Reduction of anterior dislocation of shoulder

What to see: 

Xray shoulder joint: Head of humerus not in the glenoid cavity 

How to treat: 

1.Kocher's method 

2.Milch technique 

3.Stimson's method

KOCHER'S METHOD

• Flexion of the elbow to a right angle

• traction in the line of the humerus

• external rotation of the arm: this brings the head of the humerus to face forwards 

• the elbow is pulled across the body: this adducts the humerus and disengages the humeral head 
• internal rotation of the arm: this lets the humeral head fall back into the glenoid

MILCH METHOD 

• Have the patient lie on a stretcher; the patient can be either supine or prone based on his or her comfort

• Have the patient abduct the affected arm to place their hand behind their head, if they are able, and then straighten the arm at the elbow

• If the patient cannot do this unassisted, then grab patient's arm at either the elbow or the wrist and guide arm into full abduction

• With the arm fully abducted, apply gentle longitudinal traction and gentle external rotation to achieve reduction

 

 

• If reduction does not occur quickly, apply gentle cephalad pressure to the humeral head while continuing to hold traction

STIMSON'S METHOD 

• The patient is placed in the prone position on an elevated stretcher/bed

• The affected shoulder should be off the edge of the stretcher/bed, hanging downward in 90° of forward flexion

• The stretcher/bed should be high enough to allow the patient's arm to dangle without touching the floor

• To prevent the patient from sliding off the stretcher, he or she is tightly strapped down with a sheet, and 2-10 kg of weight is securely fastened to the wrist of the affected arm to provide continuous traction

• If weights are unavailable, two to four 1L containers of normal saline can be used

• The patient is instructed to maintain this position for at least 15-20 minutes or until reduction is accomplished

Written by our guest author Swapnil Bhagat

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

 Mantoux Test

 

REQUIREMENTS: 

Cotton, spirit, 26G needle, Tuberculin syringe, PPD-RT with Tween-80, scale 

PROCEDURE: 

 ▪ Select the preferred site of injection

- Non-dominant hand forearm, flexor surface (but can be given on either side) - 4 inches below elbow joint. 

▪ Ensure adequate lighting

▪ Select healthy skin which is free from intracath &/or injectable drug administration or any test dose, hairs, veins, sores, scars

▪ Take all aseptic precautions

▪ With the help of 26G needle, draw 0.1 ml of 5 TU PPD-RT with Tween-80 solution, without trapping any air bubble (for that don't vigorously shake the vial)

▪ Inject the PPD intra- dermally on volar of forearm. Position the syringe at 10-15 degrees to the forearm and insert just below the epidermis

▪ An elevation of the skin (a wheel) 6 to 10 mm in diameter should be produced. (If not produced, repeat the injection, on the other forearm or 2 inches away from the original site on the same forearm) 

▪ Patient should be instructed to keep the test site clean, uncovered, not to scratch the area or rub the area.

▪ Record the time and date of administration of test

 

▪ The test should be read between 48-72 hours after administration

 

▪ For this, measurement of induration horizontally across the arm is measured by drawing a line over it using a pen

▪ Exact measurement of the induration in millimetres(mm) should be measured. Erythema should not be measured

VIDEO LINK: https://youtu.be/F08U1DNSFy8   

Written by our guest author Manpreet Kaur

Illustration by Anveshi Nayan
#Ae(ONE)INTERN

 Toe nail removal

 

1. The patient is placed in the supine position, with the knees flexed (foot flat on the table) or extended (foot hanging off the end of the table). The physician wears sterile gloves. 

 2. The toe is prepped with povidone-iodine solution followed by spirit

 3. A standard digital block is performed with 1 percent lidocaine (without epinephrine), using a 5 mL syringe and a 22-24 G needle. About 2 to 3 mL of lidocaine on each side of the toe is usually sufficient for adequate anesthesia. Wait for some time allows the block to become effective

 

4. After checking the effect of anesthesia, slide one tip of an open artery forceps between the nail plate and the underlying nail bed (till the base of the nail plate). Grasp the nail firmly between the jaws of the artery forceps and clamp the artery forceps. 

