tan GENERAL ORTHOPEDIC re ui HOMERS EBACTIS to surgical neck of uMIErUS. nding height: 260 years old younger individual Diystee|nct wemrg wen wil be required to submit your maces, Sea aie og Beate et ceca Your medial eave and emergency ease” PO vil, leave > 4 months, House officer no again as 1™ poster. 1 Start theta Fal rom st couetlbrons nour pa ead st Pate exter Soft asue swelling toss of normal convex contour of the shoulder pen lracture are rare but should be ruled out sensation over lateral aspect of proximal arm (regimental patch area) should be examined to rule out axillary nerve injury. Radial pulse and CRT ofall fingers should be examined and (COMPARED to the contralateral side. meg DG A Gras ven ‘Neer view (Lateral Y) = .Classification: 1+ Neor’s classification is based on proximal humerus — ‘+ Humeral head, humeral neck, 1 Greater tuber tuberosity BerStY ana YP = r SSomocinvoul oat palpate for distal pulses and cy A iy al eran ail ae) =e | gees Be | ame ee rend conmaninting wth tere — @§» | Ba » ‘he, to rule out open fracture —_ “4 Sign and symptoms: Siiccttion S. = Pain at fracture: se | Pee eee eememan + Reduced range of motion trom rm physleal examination should be documented Treatment: ‘© Based on functional requirement of a patient + Non-operative: ‘= Acceptable fracture is displacement of < ‘angulation of <45 degree ‘* Immobilization for stable fracture © ‘and cuff sing, Passive ROM shoulder exercise S10 weeks; sing can be used during 1514 injury. = Operative - depends on facture cassie © ORIF — with plate + Percutaneous pinrr Pen fracture Seamer acts + Murpie bires oncom ae ae Obey ete, Fioating elbow + Type ects intra-articular fracture Seo eee in mite ‘extension et nerve palsy after CMR Significant vascular injury | + Neurologic deficit after penetrating injury Nonunion Pathologic fracture i Holstein-Lewis Fracture: ‘© Spiral fracture of the distal one-third of the hum: ‘commonly associated with neuropraxia of the rac incidence) 2 Distal two column (condyle) fracture:( Ju (Jupiter classification) TART Transverse fracture proximal to or at upper olecranon Low: Transverse ta fracture just proximal to trochiea (common) a racture ine through both columns with distal vertical Nodal ema 20ment (sk of AVN) tani fracture line exits medially Proximal fracture tine exits laterally a‘of the proximal or middie third of the ulna te ote alocaton ofthe radial head (most im ehidren and young adults) acture ofthe proximal or mile third of the ulna ‘dislocation of the radial head (70 10 ‘of adult Monteggia fractures) | Treatment | Non-operative treatment may be reserved for wi significant medical comorbidities “ery at Operative: ‘* ORIF: two plates applied to either column (double = FracturedPan be protected with hanging i for ORIF + Total elbow arthroplasty: useful for patents years, particularly with osteoporosis or meu iv, FRACTURE OF RADIUS AND ULNA ‘Signs and symptoms: of to nar metaphysis ata cornois [cae wt tert locaton ofthe racial Head cture of the proximal or middle third of the ulna radius with dislocation of the radial head in any ‘© Pain and swelling and deformity. © Circulation - Radial and ulnar pulses Assess Median, ulnar and radial nerve functor = AINS PINinjury ‘© Walch out for compartment syndrome =" A.porogga fracture in adult should be treated by ORIF. FzSa! head wil usually reduce after anatomical reduction of Sar is anatomic, but radial head does not reduce, open ‘eon ‘eaureg, " S€8rate approach for annular ligament repait is Treatment © ORIF: DCP ; Protect with above, elbow decks! ORIF. $ 6 ‘* Severely displaced fragmen CORIF, to prevent severe swelling ican be reduce and painVi GALEAZZI FRACTURES Fracture oFxadial shaft with distal radio-vinar dis ‘Sub classified based on dista surface Type 1: within 7.5m from articular surf 2 of radial tractor . nn rem nat ae nts - high eneray unekaints -1ow enery ! als en Type 2: more proximal than fype 1; lower rato of DR oe ra oiclat ea ius Poa + ASA ries must be evaluated +” ORIF with DCP isthe treatment of choice for adut adil sivioid fracture - indication of higher energy + Anatomic reduction of radius wil usvally reduc ‘= Unstable DRUJ should be pinned with K-wire steop0r9=e of distal radius fractures in women >5% supination, and kept for 6 weeks | High incidence of 30 {A-C :Galeazi fracture after fixation with Small 0 : Galeazz fracture after fixation with smsil