ls /home/daytona/workspace/ && ls /home/daytona/skills/docx/

mkdir -p /home/daytona/workspace/elbow-poster && ls /home/daytona/workspace/elbo…

~/elbow-poster/handout.js

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const children = [

  // TITLE BLOCK
  new Paragraph({
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    spacing: { before: 0, after: 100 },
    children: [new TextRun({ text: 'CHRONIC ELBOW DISLOCATION', bold: true, size: 52, color: '1F3864', font: 'Calibri' })],
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  new Paragraph({
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    children: [new TextRun({ text: 'Summary Handout for Poster Presentation', italics: true, size: 26, color: '2E74B5', font: 'Calibri' })],
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    children: [new TextRun({ text: 'Source: Rockwood and Green\'s Fractures in Adults, 10th Edition (2025) — Chapter 40', size: 20, color: '595959', font: 'Calibri' })],
  }),
  divider(),

  // 1. DEFINITION & EPIDEMIOLOGY
  heading1('1. DEFINITION & EPIDEMIOLOGY'),
  bullet('A simple elbow dislocation has NO associated fractures (complex = fracture + dislocation).'),
  bullet('Classified by chronicity:', 'Chronicity: '),
  subbullet('Acute: < 3 weeks'),
  subbullet('Subacute: 3–6 weeks'),
  subbullet('Chronic (missed/neglected): > 6 weeks'),
  bullet('2nd most commonly dislocated joint in adults (rate: 5.2 per 100,000 person-years).'),
  bullet('Almost 50% occur in sports; males most at risk (football); females in gymnastics/skating.'),
  bullet('Adolescent males are the highest-risk group.'),
  bullet('Chronic dislocations are more common in the developing world due to delayed or missed treatment.'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 2. PATHOMECHANICS
  heading1('2. PATHOMECHANICS (O\'Driscoll Mechanism)'),
  bodyText('Typical mechanism: Fall on outstretched hand → valgus + axial + posterolateral rotatory force.'),
  bodyText('Soft tissue injury progresses LATERAL → MEDIAL:'),
  subbullet('Stage 1: Lateral ulnar collateral ligament (LUCL) disruption → posterolateral rotatory instability (PLRI)'),
  subbullet('Stage 2: Capsular disruption (anterior + posterior)'),
  subbullet('Stage 3A: MCL posterior bundle torn → varus instability'),
  subbullet('Stage 3B: MCL anterior bundle torn → complete dislocation'),
  bodyText('In chronic cases: both MCL + LCL are fully disrupted, with scar tissue filling the joint, and flexor/extensor muscle origins detached from distal humerus.'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 3. ANATOMY OF STABILIZERS
  heading1('3. ELBOW STABILIZERS'),
  heading2('Static Stabilizers'),
  twoColTable([
    ['Joint capsule', 'Contributes in full extension + flexion'],
    ['Lateral Collateral Ligament (LCL) complex', 'Primary varus + posterolateral rotational stabilizer\nComponents: Radial collateral, Annular, Lateral ulnar collateral'],
    ['Medial Collateral Ligament (MCL)', 'Primary valgus stabilizer\nAnterior bundle = key (sublime tubercle insertion)'],
    ['Coronoid process', 'Bony anterior buttress against posterior dislocation'],
  ]),
  heading2('Dynamic Stabilizers'),
  bullet('Biceps, brachialis, triceps — provide compressive stability.'),
  bullet('Common extensors → varus stability; Common flexors → valgus stability.'),
  bullet('Pronation stabilizes LCL-deficient elbow; Supination decreases stability.'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 4. CLINICAL EXAMINATION
  heading1('4. CLINICAL EXAMINATION'),
  heading2('4a. Acute Presentation'),
  bullet('Obvious deformity with elbow held in semi-flexion.'),
  bullet('Disruption of epicondyle–olecranon triangle:', 'Key sign: '),
  subbullet('At 90° flexion, medial epicondyle + lateral epicondyle + olecranon = isosceles triangle'),
  subbullet('Loss of this triangle = dislocation/subluxation'),
  bullet('Posterior prominence of olecranon; anterior fullness from distal humerus.'),
  heading2('4b. Chronic Presentation'),
  bullet('Fixed deformity — elbow held in flexion, may not extend.'),
  bullet('Loss of range of motion: reduced flexion-extension + forearm rotation.'),
  bullet('Crepitus on movement.'),
  bullet('Muscle wasting (disuse atrophy).'),
  bullet('Fibrous ankylosis in long-standing cases.'),
  heading2('4c. Neurovascular Examination (MANDATORY)'),
  twoColTable([
    ['Ulnar nerve', 'Most commonly injured — check sensation (ring + little finger), intrinsics (first dorsal interosseous, hypothenar)'],
    ['Median nerve', 'May be entrapped in joint post-reduction — check thumb opposition, palmar sensation'],
    ['Radial nerve / PIN', 'Check wrist + finger extension'],
    ['Brachial artery', 'Compare bilateral radial + ulnar pulses; use arm-arm index if pulses asymmetric'],
  ]),
  heading2('4d. Stability Tests'),
  bullet('Valgus stress test — assess MCL integrity.'),
  bullet('Varus stress test — assess LCL integrity.'),
  bullet('Posterolateral Rotatory Instability (PLRI) test — lateral pivot shift of elbow (O\'Driscoll test).'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 5. IMAGING
  heading1('5. IMAGING'),
  bullet('AP + Lateral + Oblique X-rays — first-line; confirm direction of dislocation, rule out fractures.'),
  bullet('CT scan — if associated fracture suspected (coronoid, radial head, distal humerus).'),
  bullet('MRI — if ulnar nerve entrapment in joint is suspected.'),
  bullet('Key X-ray finding in chronic dislocation:', 'Note: '),
  subbullet('Coronoid process fracture may indicate an unrecognized prior dislocation'),
  subbullet('Heterotopic ossification around joint'),
  subbullet('Joint space obliteration / subchondral changes'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 6. CLASSIFICATION
  heading1('6. CLASSIFICATION'),
  heading2('By Direction'),
  twoColTable([
    ['Posterior / Posterolateral', 'Most common (majority of cases)'],
    ['Anterior', 'Rare; high-energy mechanism'],
    ['Medial / Lateral', 'Uncommon'],
    ['Divergent', 'Very rare; radioulnar dissociation'],
  ]),
  heading2('By Chronicity'),
  twoColTable([
    ['Acute', '< 3 weeks'],
    ['Subacute', '3–6 weeks'],
    ['Chronic / Missed / Neglected', '> 6 weeks — requires surgical treatment'],
  ]),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 7. TREATMENT
  heading1('7. TREATMENT'),
  heading2('Acute — Nonoperative (First Line)'),
  bullet('Closed manipulative reduction under sedation/anaesthesia.'),
  bullet('Assess stability post-reduction fluoroscopically — define safe arc of motion.'),
  bullet('Splint at 90° flexion, forearm in pronation, for 1–2 weeks maximum.'),
  bullet('Early active ROM commenced within 1 week to prevent stiffness.'),
  bullet('Outcomes: >90% achieve good/excellent function.'),

