PERIOPEI{ATIVE

VEXam
PERIOPERATIVEMANAGEMENT
PERIOPERATIVEMANA GEMENT
PERIOPERATIVE MANA GEMENT
PERIOPERATIVE MANAGEMENT
PERIOPERATIVEMANAGEMENT
PERIOPERATIVEMANA GEMENT
PERIOPERATIVEMANAGEMENT
PERIOPER{TIVE MANA GEMENT
PERIOPERATIVEMANA GEMENT
PEruOPERATIVEMANAGEMENT
PERIOPER{TIVE MANAGtrMENT
PERIOPtrR{TIVE MANAGEMENT
PERIOPER{TIVE MANA GEME,NT
PERJOPER"ATJ \'=F\4 A},JAGE\4 E \; T
FER}O}'ER"ATJ \,'i- \,f,T}iA C E\4 E \T
[ } E Ri O PE I T A T ]\'FM i \A GE \{ F }iT
P ERI OI}E,R.{TJ VE \,f,qN,AG E\4 r\T
F EP.'J OPERATI \,'E't,lAN .a,C E \/i E:i T
jlf Ri CFtr ilA,Tl \' F lr{Air.A C E\,iE liT
PFR.ICIiE R-A,TI\''EiriAN A C E \{Eli T
EOSPTTAT.CHARTB,IG
Preoperanve nole
32 rlo BF presenrs for surgcai correcuon of her parnfiri bunion lefi foot Condinon has nol resolved lvit}
consenztive
therapr'.
PMH: IDDN( HTN (n'elJ-controlled)
Meds: insulin Procardia
Allergres: no }gtoun dnrg allerpes (NIOA)
Social Hisot.t':
Pas SurgicalHjson:
I-abs: Chemrs4'= Na Cl BU^-
Glucose
K CO creat

CBC= r*6 hemogJobin ptrrclcrs PTIINR/PTT=

lrenutocnl

Urinall'ss:
Serum HCG:
Fool x-ra1s.
Chest x-rar': no actjve lung disease
ECG: normal sinus rh1'thm

Imprc'ssion: hall uri abdrooralgus defornun' lefl foot

Plan: l. surgical correction Ieff tE:nion deformiq' as per anendrng

2. pauent medicalll'cleared for procedureas Dr. PMD
3. consenlsigd
f"rocedure revieu'ed u'ith panent including risks. benefiu and complicanons: all quesions ansuered)

Posopcranve nole
"SAPPPA mM PC"
eponlm:
S. surgeon
A: aqsr$ant(S)
P: preoperalve diagrrosis
P: pos operatir'e dagnoss
P: prrcedure
A. ancsthcsa (ie-general; spiral: local: I\/ sedationu'ith local)
H: hemosusrs (ie-ankle or thigb prreumadctourniquet irdlated to _ mmllg for _ minules: lo.:al control)
E. esnmatedblood loss
M: materials (ie-zunres: drains: fixadon bone grafts: etc)
I: inlectables(je-rntra- or posl-op local anesthesia;seroids)
P: parhologr' (ie-bone: sofi Gsue: foreigr bo{')
C: cornpbcanons
C: condruon - Suble. Fair. Guatded Cridcal

Padent roleraredboth procedure and anestlresiaq'ithorn apatenl complicatjons and u'itlr I'ital sigrs remaining
sable tluoug}our procedue. Pauent transponed fiom OR to RR nith rzscular sranrs inuo to (R/l-) LE.
esconed br, member of aneslresa deparment and podiafic slupcal resident.

159
Poo-op and Admission Orden
"ADC VANDILI,IAX"
eDon\:rn:
A: Admit to the senice of Dr. Mlodzienski(PodiatricSurgen')
D rti2gDosls
C: condition(ie-suble)
I
\/: r'itals (ie-monitorriul signsq shiff asper floor protocol)
A acrivit_v(ie'bedrcst)
N: nursing(iederzte lefi leg andapplviceto dorsumfoot;
D:dia
I
I: rns/ous
L: labs
M: meds
-A:ancilla4' persorulel(ie-ph1'sical tlrerap:,socialsen'ice)
X: x-rap

In-Padenthogress Noe
I
2/2E/95
6:30am
Podiaric Sureen'
S: Panen'r"isted at bedside:oflen no complaints
Patjent deruesexperiencing SOB. chest parn cougll calfthigh pain
I
Good appetite- - rnu-seaA'omining - abd paln
+ r,oid + BM

O: T mar , T pesentll' . BP, P. R

LunS - clear to ausnrlution (CTA)
Lefl foot - NVS inuo
u ound edges appcar healthl'- r'iable
I
u,ound margins approxmated u'ilh sutures
- dehisenct- - draragq - prnrlence
- erytbem:. mild locafized edem"
I-ab6 - u,ound culture lefl foot [colJmed 2127/95]MRSA sensirivelo lancomvci.n
X-ra1's - no erosive changesconsisenl s'itlr oseomvelirjs noted

A: l. SiP I & D ditbetjc foot infection- n'ound serus rmpror"ing

I
2. IDDN4-blood sugan uell-conrolled

P: 1. dressing changeperforme. u'ilJ continue rlailv local u'ound care

2. continue IV Abx n'ill check peakrtough levels
vancomvcin (day #5)
3. u'ill rereat u,ound cultures and CBC lomortou'

Signanre

Basic Preop l:bs

Reasons for orderi-nglabs
a) indication of infection
b) indication of anemia
c) indir-tion of hemorrhage
d) indicadon of h1'per- or h1'pogll'cemic state
e) indicqtion of renal disease
I
I rrdicatioon of coaguJoPathes
g) i:rdicarion of memboijc disease

160
I
NonndEb1|5lues
a) CBC qith diflerential
WEIC: 5000-10000 cell9ul
R B C : m e l e s4 . ' 7 4 . 1 : i1 0 c e l l V u l
females 4.2-5.4x l0 cellVul
hemo$otnn: mzles l4-18 g/dl
females 12'16 gd
hematocril: males 40'54%
fernales 3'147u/o
mqrn ceUhemoglobrn(MClIt:27-31 picograms
nrean cell hemog:lobinconcenuzltion(MCHC): 33-37'/'"
n'reancell volume (MC9: males 80-94 um
fenrales8l-99 um
plateles: 150000{50000 ul

segnrentedneunophiJs:4l'7lo.io basophils:0-lozir
sabsneurrophils:S-l0f/o llmphoqres:2444y"
msrnophils: l-37o monocl'tes:3-77o

rericuloore counl (norrral = l-SVo)

indicator of enrhropoieuc actirrw
retjculoqnes arc inrmature RBC's u'hich silJ possessa nucleus
value) lvit-b an
,ormal bone rnarrou' responds lo decreasein enrlrrocrres- (rndrcated b-r' hemarocrit
increasein produaion of reticuloclres

I.efi sldff
m4'be rndicadon of infecDon loxemia' hemonlrage
80%
prescnl in rhe CBC .n-henmore tuln2Cf./os€esare seen or u'hen Oleronl PMN counl is gearer lhan

b) Cbemisuf'
sodium: 134-149medl
potassium: 3.2-5.2 mqA
chloride: 94-l l0 mmol
carbon dioxide. l9-32 mmoM
BIJN: G26 mgldl
creatinine: 0.4- 1.5 ntg/dl
gJucose:56'Da m{d

c) Coagularion Sudies
PT {got}uonrbin ume). l0.l-13-l seconds
PTT-(acrn'aredparual rlromboplasrin dme): 23'5-34'3 sec
d) Urinallsis
color-'r'elloq
appearance:clear
gJucose(glu ua): negaove
kerones(ka ua): neei$\t
rcculr blood roc bld u;: negative
FrotelD (Pro ua): negative
rutrales (nil): neggdve
biiirubrn (bi-bru): Degove
specrtrc8ra\1q': 1-01G1.025
pll:5.0-7.5
leuiioqte eserase(leu): negauve
urobili-nogen:0.2- I .0 eu/d

161
 CBtiiiih
tnGryr€dngtbe-
ke1'poinls lo nole include:
a) WBC count
cell
>correlate counl \\1th differential to derermi-neexent of infecoon lefi shifi- eleranon of a specific
lineage (ie-eleruion of llmphocrres ma)' indrcate a state of chronic infecnon)
b) RBC count
>correlare $'ith indjces (MCR MCV. MCHC) to determr-neanemic statesand specific t-r-pesof anemias
c) HemogJobin
>fldjrqreq o\rgen cal4ing capacin' of RBC lo tissues: major concern rn po9-op healrng
d Hematocrit
>correlate $rth RBC count and indices to determine anemic sales

Alrcrarions in l:b Parameters

complae iisting of factors
There are numcrous faaors that can alter eve4' aspect of the prc-op lab rzlues. A
l}ul nrav alter $e
Braen &
rariouslab.ralues can be found in anv referencemanual (ie-Cijnicran's Pocket Reference b1' Gomella-
Olding)

.. al4?5
;.F,h.

ft --s-

Aar.nnli^OO'3
J.1EE ({,,,11)
s9 i ++ Fo Ttp
1
En&:ne
tpg) - i
enrlnurs. niurf -:5l!tTul!----------&
-''
rr.3sg=€ --, gg
0ral€ClE, Fulrlatf .}Jodi E r oFc@ lXI n!

_T::FT-
taIFruA.q Ero.' FrT !r Ktror

t62
 Wvtt@ Hsfi#Poetr
:thrre:tElB
-
ds ti,dlB ft r,lt.

