The document discusses the management of mangled extremities. It covers components of mangled injuries including soft tissue loss, fractures, vascular and nerve injuries. It discusses the assessment, decision to amputate or attempt salvage, and principles of amputation and limb salvage. Key factors in the decision include the extent of soft tissue damage, viability of nerves and blood vessels, amount of bone loss and potential for functional recovery. Serial debridement, skeletal stabilization, wound management and soft tissue coverage are also addressed.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Surgical hemostasis is one of the pillars of modern surgery. Adequate hemostasis in a surgical patient involves a detailed perioperative clinical evaluation and investigation, and various intra operative techniques and options. Ensuring adequate surgical hemostasis reduces morbidity and mortality by modulating the metabolic response to trauma, decreasing the incidence of post operative anemia, reduces rates of surgical site infection and ultimately improving wound healing
Open fractures are unique, complex, and emergently presenting injuries that expose sterile bone to the contaminated environment.
Because a fracture disrupts the intramedullary blood supply, the additionally stripped soft tissue envelope further devitalizes the bone.
The more severe the soft tissue injury or open wound, the more severe the osseous injury.
Historically, open fractures were associated with infection, delayed union, nonunion, amputation, or death.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Surgical hemostasis is one of the pillars of modern surgery. Adequate hemostasis in a surgical patient involves a detailed perioperative clinical evaluation and investigation, and various intra operative techniques and options. Ensuring adequate surgical hemostasis reduces morbidity and mortality by modulating the metabolic response to trauma, decreasing the incidence of post operative anemia, reduces rates of surgical site infection and ultimately improving wound healing
Open fractures are unique, complex, and emergently presenting injuries that expose sterile bone to the contaminated environment.
Because a fracture disrupts the intramedullary blood supply, the additionally stripped soft tissue envelope further devitalizes the bone.
The more severe the soft tissue injury or open wound, the more severe the osseous injury.
Historically, open fractures were associated with infection, delayed union, nonunion, amputation, or death.
examination,impingement syndrome,rotator cuff injury,shoulder,shoulder instability
All about orthopaedic shoulder examination. comprehensive ppt with all tests arranged symptom wise
AMPUTATION:
“Surgical removal of limb or part of the limb through a bone or multiple bones”
DISARTICULATION:
“Surgical removal of hole limb or part of the limb through a joint”
The effect of intact fibula on functional outcome of reamed intramedullary in...Love2jaipal
detailed journal club presentation on The effect of intact fibula on functional outcome of reamed intramedullary interlocking nail in open and closed isolated tibial shaft fractures
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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
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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
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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10. RESUSCITATION
Place in context of ATLS protocol
ABC
Fluid and Blood Replacement
Examination
IV antibiotics
Tetanus
Gross debridement and wound wash
Sterile dressing
Splint limb
12. ASSESSMENT
SOFT TISSUE
How big is the laceration?
Is there loss of skin, muscle?
How contaminated is it?
What environment did the injury occur in (ie: barnyard, aquatic, etc.)?
VASCULAR
Palpable pulses? Asymmetry?
Doppler pulses? Asymmetry? Wave form?
Color, temperature of limb
Compartments
Expanding hematoma, pulsatile bleeding
NEUROLOGICAL
Sciatic --> Tibial + Peroneal
Femoral --> Saphenous
13. DECISION TO AMPUTATE
1. Is the limb salvagable?
2. If salvaged, will a
functional limb result?
POTENTIAL SCENARIOS
Immediate amputation
Attempted salvage with early amputation
Successful salvage
Unsuccessful salvage with late amputation
14. MANGLED EXTREMITY SCORES
How we decide on salvage versus amputation?
Predictive Salvage Index (PSI)
Mangled Extremity Severity Score (MESS)
Limb Salvage Index (LSI)
Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age (NISSSA)
Score
Hannover Fracture Scale-97 (HFS-97)
Trauma Scores:
Do not correlate well with final limb function
17. LIMB SALVAGE
When to consider salvage?
Anatomically intact sciatic/tibial nerve
Can reconstruct vascular supply: proximal injury, warm ischemia < 6 hrs
Moderate soft tissue injury or loss
Moderate bone loss
Functional ankle, foot and knee
Younger patients
20. DECISION TO AMPUTATE
Indications for Primary Amputation in Lower Extremity Open Fractures*
Absolute:
a. complete disruption of the posterior tibial nerve in an adult
b. crush injury with warm ischemia >6H or nonreparable vascular injury
Relative:
a. life threatening polytrauma (ISS > 20)
b. severe ipsilateral foot trauma
c. prolonged course to provide soft tissue and tibial reconstruction incompatible
with personal,sociologic and economic consequences for the patient
*civilian world
21. RISK FACTORS FOR AMPUTATION
Gustilo III-C injuries � comminuted,
Open tib-fib fractures with vascular disruption.
