Prophylaxis for Venous Thromboembolism in patients undergoing THR and TKR

 THR and TKR

• Indications 

• PAST

• Present

Total hip replacement (THR) surgery,
as we know it, began in 1960.

Total knee replacement (TKR), as currently performed, was first described in 1971.

• While these operations are very successful,deep-vein thrombosis (DVT) and pulmonary embolism (PE) have been significant complications.

The reported prevalence of

• DVT in patients not receiving prophylaxis in clinical trials using mandatory venography has been 45%–57% after THR and 40%–84% after TKR.

• The reported prevalence of PE in other trials has been 0.7%–30% after THR (prevalence of fatal PE, 0.1%– 0.4%), and 1.8%–7% after TKR (prevalence of fatal PE, 0.2%–0.7%).

Patients with thrombophilic syndromes show even higher rate of venous thromboembolism as evident from the table above.

Based on AHA 

• VTE consists of 2 related conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE).

• In 1884, Rudolph Virchow first proposed that thrombosis

        was the result of at least 1 of 3 underlying etiologic factors:

• Vascular endothelial damage, Stasis of blood flow, and Hypercoagulability of blood.

• In assessing whether prophylaxis is indicated, physicians should consider both the strength of individual risk factors and the cumulative weight of all risk factors.

Risk factors to consider for VTE , according to Canadian Orthopaedic association

Guidelines for Starting Pharmacologic Treatment in patients undergoing THR and TKR. 

Preventing Venous Thromboembolic Events in Patients undegoing THR/TKR

 

• A variety of strategies to prevent venous thromboembolism are available: 

• Pharmacological

• Oral antiplatelet agents

• Injectable low-molecular-weight heparins

• Injectable unfractionated heparin

• Injectable or oral factor Xa inhibitors

• Injectable or oral direct thrombin inhibitors

• Oral vitamin K antagonists 

• Mechanical modalities

• Graduated compression

• Intermittent pneumatic compression

• Venous foot pump 

• Combinations of these

Patients with a high risk of bleeding should be started on mechanical methods of prophylaxis (intermittent pneumatic compression and/or elastic stockings) at least until bleeding risk is reduced. In general, patients with one of the weak or moderate risk

• Whereas VTE prophylaxis has generally been recommended for 7 to 10 days, recent studies have found that extending preventive treatment through the 4 weeks after hospital discharge is beneficial in patients undergoing surgery for cancer or total hip replacement. Additional data are needed to define the optimal duration of VTE prophylaxis in other high-risk.

see the timing of anticoagulation required on the first box above , how long does medicine require . 

Thank You.

Viva topics Grilling - Ac. Osteomyelitis,CTEV,CP, Gait Analysis ,ABC,Supracondylar fracture, Perthes Disease , Bone

 Viva 1

A child has hx of fever, malaise & painful walking on his right side. 

How to approach patient ? 

Assess in line of Septic Arthritis and Acute Osteomyelitis 

How do you manage ? 

Detailed Hx. - 

Treatment Hx. - 

Past Hx. -allergy to Amy medications if any 

Examination- BP , pulse , Temperature 

Local examination 

Gait 

Inspection 

Resting Posture of Hip (FABER ) 

ROM 

local tenderness 

USG - hip effusion 7 mm 

Inv. 

AP / Lateral radiographs of hip - to r/o fractures , any structural abnormality

Predictive markers of hip sepsis 

Temperature> 38 .5 deg. Celcius 

WBC > 12,000 cells /mm3 

ESR > 40 

NWB 

X 1 = 3 % , x 2= 40 % ,x 3 = 93 % ,x 4= 96.6 % 

Sx . 

Anterolateral Approach to hip 

Remove ellipse of capsule , allow free drainage 

Samples for c/s 

Irrigation 

Hip Spicas - post operative -to prevent subluxation and dysplasia 

Approximate Abx. 

initially broad spectrum abx then adjusting 

Prolonged course 

Serial infiammation markers

Larger f/u - growth and development of acetabulum 

Viva 2 

photograph of a normal child with a club foot deformity 

 Cavus & adductus of mid foot , Varus and Equinus Hindfoot ,  

classification of severity of the deformity 

Pirani 

Midfoot - Severity of Medial Crease

- Coverage of talar head

- Curvature of lat border

Hindfoot - rigidity of Equinus 

 Severity of posterior crease 

     -degree of emptyness of heell

How to manage club foot in babies ? 

(different treatment for grown up child , require bony procedures )

Hx-of deformity in Parents

Examination

Classify - syndromic vs Idiopathic 

Ponseti cast 

Start with manipulation & serial cating

Ist cast. 

DF - 1st ray unlock forefoit and mid foot. 

- Elevation & Ist ray supination

2nd Cast

-Abduct at mid foot level, using hand of talus fucrum 

Above knee casts - moulding into corrected position . 

Midfoot corrects after 4 to 5 casts 

Achilies tenotomy for residual Equinus 

Final cast for further 3 weeks .

Babies - Denis Browne boots with a bar (23 hours a day for 3 months , then night time until 5 years. It holds foot at 70 degrees ER. 

It also avoids need of surgical release . 

25 % require TA transfer laterally for Inversion in swing after age of about 5 years. 

Viva 17

what is Cerebral Palsy ? 

Neuromuscular disorder cused by non Progressive leison to immature developing brain before age of 2 yrs ( although neurological injury non Progressive ,MSK features evolve ) 

Types umber fry nen pagresive, ask

الله

Types-

Anatomical - Hemiplegia (40 %) , Diplegia (30 % ) , Total Body Involvement (30 % ) 

Physiological 

 Spastic (60 %), Dystonic (20%) , Ataxic (10 %) 

Hypotonic (10%) 

GMFCS

What is Spasticty?

Velocity dependent increased tone of muscles . Represents as increase response to stretch reflex.

