Variant No.

1. Algorithm of examination of the patient with acute trauma

2. Dislocation of the clavicle - the typical mechanisms, diagnosis, treatment principles.

Exam Findings:
- brachial plexus
- ref: Injury to the brachial plexus by a fragment of bone after fracture of the clavicle

- Radiology:
- Serendipity View
- best visualized sitting up w/ AP view & view w/ beam angled 30 deg. cephalad;
 - w/ frx of clavicle, distal fragment & arm tend to sag, while proximal fragment, held by
SC joint tends to point upward;
- in any clavicular frx, carefully scutinize x-rays for presence of scapular frx, which
represents a floating shoulder;
- references:
- Upright versus supine radiographs of clavicle fractures: does positioning matter?
- Non Operative Treatment:
- it is difficult to reduce and maintain the reduction of clavicle fractures;
- despite deformity, healing usually proceeds rapidly;
- union usually occurs rapidly & produces prominent callus;
- w/ midshaft fractures, there will also be some degree of malunion;
- in these patients be attentive to medial cord nerve symptoms (more often ulnar
nerve);
- distal clavicle fractures may have a high incidence of non union but most of these are
asymptomatic, and of these only a
small number will be severe enough to require surgery;
- indications for surgery:
- open fracture
- gross displacement of fracture w/ tenting of skin
- fractures w/ signficant medialization (causing medialization of the shoulder girdle);
- ref: Fixation of Displaced Midshaft Clavicle Fractures in Skeletally Immature Patients
- surgical considerations:
- subclavian artery (axillary artery begins as it crosses the first rib)
- brachial plexus (esp lower trunk damage (C8, T1);
- look for posterior cord injury
- references:
- Injury to the brachial plexus by a fragment of bone after fracture of the clavicle.
- Clavicular caution: An anatomic study of neurovascular structures.
- floating shoulder:
- multiple authors have reported excellent results with healing rates greater than 99%
for variety of immobilization techniques;
- incidence of nonunion, malunion, NV complications total < 1%;
- single disruptions of SSSC have uniformly good results with nonoperative treatment;
- double disruptions of SSSC are a combination of innocuous injuries which create
instability for UE best surgically treated
- ORIF simpler fracture reduces other injury satisfactorily

- Surgical Choices:
- intra-medullary clavicular fixation:
- references:
- Non-union of frx of mid-shaft of clavicle. Treatment w/ modified Hagie IM pin
and autogenous bone-grafting.

- plate fixation: (Synthes Clavicle Products)

- consider unicortical fixation with a Synthese 3.5 mm pelvic reconstruction locking
plate (unicortical screws will not risk
injury to the deep neurovascular structures; (axillary artery)
 - post op exam includes neurovascular check - check for full abduction and ext
rotation (inorder to test for thoracic outlet syndrome);
- careful to note potential vascular complications;
- references:
- A radiological study to define safe zones for drilling during plating of
clavicle fractures
- Safe drilling angles and depths for plate-screw fixation of the clavicle:
avoidance of iatrogenic subclavian NV bundle injury
- advantages of anteroinferior plating:
- include less hardware prominence and the ability of the surgeon to direct
instrumentation away from infraclavicular neurovascular structures
3. Dupuytren's contracture - aetiology, diagnosis, treatment.
Dupuytren's contracture is a thickening of the fibrous tissue layer underneath the skin of the
palm and fingers. Although painless, the thickening and tightening (contracture) of this
fibrous tissue can cause the fingers to curl. Dupuytren's contracture is more common in men
than in women.
Cause

Symptoms of Dupuytren's contracture include painful bumps (nodules) under the skin that
develop into tight bands of tissue, causing the fingers to curl.
The cause of Dupuytren's contracture is not known. It is not caused by an injury or heavy
hand use.
There are factors that put people at greater risk for developing Dupuytren's contracture.
 It is most common in people of Northern European (English, Irish, Scottish, French, Dutch) or
Scandinavian (Swedish, Norwegian, Finnish) ancestry.
 It often runs in families (hereditary).
 It may be associated with drinking alcohol.
 It is associated with certain medical conditions, such as diabetes and seizures.
 It increases in frequency with age.
Symptoms

Dupuytren's contracture symptoms usually occur very gradually.

