The document summarizes patella fractures and extensor mechanism injuries. It begins by discussing the history of surgical treatment and advances in fixation techniques. It then covers mechanisms of injury, physical exam findings, imaging studies, fracture classification, and treatment approaches. Fractures are classified as displaced or nondisplaced, and treatment depends on factors like fragment separation, articular displacement, and integrity of the extensor mechanism. Nondisplaced fractures are typically treated nonoperatively while displaced fractures often require open reduction and internal fixation techniques like tension band wiring.
An Introduction, History, Diagnosis, Current Guidelines on Treatment of trochanteric fractures of femur. Presentation also contain an introduction of Dynamic Hip Screw and Surgical Techniques.
An Introduction, History, Diagnosis, Current Guidelines on Treatment of trochanteric fractures of femur. Presentation also contain an introduction of Dynamic Hip Screw and Surgical Techniques.
Osseous anatomy, Types of approaches(Position,landmarks,Incision,Superficial and Deep surgical dissection) , structures at risk, Extensile approaches with diagrams and eponymous .
Osseous anatomy, Types of approaches(Position,landmarks,Incision,Superficial and Deep surgical dissection) , structures at risk, Extensile approaches with diagrams and eponymous .
A short presentation on knee cap fractures its causes, diagnosis and management. This also gives brief idea about different methods of treatment for knee cap fractures.
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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
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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
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.
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1. Patella Fractures and Extensor
Mechanism Injuries
Rockwood And Green's Fractures In
Adults, 7th Edition 2010
BY: HAMID HEJRATI
RESIDENT OF ORTHOPEADIC SURGERY
MEDICAL UNIVERSITY OF MASHAD
2. INTRODUCTION
Until the nineteenth century treated nonoperatively with extension splinting…. critical
structural and biomechanical functions of the patella were not understood…
Sir Hector Cameron of Glasgow, Scotland, performed the first open reduction and internal
fixation of a patella fracture in 1877 with interfragmentary wiring.
Numerous techniques of fracture reduction and fixation emerged, but stable fixation was
difficult to achieve.
The greatest advance in patellar fracture fixation, however, occurred in the 1950s with
presentation of the anterior tension band technique by Pauwel.
3. INTRODUCTION
Currently, three forms of operative treatment for displaced patella fractures are most
commonly used:
1. Open reduction and internal fixation, usually with a tension band wiring technique
2. Partial patellectomy
3. Total patellectomy
The goals of surgical treatment are:
A. Restoration of the articular surface of the patella
B. Maximum preservation of the patella
C. Preservation of the functional integrity and strength of the extensor mechanism
4. MECHANISM OF INJURY
approximately 1% of all skeletal fractures
Direct injuries may be low-energy or may be high-energy
Indirect injury can occur secondary to the large forces generated through the extensor
mechanism and typically result from forceful contraction of the quadriceps with the knee in a
flexed position and frequently cause a greater degree of retinacular disruption compared with
direct injuries
It is critical to survey for associated injuries of the ipsilateral limb, including hip dislocation,
proximal femur fractures, or fractures about the knee
The majority of patellar fractures have a transverse fracture pattern resulting from excessive
tensile forces through the extensor mechanism.
5. HISTORY AND PHYSICAL EXAMINATION
Correlation of the fracture with the mechanism of injury will help the surgeon to anticipate both
the fracture pattern and degree of soft tissue injury
The absence of a large effusion in the presence of palpable bony defect should raise concern for
associated retinacular tears
Displaced patella fractures typically present with an acute hemarthrosis and a tender, palpable
defect between the fracture fragments
Competence of the extensor mechanism must be assessed
It is critical to note, however, that the patient's ability to extend the knee does not rule out a
patella fracture but rather it suggests that the continuity of the extensor mechanism is
maintained via an intact retinacular sleeve
6. IMAGING
Plain Radiography
The Anteroposterior (AP) radiographic
view
The patella should lie within the midline of the
femoral sulcus, and the distal pole should be no
higher than 20 mm above a tangential line
connecting the distal femoral condyles
7. Vertical and horizontal fracture lines should be carefully noted. Typically, the degree of fracture
comminution is underestimated by the radiographically evident fracture lines.
The distal femur and proximal tibia should not be ignored and must be carefully inspected for
occult condylar or plateau fractures.
8. A bipartite or tripartite patella can often
be mistaken for a fracture in the setting of
a trauma history. The opposing edges are
cusually smooth and orticated on plain
radiographs. The finding is typically
bilateral, and contralateral knee
radiographs often confirm the diagnosis.
The most common bipartite pattern is
located in the superolateral aspect of the
patella and is not associated with any pain,
tenderness, or functional compromise of
the extensor mechanism on physical
examination.
