Frykman Classification of Distal Fracture of base of the first Neer classification of proximal humeral head #

Radial # metacarpal bone 1-part 2-part 3-part 4-part

GT GT+SN “CLASSIC”

SN LT+SN (RARE) “VALGUS IMPACTED”

Galeazzi Fracture
LN (RARE)
Impression # Head split

Gartland’s classification of supracondylar

Fracture shaft of ulnar, together with distal third of radius with fracture of humerus
disruption of the proximal radioulnar dislocation or subluxation of distal
joint and dislocation of radiocapitallar radio-ulnar joint
joint

Salter–Harris fracture
= Fracture that involves the epiphyseal plate or growth
plate of a bone

Type I: undisplaced or minimally displaced fractures.

Type II: displaced with posterior cortex intact
Type III: displaced with no cortical intact

Gustillo Anderson Classification of Open

Fracture
I – open fracture with a wound <1cm and clean
II – open fracture with wound > 1cm with extensive soft tissue
damage and avulsion of flaps
IIIa – open fracture with adequate soft tissue coverage of bone in
• Galeazzi fracture - a fracture of the radius spite of extensive soft tissue laceration or flaps or high energy
with dislocation of the distal radioulnar joint trauma irrespective of size of wound
• Colles' fracture - a distal fracture of the
IIIb – open fracture with extensive soft tissue loss, periosteal
radius with dorsal (posterior) displacement of
the wrist and hand stripping and exposure of bone
• Smith's fracture - a distal fracture of the IIIc – open fracture associated with an arterial injury which requires
radius with volar (ventral) displacement of the I II IIIa IIIb IIIc repair
wrist and hand
• Barton's fracture - an intra-articular
fracture of the distal radius with dislocation of Irrigation: 3L 6L 9L ORTHOPAEDICS CLASSIFICATION
the radiocarpal joint
• Essex-Lopresti fracture - a fracture of PART 1 (UPPER LIMB)
the radial head with concomitant dislocation HTARW5B/GKS2013/3-
of the distal radio-ulnar joint with disruption of Together In Delivering Excellence (T.I.D.E.)
the interosseous membrane
Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah
 Letournel classification acetabular # Pipkin classification of femoral head fracture
Simple Types

Anterior column Anterior wall Posterior column Posterior wall Transverse

Associated Types

Type I - # below fovea/ligamentum (small)

Type II - # above fovea/ ligamentum (larger)
Type III - type I or II with associated femoral neck # (high risk of AVN)
Type IV - type I or II with associated acetabular #
T-type Transverse Posterior column Anterior + posterior Both columns
+ posterior wall + posterior wall hemitransverse

Garden classification of femoral neck #

Russel Taylor classification of subtrochanteric #

Garden I fracture Garden II fracture Garden III fracture Garden IV fracture

incomplete and complete and complete and complete displaced with
minimally nondisplaced partially displaced no engagement of the 2
displaced principal fragment

Evan classification of intertrochanteric #

Schatzker classification of tibia plateau #

Evan 3 Displaced 3 Evan 4 Displaced 3 Evan 5 Displaced 4

Evan I Evan 2 parts fracture with parts fracture with parts fracture with
Undisplaced 2 Displaced 2 posteromedial large posteromedial comminution
parts fracture parts fracture comminution comminuted involving both
fragment trochanters

Lateral tibial Lateral tibial Focal Medial tibial Bicondy Tibial

plateau # w/o plateau # depression plateau #, lar tibial plateau
depression with
depression
with no
associated
with or
without
plateau
#
fracture with
diaphyseal
Lisfranc classification of tarsometatarsal injury
split depression discontinuity