 5. Gently rotate the artery forceps along its long axis 360 degrees, removing the nail in the process

 6. Clean the nail-bed and apply antiseptic sterile dressings

7. Any infection or abscess of nail bed should be cleaned or drained

VIDEO LINK: (**The separation of nail may be done as shown in video by cuticle separator, but is usually not done so here) https://www.youtube.com/watch?v=E6jp5bBXA04 

Written by our guest author Varun Bansal

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

Tube Thoracostomy (ICD insertion)

 

Procedure:

1. Position of Patient:

 

2. Site:

 

 

3. Apply antiseptic solution to a wide area of the chest wall and drape

4. Local anesthesia: 

-Use the 25-G needle to inject 5 mL of the local anesthetic solution into the skin overlying the region of initial skin incision

-Use the longer needle to infiltrate about 5 mL of the an subcutaneous tissue superior to the expected initial incision

-Redirect the needle to the expected course of the chest tube (following the upper border of the rib below the fifth intercostal space), and inject approximately 10 mL of the anesthetic solution into the periosteum (if bone is encountered), intercostal muscle, and the pleura

-Aspiration of air, blood, pus, or a combination thereof into the syringe confirms that the needle entered the pleural cavity

 5. Steps to insert the tube: 

• The skin incision is made in between the midaxillary and anterior axillary lines over a rib that is below the intercostal level selected for chest tube insertion with the help of 11 no. blade. The incision is made 4 cm long

• Use a hemostat or Kelly clamp to bluntly dissect a tract in the subcutaneous tissue by intermittently advancing the closed instrument and opening it

• Palpate the tract with a finger as shown, and make sure that the tract ends at the upper border of the rib above the skin incision. Insertion of the chest tube as close as possible to the upper border of the rib (minimize the risks of injury to the nerve and blood vessels that follow the lower border of each rib)

• Use a closed large Kelly clamp to pass through the intercostal muscles and parietal pleura and enter into the pleural space

• It should be done in a controlled manner so that instrument does not enter too far into the chest, which could injure the lung or diaphragm

• Upon entry into the pleural space, a rush of air or fluid should occur. Use a sterile, gloved finger to appreciate the size of the tract and to feel for lung tissue and possible adhesions. Rotate the finger 360º to appreciate the presence of dense adhesions that cannot be broken and require placement of the chest tube in a different site

• Measure the length between the skin incision and the apex of the lung to estimate how far the chest tube should be inserted

 

• Grasp the proximal (fenestrated) end of the chest tube with the large Kelly clamp and introduce it through the tract and into the thoracic cavity as shown. Clamp the distal end of the tube with a hemostat

7) Connect the chest tube to the drainage device as shown (the distal end of the chest tube can be cut to facilitate its connection to the drainage device tubing). Release the cross clamp that is on the chest tube only after the chest tube is connected to the drainage device

8) Secure the chest tube to the skin using 0 or 1-0  silk or nylon stitches. For securing sutures, two separate through and through, simple, interrupted stitches on each side of the chest tube are recommended

This technique ensures tight closure of the skin incision and prevents routine patient movements from dislodging the chest tube

Each stitch should be tightly tied to the skin, then wrapped tightly around the chest tube several times to cause slight indentation, and then tied again (but not piercing the tube) 

9) Create an occlusive dressing to place over the chest tube by turning regular gauze squares (4 x 4 in)  into Y shaped fenestrated gauze squares and using 4-in adhesive tape to secure them to the chest wall. Make sure to provide enough padding between the chest tube and the chest wall

10) Obtain a chest radiograph to ensure correct placement of the chest tube

VIDEO LINK: https://youtu.be/kEc8fn6ownc

 

Written by our guest author Mohit Singla

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

 

 Suturing Techniques

SIMPLE INTERRUPTED SUTURES

REQUIREMENTS: 

• Needle holder 

Needle holders should be held with your dominant hand

 

 

 

• Toothed forceps 

 Hold the forceps with your non-dominant hand in the same way you would hold a pen

Be gentle when using toothed forceps to manipulate skin, do not grip it too tightly or you may damage the wound's edges

 

• Scissors (to cut the sutures) 

• Written Informed Consent 

PROCEDURE: 

1. Load your needle holder by placing the needle in the tip of the holder. Needle should be held at the junction of 2/3rd distance from tip

Plan the entry and exit of your suture on either side of the wound such that on a cross-sectional view, the final suture, once tied, should appear square

2. First suture should always be in the centre of the wound

OUT-TO-IN 

3. Gently lift the skin with the forceps and pierce the skin surface with the needle perpendicular (90°) to the skin at approximately 4mm from the wound edge

