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Cpc orthopaedics

Cpc orthopaedics






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  • First of all, it was stated that the vital signs had been stabilized and there was absence of head and spinal injury, so we assumed that airway, breathing and circulation had been performed which are part of primary survey
  • local anaesthesia, sedate him, and apply iodine to the skin where the pin will go in and come out.
  • Capillary basement membranes become leaky

Cpc orthopaedics Cpc orthopaedics Presentation Transcript

  • Nanthini S
    Lynette Lee
    Oon Li Keat
    CPC OrthopaedicsWITH PROF. RAZIF ALI
  • History
    • Mr. M
    • 25 year old motorcyclist
    • Thrown off in a collision with a lorry
    • Brought to A&E unit in a hospital
  • On examination
    No head and spinal injury
    Vital signs stable
    Initial assessment:
    closed fracture of his left femur
    closed distal extraarticular fracture of his right radius
    soft tissue injury of his right shoulder
    Decision was made for:
    internal fixation of his left femur
    closed reduction and POP of his right radial fracture as a semi emergency.
  • Question 1:
    In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other procedures / actions you would do as part of treatment or investigation not mentioned above?
    (10 marks)
  • Continuation of the primary survey
    Disability (D) of the central nervous system
    Basic neurologic assessment with AVPU score:
    A – Alert
    V – Responds to verbal stimuli
    P – Responding to painful stimuli
    U – Unconscious
    Pupil size, inequality and reactivity to light
    GCS score
  • Continuation of the primary survey
    Exposure/Environmental control/X-Rays (E)
    Full exposure of the patient
    Assess from head to toe for injuries not recognized and managed
    Keep patient warm
  • X-rays:
    Cervical spine: lateral view of C1-T1
    Chest : Anteroposterior view
    Pelvis : Anteroposterior view
    Focused abdominal sonography for trauma (FAST) scan on ‘5Ps’:
    Perihepatic – liver lacerations
    Perisplenic – splenic lacerations and rupture
    Pelvic – free fluid e.g. haematoma
    Pleural – haemothorax, pneumothorax
    Pericardial – pericardial effusion
  • Adjunct to primary survey
    Vital signs
    Oxygen saturation e.g. pulse oxymetry, blood gases
    Urine catheterization – hourly urine output
    Nasogastric aspiration output
  • Secondary survey
    Complete history and physical examination
    Each region of the body to be fully examined:
    Reassessment of all vital signs
  • Head
    Check for bruising, swellings
    Look for signs of basal skull fracture:
    Battle’s sign
    Racoon’s eyes
    Examine nose and ears for CSF leakage
    Pupil size and responsiveness
  • Chest
    Respiratory distress - Grunting, stridor
    Bruising and skin imprinting
    Mediastinal shift
    Penetrating injuries
  • Abdomen and pelvis
    External injuries
    Abdominal distension by gas or fluid
    Tenderness and guarding
    Bleeding from urethral meatus
    Presence of palpable bladder
    PR exam: blood, high-riding prostate, anal tone
  • Limbs
    Check the neurovascular status of each limb
    Analgesia – orthopaedic injuries are extremely painful
    Correct obvious deformity by temporary splinting
  • Name of procedure and Purpose
  • Skeletal traction of left proximal tibia
    • To reduce a fracture or dislocation
    • To prevent or reduce muscle spasm
    • To immobilize a joint or part of the body
    • To treat joint pathology
    • Ensure adequate analgesia / sedation
    • Place patient in supine position
    • Record baseline neurovascular observations:
    • Pulses
    • Skin colour and temperature
    • Capillary refill time
    • Movement of joints
    • Swelling and sensation
    • Observe affected limb for any:
    • Wounds
    • Swelling
    • Infection
    • Soft tissue damage
  • Principles of Skeletal Traction
    Align the distal to the proximal fragment
    Remain constant
    Allow for adequate exercise and diversion
    Allow for optimum nursing care
    Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making sure it goes under the periosteum.
  • Bohler’s Stirrup
  • Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight.
    The weight may pull the patient out of the bed, thus need to exert countertraction by raising the foot off his bed.
  • Complications
    • Due to procedure itself
    • Infection of the pin tract
    • Injury to common peroneal
    • Excessive traction
    • Due to prolonged bed rest
    • Thromboembolism
    • Decubiti
    • Pneumonia
    • Atelectasis
  • Compartment Syndrome
  • 9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ?
