By S. Gunnar. Harding University.
Acromio-Clavicular Joint Dislocation Defnition: Classifed in 6 diferent types depending on which ligaments are sprained or torn purchase dapsone 100mg with visa. Recommendations - Physical therapy under supervision post immobilization removal - Pre and post reduction: X-Ray and Neuro-Vascular status evaluation is mandatory 1 generic dapsone 100 mg on-line. Hip Dislocation Description - Traumatic hip dislocation of the hip joint may occur with or without fracture of the acetabulum of the proximal end of the femur buy 100 mg dapsone fast delivery. Traumatic Knee Dislocation Defnition: Is the complete displacement of the tibia with respect to the femur and with disruption of 3 or more of the stabilizing ligaments generic 100mg dapsone overnight delivery. Surgery Clinical Treatment Guidelines 51 Chapiter 1: Orthopaedic Surgery Management A knee dislocation is a potentially limb threatening condition, therefore immediate reduction is recommended even before a radiography evaluation. Conservative • Immediate closed reduction and immobilization at 20-30o of fexion for 6 weeks • Range of motion/exercise should be instituted afer adequate sof tissue healing 6-12 weeks Surgical • Indications → Unsuccessful closed reduction → Open injuries → Vascular injuries → Residual sof tissue interposition Recommendations - Acute repair of lateral ligament followed by early functional bracing is advised (meniscal injuries to be addressed at time of surgery - Medial collateral injuries generally heal without surgery - Te role of cruciate reconstruction in the acute setting remains controversial 1. Patellar Dislocation Description: Patella dislocation is more common particularly in females due to physiologic laxity and in patients with hyper mobility (athletes) Causes - Physiological laxity - Direct trauma to the patella - Connective tissue disease (Marfan Syndrome) - Congenital abnormality of the patella and trochlea - Hypoplasia of the Vastus Medialis muscle - Hypertrophy of the lateral retinacular 52 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 Signs and symptoms - Pain focused around the knee joint - Inability to fex knee - Hemarthrosis - Swelling with tenderness of the knee - Palpated displaced patella Investigation - X-ray of the knee (Anteroposterior and Axial views) Complications - Recurrent dislocation - Re-dislocation - Patella-femoral Arthritis Management Conservative • Closed reduction with cylinder casting for 2- 3 weeks • Isometric quadriceps exercises afer removal of the cast Surgery • Recurrent episodes require operative repair Surgery Clinical Treatment Guidelines 53 Chapiter 1: Orthopaedic Surgery 1. Septic Arthritis Defnition: Septic arthritis is the infammation of a synovial membrane with purulent efusion into the joint space usually caused by bacteria. Chronic Osteomyelitis Defnition: Exogenous or hematogenous infection that has gone untreated or has failed to respond to treatment. Fracture of Wrist Bones Description - Carpal/wrist bones are in 2 rows: • A wrist fracture is a break in one or more of the bones in the wrist. Causes - Fall on the outstretched hand and extended wrist - Motor vehicle accident - Sports contact injury 1. Fracture of the Scaphoid Bone Description: Scaphoid fractures are by far the most common of the carpal fractures, estimated at 70-79%. Classifcation Herbert classifcation of scaphoid fractures - Type A fractures are stable and acute including: • A1: Fracture of the tubercle • A2: Incomplete fractures of the scaphoid waist - Type B fractures are unstable and include: • B1: Distal oblique fractures • B2: Complete fracture of the waist • B3: Proximal pole fractures • B4: Transscaphoid perilunate fracture dislocation of the carpus - Type C fractures are characterized by delayed union. Other Wrist Bone Fractures Description: Commonly associated with above carpal bone fractures. Metacarpal Fractures Description: Metacarpal bones are located between carpal bones and phalanges. From radial to ulna we have thumb (First) Metacarpal and second to ffh metacarpal. Bennett’s and Rolando’s Fractures Description - Bennett’s fracture is an intra articular fracture of the base of the thumb metacarpal characterized by one small ulna fragment. Causes - Fall with axial loading through the thumb metacarpal - Direct blow of the thumb metacarpal - Injury involving forced abduction of the thumb Signs and symptoms - Pain and swelling - Decreased range of motion of the thumb - Shortening of the thumb - Dorsal and radial displacement of the metacarpal bone Surgery Clinical Treatment Guidelines 65 Chapiter 1: Orthopaedic Surgery Investigations - Plain x-ray (Antero-posterial and oblique views) Management Surgical • If the Bennett’s fragment is less than 15-20% of the articular surface: Closed reduction and percutaneous pin fxation followed by a thumb spica splint for 4-6 weeks. Fractures of Phalanges Proximal and middle phalanges Defnition/Description: Fracture of the bones of the proximal or middle phalanges of the fngers. Distal Phalanges and Nail Bed Injuries Description: Distal phalanges fractures are ofen associated with nail bed laceration. Dislocations of the Hand Joints Defnition: A dislocation is a misalignment of the bones forming a joint. If relocation is difcult under those circumstances do an open reduction • Splinting in functional position for 4 weeks and then physiotherapy Surgical • Sometime the volar plate or tendons can be entrapped into the joint