Lung Zones: Lateral position Top lung a.) ventilation b.) perfusion; bottom lung c.) ventilation d.) perfusion
a. ) high
b. ) low
c. ) low
d. ) high
60
Beach chair position: What type of spinal injury is possible?
cervical neck injury due to dislodgment of head from holder
61
Beach chair position: What is at risk with the airway
inadvertent extubation
62
Beach chair position: What type of peripheral nerve injury is possible?
brachial plexus injury on the opposite side as you pull shoulder
63
Beach chair position: What are the advantages to beach chair position? List 4 - 1 nerve, 1 anesthesia, 2 surgical.
1. reduced rate of brachial plexus
2. better respiratory mechanics
3. excellent access to the shoulder
4. weight of the arm distracts shoulder joint
64
```
Beach chair position: What happens to the
a.) CVP
b.) MAP
c.) PAP
d.) CO
e.) PVR
f.) TPR
g.) CPP - by about how much?
And what do volatile anesthetics do to the body's response?
```
a. ) decrease
b. ) decrease
c. ) decrease
d. ) decrease
e. ) increase
f. ) increase
g. ) decrease - about 15%
Volatile anesthetics blunt compensatory mechanisms
65
Beach chair position: What can happen to venous return (in the lower extremities)?
hindered
66
Beach chair position: What happens with cerebral autoregulation?
hindered with hypertension
67
Beach chair position: Is induced hypotension ok to reduce blood loss?
No - should avoid.
68
Beach chair position: What is greater BP in arm or BP in brain?
BP in arm
69
The distance from the cuff to what part on the body will estimate the CPP?
Distance between the cuff and auditory meatus
70
Beach chair position: There is 1mmHg change for how much increase in height (cm)? Or for every 1 cm in distance is how much change in mmHg?
1mmHg for every 1.25 cm
| 0.77mmHg for every 1cm
71
Prone positioning: What is the incidence % of vision loss after all spine cases?
0.028-0.2%
72
Prone positioning: What are risk factors for vision loss after spine surgery? List 5 (2 patient factors, 3 surgical factors)
1. ) preexisting atherosclerosis
2. ) CV disease
3. ) Excessive blood loss
4. ) excessive crystalloid administration
5. ) Excessive surgical length
73
Prone positioning: Post-op vision loss presents immediately or many days after surgery?
immediately
74
Prone positioning: Retinal vascular occlusion happens how? How does ischemic optic neuropathy occur?
Direct pressure to periorbital region of the eye -> increased intraoccular pressure -> retinal artery occlusion -> and blindness as a result of decreased perfusion.
Unclear how ischemic optic neuropathy occurs.
75
Prone positioning and how to avoid POVL? List 3 things to avoid when managing a patient.
1. ) avoid direct pressure on globes
2. ) avoid perioperative hypotension
3. ) avoid perioperative anemia
76
Prone positioning and how to avoid POVL: What type of bed movement could help?
10 degrees of reverse trendelenburg
77
Prone positioning and how to avoid POVL: When would you transfuse blood?
Transfusion threshold to keep hematocrit > 30% in at-risk patients
78
Prone positioning and how to avoid POVL: How much crystalloid (large vs. small amount)?
Avoid infusions of large amounts of crystalloid
79
Prone positioning and how to avoid POVL: How would you handle long >8hour surgeries?
Consider staging
80
Prone positioning and how to avoid POVL: Where would you keep mean arterial pressure?
MAP at patient's baseline
81
Prone positioning and how to avoid POVL: When would you preform postoperative visual exam in at-risk patients
As soon as possible
82
Prone positioning and how to avoid POVL: Would you want to change any perfusion-related medications before surgery?
NO
83
Arthroscopy: What is it? What is most common? What other joints could you perform this with? What is the advantage (list 4)?
Examination and treatment of a joint space with an endoscope.
Knee most common - also could do shoulder, wrist, hip, ankle
Advantage: less blood loss, reduce post-op pain, shorter/no hospitalization, shorter rehab.
84
Arthroplasty: What is it? What are the goals (list 3)?
Surgical replacement of all or some parts of a joint.
| Goal: pain relief, stability, deformity correction
85
Arthroplasty: What is the most common joint? How much blood is typically lost? When is the blood lost?
Knee. About 2 units of blood loss and usually occurs in the drain placed and see over the next 24 hours.
86
Knee arthroplasty: What type of anesthetic is used?
Any anesthetic: general, spinal, "triple" blocks (femoral, sciatic, and lateral femoral cutaneous nerves)
87
Knee arthroplasty: What are three physiologic complications that can happen during a total knee arthroplasty?
