Free class I 1:31:45

ULNAR NERVE INJURY (ULNAR CLAW)

Short History
• Duration
• Numbness / tingling of the medial 1 and ½ fingers
• Ask for dominant hand, occupation and disability
• History of cut injuries

Positioning Of The Patient

• Seated

Exposure
• Expose to elbows and ask the patient to keep both hands palm upwards
on a pillow/ lap

Examination

Look Feel Move

Compare both hands, both sides • If no scar: Palpate the ulnar nerve posterior to • Dorsal interossei (abductors)
• Ulnar claw hand lumbricds
← not
are
working the medial epicondyle o Keep the hand on a flat surface and
o Hperextenteion of MCP joints o In leprosy the ulnar nerve is thickened spread out the fingersagainst resistence
o Flexion of the IP joints Ask patient to close eyes
• Palmar interossei
• Hypothenar muscle wasting Compare with other fingers and other hand
o Use a paper and assess the ability to
• Dorsal guttering beDorsal inlevroseus washing Can • Palmar aspect of little finger and medial ½ of
grasp it in-between fingers card
←
← use
clearly
.

ring finger
seen
since dorsal skin
• Medial forearmIf wasting is thin

[ aboveelbow
FDPc-
Flex
Carpi Ulnar is
• Adductor pollicis: Froment's test
• Sensory loss + over the palm / hypothenar
,

• Scars at the wrist / forearm

eminence
• Check the thumb and first web on dorsum (to
exclude other diagnoses)

-Y
1. What is ulnar paradox?
median
c-
Ulnar

Radial → Dorsum
of
first web
space

exclusive zone -
 MEDIAN NERVE INJURY
Short History Due to overlap -

• Duration of ulna and

• Numbness / tingling of the lateral 3 and ½ fingers median

• Ask for dominant hand, occupation and disability

• History of cut injuries

Positioning Of The Patient

• Seated

Exposure
• Expose to elbows and ask the patient to keep both hands palm upwards
on a pillow/ lap

Examination

Look Feel Move

Compare both hands, both sides Compare with other fingers and other hand • Weakness of lateral 2 lumbricals and muscles of
• Ponting index/ Ape hand / Benediction hand • Palmar aspect of thumb, index and middle thenar eminence (abductor pollicis brevis, Pen test
←

o Inability to flex the index finger
o Thumb in the same plane as other
fingers
• Thenar muscle wasting
• Lateral forearm wasting
• Scars at the wrist / forearm
First position
fingers and lateral ½ of ring finger opponence pollicis, flexor pollicis brevis) thumb
along index
• Loss of sesation over the thenar eminence • Clasping Test: (Oschner's tests) finger
• Check the little finger and first web on dorsum o Instruct the patient to grasp the hands
(to exclude other diagnoses) o The index ringer gets pointed

1. Explain the deformity?

Ape hand Thenar washin test

Clasping
 RADIAL NERVE INJURY
Short History
• Duration
• Numbness / tingling of the dorsum of the 1st web space
• Ask for dominant hand, occupation and disability
• Aetiology
o Fracture of humeral shaft
o Crutch palsy: Axilla
o Saturday night palsy: Spiral groove
o Tourniquet palsy: Most commonly damaged nerve is the radial

Positioning Of The Patient

• Seated
Exposure
• Expose to elbows and ask the patient to keep both hands palm upwards
on a pillow/ lap
Examination

Look Feel Move

Compare both hands, both sides Compare with other fingers and other hand • Triceps: Extend the elbow against resistence
• Finger drop • Loss of sesation over the dorsum of the 1st web • Brachioradialis: Flex the elbow with semi-
• Wrist drop space pronated forearm against resistance
• Extensor compartment wasting • Check the little finger and thumb (to exclude • Supinator: Supinate with the elbow extended
other diagnoses)

.,-
1. At which location is the injury?

