Contacts

K5: 5201 / 5203 Book OT:

K6: 5301 / 5303 → pt profile
Ortho Clinic: 3800 → new order
Mr Vijay 3801 → choose OT surgery + type of op
Mr Farid 3802 → choose Surgeon, change date, emergency
IT: 3131 / 3132 / 3130 → waitlist
OT: 4401/ 4409 → record consent
→ back to menu
Elective OT: SUN, WED,THURS, SAT → OT surgery → booking verification
CLINIC (SPECIALIST): MON, WED → emergency, find pt’s name, right click &
assign theater
Routine Work of HO: → booked case → find pt’s name
Morning round 7am – 8am → verify
MO / Specialist round 8am (call 3131/3132 if do not know how to operate)
X-ray conference / CME
Ward works / clinic / assist in OT / Local OT In OT:
Procedures / Discharges Reach 10 minutes before op
On call / Orthopedic emergencies Check OT list, Pt’s consent
Order c-arm orthopedic
Ortho emergencies: TO INFORM MO Call MA & I/I
1. Talus, scaphoid , neck of femur# Prepare antibiotic if pt not on AB (zinnat /
2. Dislocations (must reduced w/in 6 hrs) cefobid)
3. Septic arthritis à Jt fluid Ix stat : C&S, Prepare gloves for surgeons
FEME, AFB, crystal, gram stain, cytology Universal hand washing
4. Open # Position, clean and drape pt
5. Poly trauma (2 or more # at limbs)
6. pelvic # Post-Op (in daily round):
7. impending Compartment syndrome Pain / pain killer given?
Swelling / tight cast
Other emergencies to inform MO Circulation chart
1. Hypoglycemia (moving distal limbs / sensory)
2. hyperK Wound site infection
3. SOB Fever
4. chest pain / MI j-vac
r/v check x-ray
Pre-Op require physio?
*** Full hx/ Past Med Hx / Full PE Pale/ r/v post-op Hb
*** FBC / GSH / BUSE only for < 35 y/o WI
*** FBC/RP/ coag. profile / RBS/ GSH / When is STO
ECG / CXR for 35 y/o and above
*** CXR for all smoker regardless age
*** aspirin / ticlid must be withheld 7 days
before op (t1/2 platelet is 5 - 7 days)
*** smoker/ asthma / h/o rib # : Neb before op
*** implant (k-wire / DHS / ILN / plating) :
1.5g cefuroxime to OT
*** SBE prophylaxis: ½ hr pre-op:
IV ampicillin 2g & IV gentamycin 80mg stat
TKR/THR regime
Discharges:
Medication hx – to inform if pt taking aspirin / → Record D advice: disharge home / DAMA
ticlid / warfarin / heparin before op → D diagnosis
Counsil risk & complications for op (to give pt → D summary (to be sweet & simple)
in written article) Dx, Simple hx
s/c clexane 0.4ml OD start on 6pm day pre- Procedures done, date
op(IF MUSLIM --**COUNSEL) Op finding
(alternative: fondaparinux – to be given after
op) Plan (most important):
Refer medical if uncontrolled DM / HPT / fever Antibiotics
/ lungs creps / chest pain analgesics
x-ray hardcopy (hip/pelvis/knee) Daily dressing
To insert CBD on 6am day of operation TCA date to r/v HPE / C&S / wound
to bring cefobid 2g to OT and STO date
**pre-op anesthetic med: T.ativan XOA
(lorazepam)ii/ii ON 1/7 –given the night before MC (stated date - to be sign by MO)
op—to prevent anxiety Light duty
WB / non WB / partial WB

Post-THR/TKR TCA:
take r/v post-op Hb For fracture: TCA 3/52
r/v pt 2 horly after op until stable – esp BP / LL: NWBC, 2nd F/up: PWBC
pain score / SOB / chest pain If callus seen (1st f/up): TCA 6/52, if alignment
IV cefobid 1g bd good, callus seen (2nd f/up): TCA 2/12
cont s/c clexane until ambulation (normal
duration 5 days only for female) # MTB — callus seen then remove k-wire and
check x-ray after off spinal WB with heel
physio Discharge when bone healed, fracture well
united
Analgesics:
IV dysnastat 40mg ON(parecoxib sodium) for Ulcer / cellulites - daily dressing
2/7 only dirty wound: TCA 1/52
clean wound: TCA 2/52
If epidural was off: Ulcer (SSG) D when epithelialization noted
T. arcoxia 60 - 120mg OD or
T celebrex 200mg – 400mg bd Run blood (urgent blood)
IM tramal 75mg tds or Take GXM, order in comp, form
IM pethidine 75mg tds or Record consent
**IM NUBAIN 10MG STAT AND THEN Go blood bank and sign for whole blood
PRN (for pt with pain & c/o giddiness with
pethidine or tramal)
If dizzy:
IV maxolon 10mg stat or
IV phenergen 25mg tds

