mercoledì, novembre 10, 2004
:: night duty ::yooohooo! i'm finally back from night duty! in fact, i spent just slightly more time doing night duty as compared to the time i took to get home! can u believe it?!?!... maybe i shld just camp overnight! i happened to discover this foldable relaxing chair in one of the deserted cubicles... maybe it's time to make it useful again!
stuff EW and i did today:
first we needed to find a case to clerk for tutorial tomorrow, so we asked the HOs and MOs, but alas, no one was able to give us much except lots of OMs (osteomyelitis) and #s (fractures)... so we met this really nice doc who got us to help the HO do an ECG... hehehe... the first ECG came out as flat line cos... dopey (ie me) forgot to connect the right lower limb lead. haha... next we heard there was a MnR (manipulation and reduction) but also dunno what happened, in the end maybe they did it before we could go see... but everyone was v gan jiong this evening cos there was a 'cool' case of NOF# (neck of femur #) going on in the OT... first, chang told us as we walked past him, next two MOs told us, all quivering with excitement...
anyway, we decided to head where all the action was.... the OT! having changed at record speed, we ran to the OT and realised that if we wanted more mobility within, we had to wear the lead apron... or else we would have to dive behind the protective lead shields everytime chang called out - 'x ray!' as it turned out, this happened every couple of minutes or so... the x-ray was taken using II (image intensifier), i believe it gives better resolution than normal x-rays. anyway, the nice MO taught us how to interpret tt x-ray. it was a NOF# Garden 4. he also taught us an even simpler way of defining the Garden classification -
stage I - partial #
(stages II to IV - complete #)
stage II - complete #, no displacement
stage III - complete #, partial displacement
stage IV - complete #, complete displacement
the management is as follows... most importantly, depending on the age of the patient and the grading of the #.
mx can be conservative ie straight leg (Buck's) traction, which can be skin traction or skeletal traction.
the next would be a surgical approach. a lot depends on the age of the patient. for someone young, ie below 55/60 (? not sure of the age limit), it's probably better to use cancellous screws to fix it. also it has to be done within 6 hours of the injury, for revasularisation to be successful, the longer the delay, the poorer the prognosis. all #s of the femur shld be fixed with cancellous screw, except basal # which can be fixed using dynamic screws (i think, it's the one with a plate and screws).
the process: first, two guide wires are drilled into the bone, once the position is confirmed and appropriate (via II), the screws are added, they have a hole through which the guide wire goes. the screws dun go all the way thru, this means tt it is not fixed but the femoral head is actually pulled towards the rest of the femur. normally the lower screw is done first then upper, so that a 'valgus' ... is created.
if AVN (avascular necrosis) sets in after the screws are placed, well... v sad... will have to replace the joint. if a non-union or mal-union takes place, then a valgus osteotomy would be done at the prox femur. the result is a slightly longer lower limb, but does not predispose to OA (osteoarthritis).
for someone above 55/60, a hemiarthroplasty is the rx. cancellous screws are not encouraged due to the high risk of AVN. there's no need for a total hip replacement since the acetabulum is still good...
right after this # was fixed, ANOTHER SIMILAR NOF# came in! aiyo! then chang said 'oh, oh, u know, things come in three...' but this time round, it was a 19 yo F, and it was already 10+ hours since she suffered the injury, chang seemed a bit disturbed... but i guess the prognosis shldn't be too bad, since she's really young. let's hope for the best. next up, the two of us had a little chat with some nice year 5s. then we went to the wards... clerked a case of PID. the man was really nice to talk to us at like 8+ kind of thing... and even let us examine him. heheh, we did it in the physiotherapy area for the patients...
knocked off at ard 9.30pm, and i reached home at 11.30pm. exhausted.
PS: the MO/HO told us that although we might find visits to those rehab centres, sports centres and so rather 'FON' now, we'll find them useful as HOs in the future, cuz we would then know who and where to refer the patients to.
waa... now really tired. have long since compiled our sports injury seminar and added a few pictures, still waiting for input fr R and ERR. maybe i'll do it tomorrow morning.
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francesca chiu
2 eyebags & 5 wrinkles
on long-term dormicum drip
KIV IMH
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