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General Instructions for Care of Hospital Equipment • Use articles only for the purpose for which they are intended • Keep articles clean and in good condition order viagra with a mastercard. Use the proper cleaning method • Protect mattresses with rubber sheets • Use protective pillowcases on pillows order 50mg viagra with visa. Hot water coagulates the protein of organic material and tends to make it adhere • Wash well in hot soapy water discount viagra 50mg without prescription. Use an abrasive, such as a stiff-bristled brush, to clean equipment • Rinse well under running water • Dry the article • Clean the gloves, brush and sink 3. Care of Linen and Removal of Stains • Clean linen should be folded properly and be kept neatly in the linen cupboard • Dirty linen should be put in the dirty linen bag (hamper) and never be placed on the floor • Torn linen should be mended or sent to the sewing room • Linen with blood should be soaked in cold water to which a small amount of hydrogen peroxide is added if available • Linen stained with urine and feces is first rinsed in cold water and then washed with soap • Iodine stained linen- apply ammonia, rinse and then wash with cold water • Ink stained linen – first soak in cold water or milk for at least for 24 hrs then rub a paste of salt and lemon juice on the stain and allow the article to lie in the sun • Tea or coffee stains – wash in cold water and then pour boiling water on the stain Basic Nursing Art 9 • To remove vitamin B complex stains dissolve in water or sprit • Mucus stains – soak in salty water • Rust _ soak in salt and lemon juice and then bleach in sun 4. Care of Pick Up Forceps and Jars Pick up forceps: an instrument that allows one to pick up sterile equipment. Pick up forceps should be kept inside the jar in which 2/3 of the jar should be filled with antiseptic solution • Wash pick up forceps and jars and sterilize daily • Fill jar with disinfectant solution daily • Care should be taken not to contaminate tip of the forceps • Always hold tip downward • If tip of forceps is contaminated accidentally, it should be sterilized before placing it back in the jar to avoid contamination. Rubber Bags Example: hot water bottles, ice bags should be drained and dried They should be inflated with air and closed to prevent the sides from sticking together 6. Rubber Tubing • Should be washed with warm, soapy water • The inside should be flushed and rinsed well Admission and Discharge A. Admission Basic Nursing Art 10 Admission is a process of receiving a new patient to an individual unit (ward) of the hospital. Make introduction and orient the patient • Greet the patient • Introduce self to the patient and the family • Explain what will occur during the admission process (admission routines) such as admission bath, put on hospital gowns etc. Observation and physical examination such as: • Vital signs; temperature pulse, respiration and blood pressure Basic Nursing Art 11 • Intake and output • Height and weight (if required) • General assessment b. Record keeping or maintaining records • Record all parts of the admission process • Other recording include ⇐ Notification to dietary departments ⇐ Starting kardex card and medication records ⇐ If there is specific form to the facility, complete it. Plan for continuing care of the patient • Referral as necessary Basic Nursing Art 12 • Give information for a new person involved in the patient care. Teaching the patient about • What to expect • Medications (Treatments) • Activity • Diet • Need for continued health supervision 4. Do final assessment of physical and emotional status of the patient and the ability to continue own care. Check and return all patients’ personal property (bath items in patient unit and those kept in safe area). Help the patient or family to deal with business office for customary financial matters and in obtaining supplies. Keep records o Write discharge note o Keep special forms for facility Discharge summaries usually include: • Description of client’s condition at discharge • Current medication • Treatment (e. When the patient want to leave an agency without the permission of the physician - unauthorized discharge the following activities are indicated: 2. If the client refuses to sign the form, document the fact on the form and have another health professional witness this 6. Provide the patient with the original of the signed form and place a copy in the record 7. When the patient leaves the agency, notify the physician, nurse in charge, and agency administration as appropriate • Assist the patient to leave as if this were a usual discharge from the agency (the agency is still responsible while the patient is on premises) Charting Chart: is a written record of history, examinations, tests, diagnosis, prognosis, therapy and response to therapy Purpose Basic Nursing Art 14 • To document