Frykman Classification of Distal Fracture of base of the first Neer classification of proximal humeral head # Radial # metacarpal 1-part 2-part 3-part 4-part

GT GT+SN “CLASSIC”

SN LT+SN (RARE) “VALGUS IMPACTED”

Galeazzi Fracture LN (RARE) Impression # Head split

Gartland’s classification of supracondylar

Fracture shaft of ulnar, together with distal third of with fracture of humerus disruption of the proximal radioulnar dislocation or subluxation of distal joint and dislocation of radiocapitallar radio-ulnar joint joint

Salter–Harris fracture = Fracture that involves the epiphyseal plate or growth plate of a bone

Type I: undisplaced or minimally displaced fractures. Type II: displaced with posterior cortex intact Type III: displaced with no cortical intact

Gustillo Anderson Classification of I – open fracture with a wound <1cm and clean II – open fracture with wound > 1cm with extensive soft tissue damage and avulsion of flaps IIIa – open fracture with adequate soft tissue coverage of bone in • - a fracture of the radius spite of extensive soft tissue laceration or flaps or high energy with dislocation of the distal radioulnar joint trauma irrespective of size of wound • Colles' fracture - a distal fracture of the IIIb – open fracture with extensive soft tissue loss, periosteal radius with dorsal (posterior) displacement of the wrist and stripping and exposure of bone • Smith's fracture - a distal fracture of the IIIc – open fracture associated with an arterial injury which requires radius with volar (ventral) displacement of the I II IIIa IIIb IIIc repair wrist and hand • Barton's fracture - an intra-articular fracture of the distal radius with dislocation of Irrigation: 3L 6L 9L ORTHOPAEDICS CLASSIFICATION the radiocarpal joint • Essex-Lopresti fracture - a fracture of PART 1 (UPPER LIMB) the radial head with concomitant dislocation HTARW5B/GKS2013/3- of the distal radio-ulnar joint with disruption of Together In Delivering Excellence (T.I.D.E.) the interosseous membrane Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah Letournel classification acetabular # of femoral head fracture Simple Types

Anterior column Anterior wall Posterior column Posterior wall Transverse

Associated Types

Type I - # below fovea/ligamentum (small) Type II - # above fovea/ ligamentum (larger) Type III - type I or II with associated # (high risk of AVN) Type IV - type I or II with associated acetabular #

T-type Transverse Posterior column Anterior + posterior Both columns + posterior wall + posterior wall hemitransverse Garden classification of femoral neck # Russel Taylor classification of subtrochanteric #

Garden I fracture Garden II fracture Garden III fracture Garden IV fracture incomplete and complete and complete and complete displaced with minimally nondisplaced partially displaced no engagement of the 2 displaced principal fragment

Evan classification of intertrochanteric #

Schatzker classification of tibia plateau #

Evan 3 Displaced 3 Evan 4 Displaced 3 Evan 5 Displaced 4 Evan I Evan 2 parts fracture with parts fracture with parts fracture with Undisplaced 2 Displaced 2 posteromedial large posteromedial comminution parts fracture parts fracture comminution comminuted involving both fragment trochanters

Lateral tibial Lateral tibial Focal Medial tibial Bicondy Tibial plateau # w/o plateau # depression plateau #, lar tibial plateau depression with with no with or plateau fracture with Lisfranc classification of tarsometatarsal injury depression associated without # diaphyseal split depression discontinuity

