Monday, 21 May 2012

week 2

so last week went by so fast.  I saw yet even more stuff than last week, so much I can't remember half of it.
So this has been a busy week both in clinic and in the OR.  Wednesday was an 11hr day.  We've had a few cases that have been polytraumas so a lot of work orthopaedic wise but also a lot of work for the colleagues over in general surgery.  We had one guy who came off his motor bike over the weekend, went into a concrete wall at high speed.  Managed to smash up both his tibias pretty badly-he has open fractures which were badly contaminated.  The pictures taken of his legs in the ED are absolutely awful, his ankle is hanging off and he has a really bad degloving injury of his right tibia.  Somehow, somehow he is still neurovascularly intact in both his ankles but he developed fat embolus syndrome which apparently, is quite rare.  My attending reckons that you'll be lucky to see one a year (and my hospital is a high throughput trauma centre too so it would be very unlikely that you'd see one at a DGH)   Anyway the fat embolus totally messed him up, he got super hypoxic and needed loads of oxygen and he became acutely confused and didn't know where he was or what his name was so he was clearly too unwell to be taken to theatre.  The problem was that he has open fractures that haven't been definitely fixed, he's only had an initial washout but he needed the wounds to be irrigated and debrided to reduce the risk of infection.  So essentially it's a balance - fix the fracture and stop it from getting infecte which will delay the healing process overall or take him to theatre too soon and he could potentially die on the table or in the postop period.  So it's a difficult situation.  But here in America, the orthopods defer to the general surgeons, who are primarily responsible for his care.  I'm not sure it's exactly the same as at home but it's not completely different.  So yesterday, we did a very minor irrigation and debridement yesterday and fixed his external fixation as it wasn't really fixating very well.  External fixation is basically where there is a metal frame around the limb holding the fractures pieces where they should be.  I think because our patient was too unstable plus he has open fractures, that's why he was treated with external rather than internal fixation.  I was under the impression that open fractures are more likely to be contaminated and hence there is a high chance of infection of the internal hardware hence there's no point in putting it in but apparently you can so i would imagine he was very unstable.
I do really like poly trauma but this case was super hard.  He is the same age as me and I find it just a bit difficult but then I think, this is what we're here for-we're here to fix his injuries and get him on the road to recovery.  It's just hard when you know he could potentially lose his foot or he could have died and that can be a tough one to deal with.
Proximal humeral fracture: this was fixed with a locking plate.  Not all these fractures need to be fixed but our patient had the head of her arm bone come away from the shaft really and that needed to be resolved.  The locking plate principles are universal essentially what you need to understand is the basic principles and forces acting on the fragments.  The thing I like about this specialty is that things happen in a relatively predictable way.  Ankle fractures- the injury you get can be predicted from the way in which the patient's foot went.  There's a whole classification system based on it.  It's also applied physics and biomechanics,  I find this a hugely interesting concept.  I've always found this to be incredibly interesting.  Nothing fascinates me more than the active individual and how your body copes with the the stresses placed on it during these activities.  Part of the reason why I love orthopaedics.  So my attending explained how a locking plate works and he makes it sooo simple, even for me who struggles epically with physics.   And the principles are the same for anywhere else they may be used in the body.  This is what orthopaedics is about: principles, not the actual methods-they're easy to learn once you know how and will obviously change but the principles are what to come to mind when you're looking at an x-ray with a fracture on and this is what will ultimately determine your management.

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