Management of spasticity 

Multidisciplinary approaches-

family and patient in goal planning 

decissions abt treatment 

Exploring expectation 

Non-operative 

PT -Physiotherapy 

Botulinum toxin - Cl. Botulinum toxin prevents release of Acetylcholine at NMJ .

effective for 3 to 6 months Combined with plasters & targeted PT/ Orthotics to maintain stretch . 

Baclofen Pump and Injections 

  GABA Agonist / inhibitory neurotransmitter 

  Acts - centrally and peripherally to decrease spasticity 

 Intrathecal injections - can increase dose and reduce systemic side effects

  Surgery 

SEMLS- Avod Birthday Operation 

soft tissue lengthening to tight muscles. 

Muscle transfer

Osteotomy 

What is Gait Analysis?

Systemic discription , assessment and measurement of quantities that characterizes human locomotion.

Involves Kinematics ( movement of individual parts of body) & kinetics (forces how they interact and & produce the movement ) as well EMG and energy consumption .

Gait analysis- 

2 D Video

3D computer analysis 

. - breaks movement of individual parts into graphic form . 

Use force platesn, measures ground reaction force & EMG records muscle firing patterns

Gait analysis looked at in conjuction with a Static detailed physical examination. 

Vivo- 3

You got an X-ray 

Reads like

AP Radiograph of skeletally immature child showing a multiloculated lytic lesion in proximal metaptysis. The zone of transition in Sharp indicating benign lesion & no associated periosteal reaction . 

Diagnosis 

 

Simple Bone Cyst 

ABC 

Infection 

HE presensts after few weeks with severe pain . 

 What you think has happened?

Pathological fracture 

 A fallen fragment sign 

How do you manage ? 

 Thorough hx. 

 Examination 

  Manage expectantly 

  # stimulates new bone formation.

Pt. treated expectantly but lesion persists . How to manage ? 

If expectant non operative measures fail

Aspiration of cyst done .

Inject steroid on bone graft, marrow to try and stimulate new bone formation.

-If it fails , repeated attempt is worthwhile.

Surgery - Curette out lining of cyst through a cortical window and Stabilizing bone to

prevent fractures 

Flexible IM nails across lytic area.

If cavity adjacent to growth plate , important not to damage physis.

Viven-19iva 4 

You got an X ray Gartland type IIIA , supracondylar fracture . 

Questions 

How do you manage the case ? 

Hx. - MOI , Other injuries ,drug allergy 

Examn . - assess presence of open injury 

Assess distal NV (Hand colour , capillary refill of finger tips , radial pulse ,sensation in specific dermatomes , motor function in ulnar ,median ,radial and AIN nerves ) 

Treatment 

Analgesia 

Temporary back slab 

Consenting 

OT set up with C-arm back up 

 CR - 

technique

Continuous traction in 20 degrees flexion , several minutes. 

-- correct valgus /varus and rotational deformity 

-flex arm 

-Pronate forearm to lock fragments 

Insert a lateral wire 1.6 mm k wire first 

Extend arm a bit to plan a mini open approach to medial side .

 

Bend and cut wires in clinic in 3 to 4 weeks time. 

Splint arm in back slab in near extension 

Reassess perfusion of hand and watch for compartment syndrome 

Not able to feel after pinning. What to do ? 

Assess colour of hand and warmth , capillary

Refill time

for a pink and warm hand , with adequate Capillary refill of finger tips , I would monitor situation with a regular review. 

Artery in spasm (if) will lead to loss of pulsation.

- If hand white and CR reduced , remove splint, extend elbow and see situation. 

If not contrat vascular /plastic surgery for urgent review as artery has been caught up in fracture and has been occluded by rodeuction.

If requires exploration anteriorly.

Viva 4 

You are shown an AP Pelvis of skeletally immature child with flattening of femoral head with deformity suggestive of Perthes disease. 

What is underlying disease ? Who gets it ? 

Idiopathic AVN of Proximal femoral epiphysis in childhood . 

Unknown actiology, 

sequeale of acetabulon procedure

Boys & Girls = 4: 1, Bilateral -20%

Classification

1. Initial l Aversvascular event (crescent sign presenting subchondral fracture )

2. Fragmentention

3. Resolutions and re-ossification

4. Remodelling

Herring’s classification 

Piller height on AP radiograph 3 during fragmentation .

3 >50% maintained 

<50 % maintained 

Caterall’s classification - depending on head involved on lateral Radiograph 

Also Added head at risk sign . 

Clinically

Obese 

Progressive and decrease ROM 

Abduction contracture 

ER with flexion 

Radiographically 

Horizontal Physis 

Lateral Subluxation of epiphysis

Lateral calcification

Diffuse Metaphyseal Sign 

+ Gaze Sign-inverted l V shaped lucency in lat. Metaphysis 

Stullberg's classification based on shape of femoral head 

I- normal 

II - head spherical which is spherical (magna / Bevel ) fits in socket which is congruent 

III - mushroom head congruent 

IV - flat head and flat socket careongruemt mont

V - flat head incongruent .

Principles of mx. 

Goals

Symptomatic Parf

Containment

Restore ROM,

goals achieved by non operative and operative measures.

Management based individual basis taking into accounting their age, chalinic signs & radiological appearances on X-ray .

Vivo.5 

What is bone ?