Winquist classification of femoral shaft fracture Sanders classification of calcaneal fractures I. Tiny cortical fragment lateral II. Butterfly fragment is I - # are non-displaced # (displacement < 2 mm). large but there is still medial II - # consist of a single intrarticular # that divides the 50%of cortical intact calcaneus into 2 pieces. IIA: # occurs on lateral aspect of calcaneus. between the main IIB: # occurs on central aspect of calcaneus. fragments IIC: # occurs on medial aspect of calcaneus. Homolateral Isolated Divergent III. Butterfly fragment Type IIA Type IIB Type IIC III # consist of 2 intrarticular fractures that divide the calcaneus into 3 articular pieces. involves more than IIIAB: 2 # lines are present, 1 lateral and 1 central. 50% of the bone IIIAC: 2 # lines are present, 1 lateral and 1 medial. ORTHOPAEDICS CLASSIFICATION IIIBC: 2 # lines are present, 1 central and 1 medial. width IV # consist of # with more than 3 intrarticular PART 2 (PELVIC & LOWER LIMB) IV. Segmental fractures fractures. HTARW5B/GKS2013/3b- Together In Delivering Excellence (T.I.D.E.) Type IIIAB Type IIIAC Type IIIBC Type IV Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah Localisation of level of injury Wrist extension DENIS THREE COLUMN CONCEPT Vertebral spine Spinal Cord Segment C6 Anterior column: C1-C7 Add 1 Elbow flexion AAL: Anterior longitudinal ligament T1-T6 Add 2 AAF: Anterior annulus fibrosus T7-T9 Add 3

Middle column: T10 L1,L2 PLL: Posterior longitudinal ligament T11 L3,L4 PAF: Posterior annulus fibrosus T12 L5,S1 L1 rest of sacrococcygeal Posterior column: Wrist flexion segment Finger flexion Finger SSL: Supraspinous ligament abduction ISL: Interspinous ligament LF: Ligamentum flavum Upper limb myotomes PC: Facet capsule and dermatomes Finger Extension T1

# Type & DENIS CLASSIFICATION OF SPINAL TRAUMA Anterior Middle Posterior Central cord Anterior cord column column column column lesion lesion MAJOR INJURIES MINOR INJURIES involvement Compression None or • Upper > lower • Motor - • Transverse process # Compression None limb involved • Sensory - • Articular process # # distraction • Sacral sparing • Proprioception + • Par interarticularis # None or Burst # Compression Compression • Due to • Due to • Spinous process # distraction hyperextension/ hyperextension

None or Spine OA with disc or bone Seatbelt Distraction Distraction compression compressing ant spinal a Compression Distraction Distraction Fracture/disl rotational/ rotational/ rotational/ ocation ± ± ± shear shear shear Cord hemisection Posterior cord (Brown Sequard lesion Criteria of unstable spine injury Bulbocavernosus Syndrome) Stable fractures - don't cause spinal deformity or neurologic deficit, • On palpation gap between 2 spinous processes reflex • Proprioception - • Ipsilateral involves monitoring anal still able to weight bear increased • Motor + paralysis with • Neurological deficit sphincter contraction in Unstable fractures - unable to weight bear, may progress and • Sensory + contralateral loss • Vertebral compression >1/3 response to squeezing of pain sensation causing further neurological and structural damage. the glans penis or • Vertebral displacement >1/3 • Due to unilateral tugging on an indwelling • Vertebral canal compromisation > 1/3 lamina or pedicle Foley catheter TLICS:Thoracolumbar Injury Classification and Severity Score • Bilateral facet joints dislocation # • According to Denis 3 columns concept: 2 columns Morphology Posterior Ligamentous complex (PLC) disrupted 0 No abnormality 0 Intact great toe • Root pain - dorsiflexion • Sensory saddle shape distribution with 1 Compression 2 Suspected / Indeterminate Lower limb myotomes perianal anaesthesia, symmetrical 2 + 3 Injured Conus • Motor changes - and dermatomes medullaris 3 Rotation/translation • Sphincter involved + 4 Distraction Hip flexors • Reflexes – knee jerk normal • Ankle jerk lost

