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Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
Pitfalls in orthopaedics
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Pitfalls in orthopaedics

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  • 1. Pitfalls in Orthopaedic<br />opps<br />Lt Col S K RAI<br />Capt PramodMahender<br />
  • 2. Case Study<br />A case was tried where a 10-month-old girl suffered anoxic brain injury after “being deprived of oxygen for 40 minutes, forgot the keys to an onboard medicine cabinet and later falsified records related to the rescue”<br />
  • 3. Medicolegal Outcome<br />The girl, now 5, is a spastic quadriplegic with severe brain damage <br />State health officials heard of the case only after a story appeared in the state Lawyers Weekly <br /> The $10.2 million(50 crores) settlement included a confidentiality agreement that kept secret the identities of the family, the hospitaland the EMS technicians <br />
  • 4. Errors<br />Not all errors result in harm to the patient, and many react only to errors that are considered to have an adverse effect on a patient (injury or death)<br />
  • 5. Orthopaedic Emergency<br />Examples?<br />
  • 6. Orthopaedic emergency<br /><ul><li> Trauma</li></ul>Non-trauma<br /> - Osteomyelitis, Septic arthritis, Pyomyositis<br /> - Gouty arthritis<br /> - C1 - C2 subluxation<br />( Rheumatoid arthritis)<br /> - Acute disc syndrome<br />
  • 7. Assume the cervical spine to be unstable until proven otherwise <br />up to 50% of patients sustaining C-spine trauma develop neurologic abnormalities (nerve root compression and weakness to quadri- plegia and death). <br />10% are initially neurologically intact, but develop deficits during emergency care <br />risks of airway management<br />
  • 8.
  • 9. C-spine evaluation<br />bone and soft tissue<br />X-ray exam: „one view is no view”,<br /> AP-lateral<br />open mouth view -atlanto-occipital and atlanto-axial joints, the odontoid process,oblique – intervert. foramina<br />CT<br />lateral cervical spine - sensitivity of about 85%<br /> 92% in a three view series <br /> 100% when selective CT scanning is employed<br />
  • 10.
  • 11. The primary survey –life threatening conditions are identified and management is begun simultaneously!<br />A - Airway maintenance with cervical spine control <br />B - Breathing and ventilation <br />C - Circulation with hemorrhage control <br />D - Disability: neurological status <br />E - Exposure: completely undress the patient<br />
  • 12. Circulation<br /><ul><li>Does patient have radial pulse?</li></ul>Absent radial = systolic BP &lt; 80<br /><ul><li>Does patient have carotid pulse?</li></ul>Absent carotid = systolic BP &lt; 60<br />
  • 13. Circulation<br /><ul><li>No carotid pulse?</li></ul>intubate<br />CPR<br />Pneumatic AntishockGarment<br /><ul><li>Survival rate from cardiac arrest secondary to blunt trauma is &lt; 1%</li></li></ul><li>Circulation<br /><ul><li>Serious external bleeding?</li></ul>Direct pressure <br />Tourniquet as last resort<br /><ul><li>All bleeding stops eventually!</li></li></ul><li>Circulation<br /><ul><li>Is patient in shock?</li></ul>Cool, pale, moist skin = shock, until proven otherwise<br />Capillary refill &gt; 2 sec = shock until proven otherwise<br />Restlessness, anxiety= shock until proven otherwise<br />
  • 14. Circulation<br /><ul><li>If possible internal hemorrhage, QUICKLY expose, palpate:</li></ul>Abdomen<br />Pelvis<br />Thighs<br />
  • 15. Circulation<br />Large bore IV lines<br />BP<br />HR <br />Alghevar scheme - quantification of shock: <br />SBP / HR <br /> &gt;1 no or minor clinical symptoms<br /> &lt;1 major shock<br />Pulses<br />Indirect signs: UO, skin, tachypnoe, altered consciousness, empty” periferal veins <br />
  • 16. Circulation<br />warmed intravenous infusions<br />Control: <br />external hemorrhage<br />internal hemorrhage:<br />MAST suit<br />Pelvic binders<br />Surgery  stabilisation  secondary survey<br />
  • 17. Disability (CNS Function)<br /><ul><li>Level of Consciousness = Best brain perfusion indicator
  • 18. Check pupils</li></ul>The eyes are the window of the CNS<br />
  • 19. Disability (CNS Function)<br />Decreased LOC in trauma = Head injury until proven otherwise<br />
  • 20. B. Initial treatment of major fractures<br />Shock in orthopaedic patient<br /> - Hypovolemic shock<br /> - Neurogenic shock<br />Major fracture<br /> - Pelvis<br /> - Spine (cervical)<br /> - Femur <br /> - Multiple fractures <br /> - Hip<br />(shock)<br />(shock)<br />(shock)<br />(shock)<br />
  • 21. Associated injury<br />Fracture pelvis ; Urethral injury<br />Fracture scapula ; Shoulder, chest<br />Fracture calcaneus ; Spine (thoracolumbar region)<br />
  • 22. Which are Emergencies?<br />Closed fracture, n.v. normal<br />Closed dislocation, n.v. normal<br />Open fracture<br />Open dislocation<br />
  • 23. Mercifully Few Emergencies<br />Open Fractures and Dislocations<br />with or without vascular injury<br />with or without neurological impairment <br />
  • 24. Not “broken”…<br />…but still a <br />limb-threatening<br />emergency!<br />
  • 25.