-.c !6,a, J6Lrn .- dzelrs

rto€l

'r"l
f s.
Q.r
s 3gi
$ rs:.rc---. -.' -
w\.r,te vercoeet
dt-e.)s (g"r'ty)
s,q i*& fo rQ-l r , , s7 r e pni.,
r?tu -i1- nvts
?€ao
lrsrntDl lh.6ru

e. * @& -. .6 r 2 1 r l 5 € ?. -
. Ou. S , tS ur iGt(l rc E 6Ytia6. bl m['
rCiri> -a "O[ trc q$ff ! !r Iru leo*

Peri-onerat ive Co m nli c'ations

Fever

uithana'erase
4 c e7..-ss.s). of 37or 98.6
reruperarure
};:Ttrffi is 36.5_37 facrors
is unaflected b1' errernal cooling
higher becau-set'is r.arue
o rect2r lempcr:r'\ues are us'e'v r F
associateduither-aporadgarh2loccursu'henlra]lemp€I:lru'esaremeasured finding and the
F during tlre postopcrative period is a significant
. bodl, rempemlurE lycaler oun.l00.4
erioiogl' titoUa tr determined
h1'pothalamusis responsible for trermoregulaoon
. crurenl theo4' states thal tte anrerior in dre a'nr a:rd $e
oi,e]Trp.r"*e $'ith dre lo$'esl readrng
r u)oSt people exlu=bitdrunul oucruation
highesr reading in the P'm

Pcri-operativc fcver

. Mallgrranr h1'Penherrnra
c incidence
\+ 1/12000 Pedrarncane$hencs
r+ 1/40000 adulu anesdreucs
. s1lscePiblePonents patients)
r+ eleyared CPK preoperativell' {occurs.in-7V/o of susceptible
of anestbesiaprobl ems
\+ i"Ji: fu ooft' i Oo-tolo-r inieriunce)
'+ EKG abnormalioes presence of cafleine.
in viro isometnc conra crure tesung in $e
\' Ci*"".i. - :ikeletalmuscle biopsi' and
helolhane' or bot-b

. tiggeing ogents
etlrer' halo*rane' enllurane)
\+ anestlreuc agcnts (ir*r'alarional agenls sucb as
t+neuromuscu]arblockingagents(i.e.succinvlcbolile)
5 Sress

163
 . .- sit7np I o ms'5rITLS -
\+ rapidll' progressive reactron
r+ first sip usuallv arnthuruas
\+ masseler muscle spasm
t- rapidlY rising temperature
\+ uchlpnea/tach1'cardia
L+ profusehl,perhidrosis
\+ merabolic and respirato4' acidosis
r+ dark monled skin
,+ hyperkalemis l$ding to cardiac {'srlrhmtas
'+ elevated CPK levels
\+ excessive my'oglobin release

. neonnenl
L+ Stop the administration of alestlresia
\+ change anesdteucrubilg
\+ bvpen'entilate udt-blOOYo02
\+ correcl the acidosls
.* cool tlre prtienr

\+ Danuolene sodium (dantnum)

subside or until rnanimum dose of l0 mglkg has been reached

before scheduled surger]'

produced b1' stress. The sarcoplasmic retjculum n'ithin muscle contains - i000 times $e amou:rl of
Ca* normalll'present in t-hesarcoplasm. ln order for muscle conracrjon lo ocflrr. sarcoplasmic
1sfis1jrrm mu$ releas€ Ca- into the sarcoplasm- Tbe sarcoplasmic reticulum t}ten musl res€gueser
the Ca* in order for muscle reloiation lo occut. When malig:rant h1'pen}rermia occurs the C-a* ions
cannol be reabsorbed b1'the sarcoplasmic reticulum: tre concenratjon of Ca* inside the cell rises
actir,'ating a series of meubohc reactions leading to the amptoms of malignant h1'pertlrermia
Danuolene u'orks b1' preventing the releaseof Ca* from the sarcoplasmicreticulum.

Posropcrative Fever

o rulemoruc [\\'ind Walk, Water. Wou:rd Wonder dtugs]

. The mnemonic onlv sen,esas a guide to derernunethe possible causeof a post operarive fever. Il
repres€nlq Oremore common erlologies of fever a! a given nme during t}re pos operative period Keep
rn mind rhel mosl of t-beetiologles can potenualJl occur al aln' ume dun-ng the perioperauye period
(dependmg on n'hv the prtient is hospitalized and q'hat proceduresare performed).
. tnlraolxronve
!+ malienanr blper$ermia
. [\/indl ]2-24 hours posl oP
.- atelecrasis
,+ posl op brpenhermra

164
 - --fl\tdkJ 24 hours'post
r+ thrombophJebitis
r- pujmonan'embolism
o F\;alerl 48 hours post op
,e un
, lWoundl 72 hoursposl op
,+ post op u,ould rnfecDon
r [\\'onder drugsJ anvnmeposl op
\+ drug fever
. Other causesJon.r,imepg op
\+ IV catheter phiebitiVinfeaion
\+ catreler infecuon
r+ constpa.tion (?etiologi')
r+ benign postopcrativefever (temperarweincreaseof less rha 2 F 48-52 and 72-78 hogrs posl op
u'ithout an1'sigru of complicaoon)
. n,ork up
. The u'ork up of postoperativefever begins urlh a careful and lhorough H&P. The parienr should be
quesrioned specif calll'abul q\mploms sucb as SOB. chesrparn, dvsuna. parn ar the IV sire erc. .
Look to see if tbe prdent is on anv neu' medjcations(i.e. lou' dose hepann. antibiotics) to ry and
deternrine if the fever rna]'be a resull of a medicatjon. Be sure to ilspect all catheter srtes. I:boraton
evaluatjon car begin u'ith simple tests such as a CBC uitr differenrial. UA and CXR Blood culrures
should also be obtau:ed il it is believed t}lat tlre fever is from a seprrc source. h is recommended that 2
sets of blood cultures be obuined to a'r'oid tbe potential of uearing a conrarnirulung organisn that is
found in onll one bottle

Scvcrc inrract able pain

5 sutures loo ti€ttl

e consrricrive/tighr dressings
!+ hemalOme
'+ ischemia

\\'hirc roc

orteriol in nolure tusaallv caused b), macremboli. arteial insaficiencv. ot,er srretching of
neurot,ascular bundle w,ilh loe lenglhening or repostioning)
u-ruallv an acurc incident, therefore lhe onset oJ ischemia is rapid and severe (no nme
for collateral
crrc-ulalton to develop)
s),mpIoms,/stgn-\
'*excruciaung pern
*pale coloratronri'ith blue monlng
.- parasthesla
.+ pulselessness
IreoImenI
'+ avoi d nicotindcafleine
'-D/C icelelelarion
'.place foot i:: dependentposiuon
'* loosen outer/inner bandage
'+piSon/route lo€ on K u.ire
r>ll'arm compressesto proximal neurorascular br:ndle
'+local nen'e block proxinal lo area to proride disal vasodilarion
'+ r'asgular $uger_\'consult

165
 t
Blue loc

a represen$ stasis-frompoor arterial in-llov'or sluggishvenousoutl1ov

t
a eriologv
.*micro€mbobc shon'er
r+post op complication
t
t
> right dressiny'cas
> "tourniquet eflect" of large 't'olume of local anestheuc
> poor tissue handltng techruque
- impingement of tissue betrveenbone or fixation device
> dissecring hematoma
.* paraneoplastic di gital r-brombosis
*+uansienl vasospasmof dig:tal vessels
I
> coUagenvascular diseases(rheumatoidarthritis. SLE. sclerodernu)
> Ralnaud's dtseaseor pbenomena
> acroc]'anosis I
IreanrenI
'*blue toe secondal'lo venous rnsufflciencv
> loe is usualll' 'u'arm and mal' blanch n'ith pressure(rna)' not blanch if severe)
t
> inspct dressrng
> DIC ice ar:d elevation
> avoid dependeno'
> do nol anempl to increasevascular perfusion
I
'*blue toe secondary to arterial insufficiencl'
> loe rs cold and does not blanch uith pressure
1
> lnspect dressing/l( n:res
> D/C ice and elevauon
> avoid nicotine and cafleine
> heal ro popliteal fossa or anterior groin
I
> Otermostat controlled heat lamp over fool trith temperarure nol lo erceed 90 F
> r'asodilators T
> il condjuon persists 12-18 hours- consider more radical mcasures
I
blue toe ryndrome mav also be seenin non'sargical setnngs
'*drug induced
.- anti coagujanl tlerap\' (coumadin)
'*prednisone therapt'
t
'*secondary slphilis
'*pheochromoc\loma
'+ hvpercoaguable sutes
'-polvcvthern:a I'era
t
-* tluomboqvtosts
s coa gulation disorders
'* aneri oslerosis obb terans
T
'+ tluomboan gii ti s obl i t eraru
'+cvanotic congeniuJ bean disease
I
t
166
t
t
ANE]\{IAS

Classif c"uon
a) rclauve
1. pregnanq'
2. nutritional defi cienq'
3. splenomegall'
4. macroPobrilnelrua

b) absolute
I decreased rcd blood cell production
>drsurbance of proliferation and diflerentiation of sem cells
-aplasnc anemia
-rm'elodvsPlasuc anemia
>drmlbance of proliferarion and diflerennation of enrhroid progerulor cells
-pure red cell aPlasta
-anetruaof chroruc renal drsease
-anelrua of endocrine dsease
-congcniul $'senthroqti c
>drsubonce of hcmogJobrnqrnthesis(h1'pocluonuc)
-iron deficiens\'
-$alassenrul
-idiioprhic prrlmonary hemosidcrosis
>dimubance of DNA sr.nrhesis(meglobla*ic anemra)
-\r nnin Bl2 deficienq'
-fobc acid defioenq'
-pr:rinelpnrimidrne metabolic defecrs
>uni'TouI or muJtiple mechani-sns
-anerniaof chronic disease
-sidcroblasoc anemia
-ane[ua associatedn'it]r marroq' inflratton
-ancmra associatedn'ith nuritional defici encl'
2 rrcrcased red blood ceUdesrucnon
> irnrirsic abnormalll'
-membrale defeas (ie-berediu{r' spbercqross)
<n4me deficienry (ie46PD deficrenq': porphlria)
-gJobrnabnorrnahtl' (ie-sidle cell disease)
-paroxvsmal nocturual hemogJobtnuria
>ex'u-ursic abnormalin'
-mechanical
-chemical of Ph1'sical
-infectious
-antibo{'medarcd
-hlperacove macroPhage q'stem
$lood loss