Neurological status • Root pain + 0 Intact Knee extensors • Sensory may invoke any part of lower Cauda limb, asymmetrical 2 Root injury equina • Motor changes ++ (wasting) 2 Complete cord / conus medullaris injury syndrome • Sphincter ± 3 Incomplete cord / conus medullaris injury Ankle • Reflexes – knee jerk normal/ 3 Cauda equina dorsiflexor • Ankle jerk lost/ Ankle plantar ORTHOPAEDICS ESSENTIALS Treatment flexion PART 3 THE SPINE TLICS <= 3: non-operative HTARW5B/GKS2013/4- TLICS = 4: consider for operative or non-operative intervention Together In Delivering Excellence (T.I.D.E.) TLICS >=5: operative Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah Name Active Ingredient Indication Contraindication Advantage Disadvantage 1. Opsite semi-permeable-thin, adhesive superficial wounds highly exudative wounds • some moisture evaporation • exudate may pool transparent polyurethrane film as secondary dressing • reduce pain • maybe traumatic to remove • barrier to external contamination • allows inspection 2. Jelonet non-adherent moist (Tulle Gras burn allergy • reduces adhesion to wound • does not absorb exudate Bactigras dressing) wounds healing by secondary • moist environment aids healing • requires secondary dressingg PARAFFIN gauze impregnated with paraffin intention • allergy or maybe with antiseptics or • may delay healing when antibiotics impregnated 3. Kaltostat Calcium alginate moderately/highly exudative wounds dry wound • forms gel on wound & hence moist • may require secondary dressing CALCIUM natural polysaccharide from need for hemostasis hard eschar • environment • not recommended in anearobic ALGINATE seaweed • reduces pain infections • can pack cavities • gel can be confused with slough • absorbent in exudative wounds • or pus in wound • promotes hemostasis • low allergenic 4. Duoderm E hydrocolloid dressing-hydrophilic burn (small) abrasions dry wound • retains moisture • avoid on high exudate wounds, sinus HYDROCOLLOID colloid mildly exudating ulcers infection • painless removal tracts bound to polyurethrane film coated donate moisture & absorb exudates full thickness wound • facilitate autolytic debridement • fragile skin with adhesive mass • thermal insulation • worn for 3-5days-fewer dressing changes 5. Duoderm hydogel - water or glycerin-based pressure ulcer stage II-IV, heavily draining wound • rehydrate the wound bed • need 2ndary dressing Hydroactive 80-99% water on a nonadherent, partial & full thickness wound • reduce pain • avoid heavily draining wound HYDOGEL cross-linked polymer dermabrasion, painful wound • used on infected wound with • absorptive properties may macerate dermal ulcer, radiation burn • topical medication • periwound skin donor sites • promote autolytic debridement necrotic wounds 5. Aquacel soft, sterile, nonwoven pad or moderate to heavily draining wound dry eschar • retains moisture • dressing non-adherent, need HYDROFIBER ribbon with partial & fully thickness wound non-exudating wound • absorb & retain exudate & harmful • 2ndary dressing to secure it SODIUM sodium carboxymethylcellulose pressure ulcer (stage III & IV) 3rd degree burn • components CARBOXY- surgical wound, donor site heavy bleeding • do not damage tissues surrounding METHYLCELLUL dehisced wound, cavity wound • exudating wound when dressing OSE wounds with sinus tracts or tunnels changes • removal trauma free • reduce dead space • no frequent change 6. Aquacel Ag ionic silver for immediate and infected/highly colonized wound stage I pressure ulcers • inhibit pathogen growth, especially • 2ndary dressing to secure silver SILVER controlled partial thickness (2nd degree) burn 3rd degree burn • antibiotic-resistant strains dressing release DFU, leg ulcers non-exudating wounds • effective antimicrobial action up to 7 • allergy traumatic wound days • not to use with topical medication wounds prone to bleeding • silver turns black when oxidizes, may oncology wounds with exudate • stain or discolor periwound tissue

