Archive for the ‘Orthopaedics & Traumatology’ Category

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

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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

House Officers Workshop Malaysia goes online! Content to be updated soon…