diagnosis or treatment of a patient while in the hospital and after discharge if the patient return for treatment at a future time. Nausea, headache, numbness Basic Nursing Art 15 As part of the admission process a new chart should be opened and certain forms must be filled Orders of Assembling Patients Chart a. Cotton Rings: are small circles of cotton rolled with gauze or bandage with hole in the middle. Air Rings: • Should be filled with air and covered with pillow case • Not commonly used • Should be changed frequently • Used to relieve pressure from the buttocks (to prevent bed sore) 3. Pillow: • Placed under head, back, between knees or at the foot of the bed to prevent foot drop and keep the patient. Basic Nursing Art 16 • Are used to give comfort, support and to position a patient properly. Splints: Are rigid supports that help maintain the wrists in hyperextension as a means of Preventing palmar flexion and constructors. Lifting and Moving a Patient Body Mechanics: is the effort; coordinated, and safe use of the body to produce motion and maintain balance during activity • A person maintains balance as long as the line of gravity passes through the center of the body and the base support Line of gravity: an imaginary vertical line drawn through an object’s center of gravity • The point at which all of the mass of an object is centered • Base of support: the foundation on which an object rests Principles • Balance is maintained and muscle strain is avoided as long as the line of gravity passes through the base of support • The wider the base of support and the lower the center of gravity, the greater the stability • Objects that are close to the center of gravity are moved with the least effort Purpose of Proper Body Mechanics • Promotes body musculoskeletal functioning • Reduces the energy required to move and maintain balance • Reduce fatigue and decreases the risk of injury • Facilitates safe and efficient use of appropriate groups of muscles The center of gravity of a well-aligned standing adult is located slightly anterior to the upper part of the sacrum. Standing position posture: is unstable because of a narrow base of support, a high center of gravity and a constantly shifting line of gravity. Basic Nursing Art 18 Person resting in a chair or bed o The presence of the chair gives wider base of support o The center of gravity is lower o The line of gravity is less mobile thus; a person has greater stability and balance in a sitting or lying position than a standing position. Moving a Patient Purpose: o To increase muscle strength and social mobility o To prevent some potential problems of immobility o To stimulate circulation o To increase the patient sense of independence and self-esteem o To assist a patient who is unable and move by himself o To prevent fatigue and injury o To maintain good body alignment Ensure that the client is appropriately dressed to walk and wears shoes or slippers with non-skid. Facilitates blood flow to the brain ⇒ If a chair is not close by assist the client to a horizontal position on the floor before fainting occurs Controlling Postural Hypo tension o Sleep with the head of the bed elevated (8-12 inches). Mention some of the nursing responsibilities during admission and discharge of the patient. In most instances beds are made after the client receives certain care and when beds are unoccupied. Closed bed: is a smooth, comfortable and clean bed, which is prepared for a new patient • In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and under the pillows. Open bed: is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier of a client to get in. Occupied bed: is a bed prepared for a weak patient who is unable to get out of bed. To conserve patient’s energy and maintain current health status Basic Nursing Art 22 Anesthetic bed: is a bed prepared for a patient recovering from anesthesia ⇒ Purpose: to facilitate easy transfer of the patient from stretcher to bed Amputation bed: a regular bed with a bed cradle and sand bags ⇒ Purpose: to leave the amputated part easy for observation Fracture bed: a bed board under normal bed and cradle ⇒ Purpose: to provide a flat, unyielding surface to support a fracture part Cardiac bed: is one prepared for a patient with heart problem ⇒ Purpose: to ease difficulty in breathing General Instructions 1. Linen for one client is never (even momentarily) placed on another client’s bed 5. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered for disposal 6. Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain Basic Nursing Art 23 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on the other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the clients feet. Vertical - make a fold in the sheet 5-10 cm 1 to the foot Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot 10. While tucking bedding under the mattress the palm of the hand should face down to protect your nails.

