Contacts

K5: 5201 / 5203

K6: 5301 / 5303
Ortho Clinic:
3800
Mr Vijay
3801
Mr Farid
3802
IT: 3131 / 3132 / 3130
OT: 4401/ 4409
Elective OT: SUN, WED,THURS, SAT
CLINIC (SPECIALIST): MON, WED
Routine Work of HO:
Morning round 7am 8am
MO / Specialist round 8am
X-ray conference / CME
Ward works / clinic / assist in OT / Local OT
Procedures / Discharges
On call / Orthopedic emergencies
Ortho emergencies: TO INFORM MO
1. Talus, scaphoid , neck of femur#
2. Dislocations (must reduced w/in 6 hrs)
3. Septic arthritis Jt fluid Ix stat : C&S,
FEME, AFB, crystal, gram stain, cytology
4. Open #
5. Poly trauma (2 or more # at limbs)
6. pelvic #
7. impending Compartment syndrome
Other emergencies to inform MO
1. Hypoglycemia
2. hyperK
3. SOB
4. chest pain / MI
Pre-Op
*** Full hx/ Past Med Hx / Full PE
*** FBC / GSH / BUSE only for < 35 y/o
*** FBC/RP/ coag. profile / RBS/ GSH /
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: hr pre-op:
IV ampicillin 2g & IV gentamycin 80mg stat

Book OT:
pt profile
new order
choose OT surgery + type of op
choose Surgeon, change date, emergency
waitlist
record consent
back to menu
OT surgery booking verification
emergency, find pts name, right click &
assign theater
booked case find pts name
verify
(call 3131/3132 if do not know how to operate)
In OT:
Reach 10 minutes before op
Check OT list, Pts consent
Order c-arm orthopedic
Call MA & I/I
Prepare antibiotic if pt not on AB (zinnat /
cefobid)
Prepare gloves for surgeons
Universal hand washing
Position, clean and drape pt
Post-Op (in daily round):
Pain / pain killer given?
Swelling / tight cast
Circulation chart
(moving distal limbs / sensory)
Wound site infection
Fever
j-vac
r/v check x-ray
require physio?
Pale/ r/v post-op Hb
WI
When is STO

TKR/THR regime
Medication hx to inform if pt taking aspirin /
ticlid / warfarin / heparin before op
Counsil risk & complications for op (to give pt
in written article)
s/c clexane 0.4ml OD start on 6pm day preop(IF MUSLIM --**COUNSEL)
(alternative: fondaparinux to be given after
op)
Refer medical if uncontrolled DM / HPT / fever
/ lungs creps / chest pain
x-ray hardcopy (hip/pelvis/knee)
To insert CBD on 6am day of operation
to bring cefobid 2g to OT and
**pre-op anesthetic med: T.ativan
(lorazepam)ii/ii ON 1/7 given the night before
opto prevent anxiety
Post-THR/TKR
take r/v post-op Hb
r/v pt 2 horly after op until stable esp BP /
pain score / SOB / chest pain
IV cefobid 1g bd
cont s/c clexane until ambulation (normal
duration 5 days only for female)
check x-ray after off spinal
physio
Analgesics:
IV dysnastat 40mg ON(parecoxib sodium) for
2/7 only
If epidural was off:
T. arcoxia 60 - 120mg OD or
T celebrex 200mg 400mg bd
IM tramal 75mg tds or
IM pethidine 75mg tds or
**IM NUBAIN 10MG STAT AND THEN
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

Discharges:
Record D advice: disharge home / DAMA
D diagnosis
D summary (to be sweet & simple)
Dx, Simple hx
Procedures done, date
Op finding
Plan (most important):
Antibiotics
analgesics
Daily dressing
TCA date to r/v HPE / C&S / wound
STO date
XOA
MC (stated date - to be sign by MO)
Light duty
WB / non WB / partial WB
TCA:
For fracture: TCA 3/52
LL: NWBC, 2nd F/up: PWBC
If callus seen (1st f/up): TCA 6/52, if alignment
good, callus seen (2nd f/up): TCA 2/12
# MTB callus seen then remove k-wire and
WB with heel
Discharge when bone healed, fracture well
united
Ulcer / cellulites - daily dressing
dirty wound: TCA 1/52
clean wound: TCA 2/52
Ulcer (SSG) D when epithelialization noted
Run blood (urgent blood)
Take GXM, order in comp, form
Record consent
Go blood bank and sign for whole blood

correction)
Anemia Pt:
Check Hb level before every WD!
Hb 8 10 Hb: Double hematinics (ferrous,
folic, vitBco, ascorbic acid)
Hb < 10 with anemia sx (giddiness, palpitation,
pale, low BP), or Hb < 8 : transfusion STAT
If severe anemia + fever before transfusion:
give PCM, tepid sponging, piriton, then
transfuse!
Observe for transfusion reaction by other
ways (skin changes / itchiness)
If Transfusion reaction:
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
HyperK
(to INFORM MO DO NOT DELAY):
ECG STAT (to see if peak T wave / arrythmia)
10ml ca gluconate 10% (100% ,dilute 1ml ca
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