DCP, = Fiat rads fractures are a predictor of subsequent fractures tee DEXA scan is recommended in woman with a distal radius fracture Eponyms: inch | A depressed fracture of the lunate fossa of th articular surface of the distal radius Fracture dislocation of radiocarpal joint with intra articular fracture involving the volar or dorsal lip (volar Barton or dorsal Barton fractur Radial styioid fracture Low energy, dorsally displaced, extra-aricular peactire, Low energy, ae volar displaced, extra-articularManagement ~ 2 Extra articular ‘GM and above elbow cast uso e mACTIE ‘i Dect bow onthe pont of shoulder 1 Rarely need fixation + tna aren con a Dus ryan HCN oy chm and AEPOP Seon arn nacre er 1 fot acceptable for ORIF > Pree at lig neabizaon ‘© Locking plate / buttress plate rated eg, exorcee should begin in 2-4 weeks time i or re merc can bron or 6 wots was Srerenouda be sold 6-10 woaks for ORIF: Somatic non-union jar injury involvement Conservative management Cast for 6/52 ONLY ist physiotherapy once of ications * sym Neurovascul ‘skin tenting Setng shoulder: fracture of clavicle with fracture or surgical peck of scapulavhumerus + Open fracture no stempt at reduction should be made for clavicle fracture . LAN JOINT INJURIES. ‘ACK Located between the medial margin of acromion and \ fee gin of acromion and lateral ee cen bd oe. , Ed — a Adil eight iam amestorte 4 fail inination ase . intrarenal a Be} \ na variance 0-20 oui ot RENCE Sow err wom‘Signs and symptoms: 2 Pain and deformity over ACJ 2 Clinical iad contims the diagnosis of ACY in. a LS ee ae Br: 2. Pain with F088 arm adduction toarm elevated to 90' and adducted across elbow flex in 90° oo 3. Relieve of symptoms by injection of LA, Set, Classifications: Graded according to amount of injury to ACJ and coracccta joint (trapezoid and conoid ligament, Tossy-rockwood AC joint dislocation classification Normal AGI radiograph. Only minor strain © 207 0 ligament Lateral end of clavicle may be slighty elev ‘compared to unaffected side, AC.) appears to = ‘Coracoclavicular space remains sirsla 0 "AGIs completely displaced and coracociv\ than the normal shoulder (by 25-100%)LOWER LIMB Fe i ‘Types of proximal femoral fracture The fracture pater wil determine the management £9 Undispaced ltracapauar fracture (1 02) > sow at - Deplced intracapsular fracture (1 or2)-> Hemi Basal neck niertvochanterc fracture > OMS ‘Subtoctranter actu > DHS DCS / PFN NECK OF FEMUR FRACTURE Risk increasing with old, mainly due to oste0P2 Healing potential is low dt lack of periosteal aye Higher risk of AVN dt disruption of blood SUPP + Major blood supply - medial femoral ecu Cause: + Fallin elderty High energy impact in youn pater! jeg in external rotation and abduction with rll os _garden”s Classification (y- a litem Tent tent ‘Wearent cansonave + inprevously non ambulator 3 & il patient 1 Scen Fixation + Non displaced transcervical fracture + Garten rand 2racure hem total Eeiat Thompson hemiantroplasty with metabolic bone disease which previously active Comsteton tna = Pslocation 2INTERTROCHANTERI FRACTURE FEMUR (1 FEMUR (IT) Cause by fal - from direct and indirect fo (Gccurs along lines between greater and lees ty Extra capsular - has an excellent blood su Heals wel Classification - Evan's Classification oe EVANS CLASSIFICATION te jenboard injuries) fracture and knee injury tom OM olen thigh ~shortened leg fs Yor neurovascular jist and Hansen Classification Peron ochre warps conse bomen pT oe jes ‘Groaer than 50% conte a — ——— a me Pe eter [mw | Some [Lives _| pesteremesta! support 4 Flee os : fen Crees POP anager re FOP 1 Non Opratve Re Fons’ oder Skin acton Saricspua 2 Even wio treatment, fracture usual ‘Allows wt bearing in 12 weeks Marked varus of head & neck with © ‘© Usually result in a short leg gait & I" Operative Dynamic Hip Screw < Proximal Femur intramedullary ' + Paing Nerve — ey & Femoral Artery and Nerve inju ed Ung neem syndrome 'Non Union¥. DISTAL FEMUR FRACTURE Mechanism - rect high energy orc or Three pes: Classification AO ae Al B L. 4, A ELBTEAL ERASE een 9 (e.g. fall from height) se ara en to prone ie trauma In osteoporotics ification SH oading rom minor Sign & Symptoms © Extreme pain + Knee effusion (hemarthrosis) «Shortened, externally rotated leg if displaces Treatment = ORIF = Retrograde nail = Locking plate / buttress plate = Lag screw fixation * Early mobilization and strengthening i §vil Operative management + Lag screw / Plating and bone graft + Indications + Artcular stop off 3mm ‘Condylar widening > Smm + Varus/vaigus instabiity + Allmedial plateau fracture = Allbicondylar fracture Complication: ‘© Ligamentous and meniscal injuries, = Fixed flexion deformity TIGIAL SHAFT FRACTURE ‘Mechanism + MVA, falls, spor injuries Clinical Features ‘Check for neurovascular injuries ‘Always be on the alert for signs of an impendin ‘syndrome, Treatment CMR & Above Knee Cast + Cast x 3 months = Change to PTB cast if delayed union © ORIF- IMnail/ plate + Non - union fracture = Comminuted fracture = Failed CMR ‘Open fracture - external fixation ‘Complications = High incidence of neurovascular injury ané 2" syndrome «Poor soft tissue coverage in open fractu® yess msene : Fava jleolus fracture es reser ous Hace se cts rac Posten gracture-dislocations a Sea ac es eae ons ty cissiteation Gani ober (location of fibular fracture) BELi Lauge-Hanson Based on foot positon and force of appiog + Supination Adduction (SA) ‘+ Supination Ext Rotation (SER) Pronation Abduction (PA) + Pronation Ext Rotation (PER) 1 pispiaced ‘and bimalieolar-equivalent fracture Brat aie re th > 25% or>2TIm slap + ORI 1 malleolus - Lag Screw + Medial leolus - Plate (1/30 tubular plate) ‘malleolus - Lag Screw + High energy axial load (mva, falls from height) + Characterized by ‘Aricular impaction and comminution Metaphyseal bone comminution ‘Soft issue injury (open or Tscherne IW/Ill closed fractures) 4 Musculoskeletal injuries ‘agents typical with intact ankle ligaments Medial malleolar (deltoid ligament) Treatment Non-operative * Below knee cast/boot + Indications: ‘ © PosterolateralWVolkm: + Isolated nondisplaced medial malieolus __ ior tgameny a 2IMeN (Posterior inferior avulsions el AnterlateralChapen + Isolated lateral malleolus fracture with <9" ener igen "2ament (anterior incr and no talar shift nin ole ‘= Posterior maileolar fracture with < 25° | a ‘2mm step-off— ins oxta-af eee * co crn ft Se NS or po ‘ “a oss ea ere round age 6-7 years childhood OF Ma rae, * May lead to growth disorders due to: we MQ growth) ie ne most often a cian ya 8%) 8 none pt om aton for extension Cad SALTER — HARIS CLASSIFICATION OF PHYSEAL Fach us | | | f wm ly | \ | = , = . 5S IS oo becca’ cul ctl od | | pct tn: Rae + Osta radus fracture (occurs in 5-6%) I SS oJ + Pryscal Examination: >) ii JP) + Yeeros — tok for brachial artery injury ee mlm, | =] Examine racial pulse and GRT | met fee |S BE ja:kttooaie Defcts — median, radial & ulna nerve soma | tearoe | a i of ‘portion of eal ay walled arm is stghty decreased (Le. vascular | Irverophic | Pr and |, tyisa, aa | ot tneent ‘apply a continuous pulse oximeter | am Semone | tna | * On Tor type | AEPOP : Cptaneous pn fixation "eduction and Kwie insertion i |‘Angle a I Artior tan “ [an —* Complications: CubitusVarus Volkmann's Contracture Vascular Injuries Neurologic Deficits Fe sacl ot comple ran o¢amION Must BE REDUCED AS SOON AS * POSSIBLE, yqysT BE DONE AND REVIEW SH oy UNDER SEDATION FALED, PREPARE + RECT CmR UNDER GENERAL ANESTHESIA Koop NBM Inform medical officer 1 £06 BOXR in pt> 40 vis ee Sf ant disocaton aw race + 95% 2 umera head infront of glenoid {patent hold arm in hand-shake position «+ Posterior distocation ‘+ ght bub sign + Empty anterior glenoid fossa ‘Shoulder DislocationManagement: Close manipulation and reduction © Putarm sling and bod Methods of reduction wens! jgucted. Meetocancn ae naan rotated, ad ave scatauis atie ; 5 pou ‘slight flexed) om et yo ily rotated. abducted, Y trap for 215 2aoncan be apptied oot + Rca rotaion shoud Feet « Dotlescopic test to check for the ie stably terior oe ree. ; 7 erence ie a to neutral and tract pumsors Method e‘3. DIABETIC FOOT + Thorough history and physical examin '* Local examination ~ both lower limbs, = i. Evaluation OF he Musculcstoe + Alitude & posture + Deformites - Hammeroes Bu Pesplanus or cavus / Charcot defor ‘amputations / prominent metatarenn® Limtled ROM ~ activ and pacer "==> TA contractures / equines / oot Gait evaluation a Muscle group strength testing Plantar pressure assessment tal Status fi. Evaluation Of The Skin & Nails Of The Foot ‘= Skin appearance: color, texture, turgor, qual skin * Calluses, heel fissures, cracking of skin dve o ‘sweating in autonomic neuropathy * Nail appearance: Onychomycosis, dystont hypertrophy, paronychia < + Presence of hair * Ulceration, gangrene, infection = Interdigital lesions * Tineapedis Evaluation of Vascular Status ofthe Foot & | = Pulses (DPA, PTA, popliteal, femoral) 1 = CRT (normal <3 seconds) = Venous filing time (normal = Presence of edema ‘= Temperature gradient = Colour changes: Cyanosis. der Changes of ischemia: Skin atrophy” ‘abnormal wrinkling, diminishes pede! "=" 1<20 seconds) 9 rubo pendent ru segmental artery indices (ABI) ~ easy way to determine ‘iow but may be misleading due to 4 of tno arteries giving rise to higher pressures --<0.9 abnormal. ala ewratly and be more relabe nthe assessment more ting. polenta In general, 85%-100% of foot ni Heal when toe pressures are >4OmmHg and (ese nan 10% wil heal f<20mmH, ‘Transcutaneous oxygen tension (TePO2) — 30mmHg correlates with ening, Measurements require an experienced ‘technician and may vary depending on measurementvii vi Evaluation Of Neurological Status * Vibration perception: Tuning fon + Pressure & Touch: Conon wnt (6:07) 109m (Semmes Weinston Pain: Pinprick, using sharp and bun = Two-point discrimination “y + Temperature perception: hot and cols + Deep tendon reflexes: ankle, knee + Clonus testing + Babinski test + Romberg's test Uloer Examination = Location’ r = Size = Depth : = Margins q = Swelling Evaluation of Patient's Footwear Type and condition of shoes / sandal - Fit + Shoe wear, pattern of = Foreign bodies = Insoles, orthoses wear, lining We Investigations: + FBS (4159mmo) oe 2 aps 44-78) 4 " HbAtc (<60mmer") » FBC Wah), bon 1 mee aie ice, Penetrats tough Tato tendon | 2 yner’s Classification Ppre-ueer. NO open lesion. May have deformities, ; Besad tees of ices or pease para of on witcu DenER a eet oer. Dsupton of sn wou penaaton ef scutancous a ayer | Fa tapul without deep abscess or oxeomyelte + Daep ulcer with abscess, osteomyelitis or joint sepsis. Be coor pres toece reactore, cosces on Meidngtaca end tenon sheath Ivectone, [arena of peooraphical portion of the foot suchas | fee ffl or eet | “Gangrene or necrosis of large portion of the foot tecorig major mb amputation, University of Texas Diabetic Wound Classification Stage A Grade 2 | (The inclusion of stage | ‘makes this Classification a better Predictor of outcome)Principle of treatment © Debridement of necrotic tissue&Wound ca Reduction of plantar pressure (off-loading) Treatment of infection ‘Medical management of co morbiities ‘Surgical management to reduce or remove ‘and / or improve soft tissue cover = © Reduce risk of recurrence 4, OSTEOMYELITIS ‘Acute OM - common organism Staph Aureus Chronic OM ‘+ Sequel of acute OM ‘s Secondary to open fracture / operation ‘Common pathogen + Staph aureus ecoli proteus s. Pyogenes. pseudomonas Presentations ‘* Pain and fever «Tender, infjammed and edema Sinus tract ( chr OM) Investigations: “e Raise total white, ESR & CRP * 1 bromine, P sete epic and fever an cause + Wetppate staat sample for utr taken + Aci posed on most IKely Organs Suspected © Gir children! adut © ON Lely staph aureus: 1 Sanilac and sii aia ‘should then base on organism Anite ‘organism spectc after cuture alae __ fanatic should be continue for atleast 6is2 «Sujal intervention Seeqvestrectomy and sinusectomy «+ ESR & CRP monitoring 5. PREOPERATIVE & POST-OPERATIVE CARE ‘A ANTIBIOTIC PROTOCOL TO OT |. ARTHROPLASTY (THRITKR) 4. lV Ceftriaxone (Rocephi Wy Stearn ine) 2gm for induction Ambien! Clavulinic Ack! (Augmentin) 12am for 2 SPINE SURGERY aw 4 Tac ee (Cefobid) 29m for induction IVE OP (PLATE/ NAILWiRE) (Zinacef) 1.59m for induction ERYB. ARTHROPLASTY (THRITKR) Pre-operative preparation Examine for hip or knee range of motion Patient referred to dental ch ‘Antibiotic prophylaxis to OT ‘Rocephine 29 — given to patient after na Becca TAP etc) Company and system of arthroplasty Patient visited GA clinic and passed for op Look for any special order by anesthetist {GXM, Blood Ix 1/7 prior op ‘Augmentin 1.29 - for irigation Post-operative management THR = Others: ‘Do post -op review as soon 2s pi ‘Monitor al the vital sign — BP, pulse Circulation of operated limb - pulse Looked for any bleeding - radivac: Post-op Hemoglobin DO NOT ALLOW ADDUCTION - Tromoved redivac fess than 207!" surgeon Check xray once off e>4 + PELVIG—AP VIEW t RiGHT/ LEFT HIP- LATER, © Encourage patient o it uP 2” ‘Wound inspection on 389 ° ‘Antibiotic for 5 days idural/ PC se for dental clearance me con a patient ave nthe wad rian ogn