Serial debridement is a surgical technique used to treat infected wounds or open fractures. It involves performing multiple debridement procedures over time to remove all non-viable tissue from the wound until only healthy, bleeding tissue remains. The key aspects of serial debridement include: - Repeated debridement surgeries are performed, typically every 48-72 hours. - Each surgery aims to remove more infected, necrotic, or non-viable tissue until the wound base is clean with bleeding tissue. - Antibiotics are usually administered between procedures to help control the infection as more dead tissue is removed. - The goal is to eliminate the source of infection and promote healthy granulation

1. 1. What are the risk of the deltoid splitting approach in proximal head fracture ?
A: Injury to the anterior motor branch of the axillary nerve during surgical exposure for
proximal humerus fixation is a concern when using either deltopectoral or deltoid-splitting
approaches. The deltopectoral approach requires substantial soft tissue dissection when
used for fracture fixation, especially with displaced greater tuberosity fragments.
Conversely, the axillary nerve may be more at risk during a deltoid-splitting approach due to
its anatomic location, as it traverses the field of exposure. Several studies have compared
the 2 approaches and found similar clinical, radiographic, and electrophysiological
outcomes. There has been a multitude of studies describing various methods of identifying
the location of the axillary nerve for the deltoid-splitting approach and have documented
various “safe zones” for this exposure.
Traver, J.L. et al. (2016) “Is the axillary nerve at risk during a deltoid-splitting approach for
proximal humerus fractures?,” Journal of Orthopaedic Trauma, 30(5), pp. 240–244.
Available at: https://doi.org/10.1097/bot.0000000000000492.
2. Pls explain the pathway of the Axillary nerve ?
A: Directly inferior to joint capsule, it travels posteriorly with post. circumfl ex humeral art.
thru quadrangular space, then bends anteriorly approx. 5cm distal to acromion. It can be
injured in glenohumeral dislocations and lateral approaches.
Axillary nerve is one of the terminal branches of posterior cord of brachial plexus, which is
most commonly injured during numerous orthopaedic surgeries, during shoulder
dislocation & rotator cuff tear. All these possible iatrogenic injuries are because of lack of
awareness of anatomical variations of the nerve. Therefore, it is very much necessary to
explore its possible variations and guide the surgeons to enhance the better clinical
outcome by reducing the risk and complications.
Gurushantappa, P.K. (2015) “Anatomy of axillary nerve and its clinical importance: A cadaveric
study,” JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH [Preprint]. Available
at: https://doi.org/10.7860/jcdr/2015/12349.5680.

2. 1. Why is CT scan necessary after post hip reduction ?
Recent articles and textbooks of orthopaedic traumatology recommend routine
computed tomography (CT) scans after successful reduction of simple posterior hip
dislocations. This is based on the belief that CT, even in cases with concentric
reductions, may identify fractures or intraarticular loose bodies not apparent on
standard radiographs. This study was conducted to assess the usefulness of CT after
concentric reduction of simple posterior hip dislocations. The hospital database was
searched for all traumatic hip dislocations in the past 4 years. Charts and radiographs
were reviewed, and only patients with simple posterior hip dislocations (no
acetabular or femoral head fractures) and a concentric reduction identified on plain
radiographs were included. Twenty-three patients who met these criteria and had
subsequent CT scans to evaluate the hip joint were identified. CT scans confirmed
the concentric reduction in all patients.
Frick, S.L. and Sims, S.H. (1995) “Is computed tomography useful after simple posterior
hip dislocation?,” Journal of Orthopaedic Trauma, 9(5), pp. 388–391. Available at:
https://doi.org/10.1097/00005131-199505000-00005.
2. What is the dangerous of Smith Petersen approach ?
Probably the most commonly injured structure with this approach is the lateral femoral
cutaneous nerve, which usually exits the pelvis close to the anterosuperior iliac spine and
runs in an oblique course down the thigh. The nerve is typically found in the lateral flap of
this approach, but if it crosses more medially than is normal, it may need to be sacrificed and
allowed to retract into the pelvis. The other structures at risk are the femoral nerve and artery.
The nerve sits more laterally than the artery and is encountered first. Additionally, it gives off
branches to the sartorius, and if there is any dissection along the medial aspect of the
sartorius, that muscle can be denervated. This nerve is anterior to the pectineus muscle,
which is generally used to protect the nerve. It may branch fairly high, sending offits motor
branches to the sartorius and the rectus.
Atlas of Orthopaedic Surgical ExposuresDOI: 10.1055/b-0034-39502

