1.

Open fracture classification

2. Hypovolaemic shock
3. Carpal tunnel syndrome

a. Anatomy

b. Diagnosis
 c. Prognostic factor
d. Cubital fossa anatomy
4. How to identify brachial artery

The brachial pulse can be located by feeling the bicep tendon in the area of the
antecubital fossa. Move the pads of your three fingers medial (about 2 cm) from the
tendon and about 2–3 cm above the antecubital fossa to locate the pulse
5. Compartment syndrome

I LAST STOPPED HERE TO BE CONTINUED NIGHT SHIFT

6. Necrotising fasciitis

Necrotizing fasciitis (NF), Necrotizing fasciitis is a life threatening infection that spreads
along soft tissue planes
Risk factors
o immune suppression
 diabetes
 AIDS
 cancer
o bacterial introduction
 IV drug use
 hypodermic therapeutic injections
 insect bites
 skin abrasions
 abdominal and perineal surgery
o other host factors
 obesity
Presentation
 Symptoms
o
o early
 1. localized abscess or cellulitis with rapid progression
 2. minimal swelling
 3. no trauma or discoloration
o
o late findings
 1. severe pain
 2. high fever, chills and rigors
 3. tachycardia

 Physical exam
o 1. skin bullae
o 2. discoloration
 3. ischemic patches
 4. cutaneous gangrene
o 5. swelling, edema
o 6. dermal induration and erythema
o 6. subcutaneous emphysema (gas producing organisms)

The very first symptom of NF. The center is clearly getting darker red (purple).
 

Early symptoms of necrotizing fasciitis. The darker red center is going black.
Necrotizing Fasciitis Classification
Type Organism Characteristics
Type 1 Polymicrobial • Most common (80-90%)
Typical 4-5 aerobic and • Seen in immunosuppressed (diabetics and cancer
anaerobic species cultured: patients)
• non-Group A Strep • Postop abdominal and perineal infections
• anaerobes including Clostridia
• facultative anaerobes
• enterobacteria
• Synergistic virulence between
organisms
Type 2 Monomicrobial • 5% of cases
• Group A β- • Seen in healthy patients
hemolytic Streptococci is most • Extremities
common organism isolated
Type 3 Marine Vibrio vulnificus • Marine exposure
(gram negative rods)
Type 4 MRSA

The start of necrotizing fasciitis

Diagnosis[edit]
 Necrotizing fasciitis producing gas in the soft tissues as seen on CT scan

Necrotizing fasciitis as seen on ultrasound[12]

Medical imaging[edit]
Imaging has a limited role in the diagnosis of necrotizing fasciitis
Plain radiography may show subcutaneous emphysema (gas in the subcutaneous tissue),
which is strongly suggestive of necrotizing changes, but it is not sensitive enough to detect
all the cases, because necrotizing skin infections caused by bacteria other than
clostridial infections usually do not show subcutaneous emphysema.
CT scan may show fascial thickening, edema, subcutaneous gas, and abscess formation.
MRI, when fluid collection with deep fascia involvement occurs, thickening or enhancement
with contrast injection, necrotizing fasciitis should be strongly suspected.
Ultrasonography can show superficial abscess formation, but is not sensitive enough to
diagnose necrotizing fasciitis.

Scoring system
LRINEC Scoring system
o score > 6 has PPV of 92% of having necrotizing fasciitis

 CRP (mg/L)
 ≥150: 4 points

 WBC count (×103/mm3)

 <15: 0 points
 15–25: 1 point
 >25: 2 points

 Hemoglobin (g/dL)
 >13.5: 0 points
 11–13.5: 1 point
 <11: 2 points
 Sodium (mmol/L)
 <135: 2 points

