1. Nanthini S ThyeCheeKeong Lynette Lee NurNadiatulAsyikin NursheilaIzrin Oon Li Keat HurulAini CPC OrthopaedicsWITH PROF. RAZIF ALI

3. 25 year old motorcyclist

4. Thrown off in a collision with a lorry

6. Question 1: In the Accident & Emergency Room while waiting to be admitted to the ward, describe FIVE (5) other procedures / actions you would do as part of treatment or investigation not mentioned above? (10 marks)

7. Continuation of the primary survey Disability (D) of the central nervous system Basic neurologic assessment with AVPU score: A – Alert V – Responds to verbal stimuli P – Responding to painful stimuli U – Unconscious Pupil size, inequality and reactivity to light GCS score

8. Continuation of the primary survey Exposure/Environmental control/X-Rays (E) Full exposure of the patient Assess from head to toe for injuries not recognized and managed Keep patient warm

9. IMAGING

10. X-rays: Cervical spine: lateral view of C1-T1 Chest : Anteroposterior view Pelvis : Anteroposterior view Focused abdominal sonography for trauma (FAST) scan on ‘5Ps’: Perihepatic – liver lacerations Perisplenic – splenic lacerations and rupture Pelvic – free fluid e.g. haematoma Pleural – haemothorax, pneumothorax Pericardial – pericardial effusion

11. Adjunct to primary survey Vital signs Oxygen saturation e.g. pulse oxymetry, blood gases Electrocardiography Urine catheterization – hourly urine output Nasogastric aspiration output

12. Secondary survey Complete history and physical examination Each region of the body to be fully examined: Chest Abdomen Pelvis Limbs Reassessment of all vital signs

13. Head Check for bruising, swellings Look for signs of basal skull fracture: Battle’s sign Racoon’s eyes Examine nose and ears for CSF leakage Pupil size and responsiveness

14. Chest Respiratory distress - Grunting, stridor Bruising and skin imprinting Mediastinal shift Penetrating injuries

15. Abdomen and pelvis External injuries Abdominal distension by gas or fluid Tenderness and guarding Bleeding from urethral meatus Presence of palpable bladder PR exam: blood, high-riding prostate, anal tone

16. Limbs Check the neurovascular status of each limb Analgesia – orthopaedic injuries are extremely painful Correct obvious deformity by temporary splinting

17. Name of procedure and Purpose

19. To prevent or reduce muscle spasm

20. To immobilize a joint or part of the body

22. Place patient in supine position

23. Record baseline neurovascular observations:

24. Pulses

25. Skin colour and temperature

26. Capillary refill time

27. Movement of joints

28. Swelling and sensation

29. Observe affected limb for any:

30. Wounds

31. Swelling

32. Infection

37. LOCAL ANAESTHESIA Inject local anaesthetic into the skin, subcutaneous tissue, and periosteum of both sides, making sure it goes under the periosteum.

38. Bohler’s Stirrup

39. Cord/ Rope is then attached to the pin’s holder and passed over a pulley, and fixed to a weight. The weight may pull the patient out of the bed, thus need to exert countertraction by raising the foot off his bed.

41. Infection of the pin tract

43. Due to prolonged bed rest

44. Thromboembolism

45. Decubiti

46. Pneumonia

49. 9) The problem you suspected in QXN (8), describe 4 other symptoms and/or signs would you look for ? 6 “P”s? use them as criteria is Not reliable Only pain & paraesthesia useful The rest are uncommon or late signs Eg. Paralysis or even muscle weakness indicate irreversible muscle damage

50. Symptoms Pain out of proportion to apparent injury (early and common finding) Persistent deep ache or burning pain Paresthesias (onset within approximately 30 minutes to 2 hours of ACS; suggests ischemic nerve dysfunction)

51. Signs Pain with passive stretch of muscles in the affected compartment (early finding) Tense compartment with a firm "wood-like" feeling Diminished sensation (two point discrimination found to be earliest)

52. Late signs Pallor from vascular insufficiency (uncommon) Muscle weakness (onset within approximately two to four hours of ACS) Paralysis (late finding)

53. 10) What first aid in the ward can you immediately give after you suspect the problem in QXN 8? relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed Maintain perfusion: Hypotension reduces perfusion, exacerbating tissue injury, and should be treated with intravenous isotonic saline. The limb should not be elevated. Elevation can diminish arterial inflow and exacerbate ischemia [62]. Analgesics should be given and supplementary oxygen provided. Further research

