Term
|
Definition
| a broken bone that is in communication through the skin with the environment. |
|
|
Term
| which classification do we use for open fractures? |
|
Definition
Gustilo and Anderson classification.
Based on size of wound and amount of soft tissue injury.
This correlates with both infection and amputation rates. |
|
|
Term
| describe the gustily and anderson classification of open fractures |
|
Definition
type 1 - smaller than 1 cm diameter. simple fracture pattern, clean wound with no skin crushing.
type 2 - >1cm diameter but w/o significant soft tissue crushing. fracture pattern may be more complex
type 3 - fracture with extensive soft tissue injury. also included are fractures older than 8 hours. type 3 subdivided into 3 types
3a- adequate soft tissue coverage of fracture
3b-inadequate soft tissue coverage of fracture
3c-any open fracture associated with vascular injury that needs repair |
|
|
Term
|
Definition
prevent infection, promote healing and restoration of fx.
fluid resus, analgesia, splinting, Abx and tetanus.
handle wound to only remove gross contaminants and to take a photo
debridement performed by rtho and plastics working together within 24 hours. |
|
|
Term
| complications of open fractures |
|
Definition
osteomyelitis can cause non union or lead to need for amputation.
tetanus infection
non union of joint
neurovascular injury
compartment syndrome. |
|
|
Term
| define compartment syndrome |
|
Definition
it is caused by increased pressure within a closed anatomical space. this compromises the circulation and fx of the tissues within that space.
it can result in temporary or permanent damage to muscles and nerves. |
|
|
Term
| name the 4 compartments in lower limb that can be affected in compartment syndrome |
|
Definition
1 anterior tibial
2 superficial posterior
3 deep posterior
4 peroneal compartment |
|
|
Term
| if there was compartment syndrome in the anterior tibial compartment, which structures are venerable? |
|
Definition
Deep perineal nerve
anterior tibial artery |
|
|
Term
| if compartment syndrome affected the superficial posterior compartment, which structures would be at risk of being hurt? |
|
Definition
| NONE. there are no major nerves or vessels here |
|
|
Term
| if compartment syndrome affected the deep posterior compartment, which structures would be affected? |
|
Definition
Posterior tibial nerve and vessels
peroneal artery |
|
|
Term
| if compartment syndrome affected peroneal compartment. |
|
Definition
| deep and superficial perineal nerves. |
|
|
Term
| what is phlegmasia cerula dolens? |
|
Definition
a severe form of DVT resulting from extensive thrombotic occlusion of major and collateral veins of an extremity.
characterised by sudden severe pain, swelling, cyanosis and edema of affected limb.
there is a high risk of massive PE even with anticoagulation.
Underlying malignancy found in 50% |
|
|
Term
| causes of compartment syndrome |
|
Definition
fractures esp those of forearm and lower leg that have been internally fixed or become infected.
crush injury
burns
infection
prolonged limb compression
vascular causes: reperfusion injury
iatrogenic: IM injections
muscle hypertrophy in athletes. |
|
|
Term
| presentation of compartment syndrome |
|
Definition
usually present within 48 hours of injury. high index of suspicion needed
increased pain despite immobilisation
sensory deficit in distribution of nerves passing through compartment
muscle tenderness and swelling
excessive pain on passive movement
peripheral pulses present |
|
|
Term
| ix in compartment syndrome |
|
Definition
diagnosis is mostly clinical
you can measure the pressure using a wick catheter, needle manometry, infusion techniques, pressure transducers or side ported needles.
MRI can help in ambiguous cases. |
|
|
Term
| rx of compartment syndrome |
|
Definition
remove any restrictive dressing on the leg e.g plaster cast etc.
open fasciotomy. the pressure of the compartment must be > 30-40mmhg to do this procedure.
the skin and deep fascia is divided along the whole length of the compartment.
after the procedure, the would should be left open and sutures may be used to encourage healing
debridement may be needed for muscle necrosis |
|
|
Term
| complications of compartment syndrome |
|
Definition
tissue necrosis develops within 12 hours
muscle necrosis leads to fibrosis and shortening resulting in an ischemic contracture (Volkmann's ischemic contracture) |
|
|
Term
| which type of shoulder dislocations are more common? |
|
Definition
anterior dislocations.
they are almost always due to trauma |
|
|
Term
| what combination of movements tend to occur for an anterior dislocation of the shoulder? |
|
Definition
people fall with a combination of abduction, extension and a posteriorly directed force on the arm.