 Creatinine (umol/L)
 >141: 2 points

 Glucose (mmol/L)
 >10: 1 point

Operative
o emergency radical debridement with broad-spectrum IV antibiotics

 indications
-whenever suspicion for necrotizing fasciitis

 operative findings
-liquefied subcutaneous fat
-dishwater pus
-muscle necrosis
-venous thrombosis

 technique
hemodynamic monitoring with systemic resuscitation is critical
hyperbaric oxygen chamber if anaerobic organism identified

 antibiotics
 initial antibiotics
start empirically with penicillin, clindamycin, metronidazole, and an aminoglycoside
 definitive antibiotics
 penicillin G
for strep or clostridium
 imipenem or doripenem or meropenem
for polymicrobial
 add vancomycin or daptomycin
if MRSA suspected

o amputation
 indications
 low threshold for amputation when life threatening

7. Shoulder dislocation
1. Anterior Shoulder dislocation
- Identify the x-ray –
o a/w greater tubercle fracture/ axillary nerve injury always look for associated
fractures
o overlapping shadow of humeral head and glenoid fossa, head lying ant, medial &
below to socket
- Clinical Presentation
o Arm held in an abducted and ER position
 o Loss of normal contour of the deltoid & acromion prominent posteriorly &
laterally
o Humeral head palpable anteriorly
o All movements limited and painful
o Palpable fullness below the coracoid process and towards the axilla

- How to manage it – management in ED and ward

o Xray-to exclude fracture dislocation
o Cmr under sedation
o Check xray
o Arm sling (3weeks-young pt, risk recurrence) (1 week-stiffness is a risk)
- How to perform
o Kocher
 Bend the affected arm at 90º at the elbow, adducted against the body;
the wrist and the point of the elbow can be grasped by the surgeon.
Slowly externally rotate between 70º to 85º until resistance is felt; in a
conscious patient take plenty of time and try to distract the patient with
conversation and then continue. Lift the externally rotated upper arm in
the sagittal plane as far as possible forwards now internally rotate the
shoulder this brings the patient's hand towards the opposite shoulder".
The humeral head should now slip back into the glenoid fossa with pain
eliminated during this process.


o Stimpson
  Stimson's Method usually requires the patient to have a powerful
anagelsic beforehand, and has the patient prone on a table with the
affected arm hanging down in forward flexion. A sandbag is placed
under the clavicle on the affected side, and an approx. 10lb weight is
applied to the wrist on the affected side. The spasming muscles
eventually relax and the joint normally reduces spontaneously


o Hippocrates
 Hippocratic Method begins with the patient supine, the surgeon grasps
the affected side at the hand and forearm. The stockinged heel of the
surgeon is placed in the axilla (not pressed hard) this acts as a fulcrum
whilst the arm is adducted9. Potential complication can result in
damage to the axillary nerve


o sedation and antidote for cmr
- What are the complications
- What plating to use in humerus fracture
- What are the nerves affected, how to check for it
- How to manage axillary nerve injury
- Cover other types of dislocations and cmr techniques
- Post cmr management- how to decide if check xray is acceptable
- CMR sedation and dosage, what to monitor- how frequent post op spo2 monitoring
- * by products of opiods
- Inferior dislocation x-ray

8. Hip dislocation
2. Posterior Hip Dislocation
- Why posterior ?
o Dashboard injury
o Femur thrust in posterior direction & femoral head forced out of socket
o increasing flexion and adduction favors simple dislocation
o associated with
 osteonecrosis
 posterior wall acetabular fracture
 femoral head fractures
 sciatic nerve injuries
  ipsilateral knee injuries

- Clinical presentation – how to examine

o Leg shortened, ADDucted, INTernally rotated, slightly flexed

- Identify on x-ray, state the hip lines, indication of the lines

o Femoral head out of pocket & above acetabulum
o Femoral head is usually displaced posterior, superior, and slightly lateral to the
acetabulum

o femoral head smaller then contralateral side

o Shenton's line broken
o Lesser trochanter shadow reveals internally rotated limb as compared to
contralateral side
o scrutinize femoral neck to rule out fracture prior to attempting closed reduction
o AP pelvis and Judet views after reduction to evaluate associated acetabular
fractures

