Distal Radius Fracture Reduction

Distal Radius Fracture Reduction 

 

1. Get X-RAY WRIST AP and Lateral View 

    

   

2. ANAESTHESIA- (Sometimes people don’t give any anaesthesia, which should be avoided)

2 Options: 

A. Hematoma Block 

-Locate fracture site
-Under sterile prepration using 20G needle Pierce and go deep
-Pull back to confirm fracture site (you will get blood)
-Inject 5-6 cc 1% lidocaine
-Wait for 10-15 min

 

B. Sedation

 

3)REDUCTION FOR COLLES

• Hold the hand of patient as if "shaking hand". Dis-impaction of fragment: (by traction and counter-traction) 

• Palmar flexion and ulnar deviation pronation (see pic) 

(it may be necessary sometimes to accentuate the fracture while applying traction to free the fragments before pushing it into place) 

 

 

4)CAST is applied with moulding (contrary to normal rule of immobilizing one joint proximal and one joint distal, the elbow joint is spared here as generally the patients are elderly) 

(while applying cast continuous traction is given by the assistant by pulling from finger) 

 Three-point moulding of cast

-1 hand at fracture site
-Other distal to fracture site on opposite side of wrist
-Assistant hand is applied at elbow

5) X-RAY to confirm the reduction and correction of dorsal and lateral tilt 

Repeat x-ray every week for first 3 weeks to detect re-displacement.

 

Written by our guest author -Pratik Mundada
Illustration by Devi Bavishi
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Cytomegalovirus mononucleosis signs/symptoms/clinical manifestations

 CMV mononucleosis signs/symptoms/clinical manifestations

I thought of turning it into a mnemonic! ABCDEFGH...

Timeline for USMLE for IMGs

BEST WAY TO PLAN YOUR USMLE JOURNEY

• September 1st of every year is when ERAS starts accepting applications. The deadline usually is September 15th (except Match 2021 where it was Oct 21st and Match 2022 where it is Sept 29th)

• This means you need to have all your documents and scores ready before September 15th.

• ECFMG certification: This takes anytime between 7 days to 3-4 weeks to arrive from the day you apply for it.
  1. When can you apply for ECFMG certification: When you have all your step 1, 2 CK, and OET scores in hand + You have graduated medical school and your credentials are verified.
  2. Credential verification: Your medical school needs to send your degree and final transcript to ECFMG. This process can take between 1-4 weeks.
  3. There is usually a delay in score reporting that happens for Step 1 and Step 2 CK around May-June every year. Be on the lookout for that and plan accordingly. If there is no delay, your Step scores should come within 3-4 weeks of taking the test. 

Crescent-shaped gametocytes in P. falciparum malaria

The most definitive finding of P. falciparum that can be seen in a blood smear when viewed under a microscope is the shape of the gametocytes.

Here is my mnemonic for it.

Urinary Catheterisation

 URINARY FOLEY’S CATHETERISATION

• Wash hands and wear sterile gloves.

• Ask someone to put lignocaine jelly at the back of your left palm.

 

 

 

• Don’t touch any sterile field with your left hand.

• As the bulb of the penis is reached it should be gently rotated down in line with the patient’s body and catheter should be further advanced till the Y of catheter is at the level of urethral meatus.

• Wait for urine to drain.

 If no urine is draining:

a) Gently press supra-pubic region)

b) Aspirate via the urobag port using a sterile syringe.

c) Disconnect and reconnect the urobag and foley's catheter.

• After visualization of urine return, inflate the distal balloon by injecting 20-30 ml of normal saline through the cuff inflation port. (Distilled water is preferred).

• Gently withdraw the catheter from the urethra until resistance is met (else excessive intravesical length of foley’s can cause it’s knotting and failure of removal).

• Reduce the foreskin (else paraphimosis can occur).

 

*For females, do not insert the whole length of foley’s as female urethral length is only around 4 cm.

• Keep the catheter and collecting tube free from kinking.

• Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

 

URINE SAMPLE COLLECTION FROM A CATHETERISED PATIENT

I) If a small volume of fresh urine is needed for examination (i.e., urinalysis or culture), clamp the catheter for sometime so that urine is collected in the catheter tube.

Disinfect the site of collection.

Remove the clamp

II) Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag.

 

URETHRAL CATHETER REMOVAL

Use a syringe to empty the balloon, and then apply gentle traction. 

 

Written by our guest author - Anveshi Nayan

Illustrations by Anveshi Nayan

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Suture and Staples removal

SUTURE/ STAPLES REMOVAL

• IN MOST CASES, sutures and staples applied to surgical wounds are removed in 7 to 10 days.

• Inform patient that they might feel slight discomfort, such as a pulling sensation or stinging.

• Wear clean gloves and remove the dressing.

• Inspect the wound for edge approximation and signs of infection 

1. If after the longest adequate time, wound hasn’t approximated, it means it never will until underlying cause for the same is treated and so, sutures are removed nevertheless.

