SOLVED PYQ PAPER-I

1.Quinsy (Peritonsillar Abscess) – Clinical Approach

Definition:

Quinsy is a collection of pus between the tonsillar capsule and the superior constrictor muscle of
the pharynx, usually a complication of acute tonsillitis.

Clinical Features:

Severe unilateral sore throat

Fever and malaise

"Hot potato" voice (muffled)

Dysphagia or odynophagia (painful swallowing)

Trismus (difficulty opening mouth)

Drooling

Swollen, fluctuant peritonsillar area (usually one side)

Uvula pushed to the opposite side

Diagnosis:

Clinical diagnosis is usually sufficient.

Oral examination: swelling, asymmetry, and uvular deviation.

CT scan of neck with contrast – used if diagnosis unclear or to differentiate from deep neck
space infection.

Management:

Initial Steps:
1. Hospital admission (moderate to severe cases or trismus)

2. Airway assessment

3. IV fluids if dehydrated

Medical Treatment:

IV antibiotics (e.g. amoxicillin-clavulanate or clindamycin)

Analgesics and antipyretics

Steroids (e.g. dexamethasone) may reduce inflammation and improve symptoms

Surgical Drainage:

Needle aspiration – first-line and often curative

Incision and drainage (I&D) – if needle aspiration fails

Quinsy tonsillectomy – rarely performed acutely; interval tonsillectomy done after 6 weeks in
recurrent cases

Complications:

Airway obstruction

Extension to parapharyngeal or retropharyngeal space

Sepsis

Internal jugular vein thrombosis (Lemierre's syndrome)

Recurrent peritonsillar abscess

2.TAVI (Transcatheter Aortic Valve Implantation)

Definition:
TAVI (also called TAVR – Transcatheter Aortic Valve Replacement) is a minimally invasive
procedure to replace a stenosed aortic valve that fails to open properly, without open-heart
surgery.

Indication:

Primarily used in patients with:

Severe aortic stenosis

Who are high-risk or inoperable for surgical aortic valve replacement (SAVR)

Increasingly used in intermediate- and low-risk patients based on current guidelines

Patient Selection:

Symptoms: Dyspnea, angina, syncope (classic triad of aortic stenosis)

Confirmed severe aortic stenosis on echocardiography

Multidisciplinary Heart Team assessment (cardiologist, cardiac surgeon, anesthetist)

Access Routes:

1. Transfemoral (most common)

2. Transapical

3. Transaortic

4. Trans-subclavian/axillary

5. Transcarotid

Procedure:

1. Balloon valvuloplasty may be done to open the native valve

2. Bioprosthetic valve mounted on a balloon-expandable or self-expanding stent is advanced to
the aortic valve site

3. Valve deployed under imaging guidance (fluoroscopy and echocardiography)

Advantages:

Minimally invasive (especially important in elderly/frail)

Shorter hospital stay

Faster recovery

Reduced need for general anesthesia in many cases

Complications:

Vascular injury (due to large sheath size)

Stroke (due to embolization)

Paravalvular leak

Heart block requiring permanent pacemaker

Valve malposition or embolization

Aortic rupture (rare)

3.SICS (Small Incision Cataract Surgery)

Definition:

SICS is a manual, extracapsular cataract extraction technique in which the cataractous lens is
removed through a self-sealing scleral or corneoscleral tunnel (typically 6–7 mm), without
sutures, and an intraocular lens (IOL) is implanted.

Indications:

Senile cataract (most common)

Traumatic cataract

Congenital cataract

Cataract with poor mydriasis (with modifications)

Preoperative Preparation:

Detailed ophthalmic evaluation (visual acuity, slit-lamp exam, intraocular pressure, fundus
check)

Biometry for IOL power calculation

Medical fitness for surgery

Patient counseling and informed consent

Surgical Steps:

1. Anesthesia – usually peribulbar or retrobulbar block

2. Conjunctival peritomy – to expose sclera

3. Scleral tunnel incision – 6–7 mm made ~2 mm behind limbus

4. Capsulorhexis – continuous curvilinear or can-opener type

5. Hydrodissection – to loosen lens nucleus

6. Nucleus delivery – via viscoexpression or irrigating vectis

7. Cortex aspiration – using Simcoe cannula

8. IOL implantation – usually posterior chamber IOL in capsular bag

9. Wound closure – self-sealing; sutures not typically required

10. Antibiotics/steroids injected subconjunctivally

Advantages:

Low cost (ideal for developing countries)

No need for expensive phacoemulsification machine

Effective in hard cataracts

Self-sealing wound (fewer sutures)

Disadvantages:

Larger incision than phaco (slightly more induced astigmatism)

Longer healing time compared to phaco

Requires surgical skill for tunnel construction and nucleus delivery

Postoperative Care:

Topical antibiotics and steroids

Protective eye shield

Regular follow-up for visual acuity and intraocular pressure

Complications:

Wound leak

Iris prolapse

Posterior capsule rupture

Endophthalmitis

Cystoid macular edema

Posterior capsular opacification (late)

4.Cyanotic Congenital Heart Disease – Clinical Approach

Definition:

Cyanotic heart diseases are congenital cardiac defects that allow right-to-left shunting of
deoxygenated blood into systemic circulation, leading to cyanosis (bluish discoloration of skin
and mucosa due to reduced oxygen saturation).

---

Pathophysiology:

Right-to-left shunt bypasses pulmonary circulation → mixing of oxygenated and deoxygenated

blood → systemic hypoxia.

Causes include obstruction of pulmonary blood flow, abnormal communication between

chambers, or transposition of great vessels.

Mnemonic:

The "5 Ts" of Cyanotic Heart Disease

1. Tetralogy of Fallot (TOF)

2. Transposition of the Great Arteries (TGA)

3. Tricuspid Atresia

4. Total Anomalous Pulmonary Venous Return (TAPVR)

5. Truncus Arteriosus

Clinical Features:

Central cyanosis (not relieved by oxygen)

Clubbing (after 6 months)

Dyspnea on exertion

Poor feeding and failure to thrive in infants

Cyanotic spells (especially in TOF)

Fatigue and delayed milestones

Polycythemia (as compensation for hypoxia)

Murmurs (depending on defect)

Diagnostic Workup:

1. Pulse oximetry – low oxygen saturation

2. Chest X-ray:

Boot-shaped heart (TOF)

Egg-on-string appearance (TGA)

Snowman sign (TAPVR)

3. ECG – chamber hypertrophy patterns

4. Echocardiography – gold standard for anatomical diagnosis

5. Cardiac catheterization – detailed anatomy and pressures

6. Hyperoxia test – little or no improvement with 100% O₂ supports cyanotic CHD diagnosis

Management:

•Initial Stabilization:

Oxygen (may not fully correct hypoxia)

Prostaglandin E1 infusion – to keep ductus arteriosus open (especially in duct-dependent
lesions like TGA)

Correct acidosis, hypoglycemia, hypothermia

•Definitive Treatment:

Surgical repair – timing and type depend on specific defect:

TOF → total repair or BT shunt

TGA → arterial switch

TAPVR → anastomosis of pulmonary veins to left atrium

Tricuspid atresia → staged Fontan procedure

Truncus arteriosus → separation of pulmonary and systemic circulation with grafts

Complications:

Brain abscess

Stroke (due to paradoxical embolism)

Infective endocarditis

Growth retardation

Polycythemia-related thrombosis

5.Mallampati Score – Airway Assessment Tool

Definition:

The Mallampati score is a preoperative clinical assessment tool used to predict the ease of
endotracheal intubation by evaluating the visibility of oropharyngeal structures.

