other methods of immobilization

•What is this . ?

•Enumerate other methods of immobilizations. ?

Thomas leg splint

Other methods of immobilization :-

1-skin and skeletal traction.

2-pop

3-external and internal fixation

4-functional brace

5-fiberglass

1.What is this.

2.its complications.

Skin traction

Wt used maximally 5kg ,1/10 of body wt.

Complications :-

Allergy, neurovascular injury , compartment syndrome, nerve palsy( foot drop ) ,failure of the kit, stiffness ,

abrasion , infection and dermatitis .

•What is this?

•When we are using it.

Gallow’s traction ( body weight <12 kg and age < 2 yr )

Used in

dislocation of lower limb and fracture of lower limbs and pelvis.

Fracture of femur and tibia.

•What is this.

•When we are using it.

Balanced suspension skeletal traction with Thomas leg splint

Used in :

1. Conservative treatment of patient with fracture shaft of femur and tibia .

2. In compound fracture .

Balanced suspension skeletal traction with Thomas leg splint.

When we use this jepsona?

What are the complications?

Used for :

1. Fracture and dislocation . 2. Post operative for stabilization. 3. Acute injury (back slap) . 4. Osteomyelitis .

5. Septic arthritis .

Complication:

Early : 1. Neurovascular injury . 2. Skin ulceration and blistering . 3. allergy .

Late : 1. Joint stiffness , 2. Muscle atrophy.

What is this? What are the uses her? what are the complication ?

External fixation :-transfixing pins to bone distal and proximal to fracture site ,holded externally by external frame.

Indications :-

1-compound fracture.

2-infected non union fracture

3-fracture associated with vessels and nerve damage.

4-in bone lengthening.

5-in pelvic fracture.

6-severe complicated fracture

7-severe multiple injuries

Complications:

Over distraction Reduce load transmission.

Pin tract infection.

.Vascular or neurological injury during insertion.

•Enumerate methods of internal fixations you see.?

•Give 2 complications.?

Method From the left(mode of internal fixation).

1-screw 2-plate and screw 3-intermedullary nails. 4-internal locking nails 5-DHS.

Complications :-

1-infection 2-refracture 3-implant failure 4-non union.

Describe skin changes you see.?

Enumerate other immediate soft tissue complications might occurred in fracture.?

Describe : 1. Bruises . 2. Clot of hematoma . 3. Blistering and patch of gangrene . 4. Sutured wound .

Complication : 1. Muscle and tendon tear . 2. Neurovascular injury .

Other soft tissue complication : 1.Crush syndrome . 2. Compartment syndrome . 3. shock .

1.What is this.

2.How many weight you should apply.

Skeletal traction .

Weight : 1/6 of body weight ( more than 5 kg ).

What is this?

Functional brace

Useful in :1 -allow mobility of joint. 2-prevent stiffness. 3-light wt.\

•Describe this film.

•How you can treat this patient.

-Describe the radiological finding you see:

x-ray of forearm of adult pt ,AP and lateral view showing transverse fracture of radius and ulna at lower third

with overlapping and periosteal reaction.

Enumerate the principle of two? 1 -two views 2-two joints 3-two limbs

4-two injuries 5-two occasions. 6-two tissues.

Rx :-ORIF+physiotherapy.

•Patient sustained trauma to the upper limb.

•What is your diagnosis.?

•Enumerate the principle of treatment of this fracture?

Description :- plain x-ray of arm and forearm and wrist joint of adult pt , lateral view

There is transverse fracture of the proximal one third of ulna subluxation of radioulnar joint and soft tissue

swelling.

Dx:-montagia fracture.

Rx:-OR and IF (restore the length of ulna).

•This patient gave history of fallen from height.

•Why we take 2 films.?

•What is your diagnosis. ?

Why we take 2 films always?

According to the rule of two , two views ,two limbs ,two injuries, two joints, two occasions , two tissues.

To compare and to find associated injuries.

DX : wedge fracture of the vertebra.

•How many views you can see.?

•Enumerate others with there benefits. ?

Plain x ray: AP & lateral view showing circular opacity in front of elbow joint.

Other views on x ray

-axillary viewposterior shoulder dislocation.

-axial view

-sky lineknee joint

-oblique viewscaphoid fracture.

•What is this?

•What are the methods of stoppage bleeding in such patients.?

Open or compound fracture .

Method : 1. Clean dressing and pressure . 2. Torniqute proximal to fracture and tight enough to close vessels .

3. ligation of the vessels .