55. Capillary blood flow becomes compromised at 20 mmHg. • Pain develops at pressures between 20 and 30 mmHg. • Ischemia occurs at pressures above 30 mmHg. Traditional recommendations for decompression include absolute pressure readings above 30 mmHg [49], or above 45 mmHg [1]. The delta pressure is found by subtracting the compartment pressure from the diastolic pressure. Many clinicians use a delta pressure of 30 mmHg to determine the need for fasciotomy. Others use a difference of 20 mmHg [15].

59. PATHOPHYSIOLOGY ↑ Compartmental volume (↑ fluid content) ↓ Compartment volume (constriction of the compartment) ↑ INTRACOMPARTMENTAL PRESSURE Due to inelasticity of fascia venous outflow is reduced (obstruction) oedema Inadequate venous drainage But early-Lymphatic Drainage compensate Vascular congestion Muscle and nerve ischaemia,necrosis Further ↑ intracompartmentalpressure (venous pressure ) ( arteriovenous pressure gradient) ↓ capillary perfusion Compromise arterial circulation (late)

60. Compartment Syndrome:Sequela After Initial Injury Tissue damage- irreversible tissue death within 4-12 hours permanent disabilities can develop from undiagnosed compartment syndrome Amputation- sometimes tissue beyond repair and only measure to prevent gangrene and death is amputation

61. Muscle infarcted Replaced by inelastic fibrous tissue ( Volkmann’s ischaemic contracture) Necrosis of the nerve and muscle within the compartment Vicious circle that Ends after ~12 hours Nerve -capable to regenerate

62. 12) If the problem still continues despite first aid in QXN 10, elaborate what would you do?

63. Fasciotomy Fasciotomy -definitive and only treatment for acute compartment syndrome (ACS) If intra-compartment pressure > 40mmHg Immediate open fasciotomy Morbidity from delay is significant, so the operation should be performed immediately. The wound should not be stitched until a post-surgical assessment has been done at 48 hours. subsequent skin grafts may be needed for successful healing

64. Cross section of a forearm.Palm up.

66. the thick, fibrous bands that line the muscles are filleted open, allowing the muscles to swell and relieve the pressure within the compartment Depending upon the amount of swelling (edema), a second operation may be required later to close the skin after the swelling has resolved. If muscle necrosis, do debridement

67. Hyperbaric oxygen -considered as an adjunct treatment after surgery to promote healing and reducing repetitive surgery Treatment will also be directed to the underlying cause of the compartment syndrome try to prevent other associated complications including kidney failure due to rhabdomyolysis

68. 13) You did a secondary survey, he complained of pain in left hip; you found he was tender in the left iliac region.What investigation will you order ? ( 1 mark ) ANTEROPOSTERIOR RADIOGRAPH OF PELVIS VITAL SIGNS

69. Anatomy of the pelvic bone

72. 14) What did the investigation in Figure 2 show ? ( 1 mark ) ISOLATED FRACTURE OF LEFT ILIUM WITH INTACT PELVIC RING

73. 15) IN THE SAME NIGHT after admission to A&E ( 10 HOURS after admission ), his pulse rate became 140 beats a minute and blood pressure became 70 / 40 mm Hg. He looked pale, there is pallor of conjunctivae and sweaty palms and forearms but he is still conscious. Explain briefly what pathophysiology may be happening here.(2 marks) Tachycardia Hypotensive Anaemic Sweaty palms * HYPOVOLAEMIC SHOCK(CLASS III) PELVIC FRACTUREBLOOD VESSEL INJURYBLEEDINGHYPO VOLAEMIC SHOCK

76. 16) Name 3 investigations / actions / procedures you would do to stabilize the above situation.( 3 marks) Resuscitation: a)Vascular access:Insert TWO large bore cannula,Arterial line? b)Blood investigation c)Fluid therapy,oxygen Stabilization of the fracture: -pelvic binder/external fixator Repeat FAST scan Refer to orthopaedic team for further management of the fracture

77. 17) Name 3 investigations / monitoring procedures to help you know that you really stabilized the above problem adequately.( 3 marks) a)Vital signs,Pulseoxymetry and CVP monitoring if available b)ABG C)CBD-urine output monitoring