Procedure:

Patient is sitting upright, head in neutral position.

Mouth opened wide.

Tongue protruded fully without phonation.

Examiner observes visible structures in the oral cavity.

Classes of Mallampati Score:

1. Class I

Soft palate, fauces, uvula, and pillars are visible

→ Easy intubation

2. Class II

Soft palate, fauces, and uvula are visible

→ Usually easy

3. Class III

Soft palate and base of uvula are visible

→ Moderate difficulty

4. Class IV

Only hard palate is visible

→ High chance of difficult intubation

Clinical Relevance:

Helps anesthesiologists plan airway management.

Often used in combination with thyromental distance, neck mobility, and mouth opening for
complete airway evaluation.

Class III and IV are associated with higher risk of difficult laryngoscopy.
Limitations:

Subjective (depends on patient cooperation and examiner skill)

Can vary with posture or tongue effort

Best used as part of a comprehensive airway assessment

6. IABP – Intra-Aortic Balloon Pump

Definition:

Intra-Aortic Balloon Pump (IABP) is a mechanical circulatory support device used to augment
cardiac output and improve coronary perfusion by inflating and deflating a balloon in the
descending aorta synchronized with the cardiac cycle.

Mechanism of Action:

A balloon is placed in the descending thoracic aorta (via femoral artery).

Inflates during diastole → pushes blood back into the coronary arteries → increased coronary
perfusion.

Deflates just before systole → reduces aortic pressure → decreased afterload, easing LV
workload.

Mnemonic:

> "Inflate in diastole, deflate in systole"

Indications:

Cardiogenic shock (especially post-MI)

Acute LV failure

Refractory angina

Mechanical complications of MI (e.g. VSD, mitral regurgitation)

Bridge to definitive therapy (e.g. CABG, transplant)

High-risk PCI or failed PCI

Contraindications:

Severe aortic regurgitation

Aortic dissection

Severe peripheral vascular disease

Uncontrolled bleeding or coagulopathy

---

Insertion:

Usually via femoral artery (percutaneous)

Positioned in descending thoracic aorta, 2–3 cm below the left subclavian artery

Placement confirmed by imaging (fluoroscopy or X-ray)

Monitoring:

ECG and arterial pressure waveform used for timing

Balloon timing must match cardiac cycle

Monitor for limb ischemia, bleeding, hemolysis, infection

Complications:

Limb ischemia (most common)

Aortic dissection or perforation

Balloon rupture
Thrombocytopenia

Infection at insertion site

Embolization

Weaning and Removal:

Gradual reduction in support (e.g. 1:1 → 1:2 assist ratio)

Remove when hemodynamics stabilize and underlying cause is managed

7.Bain Circuit – Anesthesia Breathing System

Definition:

The Bain circuit is a coaxial modification of the Mapleson D breathing system, used for
spontaneous or controlled ventilation during anesthesia. It is a semi-closed circuit with a fresh
gas flow system and a coaxial design.

Components:

Inner tube: Delivers fresh gas from the machine to the patient

Outer tube: Carries exhaled gases away from the patient

Reservoir bag: Allows manual ventilation

Adjustable pressure-limiting (APL) valve: Releases excess gas

Mask or airway connection: Interface with patient

Working Principle:

Fresh gas flows through the inner tube.

Exhaled gases travel back through the outer tube.

A high fresh gas flow (FGF) (2–3 times minute ventilation) prevents rebreathing of CO₂.

Suitable for short procedures, especially in healthy patients.

Advantages:

Lightweight and compact

Provides warming and humidification of inspired gases (due to coaxial design)

Low resistance to breathing (ideal for pediatric and spontaneous ventilation)

Easy to use and cost-effective

Fast response to changes in anesthetic concentration

Disadvantages:

Inner tube disconnection or kinking → risk of CO₂ rebreathing (called "Bain circuit
disconnection" hazard)

Requires high fresh gas flow → not economical for long surgeries

Not ideal in patients with poor lung function or requiring precise ventilation control

Uses:

Day-case surgeries

Transport of intubated patients

In pediatric anesthesia (with modification)

In settings with limited equipment (field anesthesia)

8.Mapleson Circuits – Anesthesia Breathing Systems

Definition:

Mapleson circuits are semi-open, non-rebreathing breathing systems used in anesthesia to

deliver fresh gas and remove CO₂. They are classified (A–F) based on the position of the fresh
gas flow (FGF), reservoir bag, and expiratory valve.
Types of Mapleson Circuits:

●​ Mapleson A (Magill's circuit)

Best for: Spontaneous ventilation

Worst for: Controlled ventilation

Low FGF needed (equal to minute ventilation)

●​ Mapleson D (and Bain circuit – a coaxial D)

Best for: Controlled ventilation

Worst for: Spontaneous ventilation

Requires higher FGF

●​ Mapleson E (Ayre’s T-piece)

No valve or bag

Low resistance – ideal for neonates

Requires high FGF

●​ Mapleson F (Jackson-Rees modification)

Same as E + bag

Allows manual ventilation and observation of chest movement

Common in pediatric anesthesia

9.Mechanical Heart Valve – Overview

Definition:
A mechanical valve is a prosthetic heart valve made from durable materials (like titanium,
carbon, or pyrolitic carbon), designed to replace a diseased native valve (usually aortic or
mitral), and last a lifetime with lifelong anticoagulation.