9. The lateral radiographic view
Critical to define fracture pattern and associated extensor
mechanism disruption
It is essential to obtain a true lateral view that allows for
reliable determination of patellar height and identification of
occult injuries and fracture pattern
The distal patellar pole and tibial tubercle should be carefully
inspected for subtle avulsion fractures.
10. Patellar height should be assessed by the Insall-
Salvati ratio, which compares the height of the
patella to the length of the patellar tendon. In a
normal subject, a ratio of 1.02 ± 0.13 is expected.
A ratio of less than 1.0 suggests patella alta and
disruption of the patellar tendon. A ratio of
greater than 1.0 is associated with patella baja and
quadriceps tendon disruption.
11. With the knee flexed 90 degrees, the
proximal patellar pole normally rests at
or below the level of the anterior cortex
of the femur.
With the knee flexed 30 degrees, the
inferior patellar pole normally projects to
the level of the Blumensaat line (the
distal physeal scar remnant).Loss of this
relationship is suggestive of extensor
mechanism disruption.
12. With the knee flexed 30 degrees, the
inferior patellar pole normally projects to the
level of the Blumensaat line (the distal
physeal scar remnant).Loss of this
relationship is suggestive of extensor
mechanism disruption.
A, Normal knee. Lower pole of patella at
Blumensaat line at 30 degrees of flexion of
knee. B, Patella alta. Patella significantly
proximal to Blumensaat line.
13. The tangential or axial view of the patellofemoral joint
vertical or marginal fracture lines and associated osteochondral defects may only be visualized
on this view
14. Computed Tomography
Frequently, however, the patella may be incidentally imaged during the evaluation of an
ipsilateral distal femoral or proximal tibial fracture.
CT allows for improved evaluation of articular congruity and fracture comminution, it rarely
provides additional information that will alter the treatment plan that has been rendered based
on physical examination and plain radiographs.
CT scanning plays a more important role in the evaluation of patellar stress fracture, nonunion,
or malunion. Apple et al demonstrated a 71% sensitivity of tomography in detecting stress
fractures in elderly, osteopenic patients, compared with 30% with bone scans and 0% with plain
radiographs alone.
CT is also useful to characterize trochlear anatomy and lower extremity rotational alignment
with patellofemoral tracking disorders.
15. Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) has been used increasingly to identify extensor mechanism
injuries as well as chondral or osteochondral injuries associated with patellar fractures.
The normal quadriceps and patellar tendons have a laminated appearance with homogeneous,
low signal intensity on MRI.
Trauma to the patella or adjacent soft tissues results in hemorrhage and edema and is
associated with increased signal intensity on T2-weighted images.
T2-weighted images of articular cartilage and delayed gadolinium-enhanced imaging of articular
cartilage (dGEMRIC) allow for the identification of chondral injuries.
16. Lateral patellar dislocations are also associated with a characteristic edema pattern on MRI that
allows for confirmation of the diagnosis even after spontaneous reduction following the injury.
In addition to a traumatic effusion, contusion of the lateral femoral condyle and medial patellar
facet with increased signal on T2-weighted images, disruption of the medial patellofemoral
ligament, retinacular tears, and osteochondral loose bodies are frequently seen.
17. FRACTURE CLASSIFICATION
Practically, a treatment-based approach begins with classifying patellar fractures as displaced or
nondisplaced.
Displaced patellar fractures are defined by separation of fracture fragments by more than 3 mm
or articular incongruity of more than 2 mm.
Described patterns include transverse or horizontal, stellate or comminuted, vertical or
longitudinal, apical or marginal, and osteochondral.
A special category of patellar sleeve fractures can occur in skeletally immature patients in which
a distal pole fragment with a large component of the articular surface avulses from the
remaining patella.
18.
19. Nondisplaced Fractures
Transverse
A. 35%
B. Intact lateral and medial retinacula and extensor mechanism remains competent
C. 80% of these fractures occur in the middle to lower third of the patella
D. If Fragment separation <3 mm
Treatment: Cylinder cast
Contraindications (Relative): Loss of reduction
20. Nondisplaced Fractures
Stellate
A. Approximately 65% of these injuries are nondisplaced
B. Direct blow injuries to the patella with the knee in a partially flexed
position
C. lateral patellar retinacula are usually not torn with the injury
D. Damage to the patellar and femoral articular surface is not
uncommon
E. careful evaluation on tangential views or MRI is necessary to identify
occult osteochondral lesions
F. If Articular displacement <2 mm
Treatment: Range-of-motion brace
Contraindications (Relative): Disruption of the extensor mechanism
21. Nondisplaced Fractures
Vertical
A. 12% to 22% of patellar fractures
B. The fracture line is most commonly seen involving the lateral facet and
lying between the middle and lateral third of the patella
C. Lateral avulsion or direct compression of the patella in a hyperflexed
knee is responsible for this pattern of injury
D. The patellar retinacula are intact
E. Easily missed on an AP radiograph, emphasizing the importance of an
axial view to identify this injury.
