Pilon fractures refer to fractures of the distal tibial articular surface. They account for 5-7% of all tibial fractures and are usually caused by high-energy impacts. Pilon fractures are classified using the AO/OTA system into extra-articular, partial articular, or intra-articular fractures depending on the degree of articular involvement. Treatment depends on the fracture type and soft tissue status, ranging from non-surgical management with casting for non-displaced fractures to surgical options like open reduction internal fixation or external fixation followed by delayed internal fixation to restore the articular surface and alignment while protecting soft tissues. Complications can include wound issues, malunion, nonunion, and post-traumatic
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Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
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1) Subtrochanteric Fracture
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called peritrochanteric fracture.
*Unique Aspect
Blood loss is greater than with femoral neck or trochanteric fractures – covered with anastomosing branches of the medial and lateral circumflex femoral arteries branch of profunda femoris trunk.
2) Femoral Shaft Fracture
Femoral shaft fracture is defined as a fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle
The femoral shaft is padded with large muscles.
- reduction can be difficult as muscle contraction displaces the fracture
- healing potential is improved by having this well-vascularized
*Age
-usually a fracture of young adults and results from a high energy injury
-elderly patients should be considered ‘pathological’ until proved otherwise
-children under 4 years the suspected possibility of physical abuse
*FRACTURES ASSOCIATED WITH VASCULAR INJURY
Warning signs of an associated vascular injury are
(1) excessive bleeding or haematoma formation; and
(2) paraesthesia, pallor or pulselessness in the leg and foot.
~Warm ischemia in 2-3H
~If > 6H – salvage not possible
*‘FLOATING KNEE’
Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating’
3) Distal Femoral Fracture
Defined as fractures from articular surface to 5cm above metaphyseal flare
*clinical feature
The knee is swollen because of a haemarthrosis – this can be severe enough to cause blistering later
Movement is too painful to be attempted
The tibial pulses should always be checked to ensure the popliteal artery was not injured in the fracture.
Reference: Apley's System of Orthopaedic and Fracture (9th edition)
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.
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Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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2. What is
Pilon fracture?
• All the fractures of the distal tibia involving
the distal articular surface should be classified
as pilon fractures
except medial, lateral & tri-malleolar fractures where the
posterior malleolus is< 13 of the articular surface
If isolated fracture of the posterior malleolus which is more
than 1/3 of articular surface should also called as pilon
fracture.
3. ANATOMY
• TIBIAL PILON: Distal end
of Tibia including
articular surface
• Proximal limit of tibial
pilon ; 8 to 10 cm from
the tibial articular
surface
EXCLUDING BI-MALLEOLAR
&TRIMALLEOLAR fractures
4. EPIDIOMOLOGY
• Accounts for approximately 5-7% of all tibial fractures
• Accounts for <1% of all lower extremity fractures
• Average age ;35-40 years rare in children and elderly
• Common in men than women; (3:1)
• High energy fractures 25 to 50% of the patients have
additional injuries
5. MECHANISM
• Pilon fractures are most often caused by axial
loading (high energy impacts)
• such as fall from height
• motor vehicle accident
-leads to high degree of disruption of articular surface and soft tissue
affection
• It may be caused by shear loading (rotational or lower
energy impacts)
Leads to less degree of disruption of articular surface
6. EVALUATION OF PILON FRACTURES
1. Presentation of patient
2. Physical examination
3. Imaging
11. IMAGING
• ROUTINE X RAYS –
1. Anterio-posterior
2. Lateral
3. Mortise view
Ct scan – to know the fracture pattern and intra-
articular involvement.
12. CT Scan
• Extent of articular involvement
• Orientation of fracture
• Extent of comminution or
impaction of fracture
• Surgical decision making
13. The classic articular components of pilon
fractures
• Anterolateral(chauput fragment)
• Medial fragment bearing medial
malleolus
• Posterior malleolus
• Die punch fragment
15. AOOTA CLASSIFICATION
• Three main subgroups
A) Extrarticular(4,3-A)
B) Partial articular(4,3-B)
C) Intra aricular(4,3-C)
• These fractures are further divided in to sub-groups
depending upon the comminution
• Most of B- type fractures are torsional injuries
and
C-type of fractures are high energy compressive injuries
16.
17.
18. Associated injuries
• Because of their high energy nature, these
fractures can be expected to have specific
associated injuries like
1. Calcaneal fractures
2. Tibial pleatue fractures
3. Pelvic fractures
4. Vertebrae fractures
20. • Surgical treatment of tibia pilon fractures is challenging
because of articular comminution, metaphyseal bone loss
and serious soft tissue injury.
• Management of this injury must include articular surface and
metaphysis reconstruction as well as treatment of injured soft
tissue envelope.
• Timing of surgery is crucial in pilon fractures because of
extensive soft tissue damage.
• Main target of treatment is preserving the function of the
ankle
21. Goals of surgical treatment
1. To obtain anatomical articular alignment
2. Restore axial alignment
3. Achieve joint stability
4. Regain pain-free and functional mobility
5. Avoiding INFECTIONS
22. Treatment challenges
• Difficult to get anatomical restoration of joint
• Instability of ankle -ligament and soft tissue
injuries
• High soft tissue complication
• Open surgery –high incidence of poor wound
healing,infection,delayed union and non-union
23. Three important anatomical zones to
be considered in the decision
making treatment and prognosis
• Articular surface
• Metaphysis
• Fibula
25. Non-surgical
• Undisplaced fracture and debilitated patients
A1,B1 and C1
Long leg cast for 6 weeks fallowed by brace and ROM excercises
Disadvantages;
• Loss of reduction
• Inability to monitor soft tissue status in the cast
37. First step
• 1. Fix the # fibula(90%)
through postero lateral
approach to regain the
correct length of the tibia
and facilitate three
dimensional view of the
fracture
• 2.External fixator-
• a)Ankle Spanning
b) Non spanning - illizarov
-hybrid
38.
39.
40.
41.
42. Second stage
• After 10-14 days average(10
days)
• Remove the Ex Fix
• Through antero lateral incision
• Articular reduction & fixation
with pre countered plate and
screws
• Additional antero medial
incision may require to fix
MM or large medial fragment
• Two incision required-
maintain not<6-7 cm between
two incision
43.
44. Open Pilon Fracture
• Usually –C fractures
meticulous debridment+Ex Fix
soft tissue cover(plastic surgery)
delayed definitive ORIF