Types of Mechanical Valves:

1. Ball-and-cage valve

Example: Starr-Edwards valve

Oldest type, now rarely used

High thrombogenicity

2. Tilting disc valve

Example: Medtronic-Hall valve

Single leaflet that tilts to open

Better hemodynamics than ball valves

3. Bileaflet valve (most commonly used today)

Example: St. Jude Medical valve

Two semicircular leaflets that pivot

Excellent durability and flow characteristics

Indications:

Severe valvular disease (stenosis or regurgitation) requiring replacement

Young patients (< 50 years) where long durability is preferred

Patients already on long-term anticoagulation (e.g. AF, prosthetic valve)

Cases of redo surgery where tissue valve would fail

Advantages:

High durability (often lasts >25 years)

Lower risk of structural degeneration compared to bioprosthetic valves

Disadvantages:

Requires lifelong anticoagulation (e.g., warfarin)

Risk of bleeding and thromboembolism

Not ideal in:

Women planning pregnancy (teratogenic anticoagulants)

Patients with poor compliance

Audible click may be bothersome to some

Postoperative Management:

Lifelong warfarin anticoagulation

Target INR:

Aortic valve: 2.0–3.0

Mitral valve: 2.5–3.5 (higher risk of thrombosis)

Low-dose aspirin may be added in some cases

Regular INR monitoring

Complications:
Thrombosis and thromboembolism (stroke, limb ischemia)

Bleeding from anticoagulation

Infective endocarditis

Hemolysis (due to mechanical damage to RBCs)

Paravalvular leak

Valve dysfunction (rare but possible)

10.Sternotomy – Surgical Approach Overview

Definition:

Sternotomy is a surgical incision through the sternum (breastbone) used to gain access to the
heart, great vessels, lungs, and mediastinal structures. It is a standard approach in cardiac
surgery.

Types of Sternotomy:

1. Median Sternotomy (most common)

Vertical midline incision through the sternum

Widely used in open-heart surgeries (e.g., CABG, valve replacement)

2. Partial Sternotomy

Upper or lower part of the sternum is split

Used in minimally invasive surgeries

3. Transverse Sternotomy

Horizontal cut (rare)

Sometimes used in thoracic procedures

Indications:

Coronary artery bypass grafting (CABG)

Valve replacement or repair (aortic/mitral/tricuspid)

Congenital heart defect repairs (e.g., ASD, TOF)

Heart transplant

Great vessel surgery (e.g., aortic aneurysm repair)

Mediastinal tumor removal

Procedure (Median Sternotomy):

1. Patient is positioned supine with neck extended

2. Skin incision from suprasternal notch to xiphoid

3. Sternum divided longitudinally using a sternal saw

4. Rib spreaders are placed to open chest

5. After surgery, sternum is closed with stainless steel wires

6. Skin and subcutaneous tissues are sutured

Postoperative Care:

ICU monitoring (ventilation, hemodynamics)

Pain control (epidural, IV analgesics)

Sternal precautions (no lifting, support with pillow while coughing)

Early ambulation to reduce pulmonary complications

Complications:

Sternal wound infection (especially in diabetics or obese)

Mediastinitis (serious, life-threatening)

Sternal dehiscence (wound reopening)

Bleeding

Pneumothorax or hemothorax

Chronic sternal pain

Advantages:

Excellent exposure to entire mediastinum and heart

Allows complex multi-vessel and multi-valve surgeries

11.Glycine Irrigation Solution –

Definition:

Glycine irrigation solution is a non-electrolyte, hypotonic, sterile aqueous solution commonly

used for urologic and gynecologic endoscopic procedures, particularly during monopolar
electrosurgery to prevent electrical conduction.

Common Formulation:

1.5% Glycine solution (15 g/L)

Clear, colorless, non-conductive

Osmolarity: ~200 mOsm/L (hypotonic)

pH: ~6.4

Uses:

Transurethral resection of the prostate (TURP)

Bladder tumor resections

Hysteroscopic surgeries

Why Glycine?

Non-conductive: Safe with monopolar electrocautery

Transparent: Allows clear visualization during endoscopy

Low viscosity: Flows easily through irrigation channels

Hypoallergenic and non-toxic in limited volumes

Absorption Risks – TURP Syndrome:

When large amounts are absorbed through prostatic venous sinuses:

TURP Syndrome Features:

Fluid overload

Hyponatremia (dilutional)

Hypo-osmolality

CNS symptoms: nausea, confusion, seizures, coma

Visual disturbances (glycine metabolized to ammonia)

Bradycardia, hypertension or hypotension, pulmonary edema

Management of TURP Syndrome:

Stop procedure immediately

Administer hypertonic saline (3%) for severe hyponatremia

Diuretics (e.g., furosemide) for fluid overload

Support airway and breathing

ICU care in severe cases

Advantages:

Compatible with monopolar instruments

Inexpensive and widely available

Allows good endoscopic visibility

Disadvantages:

Risk of fluid absorption

No electrolytes → cannot correct hypovolemia

Not suitable for bipolar cautery (normal saline preferred there)

12.Pigtail Catheter –

Definition:

A pigtail catheter is a thin, flexible, radiopaque tube with a curled (pigtail-shaped) distal end,
used primarily for drainage of fluid or air from body cavities, especially the pleural, pericardial, or
abdominal spaces.

Why "Pigtail"?

The curled end resembles a pig's tail.

This coil prevents migration of the catheter and minimizes trauma to surrounding tissues.
Uses/Indications:

1. Pleural effusion drainage (serous, purulent, hemorrhagic)

2. Pneumothorax management

3. Pericardial effusion drainage (pericardiocentesis)

4. Abscess drainage (liver, pelvic, renal)

5. Percutaneous nephrostomy

6. Biliary drainage

Insertion Technique:

Performed under ultrasound or CT guidance

Seldinger technique often used:

1. Needle puncture of fluid cavity

2. Guidewire placement

3. Dilatation of tract

4. Catheter advanced over guidewire

5. Pigtail loop forms inside cavity

Catheter is fixed to the skin and connected to a drainage bag

Advantages:

Minimally invasive

Less painful than large-bore chest tubes

Lower risk of complications

Can be inserted at bedside or under imaging

Disadvantages:

May clog easily, especially with thick pus or blood

Slower drainage compared to large-bore tubes

Not ideal for massive hemothorax or trauma cases

Complications:

Bleeding

Infection at insertion site

Organ injury (lung, liver, bowel)

Dislodgement or blockage

Subcutaneous emphysema

Care and Monitoring:

Ensure catheter is patent and draining

Monitor fluid output and characteristics

Check for signs of infection or leakage

Daily chest X-ray (in case of pleural use) to assess resolution

13.Hudson’s Drill – Neurosurgical Instrument

Definition:

Hudson’s drill is a manual hand-operated surgical drill used primarily in neurosurgery to create
burr holes in the skull for procedures like craniotomy, evacuation of hematomas, or ventricular
access.