Nodules. One or more small, tender lumps (nodules) form in the palm. Over time, the
tenderness usually goes away.
Bands of tissue. The nodules may thicken and contract, forming tough bands of tissue under the
skin.
Curled fingers. One or more fingers bend (flex) toward the palm. The ring and little fingers are
most commonly affected, but any or all fingers can be involved. As the bend in the finger
increases, it may be hard to straighten your finger. Grasping large objects and putting your hand
in a pocket becomes difficult.
Doctor Examination

Your doctor will examine your hand and test the feeling in your thumb and fingers. Your grip and
pinch strength may also be tested.

During the examination, your doctor will record the locations of nodules and bands on your
palm. Using a special device, he or she will measure the amount of contracture in your fingers.
Your doctor may also measure the range of motion in your fingers to determine whether there is
limitation in your flexion.

Your doctor will measure the bend in your finger, and note where the bands of tissue and
nodules are.

Your doctor will refer back to these measurements throughout your treatment to determine
whether the disease is progressing.

Treatment

There is no way to stop or cure Dupuytren's contracture. However, it is not dangerous.

Dupuytren's contracture usually progresses very slowly and may not become troublesome for
years. It may never progress beyond lumps in the palm.

If the condition progresses, nonsurgical treatment may help to slow the disease.

Nonsurgical Treatment
Steroid injection. If a lump is painful, an injection of corticosteroid - a powerful anti-
inflammatory medication - may help relieve the pain. In some cases, it may prevent the
progression of contracture. Several injections may be needed for a lasting effect.

Splints. Splinting does not prevent  increased bend in the finger. Forceful stretching of the
contracted finger will not help either, and may speed the progression of contracture.

Surgical Treatment

Surgery is recommended when your doctor has confirmed through measurements over time
that the disease is progressing. Some patients turn to surgical treatment when hand function is
limited; they have trouble grasping objects or putting their hands in their pockets.

Surgical procedure. Surgery for Dupuytren's contracture divides or removes the thickened bands
to help restore finger motion. Sometimes the wound is left open and allowed to heal gradually.
Skin grafting may be needed.

Complications. Although rare, risks of surgery include injury to nerves and blood vessels, and
infection. Permanent stiffness of the fingers may occur, although this is also rare.

Recovery. Some swelling and soreness are expected after surgery, but severe problems are rare.

After surgery, elevating your hand above your heart and gently moving your fingers help to
relieve pain, swelling, and stiffness.

Physical therapy may be helpful during recovery after surgery. Specific exercises can help
strengthen your hands and help you move your fingers.

Most people will be able to move their fingers better after surgery.

Recurrence. Approximately 20% of patients experience some degree of recurrence. This may

require further surgery.
New Developments

Enzyme Injection
An enzyme injection has recently been approved by the Federal Drug Administration for
treatment of Dupuytren's contracture. It is being administered by surgeons trained in the
technique. The enzyme is able to break down the tough bands and improve motion without
surgery.After numbing the hand with a local anesthetic injection, the surgeon injects the enzyme
directly into the diseased tissue. During the several hours following the injection, the enzyme
dissolves the contractile tissue, allowing the finger to straighten.
This procedure is performed in the doctor's office, and is associated with less pain and swelling
than with surgery. Early results for this injection appear to be as good as surgical results.
Although rare, the injection may cause allergic reactions or flexor tendon tears. Other
complications include the same as those listed above for surgery. Early results are promising, but
long-term recurrence rates have not yet been reported.
Needle Aponeurotomy
Needle aponeurotomy is another new, less invasive procedure being performed by surgeons
trained in the technique. After numbing the hand with a local anesthetic injection, the surgeon
uses a hypodermic needle to divide the diseased tissue. No incision is required and this
procedure can be done in the doctor's office. Complications are no greater than with surgery,
and the patient experiences less pain and swelling immediately after the procedure. Early results
appear equivalent to surgery, but long-term recurrence rates are unknown.
4. Male 42 years old, construction - fell from 3 floor of a house under construction. Lying on
his back, there is no consciousness. Pulse 52 per minute, blood pressure 140/80 mm Hg On
examination - angular deformity of the right shin with a wound in the area of deformation of
0.5 x 0.5 cm and mydriasis right. Identify presumptive diagnosis. Determine the volume of
medical care in the prehospital period. What further examination should be carried out in
the receiving hospital ward? Specify possible treatment policy in the hospital