4. Supinate your wrist so that the needle passes through the dermis and rises out of the middle of the wound

5. Use your forceps to hold the needle whilst you release your needle holder

6. Re-grasp the needle in the same place with your needle holder

IN-TO-OUT 

7. Lift the opposing skin edge gently with your forceps

8. This time the needle has to travel perpendicularly through the dermis from inside to outside. Use the curvature of the needle and supinate your wrist to move the needle through the skin

 9. As a guide, forceps may be kept near the exit point as follows: 

10. Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the needle as it travels through the skin, pulling the suture through as you go. You should now have a suture crossing perpendicularly to the wound, approximately 4mm from the wound edge

 

KNOT TIE 

11. Put down the forceps. 

12. Pull the suture through so that there is approximately 3cm of length on the opposing side

13. Hold the suture in your non-dominant hand and the needle holder in your dominant hand

14. Loop the suture away from you around the needle holder twice, then grasp the suture end with your needle holder

Tip: To remember which direction to loop in, place the needle holder in between the two limbs of the suture. Then, loop the suture material such that it lies over the needle holder first

15. Pull the needle holder towards you and push your non-dominant hand away to lay the first knot

16.Let go of the suture with your needle holder but keep hold of it in your non-dominant hand

17. Now loop the suture back towards you around the needle holder once and grasp the suture end with your needle holder. Take care not to pull the suture upwards (so that the surgical knot remains tight

 

18. Push the needle holder away from you and bring your non-dominant hand towards you to lay the second knot

19. Finally, loop the suture away from you around the needle holder once, then grasp the suture end with your needle holder. Pull the needle holder towards you and push your non-dominant hand away to lay the final knot

20. Once the knot is tied, use the needle holder to pull the knot to one side so it is not overlying the wound

21. Now cut the suture between 5-6 mm in length (If it is too short the knot will (If it is too long, the suture material will become trapped within other knots and they will come undone)

VERTICAL MATTRESS SUTURE

 PROCEDURE:  

Steps 1-10 as above but take a bigger 'bite' of skin either side, meaning you enter and exit the skin approximately at 5-8mm from the wound edge. (Till A and B step in the figure)

11. Now re-load the needle facing the opposite direction (away from you). The aim is the throw another suture across the wound directly above or superficial to your original throw, taking smaller bites of the skin edge to evert the wound edges. You need to bring your suture back to the side of original entry so that you can tie your knot away from the wound

12. Again, you can remove your fingers from the needle holder handle if you find this increases your dexterity. Gently lift the skin with the forceps, and pierce the skin surface with the needle perpendicular to the skin

13. Because your needle is loaded facing away from you, you will need to pronate your wrist so that the needle passes through the dermis and rises out of the wound

14. Use your forceps to hold the needle whilst you release with your needle holder

15. Re-grasp the needle in the  same place with your needle holder

16. Lift the opposing skin edge gently with your forceps

17. This time the needle needs to travel perpendicular through the dermis from inside to outside. Use the curvature of the needle and pronate your wrist to needle through the skin back to where you started

18. Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the needle as it travels through the skin. Finally, pull the suture through

KNOT TIE: Similar to above

VIDEO LINK FOR ALL SUTURE TECHNIQUES:
https://www.youtube.com/watch?v=TFwFMav_cpE&feature=youtu.be

 

Time line:
0:48 - Instrument tie and Simple interrupted sutures
04:37 - Simple buried suture (subcutaneous interrupted)
06:17 - Vertical Mattress suture
08:07 - Horizontal Mattress suture, Figure of 8 suture, Half- buried Horizontal mattress suture
10:53 - Simple Running (or Continuous) suture
12:55 - Simple Running (or Continuous) suture with interlocking
15:05 - Subcuticular running (or Continuous) suture

VIDEO LINK for simple interrupted sutures: 

For Right-Handed: https://youtu.be/z8oWv-nVO6g  

For left-handed: https://youtu.be/iuxOv3Y0OX4

 

VIDEO LINK for vertical mattress: https://lacerationrepair.com/techniques/basic-suturing-techniques/vertical-mattress-sutures/  

 

Written by our guest author Akanksha Barnwal

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

 

Management of Normal Labor

NORMAL LABOR/ EUTOCIA 

- Spontaneous onset 

- At term 

- Vertex presentation 

- Without undue prolongation 

- Natural termination with minimal aids 

- Without any complications

ADMISSION: 

1. Admit in waiting ward if in early labor OR admit in Labor Ward if cervix > 4 cm dilated, uterine activity is optimum, show, and/or spontaneous rupture of membranes present. Delay transfer to the labor ward until in active labor (i.e., equal to or greater than 4 cm dilatation practically) is established