Components:

1. Drill body (handle) – manually operated (T-shaped)

2. Perforator bit – for initial entry through outer table of the skull

3. Dura guard/stopper – prevents penetration into the brain

4. Drill bits – detachable, of varying sizes

Uses:

Creating burr holes for:

Craniotomy

Evacuation of subdural hematoma

Intracranial pressure monitoring

Ventriculostomy or shunt placement

Emergency decompression in head trauma

Neonatal/infant skull access (with caution)

Working Principle:
The surgeon manually rotates the T-handle

The perforator pierces through the skull's outer and inner tables

A guard mechanism helps prevent injury to underlying brain tissue

Advantages:

Portable and inexpensive

Can be used without electricity (ideal in rural/emergency settings)

Simple to use and sterilize

Disadvantages:

Requires manual effort and surgical skill

Risk of plunging (sudden entry through bone causing brain injury) if guard not used properly

Slower than powered drills

Less precision in thick or sclerotic bone

Modern Alternative:

Pneumatic or electric drills with automatic clutch systems

Craniotome – powered saw used to connect burr holes

15.CUSA – Cavitron Ultrasonic Surgical Aspirator

Definition:

CUSA stands for Cavitron Ultrasonic Surgical Aspirator, a surgical instrument that uses
ultrasonic vibrations to emulsify soft tissues (especially tumors) and simultaneously aspirates
and irrigates the area. It is commonly used in neurosurgery, hepatic surgery, and tumor
debulking.

Working Principle:

The CUSA probe vibrates at ultrasonic frequencies (~23–36 kHz)

Selective tissue fragmentation: Soft tissues (like tumors) are emulsified, while tougher structures
(blood vessels, nerves, connective tissue) are preserved

Irrigation and suction work concurrently to clear the surgical field

Components:

1. Ultrasonic handpiece with a titanium tip

2. Irrigation system (delivers saline to prevent overheating)

3. Suction system (removes emulsified tissue)

4. Control console (adjusts power, suction, irrigation rates)

Uses/Applications:

Neurosurgery:

Brain tumor resection (gliomas, meningiomas)

Preserving nearby neural structures

Liver surgery:

Hepatic tumor removal

Liver resections (selective parenchymal dissection)

Pancreatic and kidney surgeries

ENT and spinal surgery (limited cases)

Advantages:

Selective tissue removal: Spares vessels and nerves

Reduces bleeding

Minimally traumatic to surrounding tissues

Improved visibility with constant suction and irrigation

Disadvantages:

Expensive equipment

Requires training and experience

Not effective on calcified or fibrous tissue

May produce heat → risk of thermal injury if misused

Contraindications/Precautions:

Avoid in areas with dense calcification

Do not use near critical heat-sensitive structures without precautions

Use appropriate settings to prevent overheating

16.Humby's Knife – Skin Grafting Instrument

Definition:

Humby’s knife is a manual surgical instrument used to harvest thin split-thickness skin grafts,
typically from the thigh, buttock, or other donor sites. It allows controlled cutting of uniform skin
layers.

Structure:

Long handle for firm grip

Adjustable roller at the distal end to control thickness of the graft

Straight blade fixed at the end

Entire instrument is usually stainless steel

Uses:

Harvesting split-thickness skin grafts (STSG) for:

Burns

Chronic ulcers

Traumatic skin loss

Reconstructive surgeries

Technique:

1. Donor area is cleaned, shaved, and lubricated.

2. Skin is stretched tight.

3. The knife is drawn across the skin with steady pressure.

4. Roller thickness is adjusted (typically 0.008–0.012 inch).

5. The graft is removed and placed in saline.

Advantages:

Simple, inexpensive, reusable

Can harvest wide grafts

Roller adjustment allows control over graft thickness

Useful where power devices (like dermatome) are not available

Disadvantages:

Requires manual skill and control

Graft may be irregular if pressure is uneven

Not suitable for very thin or very precise grafts

Time-consuming compared to powered dermatomes

17.Fibreoptic Bronchoscopy – Overview

Definition:

Fibreoptic bronchoscopy (FOB) is a minimally invasive diagnostic and therapeutic procedure

that uses a flexible bronchoscope with fiberoptic light transmission to visualize the
tracheobronchial tree.

Types of Bronchoscopes:

1. Rigid bronchoscope – for large airway intervention (OR-based)

2. Flexible fibreoptic bronchoscope – for diagnostic and most therapeutic purposes

Can be passed nasally or orally

Suitable for conscious sedation and ICU use

Components of Fibreoptic Bronchoscope:

Light source (via fibreoptic bundle)

Flexible insertion tube

Control lever (for angulation)

Working channels for suction, biopsy, irrigation

Indications:

●​ Diagnostic:

Evaluation of persistent cough, hemoptysis, wheeze

Suspected lung cancer or TB

Bronchial washing, brushing, and biopsy

Transbronchial lung biopsy

BAL (bronchoalveolar lavage) for infection or interstitial disease

Foreign body localization

Airway anatomy assessment (e.g., tracheomalacia, stenosis)

●​ Therapeutic:

Removal of foreign body

Mucus plug clearance

Laser or stent placement in airway obstruction

Electrocautery or cryotherapy for tumors

Intubation guidance in difficult airway

Preparation:

Fasting for 6–8 hours

Informed consent

Premedication: local anesthetic spray, atropine (to reduce secretions), mild sedatives

Monitoring: SpO₂, ECG, BP

Procedure:

Patient in semi-recumbent or supine position

Scope introduced via nose, mouth, or endotracheal tube

Visualization of larynx → trachea → bronchi

Suction, biopsy, or lavage performed as needed

Post-Procedure Care:

Monitor for respiratory distress, bleeding

NPO until gag reflex returns

Observe for complications

Complications:

Cough, sore throat

Hypoxia

Bronchospasm

Bleeding (especially after biopsy)

Pneumothorax (rare, mainly after transbronchial biopsy)

Infection

Contraindications:

Unstable cardiovascular or respiratory status

Severe hypoxemia

Coagulopathy (relative)

Uncooperative patient (without sedation)

18.Arthroscopy –

Definition:
Arthroscopy is a minimally invasive surgical procedure that uses an arthroscope (a fiberoptic
camera) to directly visualize, diagnose, and treat problems inside a joint, most commonly the
knee, shoulder, ankle, elbow, hip, and wrist.

Instruments Used:

Arthroscope (camera with light source)

Saline or lactated Ringer’s solution (for joint distension)

Monitor screen

Small surgical tools (probes, scissors, shavers, cautery, etc.)

Common Indications:

●​ Diagnostic:

Undiagnosed chronic joint pain or swelling

Loose bodies in joint

Synovial biopsy

Intra-articular bleeding (hemarthrosis)

Suspected internal derangement

●​ Therapeutic:

Meniscal tear repair/removal (knee)

Ligament reconstruction (e.g., ACL)

Removal of loose fragments or cartilage

Synovectomy (e.g., in rheumatoid arthritis)

Subacromial decompression (shoulder)

Rotator cuff repair

Articular cartilage debridement

Procedure:

1. Performed under local, spinal, or general anesthesia

2. Joint is distended with fluid

3. Small incisions (portals) made near the joint

4. Arthroscope inserted through one portal

5. Instruments inserted through others for biopsy or repair

6. Joint is visualized on monitor, and pathology is treated

Advantages:

Minimally invasive

Less postoperative pain

Shorter hospital stay and faster recovery

Smaller scars and reduced blood loss

Early mobilization

Disadvantages:

Limited field of vision in tight or complex joints

Risk of incomplete diagnosis if anatomy is distorted

Requires skill and expensive equipment

Complications:

Infection

Bleeding or hemarthrosis

Thrombophlebitis

Joint stiffness or effusion

Nerve or vessel injury

Instrument breakage (rare)

Postoperative Care:

Ice packs, limb elevation

Analgesics

Physiotherapy for mobility

Wound care

Follow-up imaging or clinical assessment

19.Posterior Approach to Spine –

Definition:

The posterior approach to the spine is a surgical technique where the spine is accessed through
an incision in the back (posterior). It is the most commonly used approach for spinal
decompression, fixation, and tumor or infection management.