§
2. What is the posterior interosseous nerve? spiral
groove

"" -

3. How do your treat this condition? Below elbow →

Finger drop
µ , , .mn
,

* .. . aww → a. + a,
↳ #
of humerus
arm
Deep
surgery →
( meta )
,,g ,
, , ,
,,
[ sensory
or

]
PIN
↓
Dorsum
Extensor of
digitorum 1ˢᵗ web space
 DISCUSSION

¥f
1. What is the pathophysiology behind CTS? +

i. →

← →
→
Minimis
2. What are your differential diagnoses?
→
←
→
¥ ±
→
←
←
→ ,

ji
,

→
:
3. How will you investigate this patient? FPL
D Flexor P B
,

{ a) Abductor
"
+
A "
D Flexor M

)
in P B
4. How will you treat this patient? coming 2) Abductor M
" &

j (
③ P "
"
" ""

◦ "" " "

3)
" ' "
hypothenar Opponents M
5. What are the non-surgical methods of treatment?
↓
↓
6. How do these non-surgical options help? Median nerve Ulnar nerve

7. Can you show me how the incision is made? + interviews

Is palmar
↓

8. What are the complications of CTD/CTR? 3- PAD +

AP → Palmar → Adduct
4- DAB →
Dorsal → Abduct
} " ""

Median nerve

L -

Lumbricalis
0 -

Oppenonensp

A -
Abductor P B

F-
• •

Flexor PB •

lumbriccls → Flexes MCP I II → median

↳ Extends DZP , P2P
☒ → ulnar
 DD ✗ Us Pronator teres XD → median nerve
-

runs between the two heads

of

/
the pronator teres get compressed
Cervical
spondylosis [ radical apathy)
→ can
.

µ
All the clinical Fx of carpel tunnel except
here there is loss of thenar

CARPAL TUNNEL SYNDROME

sensation over the
cervical rib ← eminence .

Short History Pdmavislongus

I
• Duration
• Pain in the hand especially at night and after activity
• Difficulty squeezing coconut, clothes
can have • Numbness / tingling of the lateral 3 and ½ fingers (Palmer)
'

catinjuries• Ask for dominant hand, occupation and disability A-

Can beb aswell
/L

• Aetiological factors:
o Arthritis

§¥f
o Diabetes
o Pregnancy
o Hypothyroidism carpel tunnel
o Colles Fracture
Obesity
•

Positioning of The Patient

Boudary
• Seated
Floor → Two rows of
carpel bone,
Exposure
• Expose to elbows and ask the patient to keep both hands palm upwards Roof → Flexor
Retinaculum
on a pillow/ lap Lateral →
Scaphoid ,

trapezium
Examination Medial → Hook of hamate
Pisilovm
Look Feel Move
Compare both hands, both sides Compare with other fingers and other hand • Weakness of lateral 2 lumbricals and muscles of
• Thenar muscle wasting • Palmar aspect of thumb, index and middle thenar eminence (abductor pollicis brevis,
• Scar from previous surgery (especially on the fingers and lateral ½ of ring finger opponence pollicis, flexor pollicis brevis)
other side as it is commonly bilateral) • CTS does not cause sensory loss on the palm • Pen test
• Forearm muscle wasting and dorsal guttering (thenar eminence) [
Palmar
the median
given off before
cutaneous nerve

carpel tunnel
nerve enter the
is

and
• Tinel’s test: Tapping over the median nerve at
the carpel tunnel
wrist reproduce tingling sensation
runs above the

that points to another diagnosis • Check the little finger and first web on dorsum
_

(to exclude other diagnoses) • Phalen’s test: Maximal flexion of wrist for 1
minute exacerbate symptoms
• Adson’s test to exclude thoracic inlet syndrome
not
essential
{• Alan’s test to identify dominant artery
to do
 CARPAL TUNNEL SYNDROME20:288
Introduction
• The best knownnerve entrapment syndrome
• Pathophysiology
o Venous return is impaired due to compression inside the carpal
tunnel leading to oedema
o This leads to ischemic neuropathy
o Direct compression of the nerve
• Differential diagnosis
o Cervical radiculopathy
o Thoracic inlet syndrome

History
• Male > Female
• Age 40 – 50 years
• Pain in the hand especially at night and after activity
• Difficulty squeezing coconut, clothes
• Numbness / tingling of the lateral 3 and ½ fingers (Palmer)
• Dominant hand, occupation and disability
• Aetiological factors:
o Arthritis
o Pregnancy
o Hypothyroidism
o Colles Fracture
Examination