•How many types of missile inquire you know. ?

•What is the main pathophysiologic changes that happened.?

High velocity missiles”>663m/sec”

Low velocity missiles”<600m/sec”

Steps of any bullets injury:-

1.wound”laceration of skin”

2.Shattering of bullet احتمال نلاقيها بمكان بعيد عن الاصابة

3.Cavitation :-propagation of energy inside the wound.

4.Shock wave:-faraway from bullet path.

Describe this effect.

When it has been happened?

Shock wave phenomena .

1. External fixation .

2. Comnnitted fracture .

•This female has been fallen on the ground .

•What is your diagnosis?

•What are the main clinical signs in this case you might see?

Dx:- femoral shaft fracture.

Description :-extensive bruises , ecchymoses ,of the Rt arm of this female pt.

Clinical sign:-wrist drop.


•What is the main clinical sign in this fracture you check for?

•How you can performed it?

Description :-comminuted fracture of the shaft of humerus with lateral displacement of

the pieces.

Wrist drop

By asking the pt to do dorsiflexion of wrist and fingers.

•This patient unable to dorsiflex his wrist.


WRIST DROP . ( RADIAL NERVE INJURY).

•How many types of nerve injure you know?

1. Neuropraxia : temporary loss of nerve function caused by compression on the nerve .

2. Axonotamesis : rupture of tendon with intact nerve sheath caused by pressure or crushing.

3. Neurotamesis : complete severance of a peripheral nerve ( degeneration of n fibers distal to point of

severance slow nerve regeneration ).

•This child fallen on the ground. presented with this deformity.

•Describe it?

•Mention main clinical sign you check for?

S – shape deformity ( transvers supracondylar fracture with posterior displacement and overlap ).

Clinical sign : 1. Radial pulsation and capillary refiling .

2. ulnar , radial , median n ( sensory and motor ).

Describe this deformity?

Mention other complication might occur in supracondylar fracture?

Dx:-cubits Varus deformity "gunstock deformity”.

Complication :

Early : 1. Vascular damage ( compartment syndrome ). 2. Nerve damage ( ulnar and median ) from operation .

Late : 1. Malunion. 2. Joint stiffness of myositis ossification .

•This patient had fracture radius and ulna. Treated by bone setter. he developed complication from bad

immobilization>

•What is the main complication occurred?

•What is the cause?

Claw hand deformity ( volkmanns contracture )

Complication :

Wrist ( flexion ) … metacarpoharyngeal joint ( extention )….. phalynx ( flexion ).

Causes : ischemia of flexor muscle.

•This is fasciotomy has been done for this patient?

•why we use it?

To relieve compartment syndrome

Done if 3 out of 5p become +ve.

This is an x ray for elderly patient fallen on the ground, With painful hip.


•What is the type of fracture here?

Fracture of neck of femur .

Intra capsular and displaced .

This patient treated conservatively with pop.


•Do you agree about this alignment?

Dx :- oblique and displaced fracture of tibia and fibula

No ,I don’t agree.

•This patient gave a history of acute osteomyelitis.

•What is this late complication?

•Give an example of immediate complications might happened?

Dx:- Rt genu Varus deformity.

Immediate complication : 1-septic arthritis. 2-suppurative arthritis.3-persistent infection 4-growth disturb.

•This patient had history of hemoptysis .developed pain in the thigh.

•Describe bony changes in the femur?

•What r diagnosis?

Description :- Oval osteolytic lesion with no periosteal reaction developed in the upper

part of the rt femur.

Dx:-bronchogenic ca with secondary bony metastasis.

•This patient fallen on the ground. developed sever pain and inability to move his upper limb.

•What are the clinical signs that you find in this patient?

•What investigation needed to confirm diagnosis?

Anterior shoulder dislocation .

1. The patient support his arm with other hand .

2. Visible or palpable bony mass below the clavicle .

Investigation : x-ray ( AP view , lateral view and axillary view ).

•Describe the radiological changes in this x ray.

•What is the complications associated with this problem?

Anterior shoulder dislocation

Axillary nerve injury with wrist drop as complication

Presentation :-the pt support the arm with the other hand ,palpable or visible bony mass below the clavicle.

•Enumerate methods of reduction for anterior shoulder dislocation ?

•Describe Kocher's method as in this patient.?

1. Stimson method . 2 . Hippocratic method

3. Kocher's method : under G.A with assistant do counter traction eith elbow flexion at 90 then lateral

rotation ,no traction and adduction.

•Describe this method of examination?