Preoperative Eral uarjon

a) hemoglobinrbernatocnl Gf gMlct)
most anemias(unles
l. snoUObe eraluared in all patients(especialh'rn mensru:drg fernales)since
selere) are aqmpomqtic
elective sursell' should be
2. Ho should be above |ry/. (Hgbz l0 gr) for maies u'td37o/ofor females. or
delal'ed determi::e caus€:repeal rcst to rule-ou lab error

r67
 t
b) Apla*ic Anemia
riith drugs.
I
l"lai-be congeruul (ie-Fanconi. Espren-Damesirdi). idiopathic. acquircd or associared
chenucal
Condinon is
agenls. radiadon infecuon nreubobc

parcltopena. The anemrais

chanoerzed b1'rhe loss of
changes
hematopoetic
(ie- pregnanq')
cells.
or rmmunologc
frq'replacement of
fanon.
rnarroq'and
generalll'normocltic and the prognosisis largell' &termined b1' sevenq'
t
Recognition and remor"l of causernal' lcad to remission.
I
of associaredrhromboqropenia and lcuitopcnia.
Trarrsf,usjonsare usuallv nol Decesss:rr1'unlesshentog:lobin falls below 6-7 gn/dJ-. Regonse to
glucoconicoids. androgeru and immrmosuppressive agents are rzriable. Bone marrrou'rransplanu are being
panens.rrifi severeaplastic anemia n'ith mavked bone marrou'hlperplasia.
forformeO in

c) Iron Defi cienq' Anemia

t
The most adranced suge of iron deficienq-, charaaerized b,vdecreasedor absenl iron sores, lon' serum
rron concenuation. lorv transfemn saluration and loq'hemogJobin concentration or bernalocril ralue.
Mal,occur as a resrlr of inadeguaredieu4'uon inuke. malabsorptjon of iron cbronic blood loss
pregrano'and laoation irurarascular hemoll'sis
diversion of
or a
I
iron ro feral and infrnt erytluopoiesis dunng
combinarion of these czluses.The nrosl cornmon Eluses are excessiveblood loss d:e to heall
bleeding mu;riple pregnanciesor GI bleedrng. In severeuncontplicated iron deficiencv anernia the
mensmnl

enrhrofres are h1'pochromicand nucroqtic, plasma iron concenrradonis decreased iron bindlng capaotf is
I
increased- scrum femnn conc€nrarjoD is lou'and the fiee eD'thrcc]le protoporpb'rnn concenrration is
lncreased
Farigue irriubilifl. palpiutiors. u,eal:ressand headacheare conilron complains of palienu lvith iron
l
deficienqi Once it hasbeen establishedthat a person is iron &ficient and the causeidentified
replacemenr trerapv sbould be insrirurcd rmmediatell'. Oral or;nrenteral ue:ltrDeDl ls reguircd u'itb oral
,drrrirri*uon
indicared
berng the prefened roue. Unless the anemia is enemelv severe. blood ral$xion ls nol I
d)' Megaloblastic Anemia
,if-ril1. of disorders shouing charaaeristic abnormaUtiesof blood and marrou'caused b-vi:npaued
I
DNA srntlesis. Deficiencies of I'itamin Bl2 and folate accounl for over 957o of the nregaloblastic
anenrias- Ancmia m4r'be
hematocrit becomes exuemely
mild or s€\'ere.bu becauseit develops slou'ly- few qmpoms apr
depressed
fadgue- Iigbr-headedness and shortncssofbrcath,
\Vhen thev appear, s\mFoms include s'ealoesg
until rbe
palpiurions
Patientscharaoerisocelll' shou'sligbtjaundice and
T
"lemorl-r'ellon'n tint'
se\/erepallor. producrng rlrc rclhale
I
Diflerenuadon of pernicious arernia (inabilin'to absorb vihmin Bl2 second.rryto lack of gastic inriruic
from or}er megaloblanic anemias is essential since ueatmeil \\'itl B12 (cobalamin) must be
facaror)
contrnued for rhe patient's life. Alrhough correction of Orehematologic abnormalities of pemiciotts
anemia mirv occlr' folJouingrbe adminisradon of large doses of folare- neurologic damage proglessesand
l
-u-.. ..,,"o be irre'ersibl.. Tir. mos belpfirl diagrromc rc$s ar€ semm vrtanin Bl2 and folate levels the
Schrliing udnan'Bl2 excretion test- and gasic analysis'
Ufairt *r"-p1' for pernicious anemia consists of I00-1000 ug IM riailv of cobalamrn for two u'eeks-
I
follo*,ed br. IOO-fOOOug IM eacb montr for Me. To correa a folic acid defioenq' anemia, l-5 mg folate
pO for 4-5 s,eeks rs adginisered and lsr:all1'adequere to replenish @' sores and correcl the anemta

e) Sickle Cell Anemta

Sickle cell anemia $as first descnb€d bv Henicli in 1910 and represcnrsOle mosl colrrmon form of
congeniral hemolroc anemia affecrilg l/600 blacks 0romozl'gotes). Approximareh' 8oloof American
tr:r,e r-UesicHe ceU u-ajt (hetemzJ'gores) and
falciporum
the incidence
malaria'
increases rn areassucb as Wesern Afrjca
black
dre to tts I
protecrive quelin'aeailsl
The rerm
e>posed to
;si.kle cell' disorder rcfers to sates in u'hich thc red blood ceUassumesa sickle shape uhen
lou, ox-r,gentension Under los, ox)'gen rersion the red blood cell sjckies. c""si!8 sludging
rhar slou,s blocd flou-. this $asts crealesgr€ler hlpoxia tlrat perpenntes the q'cle and poduces paln as
t
u'ell as i:rfarcoon.

168
t
t
 -Hcmolf -
obin is compnsedof nvo alpha and nvo beu chains.-*JemogJobil'S representsa subsdnrdonof
rzline for gJuramicacid ar posuon 6 of tlre beu chain Red blood cells contaimng this qpe of
hemogJobrn are c)raracrerized br slroner sunrral and ten&no'to adberelo vascu.larendot}eirurn
res:jtrng ir anenuaand vascularocclusion

Nornral. Hgb A1=960/o Hgb A2=3% Hgb F=lozi,

Sjckle Cell Trart. Hgb Al=55-75% Hgb 5:25{5%
Sickle CeI Anemia: Hgb Al=l-25% Hgb 5=75-959a

'sickle
Screeningfor henrogJobinS can be done ria the cel.lprep". u'herebv the red blood ceUsickling b
obsenzble under a microscope. Positir,e screentngtesu should be follon,ed sith hemoBobin electrophoresisro
deremr-ineilre specifc lremop:lobrnopathl'.Manl'patienu n'ith sickle cell anemia are rn good hcalth nruch of
the ume. but tlus sule rnav be intemrged bl a suddencrjsrs (infarcdve. aplastic. hemolrtic or seguesrative)
uhich car occasionallvprove fatal.

Tlpical lab findings in sickle cell anemia inclu&:

decreasedHgb
decreasedHcr
normal MCV
normal to increased WBC
nomal ro increasedplatelets
rncrea-sedreti culocrte count
elerated serumbilirubin
elerzted scrum LDH

Thougtr aI svsems ru)'be afleoed tlre bean is frequentlv t}le site of lbe mos prominent pb1'sical
findings. h u ofien enlargedto both the lefi and riglu uitr svsolic and dia-sobc flou murmurs heard Painful
"punched oul-
ulcerauon around the anliles characterzed b1' apearance uith rolled e,rges are nol an
lurcorunon ss,quelae. Trearrnentgeneralll'consiss of a combinaoon of bed rest- Iocal u'ound care and
occasronalantbjottcs. Bonl'sickling can predisposelo osleomvelitis. mos commonll due to Salmonella
althoug} pneumococcal and suphl'locrccal infection have been dcscnbed
M:uragemenl of sickle cell anemia is nuin\' Smptonr2ric and suponil'e. During painful crises rnaintain
a@uate hvdratjon imprwe ox1'genadon(ie-ox1'genria rusal cannula),pnovide analgesia(iemorphrne.
mependine) and considerfobc acid supplemenurion. Therap'to enhanceproducrion of hemogJobiaF in these
potienrsis srill rnvenigational. There is no i:rcreasedrisk of using pneumarictournigues in podenu qith sickle
ceI rart. Hou,er,er.both pneumatictourniguetsand local aneslesia u'ith epinephrureshould be avoided in
pauentsu'ith sickle cell anemia. If general anesthesiais neccssan'.an inhalational anesletic is preferred and
adecuate mai-ntenance of on' penadon hvdranon'r'entil adon 15ssseatirl

BIOOD TRA}'SFUSIONS

Red Cell Antigens and Annbodies: Serologic Consideratjons

a) te$s for red cell anogers
l. red cell tlping is s6rralll'performed b-r'erposi::g t}te cells to specif c and-sera ircubatirg al 37 C and
obsen'i-ogfor aggJunrntion
2. the ABO and Rb r1?esarc dercrmired for all blood donors and rrrpiens ro avoid transrnissionof ABO
incomporibleblood and to prevcnl allo-immuniz.rrion b1'tbe Rh antigen.
>ress for addirronalRh antigensand anobodiesand tlose in other -eenetics\'$ems (ie-Kell Kidd
DuS') are often resulrd u'hen a parient has been allermmunized

169
 )

Tbe_AE.O lvs!@_ )
a) s€nun of ','imratt't-att ittdi.iarats .onr- -ntoai"s corr.rponA-g ,o the A or n anugens not presenl on
their red cells.
b) ABO fprng is perforrned reguJarll'[' tesing red cells for ageluunaoon br' ]sro*n anti-A and anti-B and t
rhen b-r' lesring fte serum for is abiJ:1'ro aggJutinareloroun A B and o red cells.
)
BJood T-rpe Subsrirurjonsfor Transfirsion (ABO and Rh)
a) accepable: A or B red blood cells to AB padenls, Rh-negadve n'hole blood or rbc's ro Rh-posirive potients
b) usualll' accepable: A or B u'hole blood ro AB paoenu: O red cells lo A B. or AB oalenu )
c) acceFable in emergenn': Rh-posinve uhole blood or rbc's to -
l. Rh-negative unsersirized men
2. Rh-negative unsensitizedpostnenoFusal women
d) nn,er acccpabl e (excepnon : bone marms' ransplanration)
I
l. A n'bole blood or rbc's lo O or B parienu
2. B ulrole blood or rbc's lo O or A psDents 7
3. AB u'hole blood or rbc's ro O- A or B parients \

The Rh S1'sem
a) an indiridual inherirs a complex halotlpe from each parenl
b) rcd cells of botlr donors and recipenu are nped b-r'resing t}em rrirb anti-D. If celJagglutinarion occurs-
t}te Dpe is Rh-positive
I
>if cclls are not aggJutiruted padent is consideredRlr-negative and is resed further for
reacdng anug€ns
c) all Rh-negadve parienr-sshould recejve Rh-negatit'e rbc,s
nrore n.eaklr.
I
150z6
>ob'riousll'. Rh-negative blood ma1'be gven to Rh-positive padents hrt this rarely'
of the poprlation is Rlr-negarive
occurs since onlr.