Look Feel Move

Compare both hands, both sides
• Thenar muscle wasting
• Scar from previous surgery (especially on the
other side as it is commonly bilateral)
• Forearm muscle wasting and dorsal guttering
that points to another diagnosis
Compare with other fingers and other hand
• Palmar aspect of thumb, index and middle
fingers and lateral ½ of ring finger
• CTS does not cause sensory loss on the palm
(thenar eminence)
• Check the little finger and first web on dorsum
(to exclude other diagnoses)
• Weakness of lateral 2 lumbricals and muscles of
thenar eminence (abductor pollicis brevis,
opponencepollicis, flexor pollicis brevis)
• Pen test
• Tinel’s test: Tapping over the median nerve at
wrist reproduce tingling sensation
• Phalen’s test: Maximal flexion of wrist for 1
minute exacerbate symptoms

Clinical Surgery
 What is the pathophysiology behind CTS? Treatment
• Venous return is impaired due to compression inside the carpal tunnel • Removal of underlying cause
leading to oedema 2 compresses the artery
• This leads to ischemic neuropathy How do these non-surgical options help?
• Direct compression of the nerve
Non-Surgical
What are your differential diagnoses? • Local steroid injection
• Cervical radiculopathy o Help reduce oedema and any secondary inflammation
• Thoracic inlet syndrome • Splinting
o Relieves pain by reducing movements that increase pain
How will you investigate this patient?
• Physiotherapy
Invesigations
• NCS o Reduce oedema
Nerve conduction studio , slow conduction velocity
-

o Rules out proximal lesions

.

in median nerve Surgical

o Determines the severity what will you compare this • Carpal tunnel decompression (CTD)
• X-Ray Cervical spine value with → with ulna .
o Surgery is done under local anaesthesia
o AP nerve
o A blood less field is achieved by applying a pneumatic cuff
o Lateral • Incision
o Along the radial border of the ring finger, from the distal palmer
crease to the distal border of the extended thumb
o Flexor retinaculum is divided to release the median nerve
Can you show me how the incision is made?
• Incision
o Along the radial border of the ring finger, from the distal palmer
crease to the distal border of the extended thumb
o Flexor retinaculum is divided to release the median nerve
can be Done under LA but ideally under AA

What are the complications of CTD/CTR?

• Recurrence due to incomplete division
• Damage to palmar cutaneous nerve à painful neuroma
• Damage to motor branch / recurrent branch
• Damage to main trunk of median nerve
• Implantation dermoid

Clinical Surgery
 INDIVIDUAL NERVES
History
• Dominant hand
• History of cut injuries
• For radial nerve20:282: Use of crutches, Humeral shaft fractures
Examination

Ulnar Nerve20:283 Median Nerve20:284 Radial Nerve20:282

Look • Ulnar claw hand • Pointing index / Ape hand / Benediction • Wrist drop
o Hperextension of MCP joints of 4th hand • Finger drop
and 5th digits o Inability to flex the index finger • Extensor compartment wasting
o Flexion of the IP joints o Thumb in the same plane as other
• Hypothenar muscle wasting fingers
• Dorsal guttering • Thenar muscle wasting
• Medial forearm wasting • Lateral forearm wasting
• Scars at the wrist / forearm • Scars at the wrist / forearm
Feel • Sensory loss over palmar aspect of little • Palmar aspect of thumb, index and middle • Loss of sensation over the dorsum of the 1st
finger and medial ½ of ring finger fingers and lateral ½ of ring finger web space
• Sensory loss + over the palm / hypothenar • Loss of sensation over the thenar eminence
eminence
Move • Dorsal interossei (abductors) • Weakness of lateral 2 lumbricals and • Extensors of the wrist
• Palmar interossei muscles of thenar eminence (abductor • Extensors of fingers
• Adductor Pollicis: Froment's test1:444 pollicis brevis, opponenspollicis, flexor • Extensor of elbow
pollicisbrevis)1:446 • Brachioradialis: Flex the elbow with semi-
• Pen test pronated forearm against resistance
• Clasping Test: (Oschner's tests) • Supinator: Supinate with the elbow extended
o Instruct the patient to grasp the hands
o The index ringer gets pointed:
Pointing index