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Even tissues like the heart and brain depend mainly on ketone bodies during such conditions to meet their energy demand order viagra us. Liver does not contain the enzyme required for activation of ketone bodies Aceto acetate is activated by two processes for its utilization buy viagra with american express. Aceto acetate and β-hydroxy butyrate are the normal substrates for respiration and important sources of energy 50 mg viagra amex. Brain switches over to utilization of ketone bodies for energy during starvation and in uncontrolled diabetes. Prolonged starvation, depletion of carbohydrate stores results in increased fatty acid oxidation and ketosis. Similarly in starvation, due to hypoglycemia, there is less insulin, lipolysis increases and ketogenesis increases. Denovo synthesis of fatty acids take place in cytosol of liver, lactating mammary gland, adipose tissue and renal cortex. The formation of malonyl CoA is the committed step in fatty acid synthesis For the synthesis, all the enzymes are required in the form of fatty acid Synthase complex. The formation of malonyl CoA is the committed step in fatty acid synthesis For the synthesis, all the enzymes are required in the form of fatty acid Synthase complex. Biosynthesis of Cholesterol Cholesterol is synthesized in the cell cytosol and endoplasmic reticulum from acetylCoA. Squalene undergoes cyclization, loses three carbon atoms,aquire a double bond,forms cholesterol Regulation of Cholesterol Synthesis: Acetyl CoA is converted to Mevalonate. Catabolism of Cholesterol: Intestinal Bacteria converts cholesterol to coprostanol which is excreted in feces. The patients are treated with chenodeoxycholic acid to solublize the cholesterol or the stones are removed by surgical intervention. It causes obstruction to blood flow, leading coronary heart disease, stroke, myocardial infarction etc. Atherogenesis is the process by which atherosclerotic plaques form, a critical step in the disease, atherosclerosis. Ultimately, this accumulation of cholesterol becomes one of the chief chemical constituents of the atherosclerotic plaque that forms at the site. Glucocerebroside accumulates in liver, spleen, brain and bone marrow, due to the deficiency of glucocerebrosidase. Fatty Liver: Excess accumulation triglycerides in liver causes fatty liver,Liver cirossis and failure of liver function. Causes are: • Elivated levels of free fatty acid in blood • Deficiency of lipotropic factors,which help in the mobilization of fat from liver • Failure in the secretion of lipoproteins from liver • Chronic alcoholism • Prolonged treatment with antibiotics Lipoproteins Plasma lipids contain triacylglycerols, cholesterol and other polar lipids. Based on their density they are classified into four subgroups: 102 Chylomicrons: These are derived from intestinal absorption of triacylglycerols and other lipids and have a very short lifespan. Chylomicrons transport dietary triacylglycerols and cholesterol from the intestine to the liver for metabolism. Membranes give cells their individuality by separating them from their surrounding and they are highly selective and semi permeable containing specific gates, pumps, and channels. Membranes control the flow information between cells and their environment since they contain specific receptor molecules in the form of glycoproteins. Proteins are found submerged in the sea of the lipid bilayers (intrinsic proteins) or loosely bound (extrinsic proteins) and cholesterol is also found intercalated between the lipid bilayers giving the fluidy nature of membranes. Membranes can be regarded as a sea of lipid bilayers and due to the presence of unsaturated fatty acids and cholesterol. This fluidity enables lateral diffusion of molecules such that integral and non-integral proteins span the whole membrane structure. The modern representation of lipids as fluidy and dynamic structures is called the fluid mosaic model. The molecules forming membrane structures do not flip-flop or undergo traverse diffusion and therefore, membranes are asymmetric structurally and functionally. The outer and inner surfaces of all known biological membranes have different components and different enzymatic activities. Cells produce proteins with strikingly different properties and activities by joining the same 20 amino acids in many different combinations and sequences. This indicates that the properties of proteins are determined by the physical and chemical properties of their monomer units, the amino acids. Stereochemistry (Optical activity) Stereochemistry mainly emphasizes the configuration of amino acids at the α carbon atom, having either D or L- isomers. Except for glycine, all amino acids contain at least one asymmetric carbon atom (the α - carbon atom). Common groupings of amino acids are aliphatic, hydroxyl/sulfur, cyclic, aromatic, basic, acidic and acid amides. Structural Classification This classification is based on the side chain radicals (R-groups) as shown in the table 5. Electrochemical classification Amino acids could also be classified based on their acid – base properties