d) tle otler Rh anngers (C, c. E. e) are much less immunogenic rlnn D and lt is rmfr-actical to march tlem rn
donor and panen blood
r
CompotibiLig' Tess
t
a) pre-ran$rsion compatibiliq'tess include Dping parjent and donor red cells for ABO and Rh, screening
pauenl and donor senuns for significrnt unerpecred annbodies. and rcacdng donor red cells *,itb patjent
(rna;or crossrnatcb)
serum

l. major crossrnarh determinestle presenceof anv allo-anu-bodiesin the recipienl's plasrna tlnt ma1,
t
desrol'donor red cells and sen'esas a final verif cadon of the comparibilitv of donor red cclls and tbe
recipient's serum
2. u'hiJe all trandrsions mus be precededb1' an accepable compotibilin' resr tbe gToss.narcbponion need
I
not be performed pnor lo operarit,e procedures thal almog cenain\' u'ill nol regure tran6rsion
3. qrossmarchingblood based on intraoperative lqage(lanonrras N4SBOS - Var.i-.rm Surercal Blood
Or&r Schedule) alJou'sconsenzdon of blood resourcesand contairu laboraton'costs r
Trandxion of Red Blood Cells and \Ahole Blood
a) RBC's ir the managemenl of chroruc anernia and acrxc bood loss
1. RBC's should be trandrsed n'benever the deficienq, of circulanng red celi massis too severeto be
T
rreatedconsenativell
2. for immediate correction of acue and chronic anemia lfartsfusion of RBC's should be the nrle and n,hole
blood tbe exceprion l
t
I
170
l
I
Trearn entof Hlporol eEcsbitcl
a) smceresoratjonof Essueperfusronis of moreimmediareimponancetiranresoranonof ox1'gen-€rvlng
qrpacrr)'. rmnredrate
establislurrent of r\/ f]uidsarerequed
of larger\r Lnesandadnr-uristrauon
inidalh.
Arailable preparaDonstnclude -
I cr-rsralJordsolutjons: prirnarih' sahnesoluoons
2. colloid soludons: prod:ced anificialll' (iedexrran) or dernauves of plasma (ie-plasruaprotein fracdon:
alhrmrn)
3. rrfiole blood and its components
b) rhe follosring gutdelines are an acceFableapproachto tbe marugentenl of t}ese patlenls -
l. almos all shock patients uiOr lrvpovolemrashould recervebalancedsaline solutrons initialll: some use
dcrrran in saline or piasrnaprotein sohmons
2. shock pauents qith anemia lqmpornatic) shouJdreceive packed RBC's
3. plasrrn prorcin lossesproducing scnun albumin levels of 2 g/d- or less can be correaed ria infusion of
albunln or plasnu protein fracoors

prior ro tranfusions givc paticnts Bcnadry'l 50 mg po/Tvlcnol 650 mg po lo prevent possiblenrinor reactjorx

Side Alleos of trandusions:

l. Fever
2. Rash (inicaria pruritis)
3. Hemolltic anemia
4. Resprrator.t'dsuess
5. Volume overload
6. Noncardiogeruc pJmona 1' edema

Screcnbg hocedures to Deteo Coagulation Disorden

platclet counl delection of plaela defioenq'

bleedmg ume eralrretion of Plarela function
prothrombin time (Ff) erzluation of deficienciesof
faoorstr, V, VII- X
pamd thromboplasrtn evaluationof &ficiencies of
time (PI-f) faoors V. VIII. X )O. )ilI
thrombin rime &tection of abnormalities of
fibrinogen (fraor I)
also prolonged u'ith cirorlating
hepann and increased fibrin
degradation prod:as

PRf- and POST-OP I\ANAGEI\fENT

The Cardrac Panent

a) Padenu nit-b cardiac dis€as€should be eraluered ['a cardiologist-
b) Elecdr.e sugetl' should be delal,ed as long as necessaD'tobring t}e padent to tre OR rn oFrimal medical
condition
c) Tbe risk of sugery is n,eighed agains tbe risk of cardiorasculat comPbcatjons.
d) Receor III- d:e ro high mon:Iiq'rarcs. $ugeu' should be posponed al leasl sbi months if possible
e) Old I\O- if eridence of old ]rfl is found on the ECG nithout ches Frn a prerious ECG should be
obrained for comparison

171
 i-UnstableAngina-
1. carcful obsenztion and posrponementof non-emergenq' surgen'
2. maximize nredical tlrerapl'ui0r nitrates.beu-blocken and calcium channel blocken
3. if medical marugemenl is uruuccessful, get an eva.luationfor coronan' b1'passsuJger.\'before tlre
elective non-cardiac surge4'
g) l\t.ild Stablc Angina
l. nrry underyo nriror procedures safell'
2. beu-blocken and rutrate tlreraqvshould conrinue pre<rpand be resumedposl-op
h) Arnlitbmias
l. in general convenrjonai anti-arrblrhmic therapv should conti-uueup to and througb surgen' for
patients abeadv under treatmenl
2. fir'e or more PVC'Vminute arc associaleds'ith increased cardac monaliq'. Their signifcance
remar-nsconroversial 1;rorucularlf if the parient is as.rtnplomrric) and evaluarion in rerrns of
freguenq'. complexiq'and overall patient clinical sanu should be uken into accounl Thesepatients
need to be carefullv morutored and grven ano-arrhrthmic rnedicationsif rnore conrplex arrhrrhnria's
occur.

Hrrrenension
a) Mild ro moderale hlpenension ls not a significant risk to the surgtcal patient if:
l. diastolic BP is suble and <l l0 nrm Hg
2- inu-aopcrauve and recoven'room presswesare closelv morulored and ueated
b) In general anrihlpenersive medications should be conunuedup to the rime of surgen'and pos-operatirell'
c) Get poussum lcvcls on ail porienu on diureocs: rcplace ilserum ponssium is < 3.5 nEAlL before surgerl,
Coneestive Hean Failure
a) Treat appropriatelv preoperadvelv and posrponenonrmergenl sugery
'^l
b) Su'an4anz monitormg is essen in patienu u'ith CHF n'ho mus undergo emergencv surgeD'. Patients
urtlr bor&rline cardiac sutus undergoing major clecdve swgen'rnal also benefit from Suan{arz
morutortng.

Diabetic Patient
a) General Information
l. suess of anes}esia and operation exracerbates diabetic patienl's glucoseintolerance
2. to marntarn nutrjtion and prn,ent ketoacidosisand blpogll'cemia t}te Frient musl receive a minimum
of 100 gt carbobvdrate/da1'and adequateinsrlin mus be conrinuously arailable. One brer of
D5W contairu 50 Em of carbohydrate.
J. rhis patient should have oFimal nutritional narus hvdration level and elecuolvte balance before surgery
4. correct ketoacjdosis even ifbefore an urgenl operarionbecauseofassociared high monalin' rare
5. hlpogll-csemia is a more hazardousconditjon than hiperyl-v-cemia.When there is no hlperlietonemia
rnoderateblpergll'cemia (2O0'250 mgd) is nol hez"r6eus and sbould be opected dgring the earlv
posl- operative pcnd Marked hlpcrglvcemia can lead lo osmotic diuresis dehvdrarjon and
h1'perosmlanq'and 01rrc.5hsuld be avoided
6. tlrere is eridcncc t}at hrgh gJucoselevels alter leukoc'rreand fibroblast funcrjon predisposing ro
infecuon and poor s'ound healing Plasmagjucose shouJdbe mainhined bern,exn 100-200
mgd.
7. insulin requrrementsrna]' talJ abnryl1'after t-beinfecrion has been a@uately decon-rpressedAnticrpre
rhis be decreasing tbe las insuiin dose b!' one-third
b) lnsulio and CllucoseScbcdules
l. no insulin no glucose
>minor operaDonsu:r&r local n'bere tbere is lou'suess and the pauent rs erpected to eal
afier tbe sureeq\'
>no insulin or Bucose is given tbe mornrng of surgery and intraoperarive flujds contain no
derrrose
>blood s1€ars are checked and regular insuiin given as needed until tbe nexl morning n'hen
t}re usr:al regrmen is resumed
2. sub,alareous insuln n'ith IV gjucose (most common)
>nunagemenl is mosl convenient rf procedure can be done i:r the earll,morning

172
 >NPO (nothing-tn'mouth) aff.ermidnip*rr
>In theearlvmormng-
-surt IV fluids consistinsof D5 I/2NSS
-9re approx-rnatelvone-third lo one-half of the padent'susuai a.rn dose of NPH or lenle
inulin
-hold regular insulin dose

>Upon compleoon of t-beoperation-

<ontinue tle IV fluids until the parient receives2 brcn ( J00 gm of pucose) n a 24 hour period
-glve repular usulin even'4{ houn basedupon (fngemick) blood gJucoselevels. The f.rs
determinanonshould be done as soon as tlre parient arrjves in lhe recoven'room. The cbse
should be basedon thepauenl'srcsponse to prevrousdosesof i-rsulin

INSLILIN SLIDD.IGSCALE
bloodelucoselevel Reeularln<ulin
<200 no coveraete
20G250 2 units SQ
25l -300 4 unns SQ
301-350 6 unis SQ
351400 8 unis SQ

>give oral fluids and food as soon as fte patient's condirior pernrjt.<
>resxne diet and pre-op.laih,ins;ulin dose
>if the poricnt cannol be fed surt fV D5W or D10W ro loral 200 gm carbobl'drate rtaih' and dir"ide
usual NPH or Lente dose rnlo nvo equal dosesgiven 12 houn apcn. Olain srum
Bucose let'els every
6 hours and cor.er uith regular insulin as needed
>lou'er dose of NIPH or l-enrc if hlpoglycemia occ-urs
c) Diabetics on OraJ E-tpogll'ccmic A€enrs
I Minor Surgel'
>u'ithbold the medication on &'r' of surgery
>if surgery is earlv in rhe morning and the patienl is eating post{p, the oral agent is resumed
> if the sugen'is delaved or t}e potient is expeoed to be NPO for n'urn'r'hours-sran D5W I\/ and
moniror giucose. Regular insulin rs gn'en as needed
2. Major S*gen'
>discontinue oral hlpogll'cemic agent
>q'hen possiblean insulin regimen should be saned severaldavs before srrgen,ro derennine iruulin
levels and to sublize glucose levels
>NPO afier midnigbt t-beday before surg,en'
>one-half to one-third intermedrareacting insulin is then given on calt lo OteOR and the padcnr
marnged sith regular in-suiinba-sedon blood glucose levels dererrninedever-r'6 hoprs
>q'ith shoner dme fiames. dre orai agent is disconrinued 24 houn before srrgery. The padent should
be NPO afier midnight and receiveregular insuiin as neededbasedon gJucor levels e.r,err'6houn.
D5W fV is sartcd the morning of surgery'.
>oral htpogJl'cemic agentsc.rn be saned u'hen normal diet u resrmed