  • 26. Joint Dislocations<br />Must be reduced at once<br />Risk to circulation and nerves<br />Risk of Osteonecrosis (AVN)<br />
  • 27. Management in Musculoskeletal Injury<br />R = Rest <br />I = Ice<br />C = Compression<br />E = Elevation<br />
  • 28. Principles to approach severe musculoskeletal injury<br />First aids<br />Initial treatment of major fractures / dislocation<br />Standard radiographs of fractures / dislocation<br />Immediate definitive treatment of fracture / dislocation <br />
  • 29. A. First aids<br />Bleeding control<br />Immobilization<br />Pain control<br />Antibiotic administration<br />Tetanus prophylaxis<br />Improve microcirculation<br />
  • 30.
  • 31.
  • 32. Methods of immobilization<br />Splinting; wooden, commercial<br />Brace or support<br />Strap<br />Slab immobilization<br />Cast immobilization<br />Traction<br />External fixation<br />Open reduction and internal fixation<br />
  • 33. Purpose of immobilization<br />Temporary <br />Definite<br />
  • 34. Complication of immobilization<br />Too fit<br />Too loose<br />Too long interval<br />Too short interval <br />; pressure sore, compartment syndrome<br />; inadequate immobilization (loss reduction, <br /> delayed, mal or nonunion)<br />; muscle atrophy, osteoporosis, <br /> joint stiffness, maceration of skin<br />; inadequate immobilization <br /> (loss reduction, delayed, mal or <br /> nonunion)<br />
  • 35. Complications of casting<br />Pressure sores<br />Cast sores<br />
  • 36. Velpeau’s strap<br />Injury of <br />shoulder <br />region<br />
  • 37. Slab immobilization<br />U or Sugar tong slab for humerus fracture<br />Short or long arm slab with or without thumb spica<br />Below or above knee slab<br />Cylindrical slab<br />
  • 38.
  • 39. Advice to give patients before casting<br />Objectives and advantages of casting<br />Duration of casting<br />Activities to do and not to do during casting<br />Good co-operation is needed<br />
  • 40. Skeletal traction<br />1 lbs of traction for every 7 lbs of body weight<br />(usually uncomfort if &gt; 35 lbs)<br />
  • 41. Disadvantages<br />Costly in terms of hospital stay<br />Hazards of prolonged bed rest<br />Thromboembolism<br />Decubiti<br />Pneumonia<br />Requires meticulous nursing care<br />Can develop contractures<br />
  • 42. Skull traction<br />Gardner-Wells tong<br />
  • 43. Skull traction<br />Crutchfield tongs<br />
  • 44. Orthopaedic patients : Antibiotics<br />Cefazolin<br />Cloxacillin<br />Gentamicin<br />Amikacin<br />Metronidazole<br />Clindamycin<br />Ofloxacin<br />Cotrimoxazole<br />
  • 45. Pitfalls in paediatrics<br />
  • 46. Different point of musculoskeletal injury between children and adult<br />More incidence of fracture in children<br />More stronger and more rapid growth of periosteum<br />More difficult to diagnose<br />More ability of remodeling<br />Difference in treatment or complication<br />Less incidence of ligamentous injury or dislocation<br />Less tolerability to blood loss <br />
  • 47. Prognosis of epiphyseal plate injury<br />Type of injury<br />Age of patient<br />Blood supply of the epiphysis<br />Method of reduction<br />Open or closed injury<br />
  • 48. Fracture of Necessity<br />Galeazzi’s fracture<br />Monteggiae’s fracture<br />Lateral condylar fracture<br />Supracondylar fracture<br />
  • 49. Common Pitfalls<br />Tunnel vision<br /> “Premature closure of hypothesis generation”<br />Just the opposite<br /> “Inability to see the forest for the trees”<br />Failure to attend to the patient<br />“Fail to social interaction with patient and family” <br />
  • 50. How to approach patients<br />Bio <br />Psycho<br />Social <br />Spirit<br />
  • 51. TAKE HOME<br />In emergency medicine, the central task is not diagnosis, but management <br />Alghevar scheme BP&gt;HR<br />
  • 52. THANK YOU<br />Questions?<br />

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