and that is why it may be impossible to do a closed reduction. Recommendation - Refer to orthopedic surgeon or hand surgeon any dislocation that can’t be relocated conservatively. Burns Wound management of the burned hand follows the general principles of burn wound management. Tese spaces are the thenar, midpalmar and hypothenar spaces in the hand and Parona’s space in the forearm. Tendon Injuries Defnition: A tendon is a fbrous structure that connects a muscle to a bone. Complications - Associated arterial injuries - Paralysis - Neuromas - Hyper or hyposensitivity 76 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 1. Vessel Injuries Defnition: Laceration to the arterial supply of the hand or fngers. Complications - Associated nerve injuries - Compartment Syndrome - Loss of hand or fnger (Gangrene) Surgery Clinical Treatment Guidelines 77 Chapiter 1: Orthopaedic Surgery 1. Causes - Burn - Trauma - Tumor excisions - Debridement Signs and symptoms - Assess the size of the defect - Assess the depth of the defect - Assess whether underlying vital structures are exposed or involved Management - If the wound can be closed without compromising the function of the hand or the anatomy of the hand, do a primary closure - If a primary closure is not feasible and there is no underlying vital structures exposed, do a skin graf - If underlying structures are exposed, cover with a fap - If underlying structures are involved, repair them and cover with a fap Complications - Scar contractures - Damage of vital structures 78 Surgery Clinical Treatment Guidelines 2. General Considerations 2 Defnition: physical trauma to the spinal cord from craniocervical junction to the sacrococcygeal region. Partial: Tere is preservation of some neurological function which may be motor, sensory or both. Cervical cord injuries are divided into two namely high cervical and low cervical injuries. Spinal Fractures and Dislocation Defnition: Refers to disruption of vertebra column caused by physical trauma. Stable fractures are those with minimal or no risk of neurological damage whereas unstable fractures are those with a high likelihood of neurological damage coupled with slight movement. It has three types which are: type1, type2, type 3 (Levine classifcation), type 1 is stable; types 2 and 3 are unstable. Tis is attributed to normally increased elasticity of the spinous ligaments and intervertabral sof tissue in young population. Thoracic Fractures Description: Te thoracic canal is smaller compared to other spinal regions making it more vulnerable to even small compressive lesions. Thoracolumbar Fracture 2 Description: Toracolumber fructure is a transition zone between the rigid thoracic spine and mobile lumbar spine. Cauda Equina Defnition: It is a clinical condition arising from dysfunction of multiple lumbar and sacral nerve roots compression within lumbar spinal canal. Causes - Massive herniated lumber disc - Tumors - Free fat graf following discectomy - Trauma - Spinal epidural hematoma - Infection e. Cerebral Vascular Diseases (Spontaneous Haemorrhage) Intracranial hemorrhage may be subdural, subarachnoid and intracerebral (intra parancyma). Subdural hemorrhage is discussed under traumatic causes of intracranial hemorrhages. Intracerebral Hemorrhage Defnition:It is a hemorrhage within the brain parenchyma, commonly referred to as hypertensive hemorrhage, it is the second most common form of strokes (15-30%) but most deadly. Occurs at common sites for hypertensive bleeds (putaminal, thalamic, cerebellar and lobar). Subarachnoid Hemorrhage Description: It occurs as a result of bleeding from aneurismal rapture in 5% from perimesencephalic. Brain Abscess Defnition: Is a pus containing cavity in brain, it goes through stages. Phenytoin 15-20mg /kg as a loading dose and maintenance dose of 5mg/kg/day for 21 days or as long as seizures are present) - Surgery; excision of the cyst Indications for surgery - Large cysts causing mass efect - Cysts causing abstractive hydrocephalus Surgery Clinical Treatment Guidelines 97 Chapiter 2: Neurosurgery 2. Hydrocephalus in Children Description: It is a condition that results when normal exit and absorption of cerebral spinal fuid in the ventricles are impaired. Tis leads to progressive accumulation of this fuid in the ventricles of the brain, resulting in progressive damage to the developing brain with associated mental retardation and visual impairment. Causes - Congenital abnormality - Intraventricular hemorrhage - Infection - Head trauma - Brain tumor Signs and symptoms - Accelerated head growth - Te baby’s sof spot (anterior fontanelle) is usually full or bulging, or even tense, due to the increased pressure inside the head. Myelomeningocele Defnition: Congenital defect in vertebral arches with cystic dilatation of meninges and structural or functional abnormality of spinal cord or cauda equina. It is broadly classifed into 2 entities: - Open head trauma in which there is a scalp laceration with underlying skull fracture and breached Dura Mater (i. It can also be classifed by severity into mild, moderate and sever head trauma depending on the level of consciousness. Patients with severe maxillofacial injury will also need to be given a tracheostomy. Mannitol should be used with caution in patients with clotting disorders because it afects coagulation, and in congestive heart failure patients it increases intravascular volume before it causes diuresis. Remember steroids (dexamethasone, hydrocortisone) have no place in management of acute head injury. Complications - Post-traumatic seizures - Permanent neurological disability - Post-traumatic hydrocephalus - Post-Concussion Syndrome - Infection e. It is subdivided into acute (< 72hours) Subacute (between 72 hours and 3 weeks) and Chronic ( > 3weeks). Chronic Subdural Hematoma Cause - Minor head injury or fall ofen not remembered by patients or relatives. Epidural Hematoma Defnition: It is the collection of blood between the skull and the Dura Mater caused by a rupture of artery and vein in epidural space, as a result of a fracture of the skull at the moment of the impact in 60-90% of cases. Intracranial Hematoma Defnition: Traumatic intraparancymal hemorrhage is commonly associated with brain contusion.
