Simplified continuing ed talk created for hospital physical medicine and rehabilitation department in Saudi Arabia around 2013. Had/has many animations and movement in slides, which don't seem to work in slideshare? Somewhat outdated anyway, so needs updating.
**apologies for non-working animations. Haven’t had time to recreate this and try to re-upload to make them work properly. Slideshare just doesn’t display my ppt’s as created.
This powepoint is aimed at undergraduate medical education. It gives information regarding the orhtopedic principles of management of closed and open fractures
Simplified continuing ed talk created for hospital physical medicine and rehabilitation department in Saudi Arabia around 2013. Had/has many animations and movement in slides, which don't seem to work in slideshare? Somewhat outdated anyway, so needs updating.
**apologies for non-working animations. Haven’t had time to recreate this and try to re-upload to make them work properly. Slideshare just doesn’t display my ppt’s as created.
This powepoint is aimed at undergraduate medical education. It gives information regarding the orhtopedic principles of management of closed and open fractures
Objectives:
-Recognize the anatomy of the proximal tibia
-Describe initial evaluation and management
-Identify common fracture patterns
-Apply treatment principles and strategies for Partial articular fractures and Complete articular fractures
-Discuss rehabilitation and complications
-Learn Management in selected tibial plateau case scenarios
Objectives:
-Recognize the anatomy of the proximal tibia
-Describe initial evaluation and management
-Identify common fracture patterns
-Apply treatment principles and strategies for Partial articular fractures and Complete articular fractures
-Discuss rehabilitation and complications
-Learn Management in selected tibial plateau case scenarios
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
1. Closed Reduction, Traction,
and Casting Techniques
Jason Tank, MD
March 2014
Original Authors: Dan Horwitz, MD; March 2004; David Hak, MD;
Revised January 2006 & October 2008
New Author: Jason Tank, MD
3. Closed Reduction Principles
• Identify need for closed reduction
– Most displaced fractures should be reduced to
minimize soft tissue complications & injury
• Includes injuries ultimately treated with surgery
• Various resources for acceptable non-operative
fracture alignment parameters
– Find & utilize a reliable source
4. Closed Reduction Principles
• Prior to reduction
– H&P
• Define injury & host factors
– Trauma ABC’s first
• Evaluate skin, compartments & neurovascular status
– Urgent/Emergent reduction
» Dysvascular distal limb, significant skin tenting
• Organize/customize appropriate team for:
– Sedation need
– Reduction & immobilization assistance
– Post reduction imaging
6. Anesthesia
• Adequate analgesia & muscle
relaxation/fatigue are critical for success
• Determine goals of reduction & plan
• Customize anesthesia for each patient &
injury combination
7. Anesthesia Options
IV Sedation
• Versed: 0.5-1 mg q 3 min (5mg max)
• Morphine : 0.1 mg/kg
• Demerol: 1- 2 mg/kg (150 mg max)
• Ketamine
– Beware of pulmonary complications
with deep conscious sedation
• Anesthesia service/ED/trauma team
usually administering at most
institutions
– Pulse oximeter & careful
monitoring recommended
Pros
Potential better relaxation
Versatile for many anatomic locations
Limited memory of reduction
Cons
Non-paralyzed muscle relaxation
Cardio/pulmonary complications
-over sedation
8. Anesthesia Options
Hematoma Block
-Aspirate fracture hematoma & place 10cc of
Lidocaine at fracture site
Pros
Efficient
Usually effective
Useful for distal radius & hand
Cons
Can be less reliable than other methods.