The tibia, or shinbone, is the most common fractured long bone in your body. The long
bones include the femur, humerus, tibia, and fibula. A tibial shaft fracture occurs along the
length of the bone, below the knee and above the ankle.
Because it typically takes a major force to break a long bone, other injuries often occur with
these types of fractures.

Common types of tibial fractures include:

Stable fracture: This type of fracture is barely out of place. The broken ends of the bones
basically line up correctly and are aligned. In a stable fracture, the bones usually stay in place
during healing.
Displaced fracture: When a bone breaks and is displaced, the broken ends are separated
and do not line up. These types of fractures often require surgery to put the pieces back
together.
Transverse fracture: This type of fracture has a horizontal fracture line. This fracture can be
unstable, especially if the fibula is also broken.
Oblique fracture: This type of fracture has an angled pattern and is typically unstable. If an
oblique fracture is initially stable or minimally displaced, over time it can become more out
of place. This is especially true if the fibula is not broken.
Spiral fracture: This type of fracture is caused by a twisting force. The result is a spiral-
shaped fracture line about the bone, like a staircase. Spiral fractures can be displaced or
stable, depending on how much force causes the fracture.
Comminuted fracture: This type of fracture is very unstable. The bone shatters into three or
more pieces.
 Open fracture: When broken bones break through the skin, they are called open or
compound fractures. For example, when a pedestrian is struck by the bumper of a moving
car, the broken tibia may protrude through a tear in the skin and other soft tissues.
Symptoms
The most common symptoms of a tibial shaft fracture are:
 Pain
 Inability to walk or bear weight on the leg
 Deformity or instability of the leg
 Bone "tenting" the skin or protruding through a break in the skin
 Occasional loss of feeling in the foot

Doctor Examination
It is important that your doctor knows the circumstances of your injury. For example, if you fell from a tree, how
far did you fall? It is just as important for your doctor to know if you sustained any other injuries and if you have
any other medical problems, such as diabetes. Your doctor also needs to know if you take any medications.

After discussing your symptoms and medical history, your doctor will do a careful examination. He or she will
assess your overall condition, and then focus on your leg. Your doctor will look for:

 Obvious deformity such as angulation or shortening (the legs are not the same length)
 Breaks in the skin
 Contusions (bruises)
 Swelling
 Bony prominences under the skin
 Instability (some patients may retain a degree of stability if the fibula remains intact or the fracture is
incomplete)

After the visual inspection, your doctor will feel along your leg to see if there are abnormalities of the tibia. If you
are awake and alert, your doctor will test your sensation and muscle strength by asking you to move your toes
and see if you can feel different areas over your foot and ankle.
Intramedullary nailing. The current most popular form of surgical treatment for tibial fractures is intramedullary
nailing. During this procedure, a specially designed metal rod is inserted from the front of the knee down into the
marrow canal of the tibia. The rod passes across the fracture to keep it in position.

Intramedullary nailing.
Intramedullary nails come in various lengths and diameters to fit most tibia bones. The intramedullary nail is
screwed to the bone at both ends. This keeps the nail and the bone in proper position during healing.