2. Confirm reports of Hemoglobin, blood group, VDRL, plasma sugar (fasting and postprandial or random), HIV, HBsAg, urinalysis, TSH, and obstetric ultrasonography are ready and normal. If not, get them done without compromising care

 

3. Check if she has received tetanus immunization. If the patient is not immunized and directly presents during labor, give tetanus immunization to her immediately and the child after delivery is given tetanus immunoglobulin

4. Send blood for cross matching only if there is an indication for the same

FIRST STAGE: 

From true labor pains to full cervical dilatation. (≈10 cm)

 

Foetal heart rate (FHR) is monitored every 30 mins in first stage, 15 mins in second stage. 

In high risk pregnancies, FHR is monitored every 15 mins in first stage, 5 mins in second stage. 

Orders 

● Shave/ clip hair and prepare private parts 

● Simple enema stat 

● Left lateral position 

● Liquids/ soft diet orally 

● MATERNAL VITAL SIGNS: Temperature, pulse and blood pressure are evaluated at least every 1/2 hourly

● SUBSEQUENT CERVICAL EXAMINATIONS: Cervical dilatation and presenting part evaluated by PV every 4 hours

● ORAL INTAKE: Food should be withheld during labor and delivery as gastric emptying is remarkably prolonged once labor is established/ analgesia is given

-Sips of clear fluids (or fruit juices) are permitted to prevent dehydration

-Allow a gravida at low risk of requiring general anesthesia to eat low residue food or drink as desired or tolerated

-Usually a pint of Ringer Lactate also given to the patient

● URINARY BLADDER FUNCTION: Mother should void the bladder if possible, else catheterize and drain the urine using a simple red rubber catheter. (Distension of bladder is to be avoided as it can interfere with the fetal presenting part and lead to subsequent bladder hypotonia and infection) 

Consider amniotomy in active phase of labor (done by senior residents, not expected from interns). 

If the membranes are ruptured, IV antibiotic is started. 

SECOND STAGE: 

With full cervical dilatation and engaged presenting part, encourage the patient to bear down when the female feels the urge to push (with each uterine contraction).

Permit delay in pushing when the presenting part is above station +2, occiput is not in anterior position, as long as the fetus is well. 

The woman should be allowed to push with open or closed glottis (Valsalva manoeuvre) according to her preference. 

Continue intrapartum monitoring.

PREVENTION OF PERINEAL TEARS:  

● Application of warm perineal compresses: relaxes the muscles

● Perineal massage 

● Provide perineal support when head is coming out

● Avoid routine episiotomy (Although this is routinely done in most of the government hospitals) 

● Avoid fundal pressure

EPISIOTOMY: Done under pudendal nerve block using lignocaine during crowning when the head descends down (baby is being pushed). Cut at the time of contraction only. Mediolateral episiotomy at 60 degree on a stretched perineum is given using episiotomy scissors. 

Delivering the Baby: Ask a person to provide urethral support (put index and middle finger in the vagina against the anterior vaginal wall)  while you provide perineal support (put index fingers of both your hands inside the vagina and stretch it downwards and laterally).

Do modified RITGEN manoeuvre (Perineal support plus hand on occiput to cause controlled extension of head means the head is delivered in extension and trunk by lateral flexion). 

Immediately ask the sister to give oxytocin 10 IU given i.m

If i.v. line already in-situ, 10 IU of oxytocin is injected into the RL pouch

 

Delay umbilical cord clamping for 1 minute or till cord pulsations stop if the newborn does not require neonatal resuscitation or is  not a case of Rh isoimmunization.

 

● During this time, encourage maternal-neonatal skin to skin contact provided there are no maternal or neonatal complications while drying the neonate. Place the naked term infant on the mother's bare abdomen and cover them with a clean warm sheet.

 

● Touch the cord to check if the pulsation stops. After this, three Kocher's clamps are applied on the cord (2 towards the baby and 1 towards the placenta) and the cord is cut in between ( Provides extra 80 ml of blood to fetus).

 

● After this the baby is handed over to the neonatologist. In case of foetal distress, early cord clamping is done and then the neonatologist takes the charge

THIRD STAGE : 

Hand placed over the fundus and look for signs of placental separation:    

1) Increase in fundal height

2) Gush of blood

3) Permanent elongation of umbilical cord

4) Suprapubic bulging (most important) 

The uterus may be massaged 

 

 • Placental expulsion is done by Brandt Andrews Method (Controlled cord traction) after signs of placental separation

(a) Apply traction on the part of the cord outside the vulva, first downwards with one hand supporting the fundus of the uterus (to prevent uterine inversion), and then guiding it upwards and out of the birth canal once separation has occurred. 