Clinical Surgery
 What is ulnar paradox? Extensor
[ Radial
digitorum
)
•
Lumbrirds
When the ulnar nerve is damaged proximally the deformity is less; when y
↑ plumb
riots

the damage is distal the deformity is more

• When the ulnar nerve is damaged at the elbow, both the flexor JMc
↓ ↓
digitorumprofundus and the lumbricals are paralyzed Lumbricalis
FDS
↓
FDP
(median]
• When the damage is at the level of the wrist, flexor digitorumprofundus (ulnar]
Ulnar
Medved
-1
Median
Lateral
is intact and the lumbricals are paralyzed which causes the clawing
deformity to be more prominent, because of the unopposed action of the
flexor digitorumprofundus

Explain the deformity of Median Nerve injury ?

• The median nerve supplies the flexor digitorumsuperficialis and lateral
½ or flexor digitorumprofundus (through it’s anterior interosseous
branch)
• These muscles flex the index finger at the PIP and DIP respectively

At which location is the injury according to the degree of deformity in

Radial Nerve injury ?
• If no wrist drop + and only finger drop:
o Below the elbow: Posterior interosseous injury
o Extensor carpi radialis longer has been supplied above injury
o That extends wrist but fingers cannot be extended
§ Nerve supply to the ECRL is given at the elbow: This
muscle alone can maintain wrist extension
• If wrist drop + but can extend the elbow:
o Above the elbow, below the axilla
• If wrist drop + but can NOT extend the elbow:
o At the axilla

What is the posterior interosseous nerve?

• Main motor branch of the radial nerve
• Supplies the extensor compartment of the forearm
How do your treat Radial Nerve injury ?
• Physiotherapy
• Jones tendon transer
Clinical Surgery
 DUPUYTREN'S CONTRACTURE
Introduction
• Thickening of the palmar fascia resulting in flexion of the metacarpo-
phalangeal joint as well as the proximal inter phalangeal joint
• Most commonly involving the ring finger
• Can involve all 4 fingers.
• Other sites→
Look a the other hand
o Plantar aponeurosis. ie: Clawing of the toes
o Penis: Peyronie’s disease
§ The erected penis bends to a side, because of a fibrous
band involving the tunica albuginia
Causes
• Chronic alcohol consumption
• Idiopathic
• Phenytoin sodium
• Diabetes mellitus
Treatment
• Avoid risk factors
• Physiotherapy
• Excise the palmar fascia
• Amputation

Ulnar claw us Dupuy Tren 's

Mcp will .
Mcp
will be flexed
be hyper extended

g- Palmaris
longus
Clinical Surgery
 #

ligament
injuries
(ae
c
POP CASTS
plaste
Examination DISCUSSION
Look 1. What are the advantages and disadvantages of POP casts?

f
• Affected side and limb POP Cast applied
~ Right lower limb
to 2. Why do we sometimes initially put a back slab before POP cast?
• Extention of the cast
3. How will you manage this patient after POP application?
o Proximal end Groin
o Distal end Heads of metatared
4. What is compartment syndrome?
• What is the most likely fracture based on the cast? Most likely applied low
colles #
• 5. What other causes do you know that causes compartment
a

Oedema Distel to the cast

->

• Look at the patient’s face for evidence of pain should be syndrome?

pain in no
-

cam

• Check for color changes (pink, pallor, cyanosis) of the fingers

6. When would you suspect compartment syndrome in this patient?

Feel 7. How will you investigate a patient with compartment syndrome?