OP. ue, pa score Fjonaot 28 erated nb — pulse & CRT Creation rigeang-radvac, wound bandage postop Hemosion® ne agredvar iss han SOmUshi or s ordered by surgeon te pump OxerSE Stat ane Ponce off epidural / PCA “AP and Lateral View knee in extension (pillow under ANKLE) sit up at bed side and allow active flexion Knee ‘right ~ Keep sa extension ‘ncourage walking frame ambulation Wound inspection on day 3 and off antibiotic ©. ARTHROSCOPY Examine the knewPost-Operative management Do post -op review as S00n as patient arrive j © Monitor ail the vital sign ~ BP, puise, pain © Girculation of operated limb ~ pulse & cr © Post-op Hemogiobin Keep knee brace (locked at 0 degree) Star strengthening exercise on bed Refer sport team Wound inspection day 3 i the wa T ORTHOPEDIC EMERGENCY ee ecture wih arec communication tothe extemal tnt ples of management ne maragerent bins Arnie suey ang + Fastation is compete force IV antibiowc © ea inacof 1.59 stat then 750mg tds Flagyl 500mg stat the ts ‘5 Tetanus prophylaxis «+ Conte! bleeding Te Dont blindly clamp or place tourniquets on damaged extremities Assessment - soft tissue damage {Wound inigation - Minimum 10 water Spin fracture for temporary stabiization ae incpes of Management in the Operating Room * Aggressive debridement and irigation ® Low pressure lavage > effective in reducing bacterial cant ee high pressure lavage . effective irrigating agent = 4L of saline are used for each GustiFrac siablizaon ae Early soft is coverage / wound closure is idea! fale esha Re past bore! contains (Si eeieestialapll Duration Open Fracture Classification: GUSTILO CLASSIFICAT\o Initiate ASAP cate Continue for 24 hours after initia injury wounds able to be closed primarily Continue until 24 hours after final closure rot closed during initial surgical debrideme T [Open fracture with clean wourd. wou | Open facture wih wound> +m ee extensive sot issue damage , fap 2 ‘Open fracture with extensive sot tise 2% ty _ | damage or oss or an open segmoral type also includes open fracture cas injuries, gunshot fracture, 3 wua_| Te acre with adequate despite extensive soft tissue damao?_ “ype il fracture wih periosteal 22": wna. | exboeure, Usuaty associated wn Contamination Will often need further °° ceed fe iain tno. | Teil trace associat wit °° pair, respective of dogree 1° By ind ica 7 15-25% + Brera pelvic stability place rotational force on each tac crest Low sonsitvty for detecting instability 2 Perform ONLY ONCE ‘¢ Look for abnormal lower extremities positioning + External rotation + Limb length discrepancy ‘> Hematoma or wound over perineum © Rule out lumbosacral plexus injuries, + LSIS1 most common + Treatment: © Volume replacement — q Ideally blood {Initial management of unstable fracture Centered over greater trochanter to effect indirect + epee over ic crest /abdome . © Bag 24ament wits intemal rotation of owe i2 iNguRY Denis’ Three-Column Theory BURST FRACTURE © Involved 2 or > column © Mostly unstable ‘© Neurological deficit common, ‘= Imaging show: ‘© Reduced vertebral body height ‘© Widening of pedicle © kyphosis © Retropulsion of bone into canal COMPRESSION FRACTURE ‘© Stable fracture — 1 column + Common in osteoporotic elderly + Imaging show reduced vertebral body N*' PINAL SHOCK ‘All unconscious trauma patients should be ayy, hhave spine injury untl proven otherwise S¥™e to Commonly at thoracolumbar junction, omer through a vertebra body and F ry (Soat-bot injury) . rec ration injuries Artoir co 1 faerie rin 8 rena one ot halt vera : ame Porton et arma faint nas neurtogice! deck Midae column ‘ vertebral ny Posterior column ligamentum interspinou facet ints, " LOCATION FACT “ncoslerationideceleration injuries 2 Hypertoxion, ars cteoing 0 0 ‘pra clumn «Pate has neurological deficit‘Neurogenic shock * Characterized by hypotension & relative b advan sin if patient in spinal shock. with an acute spinal cord injury st ‘tei Bebe ‘Spinal shock ° Co lr fry pee ‘© Defined as temporary loss of spinal cord fun, activity below the level of a spinal cord injr, © Evaluation © Neurologic deficit cannot be evaluatedunt si, phase has resolved a * Retum of the bulbocavernous reflex * conus or caudaequina injuries may lea loss of the bulbocavernous reflex ‘segment with intact Sensation and muscle power 3 or sotmine wane irs COMPLETE or INCOMPLETE § asemine ASIA Impairment Scale (AIS) Grade: ton an Y. [> Voluntary ana! contraction (Sacral sparing) OR J+ Palpabie, isle muscle | srosent | ne CT Rotors? eee aoc ; rad bara fous 4-72 hous | immediatoy at spinal cord inurY ‘unctonis preserved bel jow the neurologal than half of key muscles below the ‘autonomic pat toads t0 105° sympathetic 0" ‘decreased ®Y ‘vascult rosTreatment: 335. SOsPAETMENT SYNDROME «Conservative for stable fracture F ois eal a © Extension body cast ton I toove cheers ard rec wae + Watch out for BODY CAST SYNDROME {ano aecoreresson. @ Sirgical intervention = posterior decorpresses coe: © Patient with neurological dei, operation wine vpenssng ume of compare fracture site fo ease nursing care bony, E+ ee: i, dial end rads, acres nvohing + Mutiiscipine management with ehab un Frnt. Body Cast Syndrome ‘© Clinically known as superior mesenteric artery sy is gastric dilatation with partial or complete obs ‘duodenum ee «Results from obstruction of third portion ofthe Tight casts or dressings superior mesenteric artery leading to high inte . nage + Clinical Findings: ase «© Typical presentation: is abdominal pain we : . ae, * Pain: savere and out of proportion to the clinical situation. Made worse on passive strefch test of involved muscle group (10° ‘ersitvty 97% specifiy) creel and hyponstosia (13% sont: 96% able and tense swelling of Paralysis of ling of compartments sa . Muscle necro taro hana ape SLATE SIGN. Misc hel ies ‘ompartment {and CRT are ALWAYS INTACT in acule late tage OME unless there is major arterial injury cr" ceed compare-TEMotn: Placoment of meade oe BP ang Less than 30mmHg difference between er fscctomy. Pressure is an indication for i: © Bivalve body cast x. © NG tube suction and IV fluid for 3 194 02Management: Release and bi-valving dressings oF pastar cay Hypotension should be corrected to imorave poy gradient Prepare patient for emergency fasciotomy Limbs compartment: "¢ Thigh: 3 compartments (anterior, posterior an Limbs SHOULD NOT be elevated ay yn lateral, deep posterior and warrments (anterior, 4 com « ert ecnrie?‘= Foot: 9 compartments (medial, latera, Beier eerran er on eu x4) ha, pm: 2 eomparimants(antaror end postr) Compartment Medal Tres musts oe gee to eso dg mee Abc 698 me coe + Spe esr diene bers ‘Deep eakanest Outs prise Aster tos pater takes leecesae ruses+ Forearm: 3 compartments (Volar, dorsal ang Obi ag ‘= Hand: 10 compartments (thenar, typo! policis, dorsal interossei x4 and volar intero°s 6 x y BI etc recrogcdaen ch mc sce cous wen sal ee eeeaprotny ohe AiOSepaee raspatry fare (ARDS-he pcre) ios smay be as high as 5 ~ 10% Mortality 515% © aon morally in severe pulmonary isiicent cereal tnaniestation isk factor: Rea og bones fractre (esp femur and tha) © Fai higher with non-operave therapy Dui aso ighr fan overzealous reaming of femoral canal © Mulipe trauma with major visceral injures and bled oss + Dagnosis Pho pathonogmonic sign but high index o suspicion i helt Diagnosis is made clinically. © Typeally manifests 24 to 72 hours afer he wnt suit Rarely 12h oF >72 hrs © Cassi Wad: Hypoxemia; Neurologic abnoxmaites, anda Petechial Rash © Requires at least one sign from majo citer ana four sian ftom minor entria categories ‘alary / subconjunctval petecia.anoror ore Hypoxemia (Pa02 < 6dmmng, F102 <= 0.4 * CNS manifestation = contused, estess Gurd's minor criteria ‘Tachycardia > 1 10bpm + Pyrexia > 38,5 degrees {Embal presentin retina Fatinurme © — <=) Low HET or seat valves}, + Hoh ese © GRO) ms‘Management: © Seftiimiting disease and treatment is main ‘maintain perfusion nn SUP pony © General measure: ‘© Fractures immobilization ‘© Avoid unnecessary transportation * Adequate IV line / perfusion ‘* Restoration of blood volume © Specific measure: * 02,(high flow mask) ‘+ I Pa0;< 60mmHG oF evidence of resp ¢ hypercarbia and exhaustion — mechr © Fracture fixation 8 pints ng «Conf the diagnosis: + CT Angiogram Preventions © Adequate immobilization of the fracture. : Picante oe Bed ret with fot elevation + Ongen © Adequate hycraton and analgesic BET iskopa for hypoteraicn © Pulse oxymeter monitoring for subctincal hy *IvHeparin/ LMWH Prophylaxis 02 can reduced the severity of Ft + Oral Warfarin ~ nated overiap of 3-7 cays bel 6 ha actin twee 8 PPV of go * P (mg/L) 2150: 4 point: % oth ost A ints om WBC count (x103/mm3) Pree: Pa Fever © <15:0 points i © 15-25: 1 point ° SOE yea © = >25: 2 points ie Ea we = Hemogio! 