(b) Wrap the excess length of the cord coming out around the clamp. 

(c) Repeat (a).

 

• Once the placenta appears at the vulva, both hands are used to hold and twist it gently to ensure that all the membranes are delivered intact

 

• Inspect placenta to ensure no part is retained inside

 

• Check the tone of the uterus: Contracted uterus should feel rock solid 

 

• If the uterus is not contracting, then ask the sister to give Oxytocin. If this fails, 800-1000 µg of Misoprostol is given per-rectally. If this fails, Carboprost 125 µg is given i.m. Do keep in mind the contra-indications of the latter two. Even after all this if the uterus does not contract, call a senior immediately

Following this, the vulva and vagina are carefully inspected and repaired if necessary. 

 

Episiotomy is sutured in 3 layers using Chromic catgut (0) preferably or else Rapid Vicryl: 

1. Continuous interlocking suture is taken beginning from 1cm above the apex of vaginal mucosa till the muco-cutaneous junction

2. Simple interrupted suture for the muscle 

3. Vertical mattress suture or subcuticular for the skin 

Sterile pad is applied. 

 FOURTH STAGE: 

• The patient is shifted to the side room. She is allowed to take everything (solids/liquids) by mouth just like a normal patient

 • Record the following after 1 hour: Pulse, temperature, blood pressure, tone of the uterus to be monitored. Check episiotomy scar for vulval hematoma

• Look for abnormal vaginal discharge and excess bleeding

• She is instructed not to sit cross-legged but with the extended legs for the risk of wound gaping

• The patient is asked to go to the washroom and empty her bladder. This is to ensure that there is no urinary retention, after which she is shifted to the ward

Episiotomy wound care: metronidazole+ povidone ointment iodine / povidone iodine ointment is applied 4 times/day. For excess pain, lignocaine gel is given and the patient is advised sitz bath

She is prescribed the following antibiotics generally: 

a) Amoxicillin-Clavulinic acid 625 mg TDS

b) Metronidazole 400 mg TDS 

c) PPI (Pantoprazole40 mg) OD 

Usually the patient is discharged on the 3rd day

 

Written by our guest authors Konal Ahire, Mithil Rathod and Ayushi Gupta

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

 

Trigger Finger

REQUIREMENTS: consent, povidone-iodine, spirit, a needle of 16-18G and one needle of 25G, 3 ml syringe 

PROCEDURE: 

• Prepare the site in a sterile fashion with povidone-iodine solution

 

• Using a 16- or 18-gauge needle attached to the 3-mL syringe, draw up a combination of 0.5 mL of lidocaine and 0.25 mL of corticosteroid (either triamcinolone or betamethasone)

 

• Change to a 25-gauge needle

 

• Place the needle in the midline of the finger, through the finger flexion crease at the junction of the finger and hand, and angle it approximately 50° proximally, with the bevel of the needle facing proximally

 

• This places the needle distal to the A1 pulley in the hand and is far easier than inserting the needle right at the A1 pulley. Generally, there is much less tenderness distal to the lesion at the A1 pulley

 

• Advance the needle through both flexor tendons until it contacts bone. Slowly withdraw the needle, with forward pressure on the barrel of the syringe, until the resistance encountered by the needle is decreased, indicating that the needle is within the flexor sheath

 

• This injection should not require any force, and the solution should be quite easily injected into the flexor sheath

 

(With a 25-gauge needle, injection into the flexor tendon (as opposed to the flexor sheath) requires a very large amount of force. Thus, if the flexor sheath injection seems to require a great deal of force, it is likely that the needle is positioned inappropriately in the flexor tendon) 

 

• The provider often visualizes or palpates the tendon sheath filling during injection to confirm that the needle is placed well within the sheath

 

 • When the injection is complete, withdraw the needle slowly from the sheath, and place an adhesive bandage over the injection site

 

• The provider should warn the patient that he or she may note pressure in the finger during this step. Also, warn the patient that the area injected is likely to be tender and painful for a day or two. In addition, remind the patient that steroids take some time to have effect; often, patients wait 3-5 days to experience a difference in clinical symptoms

 

• Subcutaneous injections for trigger finger have also been described and have been shown to have effect. If the injectate escapes the sheath and subcutaneous fluid is seen, the injection may still have effect