- How to differentiate between ant and post hip dislocation on xray

- Other features on x ray include –

o LT cannot be visualized, femoral head appears higher than acetabulum

- Methods to reduce it-cmr 3 methods, explain stimson method

o Stimson Method
 believed to be least traumatic;
 pt is in prone position w/ lower limbs hanging from end of table;
 assistant immobilizes the pelvis by applying pressure on the sacrum;
 hold knee and ankle flexed to 90 deg & apply downward pressure to leg
just distal to the knee;
 gentle rotatory motion of the limb may assist in reduction;
o Alli’s Maneuver
 patient is placed in the supine position;
 knee is flexed to relax the hamstrings;
 assistant stabilizes the pelvis and applies a lateral traction force to the
inside of the thigh;
 longitudinal traction is applied in line w/ axis of femur, and the hip is
slightly flexed;
 essential feature is traction in direct line of deformity, followed by
gentle felxion of the hip to 90 deg;
  surgeon gently adducts & internal rotates the femur to get reduction;hip
is gently rotated internally & externally w/ continued longitudinal
traction until reduction is achieved

- Sedation dose and reversal

o Midazolam 1amp= 5mg/5ml
 Slow iv
 1-2.5mg (0.1mg/kg)
 Not exceed 2.5mg
 Children (0.1mg/kg)
 Antidote: flumazenil: 0.02mg/kg
o Pethidine 1amp= 100mg/2ml
 Dilution: 2ml pethdine + ml water for injection (1ml=10mg)
 Adult: 25-50mg (1mg/kg)
 Elderly (not exceed 25mg
 Children (0.5-1mg/kg)
 Antidote: Naloxone (0.01mg/kg)

- Other associated injury of broken shenton line –

o sciatic nerve injury
- Complications of the dislocation
o Post-traumatic arthritis
 up to 20% for simple dislocation, markedly increased for complex
dislocation
o Femoral head osteonecrosis
 5-40% incidence
 Increased risk with increased time to reduction
o Sciatic nerve injury
 8-20% incidence
 associated with longer time to reduction
o Recurrent dislocations
 less than 2%
- Management in a 30 y/o patient – cannulated screw

9. Proximal humerus fracture

10. Ankle fracture

Anatomy

The tibia and fibula have specific parts that make up the ankle:
 Medial malleolus - inside part of the tibia
 Posterior malleolus - back part of the tibia
 Lateral malleolus - end of the fibula

For example, a fracture at the end of the fibula is called a lateral malleolus fracture, or if both
the tibia and fibula are broken, it is called a bimalleolar fracture.

Two joints are involved in ankle fractures:

 Ankle joint - where the tibia, fibula, and talus meet

 Syndesmosis joint - the joint between the tibia and fibula, which is held
together by ligaments

Cause

 Twisting or rotating your ankle

 Rolling your ankle
 Tripping or falling
 Impact during a car accident

Symptoms

 Immediate and severe pain

 Swelling
 Bruising
  Tender to touch
 Cannot put any weight on the injured foot
 Deformity ("out of place"), particularly if the ankle joint is dislocated as well

Treatment: Lateral Malleolus Fracture

A lateral malleolus fracture is a fracture of the fibula.

There are different levels at which that the fibula can be fractured. The level of the fracture
may direct the treatment.

Different levels of lateral malleolus fractures

Nonsurgical Treatment

You may not require surgery if your ankle is stable, meaning the broken bone is not out of
place or just barely out of place. A stress x-ray may be done to see if the ankle is stable.

Several different methods are used for protecting the fracture while it heals. ranging from a
high-top tennis shoe to a short leg cast. Some physicians let patients put weight on their leg
right away, while others have them wait for 6 weeks.

You will see your physician regularly to repeat your ankle x-rays to make sure the fragments
of your fracture have not moved out of place during the healing process.

Surgical Treatment

If the fracture is out of place or your ankle is unstable, your fracture may be treated with
surgery. During this type of procedure, the bone fragments are first repositioned (reduced)
into their normal alignment. They are held together with special screws and metal plates
attached to the outer surface of the bone.

Treatment: Medial Malleolus Fracture

A medial malleolus fracture is a break in the tibia, at the inside of the lower leg. Fractures
can occur at different levels of the medial malleolus.
Medial malleolar fractures often occur with a fracture of the fibula (lateral malleolus), a
fracture of the back of the tibia (posterior malleolus), or with an injury to the ankle
ligaments.

Nonsurgical Treatment

If the fracture is not out of place or is a very low fracture with very small pieces, it can be
treated without surgery.