Winquist classification of femoral shaft fracture Sanders classification of calcaneal

fractures
I. Tiny cortical fragment lateral

II. Butterfly fragment is I - # are non-displaced # (displacement < 2 mm).

large but there is still medial II - # consist of a single intrarticular # that divides the
50%of cortical intact calcaneus into 2 pieces.
IIA: # occurs on lateral aspect of calcaneus.
between the main IIB: # occurs on central aspect of calcaneus.
fragments IIC: # occurs on medial aspect of calcaneus.
Homolateral Isolated Divergent
III # consist of 2 intrarticular fractures that divide the
III. Butterfly fragment Type IIA Type IIB Type IIC
calcaneus into 3 articular pieces.
involves more than
50% of the bone
IIIAB: 2 # lines are present, 1 lateral and 1 central.
IIIAC: 2 # lines are present, 1 lateral and 1 medial.
ORTHOPAEDICS CLASSIFICATION
IIIBC: 2 # lines are present, 1 central and 1 medial.
width IV # consist of # with more than 3 intrarticular PART 2 (PELVIC & LOWER LIMB)
IV. Segmental fractures fractures. HTARW5B/GKS2013/3b-
Together In Delivering Excellence (T.I.D.E.)
Type IIIAB Type IIIAC Type IIIBC Type IV Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon,
Ling Ying, Siew Ling, Quah
 Localisation of level of injury
DENIS THREE COLUMN CONCEPT Wrist extension
Vertebral spine Spinal Cord Segment C6
Anterior column: C1-C7 Add 1 Elbow flexion
AAL: Anterior longitudinal ligament T1-T6 Add 2
AAF: Anterior annulus fibrosus
T7-T9 Add 3
Middle column: T10 L1,L2
PLL: Posterior longitudinal ligament T11 L3,L4
PAF: Posterior annulus fibrosus T12 L5,S1
L1 rest of sacrococcygeal Wrist flexion
Posterior column: Finger flexion Finger
SSL: Supraspinous ligament
segment abduction
ISL: Interspinous ligament
LF: Ligamentum flavum Upper limb myotomes
PC: Facet capsule
and dermatomes Finger Extension T1

DENIS CLASSIFICATION OF SPINAL TRAUMA # Type &

column
Anterior Middle Posterior
Central cord Anterior cord
column column column lesion lesion
MAJOR INJURIES MINOR INJURIES involvement

Compression None or
• Upper > lower • Motor -
• Transverse process # Compression None limb involved • Sensory -
# distraction
• Articular process # • Sacral sparing • Proprioception +
• Par interarticularis # None or
Burst # Compression Compression • Due to • Due to
• Spinous process # distraction
hyperextension/ hyperextension
None or Spine OA with disc or bone
Seatbelt Distraction Distraction
compression compressing ant
spinal a
Compression Distraction Distraction
Fracture/disl
±rotational/ ±rotational/ ±rotational/
ocation
shear shear shear Cord hemisection
Posterior cord
(Brown Sequard
lesion
Criteria of unstable spine injury Bulbocavernosus Syndrome)
Stable fractures - don't cause spinal deformity or neurologic deficit, • On palpation gap between 2 spinous processes reflex
• Proprioception - • Ipsilateral
still able to weight bear increased involves monitoring anal
• Motor + paralysis with
• Neurological deficit sphincter contraction in
Unstable fractures - unable to weight bear, may progress and response to squeezing • Sensory + contralateral loss
• Vertebral compression >1/3 of pain sensation
causing further neurological and structural damage. • Vertebral displacement >1/3 the glans penis or
tugging on an indwelling
• Due to unilateral
• Vertebral canal compromisation > 1/3 lamina or pedicle
• Bilateral facet joints dislocation Foley catheter
TLICS:Thoracolumbar Injury Classification and Severity Score #
• According to Denis 3 columns concept: 2 columns
Morphology Posterior Ligamentous complex (PLC) disrupted
0 No abnormality 0 Intact great toe • Root pain -
1 Compression 2 Suspected / Indeterminate dorsiflexion • Sensory saddle shape distribution with
Lower limb myotomes perianal anaesthesia, symmetrical
2 + Burst fracture 3 Injured and dermatomes
Conus • Motor changes -
medullaris
3 Rotation/translation • Sphincter involved +
• Reflexes – knee jerk normal
4 Distraction Hip flexors
• Ankle jerk lost