Thrroid Dsease
a) This condition is not a conra-indication lo elecuve sugen'
b) lt is irnponanl to gel tre psuenl euthlroid before surgen'
c) BSperthlroid Patieot
1. tlresepaDentsare aF to develop hlpenension severe carrliec d-r'srhrrhmias hlpe.nherrnia and thlroid
sorrn There u no appsrenl correlation berq'e€n ruture or severiN of surgen'to thlroid sorm.
2. bring to errthrroidstaleh'(ukes I6 u,eelcs):
>propvlthionucil 800-10(n mgda)' for I n'eek then 2tXL400 mg/da'r.mainlenancedoseor 30{0
mddal' methunazolPO
>bera-blocliers(dose=160mddal') conbol uchvcardia_ palpiutions ameg,. elc.
3. aIJpatients.udess conra-indicated should receive combination of the above drugs

I /3
 d) E-rpoth-rroid Paticnt
l. bring paDentto eutrr,roidsate (Ekesw'eeksto months).Onceachievedtlrereis no rncreasern
moiciditl associatedu'ith surge4
2. L-tlrlroxrne's long half-Me allorvs it to be sopped during tbe perioperauve period u'itloul problems.
3. mlxedema come should be sspected in ponens u'ho lail lo auzken fiom aneslresia and n'ho
manrfes CO retendon
Anemia
a) Eraluate the etiologi' of the anemia before proceding s'ith anv elecdve sugerl'
b) Treamrent is irdjvidrelized on tlre basis of the etiologl' @cr- Hgb, reticuJoc\te counl blood snearr.
Coomb's tesl bone marrou' exams and the H & P are useful to pinpoint the eriolog'). A hemopobin of l0
gm/dl and a hematocrit of 309i, have customarill'been required to assurea@uare ussue on,genadon
during surgeD'.
c) Facb paDcDl'sreguirement is based on several froors: t}te yalues lised above are Jusl guidelines.
d) Decision for u-ansfrrsionmusl be made u'eighing the benefiu versus the risb
e) Faaon regurnng higber pe-op hemogJobinlevels
l. old age
2. acute blood loss
3. coronan' anen' disease(CAD)
4. pulmorn4'disease
5. peripheral ra-scular (P\D) or cerebrorascular drsease
6. signifcant blood loss expecred
{) Faoon ma}cinglon'er pre-op lremogJobinlevel more accep.able
l. 1,outb
2. chronic anemia
3. normal exercisetolerance
4. no cardiac. prlmornrv or cerebrorasodar disease
5. linJe blocd ]oss erpected
g) Therap' should provide onlv tlrose blood componens required to corecl the defea. Oral rheraF (ie-iron
folate- rirarnin B12) is appropriate if tlre surgen'is eleajve and can u'arr. Packed RBC's crn be used for all
bul severe hemorrhaee.

Neurronenia
a) Etlolog|
l. drugs
2. infectiou agenls (especiaXyviral)
3. preleukemia mvd oproliferath'e disorders
4. congenital
5. chronic rheumatjc dsease (ie-SLE- Felty's sndrome)
b) Cancellaoon of suryery if < I O00/mm . fusk of infectjon is maricedlvincreased u'hen granuJocrtecounl is
<-500/mm
c) Trearment dependsupon the etiologt'. Pospone sutgeD' in'r'iral or drug induced casesuntil leukopoenia is
rsversed
d) GranuJoqre ranSusons hal'e Iinle indicanon for surger-r'and onll-used in an infeaed patient uilh a count
<500/mm
Hemosatic Dlsorden
a) Carefirl hrso4'is cnrcial because it mal give the f,rs indicadon of potenual hemosaric problern
quesriomng
(inclu& prior surgen'- dental procedrres mumus membrane bleeding n-an$rsions. bruisabilin'. eplstaxls
lusory,
of benratornas4reman-brcsis delal'ed bleedi:lg famiJl' htsory)
b) C€natn hemosanc problemq are seenqith norrnal rourire labs.

1 - A
I /.+
 -- -?UBIaSE
LABTEST
platelet count detecnonofdefioeno
protirrombin dme factor Ml. exnnsic pat}qa'r
Fn (trarfarin)
panral tluomboplastin faaors \aIII H- )fl
time (PIT) (heeann)
+factors V and X prothrombin and frbrinogen are requircd for botb PT and Pfi
bleedrngdme erzluation of plateletfunqjon

ABNORMAL NORN4AL DISORDER (fadors)

PIT m hemophilia MII)
Ch;rnas disease(D0
faoor )O def oeno'
llagema:r faaor QilI) def ciencr
von WiIl ebrand's drsease
W PTT faoor VII deficrenq'
PfT & PT faoors II. V. or X defioeno'
dvsfibrinogenemta
DC
vitamin K &ficienn
brmd specrum anribi orj cs
malabsorpon
bver disease
PTT & PT faaor XII deficrenc\
von Willebrand's disease
dr'$b,nnogenemra
EtrI ers-Danlos strdrome
rasorlitis
RenduOsl er-Weberdisease
replace faoors as specific as possible and posrponesuryery'ilpossible

c) anticoagulants
l. coumadrn
>coumadin rnterferes u'ith aoion of vitamin K rn the slrnthesis of fanors It VIt D( X
>disconrinue cournadir - normalizadon uithin 36-48 hrs
>uunrin K can be given but it is preferablelo discontirue coumadin (SQ or oral adminisrarion '18-24
hours for normalization): r'itamin K svill interfere q'ith pos op anti<oaguladon for I u,eelc
>emcrgeDq' sutgeD': rtiscondnuecoumadb and transfise 2-4 unirs of fresh fiozen plavru: this ma1'
necd to be repeated post-op
2. bepann
>PTT u'ill be normal if discontinued 8 hrs before surgery
>rapid revenal rna)' be achreveduith protamine sulfate ( I : I 00): usual dor is -50mg lV over -5mirutes
> hepann indrced tluomboqropenu is fairll' common

Obcsin'
a) Defined a-s@'u'eight >30ploabort ideal
b) Severe obesin'is nol rare
c) \{onalirl'rate ts 2-3 times t}rat of the norrnal padent
d) Pre-operadveera},ution is ma& more dif6cult becausefrt cunains the orcal s\sem of ineres
e) CarefirJquesioniag of prerious lung disease.hear.r'sorins blod prsssure.thrombophJebius,prlmona4-
'^l
eurbo[sm are essen
I Thorouglr cardiovascularand p:lmonaD' exarnsare essential
g) Standard Flmonan'fimctjon tests 12 lead ECG and chest r-ra1'should be accompbshedon all moderale ro
5sveleh' obesemoents

175
 t
h)-kescrtbe-reermen for oF:mum p:lmona4'fimction deepbrealhing and coughing exercises.rncendve_
spromelers and bronchodiluon followed tn' chest peroxsion if needed l
i) Uniess contraindrcatedprescnbe minidose hepanng to help prevenl D\T and Fr,rlntorun'emboiism
j) Avoid Trendelenburg posiuon becausethe weight u'ill decreaselung volume
k) Use volume pressuremorulors (ie: Su'an4anz) in severell' obesepanentsn'ith cardiorascular or
pufmonary disease
t
l) Use spinal or local arest}lesia n'here apropriate
m) Consider uaiting tu'o da1'sposl{p to extubateif problems arise inrao;rranvelr'
n) E^rl1'amhrlarion I
Steroids
a) Identi!'patiens u'ho uill need suFplementalsteroidsdring the srxs of surgen
b) Glucocomcoid defi cjenc]' rm]' resrll fiom:
I
l. pnrnar-v dvsfuncuon of the adrenal gland
2. secon&4'adrenal insuffcienq' due to pirurury drsease
3. adrcnal suppressiondue to adminisradon of oiogenous steroid
c) Conicoseroid covcrage has become a sundard practice siren treating patiens uith even suspeoed adrenal
t
deficienq' u'ho underyo srugen'
d) Cardiorasorlar coLlapseis the major concern
e) An adrernl resen'e tes is arailable
I
ft Tlre dail1, requiremcnt of conisone is approxinatelr' 300 nrg
g) Suspect adrernl deficieno'if:
l. >7.5 mg prednisonern single &ilv dosetrken for >l mo.
2. an]' seroid in divided dosesfor >5-7 days
l
3. long acting preparatons (iedexamelhasone-betametlasone) ulien for >5-7 davs
4. >20 mg prednisone taken for >5-7 days
-s. padeil nith Cushingoid :rppcarance
t
6- prolonged sbock or unexplained shock orfever
h) A nide rzrier-r'of seroid sched-rleshave been proposed no one hasa dimno advartage or,er t}re o*rer
i) example of gJucocomcoid coverage
l. minor surgeryAimitedpnoce'drre
>minirrral to additionel serojd coyerageneeded
>give regular dose uith s,r8en'and maintenrnce dose a-fiersurgen'
2. n:ra-yorsurge4'
5
>hydrrcorusone sodiurn succinate 100 mg IM or IV every 6 hours for 24 hours 10 stan u'ith preop
medicarions. Use IV route if tlere is tissue hlpoperfuson
>reduce V' 5U/o daill'begtnning POD #l until mainternnce dose or equiralenr is reached (20 mg Alvl
l0 mgPM)
I
>in pariens uith pnnran'adrenal insufficienry fludroconisone 0.1 mg riqilv musl be added ro
provide slfficjent mrneralrconjcoid actirntl' q'hen t}te dose of hvdroconisone is 100 mg or less per
da1' >u'jth shon proced,res glve a single IV or IM doseof hvdroconisone 100 mg nrth pre-
t
medications and an exca 20 mg oral dosethat e'r'ening. Resume regular regimen the nex
dav
(
Renal Disease
a) The hison'and phl'sicrl- gJomemJarfi.lu'ationr:Ile. scnun crcatinine- BLIN. uinahsis and blood chemisrn'
profiJes qill tte indicators for renal diseas€
b) Risk of surge4 is not likell' to be ilcreased il creatini-neclearances >-507onormal (normal crearinine is
<2.0) Tlre point of s,sLif canl risk hes nol been detennined
c) Regulation of 'r'olume surus is critical
l. mild to moderaterenal impairrnenl: tbesepauents are urnble to conccnlrale tbeir urine and are tlrerefore.
aI risk for volume depletion Obeen'e fluids carefirlv and replace :ls needed- Monitor bo{r'
n eigbt- VO's (i-n-s
and outs). elecroll'tes. and pH
2. severerenal rnsrrffciencr': tlreseparjentsarc al risk for lolume olerload and hrperkalemra. N4onjtor
fluid balance and dizlrze if necessan'. Consider S'nan4anz monitoring
3. UTIs are ue:ted pre-operarir,eli'based on C & S rcsults

