PBL # 5: UNABLE TO MOVE

UNFAMILIAR TERMS: 1. 2. 3. 4. 5. Acetabulum: concave surface of the pelvis Open reduction and fixation Suxamethonium Vecuronium Dantrolene

ISSUES: 1. What structures were damaged that made it extremely painful to move his lower limb? 2. Why did the orthopaedic surgeon decide to perform an open reduction and fixation? 3. Why was suxamethonium administered intravenously? 4. How did suxamethonium facilitate Troys intubation and artificial ventilation? 5. What is the importance of maintaining muscle relaxation for the duration of the operation? 6. Why was vecuronium given after the airway was secured? 7. What drastic adverse effects did Troy have to the anaesthesia and why did he experience it? 8. How did dantrolene alleviate his condition? 9. Why was there a recovery period of 48 hours? 10.What adaptation was made to the surgery protocol?

HYPOTHESES: 1. The structures that were damaged that made it extremely painful to move his lower limbs are the sciatic nerve, biceps femoris, semitenidous and semi membranosus.

2. Open reduction and fixation was decided upon to reduce the dislocation and to ensure that displaced fragments from the fractured acetabulum were not within the joint cavity and preventing break down of cartilaginous surface and dysfunction of the hip joint. 3. The suxamethonium was given intravenously as a bolus to allow for fast distribution throughout the circulatory system. 4. Suxamethonium is a short acting skeletal muscle relaxant which prevents contraction of Troys pharyngeal and laryngeal muscles to allow intubation. 5. Muscle relaxants were used to prevent displacement of the intubation tube, to prevent muscle spasms from occurring in the leg and other complications during the surgery. 6. Vecuronium is a longer acting, non depolarising neuromuscular blocker which was given in maintainence dosages. 7. Troys adverse reaction was malignant hyperthermia which is a rare hereditary disorder which is caused by the impairment in the ability of the sarcoplasmic reticulum to sequester calcium. In addition the genetic mutation leads to increased sensitivity of the ryanodine receptors and dihydropyridine receptors which make them remain open for a prolonged period of time after stimulation/activation; causing increased calcium concentration in the cytosol ; causing increased muscle contraction and therefore leads to increased heat production. 8. Dantrolene blocks the ryanodine receptors; therefore decreasing the amount of calcium being released from the sarcoplasmic reticulum. 9. His recovery period was due to the fact that he lacked the enzyme; plasma cholinesterase which caused in the decreased ability to quickly metabolise the suxamethonium and also Troys treatment for malignant hyperthermia which includes decreasing his body temperature back to normal. 10.The adaptations that were made were the use of a different anaesthesia.

OBJECTIVES: 1. Discuss the anatomy of the hip joint and the muscles associated. 2. Discuss the pharmacology of vecuronium, suxamethonium and dantrolene. 3. Discuss the procedure of an open reduction and fixation. 4. Describe the common injuries of the hip including dislocations and fractures. 5. Explain how sarcoplasmic reticulum and plasma membrane control calcium in the muscle cytosol. 6. Describe the possible adverse reactions to anaesthesia. 7. Review the structure of the neuromuscular junction.