7. Elase fibrinolysin enzymatic debridement of necrotic allergic to bovine • allergy FIBRINOLYSIN desoxyribonuclease tissue in wound & liquefaction & compound DESOXYRIBONU dissolution of exudates of injured CLEASE skin & mucous membrane ORTHOPAEDICS ESSENTIALS PART 4 DRESSINGS HTARW5B/GKS2013/4- Together In Delivering Excellence (T.I.D.E.) Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Syikin, Fong, Phoon, Ling Ying, Siew Ling, Quah Bohler’s stirrup U shaped device to hold Buttress Plating Hip Prosthesis a Steinmann pin and (Fr – to strike/shoke) The plate serves to push Used for replacement of head of femur following applying traction NOF #. Help patients to early mobilise and Dynamic Compression Plate or buttress the split tibial eliminate complication such as AVN, non union, (DCP) plateau fragment against fixation failure Exerts axial compression over displacement and Austin Moore – used in NOF# with calcar # site by combining screw hole depression. femorale intact, no osteoporosis; prosthesis has geometry while screw insertion. T and L plates are neck, collar and holes, bone cement is not Broad – humerus, femur designed to be used as required during application Narrow – tibia, , pelvis buttress plates Thompson – used in NOF# with no calcar, with

osteoporosis; prosthesis has NO neck, collar and holes, bone cement is required during application Crutchfield tongs Bipolar – used in yiounger patients with non union To apply skull traction in of femoral neck. It has low incidence of protrusio case of cervical injury acetabuli Low Contact Dynamic Compression Plates Designed to limit vascular Dynamic Hip Plate/Screw **Calcar femorale = thin plate of condensed compromise by decreasing Used in intertrochanteric cancellous bone oriented vertically within the plate-to-bone contact fracture of femur medullary canal of the proxinal part of the femur , deep to lesser trochanter

Gigli saw Twisted wire bone saw, use to cut bone during amputation Illizarov External Fixators Reconstruction Plates For limb lengthening, Have notches alongside the Dynamic Condylar Plate/Screw arthrodesis, deformity plate, which enables bending in 3 Used in distal end femur # correction and infected dimension to contour towards (unicondylar/intercondylar) non-union Cortical and Cancellous complex surfaces easily Screws Used either itself (as lag Angle Blade Plates screw) or with plates, they 95°-angled plates are used in the are non tapping screws, Condylar repair of metaphyseal fractures and thread tapping should be blade reconstruction of the femur. It provides plate done in the bone with bone very rigid fixation. tap Condylar- distal femur, Double angled intertrochanteric/sub-trochanteric #. ORTHOPAEDICS ESSENTIALS blade plate Double angled – femoral valgus Malleolar Screws repositioning osteotomy PART 5 PLATINGS, NAILS AND SCREWS Are self tapping screws HTARW5B/GKS2013/4- Together In Delivering Excellence (T.I.D.E.) CLASSIFICATION: HOPI HOPI •Posterior 70% Fall on outstretched hand with elbow slightly flexed •Anterior 10-15% Fall on the out •Central stretch hand with rotation TYPES HOPI Usually occurs in an MVA as a result of dash board injury

MOST COMMON Signs Posterior Posterior dislocation shows: FLEXION, ADDUCTION, dislocation (due to Anterior dislocation (due to INTERNAL ROTATION deformity with shortening of limb, internal rotation) external rotation of ABDucted abnormal gluteal bony mass of head of femur ) X-ray (AP and Lateral view) femoral head out of acetabulum Lesser trochanter less prominent Signs Broken Shenton’s line Absent of normal contour of ASIS shifted upward Bryan sign – anterior axillary fold looks elongated Associated fractures Callaway’s sign – axillary girth get increased Approach Duga’s sign – inability to touch opposite shoulder by REDUCTION METHODS (POSTERIOR DISLOCATION) affected hand SHOULD BE DONE ASAP TO REDUCE THE CHANCE OF AVN OF HEAD Hamilton’s ruler test – a ruler can touch lateral epicondyle and acromion process at the same time A. Bigelow method FLEX X-ray ABDUCT EXTERNAL ROTATION AP view in internal and external rotation Signs EXTENSION Axillary view Short forearm with 3 bony Approach NEUTRAL ROTATION points relation disturbed (also in