T. midazolam 5mg – 7.5mg ON if pt unable to

sleep after op
 correction)
Anemia Pt:
K fast correction (ECG MONITORING!!)
Check Hb level before every WD! Must do with ECG monitoring
Hb 8 – 10 Hb: Double hematinics (ferrous, 2g KCL in 200cc of NS
folic, vitBco, ascorbic acid) Give in 2 hours
Hb < 10 with anemia sx (giddiness, palpitation, BUSE after 2 hours
pale, low BP), or Hb < 8 : transfusion STAT
If severe anemia + fever before transfusion: Hypoglycemia (Mx stat & INFORM MO)
 give PCM, tepid sponging, piriton, then 50 mls D50% stat
transfuse! 1 pint D10% for 1 day
 Observe for transfusion reaction by Repeat DXT hourly till stable, then 4 hourly
other ways (skin changes / itchiness) Withhold first even DXT high

If Transfusion reaction: IVD Mx

100 ml urine to blood bank;
10 ml blood to blood bank (in red bottle)
100 mg IV hydrocort stat;
10 unit IV piriton stat
Auscultate lung, frequent r/v to pt;
urine & blood to blood bank after 24 hours
If severe anemia + transfusion reaction, w/hold
the blood, give PCM, piriton, inform blood
bank, change bag another blood. DO NOT
DELAY
Chronic anemia - before transfusion:
TIBC, serum ferritin, serum iron, FBP, Stool
Occult blood
PerRectal examination TRO malena
1st 10 kg: 100 cc /kg
2nd 10 kg: 50cc/kg
Next 10 kg: 20cc/kg
For non DM pt (say, 60kg), IVD 3-5 pint / 24
hours (NS & D5% in alternate drip)
For DM pt & CC pt – IVD 5 pints, all NS
In paeds, any correction use ½ NS/ D5%
Nutrition:
Prosure — suppplement for wt loss pt
Pt very cachexic, malnutrition: syrup
multivitamin 15mls tds , 1 tin ensure
supplement
Myotein, glucerna – for low albumin pt

HyperK Hypoalbuminemia
(to INFORM MO – DO NOT DELAY): Mx: high protein diet, IV human albumin 20%
ECG STAT (to see if peak T wave / arrythmia) 50ml OD 3/7
10ml ca gluconate 10% (100% ,dilute 1ml ca Refer dietitians
gluconate to 9ml H20)
50ml d50%
40ml Nahco3 (optinal: ask MO first)
Iv actrapid 10 u stats (o.1 ml)
Repeat BUSE 4hr later

Low K / HypoK:
aim: K > 3.0 → can do op
K 3.0 – 3.5 : mixt KCL 10ml tds 3/7 or IV
KCL 3g/ day (1-2g KCL in 1 pint NS)
K < 3.0 : either fast correct or
IV KCL 6g / day (maximum of slow