Bone is a dynamic form of specialized connective tissue 

Cells - 10 % 

Osteoblasts 

Osteoclasts 

Osteocytes 

 ECM - 90 % 

Organic 

Collagen- type I 

Inorganic 

calcium phosphate 

Osteocalcium phosphate 

Function of Bones

Movement 

support & polkrotect internal organs 

Production - WBC/ RBCs

Storage of Calcium and Phosphate

Differences

Osteoblasts 

Derived from undifferentiated mesenchymal cells

Bone forming ,lay down osteoid ( type I collagen ) 

Contains RANK Receptor activator of nuclear factor kkappa - B

Osteocytes osteoblasts that have beame trapped in bone

Osteocytes - osteoblasts that have become trapped in bone matrix ( making upto 90 % of cells in bone ) , important role in homeostasis of calcium and phosphate 

wolffis hid German anatomist/engem by Jullim Dolf. of londing on tone ter, home remiadal Hot iver time to become trueer & east land

Osteoclasts 

Monocyte call lineages that multinucleated giant cells that resorb bone

Location - Small pits called Howship Lacunae, bonee surfaces. & lead culting cones.

Ruffle

d brush border , increase surforce area, create ? low PH to disolve inorganic constituents 

Enzymes Release - tartarate resistant acid phosphatase - break down organic matrix components,

inhibitors- osteoproteogerin 

Wolff’s law 

German Anatomist /Surgeon by Julius Wolff 

If loading on bone increases , bone remodels itself over time to become stronger to resist load. 

Bone | Perthes disease |Supracondylar Fracture | ABC | Gait Analysis |Cerebral Palsy (CP )|Congenital Talipes Ewuinovarus (CTEV)|Septic Arthritis |Acute Osteomyelitis|

Crush injury of Finger |Hip Dysplasia |Intoeing |Slipped Capital Femoral Epiphysis (SCFE) |Non accidental Injury (NAI)

 Viva 1 

Mx of Crush Injury 

Relevant History 

Handedness , Occupation , MOI,

Comorbidities 

- Tetanus prophylaxisis- if indicated

Antiseptic (Betadine ) dressing

 

Radiographs to exclude #s

Wound Exploration 

Repair nail under LA ( digital block and digital tourniquet) 

Steps of procedure 

Remove nail plate

Inspect nail bed, wash thoroughly

Copious lavage lavage

Reduce fracture , stabilize using k- wire

Removal- at 4 weeks

fapairs mail bud i a Gutare (VICRYL fapide) 60 abebable

Repair nail bed with a absorbable suture 6-0 ( vicryl rapide ) 

Wash and replace nail plate 

Use Figure of Eight suture to hold nail plate in place 

what to explain to patient ?

 - Nat Plate falls off & new one comes which will be disfigured .

-Risk of long term nail defirmity 

-Discomfort in region of nail deformity 

-DIP jt stiffness.

Viva 2 

→Describe radiographic findings,

AP pelvic radiograph showing a dislocated let hip and dysplastic acetabulum 

Shenton’s line Broken and femoral head lies lateral & superior to inferomedial quadrant (made by intersection of Perkins & Hilgenreiner’s lines)

How to proceed in such cases ?

Full Hx.

Examination

Risk factors - rule out family hx.

- 1st born (low intrauterine space)

- Breech

- oligohydraminous 

look for underlying NM disorders-Spina Bifida, Arthrogryposis , CP

Trendelenburg gait, LLD. FFD, & decrease Abdn of (Lt ) hip

Inv. 

EUA, Arthrogram to delineate anatomy of acetabulum , soft tissues, proximal femur.

Mx 

CR.

OR-failure to closed reduction ., unstable reducible hip, soft tissue interposition preventing a congruent reduction .

Blocks to Reduction -

(1) Inverted limbus

(2) ElemElongated ligamentous teres  

 (3) Hourglass constriction of capsule 

(4) Psoas tendon

(5) Pulvinar

what are different approached to expose hip joint ? 

 Modified Anterior (Ilio femoral ) approach 

Skin incision parallel and distal to iliac crest 

2 cm distal to ASIS and extending medially within groin crease .

Skin imeising- 11 4 distal to iline crest.

- 2 cm distal to ASIS & extend. medially dithin groin crease.

Protect Lat. cut. N. of thigh:

Internervous Plame - TFL (Sup. Gluteal N.) and Sartorius (Femoral N.)

Splitting Iliac crest apoplysis 

 Elevate muscles en-maase on both sides & pelvis down y to sciatic notch and superior border of acetabulum.

Divide straight head of Rectus femoris and make a T-Shaped calsular incision to enter hip joint and clear acetabulum pulvinar & redundant lig. teres (not-labrum).

Inverted labrum everted with 1 or more radial cuts

Release inferior capsule

Release Iliopepsoas to be able to reduce Hip. 

Then

asses need for Shortening femoral Osteotomy or pelvic Osteotomy 

Double breasted Capsular Repair 

Close layers. 

- Hip Spica - Abdn-30° & IR ch

charge at 3 weeks 

Post operative - catch for Spica syndrome

 MRI late - check if hip enlocated 

Long Term f/u if hip develops normally. Normal

Viva -3

child sitting in W position.

How to assess ? 

Hx - enquiry about pregnancy, Birth & Dev. milestones, family fhx., significant past medical hx. and current concerns

causes of Intoeing-Metatarsus adductus, persistent femoral anteversion, tibial intorsion 

- Examination 

Rlo assymetry in lower legs 

signs suggestive of - Spinal abnormality or neurological problem.

Gait - with Shoes/ Bare foot 

foot progression Angle ( N 10~-5° to +20)

when child prone torsion profile

Metatarsus adductus- foot shape in relation to toe heel bisector line..>

Tibial torsion

thigh foot angle (N 0-20)

tibial torsion - Defined as angle between transcondylar axis of proximal tibia and bimalleober axis (N. range: 10-25°ER)

Femoral Anteversion 

IR (> 60 degrees : N = 20-60) > ER (< 20 , N 30-60)

Rowe’s method 

Measure angle from vertical (finger on GT ) to most lateral point

N 8 -14 degrees 

- I also examine spine of lower limb neurology as well as asses degree of lig. laxity .

How can we grade ligament laxity ? 