•When it was used?

Two finger method .

To check for dislocation of head of radius .

•What problem this way of baby holding lead to?

•How you reduce it?

Pulled elbow ( common problem in children ).

Sublaxation of the head of radius and forearm hold in pronation ,extension and resistance any supination

because of pain .

Reduction : forceful supination then flexion of elbow .

Describe the clinical and radiological changes seen in this patient?

Mention its complications?

Dislocation of elbow .

Clinically : 1. Patient support his forearm with elbow in slight flexion 2. loss of normal contour. 3. Loss of

normal relation to olecranon .

Complication : early (( vascular ( brachial a ) and nerve (ulnar , median) injury )).

Late ((stiffness and myositis ossification )).

•This is an x-ray for a patient fallen on outstretched hand.

•Describe the direction of distal piece displacement?


Smith fracture .

Transvers fracture of the distal end of the radius and anterior displacement and distal segment.

Describe this deformity?

Describe the radiological changes?

What is your diagnosis?

What are the complication ?

Dinner fork deformity .

Transverse fracture of the lower end of radius with posterior displacement of distal segment .

Dx : colle's fracture .

Complication :

Early : 1. vascular injury (radial artery). 2. Nerve injury ( median nerve ).

Late : 1.malunion . 2. Non-union . 3. Delayed union . 4. stiffness . 5. Suduck's dystrophy . 6. Tendon rupture.

•This patient fallen on out stretched hand with painful snuffbox.

•Describe the radiological changes?

•how you can hold this fracture?

By (AP , lateral and oblique view ) transverse fracture of the middle scaphoid bone .

Put P.O.P in glass hand position for about 6 wks then remove the P.O.P and take an x-ray if not unit repeat it

again for another 6 wks .

What is this?

How you treat this patient?

What causes ?

Dx :-mallet finger(sudden flexion injury ,the terminal phalanx droops and cannot be straight)

Rx:-by cast and hyperextension of distal phalanx with P.O.P for 6 wks .

Cause : Cut in extensor tendon .

•Describe this deformity?


Foot ( pointed downward ) …. Heel ( inverted ) ….. fore foot ( twisted ).

Dx : club foot deformity (Tulips equine Varus) .

•How you describe this clinical problem?

•What are the clinical features might occurred?

Dx : hallux valgus.

Description :-lateral angulation of big toe ,with Varus angulation of first metatarsophalangeal joint(BUNION).

Features : 1. Pain . 2. Bursitis . 3. Over riding of toes.

Rx:-if severeosteotomy.

Mildconservative (wear suitable shoes).

•How you describe this type of fracture pelvis?

•What should you do in case of possibility of urethral injure?

Open book fracture (stable or unstable ).

Describe : A gap is formed by between 2 pubic bones due to their separation .

We should do aspiration of the bladder after doing investigation :

1.cysto scope .

2. cysto gram.

3. urethrogram.

•This patient sustained dashboard injure.

•What type of injure might developed?

•Describe the clinical findings?

Dx: Dashboard injury: post dislocation of the hip.

Presentation:-beauty queen posture(leg is short ,adducted ,internally rotated and hip flexion ),severe pain.

Rx:-Reduction under GA+ABCDE.

Immobilization for 2 wks.

•Describe the clinical sings in this patient?

•How you reduce the hip?

Presentation:- leg is short ,adducted ,internally rotated and hip flexion.

Rx:- 1. Reduction under GA . 2. Traction of line of lower limb . 3. Gradual flexion of hip and knee to 90 and at

90 degree flexion ( increase traction with little rotation ) then skin traction for 3-4 wks .

What type of fracture might lead this way of fallen on the ground?

Why we use this type of fixation in this patient?

Fracture of neck of femur .

Rx : for early immobilization ( partial hip replacement ).

•Those are common site for skin changes developed in bed ridden elderly patient with fracture neck femur.

•What you call this problem?

•Mention other problems might developed in such patient?

Bed sore .

Other problem > general : 1. DVT . 2. P.E

Local : 1. Non union . 2. Fracture shaft of femur .

•This 60 years old female fallen on the ground with painful hip.

•Describe it ?


Description ( Laterally) : Ecchymosis and Bruises on the upper thigh .

Dx : fracture of femoral neck ( extra capsular type ) .

•Describe this radiological findings?

•What you call this type of fracture holding?

Description : x- ray ( AP view ) show : fracture of the head and proximal part of femur with soft tissue swelling

and displacement .

Called : inter trochanter fracture of neck of femur .

