Exam #6 Muskoskeletal & Trauma Unit

What is osteogenesis imperfecta and it’s key features?

genetic in origin 

• Brittle bones, due to not enough collagen or abnormal collagen

  • Long bones may not grow at the same rate 

  • marked scoliosis of the spine 

What is Duchenne Muscular Dystrophy?

• congenital muscle disorder

• genetic in origin/most common type

  • Deficiency of a muscle protein called dystrophin

• Diagnosis: High levels of serum creatinine from damaged muscle fibers

  • Present in both skeletal & cardiac muscles

• Characterized by delayed motor development and muscle weakness

What is Paget’s disease and it’s key features?

osteitis deformans

• acquired bone disorder

• due to genetic & environmental factors 

  • Rapid regeneration of bone in which the bone remains immature while entering the normal degeneration process 

  • Immature bone is crudely structured and weak 

    • Osteoarthritis (OA) , heart problems, bone cancer 

What is osteoporosis and it’s complications and drugs related to it?

• “lacy bones”; genetic 

• Progressive loss of bone mass 

• The greatest impact is in the spine 

  • No cure; focuses on prevention

    • X-Ray, bone density scans (low dose) hips/spine

• Treatment

  • Oral drugs to increase bone density to slow bone loss (bisphosphonates)

    • Fosamax

    • Boniva

what is gout?

acute inflammation of joints caused by kidney dysfunction or too much uric is produced by the body 

• Hot, red, and tender 

• Affects the big toe, can also affect ankles, wrist & hands 

• Occurs mainly in men 30-50 

  • Diagnosis: blood for increased uric acid and creatinine 

  • Treatment: allopurinol

What could be some dietary reasons someone get’s gout?

too much red meat, fructose, and beer

what is rhabdomyolysis?

(rhabdo) - acute muscle damage (can be life-threatening) 

• Release of protein byproduct of muscle damage by the - myoglobin 

• Causes 

  • Extreme unconditioned exercise of exertion 

  • Burns, heat stroke, or electrocution

  • Statins 

  • Snakebites 

• Symptoms 

  • Muscle weakness and soreness 

  • Dark red urine 

  • Nausea & vomiting 

How is rhabdomyolysis diagnosed & treated?

• Diagnosed 

  • Lab test (urine) for myoglobin 

  • Lab test (blood) for creatinine 

    • Can look like coco-Cola 

  • Result 

    • Can lead to acute renal failure, possibly leading to death 

  • Treatment 

    • IV fluid resuscitation 

    • Dialysis 

What is osteomyelitis?

• Infection in the bone 

• Usually begins as a superficial skin infection 

• Intermediate step before onset or gangrene 

• Can be caused by an infection with corresponding loss of circulation impairing healing

What is osteomyelitis associated with?

• Associated with 

  • Diabetes mellitus (DM)

  • Surgical infection 

  • Postoperative fistula (abnormal connection between 2 organs) 

What’s the surgical treatment for osteomyelitis?

• Antibiotics (IV and oral) 

• Surgical debridement to clear necrotic tissue down to the viable bone

  • Use of rongeur and a curette

What is osteoarthritis as a disease?

• degenerative condition of the joint from wear & tear 

• Chronic form of arthritis 

• Cartilage cushion between joints break down causing loss of lubrication and rubbing of bones together 

  • Causes 

    • Weight gain 

    • Injury 

    • Repetitive use 

    • Genetics 

    • Not “cracking” or “popping” joints 

What are some surgical treatments for osteoarthritis?

• Weight loss/exercise

• Oral medications

  • NSAIDS

  • Opioid pain meds: Vicodin

  • Glucosamine chondroitin – supplement with questionable results

  • Steroid injections into the joint

  • Physical Therapy

What are the treatments and complications of osteoarthritis in the hip?

• Surgical Treatment – permanent cure

• Hip Replacement

  • Total hip arthroplasty with prosthetic device

    • Acetabulum and femur head

  • Partial hip arthroplasty with femoral component

• Materials

  • Metal on metal (not used in US)

  • Metal on metal with polyethylene socket liner

  • Ceramic on metal

  • Ceramic on ceramic (not currently used)

  • Ceramic on metal with polyethylene socket liner

• Cemented vs. press fit

• Complications

  • Dislocation

  • Metal allergy

  • Leakage of metal fragments

What are neurostimulator devices?

failed back surgery syndrome 

• directs mild electrical impulses with pain messages to the brain

  • Spinal array and generator device  

cervical nerve compression

• More common in herniation and spondylosis

• C4-C5 (shoulder and neck pain; loss of mobility)

• C5-C6 (bicep, wrist, and thumb)

• C6-C7 (triceps, forearm, and finger)

• C7-T1 (hand grip weakness)

thoracic nerve compression

• Upper back pain, abdominal pain, chest pain, lower body dysfunction

• Can affect your breathing

• Common in scoliosis and kyphosis

lumbar nerve compression

• L1-L2 (most often anterior thigh and increase cases of cauda equina)

• L2-L3 (pain in the anterior thigh)

• L3-L4 (posterior thigh pain, lack of patellar reflex)

• L4-L5 (calf and toes, inability to stand on toes; ankle will not support weight)

What are some chiropractic treatments?