K fast correction (ECG MONITORING!!)

Must do with ECG monitoring
2g KCL in 200cc of NS
Give in 2 hours
BUSE after 2 hours
Hypoglycemia (Mx stat & INFORM MO)
50 mls D50% stat
1 pint D10% for 1 day
Repeat DXT hourly till stable, then 4 hourly
Withhold first even DXT high
IVD Mx
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 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
Hypoalbuminemia
Mx: high protein diet, IV human albumin 20%
50ml OD 3/7
Refer dietitians

gas gangrene (usually clostridium)

NF polymicrobial (usually staph)
Cellulitis / ulcer (non DM pt)

Any fever > 38C = septic workout

Wegeners classifications:
0 + risk factor (DM)
I superficial ulcer
II deep ulcer
III OM changes
IV forefoot gangrene
V hindfoot gangrene

To take Blood C&S, tissue & swab C&S, ABG,

coagulation profile TRO septic shock
DIVC

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 M qid
paeds 0.1 M / kg / day (also for tonsillitis)
eg: 15 kg, (15x0.1)/4 = 0.375 M 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 clean 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

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/sspo2
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 hyaluronateuse for clean
wound (granulation, absorb H20)
Dermasynuse for clean wound (to encourage
granulation tissue), liquid form: soaked with
gauze then apply tds(each time 15mins)
Elaseclean wound
Urgo/hydrogeluse for exposed tendon to
keep it moist (prevent from dying)
Urgutol(EOD)SSG, A/w(ragged wound),
sutured siteprevent the gauze from sticking
directly to the skin
Polymen patchbedsore
Duoderm geluse for necrotic patch to peel
off
Duoderm CGFuse for MRSAinfected
woundsame as meriplex
Duoderm patchbed sore, use for still-unclean

wound after the necrotic patch peeled off

Kaltostat patch for exudates (minimal)
absorption
Aquacel AGfor moist wound to absorb moist
Urgosorb patchdirty wound
Suprasorb patchdirty wound
Askina sorb patchdirty 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 humbys 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:

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

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)

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

Compartment syndrome

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
Acceptable:
neutral/volar angular < 11 (paeds: angulation
22-23 acceptable)
Radial head #: buttress plating
Ulna # : r/v after 3/52 (post POP) 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) put
volar slab at the hand in dorsiflex position

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 Yshaped configuration (comminuted)
5th MCB #
Boxer # - most common MCB #
- neck of 5th MTB #
Baby bennette base of 5th MTB #

Torus #: Buckling of distal end radius, common

in early teenage grp
Greenstick #: # 1 part of

CARPAL BONES:
RADIUS IS IN SAME ALIGHNMENT WITH
LUNATE AND MIDDLE FINGERS

Clavicle / acromial-clavicular joint

dislocation : arm sling for 6/52no need
admission r/v in clinic, no need operation if
no sharp point / neurological deficit

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

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 6/52no need
admission

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 jts
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 tibia ILN
If tibia # > displaced with segmental: ILN, little
displaced, nonsegmental: plating
If fibula # not involving lateral malleolus POP
If fibula # involving lateral malleolus(5cm

from tip of fibula) 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

skull thong (1 level 1 pound, C77 pounds)

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

Thoracic # : CRIB(stable)
Lumbar #: Stable (lumbar corset),
Unstable
(denis clasfcn: column > 50%) operation

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 - hage?
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

