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)