===== PAGE 23 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER External Fixators 19 Definition Fracture stabilisation by pins/wires through bone connected to external frame Indications Open fractures (Gustilo II/III) – primary indication Highly comminuted / Pelvic ring / Periarticular fractures Infected non-union / Distraction osteogenesis / Damage control Types Unilateral (Wagner / AO) – most common Bilateral / Delta frame / Circular (Ilizarov) / Hybrid Ilizarov frame Circular / Ring + Tensioned Kirschner wires Distraction osteogenesis at 1 mm/day (0.25mm x 4 times/day) AO fixator Linear / Schanz pins + rod + clamps Quick assembly / Good for temporary stabilisation Components Pin / Wire / Half-pin / Rod / Clamp / Ring Self-drilling / Self-tapping pins Pin placement Safe corridors for each bone – away from NV bundle Tibial: Anteromedial / Femur: Lateral / Radius: Dorsoradial Pin care Daily pin site care with normal saline Watch for pin site infection / Loosening / Osteomyelitis Ilizarov uses Leg lengthening / Deformity correction / Non-union / Bone CORA method for deformity correction loss Distraction osteo Corticotomy (low energy bone cut) fi gradual distraction Consolidation: 2x lengthening period / Protected weight bearing Complications Pin site infection (most common) / Ring sequestrum Refracture after removal / Joint stiffness / NV injury Conversion Convert to IM nail within 2 weeks (reduces infection risk) If >2 weeks: EF to cast then staged IMN Damage control Temporary EF ===== PAGE 24 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Hip Examination 20 Anatomy Ball and socket joint / Most stable joint in body Acetabulum (ilium+ischium+pubis) / Femoral head (ligamentum teres) Blood supply Lateral epiphyseal vessels (main) via medial circumflex Retinacular vessels / Ligamentum femoral teres (minor in adults) Gait Trendelenburg / Antalgic / Shortening gait Attitude Flexion/Adduction/Internal rotation = anterior dislocation Flexion/Abduction/External rotation = posterior dislocation Feel Bony landmarks: ASIS / Greater trochanter / PSIS Tenderness: Joint line / Greater trochanter / Groin Move Flexion 0-120° / Extension 0-30° Abduction 0-45° / Adduction 0-30° / IR 0-40° / ER 0-60° Trendelenburg Weight on affected side fi opposite pelvis drops = POSITIVE HCauses: Weak abductors / CDH / Coxa vara / NOF fracture Thomas test Detects fixed flexion deformity (FFD) of hip HObliterate lumbar lordosis fi non-affected leg lifts = FFD angle Telescoping Pistoning movement in CDH (Congenital dislocation of hip) Piston test / Ortolani / Barlow for infants Shortening True: Neck fracture / CDH / Bone loss Apparent: Adduction deformity / Pelvic tilt Measurement True: ASIS to medial malleolus Apparent: Xiphisternum/umbilicus to medial malleolus Bryant's triangle Lesser trochanter to ASIS (horizontal) + ASIS to GT (vertical) Reduced in neck fracture / CDH (shortened base) Nelaton's line ASIS to ischial tuberosity – GT should lie ON this line If GT above = neck fracture / ===== PAGE 25 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Knee Examination 21 Anatomy Largest and most complex joint / Hinge joint Medial & Lateral menisci / ACL & PCL / MCL & LCL Bursae Prepatellar (housemaid's knee) / Infrapatellar / Baker's cyst (popliteal) – associated Semimembranosus with knee pathology Look Valgus (knock-knee) / Varus (bow-leg) / Recurvatum Swelling: site / Wasting of quadriceps / (back-knee) Scars Feel Temperature / Joint line tenderness (medial vs lateral) Effusion tests: Patellar tap / Bulge sign (small effusion) Move Normal: Flexion 0-140° / Full extension Crepitus / Block