Theoretically converts closed fracture to
open fracture
-No documented ↑ in infection
9. Anesthesia Options
Intra-articular Block
-Aspirate joint & place 10cc of Lidocaine (or
equivalent local anesthesia) into joint
Pros
Efficient
Commonly effective
Useful for certain ankle/knee injuries
Cons
Can be less reliable than other methods
Intra-articular violation
Theoretically converts closed injury to
open injury
-No documented ↑ in infection
10. Anesthesia Options
Bier Block
•Double tourniquet is inflated on
proximal arm and venous system is
filled with local
– Lidocaine preferred for fast onset
– Volume = 40cc
– Adults 2-3 mg/kg
– Children 1.5 mg/kg
If tourniquet is deflated after < 40
minutes then deflate for 3 seconds
and re-inflate for 3 minutes - repeat
twice
Pros
Good pain relief & relaxation,
Minimal premedication needed
Cons
Cardiac & CNS side effects
(seizures)
11. Closed Reduction Principles
• Prepare immobilization prior to reduction
– Splint pre-measured & ready for efficient
application
– Sling or knee immobilizer in close proximity
– Have extra supplies close
– Assistant or assistive device
(ex. Finger traps) available
12. Closed Reduction Principles
• Reduction requires reversal of mechanism of injury
– Especially in children with intact periosteum
• The soft tissues may disrupt on the convex side &
remain intact on the concave side
Figure from: Rockwood and Green: Fractures
in Adults, 6th ed, Lippincott, 2006
13. • Longitudinal traction alone may not allow the
fragments to be disengaged & length re-established if
there is an intact soft-tissue hinge
– Especially in children with strong partially intact
periosteum
Closed Reduction Principles
14. Closed Reduction Principles
Reproduce fracture mechanism
↓
Traction to disengage fracture fragments
↓
Re-align fracture
***Angulation beyond 90° is potentially required
Figure from: Rockwood and Green: Fractures in Adults, 6th ed, Lippincott, 2006
15. Splinting Principles
• Splint must be molded to resist deforming
forces
– “Straight casts lead to crooked bones”
– “Crooked casts lead to straight bones”
16. Splinting Principles
Three point contact (mold)
is necessary to maintain
closed reduction
Removal of any of the three
forces results in loss of reduction
Figure from: Rockwood and Green: Fractures
in Adults, 4th ed, Lippincott, 1996.
17. Splinting
• Non-circumferential
– Permits swelling & soft tissue evaluation
• May use plaster or prefab fiberglass splints
– Plaster
• Best for customized mold
• More versatile material
• More reliable at maintaining
reduction
18. Common Splinting Techniques
• Coaptation
• Posterior long arm
• Sugar-tong
• Ulnar gutter
• Volar/dorsal forearm
• Volar/dorsal hand
• Resting hand
• Thumb spica
• Posterior long leg
• Lateral long leg
• Posterior slab (ankle)
+/- U splint
+/- Foot plate
+/-Side struts
• “Bulky” Jones
19. Splint Choice
• Considerations when customizing for each
patient & injury
– Overall patient condition
• Multi-trauma vs. isolated injury
– Soft tissue envelope
– Reduction stability
– Future treatment plan
– Experience
20. Splint Padding
• 3-4 layers thick under ALL
types of splints
• Padding Problems
– Too thin skin pressure
– Too thick less fracture
control (potential loss of
reduction)
Unpadded fiber glass splint
caused skin lesions
22. Shoulder Dislocation
• Relaxation key
• Traction
– Disengage humeral head
from glenoid
• +/- gentle rotation
• Many described
techniques
• Avoid iatrogenic
fracture propagation
• Immobilization: Sling
Figures from Rockwood and Green, 5th ed. Miltch Technique
Traction/Counter-Traction
Sheet for
traction
Arm for
traction
23. Figure from Rockwood and Green, 4th ed.
Humeral Shaft
• Gravity traction +/-
formal reduction
maneuver
• Immobilization:
Coaptation splint
– Lateral splint extends
over the deltoid
– Medial splint into axilla
& must be well padded
(*ABD pad) to avoid
skin breakdown
– Elbow unsupported
permitting gravity
traction
24. Elbow Dislocation
• Traction, flexion & direct
manual palpation of
olecranon
– Reduce medial/lateral
displacement 1st
– Address anterior/posterior
next
– Supination/pronation may
assist reduction
• Cautious elbow range of
motion after reduction
– Can guide treatment plan
• Immobilization: Posterior
long arm splint +/- sugar
tong
Figure from Rockwood and Green, 5th ed.
Manual
pressure over
olecranon
Multi-
directional
traction
25. Forearm Fracture
• Traction
– +/- need to significantly
recreate the deformity
• Especially in pediatric pts
• Immobilization = Sugar
tong splint with 3 point
mold
• Pediatric
– Splint Cast with nonop
mgnt
• Adult
– Almost always surgical thus
temporizing until ORIF -Splint around distal humerus to
provide rotational control
-Extra padding at the elbow
26. Distal Radius
• Local or regional block
– Hematoma/Bier
• Longitudinal traction
– Finger Traps or manual
– Fatigue muscles
• Exaggerate deformity
• Push distal fragment & pull
hand for length & deformity
reversal
• Immobilization: Volar/dorsal
wrist splint, 3-point mold +/-
elbow sugar tong
Volar directed
distal force over
Lister’s tubercle
-Ulnar deviation to
reestablish radial
height & length
-Patient’s thumb
collinear with
forearm
No finger
pressure
points on
splint
27. Hip Dislocation
• IV Sedation (deep) with
Relaxation
• Posterior: Flexion,
traction, adduction and
internal rotation
• Anterior: Traction,
abduction, lateralization,
rotation
• Gentle & atraumatic
• Reduction palpable &
permit significantly
improved ROM
• Immobilization: Knee
immobilizer vs.
