Click to download Orthopaedics essentials
Archive for the ‘Orthopaedics & Traumatology’ Category
The orthopedics guide is now available for download.
UPDATED VERSION APRIL 2012
However, most of the notes are based on my experience while working in Ampang Hospital, and may vary in your own healthcare centre.
Hopefully it may serve as a guide for your Orthopedic posting!
Good Luck for your next posting!
An ankle block is essentially a block of the terminal branches of the sciatic nerve. It is useful to think of the ankle block as the block of
two deep nerves
1. posterior tibial and
2. deep peroneal nerves
three superficial nerves
3. superficial peroneal
This concept is crucial for the success of the block, because the two deep nerves are anesthetized by injecting local anesthetic underneath the superficial fascia, whereas the three superficial nerves are anesthetized by a simple subcutaneous injection of local anesthetic.
1. Deep peroneal block
The finger of the palpating hand is positioned in the groove just lateral to the extensor hallucis longus. The needle is inserted under the skin and advanced until stopped by the bone. At this point, the needle is withdrawn back 1-2 mm and 2-3 mL of local anesthetic is injected. A “fan” technique is recommended to increase the success rate.
2. Post tibial block
Posterior tibial nerve is anesthetized by injecting local anesthetic just behind the medial malleolus.
Facing the medial aspect of the foot, the needle is introduced in the groove behind the medial malleolus and advanced until contact with the bone is felt. At this point, the needle is withdrawn back 1-2 mm and 2-3 mL of local anesthetic is injected.
1. Spf peroneal nerves
Superficial peroneal nerve is blocked by subcutaneous infiltration of local anesthetic over the lateral aspect of the foot.
3 Saphenous nerve
Saphenous nerve is blocked by subcutaneous infiltration of local anesthetic over the medial as pect of the foot.
It’s your first posting…you’re in the procedure room assisting your MO for the 1st time..
suddenly she yells..
MO: “Get me some orthoban, 3 rolls of POP…and some crepe bandage “
You: OMG..What buns? pee…and what crap??
To prevent such encounters, pls take some time to learn some basic apparatus used in Orthopaedics!
2. Crepe bandage
3. Plaster of paris
4. Plaster saw (aint no vacuum cleaner)
4. Zimmer splint
5. Thomas splint (lateral traction)
6. Plaster spreader
cutter (stout scissors)
CMR and POP
CMR under sedation (prepare in 5cc syringe)
* request drugs from sister or staff nurse, return ampule to sister!
1) Midazolam 1ml + 4ml H20 (1cc=1mg)
Adults give 2.5cc (half ampule/2mins) Peds : 0.1mg/kg
(antidote = flumazenil 0.02mg/kg) 1 amp
2) Pethidine 1ml + 4ml H2O (1cc=10mg)
Adults give ½ dose 2.5cc over 2 mins Peds: 1mg/kg
(antidote = naloxone: 0.01mg/kg) 1 amp
20kg = 1 cc
30kg = 1.5cc
40kg = 2cc
50kg = 2.5cc
max 2.5 cc in 2 minutes
Post POP xray
1. Radial height = 10-13mm
2. Radial tilt 11 (2-20)
3. Volar tilt 10 degrees
4. Radial Inclination = 21 -25 degrees
1. prepare 2-3 rolls POP, orthoban, prepare bucket of warm water
2. apply orthoban around hand starting distal to proximal
3. dip plaster in water until bubbles disappear
4. apply POP, starting from distal to proximal (max around hand 2 layers only)
5. smoothen the plaster and press on affected part to fix plaster (moulding)
6. make sure 90degrees (AEPOP)