Indications:

Spinal decompression (e.g., laminectomy for spinal stenosis)

Disc herniation removal

Spinal instrumentation/fusion (e.g., pedicle screw fixation)

Spinal trauma (fractures, dislocations)

Spinal tumors or infections

Congenital deformities (e.g., scoliosis correction)

Surgical Steps (Generalized):

1. Anesthesia & Positioning:

General anesthesia

Patient placed in prone position

Padding for face, chest, pelvis, knees

2. Incision:

Midline posterior incision over the affected vertebral level

Incision extends through skin, subcutaneous tissue, fascia

3. Exposure:

Paraspinal muscles dissected subperiosteally from spinous processes and lamina

Exposure up to transverse processes and facet joints as needed

4. Procedure Performed:

Laminectomy/laminotomy (for decompression)

Discectomy (removal of herniated disc)

Pedicle screw placement (for stabilization)

Spinal fusion (using bone grafts or cages)

5. Closure:

Hemostasis achieved

Layered closure of muscle, fascia, subcutis, skin

Drain placed if necessary

Levels of Spine Commonly Approached Posteriorly:

Cervical spine (e.g., foraminotomy, posterior cervical fusion)

Thoracic spine (tumors, infections)

Lumbar spine (most common for disc prolapse, stenosis)

Advantages:

Excellent exposure of posterior elements

Safe and familiar approach

Allows instrumentation and fusion

Direct access to lamina, facets, spinous process

Disadvantages:

Muscle dissection may cause postoperative pain or weakness

Limited anterior visualization (e.g., vertebral bodies, anterior disc)

Longer healing time in multilevel surgeries

Complications:
Bleeding

Infection

Dural tear and CSF leak

Nerve root injury

Epidural hematoma

Chronic back pain from muscle scarring

20.Hemostatic Agents Used in Neurosurgery

Definition:

Hemostatic agents are substances applied during surgery to achieve rapid control of bleeding
from soft tissues, dura, bone, or vascular structures. In neurosurgery, these are critical for
maintaining a clear field and minimizing brain edema and hematoma formation.

Classification and Examples:

1. Mechanical Hemostats:

These act by providing a physical matrix for clot formation.

Gelfoam (absorbable gelatin sponge):

Porous, flexible sponge that absorbs blood and promotes clotting.

Often soaked with thrombin to enhance effect.

Absorbed in 4–6 weeks.

Surgicel (oxidized regenerated cellulose):

Forms an artificial clot upon contact with blood.

Bactericidal due to low pH.

Useful for diffuse venous oozing, especially from brain or muscle.

Avitene (microfibrillar collagen):

Triggers platelet aggregation.

Effective on raw surfaces or bone.

2. Active Hemostats:

These contain biologically active substances that directly promote coagulation.

Topical thrombin:

Converts fibrinogen to fibrin.

Used with gelatin sponges or alone on bleeding surfaces.

Must not be injected IV due to risk of anaphylaxis.

Fibrin sealants (fibrin glue):

Combination of fibrinogen and thrombin.

Mimics final step of coagulation cascade.

Used in dural closure and sealing CSF leaks.

3. Flowable Hemostats:

Gelatin-based matrices combined with thrombin.

Floseal, Surgiflo:

Conform to irregular bleeding surfaces.

Useful in deep or confined areas (e.g., skull base, spinal canal).

4. Bone Wax:
Used to control bleeding from cut bone edges (e.g., skull, vertebrae).

Acts as a mechanical plug, not absorbed.

Overuse can inhibit bone healing or cause inflammation.

5. Dural Sealants:

Used to reinforce dural closure and prevent CSF leaks.

Examples: DuraSeal, Tisseel (fibrin-based), Progel.

Clinical Considerations:

Choose agent based on location, type of bleeding (arterial, venous, oozing), and surgical
accessibility.

Excess use of agents like Surgicel or Gelfoam may cause mass effect or granuloma.

Avoid intravascular injection of thrombin or sealants.

21.Various Surgical Procedures for Renal Stones (Urolithiasis)

Surgical treatment of renal stones is chosen based on stone size, location, composition,
anatomy, renal function, and response to prior medical therapy.

🔹 1. Extracorporeal Shock Wave Lithotripsy (ESWL)

Non-invasive procedure

Uses focused shock waves to break stones into fragments

Stones <2 cm, radiopaque, located in renal pelvis or upper ureter

Advantages:

Outpatient, painless

No incision
Disadvantages:

May require multiple sittings

Not effective for hard or large stones

🔹 2. Percutaneous Nephrolithotomy (PCNL)

Minimally invasive procedure

Access to kidney through small incision in the flank

Stones are fragmented and removed using nephroscope

Indications:

Stones >2 cm

Staghorn calculi

ESWL failure

Advantages:

High stone clearance

Can treat complex stones

Disadvantages:

Invasive, bleeding risk

General anesthesia needed

🔹 3. Retrograde Intrarenal Surgery (RIRS)

Uses a flexible ureteroscope inserted via urethra → bladder → ureter → kidney

Laser lithotripsy (e.g., Holmium:YAG) used to break stone

Indications:

Stones <2 cm in upper tract

Failed ESWL or PCNL

Anticoagulated patients

Advantages:

No incision

High success in selected cases

Disadvantages:

Requires expertise and expensive equipment

🔹 4. Ureteroscopy (URS)
Semi-rigid or flexible scope passed through urethra into ureter

Used for ureteric stones (especially mid and distal)

Procedure:

Stone visualized and fragmented with laser

Fragments removed with baskets

Often stent placed post-op

Complications:

Ureteric injury, hematuria, infection

🔹 5. Open Surgery (Nephrolithotomy / Pyelolithotomy / Ureterolithotomy)
Rarely performed today

Used in complex, large staghorn calculi, anatomical abnormalities, or failed minimally invasive
approaches

Indications:

Very large or multiple stones

Abnormal kidney anatomy

Failed PCNL or RIRS

Disadvantages:

Longer recovery, higher morbidity

🔹 6. Laparoscopic Surgery
Minimally invasive alternative to open surgery

Performed for ureteric stones or when other modalities fail

22.Fluid Management in Pediatric Patients

Fluid management in children is critical due to their higher water content, immature renal
function, and increased risk of dehydration and electrolyte imbalance. It involves calculating
maintenance, deficit, and replacement fluids based on clinical needs.

