Dhs procedure and hip ev

Question 1

For which fractures is a DHS performed?

Answer 1

Intertrochanteric and subtrochanteric fractures

Question 2

What angle does the c-arm have to be?

Answer 2

45 degrees

Question 3

What is the dynamic hip screw?

Answer 3

• This is a screw that is fitted with a spring to ensure that the bone and screw remain intact
during the healing process, i.e. it allows for bone resorption

-The screw acts as a shock absorber and is telescopic in nature, having the ability to decrease
in size while femur is healing
- If bone resorbs it shortens with the bone – won’t cause complications after some years

Question 4

What is the aim of DHS to the bone?

Answer 4

to stabilise femoral neck fractures especially

interthrocateric and subthrocanteric fractures

Question 5

DHS PROCEDURE

Answer 5

DMTS - Drill, Measure, Tap, Screw (sometimes screws are self-tapping – thus joined
procedure)

1. Incision made on lateral aspect of proximal part of femur
2. Guide wire introduced by aid of Imaging (AP & Lat Views) – not beyond head of femur
3. Hole is drilled via hollow screw placed through guide wire; usually drilled close to medial
   border of femoral neck:
4. Surgeon will ask for AP view to make sure he does not penetrate acetabulum (risk of
   puncturing bladder)
5. The hole is threaded
6. The DHS is manually screwed over the guide wire.
7. AP and Lateral Views to assess position of screw
8. Guide wire removed
9. Plate attached to lateral aspect of femur by means of more cortical screws
   o AP and Lateral view of plate may also be asked for

Question 6

What happens before the DHS procedure?

Answer 6

1. Park Image Intensifier on opposite side of limb to be examined

o Enter at an angle of 45 degrees

2. Make sure that table is raised enough for you to be able to manoeuvre Image Intensifier for
   AP and Lateral views
   o Lower patient dose
   o Less magnification
3. Connect Image Intensifier to Workstation. Plug into power supply and switch the unit ON.
4. Connect data cable to network to download work list
5. Before surgery, the surgeon would ask you to show him an AP and Lateral view of the
   affected limb.
6. Surgeon will perform external manipulation to align femur as much as possible
   o Remember to save images. Especially before switching from AP to Lateral and vice
   versa
7. Surgeon will scrub
8. Scrub Nurse and Surgeon will clean and cover patient with sterile drapes.
9. Image intensifier should also be covered with sterile drape/cover
   o Scrub nurse will need to do this

Question 7

What are the 5 hip fractures?

Answer 7

1. Sub-capital
2. Trans-cervical
3. Basicervical
4. Intertrochanteric
5. Subtrochanteric

Question 8

What do the 5 fractures mean?

Answer 8

Sub-capital - extends through the junction of the head and neck of femur. Above the neck

Trans-cervical –through the neck of the femur

Basi-cervical – at the base of the neck

Inter-throcanteric - passing through the trochanters

Sub-troncatheric – beneath the trochanters

Question 9

What operations should be done for each fracture?

Answer 9

Undisplaced sub-capital fracture-cannualted screw

Intertrochanteric, subtrochanteric and sometimes basicervical - DHS

Shaft fractures - interlocking nail

Transcervical - 3 cannulated screws

Question 10

How do patients with a hip/femur fracture present?

Answer 10

1. Foreshortening of the affected limb
2. External rotation of the affected limb
3. Inability to hold weight on affected limb

Question 11

AP HIP evaluation

Answer 11

• Femoral head, penetrated and seen through the acetabulum.
• Regions of the ilium and pubic bones adjoining the pubic symphysis.
• Any orthopedic appliance in its entirety.
• Hip joint.
• Greater trochanter in profile.
• Entire long axis of the femoral neck not foreshortened.
• Proximal one third of the femur.