2 Warm: . ea . J Inability 19 boar weight .5: 0 points + papi to tolerate passive ROM © 11-135: 1 point 3 me to ben postin of maximum nt yoke + <11:2 points Etrerpp in FABER poston (Flexo, Aucion + Sodium (mmol) External Rotation) © —<135: 2 points Investigations: = Creatinine (umol/L) ° Te ee onda! Be > ie © Jat uid sample ~ god standa 7 aaron 1 pppearance : Cloudy / purulent lucose (mmol/L) . ‘Cell count & differential ~ WC > 50, 000 © >10: 1 point igen + cuture , Treatment: 2 Glucose level - <60% of serum level lebridemer + Treatment: ©. Operative — drainage of jint (orthopedic emerge") mergency radical d im antibiotic -IV Taz05 re based antibiotic ‘© [antibiotic ~ organism specific antibiotic therePy © Operative ~ er © ESR, CRP & white cell monitoring © Broad spectrut = Then change to cultur > Amputation - when life threatening = Anup ob aww aca _. at PryCOMMON ORTHOPEDIC PRocEDy, RE 1. MR - Close Manipulative Reduction ‘= Done under sedation ‘© Close monitoring during CMR 'Sp02 monitoring ‘Sedation © Midazolam 1am; mg/ml slow administration intravenously had individualization dosage Normal healthy adult = 1 -2.5m9 (0.1mgi ‘© should not exceed 2.5mg Lower dosage in elderly Children: 0.1mgkg Antidote: flumazenil ; 0.02mg/kg © Pethidine 1 amp = 100mg/2m| Dilution: 2m pethidine + 8m water for —>1mi= 10mg Intravenous dosage = Adult between 25-50mg siowiy ( + Elderly: should not exceed 259 * Children: 0.5 - 1 mg/ko ‘Antidote: naloxone; 0.01mg/ko 2. CAST-POP/FIBREGLASS 4, Molar slab — from DIPJ up to 2 fn9° © Wrist ~ dorsifiex at 45° McP4 - 90° Indication’ ‘& Post tendon repair ‘© Fracture metacarpals n -Sieb—from below axilar down covering the elbow and upto 2 age ofthe neck «Indication Fracture humerus4 ‘AEPOP — Above elbow POP ‘© From MCPJ up to middle arm with frost = Indication: bum, Fracture radius & ulna Fracture supracondylar humerus 5. Scaphoid cast 6. Be From MCPJ up to 2cm from elbow coverin the IPJ Hand in glass holding position Wrist 10-15°dirstlexion Thumb — abduction, flexion Radial deviation Indication ~ scaphoid fracture yelow Knee back slab From MTPJ up to 2 cm below tibial Indication: Fracture tarsal and meta! Soff tissue injury Knee FOr cm below tibial tuberosity 1 ens 10227 , Ire? ayo ano (aloo) a. Freee dislocation tarsal, metatarsal bone 14 Above Knee POP / Full Length POP J ftom MTPJ up to upper thigh 2 indication - Fracture tibia 8 Precast (i babe ens Tendon Bearing Cast) / Sarmiento Cast : ont {up to med patella, covering medial and lateral Indication - Unig Posteriorty 2cm below the popliteal fos mae a low the popliteal f10. Cylinder Cast / slab + Sem from medial malleolus up tomy fe stil it can pull a long bone straight + Knee in neutral or normal (5-15"texion hold 2 face oT maintain accurate reduction is nator i ert ee Can nave ps ond ae Fracture patella Ligament injury (€9. PCL avision ee te oni a ‘be in the supine position (on his/her back) vie tient should a eatin body in good ai ie 2 nce; for this. Gountes represent forces in balar pallet ote a friction juce the efficiency of traction and hinder — Side: 7.5em from axillar to iliac cres Indication - Thoracolumbar fracture = cai x Check frequently to make sure tapes are not slipping, that pulleys Si ‘are working properly and that the components of the traction ‘srparatus are correctly and tightly assembled. 8 Une of pul Ors established correctly, the line of pull should be maintained See Cardiovascular system monary ereant® 21° at risk for venous thrombosis andlor 2m apperen eUOvascular Status with particular attention Postion within Pressure areas; char te changing the patients os PemMstons cf the tron avery twa tc tarSeuss wrens” pint , should rest a patients gluteal fold to fe counter traction The purposes of traction: To prevent or reduce muscle spasm To alleviate pain To immobilize joint or part of a limb To reduce fracture or dislocation To treat joint pathology Full / Half ring Thomas splint Properly placed traction will 4. Plaster ape, measuring tape and padding 4, Alignment of distal fragment to the proxi 2. Remain constant 3. Allow adequate exercise How do we apply skin traction? : 4, Allow adequate nursing care Upper tet + Precaution to be taken during upper limb application of skin traction + Care to be taken to apply the wrapping on bony prominence (radius una) SKIN TRACTION + Joint iealy be spared Preparations for skin traction 1, BOHLER BRAUN Frame Used to keep knee in flexed pos!Teehnique