1. Maintenance Fluid Requirements:

The Holliday-Segar formula is used to estimate daily maintenance fluid needs based on body
weight:

For the first 10 kg of body weight: 100 mL/kg/day

For the next 10 kg (10–20 kg): 50 mL/kg/day

For each kg > 20 kg: 20 mL/kg/day

For hourly rate:

First 10 kg → 4 mL/kg/hr

Next 10 kg → 2 mL/kg/hr

Each additional kg → 1 mL/kg/hr

2. Types of Fluids:

Maintenance Fluids:

In neonates and infants: D10W with 0.2–0.3% NaCl + KCl (after urine output established)

In older children: D5W with 0.45% NaCl + 20 mEq/L KCl

Replacement Fluids:

For ongoing losses like vomiting, diarrhea, or gastric aspirate, replace ml for ml using
appropriate fluid (e.g., NS, Ringer lactate, or D5NS with KCl).

Resuscitation Fluids:

For shock or volume depletion: use 20 mL/kg of isotonic saline (NS or RL) as a bolus. Repeat
as needed while monitoring response.

3. Deficit Replacement:

When dehydration is present:

Estimate the degree of dehydration:

Mild: 3–5% loss

Moderate: 6–9% loss

Severe: ≥10% loss

Deficit fluid = % dehydration × body weight (kg) × 10

Administer over 24–48 hours:

Half in the first 8 hours

Remaining over next 16–24 hours

Use isotonic fluids (e.g., NS or RL) for initial replacement.

4. Electrolyte Management:

Sodium:

Maintain serum sodium within normal limits (135–145 mEq/L).

Avoid hypotonic fluids to prevent hyponatremia.

Potassium:

Do not add potassium until urine output is confirmed.

Usual dose: 20 mEq/L as KCl.

Glucose:

Infants and neonates are prone to hypoglycemia; maintenance fluids should include dextrose
(D10W or D5W).

5. Monitoring Parameters:

Urine output:

Goal: ≥1 mL/kg/hr in infants and children.

Weight changes:

Daily weight helps assess fluid balance.

Vital signs:

Monitor HR, BP, capillary refill time.

Electrolytes and glucose:

Frequent monitoring in acutely ill or fluid-receiving children.

Signs of overload:

Edema, increased respiratory rate, crackles on auscultation.

23.Lumbar Decompression Surgery –

Definition:

Lumbar decompression surgery refers to surgical procedures aimed at relieving pressure on the
spinal cord or nerve roots in the lumbar spine, often due to conditions like spinal stenosis, disc
herniation, or spondylolisthesis.

Indications:

Lumbar canal stenosis

Prolapsed intervertebral disc (PIVD)

Spondylolisthesis with nerve compression

Neurogenic claudication

Radiculopathy (sciatica) not responsive to conservative therapy

Cauda equina syndrome (emergency)

Symptoms That Improve After Surgery:

Leg pain (sciatica)

Numbness or weakness in legs

Difficulty walking or standing

Loss of bladder/bowel control (in cauda equina)

Common Types of Lumbar Decompression Procedures:

🔹 1. Laminectomy
Removal of lamina (posterior part of vertebra) to enlarge spinal canal

Most common for lumbar stenosis

🔹 2. Discectomy
Removal of herniated disc material compressing the nerve root

Often done as microdiscectomy using a small incision and microscope

🔹 3. Foraminotomy
Widening the intervertebral foramen to relieve nerve root compression

🔹 4. Laminotomy
Partial removal of lamina (more conservative than laminectomy)

🔹 5. Decompression with Instrumented Fusion

Done when there is instability (e.g., spondylolisthesis)

Combines decompression with spinal fusion using rods and screws

Surgical Procedure (Laminectomy Example):

1. Anesthesia: General

2. Position: Prone with padding

3. Incision: Midline over affected vertebral level

4. Exposure: Paraspinal muscles retracted

5. Lamina removed with rongeurs or drill

6. Ligamentum flavum resected

7. Nerve root decompressed

8. Wound closed in layers; drain may be placed

Postoperative Care:

Early mobilization

Pain control (NSAIDs, opioids)

Physiotherapy

Wound care

Monitor for neurological changes

Complications:

Dural tear with CSF leak

Infection (superficial or deep)

Nerve root injury

Bleeding, hematoma

Failed back surgery syndrome

Spinal instability (may need later fusion)

Outcome:

Good relief of leg symptoms

Less effective for chronic back pain

Better outcomes if neurological deficit is not longstanding

24.Finochietto Retractor – Thoracic Surgical Instrument

Definition:

The Finochietto retractor is a self-retaining rib spreader used primarily in thoracic surgery to
separate the ribs and provide wide exposure of the thoracic cavity, such as during thoracotomy.

Design and Structure:

Consists of two broad, curved blades mounted on a ratcheted frame

Operated by a crank handle that gradually spreads the blades

Locking mechanism holds the blades apart, keeping the surgical field open

Blades may be rigid or fenestrated

Uses:

Thoracotomy (open chest surgeries)

Lung resections (lobectomy, pneumonectomy)

Cardiac surgeries (before sternotomy became common)

Rib fracture repair

Occasionally used in upper abdominal surgeries

How It Works:

1. The retractor is inserted between two ribs after initial exposure.

2. The crank is turned, spreading the blades slowly, separating the ribs.

3. The locking system maintains the rib retraction throughout the procedure.

Advantages:

Provides stable, hands-free exposure

Allows wide visualization of thoracic organs

Durable and reusable

Disadvantages:

Can cause rib fractures or intercostal nerve injury if overextended

Postoperative pain due to rib retraction

Bulky in small thoracic cavities

Care & Sterilization:

Must be thoroughly cleaned and autoclaved

Check ratchet and crank mechanism regularly for smooth function

26.Mastoid Retractor – ENT Surgical Instrument

Definition:

A mastoid retractor is a self-retaining surgical instrument used to retract skin, soft tissue, and
periosteum during mastoidectomy and other ear surgeries, especially to expose the mastoid
bone and surrounding structures.

Design & Features:

Typically has 2–3 blades with sharp or blunt prongs

Equipped with a ratchet or locking mechanism for self-retaining function

Blades are often angled or curved to fit around the auricle and temporal bone

Common variants: Jansen mastoid retractor, Wilde retractor

Uses:

Mastoidectomy (cortical, radical, modified radical)

Tympanoplasty with mastoid exposure

Cochlear implant surgery

Posterior auricular approach in ear surgeries

Occasionally used in neck dissection or small cranial procedures

Advantages:

Provides stable, hands-free retraction

Improves visibility of the operative field

Reduces need for assistant to hold tissues

Disadvantages:
May cause tissue trauma or pressure necrosis if used forcefully or for long duration

Can slip if not properly placed or secured

27.Plaster of Paris (POP) – Medical Overview

Definition:

Plaster of Paris (POP) is a quick-setting material made by heating gypsum (calcium sulfate
dihydrate) to remove water, producing calcium sulfate hemihydrate. When mixed with water, it
forms a paste that hardens as it sets, commonly used in orthopedic and surgical applications.