78. The intended operation on the femur was delayed… On DAY 3 after the accident, the patient was noted to have ↓ level of consciousness in the ward round

79. Name 1 diagnosis you suspect & what other 4 symptoms and/or signs would you look for

80. Fat Embolism Presence of fat globules obstructing arteries in the lung parenchyma & peripheral circulation after long bone or other major trauma More frequent in closed than in open # Incidence ↑ with no. of # involved Can occur in relation to other trauma Pathogenesis: mechanical & biochemical theory

81. GURD’s Criteria for Diagnosis Major Axillary or subconjunctivalpetechiae Hypoxaemia PaO2 <60mmHg CNS depression disproportionate to hypoxaemia Minor Tachycardia >110bpm Pyrexia >38.5 Retinal emboli on fundoscopy Fat globules in urine and sputum Increased ESR, decreased haematocrit and platelet For diagnosis, at least 1 MAJOR and 4 MINOR criteria must be present

82. 4 Symptoms and/or Signs Respiratory distress: SOB CNS abnormalities: Confusion, restlessness, coma Changes in V/S: ↑ temperature, ↑ PR Petechiae: neck, chest, axilla, subconjunctiva

83. Elaborate what investigations would you do?

84. Clinically: -tachycardia>110bpm, tachypnea>30bpm, pyrexia>38.5◦ _ confused / restless - petechiae Lab Ix: - ABG (PaO2<60mmHg) - FBC: ↓ hematocrit, thrombocytopenia - LFT, RP, serum electrolytes, ↑ ESR - Urine & sputum for fat globules

85. IMAGING

86. Chest radiograph: may be normal / snow-storm appearance / diffuse, ground glass appearance Head CT-evidence of microvascular injury Spiral CT Others: -ECG, TEE -D-dimers -ventilation/perfusion scan

88. What further treatment would this patient receive?

89. Supportive Mx Maintenance of adequate oxygenation & ventilation Maintain stable hemodynamics Fluids & blood products as clinically indicated Prophylaxis of DVT & stress-related GI bleeding Nutrition

90. The right shoulder When En. M recovered from the operation and ICU, he began to ambulate. He complained of a right shoulder problem when examined as shown in Figure 3A and 3B

91. Figure 3A Figure 3B

92. Question 21 Name ONE clinical test which describe the method of examination shown in the figures Shoulder impingement test

93. Question 22 Name TWO diagnoses possible for the above problem 1. Rotator cuff impingement 2. Rotator cuff tear

94. The rotator cuff muscles

95. Rotator cuff impingement “Mechanical impingement of rotator cuff tendon beneath the anteroinferior portion of the acromion, especially when the shoulder is placed in the forward-flex and internally rotated position.” NeerCS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. Jan 1972;54(1):41-50.

96. Neer’s classification Stage I: oedema and haemorrhage Stage II: fibrosis and tendinopathy Stage III: partial or complete tear

97. Clinical features Pain Gradual onset In the anterolateral part of shoulder On overhead movement Worse at night Associated with weakness and stiffness Clicking or creaking sounds during movement Joint instability Positive Impingement test Normal range of movement and strength

98. Rotator cuff tear Partial tears frequently occur with supraspinatus tendinitis Complete tear may result from sudden shoulder strain or as complication of tendinitis or partial rupture

99. Clinical features History of trauma to the shoulder Pain Sudden onset In anterolateral part of shoulder Associated with gross weakness of abduction Joint instability Persistent painful arc of abduction Decreased strength on involved muscle group Decreased range of movement

100. Conservative Treatment NSAIDS Rest, activity modification (avoid irritating activities) Ice on affected area Physical therapy for stretching/ ROM Rotator cuff strengthening and scapular stabilization

101. Physical therapy Strengthening the rotator cuff tendons Stretching and regaining lost motion caused by pain and inflammation Allowing the humerus to be better positioned under the acromion, thus reducing compression of the bursa

102. Examples of physical therapy Cross arm push External rotation on elastic resistance cord

103. Surgical treatment Arthroscopic subacromial decompression to expand the space between acromion and rotator cuff tendons Rotator cuff repair in rotator cuff tears

104. THANK YOU QUESTIONS?

105. HAPPY CHINESE NEW YEARANDHAPPY HOLIDAY!!