skin action ‘A~ Adjust requirement length (start below fracture site) and c symmetry of adhesive tape. ‘8 Protect ankle with padding and leave ample space then ¥ adhesive tape, ‘CAD Tie knot,put on thomas splint and then wrap ESF Setup bed for traction and apply weight (5 % ‘mo then Sig) Precaution to be taken during lower lint 2 Care to {lateral aspect of shin) be taken to apply the wrapping PTs shocks bo spaces between te hea an J2.low active ankle motion (~5 finger breadth)‘AVOID NGHT WRAPPING ATTHESE PRESSURE Pony. Tuberosy ora Mead ot en, ‘nates eroon (Common Pert Newe ‘Special Consideration A. Gallows traction ‘© Typicaly used in infant (less than 12 month oi) 4 waking age ‘+ tis also used for child 10 ~ 16 kg ‘© Indication: DDH 8. Kendrick Traction Device (kTD) c Light weight & Portable > Mostly used in casuaty+ Skin erosion + Peumonia Urinary Trac Infection 2, SKELETAL TRACTION Steinmann pin inseried into bone to apply traction (maximum weight up t0 20k) + 10% of body weight ‘+ Apples the tractive force directly to the bone using pins. w ‘screws and, in the case of cervical traction, using tongs o applied directly to the skull + Gxerts a longitudinal pull &controls rotation, * Advantageous for unstable or fragmented fractures and th which muscle forces must be overcome to maintain fractu ‘gnment,e.9, fractures of the femoral shatt. Preparations: BSc Sterie towels Disinfectant Syringe Needles Local anaesthetic ‘Scalpel win ponies 20° ‘Sharp pointed ste" orDenham pin ‘Jacobs chuck wit) 2 ‘Stirup In fracture shaft femur in aduit nse the pin 2c i ” tal to the tbial tubercle and ‘efor border of he bia. "oe on heater side to voi tn commen peroneal °° Used in subtrochanteric# {Compound # of femur with postere wounds, and shat femur of chieren Insert the pin trom the mec! sie in the mid-portion ofthe bone at the level ofthe proximal poe of he ‘This should be just proximal to the are ofthe femoral aes and posterior othe Synovial pouch ofthe kne ont"guns too In supracond far Fracture of humerus Inset ie pin rom te medial side ofthe ulna 2 cm from the tp of hy evanon and 1 em anterior to the posterior cortex. “Ths should avoid the unar nerve which passes through the groo. Infevorto the medal epicondyle of the humerus Halo action is indicated in adults for defintive treatm spine trauma including: *= Occipital condyle fractures Octiptio-cervical dislocation ‘calaneal traction + stable Type Il Atlas tracture (stale Joterso '* Typell odontoid fractures in young patien's + Typelland A hangman's fractures * Adjunctive postoperative stabilisation ‘Surgery. alo traction “'edeated in cidren’young people fo = 3 pal dunssoseton — fractures (burst fracture of C1 ~ Alas fractures ‘mopen fracture of ankle joint or leg 7 le odontoid fractures a, Insert the pin 4.5 cm inferior and 4 om posterior to the tip" 3 tatlanto-axial rotator subluxation elmeieiteiemeciccse roo" } See denocaton (Posterior tibial artery and nerve and to avoid entering 2 MPaxiaicervcaispinetrauns joint. : 1fative reduction in patients with spinal oefor” 8aol an coat tro eanycer 40 prolonged iniammatory ici, *ARATION mie. Cr sliver dressing doesn, ‘of wound bed preparation. VIABILITY) ation, ehitheasing {necro slough, esehar infection) 3 ~ abnormal oo, ncesse seo ‘at wound ste, no graraton sue IMBALANCE) ‘of chronic wound uid volume with product abso ‘and protoelytic enzv™® by maintaining a moist ©” agent to stimuiate he ‘A Fibrinolysin wit 99°"1yM ORESSI st facitate wound treatment utilizing sup re range 90 - 130mmHg. Optimay sv Recent technique tha! atmospheric pressure. Pressu pressure 120mmHg EOD BUSE monitoring How NPWT works? Holp removed inert fhi. reduced local issue oedema Improved blood flow to the wound «+ Provide moist environment. reduced cell death by dehytraton ‘encourage granulation tissue Reduced bacterial granuiation Promote granulation movement and growth of tissue in respond to mechanical force of suction pressure (increase mitosis) Indication: + Acute and traumatic wound + Pressure wound > Meshed graft = Flap * Venous stasis ulcer + Diabetic foot ulcer Contraindication ‘+ Fistula to organ or body cavities + Necrotis issue in eschar * Osteomyelitis ( untreated) ‘+ Malignancy in the wound Fox with adhesive fm eg Tagederm ComPemantapan Program Pagel PenbatnSsacan Guide ote Basics of Tracom: Zn Tacton aul femoral sha acres: 2 apr on pater nS anil Lav trp. 2007 Ost era