7. Perform post POP Xray!!!
1. Take plaster and measure length required (from below MCPJ to cubital fossa)
2. Place orthoban, slightly longer than plaster (for folding)
3. Start layering plaster (up to 15 layers)
4. Prepare a pail of water, fold and dip plaster in water, going in at angle of 45 degrees, until bubbles disappear
5. Remove from water and squeeze lightly excess water from plaster using 2 fingers
6. Place plaster on orthoban, smoothen the plaster and fold edges of orthoban on to the plaster (sandwich)
7. Place this sandwich with orthoban contacting skin
8. Smoothen the plaster to fit limb
9. Wrap with Crepe bandage starting from proximal end to distal.
10. Secure with tape and allow to dry
1. Position patient’s hand with wrist extended 45 degrees and fingers pointing at 90 degrees
2. Measure length from DIPJ to cubital fossa
3. Layer up to 15 layers of plaster and place on slight longer orthoban
4. Submerse in water at a 45 degree angle until bubbles disappear, squeeze and place on orthoban
5. Sandwich the plaster and orthoban
6. Place sandwich, hand first, making sure the angles are kept
7. Wrap with crepe bandage
1. Start by bandaging with Orthoban, from distal to proximal, overlapping 1/3
2. Hold on to one end of plaster and Submerse whole roll of plaster in water, squeeze slightly
3. Start bandaging plaster over the orthoban from wrist to hand, then to proximal, overlapping 1/3
4. Smoothen the plaster and apply next roll. The wrist should be square shaped, and the proximal end spherical
1. Do not wet, draw, spoil POP
2. Do not put long objects inside/scratch
3. TCA stat if pain/numbness/blue
Types of Surgery
Elective (under GA/LA/Spinal)
Common Surgical Procedures
Open Reduction Internal Fixation
Plating with screws, Interlocking plate
Tension Band Wiring
TKR- Total Knee replacement
AKA/BKA- Above/Below knee amputation
WD – wound debridement
Fasciotomy (for compartment syndrome)
Intramedullar nail, gamma nail
Before entering OT – contact OT sister for orientation
1) use the correct entrance
2) wear correct surgical attire
3) Learn technique of scrubbing
4) Learn technique of closed gloving
1) check-OT List, patient’s name, age, diagnosis and procedure
2) make sure orders done – surgery ordered, Antibiotics to OT, blood or GXM available, I-I ordered, MA present
3) Write details on the OT whiteboard
4) Open patient’s history (eHIS) and Xrays (on PACS system)
5) prepare antibiotics (if indicated)
6) call MO or specialist once patient is under anaesthesia
Antibiotics prep in OT
1. Take 10cc of water in syringe, inject into bottle of antibiotics (powder)
2. Shake the bottle till well dissolved
3. Give in IV line ( do not inject IM!!!)
Applying a torniquet
1. Find the tourniquet inflating apparatus
2. Select cuff- Small with green string= upper limbs, large brown string = lower limbs
3. Wrap 3-5 layers orthoban around area. Always apply as proximal as possible.
4. Locate the connector plug. Make sure it is facing towards the patient’s body
5. Apply the cuff. Hold on to end strings, wrap the strap tightly.
6. Elevate the limb to empty veins.
7. Adjust the pressure 250 for UL and 350 for LL, and timer (*Max duration for UL = 60mins, LL = 120mins)
8. Press INFLATE
1. Get a CBD set. Prepare correct catheter, lignocaine gel, syringe, 10cc water for inflation
2. Wear sterile gloves, with apron
3. Cleanse the penis with Clorrhexidine/normal saline
4. Administer some lignocaine into urethra with syringe (1-2ml)
5. Lubricate the end of the cathether. Pull down the foreskin. Hold the penis at 90 degrees.
6. Insert the catheter slowly until urine flows out.
7. Inflate with 10cc of water (see catheter for accurate volume of water) Tug to confirm insertion.
8. Retract foreskin !! (failure to do so may result in phimosis)
9. To remove catheter, syringe out the 10cc water and tug slowly till removed completely
<to be continued…Ring and ankle block..>
This guide is based on my experience in Hospital Ampang’s OT. Other hospitals may vary in steps.
Hopefully this may help you in your OT
Ortho General Clerking
K/c/o : Disease – Duration – medication – follow up
eg: 1) HPT, controlled?, duration, meds, follow up
2) DM, controlled? Duration, meds, follow up…
Duration : 1 hour
HOPI: short story about problem
eg: Alleged MVA (MB vs car) at Pandan Indah roundabout, at 7pm. Pt was pilon rider….etc
Fell on right side and sustained immediate pain in right elbow.
Past Medical Hx:
Social Hx: smoker, alcoholic, occupation, living environment
General : Alert, conscious, Vitals….