in elderly, a fall on the outstretched hand is a common mechanism of injury. fracture of the humeral head, neck or greater tuberosity can occur at the same time. |
|
|
Term
| what causes posterior dislocations? |
|
Definition
epileptic fit
electrocution or lightening
the shoulder is usually held in internal rotation and adduction.
an unexplained posterior dislocation should raise the possibility of a convulsion. |
|
|
Term
| if a pt presented with anterior should dislocation how would you expect them to be holding their arm? |
|
Definition
They would hold the arm at the side of the body in external rotation.
shoulder loses its roundness
an anterior bulge may be seen in thin people
abduction and internal rotation are resisted. |
|
|
Term
| what pulses and nerves should you check in shoulder dislocation? |
|
Definition
palpate radial pulse
axillary nerve (regimental patch) testing
radial nerve fx; thumb, wrist elbow weakness on extension.
check for reduced sensation on dorsum of hand
rotator cuff frequently damaged. this should be checked after reduction. |
|
|
Term
| s and s of posterior dislocation |
|
Definition
arm adducted and internally rotated
abduction and external rotation painful
arm cannot be externally rotated to a neutral position
inability to supinate
exam may resemble a frozen shoulder
nerve and vascular injury are NOT common. |
|
|
Term
| complications of anterior dislocations. |
|
Definition
axillary nerve damage
brachial plexus, radial and other nerve damage
axillary artery damage (look for axillary hematoma, cool limb and reduced pulses)
associated fracture in 30%
recurrent shoulder dislocation
bankarts and hill-sachs lesions
rotator cuff injury |
|
|
Term
| what is a Bankart's lesion? |
|
Definition
injury of anterior (inferior) glenoid labrum
cause by anterior shoulder dislocation
when it happens, a pocket at the front of the glenoid forms and allows the humeral head to dislocate into it.
it is an indication for surgery and often accompanied by a Hill-Sachs lesions (damage to posterior humeral head) |
|
|
Term
| What is a Hills-Sach lesion? |
|
Definition
a cortical depression in the posterolateral head of the humerus
caused by the forceful impaction of humeral head against the anterior inferior glenoid rim when shoulder is dislocated anteriorly
associated with anterior and posterior shoulder dislocation.
associated with continuing symptoms and instability. |
|
|
Term
| what is injured in a Bankart lesion? |
|
Definition
| The joint capsule and the inferior glenohumeral ligament |
|
|
Term
| which lesion occurs in 35-40% anterior dislocations and 80% of recurrent dislocations? |
|
Definition
|
|
Term
| which X-rays should you request for anterior dislocation? |
|
Definition
| AP + axillary or trans scapular 'Y' view. |
|
|
Term
| which XRAYS should you request for a posterior dislocation? |
|
Definition
AP and axillary lateral view
Look for the lightbulb sign in posterior dislocation on AP view. |
|
|
Term
| first aid for anterior shoulder dislocation |
|
Definition
you cannot use a simple sling as the arm is abducted and can't be brought comfortably against the chest wall.
it can be splinted in its abducted position, a pillow can be placed in the space between arm and chest, flex elbow to 90, apply sling and secure including the pillow to the chest. |
|
|
Term
| Name 5 methods available to reduce a dislocated shoulder |
|
Definition
Hippocratic method
external rotation method
Stimsons technique
Kocher's method
immediate reduction |
|
|
Term
| what is crush syndrome also known as? (Eponymous name) |
|
Definition
|
|
Term
| what is the main mechanism of injury in crush syndrome? |
|
Definition
| reperfusion injury when the pressure is released form the crushed limb. |
|
|
Term
| muscle injury release large amounts of which substances into the circulation? |
|
Definition
K+
Phosphate
myoglobin
CK
urate |
|
|
Term
| name 2 characteristics of crush syndrome |
|
Definition
Hypovolemic shock
hyperkalemia
this can lead to metabolic acidosis, AKI and DIC |
|
|
Term
| name the 6 Ps in assessing a limb for crush injury |
|
Definition
Pain
paraesthesia
paralysis
pallor
pulseless
perishingly cold |
|
|
Term
| when should you apply a tourniquet in crush injuries? |
|
Definition
If compression time has been more than 30 mins.
Also think about fluid resus and urinary catheter.