 Beighton score 

Increase finger hyperextension 2

Increase thumb hyperextension 2

Increase elbow hyperextension 2 

Increase knee hyperextension 2

Ability to place Palm on floor 2 

4 or more is suggestive. 

Typical history of extra mobility if joint. 

Surgical treatment 

It's a physiological condition at one end. 

Upto 10. , it may improve.

Even if it doesn't improve , she may be left intoeing.

Rarely a functional problem.It’s just a cosmetic one. 

Surgery - Femoral / Tibial derotational Osteotomy 

Viva 4 

Identify the disease with an explanation . 

AP radiograph if a Pelvis if a skeletally immature child . 

There is a mild slip of upper femoral apophysis with a positive Trethowa’s sign ,shown up by drawing a kleins line up the laterla border of femoral neck and noting it doesnt intersect epiphysis. 

how to classify this condition ? 

Lodler’s classification 

Stable / unstable - based on patient’s ability to bear weight secondary to pain predicting risk of AVN. 

Other Classification 

Mild < 33 % , Moderate 33-50 % , Severe > 50 % 

Useful which are pinnable or not. 

Mx. 

Full history of patient and parents 

Examine child 

Endocrinopathies 

Examination-

Hip that externally rotates and abducts with flexion 

Tr. 

Pinning slip in situ with a single cannulated screw . > 1 screw may lead to AVN and Chondrolysis . 

Note - not to use force 

 Use triangulation technique to define appropriate location of skin incision 

Thread of screw should be in center of epiphysis , perpendicular to physis 

-Slip if Posteromedial requires anterior femoral neck entry point. 

Minimum of two / three screw threads should pass into epiphysis depending on size of child and the instrument used. 

How do you manage further ? 

Prophylactic screw fixation in opposite hip - Contralateral . 

Options 

  Treat every case ase with Contralateral fixation or only high risk cases - patients with underlying endocrinopathies , < 10 years or significant LLD.

Viva 5 

How do manage a chid with Subtrochanterix obligue fracture ? 

Impression - Non-anccidental Injury

( Femur fracture in a non ambulatory child ) 

NAI 

Injury dadiendelibrately inflicted by a povearent or a care giver 

Risks - first

 born, premature babies, step children, family history of abuse ,parent IV drug abuse , 

Treatment 

Gallows traction with a radiograph at 2 to 3 weeks , & then gentle mobilization as comfort allows 

 

Hip Spica .

Crush injury of  Finger |Hip Dysplasia |Intoeing |Slipped Capital Femoral Epiphysis (SCFE) |Non accidental Injury (NAI) 

Hand Viva II

 Viva-1 what do you find in Wrist PA view ? 

( We don't have X ray , 

Suppose you saw an undisplaced fracture of Scaphoid ) 

Viva 

 Schapoid View - hand and wrist in ulnar deviation along with 15 degrees of cephalad angulation of X ray tube. 

Indications of Internal Fixation of Scaphoid fractures 

1.Displacememt > 1 mm 

2. SL Angle > 15 degrees 

3. Lunocaoitate angle > 15 degrees

4. Interscaphoid angle >20° (dorsal humpback)

5.Proximal pole # , Periluante dislocation 

6.Delayed union

Operative fixation in acute non displaced fractures 

Non union Scaphoid fractures 

Better early outcome scores in grip strength , ROM with fixation but no difference after 12 to 16 weeks 

Rate of delayed union is less with early fixation .

Complications 

AVN of Proximal Pole 

Non union 

Mx of established non-union

Arthritic changes not present 

Fixation with bone graft 

       ( Distal radius ) 

"Bone graft based on 1, 2 intermateacarpal 

branch of radial artery

Success rate - 70%

Arthritic changes present

-Radial Stylbidectomy

-Proximal row carpectomy

-Scaphoid excision 

- Four Corner Fusion 

- Wrist Arthrodesis

Viva-2

Suppose you saw an X ray / MRI . 

Findings on MRI 

What do you see in MRI ? 

TI MRI

 low signal intensity in the lunate suggestive of kienbeok’s disease

Cause

AVN of lunate bone on wrist

Staging of this condition 

 Lichtmann classification 

 (I) Normal radiographs, praettepossible Stress #

 (II) Sclerosis of Iunate, no colapse

IIIA. fragmentation & early collapse

IIIB. Schapolunate dissociation & fixed rotation 

 of schapoid 

IV. Degenerative changes on lunate .

Other important findings we see in radiographs 

Negative ulnar variance on AP n radiograph taken with forearm in mid-prone position.

Mx.

options

Non-op.

Analgesia

Splintage

operative

Joint levelling -Radial Shortening

Wrist Denervation 

Wrist fusion - Partial/total

Proximal row carpectomy

Choice depends on disease stage, degree of symptoms and partial factors.

Viva 3

You get an X ray of a patient with wrist pain . 

AP. radiograph of wrist - shows ulnar positive Variance. 

Appearance is typical of Ulnar Abutment Syndome.

Which structure is involved in this ? 

 TFCC

Anatomy of this?

Pyramid shaped fibrocartilaginous structure found at distsl aspect of ulna. 

Comprises of disc ( meniscus like structure) and a sling of ligament and acts a s a key stabilizer of DRUJ and ulnocaroal joint . 

Mx option for this condition 

Non operative 

Splints

Analgessia

-Avoid aggravating activities

Operative 

Arthroscopic wafer resection 

Open ulnar Shortening

Osteotomy 

Viva

Dorsal Compartment of Wrist 

I- APL, EPB

II. ECRL , ECRB

III. EPL

IV. EI, EDC

V. EDM

VI. ECU

De Quervaines Syndrome

 painful condition affecting first compartment of wrist joint. Commonin female, espcially post partum. 

Tell clinical Signs of DeQuervan’s syndrome. .