Chemical Formula:

Gypsum: CaSO₄·2H₂O

POP: CaSO₄·½H₂O

> When water is added:

CaSO₄·½H₂O + 1½H₂O → CaSO₄·2H₂O (solidifies)

Medical Uses:

1. Orthopedic Casts & Splints

Immobilization of fractures and sprains

Used to maintain alignment after reduction

Applied as circular cast or slab

2. Moulds & Impressions

For orthotics and prosthetics

Making moulds in maxillofacial surgery and dentistry

 3. Surgical Use

Cranial reconstruction moulds

Orthopedic surgical table supports

Used in orthopedics to make negative casts

Properties:

Quick setting: hardens in ~5–15 minutes

Exothermic reaction: releases heat while setting

Radiolucent: does not interfere with X-rays

Cheap, easy to apply, and conforming

Advantages:

Excellent mouldability

Strong when dry

Biocompatible

Easy to remove with cast saw

Disadvantages:

Heavy compared to fiberglass

Not water-resistant

Can cause burns due to exothermic reaction if applied too thick

Fragile if not properly dried

Precautions While Applying:

Use cool water to slow setting if needed

Protect skin with padding or stockinette

Avoid excessive thickness (risk of burns)

Keep elevated during drying to prevent deformation

Mark fracture site before applying cast

28.Interlocking Nail – Orthopedic Implant

Definition:

An interlocking nail is a metal rod inserted into the medullary canal of long bones (like femur,
tibia, or humerus) to stabilize fractures, especially diaphyseal (shaft) fractures. It is secured with
locking screws at both ends to prevent rotation and shortening.

Purpose:

Provides internal fixation

Maintains alignment, length, and rotation

Allows for early mobilization and weight-bearing

Common Sites of Use:

Femur (Intramedullary femoral interlocking nail)

Tibia

Humerus

Indications:
Diaphyseal fractures of long bones

Segmental fractures

Comminuted or unstable fractures

Pathological fractures

Non-union or malunion correction

Polytrauma patients (damage control orthopedics)

Contraindications:

Open physis (in children unless flexible nails used)

Severe infection (osteomyelitis)

Small or narrow intramedullary canal

Unstable patient (if definitive surgery not possible immediately)

Types:

1. Antegrade nail – inserted from the proximal end of bone

2. Retrograde nail – inserted from the distal end

3. Cannulated vs. Solid nail

4. Reamed vs. Unreamed technique

Surgical Steps (Generalized):

1. Anesthesia & positioning

2. Fracture reduction

3. Entry point created (e.g., piriformis fossa for femur)

4. Reaming (if needed) of medullary canal

5. Nail inserted over a guide wire

6. Proximal and distal locking screws placed through jigs or fluoroscopy

7. Closure and postoperative care

Advantages:

Strong fixation

Minimal soft tissue damage

Allows early mobilization

Preserves fracture hematoma (aids healing)

Can treat complex, multi-fragmentary fractures

Disadvantages:

Radiation exposure during screw placement

Technically demanding (especially distal locking)

Risk of fat embolism (in reamed procedures)

Infection, implant failure, or non-union if poorly done

Complications:

Malalignment (especially rotational)

Delayed union or non-union

Nail or screw breakage

Limb length discrepancy

Infection (osteomyelitis)

29.Open Reduction and Internal Fixation (ORIF) of Fracture Neck of Femur –

Definition:

ORIF of fracture neck of femur involves surgically exposing the fracture, achieving anatomical
alignment (open reduction), and stabilizing the fracture using internal implants (like cannulated
screws or dynamic hip screw). It is commonly done in younger patients with displaced fractures
to preserve the native hip joint.

Indications:

Displaced intracapsular fracture of femoral neck in:

Young adults (<60 years)

Physiologically active patients

Failure of closed reduction

Non-union or malunion of femoral neck fracture

Pathological fractures in younger patients

Fractures in polytrauma patients needing rigid fixation

Contraindications:

Elderly patients with osteoporotic bone (prefer hemiarthroplasty/THR)

Poor surgical candidates (severe comorbidities)

Active infection around the hip

Irreducible or severely comminuted fractures (may need prosthetic replacement)

Surgical Steps:

1. Anesthesia & Positioning

Spinal or general anesthesia

Supine position on a fracture table

Affected limb is placed in traction

2. Approach

Standard: Anterolateral (Watson-Jones) or direct lateral

Incision over proximal femur and dissection to expose fracture site

3. Open Reduction

Fracture ends are aligned under direct vision

Temporary K-wire fixation may be used

4. Internal Fixation

Implant options:

Cannulated cancellous screws (3-screw configuration)

Dynamic hip screw (DHS) with derotation screw

Screws inserted under C-arm guidance to cross the fracture site and reach the femoral head
5. Closure

Wound irrigated and closed in layers

Sterile dressing applied

Implants Used:

Cannulated cancellous screws (most common for young adults)

DHS with side plate

Pauwels screw (rare)

May combine with anti-rotation screws

Postoperative Management:

Analgesia and DVT prophylaxis

Early mobilization (non-weight bearing initially)

Physiotherapy

Serial radiographs for healing

Weight bearing as per union and stability (typically after 6 weeks)

Complications:

Non-union (10–30%)

Avascular necrosis (AVN) of femoral head

Malunion

Implant failure

Deep infection

Limb shortening
Need for revision to arthroplasty

30.Self-Retaining Retractor

Definition:

A self-retaining retractor is a surgical instrument designed to hold tissues apart and maintain
exposure of the operative field without the need for manual holding. It typically uses a ratchet,
spring, or screw mechanism to keep its blades in place.

Mechanism of Action:

Composed of two or more blades or arms.

Once placed in the desired position, the locking mechanism maintains retraction.

Allows the surgeon and assistants to operate with both hands free.

Common Types and Uses:

1. Weitlaner Retractor:

W-shaped with multiple prongs.

Commonly used in orthopedic and soft tissue surgeries.

2. Gelpi Retractor:

Has two blades with single sharp prongs and a ratchet.

Used in deeper or narrow spaces, especially in spine and perineal surgery.

3. Balfour Retractor:
Large abdominal retractor with a self-locking system.

Often used in laparotomy and open abdominal procedures.

4. Bookwalter Retractor:

Table-mounted retractor with interchangeable blades.

Used in major abdominal, pelvic, and vascular surgeries.