Intramedullary nailing allows for strong, stable, full-length fixation. The technique also makes it more likely that
the position of the bone obtained at the time of surgery will be maintained when compared with casting or
external fixation.

Intramedullary nailing is not ideal for fractures in children and adolescents because care must be taken to avoid
crossing the bone's growth plates.

Plates and screws. Tibial shaft fractures were once routinely treated with plate and screw constructs. These
tools are reserved for fractures in which intramedullary nailing may not be possible or optimal, such as certain
fractures that extend into either the knee or ankle joints.

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.

External fixation. In this type of operation, metal pins or screws are placed into the bone above and below the
fracture site. The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that
holds the bones in the proper position so they can heal.

While external fixation has yielded some reasonable results, having implants outside the body has proven to be
somewhat unpopular with many patients and physicians.

Variant No. 2
1. Features of orthopaedic patients survey
Thepriority is to assess the overall condition of the patient. Since severe trauma, especially multiple
and combined, are often accompanied by blood loss, impaired framing chest disorders of various
functions of internal organs due to their destruction or pathological changes in the system of
regulation. Often, this leads to the development of complex life-threatening schock, requiring the
most active of urgent measures to stabilize the activity of vital functions. In response to a severe
trauma develop a common pathological condition, which in the literature of recent years called
multiple organ failure (polyorganic insufficiency). Complaints patient

 questioning

 Sightseeing (Visual evaluation)

 palpation

 Auscultation

 Clinical measurements

 Determination of range of motion in the joints

 The study of muscle strength

 Defining functions
You need to know:

 a) localization, prevalence, irradiation zone;

 b) the nature;

 c) the relationship with the load, the type of movement;

 d) the intensity (mild, moderate, severe);

 d) provisions to facilitate or enhance pain (sitting, lying on its side with

reduction of reserved, flexion, extension or rotation of the limb);

 e) the possible causes and relationship with other clinical signs.

2. Uncomplicated rib fractures - diagnostics, anaesthesia methods, prevention of

complications.
 3. Congenital clubfoot - clinical and radiological diagnosis, treatment principles.

Clubfoot is a deformity in which an infant's foot is turned inward, often so severely that the
bottom of the foot faces sideways or even upward. Approximately one infant in every 1,000 live
births will have clubfoot, making it one of the more common congenital (present at birth) foot
deformities.Clubfoot is not painful during infancy. However, if your child's clubfoot is not treated,
the foot will remain deformed, and he or she will not be able to walk normally. With proper
treatment, however, the majority of children are able to enjoy a wide range of physical activities
with little trace of the deformity.Treatment usually begins shortly after birth.

Description
In clubfoot, the tendons that connect the leg muscles to the foot bones are short and tight, causing
the foot to twist inward.Although clubfoot is diagnosed at birth, many cases are first detected during
a prenatal ultrasound. In about half of the children with clubfoot, both feet are affected. Boys are
twice more likely than girls to have the deformity.

Appearance
Clubfoot can range from mild to severe, but typically has the same general appearance. The foot is
turned inward and there is often a deep crease on the bottom of the foot.In limbs affected by
clubfoot, the foot and leg are slightly shorter than normal, and the calf is thinner due to
underdeveloped muscles. These differences are more obvious in children with clubfoot on only one
side.

Classification

Clubfoot is often broadly classified into two major groups:

 Isolated (idiopathic) clubfoot is the most common form of the deformity and occurs in
children who have no other medical problems.

 Nonisolated clubfoot occurs in combination with various health conditions or neuromuscular

disorders, such as arthrogryposis and spina bifida. If your child's clubfoot is associated with a
neuromuscular condition, the clubfoot may be more resistant to treatment, require a longer
course of nonsurgical treatment, or even multiple surgeries.

Regardless of the type or severity, clubfoot will not improve without treatment. A child with
an untreated clubfoot will walk on the outer edge of the foot instead of the sole, develop painful
calluses, be unable to wear shoes, and have lifelong painful feet that often severely limit activity.