Localized Swelling along radial aspect of wrist 

Tenderness 

Finkelstein test

→

Mx. options 

Non operative 

Splinting

Analgesia

Local Steroid

operative 

- Surgical Release

If non-operative measures fail. 

under GA / regional anaesthetics & arm tourniquet

Release transverse or a longitudinal incision .

→ Adverse effects of local Steroid injection 

- Infection 

Injury of Sup. branch Radial Nerve, Painful Neuroma

- Tendon rupture

→Pitfalls of Surgery

failure to recognize anatomical variation EPB-lies in a separate compartment 

Incomplete Relief of symptoms

Painful Nuroma-injury to superficial branch of Radial Nerve

Kienbock's Disease / Ulnar Abutment Syndrome/ De Quervain's Tenosynovitis /Scaphoid Fracture 

Viva Questions (Hand ) Orthopaedics

 You see a Photograph of a right little finger. MCP jt shows Flexion . 

Diagnosis -

 Dupuytren's Contracture 

Risk Factors 

Family hx, Liver disease,

High Alcohol Intake 

DM , Epilepsy

Two main components in histology

 

 Myofibroblast

 Thick collagen Fibers 

Mx. 

Non operative 

Observation , Night time splintage

Injection - Steroids - reduces local tenderness 

               -colllgenase

Surgery 

Permanent Fasciotomy 

Mild cutaneous contracture at MCP Jt. 

Segmental/Patmar fasciotomy 

 Regional fasciectomy ( Z plasty for closure /skin graft ) 

Dermo fasciectomy and skin grafting

- PIP it arthrodesis - severe /recurrent disease 

Amputation of digits 

Counselling 

Delayed wound healing 

tendon,nerve,vessel injury 

temporary and permanent numbness 

necrosis of digit & amputation.

Incomplete correction 

Recurrence and reoperation 

Jt. stiffness

Reduced flexion and extension 

CRPS

Viva 2

Swelling voler aspect of wrist , radial to midline , cystic and soft in consistency 

Suggestive of 

Ganglion cyst

2/ 3rd - Radio carpal Joint 

1/3rd - Scaphotrapezoid jt. 

Clinical test

-Compressible 

- transillumination test +ve 

Outpatient procedure - aspiration under Local anaesthesia 

Simple Imaging - Ultrasound Scan 

 Histlogical definition- Ganglion cyst is a fluid filled cavity lined by compressed collagen & a fewer cells,

Other sites

Dorsum of wrist arise from S-L ( Scapholinare ) ligaments 

DIP Jt. - Presents as Dorsal distal ganglion , mucoid or mucoid cysts 

A2 pulley rerion in relation to flexer tendon seath.

Intraosseous ganglia - often in lunate 

Mx

Management of any disease starts from history followed by clinical examination , investigations counselling and treatment . 

Counselling - explain benign nature if disease 

       -fluctuates in size periodically and may regress spontaneously 

Treatment 

- 1) l Simple observation 

(2) Aspiration - risk of haematoma, infection artery damage, recurrence 

3) Surgical Excision 

Open or 

Arthroscopic

Anaesthetic risks

Surgical complications - nerve vessels damage

- tendon injury

-haemortma

-Pain, swelling, tenderness,stiffness

 -Recurrence

Risk of recurrence for all three treatment methods. 

.

Viva 3 - 

A photograph of hands with following deformities 

Thumbs- - z shaped 

Right middle finger - Swan neck deformity 

All fingers - Volar deviation of MCP Jts 

Symmetric deformity with Polyarthropathy consistent with Rheumatoid Arthritis 

Grading of thumb conditions radiographically 

stage -

I ) Joint Space widening , normal articular contours 

II- Upto ⅓rd subluxation ( on stress radiographs ,osteophytes < 2 mm 

Scaphotrapzpezio -trapezoidal (STT) normal . 

III) > 1/3rd >rd subluxation , osteophytes > 2 mm 

Jt. Space markedly reduced 

-pan-trapezoidal arthritis.

Why subluxation occurs ? 

Palmar (aka beal lig) ligament -very strong lig extending form trapezium to base of Ist MC. 

Degenerstion attenuation & rupture of this ligament leading to dorsal subluxation of 1st MC,

How to explain hyperextension deformity at MCP Jts ? 

Dosal subluxation at CMC Jt leads to metacarpal adduction , thumb in palm deformity and reduction in thumb span . 

To compensate that , hyperextension at MCP joint leads to increase in thumb span. 

→ Mx options.

Non-operative - activity modification , Splints , PT, Intra-articular steroids - outpatient clinic or under fluoroscopic guidance. 

Oral Analgesics 

Operative -1) Excision of trapezium- pain relief -Pinch up weakness

(2) Suspension procedure & tendon interposition arthroplasty - addition with above , no extra benefit .

3) Implant Arthroplasty - no good long term benefit 

4) CMC Athrodesis for Labourers -who require Stable thumb & good pinch,

5) First MC-basal Osteotomy 

→ How to treat this in a labourer ?

Excision of tropezius

Fusion of mcp it Under GA orl regional blck

Advantages / disadvantages of Trapezium Excision 

Good pain relief 

Improves function 

Thumb shortening

Reduce power of pinch 

Disadvantages 

painful scar 

- Nerve damage ( Superficial Radial Nerve )

Blood vessel (Radial Artery ) 

Incomplete relief of Symptoms 

Slow recovery of function 

Instability of carpus

 Fight bite puncture wound over the rt. middle finger MCP jt, that may have been caused by human tooth .

Wound may extend into joint causing cartilage damage and may be associated with joint infection and osteomyelitis. 

How to assess ? 