3. 1. The risk of beach chair position in proximal humeral head surgery ?
In the beach-chair position, the patient is placed supine on a dedicated
operating table (associated with additional costs) and then the table is
maneuvered into the desired semi-sitting position. Key considerations include
placing a cushion beneath the knees prior to elevating the trunk, maintaining
neutral alignment of the head, and using a positioning device to control the
arm. Cerebral hypoperfusion is recognised as one of the most serious
complications during arthroscopy in the beach-chair position and occurs in up
to 80% of patients.
a. Risk of cerebral hypoperfusion.
b. Potential mechanical block to using the arthroscope due to the supportive device
located at the posterior aspect of the medial border of the scapula.
c. Risk of eye injury with facemask.
Burkhart, S.S. and Nottage, W.M. (2001) “Current concepts of rotator cuff repair,” Advanced
Arthroscopy, pp. 81–88. Available at: https://doi.org/10.1007/978-0-387-21541-9_10.
2. How to prevent “screw cut out” complications in proximal humeral fracture ?
It was noted that this complication is more common in patients > 60 years in whom
osteoporotic bone is more likely to be found. We believe that the concept of subchondral
screw fixation (as in load bearing joint periarticular fractures such as femoral neck fractures)
is a misuse of the locking design for proximal humerus fractures in which rotator cuff tissue
integrity often exceeds that of the metaphyseal bone of the humeral tuberosities. For this
reason, we use short, divergent locking screws and suture fixation to minimize the risk of
varus malunion, plate failure, and intra-articular screw penetration. We have treated 53
proximal humerus fractures at our institution with this fixation technique. None have had
intra-articular screw penetration or cut-out and only two patients had an asymptomatic
varus malunion at an average follow-up of 16 months. It is our belief that such a technique
reduces the incidence of screw penetration into the glenohumeral joint and provides stable
fixation for healing. Further biomechanical and long-term clinical data are necessary to
substantiate these hypotheses.
Namdari, S. et al. (2012) “Fixation strategies to prevent screw cut-out and malreduction in
proximal humeral fracture fixation,” Clinics in Orthopedic Surgery, 4(4), p. 321. Available
at: https://doi.org/10.4055/cios.2012.4.4.321.

4. Deltopectoral Aprroach:
Advantageous:
- This approach has the advantage of allowing the surgeon to work through an internervous plane with a wide
exposure.
- This approach also allows the surgeon to convert from ORIF to hemiarthroplasty if required.
- The deltopectoral approach however requires significant soft tissue dissection to gain access to the lateral aspect
of the proximal humerus for fracture reduction and plate placement.
Disadvantageous:
- The musculocutaneous nerve is at risk from medial retraction when performing the deltopectoral approach. The
musculocutaneous nerve originates from the lateral cord of the brachial plexus. The most proximal motor branch
to the coracobrachialis muscle is located about 3 to 4 cm distal to the tip of the coracoid, being less than 5 cm in
75% of cases.
Deltoid Splitting Aproach:
Advantageous:
- The deltoid-splitting approach is favored by several authors since it allows a direct approach through the
fracture site between the greater and lesser tuberosities.
- allows for a more direct manipulation of the humeral head, as well as allowing plate and screw placement in
line with the incision
Disadvantageous:
- The deltoid-splitting approach has two major disadvantages.In anteroinferior fracture dislocations, the humeral
head fragment may not be accessible through this approach. In addition, the terminal anterior branch of the
axillary nerve may be inadvertently damaged thereby leading to potential deltoid dysfunction.
- the potential for injury to the anterior branch of the axillary nerve is its main disadvantage, as it may lead to
anterior deltoid dysfunction.

5. 1. what is serial debridement