# of epicondyles) REDUCTION METHODS B. Allis method Triceps tendon stands A. Hippocratic method 1.The patient is supine prominent(bow stringing) 1.The patient lies supine. 2.Affected hip and knee are flexed in 90 degree 2.The physician's is placed in the patient's 3.In neutral rotation of hip, an upward traction is applied along the axis of axilla against the chest wall while leaning X-ray femur and the same counter traction is given by holding the pelvis. backward. AP view – greater superimposed of distal 3.Slow, steady and gentle longitudinal traction is humerus with proximal ulna C. Stimsons’ gravity method applied to the affected arm in 30-40° abduction for Lateral – coronoid process lies posterior to The patient is laid prone with the lower limb hanging over the other end of the about one minute. condyles table 4.The foot acts as a counterforce and as a lever to Approach Femoral head is pushed down into the acetabulum and at the same time the push the humeral head laterally while the REDUCTION METHODS traction is applied downward along the axis of femur physician pulls the head toward the patient's foot Dislocation reducing the dislocation along the surface of the glenoid, effectively by traction and pressure flexing the Complications: adducting the affected arm. elbow fully as a test of reduction •Sciatic nerve injury 5.Put patient on arm sling immobilizing the limb in an above- •Vascular injury elbow plaster slab (margin shown •Irreducible dislocation Early B. Kocher method by dotted line) and a sling. •Recurrent dislocation T – Traction in line of humerus •Associated fractures E – External Rotation of humerus •AVN (15%) Complications: Late A – Adduction of arm •Nerve injury (M>U>R) •Secondary OA M – Medial rotation •Brachial artery injury •Myositis ossificans •Myositis ossifican Complications: •Recurrent dislocations Plan: CMR with fixed skin traction on Thomas splint or POP hip •Shoulder stiffness •Osteochondral fracture spika x 4-6/52 then partial weight bearing on crutches x 6/52 •Axillary nerve damage •Unreduced dislocation •Traumatic OA •Fractures of associated structures

•Recurrent dislocations (epicondyles, radius head, coronoid Manage •Unreduced dislocation process, olecranon)

Plan: CMR of shoulder joint with Velpeau’s Plan: CMR with above elbow POP x ORTHOPAEDICS ESSENTIALS strapping x 3/52 followed by physiotherapy 3/52 followed by physiotherapy PART 6 DISLOCATIONS HTARW5B/GKS2013/4- Manage Together In Delivering Excellence (T.I.D.E.)

Manage Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Fong, Ling Ying, Phoon, Quah Calcaneum Fracture Cobb’s angle Distal end radius fracture (Scoliosis) 2- Radial incline = 22 (12-28)

1- Radial height 11mm (10-26) 4- Ulnar variance ±5mm 3- DRUJ space 4mm

x

5-Volar tilt = 11 6- Step <2mm (3-16) 7- Gap <2mm

Supracondylar Fracture Wagner Classification of Diabetic Foot Ulcers: Grade 0: No ulcer in a high risk foot. Baumann’s angle Carrying angle Grade 1: Superficial ulcer involving the full skin thickness but not underlying tissues. Grade 2: Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation. Grade 3: Deep ulcer with cellulitis or abscess formation, often with osteomyelitis. Grade 4: Localized gangrene (forefoot). Grade 5: Extensive gangrene involving the whole foot.

