Ward Round Notes

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Open/Closed Open or compound fractures are exposed to the environment and therefore more likely to become infected and lead to complications. Because of this open fractures are often managed differently. Open fractures can be categorised by the gustilo classification depending on the extent of damage to the surrounding tissues: I - Low energy with wound less than 1cm. II - greater than 1 cm with moderate soft tissue damage. III - Wound greater than 1 cm with severe soft tissue damage Where - Bone and part of bone Describe which bone and where on the bone the fracture is, long bones are usually divided into distal (away from body), middle and proximal(closer to body)3rds of the bone,or can be described as a mishaft fracture if the fracture is in the middle. Other bones have particular landmarks which are more prone to fractures or relevant to management. For example, hip fractures can be described as intracapsular or extracapsular fractures.

Resuscitation Reduction Restriction Rehabilitation Eg. A 28 y/o man arrives in ED after a motorbike accident with a fractured tibia and fibula. 1) resuscitate according to ATLS guidelines. Examine limb for neurovascular deficit once patient resuscitated. X rays with 2 views. 2) Reduction - may be closed reduction by manually pulling distal fragment to line up bone under sedation or anaesthesia, or open reduction where pins and plates are put in. Depends on type of fracture etc. Open fractures are managed differently to closed fractures. 3) Restriction - eg. using plaster of paris, External fixation, internal fixation with plates/pins etc. again dependent on injury. 4) Rehab - Encouraging mobilisation, physiotherapy, occupational therapy to help adapt environment etc. References: Gosling A, Stansby G, Surgical Talk- Surgery for Finals , London, Imperial College Press, 2004

  Inflammatory arthritis Mechanical arthropathy   Swollen knee Includes: Rheumatoid arthritis, seronegative spondyloarthropathy (psoriatic arthritis, enteropathic arthritis, ankylosing spondylitis, reactive arthritis)  Osteoarthritis with herbeden's node (bony swelling)   Includes: Osteoarthritis, mechanical back pain.   Pain comes and goes and tends not to relate to movement Pain worsens with increased movement Diurnal stiffness occurring in the mornings and at night Stiffness after resting joint for prolonged period of time. Morning stiffness often lasts for a prolonged period (>30minutes) Morning stiffness can be ‘worked off’ after 20-30 minutes. Associated with heat, redness and 'boggy' swelling of the joint. Although redness may not be marked. +ve metacarpal/metatarsal squeeze  pain along joint line, no swelling. ...

Both phalen's test and tinel signs are ways of eliciting symptoms from patients with suspected carpal tunnel syndrome. In phalen's test, the wrist is flexed for 30-60 seconds, and results in tingling/numbness of the thumb, index and middle finger if positive. Sensitivity and specificity of the test is variable. Tinel's sign in carpal tunnel syndrome can be elicited by extending the wrist slightly and tapping on the radial side of the palmar surface of the wrist. It is positive if it results in a tingling sensation of the first 3 fingers.

Ottawa rules are used to decide whether an injury needs an xray to rule out fractures or not.   Ankle rules: x rays are needed if: unable to weight bear after injury and at examination (take more than 4 steps) tenderness of the posterior surface of the distal 6cm of the posterior lateral or medial malleolus. Tenderness over base of 5th metatarsal bone tenderness of the navicular or calcaneum.  

Control of serum calcium levels Bone is made up of hydroyapatite and a fibrous framework. Ca 3 (PO 4 ) 2 + Ca(OH) 2 à Ca 5 (PO 4 ) 3 (OH) Tricalcium phosphate + calcium hydroxide à hydroxyapatite Bone is maintained by osteo C lasts which ‘ C rush’/breaks down bone and osteo B lasts which B uild bone. The breaking down of old bone is also called bone resorption and the formation of new bone is called ossification . This constant relaying of bone helps reshape bones, and repair micro-damages as well as injuries. This continuous bone remodeling is called bone turnover. In adults the rates of bone formation and bone breakdown is usually almost equal. Calcium levels in the body are regulated by parathyroid hormone, calcitonin and vitamin D. The levels of calcium in blood is carefully controlled in the short term, and the total levels of calcium in the body also needs to be constantly maintained. The regulation of calcium is mainly carried out by Parathyroid hormone, whi...