Acid amino acids (Negatively charged at pH = 6. Biological or Physiological Classification This classification is based on the functional property of amino acids for the organism. Essential Amino Acids Amino acids which are not synthesized in the body and must be provided in the diet to meet an animal’s metabolic needs are called essential amino acids. About ten of the amino acids are grouped under this category indicating that mammals require about half of the amino acids in their diet for growth and maintenance of normal nitrogen balance. Non- Essential Amino Acids These amino acids are need not be provided through diet, because they can be biosynthesized in adequate amounts within the organism. Semi-essential amino acids Two amino acids are grouped under semi-essential amino acids since they can be synthesized within the organism but their synthesis is not in sufficient amounts. The set of essential amino acids required for each species of an organism can be an indicative of the organism propensity to minimal energetic losses on the synthesis of amino acids. Amino acids can be classified here as Glucogenic (potentially be converted to glucose), ketogenic (potentially be converted to ketone bodies) and both glucogenic and ketogenic. Glucogenic Amino Acids Those amino acids in which their carbon skeleton gets degraded to pyrurate, α ketoglutarate, succinyl CoA, fumrate and oxaloacetate and then converted to Glucose and Glycogen, are called as Glucogenic amino acids. Ketogenic Amino Acids Those amino acids in which their carbon skeleton is degraded to Acetoacetyl CoA, or acetyl CoA. These amino acids have ability to form ketone bodies which is particularly evident in untreated diabetes mellitus in which large amounts of ketone bodies are produced by the liver (i. Ketogenic and glucogenic Amino Acids The division between ketogenic and glucogenic amino acids is not sharp for amino acids (Tryptophan, phenylalanine, tyrosine and Isoleucine are both ketogenic and glucogenic). Some of the amino acids that can be converted in to pyruvate, particularly (Alanine, Cysteine and serine, can also potentially form acetoacetate via acetyl CoA especially in severe starvation and untreated diabetes mellitus. Ketogenic, Glucogenic and Glucogenic-Ketogenic amino acids Ketogenic and Glucogenic amino acids are as indicated in the chart except Leucine and Lysine which are exclusively ketogenic. Non-Standard Amino Acids In addition to the 20 standard amino acids, proteins may contain non- standard (proteogenic) amino acids, which are normally components of proteins but created by modification of the standard amino acids. Among the non – standard amino acids 4 – hydroxyproline a derivative of proline, 5- hydroxylysine derivative of lysine where both are found in collagen, a fibrous protein of connective tissues.

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The designation of a sugar isomer as the D- form or of its mirror images the L- form is determined by the spatial relationship to the parent compound of the carbohydrate family purchase generic viagra from india. When a beam of plane- polarized light is passed through a solution of carbohydrate it will rotate the light either to right or to left order viagra 50 mg with amex. When equal amounts of D 25 and L isomers are present discount viagra amex, the resulting mixture has no optical activity, since the activities of each isomer cancel one another. Epimers When sugars are different from one another, only in configuration with regard to a single carbon atom (around one carbon atom) they are called epimers of each other. The resulting six membered ring is called pyranose because of its similarity to organic molecule Pyran. Glycosidic bond is formed when the hydroxyl group on one of the sugars reacts with the anomeric carbon on the second sugar. Maltose is hydrolyzed to two molecules of D- glucose by the intestinal enzyme maltase, which is specific for the α- (1, 4) glycosidic bond. Structure of Maltose Lactose Lactose is a disaccharide of β-D galactose and β-D- glucose which are linked by β-(1,4) glycosidic linkage. Structure of sucrose α-(1, 2) β-Glycosidic bond Polysaccharides Most of the carbohydrates found in nature occur in the form of high molecular polymers called polysaccharides. Starch consists of two polymeric units made of glucose called Amylose and Amylopectin but they differ in molecular architecture. Amylose is unbranched with 250 to 300 D-Glucose units linked by α-(1, 4) linkages Amylopectin consists of long branched glucose residue (units) with higher molecular weight. The branch points repeat about every 20 to 30 (1-4) linkages Glycogen - Glycogen is the main storage polysaccharide of animal cells (Animal starch). Cellulose is a linear unbranched homopolysaccharide of 10,000 or more D- glucose units connected by β-(1, 4) glycosidic bonds. Humans cannot use cellulose because they lack of enzyme (cellulase) to hydrolyze the β-( 1-4) linkages. Figure: Structure of Cellulose 30 Dextrins These are highly branched homopolymers of glucose units with α-(1, 6), α-(1, 4) and α-(1, 3) linkages. Since they do not easily go out of vascular