Colle's fracture: Diagnosis and Complications


It is the most common wrist fracture which usually follows a fall on outstretched hand. The fracture occurs within 1 inch of the distal end of the commonest fractures of middle and old age (common in osteoporotic bone). The fracture occurs at cortico-cancellous junction of the bone.

Clinical features:

  1. Swelling, ecchymosis, tenderness
  2. "Dinner fork" deformity
  3. Assess neurovascular status (carpal tunnel syndrome)

X-ray: Distal fragment is -
  1. Dorsally displaced and dorsally tilted
  2. Radially displaced and radially tilted
  3. Supinated
  4. Impacted
  5. Shortened (radial styloid normally 1cm distal to ulna)
  6. +/- fracture of ulnar styloid
Complications:
  1. Median nerve injury
  2. Malunion
  3. Rupture of extensor pollicis tendon
  4. Complex regional pain syndrome

Boxer's fracture: Fracture of neck of 5th metacarpal


Boxer's fracture refers to the fracture of neck of 5th metacarpal bone (little finger) and often follows a blow with the fist. There may be local swelling, with flattening of knuckle. X-rays show an impacted transverse fracture with volar angulation of the distal fragment.

Non-Operative treatment:
A flexion deformity of up to 40 degrees can be accepted; as long as there is no rotational deformity (may have cosmetic deformity but good function). The hand is immobilized in a gutter splint with the MCP joint flexed and IP joint straight until discomfort settles - a week or two - and then the hand is mobilized. The little and ring fingers are buddy-taped to prevent malrotation.

Operative treatment: 
If the fracture needs reduction, this can be done under a local block. The reduced finger is immobilized using the same technique as above.

Bryant's triangle


The patient lies supine with the pelvis square, and the limbs in identical position. The Bryant's triangle is formed by:

  1. Anterior Superior Iliac Spine (ASIS)
  2. Tip of Greater trochanter
  3. Junction of perpendiculars from the 2 points above

The triangle should be marked on both the sides and each side of the triangle is compared with its counterpart on the normal side. The distance between the tip of greater trochanter and the junction of 2 perpendiculars measures supra-trochanteric shortening.This may occur due to:

  1. Dislocation of hip
  2. Central fracture - dislocation of hip
  3. Destruction of head or acetabulum or both
  4. Fracture of the neck of femur
  5. Coxa-vara deformity of the hip
  6. Malunited intra-trochanteric fracture

Barton's fracture


Barton's fracture is the intra-articular fracture of distal radius resulting from shearing force. It can be classified as dorsal or volar depending upon location of fragment. The diagnosis can be made by clinical presentation and radiologic evidence. The fracture is treated by closed reduction and the forearm is immobilized in a cast for 6 weeks. Open reduction and Internal fixation is required in those cases where closed reduction fails.

Bimalleolar fracture: Danis Weber A


Fractures of the ankle involve ipsilateral ligamentous tears or bony avulsion and contralateral shear fractures. The pattern of  fracture is determined by the mechanism of injury. Avulsion fractures are transverse and shear fractures are oblique (if pure inversion/eversion) or spiral (if rotational).

The X-ray above shows ankle joint of right lower limb. An avulsion (transverse) fracture can be appreciated on the lateral malleolus and a shear (oblique) fracture can be seen on the medial malleolus. This is a Danis-weber Type A (infra-syndesmotic) ankle fracture which occurs as a pure inversion injury (Supination-adduction according to Lauge Hansen classification). The avulsion of lateral malleolus is below the plafond. Open reduction and Internal fixation (ORIF) is recommended for Bimalleolar fractures.

Median nerve: Course and Innervation


Origin: C5-T1

Course:

  1. Axilla: Starts in axilla
  2. Arm: Runs along with brachial artery - initially lateral to it and later medial to it
  3. Forearm: Enters the forearm between pronator teres and biceps tendon and then travels between Flexor digitorum superficialis and Flexor digitorum profundus
  4. Wrist: Just above wrist, the nerve lies between Flexor digitorum superficialis and Flexor carpi ulnaris
  5. Hand: Enters the hand via carpal tunnel

Motor innervation:

  1. Superficial forearm: Pronator teres, Flexor carpi radialis, Palmaris longus
  2. Intermediate forearm: Flexor digitorum superficialis
  3. Deep forearm: Flexor digitorum profundus, Flexor pollicis longus, Pronator quadratus
  4. Hand: 1st and 2nd lumbricals, Oppones pollicis, Abductor pollicis brevis, Flexor pollicis brevis

Sensory innervation:

  1. Palmar cutaneous branch: Lateral palm
  2. Digital cutaneous branch: Lateral 3 and 1/2 digits on the palmar side and fingertips on dorsal side

Olecranon fracture: Tension Band Wiring


The 2 X-rays in the upper row were performed before the surgery and the lower 2 X-rays were performed after the surgery. It shows transverse displaced fracture of the olecranon process of the left upper limb. The fracture was managed with Open Reduction and Internal Fixation (ORIF) using the teachnique of Tension Band Wiring (TBW).

Distraction or tension interferes with fracture healing. Therefore, tension forces on a bone must be neutralized or, more ideally, converted into compression forces to promote fracture healing. This is especially important in articular fractures, where stability is essential for early motion and a good functional outcome. In fractures where muscle pull tends to distract the fragments, such as fractures of the patella or the olecranon, the application of a tension band will neutralize these forces and even convert them into compression when the  joint is flexed.