8. How would you manage this patient if there is evidence of

• Temperature: Check whether the fingers are cold (compare with the
compartment syndrome?
Press down
opposite sides)
• CRFT: < 2 sec (Compare the capillary refilling with the opposite side)
-
for Is
9. Show me where you would bivalve a forearm cast?
• Peripheral pulse if pulse is covered by POP check CRFT
=>

• Check for adequate tightness of the POP: Try and insert little finger, 10. What are the advantages/ disadvantages of POP casts? (past
which should be barely possible question)
• Neurology
11. Describe the compartments of the leg
o Sensory: Numbness/ parasthesia

Move 'back slab' is a slab of plaster that does not completely encircle the limb and is used for injuries which
have resulted in a large amount of swelling. It is secured with a bandage to accommodate the swelling.
• Nerology
o Motor: Check the finger/ toe movements
• Extend the fingers (patient will experience the pain if there is
compartment syndrome)
How to clinical Dx Compartment syndrom.

Patient will complain of to

out
of proportion the injury screaming and shouting
-

pain to

Compartment 4 level will interfere blood supply

-

rises beyond a which with the compact mont

↓

Clinical Surgery
 Compartment Syndrome1:408
Introduction
What is compartment syndrome? (past question)
• Compartment syndrome is raised pressure in an osseofascial compartment
to a level that compromises tissue perfusion
• Increased tissue pressure, which leads to reduced microperfusion resulting
in tissue ischaemia and irreversible muscle damage from cellular anoxia
What other causes do you know that causes compartment syndrome?
Causes
• Fractures: Most common (70%)
• Soft tissue contusions (23%)
• Rarer causes
o Bleeding disorders including anticoagulation
o Burns (particularly circumferential 3rd degree burns)
o Post-ischaemicswelling (reperfusion injury)
o Tight casts/dressings
o Extravasation of intravenous infusions (contrast under pressure)
Describe the compartments of the leg
Compartments of the Leg
When would you suspect compartment syndrome in this patient?
Clinical Features
• Pain out of proportion to the injury and increasing pain
• Extend the fingers/ toes: Pain on passive stretch c-
Compressing
further
the blood vessels
• st
Numbness: Dorsum of the 1 web space in the lower limbs
• Paralysis, paraesthesia and pallor are late signs
• Pulselessness is an extremely late sign
How will you investigate a patient with compartment syndrome?
Investigations
• CLINICAL DIAGNOSIS
• Compartment pressure monitoring
o In patients with altered level of consciousness (uncertain
diagnosis). Eg: Intubated, head injury
o Measure multiple sites near but not in the fracture site
o In all the compartments of the affected limb
An absolute pressure greater than or equal to 30 mmHg or pressure
difference (diastolic pressure – compartment pressure) less than or equal
to 30 mmHgis strongly suggestive of Compartment Syndrome
How would you manage this patient if there is evidence of compartment
syndrome?
Treatment
• Urgent bivalving of the POP is indicated20:699
• Throughout its length, throughout all the padding down to skin
• Inform seniors
• If the response is poor prepare for urgent fasciotomy1:408
Clinical Surgery
Compartment syndrome

1) Pain (+) passive stretch test (tenderness)

2) Pallor + Poikilothermia (pale and cold limb)
3) Paresthesia [change in sensation] numbness or
tingling sensation
4) CRT >2sec and Pulselessness absent distal pulses
5) Paralysis unable to move limbs

* Watch out = check signs

- movement, limb T, SpO2, sensation, passive stretch
- apply cryocuff/ice,

* impending compartment syndrome

keep NBM with IVD

remove bandages or casts,
plantar flexion
prepare consent
order OT
emergency FASCIOTOMY

compartment syndrome following TIBIA fractures are

most common in closed frx (upto 20% of frx)

- Clinical Presentation:
- symptoms may not appear for 24 hours after injury;
- clinical signs include increased pain even after
reduction and casting;
- severe tenderness over the anterior compartment
muscles rather than fracture site is an indication of
compartment syndrome;
irreversible muscle damage may occur after 4-6 hours, after which time the pain of ischemic muscles may diminish or be absent;

- Exam:
- blood pressure:
- compartment syndrome is potentiated by hypotension;
- pain:
- extreme pain out of proportion to the injury,
- pain on passive ROM of the fingers or toes (stretch pain of the involved compartment):
- patient will usually hold injured part in a position of flexion to maximally relax the fascia and reduce pain;
- pulses:
- check extremity pulse (such as dorsalis pedis)
- apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses;
- compare pulses to the opposite non injured side (to rule out vascular injury);
- pallor of the extremity,
- paralysis, paresthesias (early loss of vibratory sensation);