176
 -
a.bt'sfijctirElesons are removed or corrrectedbefore ma-rorstrrgen'
5. fluid and eleclrollne imbaiancesshould be correoed pre-op
6. meuboijc acjdosis.even trough compensatedsbould be correned n'ith sodrum bicarbonate
7. aremia: H& 9 elddl and Hct 25Y,'arc satisfaqon'for the paDenluith chroruc irsufEoeno
8. correct coaguJationdefeas seenrn chronic renal drseasepre-op
9. hemodiall'ss. u'hen necessrn'. should be planned for tle da1'bcfore surgery'
d) If rerul funajon deterjoratesor transfusionreaction occurs corsider usilg an osmotic diuretic (ie-nrannirol)
Tlus ma1' have a protecrive effeq on renal ruhrlar filnctlon
e) Nephrotoxic drugs mus be admuusered carefulll'and in reduceddoses
f; Pos+pcrative unne output of <25 ml/hr requinesimmediare eraiuarron
g) Diabetic patienu are panicularh'prone lo acute renal lailure afier contrasl dve snrdies

SWAN-GANZ CATHETER
Descnpoon
a) 0exibleguadruplelumentubcapproxnratelr'I I0 cm long artd scoredin l0 cm increnrents
b) lunrens
l. di$al(PA) lumen;
-records PAP. rcWP f
<tfain nrixed venox blood
for oxl'gen conten analvsis
2. proxirnal (RA) lumen:
-records RAP or C\?
3. balloon lumen
-terminares I cm from np
of catherer
-q'hen bolloon is inflated
il moves in direccionof
blood 0ou
-t}te infleted balloon gutde:
catheler througb the RA R\/
and irno the plmona4'
arterv u'here it lodges in
smaller brancb
-records tbe p:lmona4, capillaf' n'edge pressure (rc\\P)
in this position
IPCWP: normal]r'equal to t]re Lefl Arial pressure
t}us. sensiuveindicaror of presenceof puhnon.a4'congestion and Iefl sided CI trl

4. thermisor lumen
-contairu temperature sensitive uires
-calcutarcs cardiac outul qv frennodilution technigue

In-seruon
a) percuureous insemon ria inrcrnaljugular vein safes
b) locarion of catbeterrip determinedbv recognition of characterisricpressureuaveform of eachheart
chamber

17'l
 3
Compbcations of rig*rt heart cat-hetenzauon
a) cardiac dvsrhrthmtas
t
b) thrombosis
c) sepsls
d) plmonan'rnfarction
e) p:lm ornn' ralve Perforation
I
I) laroning of cadleter .-,--7-

t
ru
Kh
g) rupure of balloon

Indicadonsfor hemodrnamicmonitoring
a) severelvill hemo{rrrarnicallt'ursuble pouents
b) aorte cardac condidons
(jecompUcatedM: RV hfrrcdon: mitral
t
I
regurgiurion)
c) chroruc cardiac irsuffclens\'
(ie-consn cu ve peri cardrns: congestive cardiom1'opathl')
d) miscell:rneous
(i e-a cute non-m1'ocardialinfarcd on pulmorn4' edeun)

Dflerenrial Dagrrosis of common PA catlreter radings

I
log' RAP. lou' R\P: r'olume depletion
ldglr RAP- high R\D: r'olume overload
C}IF
I
cardrogenic shock
high PAP: CHF
cardiac ramPornde
incrcased prlmonan'rascular reslqance (ie-h1'poxia-pulmonan'disease. r'entilator efleo of PEEP)
I
lon' PCWP:'r'olume dePleuon
high PCWP: cardrogenic shock
LV failure
I
severe h1'Pcnension
miu'al regurglunon and senosis
volume ovcrload
cardtac tamponade
I
AlcohoUc Parient
a)Screening
1)askal1 ptlenu: Do I'ou drink alcohol including beer- rrile. or distilled spirits ?
I
2)for current drinkers :
On avenge. hou'manv dal's per u'eek do vou drink alcohol?
On a qprcal da1' utren vou drinh horv manv ddds do vou have?
-What is the nraimum number of drinks 1'ou llad on anv given occasion during the las month?
I
3)for current drinliers: (CAGE quesionnaire)
-Ha'r'evou ever feh *ral vou should Cut dosn on )'otu &inking?
-Have people Annol'cd )'ou b' criticizing 1'our drinking?
-l:lave rou ever feh bad of Guilt1' abou 1'our drrnking?
I
-Have 1ou ever had a drink firs rhing in the morning (E)'e opener) lo $ea4'\'our nen'es or gel rid of a
hangover? I
b)Assessmentfor all pcrienrs at risk of rr'it-bdraual: (Clinical lnstinne Witbdraual Assessnent for Alcohol)
1)nausea/r.omiug
2)uctile d.isrbances(irching pins and needles buming. numbness)
I
3)mmon
)auditon' disnrbances
5)paloxl'srnal $\'ear
6htsual disrubances
I
7)aruiieq'

178
T
t
 S)heart^cbe.fi:llness in head
9)agluDon
l0)onenurion and cloudtng of seruorium

c)Trearnent for uith draual

1)Lorazepam2 mg96 x 4 doses.then ) mg q 6 x 8 doses(additionaldosesas needed)
2)Prophylaxis:
-15-30mg Serar nd x 3 davs
-15-30mg Serai bid x 2 da1's
-15-30 mg Sera:i qd x 2 da1's
-multiriumins 1 ubla po gd
-$an NSS at deterntinedrate uilh 100mg ttuamindi mg folatex i bag (mav gxr,'sfolare and thianunepo)

t79
PRNCIPLES OF SURGERY
PRNCIPLESOF SURGERY
PRNCIPLESOF SURGERY
PRNCIPLESOF SURGERY
PRNCIPLESOF SURGERY
PRNCIPLESOF SIJRGERY
PRNCIPLESOF SURGERY
PRNCIPLESoF'SURGERY
PRINCIPLESOF SIJRGERY
PRINCIPLtrSOF SIJRGtrRY
PRINCIPLESOF SIJRGERY
PRINCIPLtrSoF SURGE,RY
PRNCIPLESOF SIJRGERY
PRNCIPLtrSOF SURGERY
F P ' i - \ C I P L EOSF SUR.Ci:-Fli'
ilR.I]\CIPIES OF S U R C E R ' : '
PR.TI{CiPLES OF'S U R G E R \ "
P R T N C i P L EOF S SURCER-:
P R ij t\C IP I-E S OF SUR.C'E jt-:-
FR.I]\CIFLESOF SL R.GE}ii'
iJR-i\CIPLFS[ . i r S L , R C F R ' : '
REG]ONAL A]\'D LOCAL NER\T BLOCKS

Goal:
. hovide local anesthesiato areaof rnsult
. Marntarn mirunral palient nlovemenl
. Maumum rehef to tle patient

Indicalions:
. Sut€lcaliltten'entiolt
. DiaL'nostlc
. Aspirate or sofi tissueorjoint

Equipmenl.
. Needle
. Diameler- small gauge(25 or 27)
. Leng:th- adequateto reachtatgel (tlPicalll' 1.5 inch)
. Srnnge (3cc.5cc. or l0 cc)
. Local Alestlretic (LA)
. Anlisepttcsolunon(Alcohol. Betadine.erc..1
o Prep are: distal lo proximal

Technique:
l. Idennf' peripheral nen'e(s) irulen'ating region to be anesthetized
?. Dras'-up adequateamounl of LA (insure pt is non-allergic)
3. hep enq'site'uilh antlseptlcsoluuon
. Joint enrr-r'requires beudine parnt prep (tlree times)
1. Qrronal topical anest}etic pnor lo breachrnglnlegumenl (i.e. erhl'lchJondespral'. topical
lidcrcaine)
5. Su'ifi.I1'enlerneedleperpendicularlo rnlegumenl
6. Infilrate rnu-adermalu'heal
7. Adlance needle to desired neural srucrure
8. Brplanea-splrale
* ' Al \l/A)'S, ALWAYS, ALWAYS aspirale prior to infilrrating LA
9. Infiltrate appropriate amorml of anesthetic solution
* Use least number of skin enD-iesnecessar)'to acquue desired anesthesia
* When redirectrngneedle alu'avsrrilhdraq'needle to subcutaneouslaver- then folloq' steps6 tluough 9
* Abide b}'OSltA regularions for handhng- recapping and discarding of needle and srrrnge

Complications:
. Direct urjun'to nen'e trunk
. LA roxicin'- u'atch for CNS and CV qmptoms
. Aller€lc reacDon

Nen'e Blotks:
Popliual
. lnd:cared for intra and/or post-op analgesiaof rearfoot and leg procedures
. Tibial nene/Sciatic nerveal tlre level of 0te popliteal fossa
. Optional use of nen'e stimulator for proper site infi]rrar:on is recorumended
. Sel nen'e stim. al 2.0-3.0mA
. Enlgr 7-8 crn proximal to popliteal skin crease. medial to biceps femons
muscle/tendon
. Advance nen'e stimulator sloulv until rrceps surae and,/or toe flerors nritch
. lnf lrate approx- 30-40 cr's of long acting LA
. Ancil]aD' saphenousnen'e block mrl'be irdicated

180
 l
Common Peroneal
' Diagnostic for: assessingspastic peronealnruscles.suessi:rversion rad.iographsfor
t
.
.
.
i areral ankl e insrabiljq
Ve[' superficial l -2 cm deep to skin
Palpatefibular lreadald lren'e
t
Enler lareralll'2.5 cm drsral to fibular head
.