History - including circumstances of injury 

Past Medical History 

TT

Immunization 

Examination- 

    fever, tachycardia 

  Local examination 

     Cellulitis 

      Tendon Sheath Inflammation 

       Tendon rupture 

        Septic arthritis

Inv. -X-ray -AP / Oblique 

       Fracture foreign body

Baseline Blood Inv. - CBC,ESR, CRP

Treatment 

Tetanus Prophylaxis

- Sterile dressings to cover wound

Abx after tissue c/s 

Urgent debridement under GA with a tourniquet around arm . 

Pus swab and tissue samples - histological examination and microbiological 

Extend wound-look for tendon damage

 tag tendon ends and not to do primary repair 

inspect Jt

- Irrigate

- leave wound open , dressing, splinting

Broad spectrum Antibiotics , then narrow spectrum Abx. 

Further , look after 48 hrs. 

Which organism causes infection ? 

Eikenella Corrodens Peculiar 

Staph Aureus - commonest 

Anaerobic bacteria may also be implicated. 

Which abx is given ? 

Before C/s - Brood speectrim Abs such as Co-amoxiclav, cephalosporin & metronidazole 

Describe X- Ray 

PA and lateral view of a Periluante dislocation

PA view 

Discription of Giulula’s smooth carpal lines

- that join proximal surface of row of carpal bones -at radiocarpal joint .

-that join proximal surface of distal row of carpal bones.

Hyperflexion of scaphoid (scaphoid signet ring sign)

Abnormal triangular appearance of I lunate, lunate in it's fossa. 

overlapping of lunate and triquetrum 

Explain of there is fracture of radial styloid , and other carpal bones. 

Lateral view 

Dorsal dislocation of capitate head from it's articulation with lunate at mid carpal Joint 

and dorsal translation of distal carpal row and metacarpals relative to long axis of radius . 

How to classify ?

Mayfield Sequence of Ligament Injury 

Greater Arc - fracture in one of Radial styloid, schapoid, Triquetrum, capitate, hamate

Lesser Arc - no fractures 

Stage I: failure of Radiocarpal Ligament 

 II : failure of SL lig. 

III : failure of LT lig. 

and dorsal midcarpal dislocation 

IV : Palmar Dislocation of Lunate at R/C jt. 

Periluante dislocation is Mayfield stage III lesser arc injury. 

How to assess Patient’s injury ? 

Detailed history , handedness , occupation, MOI, CO-morbidities , past trauma history and time she took last meal . 

Examination - Abnormal wrist contour , pain and swelling , signs of median nerve compression , document median nerve function , sensory motor function up

Mx

Initial Mx.

1.Exclude other injuries

2.Provide Analgesia 

3. Regular neurovascular observations 

4.Splintages 

5. Elevation (Bradford Sling or Chinese finger traps ? ) 

6. Counselling 

7. Prepare and consent patient for ungent theater

8. Minimum initial intervention 

Close (open reduction and of dislocation ) 

Carpal tunnel decompension

Definitive

CR

assisted with joystick k - wires + buried k-wire stabilization of SL , LT and mid carpal joints

OR

- Open Dorsal Anatomical Carpal reduction Buried K wire stabilization ,Repair SL ,LT, dorsal & Pal

mar RC Ligaments .

(Note - as this is Mayfield Type 3 injury all 3 ligaments from stage I to III are injured and we have to repair them all three ) 

Post operative

high elevation and careful NV observation 

 Full Pop- 2 weeks , K-wore removal @ 8 weeks and mobilization . 

Risk of post traumatic carpal instabilly or stiffness 

Keywords :

Ganglion / Periluante Dislocation / Hand involvement in RA / Trepezium Excision / Fight Bite Injury 

Resident's note 

Golden points 

Notes in Orthopaedics w

Inflammatory and Rheumatic Disorders

 Inflamatory and Rheumatoid Disorders 

Rheumatoid Arthritis

Most common cause of chronic inflammatory joint disease 

1-3 % , 4th or 5th decdes

women affected 3 to 4 times more often than men.

Causes

1) Genetic susceptibility

2) Immunologic reaction

in joints and tendons

4) Rheumatoid Factors

5) perpetuation of inflammatory factors

 6) articular cortilage distruction.

Pathology 

1)Joints and Tendons 

      Preclinical inflammation - increased ESR and CRP

     Synovitis 

       Destruction

        De formity

2) Extra articular tissues

      1) Rheumatoid Nodules

       2) Lymphadenopathy

       3) Vasculitis

       4) Visceral disease

       5) Muscle weakness

Clinical features

Insidious onset

Early stage

soft tissue swelling 

 

 stiffness.

muscle pain

Tiredness, loss of weight,

Multiple joints pain 

Morning stiffness more than 30 minutes

Physical Exmaination 

Symmetrical distribution - Swelling

tenderness - MCP Jts

- Tevenosynovitis

-Limited movement

Later Stages 

joint deformity 

Tendon rupture 

Clawed toes

 Valgus Knee and Feet 

Pain & stiffness in spines

Extra-articular features

Nodules in back of elbows, viscera, eye

Muscles wasting , lymphadenopathy,

Skin atrophy or ulceration, Scleritis, Nerve Entrapment 

Peripheral Sensory Neuropathy 

Investigations 

X- Ray

USG/MRI

Normocytic Normochromic Anaemia

        Serological tests for rheumatoid focitor - 80% cases positive 

Synovial Biopsy - Needle Biopsy , or through Arthroscopy

Diagnosis 

   Explain as Bilateral Symmetrical Involvement 

   Involving Proximal Joints of hands and Feet Persisting for more than 6 weeks in my patient aged … , female gender …

 Likely be Rheumatoid Arthritis 

D/ D S

Seronegative Inflammation, Polyarthritis 

Ankylosing Spondylitis 

Pseudogout 

Peter's Disease  

       5) Polyarticular Gout

      6) کے Sarcoidosis

      

      7) Lyme Disease 

       8) Viral Arthritis 

9) Polymyaglia Rheumatica 

Treatment 

Corticosteroid Injection 

DMARD ± sulfasalazines , hydroxy chloroquine 

- Leflunamide

- Gold & Penicillamine / TNF Inhibitors 

B) Physiotherapy 

C) Surgical Management 

Synovectomy / tendon repair as replacement and jt. stabilization . 