Cellulitis / ulcer (non DM pt)
Wegener’s classifications:
0 + risk factor (DM)
I superficial ulcer
II deep ulcer
III OM changes
IV forefoot gangrene
V hindfoot gangrene
Duration, compliance to med
f/up for DM
O/E: DPA, PTA, warm, fluctuant
XR: OM changes
Take swab for C&S
IV cloxa 500mg qid — paeds: 12.5mg/kg qid
Iv c-pen (benzylpeniccilin) — 2.4 Mü qid—
paeds 0.1 Mü / kg / day (also for tonsillitis)
eg: 15 kg, (15x0.1)/4 = 0.375 Mü qid
If capsule — paeds 15mg/kg/qid
C. Cloxa 500mg qid
T. C-pen (phenoxymethylpen.) 500mg qid
T. PCM: 1g QID
Or 15mg / kg / dose, QID/PRN
Cellulitis / ulcer (DM pt) —
Unasyn (broad spectrum – DM pt prone to
polymicrobial infection d/t immunosuppresion)
IV unasyn 1.5g tds / T. unasyn 375mg bd
or (for toxic looking pt) IV sulperazone 2g stat
and 1 g bd
*** if cellulitis quite bad, do x- ray:
TRO OM (osteopenic changes),
TRO gas gangrene/ necrotizing fascitis (gas
shadow)
If WI cleanà total contact cast (hole at the
ulcer wound site): prevent the foot from
stepping on the ground which will slower down
wound healing
Necrotising fascitis & gas gangrene
gas gangrene (usually clostridium)
NF – polymicrobial (usually staph)
Any fever > 38ºC = septic workout
To take Blood C&S, tissue & swab C&S, ABG,
coagulation profile – TRO septic shock →
DIVC
Tx: high dose IV c-pen, IV cloxa 500mg QID
Cloxa – for staph (or any beta-lactamase
producing bact)
C-pen – for clostridium (gram + organism)
IV C– pen / benzylpenicillin 2.4 mU qid or
***high dose peniciliin must give for gas
gangrene
Hydration – to insert CVP, strict I/O chart
Monitor v/s—spo2
Wound mx:
IV or C. cloxa 500mg qid → for A/w, L/w
Open wound if involve joint — antibiotic for
6/52 to prevent septic arthritis
Dressings:
Curiosin gel: zinc hyaluronate—use for clean
wound (granulation, absorb H20)
Dermasyn—use for clean wound (to encourage
granulation tissue), liquid form: soaked with
gauze then apply tds(each time 15mins)
Elase—clean wound
Urgo/hydrogel—use for exposed tendon to
keep it moist (prevent from dying)
Urgutol(EOD)—SSG, A/w(ragged wound),
sutured site—prevent the gauze from sticking
directly to the skin
Polymen patch—bedsore
Duoderm gel—use for necrotic patch to peel
off
Duoderm CGF—use for MRSA—infected
wound—same as meriplex
Duoderm patch—bed sore, use for still-unclean
wound after the necrotic patch peeled off
Kaltostat patch — for exudates (minimal)
absorption
Aquacel AG—for moist wound to absorb moist
Urgosorb patch—dirty wound
Suprasorb patch—dirty wound
Askina sorb patch—dirty wound
Solcocerryle
Povidone /golden foam — for dirthy wound/
pus / slough
SSG (Theirsch Graft)
a.k.a partial thickness graft
(epidermis + variebal portion of dermis)
Harvest using humby’s knife
Preferred donor area: thigh
Stop aspirin / ticlid for 1 week
Take wound swab before op
C/I
Absolute C/I: beta-haemolytic strep
(producefibrinolysin which dissolves fibrin)
Any nearby wound with copious discharge
Avascular wound (exposed bare bone/ tendon/
cartilage)
Relative C/I: pseudomonas
Donor area heals by epithelization: complete
healing 8 – 10 days
SSG WI: d5 recipien, D10 donor
Full thickness graft (wolf graft):
Fracture:
All Fractures – at least BACK SLAB
Circulation chart
Long bone #: must put on traction
Elevattion (to reduce swelling)
UL — hang the UL
LL — use pillow or Bohler Brown Frame
(BBF)
Compartment syndrome
Definition: reduce tissue perfusion d/t
microvascular compromise secondary to
increased compartmental pressure – leading to
ischemia & tissue necrosis
Causes: #, intracompartmental hemorrhage,
burns, tight cast / dressing, closure of fascia
defect, muscle swelling d/t over exertion
Most common site: PROXIMAL tibial
(caution: tibial plateau # !)
Can happen within 24 hours after injury
Tx: urgent fasciotomy
Forearm: volar incision, dorsal incision, hand
incision
Leg : lateral & medial (compartments: ant, sup
post, deep post, lateral)
Cx: limb loss
Open #
Gustilo Anderson grading
Grade 1
Cefuroxime
Irrigate with 6L of water
Grade II
Cefuroxime
Genta
Irrigate with 6-12L of water
Grade III
Cefuroxime
Genta
flagyl
Irrigate with 12L of water for irrigation
Radius/ulna #
Near elbow joint: plating
Shaft:
adult : plating - not removed
Paeds: intramedullary K-wire — to be removed
after 3/52
— cant use plating in children as bone will
grow in diameter
Distal end — k-wire/buttress plating