Sciatic or tibial nerve, or two of the three major upper extremity nerves,
anatomically transected
Prolonged ischemia (>4-6 hours)/muscle necrosis
Crush or destructive soft tissue injury
Significant wound contamination
Multiple/severely comminuted fractures/segmental bone loss
Old age/severe co-morbidity
Lower vs. upper extremity
Apparent futility of revascularization/failed revascularization
22. HARD SIGNS OF VASCULAR INJURY
Active hemorrhage
Large, expanding or pulsatile hematoma
Bruit or thrill over the wound(s)
Absent palpable pulses distally
Distal ischemic manifestations
(pain, pallor, paralysis, paresthesias, poikilothermy,
or coolness)
23.
24. PRINCIPLES OF AMPUTATION
Principles:
o Unless amputation is in a damage control situation (“guillotine”), the goal is a functional
extremity with a residual limb that successfully interacts with the patient’s future
prosthetic mgt.
oStaged amputation - In a patient not been adequately resuscitated, or with significant
Contamination/ infection, blast or crush mechanism, may improve functional results by
preserving length.
o Incisions through soft tissue and bone are at right angles to the longitudinal axis
of limb with few exceptions. Do not bevel the incision as this may create ischemic flaps.
o The periosteum is reflected proximal to skin incisions, and bones are transected
where the periosteum is adherent to the bone to decrease the chance for an avascular
sequestrum. Bone edges are filed after transection.
o Suture ligatures are preferred to electrocautery for control of transected vessels.
25. PRINCIPLES OF AMPUTATION
Principles:
o Risk of postoperative neuroma is minimized with simple sharp transection of nerves
while maintaining distal traction. Judicious use of sutures to control bleeding and
minimizing the use of clamps also decrease neuroma formation.
o Multilayered closure of the incisions to ensure soft tissue coverage of bones is essential.
Drains are recommended for larger amputations.
o Skin grafts should be used to preserve limb length and joints as long as adequate muscle
coverage is present to cover bone.
o Extremities are splinted to prevent contractures during healing and range of motion
exercises instituted early
26.
27. IRRIGATION DEBRIDEMENT
With the exception of tendon and nerve, if it does not bleed it is dead.
If it is dead, get rid of it.
If you cannot get rid of it, think amputation.
Serial debridements and washouts are desirable
Assess viability in OT – Color/ contractility/ bleeding
Debridement Amputation
When life over limb is the issue or in certain extremity injuries where there is no
means of limb salvage
31. a sciatic nerve that had been included in the
amputation myoplasty.
The resulting neuroma was symptomatic and
precluded prosthetic wear and walking
33. DEBRIDEMENT
With the exception of tendon and nerve,
if it does not bleed it is dead.
If it is dead, get rid of it.
If you cannot get rid of it, think
amputation.
Serial debridements and washouts are
desirable
Assess viability in OT – Color/
contractility/ bleeding
36. DAMAGE CONTROL
Hemodynamic instability,
Coagulopathy,
Acidosis,
Hypothermia of the patient
Unstable skeleton
Major wound contamination/infection or soft tissue deficits precluding wound
coverage
Requirement for any definitive repair more complex than lateral suture or end
to end anastomosis (i.e. extra-anatomic bypass, interposition graft)
Austere environment with no resources for definitive management
Other life threatening injuries requiring urgent management
37.
38.
39. DEFINITIVE REPAIR
Definitive repair should be performed provided:
Hemodynamic and physiologic stability of patient
Stable skeleton
Clean wound with adequate viable soft tissue
Availability of necessary time and resources
No other injuries requiring more urgent management
40. VASCULAR SHUNTS
Angiography
In theatre
Diagnostic
Therapeutic
Covered stent
Embolisation
Open exploration
Repair
Bypass
43. WOUND MANAGEMENT
TIMING FOR WOUND CLOSURE
ALL MAJOR STUDIES HAVE SHOWN EARLY FLAP CLOSURE WITHIN 7 DAYS LEADS TO
LOWEST COMPLICATION RATES
BOTTOM LINE: IF YOU ARE INVOLVED IN MANGLED EXTREMITY CARE A
COMMITMENT MUST BE MADE TO ACHIEVE COVERAGE WITHIN A WEEK WITH
HEALTHY VASCULARIZED TISSUE
VAC USE DOES NOT CHANGE THIS DICTUM
Soft Tissue Coverage
Primary closure
Skin grafts
Local or free flaps
46. TISSUE ENGINEERING
Issues that can be addressed with tissue engineering
Missing or injured nerve
Neuromas in-continuity
Missing bone, enhanced bone healing
Wound vascularity
Delayed wound healing
47. TISSUE ENGINEERING
TISSUE ENGINEERING CONSIDERATIONS
Bioabsorbable nerve guides supplemented by growth factors
Bone matrix to replace need for microsurgical transplantation
Angiogenic factors
Acellular tissue matrix to enhance wound healing
60. Mangled limb belongs to a patient - keep things in context
Few indications for immediate amputation - time to
consult, assess patient factors, educate
Limb salvage and amputation have similar long-term
outcomes
Long-term disability common