Stable # (<50%)-->cervical collar

>50% need operation
** any spine trauma, do operation if
neurological deficit

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 cx: sphincter d/o. if sacroiliac joint
dislocation with no neuron deficit and only
sciatica,: CRIB, pain killer
Septic arthritis:
ACUTE: must do arthrotomy washout to
prevent joint destruction
Chronic with no S/S ix and no affect fx no
need for arthrotomy washout
With S/S ix 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) will cause
long bone of # site will grow longer than the
normal bone(L)unequal limbs
In paeds:displaced fracture <50% no need
CMR: put on backslab / FLPOP
Bone healing time:
6-8 weeks for UL adult,
doubles in LL,
halfs in children
Oblique # heals faster due to high contact
surface
INTERLOCKING NAIL (ILN)
Insert 2 cotical screws prosximally to the
fracture site with 1cortical screw distally(not #
site)
ILN femur femoral nail inserted prox 2mm,
distal imm bigger than the reamed diameter
ILN tibiatibial nail prox and distal 1mm
bigger than the ream diameter
SCREWS:
Static: cortical/cancellous
Dynamic: use for near the frature site, for
micromovement of fracture site(to improve
bone healing) eg:DHS
BKA
Check Hb pre-op
2 pint WB to OT
Post BKA: uslab for the stump
Daily dressing
Refer physio for early ambulation
CEREBRAL CONSCUSSION
- h/o LOC
- headache, vomiting, dizziness, neck stiffness,
blurring of vision / papilloedema S/S
increase ICP
- KNBM, GCS charting, to inform if GCS drop
- to view Skull x-ray, CT brain TRO ICB (if
GCS drop)
- Do not give D5%, Do not give pethidine /
opiod drugs
Fall from height

TRO cervical injury, intraabd(kidney , liver),

ascending aorta, #
calcaneum,acetabulum,sacrum
3 X-ray compulsory in trauma cases:
Pelvic, Cervical, Chest XR
+ skull XR
I/O CHART
Balance +ve: input>output: lungs crept, fluid
overload symptoms
DIVC: PT prolong, plt low ** in septic shock
Cryo 6 u ( factor 8, VWF, Fibrinogen)
FFP 2-4 u (all coagulation factors)
Plt 4u
1 cycle = 1litre of fluid be ware of fluid
overload!
Withould all anticoagulant, aspirin, NSAIDS
IV vit K 10mg od 3/7 antidote for warfarin
IV 1 mg protamine sulphate antidote for
heparin
If aptt prolonged, avoid IM injection
(hematoma)
If bleeding profusely:
IV vit K (phytomenadione 10mg OD)
Transfuse 2-4 pints FFP
Chronic OM
Common Causes: infected implant
Sinus tract, pus
Tolerable pain on & pff
S&S of inflammation
Common organism: staph
XR: elevated periosteum
why sequestrum more whitish than normal
bone? Sclerotic changes
Involucrum: new bone formation enclosing
with sequestrum
Mx:
Drainage / op to remove sequestrum
Analgesia
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: atherosclerosis 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/warm 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 QIDGIVE TILL
DIARRHOE(MEANS PT TOLERATE THE
DRUG TILL MAX DOSE ALREADY)
ONCE DIARRHOEA, CHANGE TO
T.ALLOPURINOL 300MG OD
Ligament injury
Ligamnetous injury of kneeROBERT 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) 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 ankle sciatic pain (to

comfirm SLR)
Spondylolistheisis: anterior displacement
vertebral body, retrolisthesis: posterior
displacement
Spine#: dennis column>1/2: unstable: op , <1/2
stable: CRIB

Dafilon / brillon - simple interrupted

Dexon - subcuticular
STOsuture to open
Face/scalp/neck: STO D5
Abdomen: STOD7
Limbs: STO D14 (least vascularity)
STO STAT if sign of inflamn / pus discharge

TB spine: affect endplate of vertebra body

Baclofen: 10mg tds muscle relaxant
I: skel muscle spasticity ***
for PID(cant bend fwd)
S/E: drowsiness, neuron/ psy illness, reduce
convulsion threshold, hypotension, reduced
CVS fx
Carpal tunnel syndrome:
Physio,
thermoplastic splint (occupt therapy) at nite,
Surg to release (Saturday OT)
DEQUERVAINS TENOSYNOVITIS
(EXTENSOR TENDON):
FLINKENSTIENS sign: kenocort injection at
pain site** usu coexist with CTS
Procedures for HO
CMR sedation
Skel pin insertion
Recognize orthopedic emergency
Desaturate pt
Hypoglycemia / SOB / chest pain /
hypovolemic shock pt
T&S, WD, I&D, Rays amputation, irrigation
for open #, Refashioning
Wrist, digital, ankle block
Taking ABG
Set CBD, CVP
T&S: Sutures
Muscles / fascia:
Vicryl (synthetic absorbable)
Catgut (natural absorbable)
Skin