However it should not be delayed more than 48-72 hours unless intervention significantly decreases the operative risk purchase 100mg dapsone mastercard. Also most of these patients are osteoporotic and have a high chance of getting fracture in the opposite side generic 100 mg dapsone free shipping, so anti osteoporotic treatment should be started in all of these patients and so is the early mobilization as osteoporosis will increase if they stay in bed waiting for the union to occur buy dapsone 100mg with amex. Isolated injuries can occur with repetitive stress and may occur in the presence metabolic bone diseases safe 100 mg dapsone, metastatic disease, or primary bone tumors. The femur is very vascular and fractures can result in significant blood loss into the thigh. Up to 40% of isolated fractures may require transfusion, as such injuries can result in loss of up to 3 units of blood. This factor is significant, especially in elderly patients who have less cardiac reserve. Most femoral diaphyseal fractures are treated surgically with intramedullary nails or plate fixation. The goal of treatment is reliable anatomic stabilization, allowing mobilization as soon as possible. Surgical stabilization is also important for early extremity function, allowing both hip and knee motion and strengthening. Injuries and fractures of the femoral shaft may have significant short- and long-term effects on the hip and knee joints if alignment is not restored. The injured should be referred to the higher centre earliest feasible causing no further harm. Investigations: X-rays of the part including hip and knee and of other areas if required, x-ray of pelvis with both hips is must. General Investigations and specific if required according to the status of the health of the patient. Treatment: Conservative management of fractures in children in spica cast or with skeletal traction, Kuntscher’s nail for isthmic fractures, Interlocking Nailing in comminuted fractures, Plating for lower third fractures, Plating of shaft femur fracture in children. Investigations: X-rays of the part and of other areas if required, x-ray of pelvis with both hips is must. General Investigations and specific if required according to the presence of any co-morbidity. Introduction /description Lower leg fractures include fractures of the tibia and fibula. Fractures of the tibia generally are associated with fibula fracture, because the force is transmitted along the interosseous membrane to the fibula. The skin and subcutaneous tissue are very thin over the anterior and medial tibia and as a result of this; a significant number of fractures to the lower leg are open. Fractures of the tibia can involve the tibial plateau, tubercle, shaft, and plafond. Mode of injury Tibial plateau fractures occur from axial loading with valgus or varus forces, such as in a fall from a height or collision with the bumper of a car. Mechanisms of injury for tibia-fibula fractures can be divided into 2 categories: 58 Low-energy injuries such as ground levels falls and athletic injuries and in osteoporotic patients High-energy injuries such as motor vehicle injuries(esp motor cycle accidents, pedestrians struck by motor vehicles, and gunshot wounds Tibial plafond fractures refer to fractures involving the weight-bearing surface of the distal tibia. This type of injury usually results from high-energy axial loading but may result from lower-energy rotation forces. Clinical presentation: Patient may complain of severe pain, swelling and bruising down the broken leg, deformity of bones and inability to ambulate with tibia fracture. Approximately 20% of tibial plateau fractures are associated with ligamentous injuries. Limb loss may occur as a result of severe soft-tissue trauma, neurovascular compromise, popliteal artery injury, compartment syndrome, or infection such as gangrene or osteomyelitis. The injured should be referred to the higher centre earliest feasible causing no further harm. Investigations: Perform radiographs of the knee, tibia/fibula, and ankle as indicated and of other areas if required, General Investigations and specific if required according to the status of the health of the patient. In patients with tibial plateau fractures and tibial plafond fractures, computed tomography can help further evaluate the extent of the fracture. In tibial plateau fractures, radiographs may underestimate the degree of articular depression when compared with computed tomography. This is important because articular depression of greater than 3 mm may be considered for surgery. Treatment: soft tissue envelope is the most important component in the evaluation and subsequent care of tibial fractures. Signs of