Hypertension, hypoxia and CV collapse
88
Knee arthroplasty: What are the possible causes of hypertension, hypoxia and CV collapse during component insertion? List 5
Methyl methacrylate (MMA), fat embolism, air embolism, marrow embolism, thromboembolism
89
What are the physiological effects of MMA cement (bone cement implantation syndrome - BCIS)?
a. ) PVR
b. ) SVR
c. ) CO
d. ) systemic BP
e. ) arrhythmias
f. ) oxygenation
a. ) increased
b. ) decreased
c. ) decreased
d. ) decreased
e. ) increased
f. ) decreased (hypoxia)
90
Arthroplasty: High or low incidence of DVTs after hip/knee arthroplasty? What is given to prevent this risk?
High.
| LMW heparins and/or coumadin
91
Arthroplasty: What is the incidence of PEs?
1-5%
92
Hip arthroplasty: What position is it done?
Lateral decubitus (sometimes anterior approach - supine)
93
Hip arthroplasty: Why so much blood loss?
1. ) can't use tourniquet
| 2. ) femur/acetabulum richly perfused
94
Hip arthroplasty: How much blood loss can occur? What is significant with re-do hips?
Can exceed 6 units. Re-do hips - even more significant blood loss.
95
Methyl methacrolate cement: What is it's function? What type of reaction occurs? What happens to the intramedullary space and what results from this?
Function is to bind one and the prosthetic parts.
Exothermic reaction - leads to hardening and expansion of the cement
Intramedullar hypertension and resultant embolization of fat, bone, cement and/or air.
96
When does bone cement implantation syndrome (BCIS) occur during hip surgery?
When the femoral component is placed
97
What can you do to reduce risk during MMA cementing? List 2 anesthesia interventions. List 3 surgical interventions.
Increase FiO2 and maintain euvolemia
vent distal femur, high pressure lavage of femur shaft to remove debris, uncemented femoral components for hips
98
What are some blood conservation strategies during orthopedic surgeries? (list 5)
1. ) cell saver
2. ) autologous blood?
3. ) induced hypotension - cautious
4. ) normothermia - keep clotting cascade intact
5. ) spinal/epidural anesthetics
99
Is there more or less blood loss with upper extremity arthroplasty? Pain?
More
| Significant amount of pain - use local or multimodal
100
What are the indications for spinal surgery? Name 2.
intervetebral disc herniation
| spinal stenosis
101
Spinal surgery: what do they do to the affected discs? What do they do to the vertebral foramen? If more than 2 levels are affected, what can be done?
excise disc and enlarge foramen
| vertebral fusion: with bone grafts or vertebral cages
102
Spinal surgery: scoliosis surgery is approached from what location?
anterior/posterior and may require a thoracotomy to access thoracic spine
103
Spinal surgery: What consideration is necessary for the respiratory system/lungs with individuals with scoliosis?
may have restrictive lung disease due to the progress of the disease
104
What type of anesthesia works well with foot and ankle surgery?
Regional anesthesia
105
What are the 5 nerves that need to be blocked during an ankle block?
1. ) superficial peroneal nerve
2. ) deep peroneal nerve
3. ) saphenous nerve
4. ) sural nerve
5. ) posterior tibial nerve
106
What nerve is the only innervation of the foot that is not part of the sciatic system?
saphenous nerve
107
What nerve supplies the superficial sensation to the anterior medial foot?
saphenous nerve
108
What nerve is located anterior to the medial malleolus?
saphenous nerve
109
What nerve is a terminal branch of the femoral nerve?
saphenous nerve
110
What nerve runs along the anterior of the leg as a continuation of the common peroneal nerve?
deep peroneal nerve
111
What nerve intervates the toe extensors?
deep peroneal nerve
112
What nerve enters the ankle between the flexor hallous longus tendon and the extensor digitorum longus tendon?
deep peroneal nerve
113
What nerve provides sensation to the medial half of the dorsal foot - especially the first and second digits?
deep peroneal nerve
114
What is a branch of the common peroneal nerve and decends towards the ankle in the lateral compartment entering the ankle just lateral to the extensor digitorum?
superficial peroneal nerve
115
What nerve provides cutaneous sensation to the dorsal foot and all five toes?
superficial peroneal nerve
116
What nerve is located lateral to the extensor digitorum longus at the at the level of the lateral malleolus superficially?
superficial peroneal nerve
117
What nerves are direct continuation of the tibial nerve?
posterior tibial nerve and sural nerve
118
What nerve enters the foot posterior to the medial malleolus?
posterior tibial nerve
119
What nerve is located behind the posterior tibial artery at the level of the medial malleolus?
posterior tibial nerve
120
What nerve is sensory to the heal, the medial sole, and part of the lateral sole of the foot?
posterior tibial nerve
121
What nerve enters the foot between the achielles tendon and lateral malleolus?
Sural nerve
122
What nerve provides sensation to the lateral foot?
Sural nerve