Abduction pillow
Figures from Rockwood and Green, 5th ed.
28. Femur Fracture
• Traction
– Skin vs. skeletal
• See traction section of lecture
– Temporizing until surgery
• Adult
– Most Rx with surgery (IMN)
• Pediatric
– Spica cast vs. IMN vs. plate
• Immobilization:
– Traction vs. long leg splint
• Commonly in traveling
traction upon ED arrival
Evaluate for groin and foot skin
pressure lesions from traction device
29. Tibia Fracture
• Traction
+/- alignment correction
• Evaluate for compartment
syndrome
• Adult
–Definitive Rx with IMN vs.
ORIF vs. cast
• Pediatric
–Definitive Rx with IMN vs.
ORIF vs. cast
• Immobilization = Posterior
or lateral long leg splint vs.
calcaneal traction
–Monitor soft tissues
30. Knee Dislocation
• Emergent Reduction
– Vascular injury common
• Traction with gentle
flexion/extension after
varus/valgus correction
• Check Pulse/ABI
– Comprehensive NV exam
• Monitor compartments
• Immobilization = Knee
Immobilizer
+/- ExFix until surgical
reconstruction
31. Ankle Fracture
• Traction with deformity
correction
– Bend knee to relax
gastroc/soleus complex
– Posterior & lateral dislocation
• +/- Quiggly Maneuver
• Posterolateral to anterormedial
directed mold
– Medial
• Traction reduction
• Medial to lateral directed mold
– Customize mold to specific
fracture/dislocation
• Immobilization:
– U Splint
• +/-Posterior slab splint
• +/- Foot plate
• +/- Side struts
Quigley
Maneuver:
Knee flexion &
leg external
rotation, foot
supination &
adduction for
reduction
Posterolateral to
anteromedial
mold for
posterolateral
ankle fractures
32. Talus Fracture
• Traction
– Recreate deformity
– Flex knee & planter flex foot
• Commonly have skin
tenting
– Important for reduction
technique
• Immobilization:
– Posterior slab splint
+/- U splint
+/-Side struts
33. Calcaneus Fracture
• Traction & planterflexion if
posterior significant skin
pressure
– Urgent operative indication
• Significant swelling
common
• Immobilization:
– Bulky Jones Splint
• Splint Cast if nonop
mgnt after swelling
decreases
34. Midfoot Fracture/dislocation
• Traction & medial/lateral
with planter pressure
• Commonly need pins to
hold reduction
• ORIF frequently definitive
mgnt
• Immobilization:
– Posterior slab splint
+/- Foot plate
+/-Side struts
Medial to
lateral
reduction
Dorsal
lateral to
planter
medial
reduction
35. Fracture Bracing
• Allows for early functional ROM and
weight bearing
• Relies on intact soft tissues and muscle
envelope to maintain reduction
• Most commonly used for humeral shaft &
tibial shaft fractures
36. • Convert to humeral fracture
brace 7-10 days after fracture
–Improved pain
–Less swelling (nerve compression,
compartment syndrome)
• Encourage early active elbow
ROM
• Monitor for skin lesions
• Fracture reduction maintained
by hydrostatic column principle
• Co-contraction of muscles
-Snug brace daily
-Gravity traction – no elbow support
Patient must tolerate
a snug fit for brace
to be functional
Figure from Rockwood and Green, 4th ed.