compartment syndrome include crescendo symptoms- (5 P’s) puffiness/oedema, pain out of proportion with passive stretch of involved muscles, paresthesias, and pallor, and a very late finding is pulselessness and paralysis. Increased compartment pressure is present during compartment syndrome; therefore, external palpation frequently aids in the diagnosis. Compartment syndrome must be treated promptly with an emergency surgical fasciotomy Open fractures must be diagnosed and treated appropriately. Tetanus vaccination should be updated, and appropriate antibiotics should be given in a timely manner. This should involve antistaphylococcal coverage and consideration of an aminoglycoside for 60 more severe wounds. Fractures with tissue at risk for opening should be protected to prevent further morbidity. All simple both bone leg fractures, minimally displaced fractures in children / adults should be managed with closed reduction and above knee cast. In displaced fractures closed reduction and interlock nailing in shaft fractures should be done, Plating should be done for lower third fractures. Post closed reduction (pop cast) or open reduction and fixation adequate limb elevation is required and patient is encouraged to do passive exercises to avoid edema of limb, deep vein thrombosis and to aid in adequate wound healing. Tibial plateau fracture : Immobilize un-displaced fractures and keep the patient non- weightbearing for 3 months. Isolated midshaft or proximal fibula fracture- Immobilization in a long leg cast generally is not required. Recommend a few days without weight-bearing activity until swelling resolves, followed by weight-bearing activity as tolerated. In some case, immobilization in above knee cast is done Some of the complications that may arise in treatment are: A tendency to displace the fragments when swelling subsides, particularly in oblique and spiral fractures Cosmetic and sometimes functional disability if the alignment or rotational position of the fragment is imperfect Conspicuous disfigurement if apposition of the fragments is imperfect Slow union as a result of severity of the fracture, poor blood supply to one fragment, and sometimes distraction of the bone fragments 61 Occasional limitation of joint movement in the knee, ankle and foot, usually caused by associated joint, soft tissue, or vascular injury The common peroneal nerve crosses the fibular neck. This nerve is susceptible to injury from a fibular neck fracture or the pressure of a splint, Referral Criteria for higher centre (Medical College / Tertiary centre) a. Comminuted fractures, Fractures requiring Interlocking Nail, proximal intra-articular fractures, distal pilon fractures, open fractures c. Treatment: All Closed/Open (upto 3A as per gustilio Anderson classification) should managed with iterlocking Nailing. Open fractures should be managed by cupious washing of wound, wound debridement and application of External fixator/Enders/nails. In fractures with bone loss various options available are; -tiblisation of fibula and fixation with plating/ k-wires - Illizarovs Ring Fixator and Rail road fixator for gap defects and limb lengthening. Pelvic ring disruptions, more than any other fracture of the body, can lead to severe complications, including massive bleeding and organ injuries. Exsanguinating hemorrhage is the most dreaded acute complication of pelvic fracture. In addition, because of its function as a bony basin for different organs, the cauda equina and essential nerves for the lower limbs, serious injuries of those structures significantly increases the total trauma impact of the multiply injured patient with pelvic injury. The unstable untreated pelvis enforces immobility and does not allow appropriate positioning of those patients with chest and brain injuries for their necessary intensive care. As per the data from the National Crime Records Bureau,467537 persons died due to injury and violence in 2009. During the same period the non fatal injuries also increased correspondingly to 1,070,302 in 2009. For every death, it is estimated that nearly 30-50 persons are hospitalized and 50-100 are likely to receive emergency care. Majority (>90 %) of them are directly or indirectly due to human error, natural (< 10 % ) causes account for very few deaths. Since accidents are multifactorial, they call for an intersectoral approach to both prevention and care of the injured. The first hour after admission to the emergency room is most critical in terms of survival and reduction of morbidity. Sometimes only few minutes are there for decision to operate for control of bleeding, (damage control and than referral). Timing of secondary surgical procedure ---------------------------------------------------------------------Physiologic status surgical intervention timing --------------------------------------------------------------------------------------------------------------- Response to resuscitation -ve life saving surgery D-1?