Chest: Lungs Clear
Abdomen: soft, non-tender
Swelling, pain, redness..etc
Motor and neuro sensations intact
Pulses: DPA/PTA (LL) or Radial/Ulnar (UL)
*ABSI (LL): Left and Right foot (in ward)
Radiology: xray of___ : no OM changes, no gas shadows
Impression (dx): cellulitis of right leg
Orthopedic Progress notes
<AM/PM/Night/ Post Op / clinic review>
Problem: Fracture of femur…
Pre Op Dx
comfortable in bed
Oral intake well
WI: clean, no pus or discharge, no slough, no active bleeding
Vitals: BP, T, PR, SpO2
History of presenting illness
Came unaided? Crutches/Wheel chair?
Alleged____ (MVA, sports injury, fall etc) time____,
Mechanism of injury ( hand outstretched/ flexed, part contacting surface..etc)
Sustained immediate pain
With bleeding? Open wound? LOC? Swelling? Nausea & Vomiting?
Spinal – PU or BO normal?
DM duration? control? Medications, follow up clinic
signs of DM complications – retinopathy, nephropaty, neuropathy
Ulcer size, slough, pus, bleeding, signs of ifxn
Neuro sensation and motor
Ix: Xray- OM changes?
Size (in cm) Swelling? Erythema? Discharge? Pain? Warm? fluctuant? Firm? Mobile?
Trauma or Insect Bite
1) DM – DFU
- Duration- F/up clinic- Insulin/OHA
- ABSI in ward
- random glucose, FBS, DXT stix -
– DXT monitoring BD,TDS,QID
- Xray (DFU-OM changes, gas shadow)
- Antibiotics+bactigrass dressingàWDàAmputationàRayàAKA/BKA
2) UL/LL Fractures
- Xray – conservative/manipulation/surgical intervention
a) closed manual reduction
CMR + POP, back slab, splint
- post CMR POP Xray
- Acceptable = TCA
- Unacceptable = reCMR/surgery
-Traction : Skin 10% BW, Musc 5% BW
Surgery: Interlocking plate, Insertion of Long Nail, Intramedullar nail, dynamic hip screw, K wiring, tension band wiring, bone grafting, wound debridement, wound exploration, ray amputation, incision and drainage
3) Spinal fractures
– Xray, CT, MRI
- screening test
- PU/BO (PR tone exam)
- stabilization by soft neck brace/ juwet’s brace / body cast
4) Infected wound, cellulitis, abscess
– swab C & S
– antibiotics – Cloxa + C Pen
– dressing NS + Bactigrass
– I & D (abscess), saucerisation (carbuncle)
Swelling and wound
Sensation and motor
Ulna = Little finger – ½ ring finger
radial = dorsal btwn thumb-index finger, post-medial forearm, Triceps
median = thumb- ½ ring finger
musculocutaneous = regimental badge
a) Ulna: abduction fingers, thumb to little finger
b) Radial: wrist extension
c) Median : thumb abduction
Thighs: Lateral cutaneous (lat), Femoral (ant-knee-med leg), Obturator (med), Post Cut (post)
Leg: Sciatic (lat-post-dorsal), common peroneal (lat-ant-dorsal) Femoral (med)
Foot: Deep Peroneal (btwn big-2nd toe), Tibial (rest of toes), Sural (lat)
Plantar: Sural (lat), Lateral Plantar (lat), Medial plantar (med), saphenous(med), calcaneal (heel)
a) Iliopsoas = flex thigh at hip against resistance (knee 90degrees)
b) Quadriceps femoris (femoral) = extend leg against resistance (flex-straighten leg)
c) Adductors (obturator) = Adduct limb against resistance
< to be continued…neck and spinal traumas >
all info above are based on my documentation while working in Hospital Ampang….hopefully this may guide you in your Ortho rotation…more to come soon…
Workshop 2009/10 Handouts
HOW was established in the summer of 2009, founded by Dr. Christopher Sheng and Dr. Ng Kean Seng.
Our objectives were clear, to collect and compile as much details and experiences possible on the Housemanship service in Malaysia. Clearly, a lot of us overseas graduates are not used to the local system and methods. Terms may differ and protocols vary.
Here, you may download the guides completed by doctors of the House Officers Workshop. Please note that these guides were done by medical students and serves as a guide only. Hopefully, these materials will assist you during your Housemanship service!