• Adjustments

• Decompression

• Heat therapy

• Exercises

  • Steroid Injections (temporary)

laminectomy

• Creates space by removing the lamina or back part of the vertebra

• Spinal decompression surgery, usually for stenosis and spondylosis

diskectomy

• Removes a portion of a herniated disk material which is pressuring the nerve root

  • Can accompany other spinal procedures

  • Minimally invasive

• Can cause scar tissue – post laminectomy syndrome

• Can cause loss of disk height and promote additional herniation in surrounding levels

spinal fusion

• Fusing vertebral levels, so they form one bone

• Loss of flexibility of the spine

bone grafting

• Autograft from the patient’s own vertebra or iliac crest

• Allograft from cadaver

• Synthetic graft

plating systems

instrumentation 

reinforces bone graft in the vertebra above and below

anterior interbody cages

instrumentation

made of titanium & inserted using an anterior approach

posterior interbody cages

instrumentation

made of titanium & inserted using a posterior approach 

pedicle screw fixation 

Instrumentation - surgical technique in spinal surgery

• gripping vertebral segments to limit motion 

types of fractures (matching section)

• open (compound) - broken bone; open wound

• closed - the bone is broken; the skin is intact

• transverse - a fracture straight across the bone shaft

• oblique - a fracture at an angle to the bone shaft

• spiral - a fracture that twists around the bone shaft

• comminuted - a fracture characterized by multiple fracture lines and bone pieces

• greenstick - an incomplete fracture in which the bone is bent and only the outer curve of the bend is broken

• compression - a fracture in which the bone is crushed or collapses into small pieces

closed reduction

treatment for fractures

• Fracture manipulation and repositioning, and subsequent casting or splinting

• Fracture repositioning with percutaneous pinning

  • Usually, for intra-articular fractures of the wrist, ankle, and elbow

  • Kirschner wires or K-wires, which are flexible

  • External fixator, which resembles a cage

ORIF (Open Reduction Internal Fixation)

treatment for fractures

• Incision to gain access to the fracture site

• Repositioning of the bone

• Application of various appliances to hold the bone in place

• Rods, plates, screws, nails

blunt force trauma

• Velocity and force of impact contained damage

• Hemorrhage into cavities and damage to critical organs determines mortality

•  Internal organs

  • Contusions

  • Rupture or laceration

  • Fractures

Treatment: symptomatic or surgical, blood transfusions

How is blunt force trauma diagnosed?

x-ray, ultrasound, CT scan, CBC, examining body fluids for blood

• Blood loss and organ dysfunction may be immediate or delayed

• Delayed effects may not have external visible signs of trauma

penetrating injury

• Velocity and force of a projectile or implement, which breaks the skin and enters the cavity

• May leave (retain) a foreign body, risk of infection

• Blood loss and/or violation of a critical organ determines mortality

• Laceration and/or accompanying compression damage

  • Do not remove foreign body. It’s preventing blood loss.

Symptoms

• Obvious physical damage with penetration visible on x-ray

• Treatment is usually surgical removal of foreign body and repair of internal damage; blood transfusions

  • Debridement, drainage, and/or evacuation of fragments and/or blood

laparotomy

surgical treatment for internal injuries

• surgically opening the abdomen 

thoracotomy

surgical treatment for internal injuries

• surgically opening the chest cavity

craniotomy 

surgical treatment for internal injuries 

• surgically opening the skull

amputation

• Partial or complete separation of a limb or portion of a limb by a cut

• Damage to bone, nerves, blood vessels, tissue, and skin of the stump

• Reattachment (replantation) viability depends on time and the extent of damage

  • Viability in 6-8 hours if the detached part is cooled to prevent decomposition

    • Varies by body part and may be up to 24 hours if cooled

  • Viability is determined by tissue damage of both stumps

avulsion 

Tearing or pulled away – gruesome injuries

• a forcible separation or detachment such as a tearing away of a body part

  • Could include separation of limb without breaking the skin

What are the treatments of amputations and it’s complications?