Cause
Researchers are still uncertain about the cause of clubfoot. The most widely accepted theory is that
clubfoot is caused by a combination of genetic and environmental factors. Increased risk in families
with a history of clubfeet.

Treatment
The goal of treatment is to obtain a functional, pain-free foot that enables standing and walking with
the sole of the foot flat on the ground.

Nonsurgical Treatment
The initial treatment of clubfoot is nonsurgical, regardless of how severe the deformity is.

Ponseti method. The most widely used technique in North America and throughout the
world is the Ponseti method, which uses gentle stretching and casting to gradually correct the
deformity.In the Ponseti method, long-leg plaster casts are applied after the feet are correctly
positioned.

Treatment should ideally begin shortly after birth, but older babies have also been treated
successfully with the Ponseti method. Elements of the method include:

 Manipulation and casting. Your baby's foot is gently stretched and manipulated into a
corrected position and held in place with a long-leg cast (toes to thigh). Each week this
process of stretching, re-positioning, and casting is repeated until the foot is largely
improved. For most infants, this improvement takes about 6 to 8 weeks.

 Achilles tenotomy. After the manipulation and casting period, most babies will require a
minor procedure to release continued tightness in the Achilles tendon (heel cord). During
this quick procedure (called a tenotomy), your doctor will use a very thin instrument to cut
the tendon. The cut is very small and does not require stitches. A new cast will be applied to
the leg to protect the tendon as it heals. This usually takes about 3 weeks. By the time the
cast is removed, the Achilles tendon has regrown to a proper, longer length, and the
clubfoot has been fully corrected.

 Bracing. Even after successful correction with casting, clubfeet have a natural tendency to recur. To
ensure that the foot will permanently stay in the correct position, your baby will need to wear a brace
(commonly called "boots and bar") for a few years. The brace keeps the foot at the proper angle to
maintain the correction. This bracing program can be demanding for parents and families, but is
essential to prevent relapses.

For the first 3 months, your baby will wear the brace essentially full-time (23 hours a day). Your doctor
will gradually decrease the time in the brace to just overnight and nap time (about 12 to 14 hours per
day). Most children will follow this bracing regimen for 3 to 4 years.

There are several different types of braces — all of which consist of shoes, sandals, or
custom-made footwear attached to the ends of a bar. The bar can be solid (both legs move together)
or dynamic (each leg moves independently). Your doctor will talk with you about the type of brace
that would best meet your baby's needs.
Babies might be fussy during the first few days of wearing a brace and will need time to adjust. More
information about helping your baby adjust to bracing is provided at the end of this article in the
section titled "Helpful Tips for Bracewear."

A patient after correction of a left-sided clubfoot deformity with the Ponseti cast method.
Note that the calf is slightly smaller on the left side compared to the normal right leg.

French method. 
Another nonsurgical method to correct clubfoot incorporates stretching, mobilization, and taping.
The French method — also called the functional or physical therapy method — is typically directed
by a physical therapist who has specialized training and experience.

Like the Ponseti method, the French method is begun soon after birth and requires family
involvement. Each day, the baby's foot must be stretched and manipulated, then taped to maintain
the range of motion gained by the manipulation. After taping, a plastic splint is put on over the tape
to maintain the improved range of motion.

This method requires approximately three visits to the physical therapist each week.
Because this is a daily regimen, the therapist will teach the parents how to do it correctly at home.
 After 3 months, most babies have significant improvement in foot position, and visits to the
physical therapist are required less often. Like children treated with the Ponseti method, babies
treated with the French method commonly require an Achilles tenotomy to improve dorsiflexion of
the ankle.To prevent recurrence of the clubfoot, the daily regimen of stretching, taping, and
splinting must be continued by the family until the child is 2 to 3 years old.