TIPS & TRICKS: 

• Palpate the flexor sheath and mark the line with your thumb nail

• Get the patient to flex their fingers in and out if you are having trouble

• Clean with alcohol swab then no touch technique

• If the needle goes too deep it will hit the flexor tendon

• Do not injure the neurovascular bundle present on either sides of the flexor tendon

• Never inject against resistance

• Ask patient to gently move their fingers while injecting. If the syringe moves with movement of finger, it indicates that needle is in the flexor tendon

COMPLICATIONS: 

1. (Most common ) Recurrence of the triggering of the finger

2. Infection at injection site 

3. Flexor tendon rupture after corticosteroid injection 

 

VIDEO LINK: https://youtu.be/0VSxtk1oQ2s   

Written by our guest author Rishabh Rawat

Illustrations by Anveshi Nayan
#Ae(ONE)INTERN

Corn removal

 Corn Removal

REQUIREMENTS:
Written informed consent, sterile gauze pieces, povidone-iodine, ethanol, sterile plastic drape, syringe with needle with local anaesthesia, scalpel with no.15 blade, artery forceps, toothed forceps, Babcock forceps, dressing material

PROCEDURE:
• Plantar aspect of foot is sterilized with help of betadine followed by spirit

• Anesthesia- local anesthesia, if required, depending on depth and size of corn

• Patient is sitting/ supine on OT table with knee extended

• PAIRING: The hyperkeratotic tissue surrounding and over the corn area is paired with no 20-24 sterile surgical blade till erythema or transition from hard to less tissue occurs

• Take a circular incision around the corn. Extend it conically inward till you reach the core. (The corn is triangular with base deep inside epidermis. Whole of it should be removed to prevent recurrence)

• With the help of artery or hemostat hold and pull the corn while extending the incision

• Apply betadine and peroxide gauze with pressure to control bleeding

• Dressing done with help of pressure bandage

Advice to patient:
• The patient is instructed to use soft foot wear
• Tetanus immunization and antibiotics as indicated
• Advice about dressing
• Salicylic acid lotion to be applied after 2 weeks or healing to prevent recurrence

VIDEO LINK:
https://www.youtube.com/watch?v=ct9enFJmlLQ

 

Written by our guest author Nitish Garg

Illustration by Anveshi Nayan
#Ae(ONE)INTERN

Lacrimal Sac Syringing

 

 

 

REQUIREMENTS: Anesthetizing eye drops, 25G broken needle and another sterile needle, syringe with sterile normal saline, punctum dilator (used only when punctum opening is small) 

PROCEDURE: 

• Explain the procedure to the patient and take consent

• Anesthetize the using eye drops

 

• Aspirate 2 ml normal syringe by using a sterile needle attached to the syringe

• Then replace this needle with a broken 25G needle

• POSITION: The patient can be supine with the examiner at the head end of the patient or the patient can be in a semi-recumbent position

 

• Pull the lower lid downwards and outwards as this causes the eversion of eyelid and straightening of horizontal canaliculus. Identify the lower punctum in bright light

• Hold the 25G broken needle attached to syringe by right index and thumb and place it on the punctual opening

• Twist it with the light pressure and introduce into the punctum first in vertical direction (downward) 

• Then change it to horizontal direction and push it medially by rotator movement-following the course of the canaliculus (first vertically then horizontally)

• Now push the piston of syringe attached to the needle, and inject 1ml of saline into the canaliculus slowly (as fast injection may give false positive regurgitation test), and ask the patient if saline has reached his/ her throat. Alternatively, note the swallowing movement of the neck

INTERPRETATIONS: 

• Water is going freely into the throat - Lacrimal passage is patent

• Water is not going into the throat, instead, it is regurgitating through the upper punctum and partly through the same punctum: 

Common Canalicular Duct block: 

a) Soft Stop to needle 

b) Fast regurgitation 

c) Clear fluid coming out through the upper puncta generally 

Nasolacrimal Duct block: 

a) Hard Stop to needle 

b) Slow regurgitation 

c) Turbid fluid regurgitation (water is mixed with pus, mucus, mucopus or mucoid material) 

 • If little water is going onto the throat after forced syringing (some part is coming out through punctum), It is called partial nasolacrimal duct block

VIDEO LINK: https://youtu.be/zyj7dErdBwc 

Written by our guest author Krishna Borse

Illustrations by Ayushi Gupta

#Ae(ONE)INTERN