Humeral Fracture Cuff
37. Casting
• Goal of semi-rigid immobilization while
avoiding pressure / skin complications
• Often a poor choice in the treatment of
acute fractures due to swelling & other soft
tissue pathology
• Good cast technique necessary to achieve
predictable results
38. Casting Techniques
• Stockinette
– May require two different diameters to avoid
over tight or loose, redundant material
• Caution not to lift leg by stockinette
– Stretching the stockinette too tight around the
heel may case high skin pressure
39. Casting Techniques
• To avoid wrinkles in the
stockinette
• Cut along the concave
surface and overlap to
produce a smooth contour
• Applicable to ankle, elbow,
posterior knee
Wrinkled
stockinette
causing
skin
pressure
lesion to
antecubital
fossa
40. Casting Techniques
• Cast padding
– Roll distal to proximal
– 50 % overlap
– 2-3 layers minimum
– Extra padding at boney
prominences
• Fibular head, malleoli,
patella, and olecranon
41. Casting Material
• Plaster
– Use cold water to maximize molding time &
limit exothermic heat reaction (can burn skin)
• Fiberglass
– More difficult to mold but more durable &
resistant to breakdown
– Generally 2 - 3 times stronger for any given
thickness
42. Width
• Casting materials are available in various
widths
– 4 - 6 inch for thigh
– 3 - 4 inch for lower leg & upper arm
– 2 - 3 inch for forearm
43. • Avoid molding with
anything but the heels of
the palm in order to avoid
pressure points
• Mold applied to produce
three point fixation
Cast Molding
44. Below Knee Cast
• Support metatarsal heads & ensure exposure
of toes
• Ankle in neutral position
– Flex knee to relax gastroc complex
• Thicker cast material at heel/foot for
walking casts
– Fiberglass much preferred for durability
48. Forearm Casts & Splints
• MCP joints should be free for ROM if not
casting hand
– Do not go past proximal palmar crease
• Thumb should be free to base of MC
– Unobstructed opposition of thumb to little finger
Avoid digit
impingement
Cast
proximal to
palmar
crease
permitting
thumb
opposition
49. Examples - Position of Function
• Ankle - Neutral dorsiflexion – No Equinus
• Hand - MCPs flexed 70 – 90º, IPs in extension
70-90 degrees
Figure from Rockwood and Green, 5th ed.
50. Cast Wedging
• Early follow-up x-rays are required
to ensure acceptable reduction
• Cast may be “wedged” to correct
reduction
• Deformity is drawn out on cast
• Cast is cut circumferentially
• Cast is wedged to correct
deformity & the over-wrapped
51. Complications of Casts & Splints
• Loss of reduction
• Pressure necrosis – may occur as early as 2
hours
• Tight cast → compartment syndrome
Univalving = 30% pressure drop
Bivalving = 60% pressure drop
Also need to cut cast padding
52. Complications of Casts & Splints
• Thermal Injury –
– avoid plaster > 10 ply
– water >24°C
– unusual with fiberglass
• Cuts and burns during removal
– Appropriate removal technique
– Appropriate depth of saw
– Temperature of saw blade
Figures from: Rockwood and Green:
Fractures in Adults, 6th ed, Lippincott, 2006
Skin burns from
cast removal
Thumb supporting saw
during cast removal
53. Complications of Casts & Splints
• DVT/PE
– Increased in lower extremity fracture
– Prior history and family history
– Birth control risk factor
– Indications for prophylaxis controversial in patients
without risk factors
• Joint stiffness
– Leave joints free when possible (ie. finger MCP for
below elbow cast)
– Place joint in position of function
• Limits long-term morbidity associated with stiffness
54. Traction
• Allows constant controlled force for initial
stabilization of long bone fractures & aids
reduction during operative procedure
• Skeletal vs. skin traction is case dependent
55. Skin (Bucks) Traction
• Limited force can be applied
– Generally not to exceed 5 lbs
• Commonly used in pediatric patients
• Can cause soft tissue problems especially in
elderly or rheumatoid patients
– Thin extremity skin
• Not as powerful when used during operative
procedure for both length or rotational
control
56. Skeletal Traction
• More powerful than skin traction
• May pull up to 20% of body weight for the
lower extremity
• Requires anesthesia (local vs. sedation) for pin
insertion
• Preferred method of temporizing:
– Femur fractures
– Vertically unstable pelvic ring fractures
– Acetabulum fractures
57. Traction Pin Types
• Choice of thin wire vs. thick pin
– Thin wire requires a tension traction bow
Tension Bow
Standard Bow
58. Traction Pin Types
• Steinmann pin may be either
smooth or threaded
– Smooth
• Stronger but can slide if oblique
– Threaded pin
• Weaker & can bend with higher weight application
• Will not slide
• In general a 5 or 6 mm diameter pin is
chosen for adults
– Insertion may induce local bone thermal
necrosis
Bent non-tensioned
thin wire
59. Traction Pin Placement
• Sterile field with limb exposed
• Local anesthesia + sedation
• Insert pin from known area of neurovascular
structure
– Distal femur: Medial → Lateral
– Proximal Tibial: Lateral → Medial
– Calcaneus: Medial → Lateral
• Place sterile dressing around pin site
• Place protective caps over sharp pin ends
60. Distal Femoral Traction
• Method of choice for acetabular/vertically
unstable pelvic ring & some femur fractures
• If knee ligament injury suspected distal femur
instead of proximal tibial traction
– Distraction through knee joint potential neurvascular
injury
Incline traction to prevent
pretibial traction bow
pressure
61. Distal Femoral Traction
• Place pin from medial to lateral at the
adductor tubercle - slightly proximal to
epicondyle
– Minimizes risk for vascular injury
62. Balanced Skeletal Traction
• Suspension of leg with longitudinal traction
• Requires trapeze bar, traction cord, &
pulleys
• Allows multiple adjustments for optimal
fracture alignment
63. • One of many options for setting up balanced suspension
• In general the thigh support only requires 5-10 lbs of weight
• Note the use of double pulleys at the foot to decrease the total
weight suspended off the bottom of the bed
Figure from: Rockwood and Green: Fractures in Adults, 4th ed, Lippincott, 1996.