  heading2('Acute — Operative Indications'),
  bullet('Unable to maintain concentric reduction after closed reduction.'),
  bullet('Recurrent dislocation.'),
  bullet('Open dislocation.'),
  bullet('Vascular injury.'),
  bullet('Irreducible dislocation.'),

  heading2('Chronic — Surgical Treatment (Anderson Technique)'),
  boldPara('Anderson et al. (J Orthop Trauma, 2018) — 32 patients, Ethiopia — 97% good/excellent outcomes'),
  bullet('Combined medial + lateral approach — extensor mechanism (triceps) is PRESERVED.'),
  bullet('Ulnar nerve mobilized and protected.'),
  bullet('Flexor + extensor origins and collateral ligaments detached from distal humerus as a sleeve.'),
  bullet('Joint cleared of all scar tissue and heterotopic ossification.'),
  bullet('After reduction: medial + lateral soft tissue sleeves repaired to distal humerus using transosseous sutures.'),
  bullet('No supplemental fixation used.'),
  bullet('Early motion commenced using sling to limit extension.'),
  bodyText('Note: Historical posterior approach with triceps lengthening has been abandoned — triceps preservation improves motion + stability.'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 8. REHABILITATION
  heading1('8. POST-OPERATIVE REHABILITATION'),
  twoColTable([
    ['0–48 hrs', 'Well-padded splint at 90° flexion, forearm pronated. Antibiotics 24 hrs.'],
    ['48 hrs – 1 week', 'Dressing removed, active motion commenced.'],
    ['1–2 weeks', 'Avoid immobilization >2 weeks (stiffness risk). Sutures out at 14 days.'],
    ['6 weeks', 'Passive stretching begins. Static progressive splints if needed.'],
    ['3 months', 'Formal strengthening program.'],
  ]),
  bullet('LCL injury/repair: Pronate forearm; avoid varus stress.'),
  bullet('MCL injury (LCL intact): Supinate forearm for flexion-extension.'),
  bullet('Both MCL + LCL injured: Neutral forearm, limit extension to safe arc.'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 9. COMPLICATIONS
  heading1('9. COMPLICATIONS & PITFALLS'),
  threeColTable(
    ['Complication', 'Incidence / Notes', 'Prevention'],
    [
      ['Residual instability', '<10% after simple dislocation', 'Anatomic repair; active ROM; avoid varus'],
      ['Elbow stiffness', 'Most common long-term problem', 'Early ROM; avoid prolonged immobilization'],
      ['Heterotopic ossification', 'Risk with chronic/delayed cases', 'Early mobilization; NSAIDs prophylaxis'],
      ['Ulnar nerve palsy', 'Most common nerve injury', 'Mobilize + protect ulnar nerve during surgery'],
      ['Median nerve entrapment', 'Post-reduction; may be missed', 'Post-reduction check; MRI if suspected'],
      ['Redislocation', 'If both MCL + LCL not repaired', 'Repair both sides; fluoroscopic check intraop'],
      ['Vascular injury (brachial artery)', 'Rare; high-energy', 'Early ABI measurement; vascular surgery consult'],
    ]
  ),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // 10. OUTCOMES
  heading1('10. OUTCOMES'),
  bullet('Acute simple dislocation: Generally good; >90% return to prior activity.'),
  bullet('<10% report residual instability; some report stiffness and pain.'),
  bullet('Chronic dislocation (surgical): Anderson et al. — 97% good/excellent outcomes with combined approach + early motion.'),
  bullet('Outcome measures used: DASH score, Oxford Elbow Questionnaire.'),
  new Paragraph({ text: '', spacing: { after: 100 } }),

  // KEY PEARL BOX
  divider(),
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  // FOOTER NOTE
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    children: [new TextRun({ text: 'Rockwood and Green\'s Fractures in Adults, 10th Ed (2025), Chapter 40 — Simple Elbow Dislocation', italics: true, size: 18, color: '808080', font: 'Calibri' })],
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