This screw called : Dynamic hip screw .

•Describe the knee changes in this patients?

•Mention 3 causes of acute knee joint swelling?

Mild Varus deformity with swelling of the Rt knee joint.

Dx:- RA, OA , infection.

•This is posterior knee joint swelling


•Mention other causes of posterior swelling?

Dx:-Baker’s cyst.

Causes:-idiopathic/intra-articular pathology(meniscal tear)/RA/synovitis ,lipoma, abscess, bursa .

Rx:-if asymptomaticleave alone.

Symptomaticsurgical removal or aspiration.

Describe this pathology?

What you advise for managing this patient?

Description :-huge knee swelling with dilated veins, in a young, cachexic pt.

DX:- Tumor of bone.

we can diagnose it :-clinically ,X ray, CT , MRI.

Rx:-amputation.

•This patient had fever and swelling around the knee.

•Describe the clinical finding?


Description :-sinus discharge is present with red, circular area ,edematous ,muscle atrophy.

Investigation:-culture .

Dx:-chronic osteomyelitis, T.b .

•What is this ?

•Define it?

•Mention it causes?

Geno valgus ( knock knee): the distal end of the lower limb is displaced a way from the midline.

Causes : 1. Idiopathic . 2. Rickets . 3. R.A or O.A . 4. Fracture of lower femur and upper tibia with mal union.

•What is this ?

•Define it?

•Mention it causes?

Blount disease :-genu Varus deformity((bow leg))“bilateral” the distal end of lower limb displaced toward

midline

Etiology:-1. Idiopathic . 2. Blount disease 3. Hereditary 4. O.A .

Rx:- early:-bracing. Late osteotomy.

DDx:-Perth's disease.

•This is superior view for the exposed knee.

•Describe the pathology you can find?

•Mention a test to confirm your diagnosis ?

Meniscal injury :post horn “mostly affected in injuries”.

Mechanism of injury:-sport injury:-twisting of semi flexed knee

Peripheral zone of meniscus has good blood supply, while posteriorly: poor blood supply,

mid zone:- no blood supply.

Mc murry test .

•How you call this method of knee examination?

•When you can used it?

Mc murry test

Apply distraction test.

•Describe this radiological finding?

•How you can confirm clinically that this patient had such a problem?

Patellar fracture with displacement

Rx: open reduction and internal fixation by tension wire .

•Metaphyseal site of long bone is the common site for osteomyelitis development.

•Mention the cause of this site of predilection?

Causes : 1. non anastomosing terminal branch .. 2. Vascular stasis .. 3. Presence of non- organic material .

4.more labia to trauma . 5. Low rate of phagocytosis .

•What is this?

•Define it?

Ganglion :- well defined cystic swelling in the dorsum of the wrist rise from cystic

degeneration of in the joint capsule or tendon sheath .

Most common site:-scapholunate ligament.

•This is primary way of limb holding.

•Mention other methods of limb holding in fracture?

Lay people method of casting which is wrong as the proper method for POP principle:-

1-should involve the joint above and below the fracture.

2-not too tight.

3-not too loose.

Others :1. traction ( skin . skeletal) . 2. cast splintage . 3. Functional brace.

•Describe the clinical finding of this patient?

•If you discover him early how you can treat him?

Dx :- Hand infection.

Description :- swelling of the left hand,shiny skin ,red,loss of function, spindle shaped fingers with Bouchard

nodules in the index of rt hand.

Rx:-rest ,warming , Elevation , ABs ,Drainage if late.

•What is this?

•How you remove such a ring?

Swollen index finger and infected ring, with bruises and trauma to index finger

Rx :-cut it.

•This patient presented with this changes.

•Describe it ?

•What are the possible differential diagnosis?

Description :-Swelling +redness +warm +loss of function of the Rt leg with discharging sinus: pink to red

discharge.

Ddx :-

1-chronic osteomyelitis

2-T.b

3-acute suppurative arthritis.

•Describe this knee x-ray?

•What should you do before treating such patient?

Dx :- foreign body intra-articullarly.

Do lateral view then removal

Indications of removal?

1-symptomatic.

2-causes irritation.

3-interferes with functional range of movement.

4-cosmetic.

•This patient in forward bending test for spine.

•Describe what you see clinically and in x-ray?


Adam test to differentiate between

Functional or structural scoliosis .

If increasedstructural.

If reducedfunctional.

And clinically : hump , lateral deviation of the back

On x-ray : lateral tilting , rotation and rib deformity

Diagnosis : juvenile idiopathic scoliosis.

