Tips for houseman in orthopedics department
skeletal traction
SAFE ZONES FOR SKELETAL TRACTION
*Proximal Tibial Traction*
- 2cm distal and posterior to tibial tubercle
- Pin should be driven from the lateral to the medial side to avoid damage to the common peroneal nerve
*Distal Femoral Traction*
- Draw 1st line from before backwards at the level of the upper pole of patella, 2nd line from below upwards anterior to the head of the fibula, where these two lines intersect is the point of insertion of a Steinmann pin
- Just proximal to lateral femoral condyle. In average adult this point liew nearly 3cm from the lateral knee joint line
*Distal Tibial Traction*
- Pin inserted 5cm above the level of the ankle joint, midway between the anterior and posterior borders of the tibia
- Avoid saphenous vein
- Place through fibula to avoid peroneal nerve
*Calcaneal Traction*
- Insert about 1.5 inches (4cm) inferior and posterior to medial malleolus
- Pin is driven from medial to lateral side of the calcaneus
- Do not skewer subtalar joint or NV bundle
regional block
Ankle block
5 Nerve involved
https://www.slideshare.net/lihyinchong/peripheral-nerve-blockankle-blockwrist-block-digital-block
Superficial peroneal nerve , sural nerve, sapheneous nerve, posterior tibial nerve, deep peroneal nerve
Anatomical landmark
Deep peroneal nerve
In the groove lateral to extensor hallucinations longus
Posterior tibial nerve
Behind the medial malleolus
Sapheneous nerve
At the level of the medial malleolus
Superficial peroneal nerve
Laterally to the lateral malleolus
Sural nerve
At the level of the lateral malleolus
Wrist block
Radial, ulna and median nerve
Radial - just proximal to the radial styloid
Median - located between the flexor palmaris longus and the flexor carpi radialis
Ulnar - under the tendon of the flexor carpi ulnaris muscle close to its distal attachment just above the styloid process of the ulna
Digital nerve
Main digital nerves accompanied by digital vessels run in the ventrolateral aspect of the finger immediately to the flexor tendon sheath
LA inserted at the point of dorsalateral aspect of the base of finger and directed anteriorly towards the base of the phalanx
Sedation during CMR
Kid: Atropine 0.01-0.02mg/kg
Ketamine 0.5-2.0mg/kg (normally give 1mg/kg)
Adult: pethidine 25-50mg
Midazolam 2.5-7.5mg (0.1-0.2mg/kg, usually adult give 5mg from Frank Shann)
(1vial is 5mg/ml, dilute with Normal saline in total 5 ml, =1mg/ml, give accordingly, e.g. 3ml = 3mg)
Tibial pin insertion:
⁃ Allen key
⁃ Steinmann pin
⁃ Mallet pin
⁃ T handle
⁃ T&S set
⁃ Pethidine, lignocaine
Skeletal traction: 10% of BW , max 10kg
Skin traction: 5% of BW, max 5kg
APS: IV Fentanyl 100mcg, IV Morphine 10mg in 10 cc, iv ketamine 5ml
Source of infection: urti, pneumonia, uti, dvt, thrombophlebitis, ssi, fat embolism
Sodium bicarbonate dressing for tophi
Vacuum dressing-
Kaltostat (alginate)- moderately/severe exudating wound
Hydrogel - provide moisture
Hydrcolloid (eg duoderm): minimally
exudating wound, act as dressing for epithelizing wounds
Gelling fibres eg aquacel
Foams
Films
Paraffin gauze eg bactigrass, jelonet
Silver
Charcoal
NPWT
LRINEC Score
How to approach spine case
Ugih
When patient collapse
Charcot/ PTTD
DKA
Capillary blood glucose >11mmol/L
Urine ketone 2+
Venous pH <7.3, HCO3 <15
TB workup : fbc, esr, crp, mantoux, SAFB 1-3, sputum tb culture, cxr
Cervical spine nexus criteria (if meet any, need ct cervical spine)
⁃ altered level of consciousness
⁃ Intoxication
⁃ Posterior midline tenderness
⁃ Focal neurological deficit
⁃ Painful distracting injury
Unstable spinal injury
⁃ Neurological deficit
⁃ 2 columns or more
⁃ Posterior element injury
⁃ Lost more than 50% anterior vertebral body height
⁃ Greater than 25 to 35 deg kyphosis
⁃ angulation of thoracolumbar junction > 20 deg
⁃ canal comprimise > 30 percent
Juwett brace immobilize T6-L2 (if patient thin, up to L3)
⁃ bony/ soft tissue swelling
⁃ Malignant / benign
Soft tissue sarcoma (malignant): size >5cm, deeper than deep fascia
Dorsal ganglion cyst more common (scaplolunate joint common), recur and disappear (one way valve - two way valve)
Swelling first , pain later is soft tissue (pain due to central necrosis, or stretching of surrounding tissue)
Pain first, swelling later is bone swelling
Subcutaneous swelling- mobile, skin not pinchable
Fat - mobile, skin pinchable
Muscle- more mobile in transverse plane than vertical plane, less mobile and border less distinct when contract muscle, skin pinchable
SITS
Suprapinatus- job ‘s test ( thumb point down more pain - positive , repeat with thumb up - less pain)
Infraspinatus, Teres minor - external rotator
Subscapularis- lift off, Napoleon, belly press, bear hug test
neer’s test, Impingement test (with lignocaine- more specific)
Hawkin’s test
Empty can test
Drop arm test (massive rotator cuff tear)
Yergason test (bicipital tendonitis)
Speed test
Crank test
Sulcus sign
Apprehension test , jobes relocation test, release
Duga’s test
Question for those of you that work with young children: what is the best affordable Pulse Oximeter and probe for infants / babies?
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