compartment they are used for intravenous infusion as plasma volume expander in the treatment of hypovolumic shock. They have the special ability to bind large amounts of water, there by producing the gel-like matrix that forms the basis of the body’s ground substance. Since they are negatively charged, for example, in bone, glycosaminoglycans attract and ++ + + tightly bind cattions like ca , they also take-up Na and K 3. An example of specialized ground substance is the synovial fluid, which serves as a lubricant in joints, and tendon sheaths. Heparin: • contains a repeating unit of D-glucuronic and D-gluconsamine, with sulfate groups on some of the hydroxyl and aminx-groups • It is an important anticoagualtn, prevents the clotting of blood by inhiginting the conversion of prothrombin to throbin. Glycoproteins (Mucoproteins) Glycoprotiens are proteins to which oligosaccharides are covalently attached. They differ from the glycosaminoglycans in that the length of the glycoproteins carbohydrate chain is relatively short (usually two to ten sugar residues in length, although they can be longer), whereas it can be very long in the glycosaminoglycans. The glycoprotein carbohydrate chains are often branched instead of linear and may or may not be negatively charged. It also contains disaccharides: sucrose, lactose, maltose and in small amounts monosaccharides like fructose and pentoses. Liquid food materials like milk, soup, fruit juice escape digestion in mouth as they are swallowed, but solid foodstuffs are masticated thoroughly before they are swallowed. Digestion in Mouth Digestion of carbohydrates starts at the mouth, where they come in contact with saliva during mastication. Action of ptyalin (salivary amylase) - It is α - amylase, requires Cl ion for activation and optimum pH 6-7. The enzyme hydrolyzes α- (1,4) glycosidic linkage at random, from molecules like starch, glycogen and dextrins, producing smaller molecules maltose, glucose and disaccharides maltotriose. Maltase The enzyme hydrolyzes the α -(1,4) glycosidic linkage between glucose units in maltose molecule liberating two glucose molecules. Sucrase Sucrose Glucose + fructose 34 Absorption of Carbohydrates Products of digestion of dietary carbohydrates are practically completely absorbed almost entirely from the small intestine. It is also proved that some disaccharides, which escape digestion, may enter the cells of the intestinal lumen by “pinocytosis” and are hydrolyzed within these cells. Hence fructose is not absorbed by simple diffusion alone and it is suggested that some mechanism facilitates its transport, called as” facilitated transport”. This pathway is unique in the sense that it can utilize O2 if available (‘aerobic’) and it can function in absence of O2 also (‘anaerobic’) 35 Fig 2. Hence, to provide a given amount of energy, more glucose must undergo glycolysis under anaerobic as compared to aerobic. For discussion and proper understanding, the various reactions can be arbitrarily divided in to four stages. The reaction is catalyzed by the specific enzyme glucokinase in liver cells and by nonspecific Hexokinase in liver and extrahepatic tissues. The reaction is accompanied by considerable loss of free energy as heat, and hence under physiological conditions is regarded as irreversible. Conversion of G- 6- phosphate to Fructose6-phosphate • Glucose6 phosphate after formation is converted to fructose 6-p by phospho- hexose isomerase, which involves an aldose- ketose isomerization. Conversion of Fructose 6phosphate to Fructose 1, 6 bisphosphate The above reaction is followed by another phosphorylation. A,B Aldolase B: occurs in liver and kidney • The fructose- 6-p exists in the cells in “furanose” form but they react with isomerase, phosphofructokinase-1 and aldolase in the open-chain configuration. Reactions of this type in which an aldehyde group is oxidized to an acid are accompanied by liberation of large amounts of potentially useful energy. Oxidation of Glyceraldehyde 3phosphate to 1,3 bis phosphoglycerate Glycolysis proceeds by the oxidation of glyceraldehde-3-phosphate,to form1,3-bis phosphoglycerate. Dihydroxyacetone phosphate also forms 1, 3 - bisphosphoglycerate via glyceraldehydes-3- phosphate shuttle. Conversion of 3- phosphoglycerate to 2- Phosphoglycerate 3-Phosphoglycerate formed by the above reaction is converted to 2-phosphoglycerate, catalyzed by the enzyme phosphoglycerate mutase. It is likely that 2,3 bisphosphoglycerate is an intermediate in the reaction and probably acts catalytically. Conversion of 2-phosphoglycerate to Phosphoenol pyruvate The reaction is catalyzed by the enzyme enolase, the enzyme requires the presence of ++ ++ either Mg or Mn for activity. Conversion of phosphoenol pyruvate to pyruvate Phosphoenol pyruvate is converted to ‘Enol’ pyruvate, the reaction is catalyzed by the enzyme pyruvate kinase. This is another example of “ substrate level phosphorylation “ in glycolytic pathway • “Enol“ pyruvate is converted to ‘ Keto’ pyruvate spontaneously. Clinical Importance • Tissues that function under hypoxic conditions will produce lactic acid from glucose oxidation.