Surgical Treatment
Although many cases of clubfoot are successfully corrected with nonsurgical methods, sometimes
the deformity cannot be fully corrected or it returns, often because parents have difficulty following
the treatment program. In addition, some infants have very severe deformities that do not respond
to stretching. When this happens, surgery may be needed to adjust the tendons, ligaments, and
joints in the foot and ankle.

Because surgery typically results in a stiffer foot, particularly as a child grows, every effort is
made to correct the deformity as much as possible through nonsurgical methods. Even an infant
with severe deformities or clubfeet associated with neuromuscular conditions can improve without
surgery. If a child's foot has been partially corrected with stretching and casting, then the surgery
required to fully correct the clubfoot will be less extensive.

 Less extensive surgery will target only those tendons and joints that are contributing to the
deformity. In many cases, this involves releasing the Achilles tendon at the back of the ankle
or moving the tendon that travels from the front of the ankle to the inside of the midfoot
(this procedure is called an anterior tibial tendon transfer).

 Major reconstructive surgery for clubfoot involves extensive release of multiple soft tissue
structures of the foot. Once the correction is achieved, the joints of the foot are usually
stabilized with pins and a long-leg cast while the soft tissue heals.

After 4 to 6 weeks, the doctor will remove the pins and cast, and typically apply a short-leg
cast, which is worn for an additional 4 weeks. After the last cast is removed, it is still possible for the
muscles in your child's foot to try to return to the clubfoot position, so special shoes or braces will
likely be used for up to a year or more after surgery.

The most common complications of extensive soft tissue release are overcorrection of the
deformity, stiffness, and pain.
 4. A man 23 years old was hit by a train and got a detachment of the lower extremity at the
level of the middle third of the right thigh. Inhibited, confused consciousness. Pulse 120 per minute,
blood pressure 90/50 mm Hg Thigh in the middle third is a "mash-up" of the destroyed muscle mass
of foreign bodies (sand, oil). There meagre venous bleeding. Identify presumptive diagnosis. Specify
the amount of medical care in the prehospital period, during transport and in the emergency
department of a hospital.
    - antibiotic prophylaxis
    - injury, grade I & grade II open frx w/o gross medullary contamination are best treated by immediate IM
nailing;
    - w/ IM rodding: debridment should be separate procedure from nailing; frx site should be isolated from
operative field;
    - grade IIIA open femoral frx may be rx'ed w/ immediate IM nailing, if debrided w/ in 8 hrs of injury;
    - if debridment is delayed, or if IIIB injury is present, then temporary external fixation is rx of choice;
          - most grade I, II, and IIIA have low rates of infection, however, grade IIIB will have significant rates of
infection (see osteomyelitis);
          - isolated open frx w/ severe contamination require external fixation;
    - grade IIIC: frx associated w/ arterial lesions (see arterial trauma and femoral artery)
          - external fixation is best method of stabilization
          - quickly applied and may be repositioned;
          - if patient is unstable, consider amputation;

    Wound Management:

- antibiotic bead pouch: 
           - after stabilization has been completed, osseous defects may be filled w/ antibiotic-impregnated
methylmethacrylate beads; 
           - these are made by the mixing of 1.2 to 2.4 grams of tobramycin or one to two grams of vancomycin, or
both, with one package (forty grams) of methylmethacrylate over braided 26-gauge wire; 
           - these beads provide local depot administration of antibiotic and maintain a space for subsequent bone
graft; 
    - drains and closure of wounds: 
           - traditionally all traumatic wounds, including those created by fasciotomies, are left open for 48 hrs; 
           - operative incisions may be sutured closed if doing so does not produce undue tension at the skin edge; 
           - exposed tendons, joints, and bone should be covered w/ adjacent soft tissue to prevent desiccation; 
    - wound dressings: 
           - temporary coverage of exposed tissue was often obtained in the past by placement of sterile dressing
sponges soaked in isotonic saline solution over the wound, but this leads to wound desiccation; 
           - wound vac is now widely used for a variety of traumatic wounds; 
           - alternatives, such as pigskin, Epigard, etc.