Treatment

• Debridement and freshening of the amputation stump

• Sealing off blood vessels and preparing stump for grafting

• Advancement flap graft (attached bed) or free graft to stump (donor site)

Complications 

• Infections of amputation stump

• Non-healing graft due to comorbid conditions

• Non-viable graft due to failure of revascularization

• Phantom limb syndrome

What happens when your body parts are crushed?

• Part of the body is squeezed between two objects

• Massive tissue damage occurs, such as:

  • Fracture, soft tissue damage, skin damage

  • Compartment syndrome

• Increased pressure in an arm or leg, which causes serious muscle, nerve, blood vessel, and tissue damage due to blunt force

• Treatment: Surgical with potential surgical amputation

What are lacerations?

• Open wounds

  • Full thickness disruption through the skin & deeper tissues underneath 

    • Evidence of nerve damage - numbness at and distal to the site 

    • Evidence of tendon damage - loss of control 

• Mortality depends on degree of blood loss from lacerated blood vessels

• Risk of infection and development of cellulitis and gangrene

What is degrees of burns?

classified by the extent and severity of damage caused of the layers of skin affected

1st degree (superficial) burns 

Affect only the outer layer of skin - epidermis.

• The burn site is red, painful, dry, and with no blisters.

  • Mild sunburn is an example.

• Long-term tissue damage is rare and often consists of an increase or decrease in the skin color

Second-degree (partial thickness) burns

• Involve the epidermis and part of the lower layer of skin, the dermis. The burn site looks red, blistered, and may be swollen and painful

third-degree (full thickness) burns 

Destroy the epidermis and dermis. They may go into the innermost layer of skin, the subcutaneous tissue. The burn site may look white or blackened and charred

fourth-degree (underlying tissue) burns 

Go through both layers of the skin and underlying tissue as well as deeper tissue, possibly involving muscle, tendons, ligaments, and bone.

• There is no feeling in the area since the nerve endings are destroyed

What are the body parts for rule of 9’s?

EMTs use this method of quickly estimate the body surface area of a burn

• Head and Neck:

• Upper Extremities: arm, forearm, hand

• Torso: anterior and posterior

• Lower Extremities: leg, thigh, lower leg, foot

• Genital or Perineal Region: private areas

1.     Know the complications and treatments for a 3^rd degree burn

Treatment

• Surgical debridement of necrotic tissue down to granulation tissue

• Pealing or sloughing at a burn center 

• Skin grafting 

  • Xenografts - fish skin 

• Fluid restoration for dehydration and kidney failure 

Complications 

• Dehydration

• Hypothermia 

• Thrombosis

• Respiratory compromise

contusions 

• Bruising caused by broken capillaries

• Acute inflammatory response, swelling, pain, immobility

• Blood may gravitate to other areas, turn purple and yellow as blood is absorbed

  • Treatment: Tylenol, nothing with bleeding properties, rest, ice, compression, and elevation (RICE)

  • “I’ve fallen and I can’t get up”

    • Results in may 23- hour observations and potential for LTC

    • Immobility results in deconditioning in the elderly

abrasions

• Rubs off the skin due to direct contact with rough surface

  • Skinned knee (“raspberries”)

  • Grazing an object

  • Continued rubbing or scratching

  • Friction burns

    • Floor/rug/carpet burn

    • Rope burn

    • Road rash

    • Treadmills

• Minimal bleeding, but area scabs over and may form a scar

• Treatment is topical

  • Covered with breathable gauze or non-stick bandage

  • Ointments to minimize risk of infection

minor sprain

• acute inflammatory response, swelling, pain

• Rest, Ice, Compression, elevation (RICE), and immobility/NSAIDS

major sprain & complications

• acute inflammatory response, swelling pain

• Rest, Ice, compression, elevation (RICE), and immobility/NSAIDS

• Complications

  • Tearing, permanent weakening, arthritis

  • May require surgical intervention later

deep scar 

scar formation 

• fibrotic area under the skin (bumpy) or depressed area

  • massage area to break up fibrotic tissue, so it can be absorbed

  • Can take months

  • May need dermatologist intervention

superficial

scar formation

• keep soft with creams 

• massage area to prevent scar contracture 

• can take months to go away or may leave a permanent scar due to the destruction of pigment producing cells 

• dermatologist intervention 

  • chemical peel 

  • radiofrequency and ultrasonic directed therapies 

What is some post surgical complications?

• Shock - cardiogenic, septic, hypovolemic

• Wound dehiscence - separation of wound edges (internal or external)

• Infection - cellulitis (external) or abscess (internal)

• Fistula - an abnormal connection between two tissues, often accompanied by infection

• Mechanical Failure - complications from implanted devices (eroison, breakage, or leakage)

• Hematoma/Seroma - encased accumulation of blood or fluid requiring drainage