DNB Orthopaedics  MS Orthopedics  MRCS Exam GUIDE -

Orthopaedic Guidance for DNB Orthopaedics,MS Orthopaedics and Mrcs exams.Cme courses for orthopaedic surgeons.Davangere notes,solved question papers.DNB Ortho,MS Ortho MRCS,Exam Guide videos and notes 9087747888


Home Top Ad

Post Top Ad

Friday 29 June 2018



  • operative treatment in type II and III – to prevent malunion
  • medial comminution – subtle finding – if treated non operatively lead to varus mal union
  • pulseless limb – angiography not indicated – as delays fracture reduction – which corrects vascular problem
  • impending compartment syndrome – high index of suspicion – increased chance if associated forearm # - median nerve injury may mask compartment syndrome
  • lateral entry pins – as stable as cross pinning if placed well in fracture lines – no risk of iatrogenic ulnar nerve injury
  • most common elbow # in children 5-7yrs
  • 2/3r d of children with elbow injury have supracondylar #
  • boys higher incidence – difference recently equalizing
  • left or non dominant side mostly involved
Mechanism of injury and Anatomy
  • extension type (97 to 99%) and flexion type
  • extension type – fall on to outstretched hand with elbow in full extension
  • medial and lateral column of humerus – connected by thin segment of bone between olecranon fossa and coronoid fossa – high risk of#
  • elbow extended – olecranon in olecranon fossa – act as a fulcrum
  • anterior aspect of the capsule – provides tensile force on the distal humerus proximal to its insertion – results in extension type of injury
  • anterior periosteum is torn
  • posterior periosteal hinge provides stability to the fracture and facilitates reduction
  • direction of the fracture displacement indicates whether the medial or lateral periosteum remains intact
  • posteromedial displaced # (MC) - intact medial periosteum – pronation placed medial periosteum in tension and close the hinge – correcting varus malalignment
  • posterolateral displaced cases – medial periosteum torn – supination tenses the intact lateral periosteum
  • if posterior periosteum torn – unstable in both flexion and extension – multidirectionally unstable – Gartland type IV
Gartland's classification
  • Type I
    • non displaced / <2mm
    • intact anterior humeral line
    • may or may not be evidence of osseous injury
    • Posterior fat pad sign may be the only evidence
    • very stable because periosteum intact circumferentially
  • Type II
    • >2mm
    • posterior cortex intact, but hinged
    • anterior humeral line does not go through middle third of capitellum – lateral X ray elbow – signifies posterior angulation
    • no rotational deformity due to intact posterior hinge
  • Type III
    • displaced with no meaningful cortical contact
    • any rotation in AP X ray
    • usually rotation in sagittal plane and rotation in transverse +/ frontal planes
    • extensively torn periosteum
    • soft tissue and neurovascular injuries
    • comminution and medial column collapse – involvement of medial column signifies the mal rotation in frontal plane
  • Type IV
    • circumferentially incompetent periosteum fringe – instability in both flexion and extension
Clinical evaluation
  • examine entire extremity
  • associated forearm # and compartment syndrome
  • soft tissue swelling, ecchymosis
  • skin puckering – proximal segment piercing brachialis and engaging dermis – sign of soft tissue damage
  • punctuate wound bleeding – open #
  • vascular status – compromised in 20%
    • Class I
      • hand warm, red ( well perfused) – radial pulse present
    • Class II
      • hand perfused – radial pulse absent
    • Class III
      • hand cold, blue/ blanched – radial pulse absent
  • neurological status
    • ulnar nerve – cross fingers – pinch fingers- palpate I dorsal interosseous contraction
    • hand in wet cloth – area without normal wrinkling response – injury to the nerve supplying that area
X ray
  • true AP and true lateral views
  • posterior fat pad sign
  • true lateral – anterior humeral line cross the capitellum in middle third
    • extension type line passes anterior to capitellum
  • Baumann angle or humeral capitellar angle - between long axis of humeral shaft and physeal line of the lateral condyle
    • 90-260
    • decrease indicates the fracture is in varus angulation – seen in subtle comminution of medial column