to movement (locked knee) Effusion tests Bulge sign (small effusion <30ml): Stroke medial, tap lateral Patellar tap (large effusion >30ml): Press down, feel tap ACL tests Lachman test (ACL): Most sensitive – 20° flexion anterior Anterior drawer test (ACL): 90° flexion, draw pull tibia forward PCL / Ligaments Posterior drawer (PCL): Push tibia backward at 90° Valgus stress (MCL) / Varus stress (LCL) in extension + 30° Meniscal tests McMurray's: Flex/Extend + Rotate + Valgus/Varus stress fi Apley's grinding (prone): Compress + click Rotate fi Pain = meniscal Apley's distraction: Lift + Rotate fi Pain = ligamentous Thessaly test at 20° (most sensitive for meniscal tears) Patella tests Clarke's test: Compress patella + quad contraction fi pain = Patella apprehension test fi patellar PF OA instability / dislocation OA Knee Most common joint disease / Elderly / BMI / Previous injury Me ===== PAGE 26 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Gait 22 Normal gait Stance phase (60%) / Swing phase (40%) Stance phase Heel strike fi Foot flat fi Midstance fi Heel rise fi Toe-off Swing phase Acceleration fi Midswing fi Deceleration Antalgic Shortened stance on painful limb OA / Fracture / Infection / Any painful lower limb pathology Trendelenburg Pelvis drops on unsupported side / Trunk lurches over Causes: Weak abductors / CDH / Neck affected hip fracture / Polio Scissors Cerebral palsy / Spastic diplegia Adductors spastic fi legs cross each other Steppage Foot drop / Common peroneal nerve palsy Exaggerated hip/knee flexion to clear toe from ground Foot slap at heel strike (no dorsiflexor control) CMT / Peroneal neuropathy Waddling Bilateral weak abductors / Bilateral CDH / Muscular Duck-like gait / Bilateral Trendelenburg dystrophy Ataxic Cerebellar (broad base / staggers) vs Sensory (stomping / Romberg positive = sensory ataxia worse with eyes shut) Hemiplegic Circumduction of spastic lower limb Upper limb: Flexed and adducted / Stroke / UMN lesion Parkinsonian Shuffling / Festinant / Difficulty initiating / En bloc turning Flexed posture / Rigidity / Pill-rolling tremor at rest Equinus Spastic/short gastrocnemius fi toe-toe gait CP / Clubfoot untreated / Heel cord contracture Calcaneus Tibial nerve lesion fi heel walking only Loss of plantar flexion Assessment Observe: Approach / Turning / Sit to stand / Tandem GAIT: Gait / Arms swing / Initiation / Turn 26 ===== PAGE 27 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER General Notes – Orthopaedic Viva 23 Fracture def. Break in continuity of bone Classification Open (Gustilo I-IIIc) / Closed / Pathological / Stress Complete / Incomplete / Comminuted / Segmental Healing Primary: Rigidly fixed / Haversian remodelling Secondary: Callus / Enchondral ossification (most common) Callus stages Haematoma fi Granulation fi Soft callus fi Hard callus fi Periosteum is key / Blood supply Remodelling essential Union time Upper limb: 6-8 weeks / Lower limb: 10-16 weeks Cancellous bone faster than cortical bone Complications Immediate: Haemorrhage / Nerve / Vessel / Visceral injury Early: Infection / DVT / Compartment syndrome Late: Malunion / Non-union / Delayed union / AVN / OA Refracture / Volkmann's / Complex regional pain Compartment syn. 6 P's: Pain (out of proportion) / Pressure / Paralysis / HTreatment: Urgent fasciotomy (all Paraesthesia / Pallor / Pulselessness compartments) Non-union Hypertrophic (Elephant foot): Adequate vascularity / Atrophic (Horse's hoof): Poor Movement vascularity / Needs bone graft Pathological # Bone abnormally weak fi fractures under normal load Metastasis / Primary bone tumour / Osteoporosis / Paget's Open fracture Rx IV antibiotics + tetanus + wound cover + external fixation Debridement within 6 hrs (Grade III) / Plastic surgery involvement Volkmann's isch. Compartment syndrome fi muscle necrosis fi contracture 3 C's: Contracture / Clawing of fingers / Callosity ===== PAGE 28 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Surgery Instruments 24 Scalpel handles No. 3 handle: blades 10, 11, 12, 15 No. 4 handle: blades 20, 22, 23 (larger incisions) Blade 10 Large curved: Skin incisions Blade 11 Pointed: Stab incisions / Abscess / I&D; Blade 15 Small curved: Delicate / Face / Paediatric / Plastic surgery Blade 22 Large curved: Major operations / Amputation flaps Scissors Mayo's: Straight/curved – cutting fascia / sutures Metzenbaum: Delicate – dissecting tissue / curved Haemostats Artery forceps: Halsted (mosquito) / Spencer Wells / Kocher's = toothed (holding tissue) / Kocher's Spencer Wells = non-toothed Retractors Self-retaining: Balfour (abdominal) / Travers / Gelpi / Hand held: Langenbeck / Deaver / Weitlaner Army-navy / Ribbon Tissue forceps Toothed (Bonney / Adson) – skin / Dense tissue Non-toothed (DeBakey / McIndoe) – delicate structures Needle holders Hegar's (most common) / Mayo-Hegar / Castroviejo (eye) Mathieu (spring lock) / Webster Diathermy pencil Monopolar / Active electrode Hand controlled – cut / coag buttons Suction Yankauer (oropharyngeal / large cavities) Poole (abdominal – fenestrated) / Frazier (neurosurgery) Laparoscopic Veress needle (pneumoperitoneum) / Trocar & cannula Clip applicator / Endo-GIA (stapler) / Hook / Harmonic scalpel Clip applier Hem-o-lok (polymer locking clips) / Ligaclip (titanium) Used on vessels / bile duct during laparoscopic surgery Harmonic scalpel Ultrasonic energy / Cuts + seals simultane ===== PAGE 29 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Orthopaedic Instruments 25 K-wires Kirschner wires: Smooth / 0.9-2.0mm diameter Temporary fixation / Percutaneous pinning / Guide wire Screws Cortical screw: Fine thread / Lag principle Cancellous screw: Wide pitch / Trabecular bone / Head of femur Cannulated screw: Hollow / Used over guide wire Herbert screw: Headless / Scaphoid fracture / Both ends threaded Plates DCP (Dynamic Compression): Self-compressing oval holes LCP (Locking Compression): Fixed-angle locking screws Blade plate: High angle / Subtrochanteric fractures Reconstruction plate: Contourable / Acetabular / Clavicle IM Nails Kuntscher nail (cloverleaf): Earliest IM nail Interlocking nail: Proximal + distal locking bolts TEN (Titanium elastic nail): Paediatric long bone fractures Expert nail: For complex / osteoporotic fractures DHS Dynamic Hip Screw: Sliding barrel + plate HFor intertrochanteric fractures / Allows controlled collapse PFN Proximal Femoral Nail: IM device for subtrochanteric + IT Two cephalic screws (antirotation) TBW Tension band wiring: Converts tension into compression HUses: Olecranon / Patella / Medial malleolus External fixator Unilateral / Ilizarov / Hybrid / Taylor spatial frame AO / Orthofix / Stryker systems Joint replacement Femoral head (Austin Moore / Thompson) – hemi HTHR: Total hip replacement / TKR: replacement Total knee replacement Cerclage wire Encircling wire around bone – adjunct to IM nailing Long oblique / Butterfly ===== PAGE 30 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER X-Rays 26 Systematic reading Date / Name / Side marker / View / Adequacy Bones / Soft tissue / Joint spaces / Special features CXR reading ABCDE: Airway / Bones / Cardiac / Diaphragm / Everything Trachea central / Cardiothoracic ratio < else 0.5 CXR findings