-Lesser trochanter is usually not projected beyond the medial border of the femur, or only a
very small amount of the trochanter is seen

Question 12

Axiolateral hip evaluation

Answer 12

• Femoral neck without overlap from the greater trochanter
• Small amount of the lesser trochanter on the posterior surface of the femur
• Small amount of the greater trochanter on the anterior and posterior surfaces of the
  proximal femur when the femur is properly inverted
• Soft tissue shadow of the unaffected thigh not overlapping the hip joint or proximal femur
• Hip joint with the acetabulum
• Any orthopedic appliance in its entirety
• Ischial tuberosity below the femoral head

Question 13

DHS complications

Answer 13

• Avascular necrosis of the femoral head
• Fracture of the distal fragment during surgery
• Femoral fracture under the plate
• Screw breakage
• Incomplete fusion
• Late infection

Question 14

Advantages of pinning

Answer 14

Post op - no tractions as we already put them in place in surgery using pins and plate

Question 15

What can be done instead of DHS – when patient is younger?

Answer 15

Cannulated screws

Question 16

Why do we need chest x-ray before surgery?

Answer 16

Mainly to view heart, anaesthesia can be toxic especially with general aesthesia

Question 17

Types of anaesthesia

Answer 17

• General
• Local
• Epidural (a.k.a. spinal or trans-lumbar) - through L3-L4 – cauda equina

Question 18

Why do we do DHS and not let it heal?

Answer 18

To reduce the time for the patient being bedbound

Question 19

Problems in the elderly

Answer 19

• Chest infection
• pneumonia
• OA (up and about reduced chance of embolus although surgery
  imposes risk of embolus)

Question 20

ERCP info

Answer 20

ERCP (Endoscopic retrograde cholangiopancreatography)
o Endoscopic procedure (using a scope)
o Retrograde – contrast agent against normal flow – through the bile duct
(through ampulla of vater)
o Normal contrast is used (omnipaque or visipaque for people with allergy to
iodine)
o Screen (endoscopy&&xray)
o Sphictotomy – to widen sphincter
o Try to visualise to the intrahepatic system with contrast
o Reason for examination: PSC (primary sclerosing cholangistis) stricture (insert stent), ca pancreas (replace stent), stones&jaundice (remove stones)
o Primary sclerosing cholangitis (PSC) is a disease of the bile ducts that causes
inflammation and obliterative fibrosis of bile ducts inside and/or outside of the liver

Question 21

ERCP procedure

Answer 21

1. Numbs your throat with an anaesthetic spray.
2. Inserts mouthpiece to protect teeth.
3. Scope is inserted and passed through oesophagus, stomach and duodenum
4. Air is pumped through endoscope to distent the duodenum and allow visualisation.
5. Secretions from the pancreas and bile duct jointly drain into the ampulla of vater.
6. Guidewire is inserted through papilla to access pancreatic or bile duct (depending on where pathology is).
7. Using flouro with x-rays, guidewire and contrast-desired duct is cannulated so doctor can identify problem and treat it

The ampulla of Vater, also known as the hepatopancreatic ampulla or the hepatopancreatic duct, is formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla.

cannot enter from pancreatic duct as may cause pancreasititis- so volataren would be given

For treatment, your doctor may insert tiny instruments through the endoscope to:

Break up and remove stones from biliary tree
Place stents to open blocked or narrowed ducts.
Remove tumours or tissue samples to biopsy.
drain fluid collections when symptoms are presesnt

Question 22

Hazards in theatre

Answer 22

1. Biohazard
   - Patient can be infected and spread it to the staff.
2. Electrical
   - Plug in machine from monitor before switching on plug to prevent shocks.
3. Mechanical
   - Tripping over wires
4. Fire
   - Gas leak- if you smell inform
5. Radiation

• Reduce number of repeats to reduce dose to patients
• Ionizing radiation - Ionizing radiaiton- formation of free radicals- dame to cells

Question 23

What is pain in chronic pancreatitis caused by

Answer 23

Obstruction from: infections, stones, strictures, compression from fluid collection.

Question 24

What is PFN?

Answer 24

Proximal fermoral nailling