Complications 

1)Fixed Deformities

2) Muscles weakness 

3) Joint Rupture 

4)Infection 

5) Spinal cord compression 

6) Systemic Vasculitis

7) Amyloidosis 

Acute and Chronic Osteomyelitis

Acute Osteomyelitis 

Orthopaedic Diagnosis 

History 

2) Past History

3) Family History 

4) Social background

5) Examination 

Look / Feel / Move

Special tests

developmental milestones.

C ) Investigations 

Plain Radiography

   Patient - soft tissue , bones and joints 

     using contact media

2- CT

3) IMRI

5-30, 000, stronger than Earth’s magnetic field

4) Diagnostic ultrasound 

5) Radionuclide imaging - 99 m Tc

B ) Blood tests

CBC, ESR CPP - Non specific 

- Tissue typing

 - Rheumatoid factor 

- Synovial fluid analysis.

C) Bone-Biopsy 

D) Diagnostic arthroscopy 

Infection 

Direct Introduction 

(2) from contiguous infection 

(3) indirect spread from blood stream

Factors predisposing to bone infection 

- Malnutrition & general debility"

- DM

- Corticosteroid administration

- Immune deficiency

-immunosuppressive drugs.

- Venous stasis in limbs

- Peripheral l vascular diseases

 - loss of sensibility

- intrinsic invasive measures

- Trauma

Principles of treatment 

1 ) Analgesia

2) rest the affected part

3) indentify infecting organism, administer effective abx tr

4) release pus as soon as it’s detected 

5) Stabilize bone if it's fractured

6) eradicate avascular & necrotic bone

7) maintain soft tissue and skin colour 

Acute Haematogenous Osteomyelitis

Adults & Children - S. Aureus - 70%

                 -less often GABS (Str. Pyogenes) or 

                             -alpha -haemolytic Diplococus , S. Pneumoniae

1-4. children - H. Influenzae. 

                       - Kingalla kingne

Metophysis - involvement

1) Non-anastomosing losine terminal antony branches of nutrient artery

2) relative vascular stasis

3) lower oxygen tension

4) fire vessels in hypertrophic zone-bacteria pass through them and adhere to type I collagen

Pathology - 

Inflammation, suppuration, bone necrosis reactive new bone formation, resolution & healing or chronicity

Metaphysis

-Intracapsular - SHE( SHOULDER , HIP and ELBOW JOINTS ) and spreads to it.

2) Periosteum looseliy attached in children spreads along shaft.

(3) physis is barrier to spread to joint 

4) In infants ,bacteria spreads to joints 

its through physis

Clinical features 

(1) child over 4

(2) Pain, swelling , refused to move 

(3) high grade fever 

 4) Infants - symptoms are mild 

(5) Bony tenderness 

(6) TL vertebrae are comon sites 

Diagnostic Smaging

1)Plain xray

2) USG

3) 99m Tc - HDP : Increase activity in both perfusion and bone phase 

4) MRI

B) Laboratory Tests 

18 G needle.

Aspiration.

tissue aspiration 60% positive

CRP-12-24 hrs., ESP-24-48 hrs

D/P

4) Cellulitis

B) Acute suppurative Arthritis

2) Acute P

3) Rheumatism

4) Sickle cell crisis

D) Gaucher’s Disease

Treatment 

 Analgesia 

Support affected part

Abx

Pus drainage

Fix facturas

Cover wound , remove dead bone 

Choice of Abx. 

 Upto. 06 months - 3rd gen. cephalosp

                                     Covers Aureus

  6 months to 6 years - H. Influenza

Fluclox + 3rd gen ceohalosporin

Older chibaren & previously fit 

flucloxacillin & Fusidic 

 acid

Elderly previously unfit patients 

Like in 

6 months children - G ‘-’ve organisms from GI Tract , respiratory system . 

Pts. with Sickle Cell dis-

3rd gen ceohalosporins or fluoroquinolones 

MArSA-

IV Vancomycin + 3rd Gen Cephalosporin

- Garre’s Sclerosing Osteomyelitis 

Marked Sclerosis and Cortical thickening .

-Long history of bone pain and Swelling over bone 

Treatment - Curettage 

Acute suppurative Arthritis

S. Aureus

Involvement

I/A injections 

Adjacent bone abscess

Blood spread from distant site

Clinical features

1 ) Pain / swelling ) refusal to move the part, fever

2)septiceamia in infants 

3) rapid pulse, erythema over involved bone and swelling 

4 ) restricted movement 

Imaging

 

USG

X - Ray

MRI

G-stain

WBC-300/ ml is normal 

- 1000/-non infective 

> 50,000/ml - infective

D/D of Acute Osteomyelitis 

Trauma 

Irritable Joint 

4) Haemophiliac Bleed 

5) Rheumatic fever 

6) Juvenile Rheumatoid Arthritis

7) Sickles cell Disease

10) Gaucher's Disease 

11) Gout and Pseudogout

Complications 

Subluxation

Damage to cartilage

Articular cartilage erosion 

Gonococcal Arthritis

Neisseria Gonorrhoea.

Recurrent Shoulder Dislocation

 Look 

        Alignment of UE - Normal 

        Fullness of Anterior Shoulder 

        Skin - Normal 

        Muscles wasting 

           Always look from front , side and then back. If there is a mirror in front you can inspect shoulder                 movements from back also . 

       

Feel 

        Temperature - Generally normal 

        Any tenderness ? 