**colles # : below elbow cast to prevent
contracture
Carpals / MCB / phalanx #: k-wire
if MCB#: ulnar gutter after CMR
if phalnx#: zimmer / buddy splint
Ulna/ radius #
MU — Montegia — prox 1/3 Ulna # with
dislocation prox RU jt dialocatn
GR — Galleazi— distal 1/3 Radius # with
dislocation DRUJ
Post CMR: must check — radius is in same
alignment with lunate and middle finger
Radial ht: 11mm, radial inclination >20 degrees
Subluxation if <11 mm, < 20 º
Acceptable:
neutral/volar angular < 11 º (paeds: angulation
22-23 º acceptable)
Radial head #: buttress plating
Ulna # : r/v after 3/52 (post POP) à axis of
rotation — not move when rotate forearm
Radius #: after POP, r/v weekly, KIV for op,
cast 6/52
If cannot extend fingers (dt pain/anythg) à put
volar slab at the hand in dorsiflex position
Torus #: Buckling of distal end radius, common
in early teenage grp
Greenstick #: # 1 part of
Clavicle / acromial-clavicular joint
dislocation : arm sling for 6/52—no need
admission – r/v in clinic, no need operation if
no sharp point / neurological deficit
Scapula #
>85% assd with other injuries (including
severe)
Pain in back
o/e swelling & tenderness
look for pneumothorax, pulmonary contusions,
vascular injuries
most cases: arm sling for 6/52—no need
admission
if intraarticular# / large displaced (>25%):
ORIF
Scaphoid bone #:
Most common carpal bone #
Hx: Fall on outstretch arm, Swelling, Pain
worsen with gripping
O/e: tender snuffbox area
X-ray: scaphoid series
Rx: if clinical Sx+, with negative x-ray, thumb
spica for 2 weeks then re-evaluate
Non displaced #: 6-12 wks cast
Displaced#: ORIF (k-wire / Hebert screw)
MCB #
1st MCB #
Bennet#: intraarticular # and proximal & radial
dislocation of base of 1st MTB
Rolando #: intraarticular # of 1st MCB with Y-
shaped configuration (comminuted)
5th MCB #
Boxer # - most common MCB #
- neck of 5th MTB #
Baby bennette – base of 5th MTB #
CARPAL BONES:
RADIUS IS IN SAME ALIGHNMENT WITH
LUNATE AND MIDDLE FINGERS
Elbow joint dislocations:
Assd with radial head #, brachial artery &
median n injury
Inability to flex elbow
Check distal pulses
XR: “Normal radial head must be in line with
capitulum of humerus in any angle”
Posterior-lateral: >90%
Rx: CMR - <7 daysfor comfort, then early
ROM
Open if unstable or with entrapped bone / soft
tissue
Shoulder jt Dislocations:
Mostly anterior
Important info:
Duration, mechanism, h/o recurrence,
occupations, age (<20 y/o >80% recur)
O/e flattened shoulder silhoutte
Neurological deficit (axillary n injury)
CMR, then strapping for 3 weeks
Humerus # :
 With Shoulder dislocation: CMR with
Thomas splint, collar and cuff and
backstrapping
 Supracondylar# - undisplaced:elbow 90
degrees position (above elbow cast)
 Post angulated #--CMR, Dunlop
traction
 Post displace#--under GA, k-wire
 Shaft— upper 1/3: intramedullary nail,
lower 1/3: compression plating, ext fixator.
 Neck/ head humerus: undisplaced —
Uslab (cast from middle clavicle to elbow
then go back to axilla)
 Epicondyle of humerus # (most
common in paeds group) - k-wire
Femur #
 To do skeletal traction – cont fixed
traction first before that
 Indication for skin traction: old age
(osteoporotic bone), paed (growth plate)
 # m/shaft femur — nondisplaced: no
need skin traction - in elderly and
osteoporotic pt
 Neck: total hip replacement /
AMP(Austin Moore Prosthesis)
[hemiarthroplasty], screw fixation
(cannulated) , DHS
 Shaft: ILN / recon nail (screw directed
to femoral neck)
 Supracondylar: buttress plating /
lagscrew fixation for nondisplaced, little
crack # or retrograde femoral nail for
displaced #
 IT #:
 Incomplete/nondisplace: derotationed
bar ( if pt not for op: high risk op → ihd, or
on aspirin)
 Complete/displace: DHS
Classifications of # NOF
Garden classification
Tibia/fibula #
Prox # tib/fib near knee joint — buttress plating
Tibia plateau # / prox 3rd tibia # – hybrid
fixation
Shaft—