Ankle Bhrch
lnfiltrare approx. 36 cc's LA
t
.
o
Indicaredfor muJdpleforefool and mrdfoot procedures<2 hours. I&D
Toral of l0-15 cc's LA t
l. Postehor Tibial lriene
'

.
Mediallv al tle level of thc maUeolusbisecrrhe rendo achillesand ribial
nraJleolus I
Enler ar tlre bisection inflrrate 1_2cc's LA
r

.
Redirefl needledrstal antenor at 45 degreesro slan bun'needle to hub
infilrrare 1-1.5cc's LA
Agarn redirectdisal posenor al 4-5degreesro skin bun,needle to hub
and

and
T
in-filrare 1-1.5cc's LA
superf cial Peroneal A;erv'eQnterntediate and Aledial Dorsal curaneous)
' Plantar{ler *re foor at $e ankle jornl and idenrif' tbe superficial peroneal
or
I
it's rermirnl branchesrn rhe disral l6'd of tbe leg
.
.
Enler dircctr'over nen'e(s) approx. l cm proximar to ankJejornt
lnfr-lu-are
Deep Peroneal Jtiene
l-1.5 cc's LA I
.
. I cm proximal ro ankJejoint identif' rendons of ribialis anlenor and
erlensor hallucis longus
Enrer bisecuon TA and EHL. bu4' needle ro hub (if tibia is encounrered
I
reuacl needle2-3mm
r ASPIJLATE- rhen infilrare l-2 cc,s LA
Saphenous |verve
' Idenni' the Great Sphenous\/ern al the anrerolareralaspecrof rhe medial
I
r
malleolus
without exiring from Dp block redirect needle rn subcuraneousplane
direcrly medially, jus lareral ro rhe GSV
I
r ASPIRATE- r}en infiltrare I cc LA
Sural Jrjerve
' Palpare for nerve mmk 0.5-l cm inferior ro rareral malreorus
I
. Enter duecth' lareral at this level
. Inf lrrate I cc LA u'heal directlv over nene
o Redireq anreromedialin subcutaneousplane infilu-atilg
'
l-1.5 cc's LA
Agarn redirect inferjor and distalll in subcutaneousplane infilrating l-1.5
t
Mayo Block
cc's LA
t
' lndjcated for firs meratarsaland hallu:i procedures (i.e. HAV Surg.. closedreduction

l.
fracrure. etc.)

Deep Peroneal A:en'e

I
.
.
Palpate the dorsal asp€cl of l" and 2"d nrenursal bases
Enler rnlerspac€dorsal- rarse u'heal. aim piarurlv bunrng needle to hub.
aspirare-inf.lrate 1.5-2cc's LA
I
I
181
I
 ;. Ft rst -Proper Di gttal B r anch o-ftheJl edia fDorsat-Cu roneous -]{en-e-
. Wiilrour exirutg DP in-iecrionslre redirecl directlr medrallr
. lnf lrare l-1.5 cc's LA aJongsubcutaneous piane

. Enler nredial lo I"'nreurarsal tJuoughwheal. drrect rreedleplanarlr

. lnf ltrate l -1.5 cc's LA along subcuuneousplane
4. Second Proper Digtal lierve of rhe Aledial planrar ]iem,e
' Enler tttedial lo J'' tneutarsal tluough u,lreal.duect needie larerall.r'jusl to
infenor l" meutarsal base infilrate l-1.5 cc's LA
. Redirect planur lareml in subcutaneousplane and infiluzte l-1.5 cc's LA

Reverse Mays $1o"1*

l. lnrermediate Dorsal Cutaneous Branch to Fourth )nterspace ond Lateral
Plantar Branch
a Palpate the dorsal aspeq of 4s anat-5thmeuursal bases
. Enler 4u inrerspacedorsalll.. raise u'heal arm
planurtl.bun' needle
. Infiltrate 1.5 cc's LA
2. Laterol Dorsal CutoneousNene 6urol |iene)
' Wit}lout eriung irterspace in-ienion sire redirect-duectlr' larerallr'
. lnfibare I-1.5 cc's LA along suhuraneous plane
i- Proper Digttal Branch ro Frfth Digtt of the L-areral plontar irierve
. Enrer lateral ro 5u meuursal through .'heal. direcr needle medrallr.
. lnfilrate l-1.5 cc's LA along subcutaneous

HaILtx Blach
. Lldicared for nail procedures.subungualexosleclomy.elc.
. Two.point sick
l. First Proper Digital Branch of the i4edtal Dorsal Cutaneous Nen,e & First Proper Digttat
|rterve of the Medial Plantar Nerve
. Enler rhe dorsal medial aspect of t}le proximal phalaru base
. R-aiseu'heal- duect needleplantarlv infilrare 0.54.25 cc.s ln
subcutaneousplane
2. Deep Peroneal Proper Digital Bronch to Hailux & second proper Digital
Itierve Branch of the Medial Plantar /.rierve
. Enler the dorsal bleral aspeq of the proximal phalarui base
. Raise u'heal- duecr needleplanurty infiltrate 0.5{.75 cc's in
subcutaneousplane

Digital Bloc*
. lndicared for artluoplasn'- ampuurion nail procedures.etc.
. Enler t}e dorsal central aspect of the proximal phalanr base
. R:ise u'heal. direa needle planur medial- infilu'ate 0.5 cc's in subcuraneousplane
. Redirecl planur lareral. infilrare 0.5 cc's in subcutaneousplane
o Planrarl),, look for cvtcneous blanching and v'heal
fonnanon

182
 l
BONE FIEALING
t
Definiuons
a) oseoblasts: bone formauon n'hetler embn'onjc or through a healing process requires tbe presence of
osteoblasts. The osteoblastts the onir- cell capable of bone producrion Oseoblags are derived from precurson
t
located in t-he ualls of blood 'resseis. T']tesernesenchl'mal cells or periqtes diflerentiate mro oseoblass rn
areasof fracnrre. osteolomY or protrlh An adequateblood supplT mus be presenl for the cells to reach tbese
srtes. T'lte relariorslup benveen oseoblastic bone formation and a funcrional rascular nenvork s a ke\.
componenl to undcrstandrng bone heaiing
t
b) oseoclasts: large mulunucleated cells located in the rip of tlre "arnilg cones''. u'lilch dissolve borre nutrur
forming canals througlr exisirg bone. Responsiblefor bone reformanon
c) oneoid: a noncaicrfied orgaruc rnatrl\ formed bl oseobiass. 'u'hich contairx 95o/o colagen and 5o/o
t
proteogll'cans
d) nulera}zation: the process bl *'hich oseoid beconres deposired u'jth calcium phosphare. rnainlv in the
formof c^'stalline hvdoxl'a;nute In nuture bone. mineralizafion ocanrs 8-10 dal's after oseoid is formed-
Normal minsralizqrien tn larnellar bone occurs at tlre rare of I um per da]'as dercrmined ['Fros rn 1963
t
e) n'oven bonc: n'pe of bonc u'hich forms hcaling bonc callus. The rnrcrccllular subsunce contarrs a
disordered t}tree dimensional arral- of coDagen fibrils. Gteoid sea.rnsare rurrrou' and osreoblastic ceU
populanon is dense. Woven bone rapidlv mureralizes foUoumg formauon. lt ma1, proliferare ridges and
T
trabcculae to form exensive nenvorks. Osteoblastsexrude marrir rn all direcuolrs. f1,sn1 rqlh' rcmodels to
lamellar bone.
f; lamellar bone: highh' orgamzed bone laid doun il congruenl lalers u"ith parailel collagen 6ben q'hich
I
cbange directjons from one lamella to tre nex.t Osreoblass arc highl)'polarized exrrudrng matrix onJl- il
their basal cell surface. Requires a flat smoot} substrare in order to be srntheszed

Suges of Bone Heafrng

t
I. lnflammation: da1'I to dar'3-4
rnitial hematoma formation :uound site follo*'ed bn' necrosis of bone marglru
lrracrophagesimade area lo remove dead bone and tissue
II. Inductron: da1' I -
r
(durarion unlmoun)
oseoblasts or chondroblastsrnduced
good oxl,gen suph'. r'ascularin'and subiliq,
I
-rseoblass form
poor o\'gen suply. rasolanr_r'and sabiliqv
-chondroblass form I
r
pro-z.llus develops fiom tJremaruring trenutoma
III. Soft Callus: day 4lo4 rveeks
clinical union noted nrth elmination of motion across sile
formadon of callus noted
ry. Hard Callus:4 u'eeks to 4 mon*s
srUus converted to nunue lamellar bone r
)
radrographic union noted
V. Remodeling: 4 mont}rsto 2 r'ean

T'r'pesof Bone Healing

a) Priman'(direcl)
I
l. rccun q'hen bone fizgmens are rigidll,immobilized
2. suges ofbone bealing undiflerenuared and cal]us forrnadon absent
3. u'it}l ngid irnmobili'adon frameu,orii provided bv callus nol necessan'
4. d:e to the rigid immobilizarion tlre f,rzdon de'r'iceass.rmespa.11ialload apiied to the bone: tlre renrlt is
bone resorEriondue to red:ced biomeclunical dernand 7
\

l6J
I
 5. Dpes of priman'bone healmg
-gap n'rix",#;T;T::ffiJfffr.
healrng:
ceilsr]ren
oseob]asdc wirhwo*en
firled bone
and
remodeled osteoblasu inirialll' form lamella onenled 90 ro the long avs of tlre
(fracnre) stc and arc then rcplaced b'oiiallt' oriented lamella
{onu|ct healing: surfacesrn drrecl contacl
''cr:uing cones" cross interface.producrng concentnc
Flnern of neu'lamellar bone
"cuning cone" adrancesapproximatell'?0-100 um per da), as per researchdone bv Schenli
b) Seconda4' (inditecl)
1. occur: s'hen bone is nol rig:dlv immobilized
2. mouonirnsubibg' allou for addidonal hemorrlrage. nhich favors fibrocanilage fonnatton and
uldmatelY callus
3. bone callus createsa fi-ameu'ork so l}rat bone healing lrls\'occtlr. A iaver of high tensiJesrengnh
q'hich reststs
connecdve tissue is laid doun benteen fragments foUou'ed bl granriation tissue.
cotlpresslon. This frarrreu,orkrs replaced b1' fibrous canilage. Evennrallv cholrdroclastsretnove the
caniiage and oseoblass begrnto produce u'oven bone
q. bone remodels in accordanceto Wol-ffs I:l'- n'herebl' bone deynsiuon takes place on $e concal'e side
and resorption on lhe convex side. Adaptauon m4i colred some angular deformiq', hrt camot
correcl misaligrrnrent of anicular ends.