A stress x-ray may be done to see if the fracture and ankle are stable.

The fracture may be treated with a short leg cast or a removable brace. Usually, you need to
avoid putting weight on your leg for approximately 6 weeks.

You will need to see your physician regularly for repeat x-rays to make sure the fracture does
not change in position.

Surgical Treatment

If the fracture is out of place or the ankle is unstable, surgery may be recommended.

(Left) X-ray of a medial malleolus fracture. (Right) Surgical repair of a medial malleolus fracture with
a plate and screws.
In some cases, surgery may be considered even if the fracture is not out of place. This is done
to reduce the risk of the fracture not healing (called a nonunion), and to allow you to start
moving the ankle earlier.

A medial malleolus fracture can include impaction or indenting of the ankle joint. Impaction
occurs when a force is so great it drives the end of one bone into another one. Repairing an
impacted fracture may require bone grafting. This graft acts as a scaffolding for new bone to
grow on, and may lower any later risk of developing arthritis.
Depending on the fracture, the bone fragments may be fixed using screws, a plate and
screws, or different wiring techniques.

Treatment: Posterior Malleolus Fracture

A posterior malleolus fracture is a fracture of the back of the tibia at the level of the ankle
joint.

In most cases of posterior malleolus fracture, the lateral malleolus (fibula) is also broken.
This is because it shares ligament attachments with the posterior malleolus. There can also
be a fracture of the medial malleolus.

Depending on how large the broken piece is, the back of the ankle may be unstable. It is
important for a posterior malleolus fracture to be diagnosed and treated properly because of
the risk for developing arthritis.

Nonsurgical Treatment

If the fracture is not out place and the ankle is stable, it can be treated without surgery.

Treatment may be with a short leg cast or a removable brace. Patients are typically advised
not to put any weight on the ankle for 6 weeks.

Surgical Treatment

If the fracture is out of place or if the ankle is unstable, surgery may be offered.

Different surgical options are available for treating posterior malleolar fractures. One option
is to have screws placed from the front of the ankle to the back, or vice versa. Another option
is to have a plate and screws placed along the back of the shin bone.

Treatment: Bimalleolar Fractures or Bimalleolar Equivalent Fractures

"Bi" means two. "Bimalleolar" means that two of the three parts or malleoli of the ankle are
broken. (Malleoli is plural for malleolus.)

In most cases of bimalleolar fracture, the lateral malleolus and the medial malleolus are
broken and the ankle is not stable.

A "bimalleolar equivalent" fracture means that in addition to one of the malleoli being
fractured, the ligaments on the inside (medial) side of the ankle are injured. Usually, this
means that the fibula is broken along with injury to the medial ligaments, making the ankle
unstable.

A stress test x-ray may be done to see whether the medial ligaments are injured.

Nonsurgical Treatment

These injuries are considered unstable and surgery is usually recommended.

Nonsurgical treatment might be considered if you have significant health problems, where
the risk of surgery may be too great, or if you usually do not walk.

Immediate treatment typically includes a splint to immobilize the ankle until the swelling
goes down. A short leg cast is then applied. Casts may be changed frequently as the swelling
subsides in the ankle.

You will need to see your physician regularly to repeat your x-rays to make sure your ankle
remains stable.

In most cases, Weightbearing is not be allowed for 6 weeks. After 6 weeks, the ankle may be
protected by a removable brace as it continues to heal.

Surgical Treatment

Surgical treatment is often recommended because these fractures make the ankle unstable.

Lateral and medial malleolus fractures are treated with the same surgical techniques as
written above for each fracture listed.

(Left) X-ray of bimalleolar ankle fracture. (Right)Surgical repair bimalleolar ankle fracture.

Treatment: Trimalleolar Fractures

"Tri" means three. Trimalleolar fractures means that all three malleoli of the ankle are
broken. These are unstable injuries and they can be associated with a dislocation.

Nonsurgical Treatment

These injuries are considered unstable and surgery is usually recommended.

As with bimalleolar ankle fractures, nonsurgical treatment might be considered if you have
significant health problems, where the risk of surgery may be too great, or if you usually do
not walk.

Nonsurgical treatment is similar to bimalleolar fractures, as described above.