for displaced # : ILN,
for non-displaced # : plating
Distal end tibia — lag screw fixation
Medial malleolus — screw fixatiion,
lateral malleolus — palting,
**if syndesmotic jt disrupted (uneven ankle jt’s
space in mortise view) → syndesmotic screw
*** syndesmotic screw must be discharged
with STRICT NWB - remove syndesmotic
screw before weight bear
** non-displaced #: bootcast
Tarsal / MTB / phalanx: boot cast, k-wire
Patella: TBW / cerclage
Phalanges #: buddy / zimmer splint or ulnar
gutter (stabilize)
# with dislocation 2nd-5th prox head MTB:
LISFRANC DIVERGENT TYPE
Calcaneum #: boot cast
Talus bone #
Usual cause is forceful dorsiflexion
XR: Hawkins types:
I non- displaced (cast 2 months)
II subtalar dislocation
III displaced; talar body dislocation
IV talar head dislocation
Rx(type II- IV):
ORIF +/- BG emergently to avoid necrosis
Early ROM
Tibia/fibula # , mainly concern of tibiaà ILN
If tibia # > displaced with segmental: ILN, little
displaced, nonsegmental: plating
If fibula # not involving lateral malleolusà
POP
If fibula # involving lateral malleolus(5cm
from tip of fibula)à plating if displaced, POP
if not displaced
Medial malleolus #: screw fix( cancellous bone
—screw with washer(to prevent screw sinck
into cortex) )
Lateral malleolus # : plating
Tibia
Plating: primary wound healing , bigger wound
ILN: better wound healing(smaller wound),
early wt bearing (wt is loaded on the nail),
healing: callus formation
Pelvic #
High energy force
Assd with other injuries (intra-ab – GI/GU
injury - often life threatening)
PE:
Pelvic spring + / report any other tenderness /
Bruises precisely
Assess clinically – pale?
Check ABC, affected limb shortening?
Tense, Tender abd?
CBD – hematuria?
PRectal / Vaginal exam - h’age?
Neurovascular examination LL
Rectal tone / BC reflex
XR: AP, Inlet, Outlet, judet view (int & ext
oblique view) of pelvis
Shanton line – look for hip dislocation
Pelvic diastesis
AP compression type I < 2.5cm diastesis
AP compression type II > 2.5cm diastesis
APC III unstable #
Mx:
u/s abd TRO intra-ab
KIV CT scan pelvis
GXM 6 pint WB
Nina clamp – max 6 hours
For stable #: conservative (bed rest)
Ext fix if pelvic hemorrhage
SPINE #
Cervical #:
Dislocation/subluxation
→ skull thong (1 level 1 pound, C7—7 pounds)
Stable # (<50%)-->cervical collar
>50% need operation
** any spine trauma, do operation if
neurological deficit
Thoracic # : CRIB(stable)
Lumbar #: Stable (lumbar corset),
Unstable
(denis clasfcn: column > 50%) operation
Sacrum and coccyx # : stable / no neuron
deficit: CRIB, pain killer,
if child bearing age gp: counsel pt to talk to
O&G specialist for pelvimetry (risk of
obstructed labour)
Usu avoid operation due to many sympathetic
plexus à cx: sphincter d/o. if sacroiliac joint
dislocation with no neuron deficit and only
sciatica,: CRIB, pain killer
Septic arthritis:
ACUTE: must do arthrotomy washoutà to
prevent joint destruction
Chronic with no S/S ix and no affect fxà no
need for arthrotomy washout
With S/S ix à arthrotomy washout
Knee pain with S/S inflammation:
Acute exacerbation: OA/RA/ gout(+/-
inflammation sign)
PAEDS:
Closed fracture midshaft (displaced) femur,
CMR right femur, then hip spica under GA in
OT
Before CMR do backslab 1st to prevent any
further displacement
Give syrup chloral hydrate (sedation) before
backslab
Fracture in paeds:
Adult after CMR, contact >80% acceptable
Paeds after CMR, 4cm bony contact
acceptable, 1cm bony contact acceptable for 7
yo
After CMR, if # segment is in same alignment
is not acceptable (overtraction)à will cause
®long bone of # site will grow longer than the
normal bone(L)àunequal limbs
In paeds:displaced fracture <50% no need
CMR: put on backslab / FLPOP
Fall from height
à TRO cervical injury, intraabd(kidney , liver),
ascending aorta, #
calcaneum,acetabulum,sacrum
3 X-ray compulsory in trauma cases:
Pelvic, Cervical, Chest XR
+ skull XR

