Archive for the ‘Orthopaedics & Traumatology’ Category

Click to download Orthopaedics essentials

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Dear friends,

The orthopedics guide is now available for download.

UPDATED VERSION APRIL 2012

click on image to download PDF file

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!

Ankle Block

Posted: January 3, 2012 by gerardloh in Orthopaedics & Traumatology

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

1. saphenous

2. sural

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.

Deep nerves
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 At this point, the needle is withdrawn back 1-2 mm and 2-3 mL of local anesthetic is injected.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 At this point, the needle is withdrawn back 1-2 mm and 2-3 mL of local anesthetic is injected.


Spf nerves


1. Spf peroneal nerves

Superficial peroneal nerve is blocked by subcutaneous infiltration of local anesthetic over the lateral aspect of the foot.


2.Sural nerve

 

3 Saphenous nerve

Saphenous nerve is blocked by subcutaneous infiltration of local anesthetic over the medial as pect of the foot.



Ortho stuff

Posted: December 18, 2011 by gerardloh in Orthopaedics & Traumatology

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!

 

1. Orthoban

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)

 

surgical instruments

In the POP room

Posted: November 25, 2011 by gerardloh in Orthopaedics & Traumatology

CMR and POP

CMR under sedation (prepare in 5cc syringe)

* request drugs from sister or staff nurse, return ampule to sister!

 

Sedation  
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

Peds dose:
20kg = 1 cc
30kg = 1.5cc
40kg = 2cc
50kg = 2.5cc
max 2.5 cc in 2 minutes


Post POP xray

Normal values:
1. Radial height = 10-13mm

2. Radial tilt 11 (2-20)

3. Volar tilt 10 degrees

4.  Radial Inclination = 21 -25 degrees


POP

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!!!

Back slab

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

 

Volar slab

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

POP

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

POP advice

1. Do not wet, draw, spoil POP
2. Do not put long objects inside/scratch
3. TCA stat if pain/numbness/blue

In the OT

Posted: November 25, 2011 by gerardloh in Orthopaedics & Traumatology

Types of Surgery

Elective (under GA/LA/Spinal)

Emergency

Trauma list

 

Common Surgical Procedures

Open Reduction Internal Fixation

K wiring

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

Arthroplasty

 

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
learn here

 

Before Op
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

 

 

CBD

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

General Clerking in Orthopaedics

Posted: November 25, 2011 by gerardloh in Orthopaedics & Traumatology

 Ortho General Clerking


a/r/s:  age-race-sex

K/c/o : Disease – Duration – medication – follow up

eg: 1) HPT, controlled?, duration, meds, follow up

2) DM, controlled? Duration, meds, follow up…

Refered from?

c/o: pain….etc

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:

Medications:

Surg Hx:

Social Hx: smoker, alcoholic, occupation, living environment


Systemic review

General : Alert, conscious, Vitals….
CVS:
DRNM

Chest: Lungs Clear

Abdomen: soft, non-tender


Musculoskeletal

Inspection:
Swelling, pain, redness..etc

Power 5/5
ROM
Motor and neuro sensations intact
Pulses: DPA/PTA (LL)     or        Radial/Ulnar (UL)
CRT <2sec

*ABSI (LL): Left and Right foot (in ward)

Radiology:  xray of___ : no OM changes, no gas shadows
Impression (dx): cellulitis of right leg

Plan:

__________________________________________________________________________________________

Orthopedic Progress notes
(A)   

<AM/PM/Night/ Post Op / clinic review>

a/r/s:

k/c/o:

Problem:  Fracture of femur…

________________

(Post op)
Pre Op Dx

POD_ (day/hours):

PODX:

Findings:

_________________

(B)
Progress:
comfortable in bed
pain tolerable

NIL issues

Oral intake well

afebrile

o/e:

Alert, conscious,

non tachypneic

hydration fair

WI: clean, no pus or discharge, no slough, no active bleeding

Vitals: BP, T, PR, SpO2

Plan:

____________________________________________________________________________________

History of presenting illness

1) Trauma

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?

 

2) DFU

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

Family support

Ix: Xray- OM changes?

3) Abscess/cellulitis

Size (in cm) Swelling? Erythema? Discharge? Pain? Warm? fluctuant? Firm? Mobile?

Fever? Discolouration?
Trauma or Insect Bite

 ______________________________________________________________________________

Plan

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
– PCM
– dressing NS + Bactigrass
– I & D (abscess), saucerisation (carbuncle)

________________________________________________________________________________________

Physical Examination

Swelling and wound

Sensation and motor

ROM

Pulses

CRT


Upper Limbs

Sensations:

Ulna = Little finger – ½ ring finger

radial = dorsal btwn thumb-index finger, post-medial forearm, Triceps

median = thumb- ½ ring finger

musculocutaneous = regimental badge

Motor components
a) Ulna: abduction fingers, thumb to little finger
b) Radial: wrist extension
c) Median : thumb abduction


Lower Limbs

Sensations

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)

Motor components

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!

1. Obstetrics and Gynaecology

2. Medicine 

3. Paediatrics

4. Orthopaedics

5. Surgery

6. Guide Medicine Workshop

7. General List of Recommended Antibiotic

8. Medical abbreviations