CMR sedation:
1 ampoule (5mg/1ml) dormicum[midazolam]
dilute w 4mls water for injection
doasage: 0.1mg/kg
**antidone: flumazenil
1 ampoule pethidine(50mg/1 ml), dilute w 4mls
water for injection
dosage: 1mg/kg ** need to monitor SPO2
to give 1/2 to 2/3 dose of sedation first then
flush with hep. saline
Paeds < 20kg:
Chloral hydrate :
dosage: 50mg/kg, max 75mg/kg
for normal use: 1-1.5ml/kg
Refashioning of fingers :
Digital block, apply tourniquet
use posterior flap d/t more subcut tissue and
thicker skin
Or do V-Y refashinoning
V-Y plasty crush injury of tip of phalanx
(bone not exposed)
Cut off dog-ear
I&D fingers:
Area to beware of: Snuffbox: radial n,
midwrist: median n., medial to FCU: ulna n.
SKELETAL TRACTION:
for adult >18 yo, look for epiphyseal plate(if
present, cant do)10% body wt
Supracondylar pin: closed fracture NOF
(medial lateral)
Tibial/steinman pin:m/s femur,supracondylar #
(lateral medial to avoid common peroneal
nerve )
Calcaneum pin: tibia plateau #, supracondylar

femur#
(1/3 from heel: medial malleolus lateral)
Check neurological (foot drop/senstion)
circulation chart

giving medication)
Vancomycin
gentamycin
amikacin

SKIN TRACTION: elderly or children

-NOF #(AMP), -IT#(DHS)
Not done in obese pt (as traction wt is too
heavy if counted according to body wt)

Dosage of drugs
Analgesia
PCM
1g QID
(15mg/kg/dose)
(supp PCM 1 tab = 250mg)
Voltaren
50mg tds
Tramal
50mg tds
IM pethidine 50mg tds
IM nubain
10mg tds/qid

Ankle block:
Posterior tibial nerve: plantar of foot
Deep peroneal nerve btw big toe & 2nd toe
Superficial peroneal nerve: dorsum of foot
SuraL nerve: Lateral foot
Sephanous nerve: Medial surface of foot
Wrist block:
Median nerve btw FDS & FDP
Ulnar nerve: medial to FCU tendon
Radial nerve: snuffbox area
Digital block:
2 Dorsal digit nerves, 2 volar digit nerves
In OT:
Cut hard tissue muscle (LL) eg in BKA: bone
cut with giggly saw, neurovascular bundle
ligated, muscle cut with Mayo curve
Old #, callus bonesofter (must nibble) before
do any internal fixation
Cut muscle / tendone (UL) use metzebaun
scissors
When drill medullary canal k-wire insertion
must irrigate with water to prevent
osteonecrosis (black)
Principle of external fixator
Simple trauma (open #)
near, near, (2 pins near the # site)
far, far (2 pins far away from # site)
Polytrauma far away from fracture site to
avoid the heamtoma form at the fracture site
Illizarov bone lengthening 1mm/day, 1cm /
month
TDM Drugs
(To take on D3: hour before & 1 hour after

Celebrex
Arcoxia
T Brufen
T ponstan:

200mg bd
60mg OD
400mg bd
2/2 tds

NSAID: must be given with gelusil

Antibiotics
IV Tab
Cefuroxime
750mg tds 250mg bd
(IV 30-100mg/kg/day tds)
Cloxacillin
500mg qid 500mg qid
6-12mg /kg/dose qid
C-pen
2.4M qid 500mg qid
(iv 100,000nit/kg/ day, devided into qid)
Unasyn
1.5g tds
375mg bd
(sulbactam+ampicillin)
Iv 75mg/kg/day given in bd
Ciprobay
400mg bd
Flagyl
500mg tds
(metronidazole)
fusidic acid 500mg qid

500mg bd
400mg tds
500mg qid

IV gentamycin
80mg bd/tds
(2-3mg/kg/day given in bd/tds)
(5mg/kg/day if severe infection)
IV netilmycin
IV fortum (ceftazidime)
bd
IV cefobid

300mg OD
2g stat, then 1g
2g stat, then 1g

bd
IV sulperaxone
bd
IV ceftriaxone
bd
IV vanco
Sepsis: IV meropenem
Tab EES

2g stat, then 1g
2g stat, then 1g
500mg tds
500mg bd

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
Bowel prep for xray KUB: dulcolax 2 tab