Bone healing time:

6-8 weeks for UL adult, I/O CHART
doubles in LL, Balance +ve: input>output: lungs crept, fluid
halfs in children overload symptoms
Oblique # heals faster due to high contact
surface DIVC: PT prolong, plt low ** in septic shock
Cryo 6 u ( factor 8, VWF, Fibrinogen)
INTERLOCKING NAIL (ILN) FFP 2-4 u (all coagulation factors)
Insert 2 cotical screws prosximally to the Plt 4u
fracture site with 1cortical screw distally(not # 1 cycle = 1litre of fluid → be ware of fluid
site) overload!
ILN femur — femoral nail inserted prox 2mm,
distal imm bigger than the reamed diameter Withould all anticoagulant, aspirin, NSAIDS
ILN tibia—tibial nail prox and distal 1mm IV vit K 10mg od 3/7 à antidote for warfarin
bigger than the ream diameter IV 1 mg protamine sulphate à antidote for
heparin
SCREWS: If aptt prolonged, avoid IM injection
Static: cortical/cancellous (hematoma)
Dynamic: use for near the frature site, for
micromovement of fracture site(to improve If bleeding profusely:
bone healing) eg:DHS IV vit K (phytomenadione 10mg OD)
Transfuse 2-4 pints FFP
BKA
Check Hb pre-op Chronic OM
2 pint WB to OT Common Causes: infected implant
Post BKA: uslab for the stump Sinus tract, pus
Daily dressing Tolerable pain – on & pff
Refer physio for early ambulation S&S of inflammation
Common organism: staph
CEREBRAL CONSCUSSION XR: elevated periosteum
- h/o LOC why sequestrum more whitish than normal
- headache, vomiting, dizziness, neck stiffness, bone? Sclerotic changes
blurring of vision / papilloedema — S/S Involucrum: new bone formation enclosing
increase ICP with sequestrum
- KNBM, GCS charting, to inform if GCS drop
- to view Skull x-ray, CT brain TRO ICB (if Mx:
GCS drop) Drainage / op to remove sequestrum
- Do not give D5%, Do not give pethidine / Analgesia
opiod drugs 6 weeks AB
genta beads(7.5mg 30 beads for 2/52 then off
genta beads after 2/52)
Iv / oral fusidic acid 500mg tds x 6/52 (increase
bonoe penatration)
cloxa
T. Rifampicin 450mg od
Bone tumour
Most common: secondary from
Primary: Osteosarc / Ewing Sarc
Age: peak at 10 – 20; 50 - 60
Hx: swelling, night pain
o/e: hard, non tender, vascularity
Ix: ESR, CRP, ALP, Calcium, Po4, Mg
u/s / MRI / truecut biopsy
NON UNION
Check if # site mobile / tender
**smoking: atherosclerosisà reduced blood
supply and nonunion of fracture site
** infection
** inadequate / over mobilized
XR: bone end smooth / sclerosed (atrophied /
hyperthrophied)
Mx:
1) Osteotomy + BG
2) expose medullary canal at # end – peripheral
stem cell can stimulate osteogenesis & bone
healing
3) ext fix or int fix
DVT
calf pain/tender/sweollen/warmà TRO DVT
with D-dimer then US doppler
d-dimer povitive: 50% DVT, can be d/t
cellulites / inflammation / post-op
d- dimmer negative: 98% not DVT (rule out
DVT)
most important: to assess clinically, ask if reli
calf m. more painful or knee / ankle joint
RHEUMATOID ARTHRITIS
Ix: FBC, ESR, CRP, ANA, RF, hand x-ray,
wrist x-ray, DsDNA
T. METOTREXATE 10MG 1xWEEKLY
T. SALAZOSULPHAPYRIDINE 300MG BD
(ANTI-AUTOIMMUNE AB)
C.CELEBREX 200MG BD
T.PREDNISOLONE 300MG OD 2/52, 20MG
OD 2/52, 10MG OD 2/52
GOUT
T.COLCHICINE 0.5MG QID—GIVE TILL
DIARRHOE(MEANS PT TOLERATE THE
DRUG TILL MAX DOSE ALREADY)
ONCE DIARRHOEA, CHANGE TO
T.ALLOPURINOL 300MG OD
Ligament injury
Ligamnetous injury of knee—ROBERT JONE
BANDAGE
SPINE:
Check PR, BC reflex, daily neurological
examination
SPINAL SHOCK SYNDROME:
IV METHYLPREDNISOLONE
(SOLEMEDROL)STAT 30MG /KG FOR 15
MINS
MUST BE GIVEN WITHIN POST TRAUMA
8 HRS
THEN OBSERVE FOR 45 MINS
THEN 5.4 MG/KG /HR FOR NEXT 23 HRS
(BY INFUSION)
SCOLIOSIS
Postural--PE: in prone position, can adjust the
spine, Mx: change the position
Fixed--PE: prone the pt and try striahgten the
back , xray spine: Cobbs angle > 40 degress,
need operation, if little , physio
Low Back Pain
PID:
T. mobic 7.5mg OD(elderly), fastum gel,
backcare,t.neurobion 1/1 OD
If local muscle pain: methylsalicylate 25%
ointment (LMS)
If no neuro deficit (no limb weakness/ sensory
loss/PU/BO)à CRIB, physio, analgesia
If affect neuro LL, refer Kangar Hospital
if chronic, only palliative care
If spinal shock syndrome, immediately TCA
Spine :Straight leg raising test: (test L5, S1)--
+ve: sciatic pain at <60 degress…
Sciatic stretch test: lower down the LL 10
degress and dorsiflex the ankleà sciatic pain
(to comfirm SLR) Dafilon / brillon - simple interrupted
Dexon - subcuticular
Spondylolistheisis: anterior displacement
vertebral body, retrolisthesis: posterior STO—suture to open
displacement Face/scalp/neck: STO D5
Spine#: dennis column>1/2: unstable: op , <1/2 Abdomen: STOD7
stable: CRIB Limbs: STO D14 (least vascularity)
STO STAT if sign of inflamn / pus discharge
TB spine: affect endplate of vertebra body
CMR sedation:
Baclofen: 10mg tds — muscle relaxant 1 ampoule (5mg/1ml) dormicum[midazolam]
I: skel muscle spasticity *** dilute w 4mls water for injection
for PID(cant bend fwd) doasage: 0.1mg/kg
**antidone: flumazenil
S/E: drowsiness, neuron/ psy illness, reduce
convulsion threshold, hypotension, reduced 1 ampoule pethidine(50mg/1 ml), dilute w 4mls
CVS fx water for injection
dosage: 1mg/kg ** need to monitor SPO2