Amputations Norm: 5-15 Excessive = cubitus valgus Decrease = gunstock deformity

Q angle Increased in genu valgum, external tibia torsion, lateral positioned tibial tuberosity, tight **Rays Amputation – Removal of toes with metatarsal from tarsometatarsal joint lateral retinaculum ORTHOPAEDICS ESSENTIALS Norm: male= 14 ±3 PART 7 (a) ANGLES IN ORTHOPAEDICS (b) DIABETIC FOOT females= 17±3 HTARW5B/GKS2013/4- Together In Delivering Excellence (T.I.D.E.) Contributors: Dr. Tham, Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Phrindha, Fong, Phoon, Quah WELL LEG TRACTION 90-90 TRACTION PERKINS TRACTION HAMMOCK TRACTION DUNLOP TRACTION HEAD HALTER CRUSH FIELD CALCANEAL TRACTION Used in correction of Used in subtrochanteric #, Used in femur shaft # in Used in pelvis # with Used in transcondylar or TRACTION TRACTION Used in open # of ankle joint/leg abduction deformity of hip compound # of femur with adult rotational instability e.g. supracondylar fracture of the Used in cervical Used in cervical Traction is applied to the posterior wound and shaft open book, Malgaigne # humerus in children spine injury spine injury normal limb while deformed femur of children (both pubic rami+ hip is stabilised by splint posterior SI complex/sacrum #), and bucket handle injury

BÖHLER BRAUN FRAME BUCK’S TRACTION Apparatus used for HALO-PELVIS Apply skin traction in application of skeletal TRACTION femur shaft #, NOF #, traction of lower limb. It may Used in scoliosis acetabulum # after be used with transcondylar, reduction of hip tibial or calcaneal pins dislocation, to correct minor deformity of hip and knee PELVIC BINDER Used acutely in management of exsanguinating pelvic trauma, by GALLOW’S/BRYANT’S applying large amount of TRACTION compressive force to the pelvic BROAD ARMSLING AND HAMILTON-RUSSELL Used in femur shaft # in ring to reduce the volume of the FIGURE ‘8’ STRAPPING 90-90 HIP SPIKA TRACTION children <2 yrs THOMAS SPLINT pelvis Used in undisplaced and displaced Spika at 90 flexion at hip Used in femur shaft # in (with and without sling) respectively. because in children proximal adult, trochanteric # Temporary stabilisation of fragment flexes to 90 due to SCAPHOID CAST femoral shaft fracture stronger pull by flexor muscle and Applied from below elbow proximal illdevelopment of lumbar lordosis to knuckle distally and incorporating proximal phalanx of thumb. The wrist is held in dorsiflexion (glass holding positiion) Lower limb and PelvisLower Upper limb and Spine Upper limb

Slab Cast

Trapeze

BALKAN FRAME ROBERT JONES DRESSING POP CAST & SLAB A frame employed in the treatment of A tape stirrup is applied to the foot before Active ingredient of Plaster of Paris is fractured of extremities that the bandage is started Gypsum CaSO42H2O provides overhead weights and Cotton roll is wrapped around a forelimb Slab only covers a part of pulleys for suspension, traction, and after the application of the tape stirrup. circumferential of a limb whereas a continuous extension of the splinted Elastic gauze is then applied firmly bind cast covers whole of the limb fracture limb. the cotton to the leg. Elastic tape is then circumference. use to complete the dressing.

ORTHOPAEDICS ESSENTIALS

MILWAUKEE BRACE BOSTON BRACE For dorsal scoliosis PART 8 SPLINTS, CASTS, PLASTERS, FRAMES For lumbar scoliosis Miscellaneous HTARW5B/GKS2013/4- Together In Delivering Excellence (T.I.D.E.) Definition: An increase in compartment pressure to the Definition: syndrome caused by presence of fat Rapidly progressive inflammatory infection of the fascia, with secondary necrosis of point where tissue perfusion is impaired. globules in the lung parenchyma and peripheral the subcutaneous tissues. The speed of spread is directly proportional to the thickness circulation. Usually subclinical event after long of the subcutaneous layer. Necrotizing fasciitis moves along the fascial plane. Causes bone fractures in young adults (tibia/fibula) and hip Diagnosis: requires a high degree of suspicion •Fracture (tibia, radius) fractures in elderly • H/O antecedent trauma or surgery •Circumferential burns Syndrome usually appear in 1-2 days after an acute • Intense pain over the involved skin and underlying muscle; over the next several •Tight dressings injury or after IM nailing. hours to days, the local pain progresses to anaesthesia. •Crush injuries • Fever, malaise, and myalgia •Bleeding (minor injury while anticoagulated) Diagnosis: based on clinical features after • Edema extending beyond the area of erythema, skin vesicles, and crepitus. •Reperfusion injury excluding other causes • Comorbid factors, including DM

