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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) 

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