    6 “P”s?
    use them as criteria is Not reliable
    Only pain & paraesthesia useful
    The rest are uncommon or late signs
    Eg. Paralysis or even muscle weakness indicate irreversible muscle damage
  • Symptoms
    Pain out of proportion to apparent injury (early and common finding)
    Persistent deep ache or burning pain
    Paresthesias (onset within approximately 30 minutes to 2 hours of ACS; suggests ischemic nerve dysfunction)
  • Signs
    Pain with passive stretch of muscles in the affected compartment (early finding)
    Tense compartment with a firm "wood-like" feeling
    Diminished sensation (two point discrimination found to be earliest)
  • Late signs
    Pallor from vascular insufficiency (uncommon)
    Muscle weakness (onset within approximately two to four hours of ACS)
    Paralysis (late finding)
  • 10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8?
    relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed
    Maintain perfusion:
    Hypotension reduces perfusion, exacerbating tissue injury, and should be treated with intravenous isotonic saline.
    The limb should not be elevated. Elevation can diminish arterial inflow and exacerbate ischemia [62].
    Analgesics should be given and supplementary oxygen provided. Further research
  • Capillary blood flow becomes compromised at 20 mmHg.
     • Pain develops at pressures between 20 and 30 mmHg.
     • Ischemia occurs at pressures above 30 mmHg.
    Traditional recommendations for decompression include absolute pressure readings above 30 mmHg [49], or above 45 mmHg [1].
    The delta pressure is found by subtracting the compartment pressure from the diastolic pressure. Many clinicians use a delta pressure of 30 mmHg to determine the need for fasciotomy. Others use a difference of 20 mmHg [15].
    • 11) Describe the pathophysiology of the problem you suspected in QXN 8?
    Compartment Syndrome
  • Compartment Syndrome
    • Muscle groups -including the nerves and blood vessels that flow through them- are covered by
    • a tough membrane (fascia) that does not readily expand-this area is called a “compartment”
    complex pathophysiology
    the final common pathway is cellular anoxia [15]
    prerequisite for the development of increased compartment pressure is a fascial structure (prevents adequate expansion )
    widely believed hypothesis : arteriovenous pressure gradient theory [2]
    [2] Elliott, KG, Johnstone, AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br 2003; 85:625.[15] Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg 2005; 13:436.
    ↑ Compartmental volume
    (↑ fluid content)
    ↓ Compartment volume
    (constriction of the compartment)
    Due to inelasticity of fascia
    venous outflow is reduced (obstruction)
    Inadequate venous drainage
    But early-Lymphatic Drainage
    Vascular congestion
    Muscle and nerve ischaemia,necrosis
    Further ↑ intracompartmentalpressure (venous pressure )
    ( arteriovenous pressure gradient)
    ↓ capillary perfusion
    Compromise arterial circulation (late)
  • Compartment Syndrome:Sequela After Initial Injury
    Tissue damage- irreversible tissue death within 4-12 hours
    permanent disabilities can develop from undiagnosed compartment syndrome
    Amputation- sometimes tissue beyond repair and only measure to prevent gangrene and death is amputation
  • Muscle infarcted
    Replaced by inelastic fibrous tissue
    ( Volkmann’s ischaemic contracture)
    Necrosis of
    the nerve and muscle
    within the compartment
    Vicious circle that
    Ends after
    ~12 hours
    -capable to regenerate
  • 12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?
  • Fasciotomy
    Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS)
    If intra-compartment pressure > 40mmHg
    Immediate open fasciotomy
    Morbidity from delay is significant, so the operation should be performed immediately.
    The wound should not be stitched until a post-surgical assessment has been done at 48 hours.
    subsequent skin grafts may be needed for successful healing
  • Cross section of a forearm.Palm up.
  • the thick, fibrous bands that line the muscles are filleted open,
    allowing the muscles to swell and relieve the pressure within the compartment
    Depending upon the amount of swelling (edema), a second operation may be required later to close the skin after the swelling has resolved.
    If muscle necrosis, do debridement
  • Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing and reducing repetitive surgery
    Treatment will also be directed to the underlying cause of the compartment syndrome
    try to prevent other associated complications including kidney failure due to rhabdomyolysis
  • 13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What investigation will you order ? ( 1 mark )
  • Anatomy of the pelvic bone
  • 14) What did the investigation in Figure 2 show ?