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Te primary injury is the result of the 38 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 initial discount viagra 75mg free shipping, mechanical forces purchase cheap viagra line, resulting in shearing and compression of neuronal buy viagra 50mg without prescription, glial, and vascular tissue. Te secondary injury is described as the consequence of further physiological insults, such as ischaemia, re-perfusion and hypoxia, to areas ‘at risk’ in the brain in the period afer the initial injury. Critical care of multiple injuries Defnition: Multi-trauma are physical insults or injuries occurring simultaneously on several parts of the body. General Consideration Defnition: Complete separation and loss of 2 articulating bone contact surfaces. Acromio-Clavicular Joint Dislocation Defnition: Classifed in 6 diferent types depending on which ligaments are sprained or torn. Recommendations - Physical therapy under supervision post immobilization removal - Pre and post reduction: X-Ray and Neuro-Vascular status evaluation is mandatory 1. Hip Dislocation Description - Traumatic hip dislocation of the hip joint may occur with or without fracture of the acetabulum of the proximal end of the femur. Traumatic Knee Dislocation Defnition: Is the complete displacement of the tibia with respect to the femur and with disruption of 3 or more of the stabilizing ligaments. Surgery Clinical Treatment Guidelines 51 Chapiter 1: Orthopaedic Surgery Management A knee dislocation is a potentially limb threatening condition, therefore immediate reduction is recommended even before a radiography evaluation. Conservative • Immediate closed reduction and immobilization at 20-30o of fexion for 6 weeks • Range of motion/exercise should be instituted afer adequate sof tissue healing 6-12 weeks Surgical • Indications → Unsuccessful closed reduction → Open injuries → Vascular injuries → Residual sof tissue interposition Recommendations - Acute repair of lateral ligament followed by early functional bracing is advised (meniscal injuries to be addressed at time of surgery - Medial collateral injuries generally heal without surgery - Te role of cruciate reconstruction in the acute setting remains controversial 1. Patellar Dislocation Description: Patella dislocation is more common particularly in females due to physiologic laxity and in patients with hyper mobility (athletes) Causes - Physiological laxity - Direct trauma to the patella - Connective tissue disease (Marfan Syndrome) - Congenital abnormality of the patella and trochlea - Hypoplasia of the Vastus Medialis muscle - Hypertrophy of the lateral retinacular 52 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 Signs and symptoms - Pain focused around the knee joint - Inability to fex knee - Hemarthrosis - Swelling with tenderness of the knee - Palpated displaced patella Investigation - X-ray of the knee (Anteroposterior and Axial views) Complications - Recurrent dislocation - Re-dislocation - Patella-femoral Arthritis Management Conservative • Closed reduction with cylinder casting for 2- 3 weeks • Isometric quadriceps exercises afer removal of the cast Surgery • Recurrent episodes require operative repair Surgery Clinical Treatment Guidelines 53 Chapiter 1: Orthopaedic Surgery 1. Septic Arthritis Defnition: Septic arthritis is the infammation of a synovial membrane with purulent efusion into the joint space usually caused by bacteria. Chronic Osteomyelitis Defnition: Exogenous or hematogenous infection that has gone untreated or has failed to respond to treatment. Fracture of Wrist Bones Description - Carpal/wrist bones are in 2 rows: • A wrist fracture is a break in one or more of the bones in the wrist. Causes - Fall on the outstretched hand and extended wrist - Motor vehicle accident - Sports contact injury 1. Fracture of the Scaphoid Bone Description: Scaphoid fractures are by far the most common of the carpal fractures, estimated at 70-79%. Classifcation Herbert classifcation of scaphoid fractures - Type A fractures are stable and acute including: • A1: Fracture of the tubercle • A2: Incomplete fractures of the scaphoid waist - Type B fractures are unstable and include: • B1: Distal oblique fractures • B2: Complete fracture of the waist • B3: Proximal pole fractures • B4: Transscaphoid perilunate fracture dislocation of the carpus - Type C fractures are characterized by delayed union. Other Wrist Bone Fractures Description: Commonly associated with above carpal bone fractures. Metacarpal Fractures Description: Metacarpal bones are located between carpal bones and phalanges. From radial to ulna we have thumb (First) Metacarpal and second to ffh metacarpal. Bennett’s and Rolando’s Fractures Description - Bennett’s fracture is an intra articular fracture of the base of the thumb metacarpal characterized by one small ulna fragment. Causes - Fall with axial loading through the