Gurd's Diagnostic Criteria Types: Treatment Early signs (at least 1 major + 4 minor criteria) I-Polymicrobial • Prompt surgical debridement is •Tight Major Criteria II-Group A Streptococcus continued until tissue necrosis •Escalating pain 1.Respiratory insufficiency (PO2 < 60mmHg) III-Gas gangrene ceases and the growth of •Pain with passive stretch of the involved muscle 2.Neurological – depression/restless fresh viable tissue is

3.Skin - Petechial rash (axillary/subconjuctiva) Complications observed. Late signs -6P • Renal failure • Antibiotic (broad spectrum •Pain Minor Criteria • Septic shock with cardiovascular covering both gram positive •Pallor •Tachycardia collapse and negative) •Pulselessness •Fever • Scarring with cosmetic deformity • Hyperbaric oxygen therapy •Paresthesia •Jaundice • Limb loss (HBOT) •Paralysis •Retinal changes • Sepsis •Poikilothermia •Renal changes • Toxic shock syndrome •Laboratory Features Initial Management Microglobulinemia (required) SPINAL SHOCK = temporary loss of spinal cord function and reflex activity •Remove all circumferential dressings/casts Thrombocytopenia below the level of spinal cord injury, characterised by bradycardia, hypotension (due •Ensure leg is at level of the heart - the affected part should Elevated ESR to loss of sympathethic tone), and an absent bulbocarvenosus reflex not be elevated above the level of the heart because this Anemia Spinal shock Neurogenic Shock HypovolemicShock maneuver does not improve venous outflow and reduces Urine for fat globule arterial inflow BP Hypotension Hypotension Hypotension •Remove any traction Management: 1.Oxygenation. Pulse Bradycardic Bradycardic Tachycardic Definitive management 2.Fluid resuscitation Compartment fasciotomy-2 incisions, 15 cm long 6 pints NS/3 hours followed by Reflexes Absent Variable Variable Delay>12 hr. often results in irreversible muscle and nerve 3 pints of NS/2 hours followed by Motor Flaccid paralysis Variable Variable damage in that compartment 1 pint NS over 1 hour x 3

3.Surgical Care - early stabilization of long bone Time 48-72hrs immediately after injury Following blood loss Complications fractures If left untreated: rhabdomyolysis and kidney failure Mechanism Peripheral neurons Loss of sympathetic Decreased preload Prophylactic placement of IVC filters may help become temporary tone and decrease = decreased cardiac reduce the volume of fat reaching the heart. unresponsive to systemic vascular output brain stimuli resistance Treatment Immobilisation Swan-Ganz Fluid/blood Neurological monitoring for resuscitation charting (until return careful fluid Mx Haemostasis Wells Criteria: Interpretation: of bulbocarvenous Vasopressors Active cancer (1) <0 – low risk (3% probability DVT) reflex) Paresis/paralysis/recent immobilisation of LL (1) 1-2 – moderate risk (17% probability DVT) Early surgical Recent bed ridden x3/7/major surgeryx4/52 (1) ≥3 – high risk (75% probability DVT) intervention Localised tenderness over deep vein (1) Entire leg swollen (1) Management: ORTHOPAEDICS ESSENTIALS Calves swelling >3cm compare to asymptomatic limb (10 cm Heparin/LMWH below tibial tubercle (1) Compression stocking PART 9 ORTHOPAEDIC EMERGENCIES Pitting oedema (1) HTARW5B/GKS2013/4- Collateral superficial vein (1) Together In Delivering Excellence (T.I.D.E.) Alternative diagnosis (-2) Contributors: Dr. Goh, Poh, Shaun, Justine, Shanthy, Huda, Miruna, Lin, Maya, Fong, Ling Ying, Phoon, Quah