As shown in the X-ray above, a figure of "8" wire loop lies on the posterior surface of the olecranon and acts as a tension band when tightened. Approximately, 40mm below the fracture line and 5mm from the posterior cortex, a hole is drilled on the ulna. 2 K-wires are inserted almost parallely through the head of olecranon, directing towards the anteior cortex using drill guide. Long segment of the stainless steel wire is passed through the drilled holes in a figure "8" configuration beneath the triceps tendon around the protruding ends of the K-wires.

Goodsall's rule


Goodsall’s rule can be used to clinically predict the course of an anorectal fistula tract. Imagine a line that bisects the anus in the coronal plane (transverse anal line). Any fistula that originates anterior to the line will course anteriorly in a direct route. Fistulae that originate posterior to the line will have a curved path. An exception to the rule are anterior fistulas lying more than 3 cm. from the anus, which may open in the anterior midline of the anal canal.

Never Defibrillate Asystole


Almost every medical shows out there have that magical thing called "Defibrillator". One grave fallacy in such TV shows is the use of defibrillator (shock) in patients with asystole (flat ECG line). The ACLS has classified asystole as a non-shockable rhythm. This is because defibrillation in asystole is not only fruitless, but also detrimental, eliminating any possibility of recovering a rhythm. Asystole following electrical defibrillation has an even worse outcome than that in a patient whose first documented rhythm was asystole. But, remember that fine ventricular fibrillation may look like asystole and in such cases asystole needs to be confirmed in several leads.

Asystole is primarily treated with CPR (Cardiopulmonary Resuscutation) combined with an intravenous vasopressor such as epinephrine (adrenaline).

Contributor: Sulabh Shrestha

Superficial Cervical Plexus: Anatomy Mnemonic


This is a visual mnemonic for the nerve arrangement of superficial cervical cutaneous branches of cervical plexus. This mnemonic was created only for the ease to remember and may not resemble exact anatomy.

The site of injection for superior cervical plexus nerve block is the midpoint of posterior border of sternocleidomastoid. Assuming this as a center point, the various position of nerves, from north going anti-clockwise is given by mnemonic "GLAST":

  1. 1 o' clock: Greater auricular nerve (C2,C3) - Innervates skin over the parotid gland, angle of jaw and posterior ear
  2. 11 o' clock: Lesser occipital nerve (C2) - Innervates scalp behind and above ear
  3. 7 o' clock: Spinal accessory nerve (XI) - This doesn't belong to superficial cervical plexus and lies deep to the sternocleidomastoid muscle and innervates sternocleidomastoid and trapezius
  4. 6 o' clock: Supraclavicular nerve (C3,C4) - Divides into medial, intermediate and lateral branches and supply sensation over shoulder, lateral neck and anterior upper thoracic wall
  5. 3 o' clock: Transverse cervical nerve (C2, C3) - Innervates skin of front and side of neck (anterior triangle)

All these nerves are also the contents of the occipital triangle of neck. Except spinal accessory nerve, all these nerves crosses superficial to the sternoclediomastoid muscle. In general, the superficial cervical plexus supply the skin of anterolateral neck.

Contributor: Sulabh Shrestha

6 A's of Premedication


Anxiolysis:

  1. Temazepam 20-30 mg
  2. Diazepam 10-20 mg
  3. Lorazepam 2-4 mg

Amnesia:

  1. Lorazepam 2-4 mg

Antiemetic:

  1. Metoclopramide 10 mg oral or iv
  2. Ondanetron 4-8 mg oral or iv
  3. Cyclizine 50 mg im or iv
  4. Hysocine 1mg transdermal patch

Antacid:

  • Oral sodium citrate 30 ml immediately preinduction
  • Ranitidine 150 mg orally 12 hourly and 2 hour preoperatively
  • Metoclopramide 10 mg orally preoperatively
  • Omeprazole 30-40 mg 3-4 hour preoperatively

Anti-autonomic:

  • Anticholinergic: Glycopyrollate 0.2-0.4 mg im
  • Antisympathomimetic: Atenolol 25-50 mg orally or esmolol iv

Analgesia:

  1. Morphine
  2. Pethidine
  3. Fentanyl

Miscellaneous:

  1. Steroids: To patients on long-term treatment or who have received them within the past 3 months
  2. Antibiotics: To patients with prosthetic or diseased heart valves, or undergoing joint replacement
  3. Anticoagulants: As DVT prophylaxis
  4. Transdermal Glyceryl Trinitrate (GTN): To patients with IHD
  5. Eutectic mixture of local anesthetics (EMLA): a topically applied local anesthetic cream to reduce the pain of inserting an IV cannula.



Minimal Change Disease (MCD): Morphology


Synonyms:
  1. Lipoid necrosis
  2. Foot process disease
  3. Nil disease

Gross appearance:
  1. Kidneys are of normal size and shape

Microscopic appearance:
  1. Light microscopy: Normal glomeruli, Lipid in tubules
  2. Electron microscopy: Podocyte foot process effacement, No deposits
  3. Fluorescence microscopy: Negative (no complement/Ig deposits)