Neurological status • Root pain +

• Sensory may invoke any part of lower
0 Intact Knee extensors
limb, asymmetrical
Cauda
2 Root injury equina • Motor changes ++ (wasting)
2 Complete cord / conus medullaris injury syndrome • Sphincter ±
3 Incomplete cord / conus medullaris injury Ankle • Reflexes – knee jerk normal/
dorsiflexor • Ankle jerk lost/
3 Cauda equina
Ankle
plantar ORTHOPAEDICS ESSENTIALS
Treatment flexion PART 3 THE SPINE
TLICS <= 3: non-operative HTARW5B/GKS2013/4-
TLICS = 4: consider for operative or non-operative intervention Together In Delivering Excellence (T.I.D.E.)
TLICS >=5: operative Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah
Name Active Ingredient Indication Contraindication Advantage Disadvantage
1. Opsite semi-permeable-thin, adhesive superficial wounds highly exudative wounds • some moisture evaporation • exudate may pool
transparent polyurethrane film as secondary dressing • reduce pain • maybe traumatic to remove
• barrier to external contamination
• allows inspection
2. Jelonet non-adherent moist (Tulle Gras burn allergy • reduces adhesion to wound • does not absorb exudate
Bactigras dressing) wounds healing by secondary • moist environment aids healing • requires secondary dressingg
PARAFFIN gauze impregnated with paraffin intention • allergy
or maybe with antiseptics or • may delay healing when
antibiotics impregnated
3. Kaltostat Calcium alginate moderately/highly exudative wounds dry wound • forms gel on wound & hence moist • may require secondary dressing
CALCIUM natural polysaccharide from need for hemostasis hard eschar • environment • not recommended in anearobic
ALGINATE seaweed • reduces pain infections
• can pack cavities • gel can be confused with slough
• absorbent in exudative wounds • or pus in wound
• promotes hemostasis
• low allergenic
4. Duoderm E hydrocolloid dressing-hydrophilic burn (small) abrasions dry wound • retains moisture • avoid on high exudate wounds, sinus
HYDROCOLLOID colloid mildly exudating ulcers infection • painless removal tracts
bound to polyurethrane film coated donate moisture & absorb exudates full thickness wound • facilitate autolytic debridement • fragile skin
with adhesive mass • thermal insulation
• worn for 3-5days-fewer dressing
changes
5. Duoderm hydogel - water or glycerin-based pressure ulcer stage II-IV, heavily draining wound • rehydrate the wound bed • need 2ndary dressing
Hydroactive 80-99% water on a nonadherent, partial & full thickness wound • reduce pain • avoid heavily draining wound
HYDOGEL cross-linked polymer dermabrasion, painful wound • used on infected wound with • absorptive properties may macerate
dermal ulcer, radiation burn • topical medication • periwound skin
donor sites • promote autolytic debridement
necrotic wounds
5. Aquacel soft, sterile, nonwoven pad or moderate to heavily draining wound dry eschar • retains moisture • dressing non-adherent, need
HYDROFIBER ribbon with partial & fully thickness wound non-exudating wound • absorb & retain exudate & harmful • 2ndary dressing to secure it
SODIUM sodium carboxymethylcellulose pressure ulcer (stage III & IV) 3rd degree burn • components
CARBOXY- surgical wound, donor site heavy bleeding • do not damage tissues surrounding
METHYLCELLUL dehisced wound, cavity wound • exudating wound when dressing
OSE wounds with sinus tracts or tunnels changes
• removal trauma free
• reduce dead space
• no frequent change
6. Aquacel Ag ionic silver for immediate and infected/highly colonized wound stage I pressure ulcers • inhibit pathogen growth, especially • 2ndary dressing to secure silver
SILVER controlled partial thickness (2nd degree) burn 3rd degree burn • antibiotic-resistant strains dressing
release DFU, leg ulcers non-exudating wounds • effective antimicrobial action up to 7 • allergy
traumatic wound days • not to use with topical medication
wounds prone to bleeding • silver turns black when oxidizes, may
oncology wounds with exudate • stain or discolor periwound tissue

7. Elase fibrinolysin enzymatic debridement of necrotic allergic to bovine • allergy

FIBRINOLYSIN desoxyribonuclease tissue in wound & liquefaction & compound
DESOXYRIBONU dissolution of exudates of injured
CLEASE skin
& mucous membrane

ORTHOPAEDICS ESSENTIALS
PART 4 DRESSINGS
HTARW5B/GKS2013/4-

Together In Delivering Excellence (T.I.D.E.)

Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah
Bohler’s stirrup
U shaped device to hold
a Steinmann pin and
applying traction
Dynamic Compression Plate
(DCP)
Exerts axial compression over
# site by combining screw hole
geometry while screw insertion.
Broad – humerus, femur
Narrow – tibia, forearm, pelvis
Crutchfield tongs
To apply skull traction in
case of cervical injury
Low Contact Dynamic
Compression Plates
Designed to limit vascular
compromise by decreasing
plate-to-bone contact
Buttress Plating Hip Prosthesis
(Fr – to strike/shoke)
Used for replacement of head of femur following
The plate serves to push
NOF #. Help patients to early mobilise and
or buttress the split tibial
eliminate complication such as AVN, non union,
plateau fragment against
fixation failure
displacement and
Austin Moore – used in NOF# with calcar
depression.
femorale intact, no osteoporosis; prosthesis has
T and L plates are
designed to be used as neck, collar and holes, bone cement is not
required during application
buttress plates
Thompson – used in NOF# with no calcar, with
osteoporosis; prosthesis has NO neck, collar and
holes, bone cement is required during application
Bipolar – used in yiounger patients with non union
of femoral neck. It has low incidence of protrusio
acetabuli
Dynamic Hip Plate/Screw **Calcar femorale = thin plate of condensed
Used in intertrochanteric cancellous bone oriented vertically within the
fracture of femur medullary canal of the proxinal part of the femur ,
deep to lesser trochanter

Gigli saw
Twisted wire bone saw,
use to cut bone during
amputation
Cortical and Cancellous
Screws
Used either itself (as lag
screw) or with plates, they
are non tapping screws,
thread tapping should be
done in the bone with bone
tap
Malleolar Screws
Are self tapping screws
Illizarov External Fixators
Reconstruction Plates For limb lengthening,
Have notches alongside the Dynamic Condylar Plate/Screw arthrodesis, deformity
plate, which enables bending in 3 Used in distal end femur # correction and infected
dimension to contour towards (unicondylar/intercondylar) non-union
complex surfaces easily
Angle Blade Plates
95°-angled plates are used in the
Condylar repair of metaphyseal fractures and
blade reconstruction of the femur. It provides
plate
very rigid fixation.
Condylar- distal femur,
Double
angled intertrochanteric/sub-trochanteric #. ORTHOPAEDICS ESSENTIALS
blade plate Double angled – femoral valgus
repositioning osteotomy PART 5 PLATINGS, NAILS AND SCREWS
HTARW5B/GKS2013/4-

Together In Delivering Excellence (T.I.D.E.)

 CLASSIFICATION:
HOPI HOPI •Posterior 70%
•Anterior 10-15%
Fall on the out
Fall on outstretched hand with elbow slightly flexed •Central
stretch hand with
rotation HOPI
TYPES Usually occurs in an MVA as a result of dash board injury

Approach
MOST COMMON Signs
Posterior Posterior dislocation shows: FLEXION, ADDUCTION,
dislocation (due to Anterior dislocation (due to INTERNAL ROTATION deformity with shortening of limb,
internal rotation) abnormal gluteal bony mass of head of femur
external rotation of ABDucted
arm) X-ray (AP and Lateral view)
femoral head out of acetabulum
Lesser trochanter less prominent
Signs Broken Shenton’s line
Absent of normal contour of shoulder ASIS shifted upward
Associated fractures
Bryan sign – anterior axillary fold looks elongated

Approach
Callaway’s sign – axillary girth get increased
Duga’s sign – inability to touch opposite shoulder by REDUCTION METHODS (POSTERIOR DISLOCATION)
affected hand SHOULD BE DONE ASAP TO REDUCE THE CHANCE OF AVN OF HEAD
Hamilton’s ruler test – a ruler can touch lateral
epicondyle and acromion process at the same time A. Bigelow method
FLEX
ABDUCT
X-ray EXTERNAL ROTATION
AP view in internal and external rotation Signs EXTENSION
Axillary view Short forearm with 3 bony
NEUTRAL ROTATION
points relation disturbed (also in