- anterior compartment: - posterior compartment:

- variable weakness of toe extension; - weakness of toe flexion and ankle inversion;
- pain on passive toe flexion; - pain on passive toe extension (may referr to the back
- diminished sensation in the first web space; of the leg)
- diminished sensation over the sole of the foot;
- Management:
- fasciotomy
- normally the lateral fasciotomy incision is made halfway between the tibia and fibula;
- w/ a difficult fracture reduction, consider making the incision slightly closer to the tibia so that the fracture site can be
palpated and bone holding clamps can be applied;

- if cast has been applied, it should be bivalved immediately;

 The compartments

Hand

Forearm
1. Dorsal = Spf Dorsal + Deep Dorsal
2. Spf Volar
3. Deep Volar
4. Mobile wad

Arm
1. Anterior =
biceps brachii,
brachialis, and coracobrachialis.
2. Posterior =
triceps brachii and anconeus
Thigh
1. Anterior

sartorius
quadriceps (rectus femoris, vastus lateralis, vastus
intermedius, vastus medialis)

2.Medial

adductor longus
adductor brevis
adductor magnus

3. Posterior (Spf + deep)

biceps femoris
semitendinosus
semimembranosus

Leg

Anterior compartment

Tibialis anterior
Extensor digitorum longus
Extensior hallucis longus

Lateral compartment

Peroneus Longus
Peroneus brevis

Posterior compartment

Tibialis posterior
Flexor digitorum
Flexor hallucus
Plantaris
Soleus
Gastrocnemius
Fat Embolism
Etio: trauma to long bones / pelvis large fat droplets enter circulation deposition in pulmonary capillary beds

Supportive treatment only

- Adequate oxygenation , cont pulse oxymetry
- IVD fluid therapy
- Heparin
* IV corticosteroids
 old /
Seen in
post mend osteoporotic women .
Forearm # Mx →
Perfect anatomical reduction
# due to FOOSH
# Gal @ a 22
-

Otherwise might disrupt the pronation

2cm proximal to wrist joint [Radio carpet
)
,
is
which and supination
is dorsally displaced → Dinner fork Monte ggia
deformity
There

displaced
There
is

also
.
a dorsal angulation and Radial angugdah.cn and COMMON CASTS This is

plates
achieved
and screws
by 012212 by

is a
supination him and impaction .

" ed "
put
]
""
Pronation not radius
[ to : usually
→ PCP is on
correct supination
pulling
the and impaction by
.

] %! yⁿ¥%?
Flexion & and ulnar
→
Dorsal displacement
Upper Limb POP Casts
corrects
angulation
→
and
this way in an
→
Ulnar deviation To POP
for ulnar Probably
angulation placed
correct casts
the radial
displace radius → undis
→
an
and ,
#
say it is not applied
well

Colles’ Cast Scaphoid Cast Above Elbow POP Cast ‘U’Slab

• • • •
Colles proximal joint
In Colles’ #fracture In Scaphoid fracture In fractures of the radius and ulna In fracture of the shaft of the
In cast
is not incorporated → cos the # is
very distal and since these au old
women the east is kept for

•
and

• •
books

Below EJ to distal palmer crease Below elbow to distal palmer Above elbow (axilla) to distal
→

humerus
elbow
joint stiffness

(just short of MCP joints)y crease palmer crease • Above shoulder, around the
• Heads of the metacarpals are left • Heads of the metacarpals are left • Heads of the metacarpals are left elbow, to the axilla
uncovered by the plaster uncovered by the plaster← 1ˢᵗ MC Since
short
is
uncovered by the plaster • Check for radial nerve palsy
• Carpo-metacarpal joint of the • Incorporating proximal phalanx of • Carpo-metacarpal joint of the (wrist drop)
thumb is not incorporated (thumb thumb c- Since distal joint
this is the thumb is not incorporated (thumb
possible
not incorporated) • not incorporated)
movement
Wrist is held slightly extended and
← since is
at
the 1st CMC Joint '

this
. .