Carpal tunnel syndrome: to give 1/2 to 2/3 dose of sedation first then
Physio, flush with hep. saline
thermoplastic splint (occupt therapy) at nite,
Surg to release (Saturday OT) Paeds < 20kg:
Chloral hydrate :
DEQUERVAINS TENOSYNOVITIS dosage: 50mg/kg, max 75mg/kg
(EXTENSOR TENDON): for normal use: 1-1.5ml/kg
FLINKENSTIEN’S sign: kenocort injection at
pain site** usu coexist with CTS Refashioning of fingers :
Digital block, apply tourniquet
use posterior flap d/t more subcut tissue and
Procedures for HO thicker skin
CMR sedation Or do V-Y refashinoning
Skel pin insertion V-Y plasty — crush injury of tip of phalanx
Recognize orthopedic emergency (bone not exposed)
Desaturate pt Cut off dog-ear
Hypoglycemia / SOB / chest pain /
hypovolemic shock pt I&D fingers:
T&S, WD, I&D, Ray’s amputation, irrigation Area to beware of: Snuffbox: radial n,
for open #, Refashioning midwrist: median n., medial to FCU: ulna n.
Wrist, digital, ankle block
Taking ABG SKELETAL TRACTION:
Set CBD, CVP for adult >18 yo, look for epiphyseal plate(if
present, cant do)—10% body wt
T&S: Sutures Supracondylar pin: closed fracture NOF
Muscles / fascia: (medial → lateral)
Vicryl (synthetic absorbable) Tibial/steinman pin:m/s femur,supracondylar #
Catgut (natural absorbable) (lateral → medial to avoid common peroneal
nerve )
Skin Calcaneum pin: tibia plateau #, supracondylar
femur# giving medication)
(1/3 from heel: medial malleolus → lateral) Vancomycin
Check neurological (foot drop/senstion) gentamycin
circulation chart amikacin