5. O’Sullivan-O’Connor Retractor:

Used in gynecological procedures like abdominal hysterectomy.

Circular frame with multiple blades.

Advantages:

Provides a stable surgical field.

Reduces need for surgical assistants.

Improves precision and operating time.

Helps in deep or minimally accessible anatomical sites.

Disadvantages:

May cause tissue pressure injury if improperly placed or overused.

Some types are bulky and may obstruct the view.

Requires proper training for safe and effective use.

31.Hip Prosthesis
Definition:

A hip prosthesis is an artificial implant used to replace the hip joint (either partially or totally)
when it is damaged due to trauma, arthritis, avascular necrosis, or other pathological conditions.
It restores joint mobility and relieves pain.

Types of Hip Prosthesis:

1. Hemiarthroplasty:

Replaces only the femoral head, not the acetabulum.

Common types:

Austin Moore Prosthesis (AMP): Used for elderly patients with good bone stock; cementless.

Thompson Prosthesis: Requires bone cement for fixation.

Indications:

Fracture neck of femur in elderly.

Non-union or avascular necrosis in poor surgical candidates.

2. Total Hip Replacement (THR):

Replaces both the femoral head and acetabular socket.

Components:

Femoral stem

Femoral head

Acetabular cup

Indications:

Osteoarthritis,
rheumatoid arthritis,
avascular necrosis
complex fractures.

Materials Used:

Metal: Cobalt-chromium, stainless steel, titanium alloys.

Polyethylene: For acetabular liners.

Ceramic: Used for low-wear articulating surfaces.

Types Based on Fixation:

1. Cemented Prosthesis:

Fixed with polymethylmethacrylate (PMMA) cement.

Often used in elderly or osteoporotic bones.

2. Uncemented Prosthesis:

Designed for bone ingrowth into porous coating.

Preferred in younger patients with good bone quality.

3. Hybrid Prosthesis:

One component cemented and the other uncemented.

Surgical Approaches:

Posterior approach: Common, good exposure, higher risk of dislocation.

Lateral approach: Less risk of dislocation, may weaken abductors.

Anterior approach: Muscle-sparing, but technically demanding.

Complications:

Dislocation

Infection

Aseptic loosening

Prosthesis wear

Thromboembolism

Periprosthetic fracture

32.Fracture – Definition, Classification, and Management

Definition:

A fracture is a break or discontinuity in the bone caused by trauma, stress, or pathology. It may
range from a small crack (hairline) to complete separation of bone segments.

Classification of Fractures:

🔹 1. Based on Skin Integrity:

Closed (simple): Skin is intact

Open (compound): Skin is breached, bone exposed; higher infection risk

🔹 2. Based on Fracture Pattern:

Transverse: Horizontal fracture line

Oblique: Diagonal fracture line

Spiral: Twisting force; common in long bones

Comminuted: Bone broken into ≥3 pieces

Segmental: Two fracture lines isolate a bone segment

Greenstick: Incomplete fracture; common in children

Impacted: One fragment driven into another

Compression: Crushed bone; common in vertebrae

🔹 3. Based on Location:
Epiphyseal

Metaphyseal

Diaphyseal

🔹 4. Based on Displacement:
Non-displaced: Fracture ends aligned

Displaced: Fracture ends misaligned

Angulated, Rotated, or Overriding

🔹 5. Based on Cause:
Traumatic fracture: Due to injury

Stress (fatigue) fracture: Repeated strain

Pathological fracture: Occurs in diseased bone (e.g., tumor, osteoporosis)

🔹 6. Pediatric Fractures:
Torus (buckle) fracture

Greenstick fracture

Plastic deformation
Salter-Harris classification (for physeal injuries)

General Principles of Management:

🔸 1. First Aid (Emergency Care):

Immobilize the limb

Control bleeding (if open)

Pain relief

Prevent shock

Refer for imaging and definitive care

🔸 2. Reduction (If needed):

Closed reduction: Manual manipulation

Open reduction: Surgical alignment

🔸 3. Immobilization:
Plaster cast / splint

Traction (skin or skeletal)

Internal fixation (screws, plates, nails)

External fixation (rods, pins outside body)

🔸 4. Rehabilitation:
Physiotherapy to regain mobility, strength, and function

Gradual weight bearing

Monitoring for union and complications

Medications:

Analgesics

Antibiotics (for open fractures)

DVT prophylaxis (in lower limb or immobilized patients)

Calcium/vitamin D in elderly

Complications of Fractures:

Early:

Hemorrhage

Nerve or vascular injury

Compartment syndrome

Fat embolism

Infection (especially in open fractures)

Late:

Delayed union, non-union, malunion

Joint stiffness or arthritis

Avascular necrosis (e.g., femoral head)

Complex regional pain syndrome

33.Tourniquet Used in Orthopedic Surgery

Definition:
A tourniquet is a device applied circumferentially around a limb to occlude blood flow. In
orthopedic surgery, it provides a bloodless surgical field, improves visibility, and reduces
operative time.

Types of Tourniquets:

1. Pneumatic Tourniquet:

Most commonly used type.

Inflatable cuff connected to a pressure-regulated pump.

Allows precise control of pressure and inflation time.

2. Esmarch Bandage (Rubber Tourniquet):

A rubber bandage used to exsanguinate the limb before being clamped proximally.

Now rarely used due to risk of complications.

3. Silicone Ring Tourniquet (SRT):

Single-use sterile device.

Ideal for small or distal limb surgeries.

Applies uniform pressure and easy to apply.

Indications in Orthopedics:

Fracture fixation (e.g., distal radius, tibia)

Arthroscopy (e.g., knee)

Soft tissue procedures (e.g., tendon repair)

Corrective osteotomies
Application Technique:

1. Exsanguination:

Limb elevated for 2–3 minutes or wrapped with Esmarch to drain venous blood.

2. Cuff Placement:

Positioned at the proximal part of the limb (e.g., thigh or upper arm).

Soft padding applied underneath.

3. Pressure Settings:

Upper limb: ~100 mmHg above systolic BP (~250 mmHg)

Lower limb: ~100–150 mmHg above systolic BP (~300–350 mmHg)

4. Time Limits:

Ideal maximum: 90 minutes

Deflate intermittently if longer duration is needed (e.g., 10 min deflation every 90 min)

Advantages:

Clear operative field

Decreased intraoperative blood loss

Better visualization for precision

Complications:
Nerve injury: Compression neuropraxia, especially if excessive pressure or time

Muscle ischemia: Can lead to rhabdomyolysis if prolonged

Reperfusion injury: After sudden release of ischemia

Compartment syndrome (rare): Due to prolonged or improper use

Skin injuries: From poorly padded cuffs or excess pressure

Precautions:

Use lowest effective pressure

Monitor inflation time strictly

Ensure adequate padding

Confirm absence of contraindications (e.g., severe peripheral vascular disease)