64. Proximal Tibial Traction
• Place pin 2 cm posterior and 1 cm distal to
tubercle
• Place pin from lateral to medial
– Minimizes risk to peroneal nerve
65. Calcaneal Traction
• Most commonly used with a spanning ex fix for
“travelling traction” or may be used with a Bohler-
Braun frame
• Place pin medial to lateral 2 - 2.5 cm posterior and
inferior to medial malleolus
– Minimizes risk to posterior medial mal NV structures
66. Traction Complications
• 5-6mm pin insertion hole may interfere
with distal locking screw site
– Thermal necrosis osteomyelitis
• Skin issues
– Monitor traction set up frequently for problems
Washer causing skin necrosis Pretibial bow skin lesion
67. Olecranon Traction
• Rarely used today
• Medium sized pin placed from
medial to lateral in proximal
olecranon
– Enter bone 1.5 cm from tip of
olecranon & identify
midsubstance location
• Support forearm and wrist with
skin traction - elbow at 90
degrees
Figure from: Rockwood and Green:
Fractures in Adults, 6th ed, Lippincott,
2006
68. Gardner Wells Tongs
• Used for C-spine reduction / traction
• Pins are placed one finger breadth above
pinna & slightly posterior to external
auditory meatus
• Apply traction beginning at 5 lbs. and
increasing in 5 lb. increments with serial
radiographs and clinical exam
69. Halo
• Indicated for certain cervical fractures as
definitive treatment or supplementary
protection to internal fixation
• Disadvantages
– Pin problems
– Respiratory compromise
70. “Safe zone” for halo pins. Place anterior pins ~ 1 cm cranial to lateral two thirds of
the orbit & below skull equator
“Safe zone” avoids temporalis muscle & fossa laterally, supraorbital & supatrochlear
nerves & frontal sinus medially
Posterior pin placement less critical because of lack of neuromuscular structures &
uniform thickness of the posterior skull.
Figure from: Rockwood and Green:
Fractures in Adults, 4th ed, Lippincott, 1996.
71. Halo Application
• Position patient maintaining spine
precautions
• Fit Halo ring
• Prep pin sites
– See previous slide for placement sites
– Have patient gently close eyes for pin
placement to prevent eyelid dysfunction
• Tighten pins to 6-8 ft-lbs.
• Retighten if loose
– Pins only once at 24 hours
Figure from: Rockwood and Green:
Fractures in Adults, 4th ed, Lippincott, 1996.
72. References
• Freeland AE. Closed reduction of hand fractures. Clin Plast Surg.
2005 Oct;32(4):549-61.
• Fernandez DL. Closed manipulation and casting of distal radius
fractures. Hand Clin. 2005 Aug;21(3):307-16.
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complications. J Am Acad Orthop Surg. 2008 Jan;16(1):30-40.
• Bebbington A, Lewis P, Savage R. Cast wedging for orthopaedic
surgeons. Injury. 2005;36:71-72.
• Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C. Skeletal
Trauma 4th ed. Philadelphia, PA: Saunders, 2009; 83-142. ISBN:
9781416048404
• Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P, McQueen
MM, Ricci WM. Rockwood and Green’s Fractures in Adults 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2010; 162-190.
ISBN 9781605476773
73. References
• Halanski MA, Halanski AD, Oza A, et al. Thermal injury
with contemporary cast-application techniques and
methods to circumvent morbidity. J Bone Joint Surg Am.
2007 Nov;89(11):2369-77.
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indications, technique, and complications. Am J Orthop.
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Acad Orthop Surg. 1999 Jan;7(1):66-75.
74. Classical References
• Sarmiento A, Kinman PB, Galvin EG, Schmitt RH,
Phillips JG. Functional bracing of fractures of the shaft of
the humerus. J Bone Joint Surg Am. 1977 Jul;59(5):596-
601.
• Sarmiento A, Sobol PA, Sew Hoy AL, et al. Prefabricated
Functional Braces for the Treatment of Fractures of the
Tibial Diaphysis. JBone and Joint Surg. 1984. 66-A: 1328-
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