Ward Round Notes

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.

Technical issues - projection, AP film, patient rotated or inadequate inspiration.  Masses - Thyroid, Lymphoma, teratoma, neurogenic tumour.  Achalasia  Scoliosis Paravetebral abscess from tuberculosis Thoracic aortic aneurysm Ellis H, Calne R, Watson C, Lecture Notes General Surgery, 11th ed. Oxford, Blackwell Publishing 2006 Radiology Masterclass, Mediastinal abnormalities [online] available at: http://radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page9.html [accessed:02/11/2014] Van Sambeek R, Anterior mediastinal masses, [online] available at: http://eradiology.bidmc.harvard.edu/LearningLab/respiratory/sambeek.pdf, [accessed: 02/11/2014] Image: http://en.wikipedia.org/wiki/Achalasia#mediaviewer/File:Achalasia2010.jpg [accessed: 02/11/14] 

Fluid compartments:   The body is made of about 60% water, which is divided between the intracellular and extracellular space. Fluid is distributed in these spaces by osmotic forces determined by ion distribution between the intracellular and extraceullular space. Approximately 2/3rds (40% total body weight) of the body’s fluids is distributed in the intracellular space and 1/3rd (20%)in the extracellular space.

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

Fresh PR bleed: Diverticulitis Benign and malignant tumour Haemarrhoids anal fissure Ulcerative colitis Angiodysplasia Trauma Coagulopathy massive upper GI bleed Non PR bleeding - mensturation, haematuria.  Malaena: Gastric ulcer Peptic ulcer Mallory weiss tear Gastritis Benign and malignant tumour Oesophageal varicies Merkel's diverticulum Dark stools without blood - iron tablets References: Ellis H, Calne R, Watson C, Lecture notes - General Surgery,  11th Ed., Oxford, Blackwell Publishing, 2006 SurgWiki, Haematemasis and Malaena, [online] available from: http://www.surgwiki.com/wiki/Haematemesis_and_melaena [accessed:20/10/2014]