•You are going to examine such an infant.

•Mention tests that had been used?

•Describe one of them?

Ortolani's and barlow's test.

Ortolani's test :baby thigh are held with thumb medially and finger on greater trochanter then flex the hip to

90 then gently abduction up to 90 degree.

•This is femur with internal fixation.

•What you can see?

•Mention other complication might occurred in internal fixation?

Shaft of femur fracture with broken internal fixation device (plate and screw).

Complication : 1. Non union . 2. infection . 3. Fracture of implant.

•This patient presented with sever back pain?

•What is he doing?

•What you call this test?

The patient try to flex the back by doing forward movement .

1. Schober’s test. 2. straight leg raising test.

•This patient had chronic history.

•What you can see in this hand?


Description : swelling , bilateral symmetrical synovitis, subluxation, dislocation ,wasting ,ulnar deviation,

Bouchard nodes ,swan neck ,boutonniere deformity .

Dx : R .A .

•What is the radiological finding you see?

•Mentioned way of radiological confirmation?

DDH

Dx:-dysplastic acetabulum, displacement of femur.

Other methods of Dx:- US ,dynamic assessment.

•This patient sustained trauma to the leg.

•Describe this finding?

•How you confirm the diagnosis?

Fracture tibia (closed fracture)with bruises ,ecchymosis of the overlying skin, dressing

over the it foot.

Confirm by : x-ray .

•This patient presented with 10 days ,fever, swelling of lower thigh.

•Describe the clinical finding?

•How you should treat this patient?

D x :-acute osteomyelitis.

Pt is toxic ,dehydrated, ill pt, with pus discharging from the sinus, red color (bloody)

from the it knee medially .

Rx : general support , antibiotics , surgical drainage and blaster .

•Describe radiological finding for such a patient how had fever and swelling of lower thigh?

•Mention differential diagnosis?

Description:-periosteal reaction + onion peal appearance.

DDx:- owing sarcoma Or osteosarcoma.

•This is an x –ray for a patient how had history of chronic sinus discharge.

•Describe this finding?


Dx:-Chronic Osteomyelitis.

Description :-soft Tissue swelling With involcrum

Rx: sequesterectomy With bone flap or Myocutaneous flap.

•This patient sustained car accident .

•Describe the radiological finding?


Rib fracture and open book fracture

M .of injury:-multiple trauma.

•This is an x – ray for a child sustained trauma to the lower limb


•How long the duration of healing you suspect?

Femoral shaft fracture

Rx(in child till 5yrs of age)=POP spika.

Rx (after5yrs of age)=Internal fixation by flexible or rigid nail.

•This is an x ray for an adult man.


•What is the important early complication might developed?

Fracture tibia and fibula (transverse fracture).

Complication : vascular injury and nerve injure .


•What are the method of managing this patient?

Bi malleolar fracture

M. of injury:-supination and external rotation

Rx :-OR and IF

If being unilateralConservative cast.



Fibular fracture

•Those two patients presented with such a chronic swelling with history of weight loss.

•Describe it?

•What is your possible diagnosis?

Description :-an edematous swelling of the leg below and lateral to knee .

Ddx:- trauma ,tumor ,infection.



Dx :-exostosis ( osteochondroma )

Description :-single well defined bony outgrowth covered by cartilage with sessile base.



Well defined central lytic lesion with fallen fragment sign at the proximal humerus line

by thin fibrous tissue .

Dx:- simple bone cyst

•Describe this clinical finding ?

•What are the causes of this problem?

Description :-loss of big toe ,dry gangrene, ecchymosis ,bruising in RT foot .

Causes : D.M , Raynaud disease , sever burn .



Rain drop appearance

Dx:-multiple myeloma.

Presentation :-backache + RF + Old age.



Subarticular lytic lesion ,ec-centric , in the metaphysis with thinning of cortex .

Dx:-giant cell tumor.



ill defined osteolytic lesion with Onion peal periosteal reaction (( owing sarcoma or osteomyelitis )).

•Describe the clinical finding in this hand?

•How you can describe the x –ray findings?

Ollier’s disease =enchondroma

Description : fusiform swelling in the proximal phalanx and middle finger .

x-ray :

•What you call this method of bleeding stoppage?

•What precautions you should take in?

Tourniquet (( cause ischemia of U limp in 1- 1.30 hour and in lower limp 2 hour ))

Precaution :

(( Gallows traction ))

other methods of immobilization

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