Approach
# of epicondyles)
REDUCTION METHODS B. Allis method
Triceps tendon stands
A. Hippocratic method 1.The patient is supine
prominent(bow stringing)
1.The patient lies supine. 2.Affected hip and knee are flexed in 90 degree
2.The physician's foot is placed in the patient's 3.In neutral rotation of hip, an upward traction is applied along the axis of
axilla against the chest wall while leaning X-ray femur and the same counter traction is given by holding the pelvis.
backward. AP view – greater superimposed of distal
3.Slow, steady and gentle longitudinal traction is humerus with proximal ulna C. Stimsons’ gravity method
applied to the affected arm in 30-40° abduction for Lateral – coronoid process lies posterior to The patient is laid prone with the lower limb hanging over the other end of the
about one minute. condyles table
4.The foot acts as a counterforce and as a lever to Femoral head is pushed down into the acetabulum and at the same time the
push the humeral head laterally while the REDUCTION METHODS traction is applied downward along the axis of femur
physician pulls the head toward the patient's foot Dislocation reducing the dislocation
along the surface of the glenoid, effectively by traction and pressure flexing the Complications:
adducting the affected arm. elbow fully as a test of reduction •Sciatic nerve injury
5.Put patient on arm sling immobilizing the limb in an above- •Vascular injury
elbow plaster slab (margin shown •Irreducible dislocation Early
B. Kocher method by dotted line) and a sling. •Recurrent dislocation
T – Traction in line of humerus •Associated fractures
E – External Rotation of humerus Complications: •AVN (15%)
Late

Manage
A – Adduction of arm •Nerve injury (M>U>R) •Secondary OA
M – Medial rotation •Brachial artery injury •Myositis ossificans
•Myositis ossifican
Complications: •Recurrent dislocations Plan: CMR with fixed skin traction on Thomas splint or POP hip
•Shoulder stiffness •Osteochondral fracture spika x 4-6/52 then partial weight bearing on crutches x 6/52
•Axillary nerve damage •Unreduced dislocation
•Traumatic OA

Manage
•Fractures of associated structures
•Recurrent dislocations (epicondyles, radius head, coronoid
Manage

•Unreduced dislocation process, olecranon)

Plan: CMR of shoulder joint with Velpeau’s Plan: CMR with above elbow POP x ORTHOPAEDICS ESSENTIALS
strapping x 3/52 followed by physiotherapy 3/52 followed by physiotherapy
PART 6 DISLOCATIONS
HTARW5B/GKS2013/4-
Together In Delivering Excellence (T.I.D.E.)
Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Fong, Ling Ying, Phoon, Quah
 Calcaneum Fracture Cobb’s angle Distal end radius fracture
(Scoliosis)
2- Radial incline = 22
(12-28)

1- Radial height 11mm (10-26)

4- Ulnar
variance ±5mm 3- DRUJ space 4mm

5-Volar tilt = 11

6- Step <2mm (3-16)
7- Gap <2mm

Supracondylar Fracture Wagner Classification of Diabetic Foot Ulcers:

Grade 0: No ulcer in a high risk foot.
Baumann’s angle Carrying angle Grade 1: Superficial ulcer involving the full skin thickness but not
underlying tissues.
Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no
bone involvement or abscess formation.
Grade 3: Deep ulcer with cellulitis or abscess formation, often with
osteomyelitis.
Grade 4: Localized gangrene (forefoot).
Grade 5: Extensive gangrene involving the whole foot.