F. If Intact extensor mechanism no treatment
22. Displaced Fractures
Transverse
A. 52% of displaced patellar fractures
B. Evaluation of the integrity of the extensor mechanism is critical
C. Fragment separation (>3 mm) is suggestive but not diagnostic
of retinacular and extensor mechanism disruption
D. Preservation of the retinacula allows satisfactory healing
without surgery
E. If Fragment separation >3 mm Treatment: Modified anterior
tension band Contraindications (Relative): Critically ill patient
If Articular displacement >2 mm Treatment: Lag screws
Contraindications (Relative): Infection of the soft tissue or bone
If Disrupted extensor mechanism Treatment: Longitudinal
anterior band Contraindications (Relative): Nonambulatory
patient
23. Displaced Fractures
Stellate
A. Typically demonstrate a high degree of
comminution
B. Extensive comminution may result in propagation
into the retinaculum and disruption of the extensor
mechanism
C. The significant articular incongruity may warrant
operative intervention
D. Treatment in stellate or cominuted fractures
Modified anterior tension band
Cerclage, modified anterior tension band
Longitudinal anterior band
Partial patellectomy or patellectom
24. Displaced Fractures
Pole Fractures
A. Proximal pole Bony avulsions of the quadriceps mechanism
Displacement is rare approximately 4%
The lateral radiograph patella baja and a reduced Insall-Salvati ratio
treatment: Lag screw
B. Distal pole Bony avulsions of the patellar tendon
Displacement is much more common with these injuries.
Retinacular disruption with loss of knee extension
The lateral radiograph patella alta and an increased Insall-Salvati ratio
Partial patellectomy
25. Displaced Fractures
Osteochondral Fractures
A. Associated with high-energy trauma, stellate patellar fractures or after patellar dislocation
B. MRI with cartilage-sensitive sequences can improve the detection of these injuries
C. Fragments can shear from the lateral femoral condyle or medial patellar facet after patellar
subluxation or dislocation and may warrant surgical intervention
D. Loose body repair/removal
26. BIOMECHANICS OF THE EXTENSOR
MECHANISM
The patella provides the critical biomechanical functions of both linking and displacement.
Link between the quadriceps and the patellar tendon and Transmission of torque generated by
the quadriceps muscle to the proximal tibia. For young men, these forces can exceed 6000 N and
can approach up to eight times body weight.
At 135 degrees of flexion, linking occurs via transmission of forces between the extensive
contact area of the trochlea with the patellar facets and the posterior surface of the quadriceps
tendon.
Albanese et al.3 studied knee extension mechanics after subtotal excision of the patella. The
quadriceps force as a function of knee flexion angle was recorded for varying amounts of excision
and compared with the results for total patellectomy. Excision of the proximal one half or less
resulted in lower force requirements when compared with total patellectomy. The effects of
distal to proximal excisions indicate a biomechanical advantage to maintaining a fragment equal
to at least three fourths the length of the proximal patella.
27. The displacement function of the patella is most critical from 45 degrees of flexion to terminal
extension. Twice as much torque is required to extend the knee the final 15 degrees as is
necessary to bring it from a fully flexed position to 15 degrees.
The patella displaces the tendon away from the center of rotation of the knee, increasing the
moment arm and providing a mechanical advantage that increases the force of knee extension
by as much 50% depending on the angle of knee flexion. It is this displacement action of the
patella that provides the additional 60% of torque necessary to gain the last 15 degrees of
terminal extension.
The high torques generated by the extensor mechanism can result in substantial patellofemoral
contact forces. Compressive forces as large as three to seven times body weight have been
recorded during squatting or climbing stairs. Given the small contact area of the patellofemoral
articulation, it has been estimated that the contact stresses generated are greater than in any
other weight-bearing joint in the body.
28. The patellofemoral contact zones are dynamic and shift with varying degrees of knee flexion.
The patella engages the trochlear sulcus at approximately 20 degrees of flexion.
With increasing knee flexion, a horizontal band of contact area across the patellar facets moves
proximally and reaches a maximum at 90 degrees of flexion.
Beyond 90 degrees, the contact area on the patella shifts into two discrete locations on the
medial and lateral facets.
Corresponding with the proximal shift of contact on the patella, the contact zone on the femur
shifts distally on the trochlea and separates into two discrete zones on the medial and lateral
condyles with hyperflexion.
29. The management of patellar fractures is largely based on the fracture classification and findings
on physical examination, with particular attention on the integrity of the extensor mechanism.
Age, bone quality, patient expectation, and the presence of associated injuries may also
influence surgical decision making. Regardless of the treatment strategy, the goals of surgical
intervention are as follows:
Maximal preservation of the patella to maintain its linking and displacement functions
Restoration of the articular congruity of the patella
Preservation of the functional integrity and strength of the extensor mechanism