2. Serous discharge from a wound is generally not problematic

• Remove the gloves, wash your hands, and put on sterile gloves. 

• Clean the suture line with an antimicrobial solution before and after suture or staple removal.

• Always first remove alternate sutures/ staples. Assess the wound for dehiscence; if none occurs, remove the remaining sutures.

To remove a plain interrupted suture

REQUIREMENTS: Sterile gauze piece, Ethanol, Blade and Forceps

•  

  
  

• Gently grasp the knot with forceps (by your non-dominant hand) and raise it slightly.  

  Place the curved tip of the suture scissors/ blade (in dominant hand) directly under the knot as close as possible to the skin 

• Gently cut the suture and pull it out with the forceps with the direction of pull being ‘over’ the wound rather than ‘away’ from the wound (to prevent any tension on the wound).

  
  

  

• Forceps may not be available (not recommended but it may sometimes be the case) so hold the knot up with one hand and cut the suture directing the force such that the sharp edge faces away from your other hand (to prevent injury to self).

To remove staples

REQUIREMENTS: Staple remover, Sterile gauze piece, Ethanol

• Place the lower jaw of the remover under a staple. Squeeze the handles by depressing your thumb completely to close the device. This bends the staple in the middle and pulls the edges out of the skin.

  
  

  
  
  

  
  

  
  

• Do not pull up the staple removal device.

• Gently move the staple away from the incision site when both ends are visible. Hold the staple remover over a gauze piece or sharps container relax pressure on the handles, and let the staple drop into the container.

After suture or staple removal

• Count the number of sutures/ staples removed and re-confirm with patient (to ensure none is left).

• Apply sterile wound strips to prevent dehiscence. 

NOTE:

• If dehiscence occurs, cover the wound with sterile gauze saturated with sterile 0.9% sodium chloride solution and immediately notify a senior.

• Don’t remove remaining sutures or staples if dehiscence occurs.

   

  REFERENCE VIDEO LINKS:

• Removal of plain interrupted suture: https://youtu.be/Hg-bSb1FLTA 

• Removal of surgical staples: https://youtu.be/OatwWz1k2s8 (** DO NOT HOLD THE REMOVED STAPLES IN YOUR HAND)

Written by our guest authors - Anveshi Nayan and Neha Kumari

Illustrations by Anveshi Nayan

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Plaster Removal

 PLASTER REMOVAL

GENERAL GUIDELINES: 

Reassure patient and inform that the saw blade may get hot.

1. Support and position limb.

2. The noise of the electric cutter frightens some children, and so shears may be used.

3. A plastic skin protector strip may be inserted between the cast lining and a patient’s limb in the area where cutting will occur to protect the skin.

4. Cut steadily and smoothly while conversing with the patient to divert attention.

REMOVAL OF PLASTER CAST WITH STILLE’S PLASTER SHEARS:

1. Draw guidelines down the side of the cast making sure that the line does not run directly over any bony prominences. 

2. Insert the blade between the plaster and the padding wool, parallel to the skin with the handle held steadily in the vertical position. The other blade cuts through the cast from above, its handle should be parallel to the cutting line at rest. 

This is the starting position, and if the blades are incorrectly aligned, the lower blade will press into the flesh causing bruises or even lacerations.

3. After each cut, the blades should be realigned before the next cut is made. This prevents the skin wrinkling in front of the shears. 

4. Use the plaster benders to open out the cast.

5. Use scissors to cut the guaze padding. 

REMOVAL OF PLASTER CAST WITH ELECTRIC CUTTER (MORE COMMONLY DONE):

1. The electric cutter must only be used to cut completely padded casts.

2. Position the blade at the start of the guideline, apply gentle pressure and move the cutter smoothly along the line. 

   
   

3. The electric cutter should always be used carefully especially near bony prominences such as the medial border of the foot leading to the big toe. 

4. Rest of the procedure is same as above.

CARE OF THE PART AFTER CAST REMOVAL:

• Examine for any injury.

• Instructions for the patient:

1. Wash and dry the part.

2. Gentle massage with oil, or cream, may help to restore normal nutrition and elasticity to the skin.

3. Some swelling of the limb is expected after a period of immobilization, especially in the lower limbs.Excessive swelling may be managed by elastic wrapping or intermittent limb elevation.

4. Continue exercises as advised and resume normal activity gradually, resting the part at regular intervals.

Practical tips and tricks:

1. Never try to cut around corners. Always remove the blades and cut from the opposite end of the line to meet the end of the cut already made.

2. When using shears, keep the elbows relatively still and apply the cutting force from the shoulder girdle and chest muscles. This gives a more controlled power and saves energy.

REFERENCE VIDEO LINK:

Plaster cutting with electric cutter: https://youtu.be/3yW_-Aq0O0Q 

Written by our guest author - Rishabh Rawat

Illustrations by Anveshi Nayan

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