Failure to do so will result in a situation where a substandard level of care and irrational use of second-line drugs will continue to perpetuate the transmission of generic 100 mg dapsone with amex, and potentially amplify further buy dapsone 100 mg without a prescription, highly drug-resistant isolates of tuberculosis discount dapsone 100mg mastercard. The network has completed nine rounds of proficiency testing since 1994 order dapsone 100mg on line; cumulative results over the nine rounds generally indicate overall high performance of the network. Following an evaluation by the supranational laboratory, a decision is made on whether to carry out the survey or repeat proficiency testing. The network has recently agreed such criteria and details will be published in the coming year. Preliminary research has shown that at least one of the apparently borderline isolates was in fact a mixed culture containing one drug-resistant and one susceptible isolate; however, further exploration is warranted. There is a need for these costs to be met internationally to stabilize and enhance the network. The Laboratory Strengthening Subgroup seeks to assess and develop plans for improvement of entire national laboratory networks, with an emphasis on sputum smear microscopy. Improved laboratory networks will translate into improved diagnostic and treatment capacity, and more accurate surveillance of drug resistance. This is not always true of the data from individual sites, where the number of cultures examined is less than 1000, given that some drug resistance types show prevalences of 0. The total number of isolates examined is sufficiently high to guarantee statistical significance of both new cases and previously treated cases, even though all settings within some regions such as the Eastern Mediterranean and South-East Asia are not necessarily representative of the regions as a whole. The consistency of the findings argues for the robustness of the following conclusions. In patients with drug-resistant tuberculosis, additional drug resistance may develop if a prescribed multidrug regimen includes the drugs these patients are already resistant to. In this situation, some of these patients may end up effectively receiving monotherapy. In this respect the findings of worldwide drug resistance surveys are revealing, in that the prevalence of drug resistance is significantly higher among previously treated patients than among new patients in all regions. The only logical inference is that present treatment practices create significant numbers of new resistant cases and amplify already present resistance. This analysis shows a remarkable consistency, both globally and regionally, in the distribution of the major drug resistance types, as well as in the increase in drug resistance prevalence among previously treated cases relative to new cases. It should be noted that prevalence of drug resistance observed in previously treated cases is higher than in new cases in all regions. Since this difference is in great part directly related to the quality of drug treatment, this apparent characteristic could well lead to the development of an indicator that would measure the quality of treatment practices. The addition of a new drug to a failing drug regimen is an effective way of amplifying the drug resistance problem. Monoresistance can only be selected in the presence of a drug concentration leading to the selection of pre-existing mutant bacilli, whereas resistance to two drugs cannot be created simultaneously in the presence of effective concentrations of two drugs. This is because the number of bacilli present in the lesions (108) is usually much lower than the theoretically required bacillary load needed to produce double resistance, i. Results obtained in this study show that the proportions of monoresistance are lower in patients having re-treatment, whereas double resistance remains essentially unchanged. Triple and quadruple resistance are higher by about the same proportion as monoresistance is lower. Amplification caused by re-treatment is the easiest way to interpret these changes, i. The absence of a significant change in double resistance proportions can be explained by selective pressure, leading to an increase in triple and quadruple drug resistance modes thus balancing the inflow from the monoresistance mode. Since resistance in re-treatment cases mostly reflects the quality of recent treatment, these results could lead to the development of an indicator, based on the extent of amplification. The difference between previously treated and new case triple and quadruple resistance proportions could constitute such an indicator. Other pathways can and do exist but their contribution to the drug resistance problem is relatively minor. We can therefore state that monoresistance to H or to S is the foundation for the acquisition of additional drug resistance. Implications The above analysis has shown that there is circumstantial but compelling evidence that either monotherapy or “effective” monotherapy, or both, are more widespread than commonly thought. These results corroborate recently emerging evidence that standard re-treatment regimens containing first-line drugs for failures of standard treatment should be abandoned in some settings. One possible way of breaking the amplification juggernaut would be to replace S in standard regimens and/or to add a third drug to the continuation phase. It expresses the percentage of the variation in the outcome variable that has been explained by the regression on the explanatory variables. For countries conducting surveys on a sample of the population, estimates were generated by applying prevalences determined in surveys to reported notification figures for the corresponding population and thus are dependent upon the level of case-finding in the country and quality of recording and reporting of the national programme. 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