    ( 1 mark )
  • 15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and blood pressure became 70 / 40 mm Hg. He looked pale, there is pallor of conjunctivae and sweaty palms and forearms but he is still conscious. Explain briefly what pathophysiology may be happening here.(2 marks)
    Sweaty palms
  • 16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks)
    a)Vascular access:Insert TWO large bore cannula,Arterial line?
    b)Blood investigation
    c)Fluid therapy,oxygen
    Stabilization of the fracture:
    -pelvic binder/external fixator
    Repeat FAST scan
    Refer to orthopaedic team for further management of the fracture
  • 17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately.( 3 marks)
    a)Vital signs,Pulseoxymetry and CVP monitoring if available
    C)CBD-urine output monitoring
  • The intended operation on the femur was delayed…
    On DAY 3 after the accident, the patient was noted to have ↓ level of consciousness in the ward round
  • Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for
  • Fat Embolism
    Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long bone or other major trauma
    More frequent in closed than in open #
    Incidence ↑ with no. of # involved
    Can occur in relation to other trauma
    Pathogenesis: mechanical & biochemical theory
  • GURD’s Criteria for Diagnosis
    Axillary or subconjunctivalpetechiae
    Hypoxaemia PaO2 <60mmHg
    CNS depression disproportionate to hypoxaemia
    Tachycardia >110bpm
    Pyrexia >38.5
    Retinal emboli on fundoscopy
    Fat globules in urine and sputum
    Increased ESR, decreased haematocrit and platelet
    For diagnosis, at least 1 MAJOR and 4 MINOR criteria must be present
  • 4 Symptoms and/or Signs
    Respiratory distress: SOB
    CNS abnormalities: Confusion, restlessness, coma
    Changes in V/S: ↑ temperature, ↑ PR
    Petechiae: neck, chest, axilla, subconjunctiva
  • Elaborate what investigations would you do?
  • Clinically:
    -tachycardia>110bpm, tachypnea>30bpm, pyrexia>38.5◦
    _ confused / restless
    - petechiae
    Lab Ix:
    - ABG (PaO2<60mmHg)
    - FBC: ↓ hematocrit, thrombocytopenia
    - LFT, RP, serum electrolytes, ↑ ESR
    - Urine & sputum for fat globules
  • Chest radiograph: may be normal / snow-storm appearance / diffuse, ground glass appearance
    Head CT-evidence of microvascular injury
    Spiral CT
    -ECG, TEE
    -ventilation/perfusion scan
  • What further treatment would this patient receive?
  • Supportive Mx
    Maintenance of adequate oxygenation & ventilation
    Maintain stable hemodynamics
    Fluids & blood products as clinically indicated
    Prophylaxis of DVT & stress-related GI bleeding
  • The right shoulder
    When En. M recovered from the operation and ICU, he began to ambulate. He complained of a right shoulder problem when examined as shown in Figure 3A and 3B
  • Figure 3A
    Figure 3B
  • Question 21
    Name ONE clinical test which describe the method of examination shown in the figures
    Shoulder impingement test
  • Question 22
    Name TWO diagnoses possible for the above problem
    1. Rotator cuff impingement
    2. Rotator cuff tear
  • The rotator cuff muscles
  • Rotator cuff impingement
    “Mechanical impingement of rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flex and internally rotated position.”
    NeerCS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. Jan 1972;54(1):41-50.
  • Neer’s classification
    Stage I: oedema and haemorrhage
    Stage II: fibrosis and tendinopathy
    Stage III: partial or complete tear
  • Clinical features
    Gradual onset
    In the anterolateral part of shoulder
    On overhead movement
    Worse at night
    Associated with weakness and stiffness
    Clicking or creaking sounds during movement
    Joint instability
    Positive Impingement test
    Normal range of movement and strength
  • Rotator cuff tear
    Partial tears frequently occur with supraspinatus tendinitis
    Complete tear may result from sudden shoulder strain or as complication of tendinitis or partial rupture
  • Clinical features
    History of trauma to the shoulder
    Sudden onset
    In anterolateral part of shoulder
    Associated with gross weakness of abduction
    Joint instability
    Persistent painful arc of abduction
    Decreased strength on involved muscle group
    Decreased range of movement
  • Conservative Treatment
    Rest, activity modification (avoid irritating activities)
    Ice on affected area
    Physical therapy for stretching/ ROM
    Rotator cuff strengthening and scapular stabilization
  • Physical therapy
    Strengthening the rotator cuff tendons
    Stretching and regaining lost motion caused by pain and inflammation
    Allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa
  • Examples of physical therapy
    Cross arm push
    External rotation on elastic resistance cord
  • Surgical treatment
    Arthroscopic subacromial decompression to expand the space between acromion and rotator cuff tendons
    Rotator cuff repair in rotator cuff tears