Surgical Treatment

Each fracture can be treated with the same surgical techniques as written above for each
individual fracture.

(Left) X-ray of trimalleolar ankle fracture. (Right) Surgical repair.

Treatment: Syndesmotic Injury

The syndesmosis joint is located between the tibia and fibula, and is held together by
ligaments. A syndesmotic injury may be just to the ligament -- this is also known as high
ankle sprain. Depending on how unstable the ankle is, these injuries can be treated without
surgery. However, these sprains take longer to heal than the normal ankle sprain.

In many cases, a syndesmotic injury includes both a ligament sprain and one or more
fractures. These are unstable injuries and they do very poorly without surgical treatment.

Your physician may do a stress test x-ray to see whether the syndesmosis is injured.
(Left) X-ray of syndesmotic injury with lateral malleolus fracture. Note the space between the tibia
and fibula. (Right) Surgical repair.

Recovery

Because there is such a wide range of injuries, there is also a wide range of how people heal
after their injury. It takes at least 6 weeks for the broken bones to heal. It may take longer for
the involved ligaments and tendons to heal.

As mentioned above, your doctor will most likely monitor the bone healing with repeated x-
rays. This is typically done more often during the first 6 weeks if surgery is not chosen.

Pain Management

Pain after an injury or surgery is a natural part of the healing process. Your doctor and
nurses will work to reduce your pain, which can help you recover faster.

Medications are often prescribed for short-term pain relief after surgery or an injury. Many
types of medicines are available to help manage pain, including opioids, non-steroidal anti-
inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of
these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery or an injury, they are a
narcotic and can be addictive. It is important to use opioids only as directed by your doctor.
As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain
has not begun to improve within a few days of your treatment.

Rehabilitation

Rehabilitation is very important regardless of how an ankle fracture is treated.

When your physician allows you to start moving your ankle, physical therapy and home
exercise programs are very important. Doing your exercises regularly is key.

Eventually, you will also start doing strengthening exercises. It may take several months for
the muscles around your ankle to get strong enough for you to walk without a limp and to
return to your regular activities.

Again, exercises only make a difference if you actually do them.

Weightbearing

Your specific fracture determines when you can start putting weight on your ankle. Your
physician will allow you to start putting weight on your ankle when he or she feels your
injury is stable enough to do so.

It is very important to not put weight on your ankle until your physician says you can. If you
put weight on the injured ankle too early, the fracture fragments may move or your surgery
may fail and you may have to start over.

11. Holstein-lewis fracture of humerus and level of radial nerve injury (very high, high, low)

Holstein–Lewis fracture

Holstein–Lewis fracture at 5 weeks post fracture

Specialty Orthopedic
A Holstein–Lewis fracture is a fracture of the distal third of the humerus resulting
in entrapment of the radial nerve.

Anatomy and pathology

The radial nerve is vulnerable to injury with fractures of the humeral shaft as it lies in very
close proximity to the bone (it descends within the spiral groove on the posterior aspect of
the humerus). Characteristic findings following injury will be as a result of radial nerve palsy
(e.g. weakness of wrist/finger extension and sensory loss over the dorsum of the hand).
The vast majority of radial nerve palsies occurring as a result of humeral shaft fractures are
neurapraxias (nerve conduction block as a result of traction or compression of the nerve),
these nerve palsies can be expected to recover over a period of months. A minority of
palsies occur as a result of more significant axonotmeses (division of the axon but
preservation of the nerve sheath) or the even more severe neurotmeses (division of the
entire nerve structure). As a result, it is important for individuals sustaining a Holstein–Lewis
injury to be carefully followed up if there is no evidence of return of function to the arm after
approximately three months, further investigations and possibly, nerve exploration or repair
may be required. The exception to this rule is if the fracture to the humerus requires fixing in
the first instance. In that case, the nerve should be explored at the same time that fixation is
performed.
 12. Anatomy tibia
13. Anatomy femur
14. Humerus bony landmark
15. Right or left posterior medial lateral landmark
16. Capsule of hip joint
17. Brachial plexus

https://www.youtube.com/watch?v=Z_Y_kVdH9zE