stillness can
prevent

• Forearm is pronated the thumb forwards • The elbow is kept at 90 degree of

• Wrist is slightly flexed and ulnar o 'Glass-holding position' flexion
t
deviated • Full POP Incase there is joint
• The forearm is semi pronated (or
• Dorso-Radial Slab (DRB) 88 based on site of fracture)
stiffness it would be
o 2/3 of the way round in a
functional position
• Full POP upto to axilla
-

the circumference of the • Black slab or ¾ slab temporarily

wrist
• Full POP

Mobi
Clinical Surgery
 Lower Limb POP Casts class 7 3 : OC

Above Knee Cast ← Most

lower
common
limb cast Below Knee Cast/ POP Boot Non-Rotation Boot POP Cylinder
• In fractures of the tibia +/- fibula • In ankle fractures • In conservative management of • In,
• Above knee (groin) to MT heads • From tibial tuberosity to MT heads extra-capsular fracture neck of the o Fractured patella
o Heads of metatarsals are not o Heads of metatarsals are not femur o After patellectomy
incorporated in to the plaster the
incorporated in to the plaster • Similar to a POP boot, but there is o Tibial Plateau fractures
a stick connected to it to prevent it •
have

•
To

The ankle is flexed to 900 ← Tibia

fibula +

•
the widest in
at

the Ankle is flexed to 90° Above knee and above ankle

• 0 0 from rotating
joint

The knee is flexed to 20 – 30 • ← To keep

knee unlocked If plantar flexed

• The anterior superior iliac spine 97 o Achiles tendon repair
(ASIS), patella & the 2nd toe
should be on a straight line
j¥÷¥
This
o Talus fracture
part becomes

Jf "÷?
di and proximal
Joint becomes hip not

o Calcaneal fracture
• If there is a window it indicates an E.
open fracture ← always look check Mortis view → to look for taler

shift → if we

then surgery

if not pop

window Clinical Surgery

 EXTERNAL FIXATORS

1. Examine this patient’s lower limbs connecting clamps

connecting rods
[
Schanz →

Look screws

• Affected side and limb

• Type of external fixator
• What is the most likely fracture based on the frame? Center of
←

• Any shoetening of the affected limb fixator

•
•
Any areas of bone loss if it's open
→

Any wounds/ skin grafted sites

{
• Pin site infection
• Oedema
• Look at the patient’s face for evidence of pain
• Check for color changes (pink, pallor, cyanosis) of the fingers
This is
external
fixate
a
spanning
since it has above
Feel gone the joint

• Temperature: Check whether the fingers are cold (compare with the 3. What are the types?
opposite sides) • Number of planes
• CRFT: < 2 sec (Compare the capillary refilling with the opposite side) o Uniplanar Ring type
• Peripheral pulse o Biplanar
• Sensory: Numbness/ parasthesia o Multiplanar
• Unilateral or Bilateral
Move • Method of attachment to the bone
• Motor: Check the finger/ toe movements o Pin based fixators
o Pinless (clamps)
o Wire based fixators (Ilizarov)
o Hybrid
• Connecting system
2. What are its pricipals? o Tubular
• Imobilize the proximal and distal fragments o Threaded rods
o Frames and rail types
o Limb reconstruction system (LRS)

Clinical Surgery
4. What are its advantages? Disadvantage is the pins going directly into bones causing infection
• Imobilize the proximal and distal fragments (not the joints)
• Easier for wound management
• No need to immobilize proximal and distal joints
o Early mobilization
§ Prevents DVT
o Less joint stiffness
• Can mobilize early
• Allows sking grafting
• Less expensive tham internal fixarion
• Need less expertise

5. In what type of fractures is it indicated?

smelled heals
• In compound fractures with bony loss large wound when wound is → Mx with POP cast and
.

c- in →
a window .

• Closed fractures with severe soft tissue injury

• As an adjunct to internal fixation
• In damage control surgery for unstable pelvic fractures
• For limb lenghthening and bone transport

6. What are compound fractures?

• Fractures that communicate with the exterior

7. Why not internal fixation?

• Contaminated wound

Clinical Surgery