thumb metacarpal - Direct blow of the thumb metacarpal - Injury involving forced abduction of the thumb Signs and symptoms - Pain and swelling - Decreased range of motion of the thumb - Shortening of the thumb - Dorsal and radial displacement of the metacarpal bone Surgery Clinical Treatment Guidelines 65 Chapiter 1: Orthopaedic Surgery Investigations - Plain x-ray (Antero-posterial and oblique views) Management Surgical • If the Bennett’s fragment is less than 15-20% of the articular surface: Closed reduction and percutaneous pin fxation followed by a thumb spica splint for 4-6 weeks. Fractures of Phalanges Proximal and middle phalanges Defnition/Description: Fracture of the bones of the proximal or middle phalanges of the fngers. Distal Phalanges and Nail Bed Injuries Description: Distal phalanges fractures are ofen associated with nail bed laceration. Dislocations of the Hand Joints Defnition: A dislocation is a misalignment of the bones forming a joint. If relocation is difcult under those circumstances do an open reduction • Splinting in functional position for 4 weeks and then physiotherapy Surgical • Sometime the volar plate or tendons can be entrapped into the joint and that is why it may be impossible to do a closed reduction. Recommendation - Refer to orthopedic surgeon or hand surgeon any dislocation that can’t be relocated conservatively. Burns Wound management of the burned hand follows the general principles of burn wound management. Tese spaces are the thenar, midpalmar and hypothenar spaces in the hand and Parona’s space in the forearm. Tendon Injuries Defnition: A tendon is a fbrous structure that connects a muscle to a bone. Complications - Associated arterial injuries - Paralysis - Neuromas - Hyper or hyposensitivity 76 Surgery Clinical Treatment Guidelines Chapiter 1: Orthopaedic Surgery 1 1. Vessel Injuries Defnition: Laceration to the arterial supply of the hand or fngers. Complications - Associated nerve injuries - Compartment Syndrome - Loss of hand or fnger (Gangrene) Surgery Clinical Treatment Guidelines 77 Chapiter 1: Orthopaedic Surgery 1. Causes - Burn - Trauma - Tumor excisions - Debridement Signs and symptoms - Assess the size of the defect - Assess the depth of the defect - Assess whether underlying vital structures are exposed or involved Management - If the wound can be closed without compromising the function of the hand or the anatomy of the hand, do a primary closure - If a primary closure is not feasible and there is no underlying vital structures exposed, do a skin graf - If underlying structures are exposed, cover with a fap - If underlying structures are involved, repair them and cover with a fap Complications - Scar contractures - Damage of vital structures 78 Surgery Clinical Treatment Guidelines 2. General Considerations 2 Defnition: physical trauma to the spinal cord from craniocervical junction to the sacrococcygeal region. Partial: Tere is preservation of some neurological function which may be motor, sensory or both. Cervical cord injuries are divided into two namely high cervical and low cervical injuries. Spinal Fractures and Dislocation Defnition: Refers to disruption of vertebra column caused by physical trauma. Stable fractures are those with minimal or no risk of neurological damage whereas unstable fractures are those with a high likelihood of neurological damage coupled with slight movement. It has three types which are: type1, type2, type 3 (Levine classifcation), type 1 is stable; types 2 and 3 are unstable. Tis is attributed to normally increased elasticity of the spinous ligaments and intervertabral sof tissue in young population. Thoracic Fractures Description: Te thoracic canal is smaller compared to other spinal regions making it more vulnerable to even small compressive lesions. Thoracolumbar Fracture 2 Description: Toracolumber fructure is a transition zone between the rigid thoracic spine and mobile lumbar spine. Cauda Equina Defnition: It is a clinical condition arising from dysfunction of multiple lumbar and sacral nerve roots compression within lumbar spinal canal. Causes - Massive herniated lumber disc - Tumors - Free fat graf following discectomy - Trauma - Spinal epidural hematoma - Infection e. Cerebral Vascular Diseases (Spontaneous Haemorrhage) Intracranial hemorrhage may be subdural, subarachnoid and intracerebral (intra parancyma). Subdural hemorrhage is discussed under traumatic causes of intracranial hemorrhages. Intracerebral Hemorrhage Defnition:It is a hemorrhage within the brain parenchyma, commonly referred to as hypertensive hemorrhage, it is the second most common form of strokes (15-30%) but most deadly. Occurs at common sites for hypertensive bleeds (putaminal, thalamic, cerebellar and lobar). Subarachnoid Hemorrhage Description: It occurs as a result of bleeding from aneurismal rapture in 5% from perimesencephalic.

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