Dhs procedure and hip ev Flashcards
For which fractures is a DHS performed?
Intertrochanteric and subtrochanteric fractures
What angle does the c-arm have to be?
45 degrees
What is the dynamic hip screw?
• 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
What is the aim of DHS to the bone?
to stabilise femoral neck fractures especially
interthrocateric and subthrocanteric fractures
DHS PROCEDURE
DMTS - Drill, Measure, Tap, Screw (sometimes screws are self-tapping – thus joined
procedure)
- Incision made on lateral aspect of proximal part of femur
- Guide wire introduced by aid of Imaging (AP & Lat Views) – not beyond head of femur
- Hole is drilled via hollow screw placed through guide wire; usually drilled close to medial
border of femoral neck: - Surgeon will ask for AP view to make sure he does not penetrate acetabulum (risk of
puncturing bladder) - The hole is threaded
- The DHS is manually screwed over the guide wire.
- AP and Lateral Views to assess position of screw
- Guide wire removed
- 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
What happens before the DHS procedure?
- Park Image Intensifier on opposite side of limb to be examined
o Enter at an angle of 45 degrees
- 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 - Connect Image Intensifier to Workstation. Plug into power supply and switch the unit ON.
- Connect data cable to network to download work list
- Before surgery, the surgeon would ask you to show him an AP and Lateral view of the
affected limb. - 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 - Surgeon will scrub
- Scrub Nurse and Surgeon will clean and cover patient with sterile drapes.
- Image intensifier should also be covered with sterile drape/cover
o Scrub nurse will need to do this
What are the 5 hip fractures?
- Sub-capital
- Trans-cervical
- Basicervical
- Intertrochanteric
- Subtrochanteric
What do the 5 fractures mean?
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
What operations should be done for each fracture?
Undisplaced sub-capital fracture-cannualted screw
Intertrochanteric, subtrochanteric and sometimes basicervical - DHS
Shaft fractures - interlocking nail
Transcervical - 3 cannulated screws
How do patients with a hip/femur fracture present?
- Foreshortening of the affected limb
- External rotation of the affected limb
- Inability to hold weight on affected limb
AP HIP evaluation
- 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
Axiolateral hip evaluation
- 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
DHS complications
- Avascular necrosis of the femoral head
- Fracture of the distal fragment during surgery
- Femoral fracture under the plate
- Screw breakage
- Incomplete fusion
- Late infection
Advantages of pinning
Post op - no tractions as we already put them in place in surgery using pins and plate
What can be done instead of DHS – when patient is younger?
Cannulated screws
Why do we need chest x-ray before surgery?
Mainly to view heart, anaesthesia can be toxic especially with general aesthesia
Types of anaesthesia
- General
- Local
- Epidural (a.k.a. spinal or trans-lumbar) - through L3-L4 – cauda equina
Why do we do DHS and not let it heal?
To reduce the time for the patient being bedbound
Problems in the elderly
- Chest infection
- pneumonia
- OA (up and about reduced chance of embolus although surgery
imposes risk of embolus)
ERCP info
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
ERCP procedure
- Numbs your throat with an anaesthetic spray.
- Inserts mouthpiece to protect teeth.
- Scope is inserted and passed through oesophagus, stomach and duodenum
- Air is pumped through endoscope to distent the duodenum and allow visualisation.
- Secretions from the pancreas and bile duct jointly drain into the ampulla of vater.
- Guidewire is inserted through papilla to access pancreatic or bile duct (depending on where pathology is).
- 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
Hazards in theatre
- Biohazard
- Patient can be infected and spread it to the staff. - Electrical
- Plug in machine from monitor before switching on plug to prevent shocks. - Mechanical
- Tripping over wires - Fire
- Gas leak- if you smell inform - Radiation
- Reduce number of repeats to reduce dose to patients
- Ionizing radiation - Ionizing radiaiton- formation of free radicals- dame to cells
What is pain in chronic pancreatitis caused by
Obstruction from: infections, stones, strictures, compression from fluid collection.
What is PFN?
Proximal fermoral nailling