Amputations
Norm: 5-15
Excessive = cubitus valgus
Decrease = gunstock deformity

Q angle
Increased in
genu valgum,
external tibia
torsion, lateral
positioned tibial
tuberosity, tight **Rays Amputation – Removal of toes with metatarsal from tarsometatarsal joint
lateral
retinaculum
Norm:
ORTHOPAEDICS ESSENTIALS
male= 14±3 PART 7 (a) ANGLES IN ORTHOPAEDICS (b) DIABETIC FOOT
females= 17±3 HTARW5B/GKS2013/4-
Together In Delivering Excellence (T.I.D.E.)
Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Fong, Phoon, Quah
DUNLOP TRACTION WELL LEG TRACTION 90-90 TRACTION PERKINS TRACTION CALCANEAL TRACTION HAMMOCK TRACTION
HEAD HALTER CRUSH FIELD
Used in transcondylar or Used in correction of Used in subtrochanteric #, Used in femur shaft # in Used in open # of ankle joint/leg Used in pelvis # with
TRACTION TRACTION
supracondylar fracture of the abduction deformity of hip compound # of femur with adult rotational instability e.g.
Used in cervical Used in cervical
humerus in children Traction is applied to the posterior wound and shaft open book, Malgaigne #
spine injury spine injury
normal limb while deformed femur of children (both pubic rami+
hip is stabilised by splint posterior SI
complex/sacrum #), and
bucket handle injury

BÖHLER BRAUN FRAME

BUCK’S TRACTION Apparatus used for
HALO-PELVIS Apply skin traction in application of skeletal
TRACTION femur shaft #, NOF #, traction of lower limb. It may
Used in scoliosis acetabulum # after be used with transcondylar,
reduction of hip tibial or calcaneal pins

Lower limb and Pelvis

Upper limb and Spine
dislocation, to correct
minor deformity of hip
and knee
PELVIC BINDER
Used acutely in management of
exsanguinating pelvic trauma, by
GALLOW’S/BRYANT’S applying large amount of
TRACTION compressive force to the pelvic
BROAD ARMSLING AND ring to reduce the volume of the
HAMILTON-RUSSELL Used in femur shaft # in 90-90 HIP SPIKA
FIGURE ‘8’ STRAPPING children <2 yrs pelvis
TRACTION THOMAS SPLINT Spika at 90 flexion at hip
Used in undisplaced and displaced Used in femur shaft # in (with and without sling) because in children proximal
clavicle fracture respectively. adult, trochanteric # Temporary stabilisation of fragment flexes to 90 due to
SCAPHOID CAST femoral shaft fracture stronger pull by flexor muscle and
Applied from below elbow proximal illdevelopment of lumbar lordosis
to knuckle distally and incorporating
proximal phalanx of thumb. The wrist
is held in dorsiflexion (glass holding
positiion)

Slab
Cast

Trapeze

BALKAN FRAME ROBERT JONES DRESSING POP CAST & SLAB

A frame employed in the treatment of
fractured bones of extremities that
provides overhead weights and
pulleys for suspension, traction, and
continuous extension of the splinted
fracture limb.
A tape stirrup is applied to the foot before Active ingredient of Plaster of Paris is
the bandage is started Gypsum CaSO42H2O
Cotton roll is wrapped around a forelimb Slab only covers a part of
after the application of the tape stirrup. circumferential of a limb whereas a
Elastic gauze is then applied firmly bind cast covers whole of the limb
the cotton to the leg. Elastic tape is then circumference.
use to complete the dressing.
Miscellaneous