        Lymph nodes on Axilla 

      Palpation starts from medial border of clavicle , along clavicle , shoulder joint, proximal humerus          and then again back to joint, along spine of scapula and all 3 borders of scapula 

Movement 

        Abduction

        Adduction 

        Flexion 

        Extension 

        ER 

      Special Tests     

                    Apprehension Test

                    Anterior Drawer Test 

                    Jobe's Relocation Test 

                    Sulcus Test 

  Pulsation of Brachial arteries 

  Sensation  - Axillary N. 

                        Radial N. 

                        Ulnar N. 

                        Median N. 

    Power of Muscles 

                        Might not be accurate when shoulder not stable 

   Reflexes - Brachial and Triceps Reflex. 

                    

 Recurrent Dislocation might be  habitual or AMBRI or TUBS and treated accordingly. 

Brachial Plexus Injury Clinical Examination and Surgical Management in a capsule

I found students really lost when doing a Brachial Plexus Injury clinical examination. If it is done in a sequence then it won't be. I have explained it in a simplified manner. Go from the front , then side and observe on the back on inspection. Then again do the 2nd round from front, sides and  to back on palation along with movement of joints. Then on third round i would do tinel's sign , sensory exam and muscle power testing on third round. And at last i would complete the examination measuring scars, if there is descrepancy of limb length and finally pulsation of brachial / radial and ulnar arteries / lymhp nodes 

To pass any PG exam , a good history along with a comprehensive physical examination is a minimum criteria to be appreciated and be asked for treatment which allows you to pass the exam. All questions after that will help you be get extra. 

i wish you all the best. 

Please support me giving comments sothat i can work more on topics like these. 

 Look -  

 (Front ) Head -    

                          Alignment 

                          Horner's Syndrome 

            Shoulder - Scars, axillary folds , muscles wasting 

            Chest  -     Wasting of Pectoralis Major 

            Extremities- Any particular attitude of UL 

     Look (side ) 

              see the attitude of extremities and arm and back 

              comment on skin color , deltoid contour , biceps , triceps ,forearm muscles, guttering on                          dorusm of hand, thenar and hypothenar muscles 

              see axilla and boundaries 

      Look (Back ) 

               comment on alignment of head and vertebrae 

                both scapula at same level or not 

                normal posterior axillary fold 

                describe if there are any scars present 

                is there winging of scapula ? 

   Feel 

            temperature , any palplable swelling on supraclavicular region

            soft tissue tenderness

            deep bony tenderness

            scar - size , mobility , tenderness, 

            

Movement 

            C- spine - Flexion, Extension , bending and rotation 

            Shoulder - Active and Passive 

            Elbow - Supination and Pronation 

            Wrist - Flexion and Extension 

            Fingers - MCP and IP Joints 

            Measurement - if there is shortening of upper extremities 

            Pulsation of Arteries on UE/ Appley's test if any procedure to be done on hands and Wrist 

            Sensation - Dermatomes 

            Tinel's Sign     

            Reflexes 

            Power of Muscles 

                Back - Shrugging of Shoulder - to see Trapzius Muscles 

                           Serratus Anterior - Push the wall and see the winging of scapula 

                          Palpate muscles on medial border of scapula - on attention position 

                          Subscapularis muscle - Gerber's test 

                        Latissimus Dorsi - see the power of muscle in extension , internal shouder rotation and                            adduction of shoulder joint 

              Front - Check power of Pectoralis Major Muscles 

                           Supraspinatus / Infraspinatus / Teres Minor Muscles - Resisted External Rotation 

               Sides 

                       Deltoid 

                        Biceps 

                        Triceps 

                        Supinator 

                        Pronator 

                         Wrist Extensor

                        Finger Flexors 

        

Give an Impression at last 

        Assess deficits 

            deficits in C5,6 Dermatome     

            Muscles Weakness 

                Pectoralis Major 

                Deltoid 

                Rotator Cuff 

                Latissimus Dorsi 

                Elbow / Finger / Wrist Extensor 

          These help to conclude the C5, 6 Injury 

        Viva 

      Q :       At what level did the injury occur ? 

       A:        Posterior to Clavicle because Pectoralis Major is involved , nerve to Pectoralis Major exits                        below clavicle. 

             

    Next scenario , a 3 years old girl by birth has following deficits : 

       C5 , 6 Sensory Deficit 

        Muscles weakness 

                Rhomboids 

                Rotator cuff muscles 

                Pectoralis Major 

                Deltoid 

                Wrist Extensor 

                Finger Extensor 

                

    Q : What is your Diagnosis ? 

     A: Erb's Palsy 

    Q: Tell more about Erb's Point ? 

     A: C 5 Nerve root 

           C 6 Nerve root 

            two divisions of upper trunk 

            dorsal scapular nerve 

            nerve to suvclavius 

        Q:  How do you investigate ? 

            X-ray of shoulder joint - AP/ LAT - to assess joint position 

            CXR - to see involvement of Diaphragm 

            Electrophysiology - NCS and EMG 

            CT scan of shoulder joint to see glenoid retroversion 

        Q: What are different treatment options ? 

                Early Presenter 

                    Neurolysis - lesion in continuity ( action potentials along nerve )

                    Primary Repair 

                    Nerve Grafting 

                    Neurotization - Oberlin 

                 Later Presentation 

                    Tendon transfer 

                            Saha - Trapezius to Supraspinatus 

                     Release (steindler )

                   Derotational Osteotoy of Humerus is important if there is excess retroversion and shoulder                     dislocation.            

                    

    Please see the role of NCS and EMGs in Brachials Plexus Injury. 

    

Also check 

https://orthonp.blogspot.com/2020/04/algorithm-6-for-osteonecrosis-of.html

Please give comments what were missing and how can I improve . 

I will be thankful.