  • Initial management
    • Avoid tight bandaging or splinting
    • Elbow in 20 to 400 flexion in splint
    • Traction not justifiable compared to closed reduction and pinning – one night hospital stay, less complications
  • Closed reduction and pin fixation
    • GA – first reduced in frontal plane – under C arm – flexed – olecranon pushed anteriorly to correct sagittal deformity and reduce the fracture
    • Acceptable reduction criteria
      • Baumann angle restoration (>100 ) – AP X ray
      • Intact medial and lateral column – Oblique view
      • Anterior humeral line through middle third capitellum – lateral view
      • Rotational malalignment should match with the rotation of shoulder
    • Rotational malalignment unstable – if present reduced with a third fixation pin
    • Reduced # held with 2/3 Kirschner wires
    • Elbow in 40 to 600 flexion
    • Gap in # site, # irreducible, rubbery feeling on attempted reduction, median nerve/ brachial artery trapped in # site – open reduction
Open reduction
  • Failed closed reduction, open #, dysvascular limb
  • Direct anterior approach – in case of neurovascular compromise
  • Direct visualization of brachial artery and median nerve, # components
  • Small 5cm transverse incision along cubital fossa – cosmetic approach
  • Lateral approach scar tissue contraction – limiting elbow extension
  • Posterior approach - not recommended – high rate of loss of motion – risk of osteonecrosis – d/t lose of posterior end arterial supply to trochlea
Type I #
  • Long arm cast 60-900 flexion – 3 weeks
  • Follow up X ray in one and two weeks – to r/o fracture displacement
Type II#
  • Operative intervention than cast immobilization
  • Distal humerus give 20% growth of humerus – little remodeling potential
  • Growth of upper limb – I yr: 10cm growth – II yr : 6cm – IIIyr : 5cm – IV yr : 3.5cm – V yr: 3cm
  • Up to 3 years – growth remaining – non operative treatment may be offered – in cases with capitellum abuts the anterior humeral line but do not cross it
  • Child 8-10 yrs – only 10% growth remaining – adequate reduction essential to prevent malunion
  • Hyperflexion is needed to maintain the reduction – cast in such position results in raise compartment pressures
  • Pronation and flexion positions decrease the flow in brachial artery
  • Flexion and supination is good for vascular safety
  • In cases of flexion >900 needed – reduction held by pins and elbow flexion less kept ( 45 to 900)
Type III
  • If presents in extreme extension or flexion – arm carefully placed in 300 flexion – to minimize vascular insult
  • Treated with operative reduction and pin fixation
  • Medial column # should be watched for medial comminution – they may not have high displacement of type III # - some advocate closed reduction and pinning for this type to reduce cubitus varus
Type IV
  • Extremely unstable cases need open reduction
  • Closed reduction also advocated – place 2 Krischner wires in distal fragment – # reduced in AP plane – reduction verified in C arm – rotate C arm to lateral ( instead of moving arm to lateral as commonly done) – reduced in sagittal plane – Kirschner wires driven across the # site
  • Vascular injury
    • Type III supracondylar # - 20-30% absent pulse
    • Absent radial pulse itself not emergency – collateral circulation keeps the perfusion
    • Urgent fixation with pin in ER indicated
    • Absent pulse with no signs of perfusion is an emergency – arm splinted in 20-400 flexion
    • Emergency reduction – not waiting for angiography – if closed reduction not possible – open reduction by anterior approach
    • Artery freed from # site – arterial spasm relieved by lidocaine application, warming, 10-15minutes observation
    • Vascular reconstruction by vascular surgeon if pulse do not return or perfusion lost
    • Pulse present before surgery – absent after pinning and reduction – immediate open re reduction to r/o artery entrapment
  • Neurological Injury
    • Older times up to 49% but modern studies 10-20% association
    • Radial nerve previously MC but recently AIN MC in extension type injuries
    • Presents as paralysis of long flexors of thumb and index finger w/o sensory changes
    • Median nerve injury also described – sensory and motor loss present
    • Open reduction of # - exploration of nerve not necessarily indicated in a closed # - neural recovery in 2.5 -6 months
    • Nerve transections rare – exclusively for radial nerve
    • Iatrogenic injury to ulnar nerve with medial placement of pin – removal of pin
  • Compartment syndrome
    • Associated in 0.1-0.3% of SC#
    • Forearm compartment syndrome 30-33% association with SC# +BB FA#
    • Increase in compartment pressure at 90 -1200 flexion
    • Ecchymosis, swelling even in present pulses with good capillary fill should alert
    • Medial Nerve injury may mask
  • Cubitus varus
    • Reason is mal union than growth arrest
    • Baumann angle intact at reduction and remains so at healing
    • Complications of cubitus varus include increased risk of lateral condyle #, pain and tardy posterolateral rotatory instability
  • Pin track infections
    • 1-21% cases
Crossed pins compared to lateral entry pins
  • ulnar nerve injury in crossed pins are 0 -6%
  • two lateral pins to avoid ulnar nerve injury
  • elbow flexed 900 – ulnar nerve migrated to even anterior to medial epicondyle in children
  • palpation of ulnar nerve or even putting of incision over medial epicondyle – not safe enough for ulnar nerve
  • do not use medial pin OR lateral pin inserted first – elbow extended and medial pin inserted (with out elbow hyperflexion)
  • for stability
    • maximum pin separation at # site in AP view
    • pins should engage both medial and lateral column just proximal to # site
    • should engage adequate amount of bone proximal and distal to fragments
    • pins slightly in anterior to posterior direction in Lat view
  • greater divergence of pins – allow more purchase in medial and lateral column than crossed pins
  • three lateral pins have more stability than crossed pins
  • pin fixation errors
    • failure to engage both fragments with 2 pins or more
    • failure to achieve bi cortical fixation with 2 pins or more
    • failure to achieve adequate pin separation (>2mm) at # site

Order Books Videos Notes and study material

Orthopaedics made simple for DNB MS MRCS Support and Guidance for DNB Orthopaedics, MS Orthopaedics and Orthopaedic Surgeons. DNB Ortho MS Ortho MRCS Exam Guide Diplomate of National Board.Our site has been helping dnb ortho post graduates since a long time.It has been providing the dnb ortho theory question papers,dnb orthopedics solved question bank, davangere orthopaedic notes, sion orthopedic notes.We provide guidance to post graduates as to how to pass dnb and ms ortho exams, and aspiring orthopaedic surgeons surgical technique teaching videos and orthopaedic books and pdf.
Get updates email whatsapp 9087747888

1 comment:

  1. Students can get the TN 10th Model Question Paper 2022 with Solutions in PDF format from the links provided on this website. Regular and private SSLC students Students must register to appear in the Public Exam 2022 after studying these Sample Papers. TN SSLC Model Paper 2022 If you are one of the students who has registered as a Regular or Private Student, it is recommended that you download these Tamil Nadu Board SSLC Plus two Sample Paper 2022 and prepare all subjects. Model papers are a valuable resource provided by the recognised educational board.


Post Bottom Ad