Air under diaphragm: Hollow viscus perforation HDouble bubble: Duodenal atresia / Gastric volvulus Ground glass opacity: ARDS / Pulmonary oedema HHampton's hump / Westermark's sign: Pulmonary embolism AXR reading Gas pattern: SB (<3cm) / LB (<6cm) / Caecum (<9cm) 3-6-9 rule for obstruction Coffee bean sign: Sigmoid volvulus HBird's beak: Caecal volvulus / Sigmoid volvulus on contrast Rigler's sign (football sign): Pneumoperitoneum Laddering small bowel loops: SBO Fracture CXR Pneumothorax / Haemothorax / Pulmonary contusion Flail chest / Widened mediastinum (aortic injury) Hip X-ray Shenton's line: Continuous curve neck femur to superior Disrupted in neck fracture / CDH pubic ramus Density of femoral head: AVN fi sclerosis fi collapse Garden classification (I-IV) for subcapital fractures Knee X-ray Joint space narrowing / Osteophytes / Subchondral sclerosis AP + Lateral + Skyline (patella) / Cysts (OA) Spine X-ray C-spine: All 7 vertebrae + C7/T1 junction visible Atlantoaxial distance < 3mm adults (>5mm = instability) Bone tumour X-ray Zone of transition: Narrow (benign) / Wide (malignant) Codman's triangle / Sunburst pattern: Osteosarcoma Onion peel periosteal re ===== PAGE 31 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Specimens 27 Approach Name the organ / State what you see / Describe Size / Shape / Surface / Cut section systematically Appendix Length 8-10 cm / Width 6-8mm Acute appendicitis: Congested / Oedematous / Fibrinous exudate / Perforation Appendix carcinoid Yellow tumour at tip / <2cm / 95% benign Most common tumour of appendix / Silvery lustre on cut section Gallbladder Cholecystitis: Thickened wall / Mucosal haemorrhage Cholelithiasis: Mixed (most common) / Cholesterol / Pigment stones Carcinoma GB: Polypoidal / Sessile / Infiltrating Scleroatrophic GB: Carcinoma risk Stomach Peptic ulcer: Punched-out / Overhanging edges / Rugal folds Carcinoma: Ulcerating / Polypoid / converge Linitis plastica (leather bottle) Colon Carcinoma: Annular (napkin ring) / Polypoid / Ulcerating FAP: Multiple polyps carpeting entire mucosa Diverticulosis: Multiple outpouchings / Usually sigmoid Hirschsprung's: Narrowed aganglionic segment + dilated proximal Rectum Carcinoma rectum: Annular / Ulcerating / Polypoid TME specimen: Intact mesorectal envelope / CRM assessment Pancreas Pancreatitis: Fat necrosis / Haemorrhage / Saponification Ca head: Hard grey mass / Duct obstruction / Jaundice Liver Cirrhosis: Micronodular (<3mm: Alcohol) / Macronodular HCC: Solitary / Multiple / Venous (HBV/HCV) invasion / Bile staining Hydatid cyst: Daughter cysts / Brood capsule / Ecto + Liver abscess: Anchovy sauce Endocyst (amoebic) / Chocolate brown Spleen ===== PAGE 32 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Sutures 28 Classification Absorbable vs Non-absorbable Monofilament vs Multifilament (braided) CATGUT Collagen from sheep submucosa / Absorbed by Plain: 10-14 days / Chromic: 28 days phagocytosis (chromate treatment) VICRYL Polyglactin 910 / Braided / Absorbed by hydrolysis Loss of tensile strength: 3 wks / Complete absorption: 56-70 days PDS Polydioxanone / Monofilament / Prolonged support H50% TS at 4 wks / Complete absorption: 6 months / Mass closure MONOCRYL Poliglecaprone / Monofilament / Subcuticular / Smooth TS lost: 1-3 weeks / Absorbed: 90-120 days PROLENE Polypropylene / Non-absorbable / Monofilament HVascular anastomoses / Hernia repair / Fascia / Skin NYLON Polyamide / Mono (Ethilon) or Braided (Nurolon) Skin closure / Tendon repair / Nerve repair SILK Braided / Non-absorbable (slowly absorbed in vivo) HExcellent knot security / Ligation of large vessels / GI anastomosis MERSILENE Polyester / Braided / Non-absorbable Cardiac surgery / Tendon repair / Hernia mesh suturing Sizes Larger number = Thinner suture (USP sizing) 0 fi 1 fi 2 (thicker) / 2-0 fi 3-0 fi 4-0 fi 5-0 fi 6-0 (finer) Needle types Cutting: Triangular / Sharp tip – skin Reverse cutting: Third edge on outer convex curve (stronger) Round body (taper): Abdominal viscera / Muscle / Vessels Taper-cut: Fascia / Tough tissue Knot types Square knot: Same direction throws Granny knot (WRONG): Two same-direction throws – AVOID Surgeon's knot: Extra thr ===== PAGE 33 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Solutions 29 NS (0.9% NaCl) Na 154 mEq/L / Cl 154 mEq/L / Osmolality 308 mOsm/L H1st choice: Hypovolaemia / Resuscitation / Hyponatraemia correction Caution: Hyperchloraemic metabolic acidosis (large Hyperkalaemia risk / Renal dysfunction volumes) Ringer's Lactate Na 130 / K 4 / Ca 3 / Cl 109 / Lactate 28 mEq/L HMost physiological / Preferred in trauma / Burns / Post-op Contraindicated: Liver failure (cannot metabolise lactate) Hyperkalaemic patients (K 4 mEq/L) D5W 5% Dextrose in water / 252 mOsm/L / Hypotonic HMaintenance fluid / Hypoglycaemia / Hypernatraemia Colloids Albumin (5%/25%) / Dextran / Gelatin / Starch (HES) For intravascular expansion / Hypoalbuminaemia Hartmann's vs NS Hartmann's: More physiological / Less acidosis / Better for burns NS: Use in head injury (avoid hypotonic solutions) Blood products PRBC: Each unit raises Hb by 1g/dL / Compatible Indication: Hb<8 (symptomatic) / crossmatch Hb<10 (cardiac) FFP: PT/APTT > 1.5x normal / Active bleeding + coagulopathy Dose: 10-15 ml/kg Platelets: <50,000 for surgery / <10,000 prophylactic One pool raises by 20-30,000 Cryoprecipitate Fibrinogen / Factor VIII / vWF / Factor XIII Fibrinogen < 1.5g/L / Massive haemorrhage / DIC Fluid rate Holliday-Segar: 4/2/1 rule for maintenance 100ml/kg/day (first 10kg) + 50 (next 10kg) + 20 (>20kg) Trauma resus. 1:1:1 ratio (PRBC:FFP:Platelets) – massive transfusion Permissive hypotension: SBP 80-90 protocol until haemostas ===== PAGE 34 ===== SURGERY PRACTICAL SIMPLIFIED By Dr. Kiran H Parmar CHAPTER Proforma – Orthopaedic Short Notes 30 Fracture proforma Date seen / Age / Sex / Mode of injury / Time of injury Presenting complaint / Duration History Mechanism: Direct / Indirect / Pathological Energy: High / Low / Trivial Time of last meal / Tetanus status / Associated injuries Comorbidities / Medications / Allergies General exam ABCDE: Airway / Breathing / Circulation / Disability / GCS / Vitals / Major bleeding source Exposure LOCAL exam Inspection: Swelling / Deformity / Shortening / Skin condition Wound: Size / Contamination / Gustilo grade (open fractures) Palpation: Bone tenderness / Crepitus / False movement Capillary refill / Distal pulses / Motor + Sensory distal Neurovascular MUST document before + after any intervention Detailed nerve testing (specific muscles / dermatomes) X-ray report Two views / Two joints / Both cortices Bone / Joint / Soft tissue / Fracture description Fracture desc. Site (diaphysis/metaphysis/epiphysis) / Pattern / Angulation / Rotation / Shortening / Displacement Comminution Management Resuscitation fi Definitive fracture care Conservative (cast/traction) vs Surgical (ORIF/IM nail/EF) ORIF indications Intra-articular / Failed conservative / Polytrauma / Open Vascular injury / NV compromise / fracture Pathological fracture Cast rules Include joint above and below / Mould / Bivalve if swollen Window for wound / Check NV post-application / Written instructions Traction types Skin tra [Command succeeded with exit code 0]