Try to preserve heat and prevent hypothermia. |
|
|
Term
| in complete acute schema how long will you have before there is extensive tissue necrosis? |
|
Definition
|
|
Term
|
Definition
heparinisation
check for compartment syndrome
if embolic obstruction then Fogarty balloon embelectomy catheter or intra arterial thrombolysis
after embelectomy heparin rx is needed to prevent reoccurrence.
some surgeons postpone heparin for 6 hours to prevent formation of hematoma. |
|
|
Term
| List the red flags suggestive of SCCompression |
|
Definition
insidious progression
neurological symptoms: gait disturbance, clumsy weak hands, loss of sexual, bladder or bowel fx
Neurological signs
Lhermittes electric shock down the neck sign
UMN signs in lower limbs
LMN signs in upper limbs
Loss of vibration and joint position sense more evident in hands than in feet. |
|
|
Term
| where must the lesion be to produce quadriplegia and where must it be for paraplegia to occur? |
|
Definition
Cervical lesions produce quadriplegia
Thoracic lesions produce paraplegia |
|
|
Term
| what is the main ix if you suspect SCC? |
|
Definition
|
|
Term
|
Definition
Laminectomy
posterior decompression +/- internal fixation
surgery should be done before the patient loses the ability to walk
a course of dexamethosone may be given unless CI. |
|
|
Term
| name some S and S that suggest spinal mets in those with cancer |
|
Definition
pain in thoracic or cervical spine
severe unremitting or progressive lumbar pain
spinal pain aggravated by straining e.g. coughing, sneezing, passing stool
nocturnal spinal pain preventing sleep
localised spinal tenderness |
|
|
Term
| if clinical features suggest spinal mets when should the MRI be done? |
|
Definition
|
|
Term
| if clinical features suggest SCC when should the MRI be done? |
|
Definition
|
|
Term
| signs and symptoms of caudal equine syndrome CES |
|
Definition
lower back pain
bladder/bowel dysfx saddle paraesthesia sexual dysfx possible neuro deficit in lower limb (motor/sensory loss/reflex change) |
|
|
Term
| is CES a medical emergency? |
|
Definition
YES!
it needs immediate referral for ix. early diagnosis is essential and early surgical decompression is crucial for a favourable outcome. |
|
|
Term
| what is the most common cause of CES? |
|
Definition
| herniation of lumbar disc at L4/L5 or L5/S1 level |
|
|
Term
| name some other causes of CES |
|
Definition
tumour
trauma
congenital; kyphosis, spinal stenosis
infection
sarcoidosis
IVC thrombosis
post op hematoma |
|
|
Term
| how might a pt with CES present? |
|
Definition
Low back pain
pain in legs with uni/bilateral lower limb motor +/or sensory abnormality
bowel/bladder dysfx. may be fecal incontinence or constipation.
saddle paresthesia
sexual dysfx |
|
|
Term
| which ix can exclude CES? |
|
Definition
MRI scan
this is also used to diagnose CES |
|
|
Term
| what rx is there available for CES? |
|
Definition
spinal surgical decompression
if surgery cannot be done then radiotherapy may relieve cord compression from malignant disease. |
|
|
Term
|
Definition
| an infection that produces inflammation in a native or prosthetic joint |
|
|
Term
| which is the most frequent pathogen found in septic arthritis? |
|
Definition
|
|
Term
| name some risk factors for septic arthritis |
|
Definition
increasing age
DM
prior joint damage e.g. RA, gout, CT disorders
joint surgery
hip/knee prosthesis
skin infection in combo with joint prosthesis
immunodeficiency eg. infection with HIV. |
|
|
Term
| symptoms of septic arthritis |
|
Definition
classic is a swollen joint that is painful on passive and active movement.
fever and rigours present in majority but their absence doesn't rule out septic arthritis
bacteremia is a common finding that can cause vomiting hypo tensions and prostration (extreme weakness). |
|
|
Term
| which joint is most commonly affected in septic arthritis? |
|
Definition
The knee ~50% of cases.
followed by the hip, shoulder, ankle and wrists. |
|
|
Term
| what ix to do for ?septic arthritis? |
|
Definition
FBC - wcc raised in infection. raised ESR and CRP
lactate
synovial fluid exam - leukocyte count, gram staining, polarising microscopy and culture |
|
|
Term
|
Definition
surgical drainage and lavage of the joint and high dose IV Abx
Abx are initially given for 2-3 weeks IV then switched to PO for at least another 2-4 weeks |
|
|
Term
| what Abx can be given in septic arthritis? |
|
Definition
seek specialist advice is prosthesis are present
Flucoxacillin for 4-6 weeks. if penicillin allergic use clindamycin
if meticillin s.aureus is suspected use Vancomycin 4-6 weeks
if gonococcal arthritis or gram negative infection use cefotaxime (rx gram neg for 4-6 weeks and gonococcal for 2 weeks) |
|
|
Term
| which prosthetic joints get most commonly infected? |
|
Definition
Elbow, shoulder and ankle joints
followed by hips and knees.
This is different to real joints where the knee is most commonly affected. |
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