SKIN TRACTION: elderly or children Dosage of drugs

-NOF #(AMP), -IT#(DHS) Analgesia
Not done in obese pt (as traction wt is too PCM 1g QID
heavy if counted according to body wt) (15mg/kg/dose)
(supp PCM 1 tab = 250mg)
Ankle block: Voltaren 50mg tds
Posterior tibial nerve: plantar of foot Tramal 50mg tds
Deep peroneal nerve btw big toe & 2nd toe IM pethidine 50mg tds
Superficial peroneal nerve: dorsum of foot IM nubain 10mg tds/qid
SuraL nerve: Lateral foot
Sephanous nerve: Medial surface of foot Celebrex 200mg bd
Arcoxia 60mg OD
Wrist block: T Brufen 400mg bd
Median nerve btw FDS & FDP T ponstan: 2/2 tds
Ulnar nerve: medial to FCU tendon
Radial nerve: snuffbox area NSAID: must be given with gelusil

Digital block: Antibiotics IV Tab

2 Dorsal digit nerves, 2 volar digit nerves Cefuroxime 750mg tds 250mg bd
(IV 30-100mg/kg/day tds)
In OT:
Cut hard tissue muscle (LL) eg in BKA: bone Cloxacillin 500mg qid 500mg qid
cut with giggly saw, neurovascular bundle 6-12mg /kg/dose qid
ligated, muscle cut with Mayo curve
Old #, callus bone—softer (must nibble) before C-pen 2.4Mü qid 500mg qid
do any internal fixation (iv 100,000ünit/kg/ day, devided into qid)
Cut muscle / tendone (UL) use metzebaun
scissors Unasyn 1.5g tds 375mg bd
When drill medullary canal –k-wire insertion (sulbactam+ampicillin)
must irrigate with water to prevent Iv 75mg/kg/day given in bd
osteonecrosis (black)
Ciprobay 400mg bd 500mg bd
Principle of external fixator Flagyl 500mg tds 400mg tds
Simple trauma (open #) — (metronidazole)
near, near, (2 pins near the # site) fusidic acid 500mg qid 500mg qid
far, far (2 pins far away from # site)
Polytrauma — far away from fracture site to IV gentamycin 80mg bd/tds
avoid the heamtoma form at the fracture site (2-3mg/kg/day given in bd/tds)
(5mg/kg/day if severe infection)
Illizarov – bone lengthening 1mm/day, 1cm /
month IV netilmycin 300mg OD
IV fortum (ceftazidime) 2g stat, then 1g
TDM Drugs bd
(To take on D3: ½ hour before & 1 hour after IV cefobid 2g stat, then 1g
bd
IV sulperaxone 2g stat, then 1g Bowel prep for xray KUB: dulcolax 2 tab
bd
IV ceftriaxone 2g stat, then 1g
bd

IV vanco 500mg tds

Sepsis: IV meropenem 500mg bd

Tab EES 250mg qid

Anti HPT
T. nifedipine 10mg tds

Gastric
Syrup MMT 15ml tds
IV ranitidine 50mg tds / T. ranitidine 150mg bd
T. gelusil 2/2 tds
IV pantoprazole / nexium 40mg bd
t. lansoprazole 30mg OD

Constipation
Syrup lactulose 15ml tds
Ravin enema 1/1 stat

Anti-Osteoporotic Medications:
T. fosamex 70mg /kg /week
C.rocaltriol 1/1od0.25 mcg

T.Evista 60mg OD (raloxifene HCL)

Indication: to prevent and treat osteoporosis in
post menopausal women
s/e: venous thrombosis, DVT, PE, retinal vein
thrombosis, uterine bleeding)
CI: liver/renal failure, cholestasis,
endometrial/breat CA

Antiemetics
IV maxolon 10mg stat or
stemetil

Sleeping pills
T. midazolam 5mg – 7.5mg ON if pt unable to
sleep after op

IV phenergen 25mg tds

Others