ORTHOPAEDICS ESSENTIALS
MILWAUKEE BRACE
For dorsal scoliosis
BOSTON BRACE PART 8 SPLINTS, CASTS, PLASTERS, FRAMES
For lumbar scoliosis HTARW5B/GKS2013/4-
Together In Delivering Excellence (T.I.D.E.)
Definition: An increase in compartment pressure to the Definition: syndrome caused by presence of fat Rapidly progressive inflammatory infection of the fascia, with secondary necrosis of
point where tissue perfusion is impaired. globules in the lung parenchyma and peripheral the subcutaneous tissues. The speed of spread is directly proportional to the thickness
circulation. Usually subclinical event after long of the subcutaneous layer. Necrotizing fasciitis moves along the fascial plane.
Causes bone fractures in young adults (tibia/fibula) and hip Diagnosis: requires a high degree of suspicion
•Fracture (tibia, radius) fractures in elderly • H/O antecedent trauma or surgery
•Circumferential burns Syndrome usually appear in 1-2 days after an acute • Intense pain over the involved skin and underlying muscle; over the next several
•Tight dressings injury or after IM nailing. hours to days, the local pain progresses to anaesthesia.
•Crush injuries • Fever, malaise, and myalgia
•Bleeding (minor injury while anticoagulated) Diagnosis: based on clinical features after • Edema extending beyond the area of erythema, skin vesicles, and crepitus.
•Reperfusion injury excluding other causes • Comorbid factors, including DM
Gurd's Diagnostic Criteria Types: Treatment
Early signs (at least 1 major + 4 minor criteria) I-Polymicrobial • Prompt surgical debridement is
•Tight Major Criteria II-Group A Streptococcus continued until tissue necrosis
•Escalating pain 1.Respiratory insufficiency (PO2 < 60mmHg) III-Gas gangrene ceases and the growth of
•Pain with passive stretch of the involved muscle 2.Neurological – depression/restless fresh viable tissue is
3.Skin - Petechial rash (axillary/subconjuctiva) Complications observed.
Late signs -6P
• Renal failure • Antibiotic (broad spectrum
•Pain Minor Criteria • Septic shock with cardiovascular covering both gram positive
•Pallor •Tachycardia collapse and negative)
•Pulselessness •Fever • Scarring with cosmetic deformity • Hyperbaric oxygen therapy
•Paresthesia •Jaundice • Limb loss (HBOT)
•Paralysis •Retinal changes • Sepsis
•Poikilothermia •Renal changes • Toxic shock syndrome
•Laboratory Features
Initial Management Microglobulinemia (required) SPINAL SHOCK = temporary loss of spinal cord function and reflex activity
•Remove all circumferential dressings/casts Thrombocytopenia below the level of spinal cord injury, characterised by bradycardia, hypotension (due
•Ensure leg is at level of the heart - the affected part should Elevated ESR to loss of sympathethic tone), and an absent bulbocarvenosus reflex
not be elevated above the level of the heart because this Anemia
maneuver does not improve venous outflow and reduces Spinal shock Neurogenic Shock HypovolemicShock
Urine for fat globule
arterial inflow
BP Hypotension Hypotension Hypotension
•Remove any traction Management:
1.Oxygenation. Pulse Bradycardic Bradycardic Tachycardic
Definitive management 2.Fluid resuscitation
Compartment fasciotomy-2 incisions, 15 cm long 6 pints NS/3 hours followed by Reflexes Absent Variable Variable
Delay>12 hr. often results in irreversible muscle and nerve 3 pints of NS/2 hours followed by
damage in that compartment Motor Flaccid paralysis Variable Variable
1 pint NS over 1 hour x 3
3.Surgical Care - early stabilization of long bone Time 48-72hrs immediately after injury Following blood loss
Complications fractures
If left untreated: rhabdomyolysis and kidney failure Mechanism Peripheral neurons Loss of sympathetic Decreased preload
Prophylactic placement of IVC filters may help become temporary tone and decrease = decreased cardiac
reduce the volume of fat reaching the heart. unresponsive to systemic vascular output
brain stimuli resistance
Treatment Immobilisation Swan-Ganz Fluid/blood
Neurological monitoring for resuscitation
charting (until return careful fluid Mx Haemostasis
Wells Criteria: Interpretation: of bulbocarvenous Vasopressors
Active cancer (1) <0 – low risk (3% probability DVT) reflex)
Paresis/paralysis/recent immobilisation of LL (1) 1-2 – moderate risk (17% probability DVT) Early surgical
Recent bed ridden x3/7/major surgeryx4/52 (1) ≥3 – high risk (75% probability DVT) intervention
Localised tenderness over deep vein (1)
Entire leg swollen (1) Management:
Heparin/LMWH
ORTHOPAEDICS ESSENTIALS
Calves swelling >3cm compare to asymptomatic limb (10 cm
below tibial tubercle (1) Compression stocking PART 9 ORTHOPAEDIC EMERGENCIES
HTARW5B/GKS2013/4-
Pitting oedema (1)
Collateral superficial vein (1) Together In Delivering Excellence (T.I.D.E.)
Alternative diagnosis (-2) Contributors: Dr. Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Maya, Fong, Ling Ying, Phoon, Quah