Complicarioru of Bone Healing

l. nralunion: a norurulomic position of fraoure fragnrens foUou'ing the healing prccess. Malunion can
res:lt rn smrcnrral deformin. and reduced or toral loss of function. lj5rellv tlre result of poor reduCnon
combined uith irn@uate fixation
2. dclal'ed union: union is considereddelal'ed u'ben healing has not adranced al dte averagerale for the
locatjon and rlpe of fracue. holonged casting or {rrnrnic loadrng of bone rna}'be neededto hasen
lclling
3. nonunion: tlre diflerence benveendeiaved rurjon and nonuiort is not clear cul Tbe time u'ben a glven
fraqrue should be unired cannol be arbitrarily set and depends on locatiorl gpe, ph1'sical
charaoerisrics of the psuents and mode of theragr'. A nonunion rnav nol be diagrroseduntil there x
clinical or radiognphic evjdencerhar healing has ceasedand union rs unlikell'. Generallv a fiacrute of
the slufl of a long bone should not be considered a nonunion until at leasl 6 montls afler
surgerl'. The final sunr-sof a nonunion is the formadon of a pseudo-anlrosts

Diagrrosis of nonunton
a) sandard radrograph:presenceof scleroticborden or osseous void al tlre fracnrre site
b) srressfluoroscopl'
manua|Il maniprlate fuacrurcsite under 0uoroscope
slrould be rirrualll' no movement benve€nendsands osseousbndgtng should be present
Inot fi:ll1' dragrrosticof nonunion]
c) Oc-99m) bone scan
normal fracnue healing $ages on bone scan
u,eek l-rveek 4: di-ffuseuprake at fracnre ste and adjoining areasof bone
u,eek 4-u,eek 12: biphasic ponern uith upake more localized to factured endsof bone
u'eek l2-2 r'ears:coalescencesrageuith focal uptake at
fracure slte alone
hlpemophjc nonunjon u'ill demonso-ateperslstenceof biphasc sage
auophic nonurrion nill demonsrate lou' uFake actiutr al fracrure sle: mav see focal upalie sith
mlen,erung void ("cold spot")
d) romograms: help lisualize preseDceof Dzbecrrlebonor persisentfracrurehne
e) CT scan

184
 t
fl oseomedrllang ographr'
radropaguedve rn-ieoedon one sideof fracure
l
ifvenous continuin'is seenacrossfracnrresile.nonunioncanberuled out
if venousconrinuin'presenlq:ositiverest),immobilizeand injnarcNWB surus
if venousconttnrun'absent (negativelest),openreducnonn'ith bonegrafl recommended
t
Classifi cationof Nonunioru
Baseduponvascrriarsuppl)'andoseogenicpotenrial
a) Hlpemophic or H1'penzscularNonuruons
I
This qpe of nonuruonrs capableof a biologic reacdon.T?reendsof the fngmenu are riable and highlt
vascularized Tlrerearethreesubgroup u'ithin lhis caregon'-
L ElephantFtxrt nonunion:ve^'hvpemophic u'i0r heavvcallusformation. Resui6 tom unstablefixarion
t
or prennnnEweightbcaring.
2. Elorsc'sRrnf nonunion:mildlv h-rpertrophicnit} .poor callus formanon. Resulu from moderarcll.
u:rstable firzuon
3. Oligotrophic nonunion:not h1'penrophic and callus is absent. Resultsfiom displacenlentof fracrure.
I
disrracuonof fragnrensor flratjon nitlrout duea apposinonof fragmenu.

l l
l
I t
f \ i1
,J I
ft
(1
It lt I
ElephantFoot Horse'sHoof Oligorophic

b) Atrophic or Arascular Nonuniors

Thrs qpe of nonunjon is nor capable of a biologic reacrjon
I
There are four subgrouprsu'ithir tlus category -
l. Torsion \\rcdge nonunion: this tlpe has an inrcrmcdiate fragmcnt in s'hich the blood supplf is
decreased or absent The internrediate fragment is h%led to one main fi=agnrenlbut not lo lhe
I
olher.
2. Comminuled nonunion: charanerized [' lbe presence of one or more inrermediare fragmenu n'hjch are
negrotic. Tlpicalll'resuJs fiom plare brealiage and callus formation is absem.
3. Defecl nonunion: charaaerized b1' a loss of a fragmenl usualh' in the diaphvsis. The ends of rhe
t
fragrnents are r"iable. howwer, the gap is so large thar bridging cannol occur. The ends
e\/ennraI ly become arophic.
4. Arrophic nonunion: resrlts s'hen the intermediare fiagmenu are missing and scar tissue (q'hjch lacks
I
osteogerucpropernes) fills the roid

tt (r
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r i
t l t l t t
t l
t l l l
t) lt
t 1 l
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l

l
Torsion Wedee Comminued Defect

t
Atrophic

T
185
l
 -- -
Bone
E-ecmcal hoPerries-o-f
a) Wolfl. elecmc potenUalsare oearcd under the appbcaUonof gress to bone
b) Fuicda and Yasuda (19-50's).bone piezocleonon' bone becomeselectricalll'polarized
I f'
g,hen it rs dcformed the compresslonside ts elecronepuve u'itb calius producuon and
t \ .-
the tensiorside is elecroPostove
Freidenberg and Briglrron (1960's) bioelectnc potential nonstressedbone dentonsrated
I
c)
elecuoneg.auvefrolenual ln arus of acove bone grou& ard elecuoposovepotennals rn
areas ofless acrivttl'
d) Andenon and Erikon:
''srreaming polentirls"
elecu-jcal properues and bone pronrh result fronr [the pH di:fferenceberu'een
coliagen hvdron'agtnre and the surroundrngligurd medrum cztusesan electrical gradient]
e) Arlrersraed: collagen fiben have as\Tnnretncalcharge drsribunon [parallel ilrrang€menlof collagen seS
up r nel d.ipolemomenl witt grou0 occurnng louard the neglrive end of the fiber]

Treaunenl of Nonuruon-c
a) H1'pcnrophjc nonunjons - subilizasst of fraoure en&
b) Arophic nonuruors
l. resection of nonunion and bone graft s'ith flrauon
f.. Ili'^ro1' tecluuque
conjcoromv follou'ed bn,drsrraajon (to induce locaj necross and neovascularization)
"
conrpressiondigracu on ("accordron techruque )
3. clectrical srimular:on
does not correct for shonening of malposiuon
dre exacr mechanism bn' s'hich elecricat currenl stimulates bone grourh is unlinoun. In rhe 1970's
mam'invesngaron developed drflerent eleorical sdmuJatingdevices. All reponedlr' have ille sante
overall success rate of 80-857o. ho'rvever.the principles of good fiaaure marulgemenl must be sriall
folloryed- All forrn-s cannot induce bone grou'th in large gap nonunions. ln general a gap larger than one-
half the diamercr of inr,olved bone is a conrraindication to elecrical snmulauon. AII forms requrc
approximarelr' 3{ mont}rs for bone heahng
q,pes of electrical mmuiauon svsletns-
>irnasive eleorical srrmulator
Electrodes and potler pack arc dtreclJf impianred in ilre non rnion strc. This does nol requite potlenl
coopcratlon to marnun horvevel-two operationsare required - olte to place and one to rerieve ille
uruL
>semi-rnrzsive stimulator
Percnaneous elefirodes are placed al fie nonunion site and are atuched to an exernal polver pack
This reCuires one operatil'e procedure and parient cooperation is necessa{r'to maintain tbe unit
>non-inrasive nimulator
Inyolyes rhe use of an exernallv applied prlsed elecuomagnedc field to rnduce an electrical
porendal in rhe nonunion site. Toulll' noninvasive. hou'ever, requrrespauent to appll and marntain
the urut

comrressiondisraajon
(''accordion technigue")
++++#=
H i l i r ifrfi
u1i J+ )
rA )T
TTTT+ . U

186
 conicotoml and disracuon bone peeeine technique

T
g.N

-m
1lff-, E-l
\a-l-\i I
r-iF,
J ' C

qt
V\J @r I
G l v
grafi bterposiri on technique compressd brjdeing gafi technique
I
BONE STIMULAT]ON
Sumulation of bone lo promole healing has urdrcadors for more tlnn yus nonuniorn. CurrenrJl-oseogenesis is
stunulated through either electri.-rl or nrecharical (ie-ultrasound.; nreuu. Tlrree methods are available for
I
electricaj srimulaoon -
l. Faradic
2. Capaciwe (ieOseogen b'EBI)
I
3. Inducove - pfsed electrornagneucfield nonirnasive
Althouglr elearical sintulatjon has achieved promising results. researchconrinues to define oprimal lre:llnrenl
pafirmerers.
Keep in mind th,atelectrical stimulauon u'ill nol correct angular deformitl'. rotational deformiry. shonening or
T
anicuiar surfacedefect Also. ru potential for oncosenesisis still rurcenainas ofvet.
I
Tissue Effects of Elecrical Stimr:larion
a) increased pH: promotes bone formadon
f . inhibil oseoclas resorp{ron
2. stimularc mileral deposition ir fraoure repair
I
b) decre:sed pO : enlnnces calcium deposirion
l. sdmulates oprimal bone grouth rn \'!tro
2. grosth plarc cartiJageand bone cells follou' art anaerobic rneubol.ic parlrual
3. found in bone and canilage cells in fi-acture callus
I
c) desensitize oseoclas to PTH

lndicarions
I
nonunioru: &laved uniors
con gerrital pseudo-arthross
enhance sun'iral rate of bone grafi l
repair follonir:g resectionof nr.assverumor
Charcot reconstrucdon
A\t! I
I
i87
t
L0ntralndrczltroIL<
**nttoU"O t*tion
snoriai pseudoanhrosts
ffaflure g:.p> l cm (or l/2 diameter of the bone)
preSnancv
acDl'e osleoml'elius (mrasve technigues)
pctj rol ogrc fracure secondan' lo n:aliErunt turuor

Erogen lnc developed a differenl method to mmulate oseogenesis based upon lo\r' rnrcnsn'. puJsed
ulu-asound called SAFHS (soruc accelerated franure healing s'sem) t}erap1 . Tlus method provides a
nrechanical stinulus and is lou energv level di-flerenriatesit from convenuonal fhiglr energr') ultrasound
udlized in rehabihution tlrerapr'.
Possible mechanismsof action -
a) drrect mechanjcal eflect
b) increased perfu sion t-luough nricrovasculature
c) increasedblood 0ou
d) indircct elmro-hneuc eflm

Srudresinvoh'ilg rabbil tibial fraoures have rielded 87-91y" successrares. Also. a femoral fiacrure sud'fiom
the lr4a1'oClinic concluded that the efleas of t}e ultra-soundtherapl' \\'ere nol inhibited bt' the presenceof an
inrametullal'rod
Eleorical or ultra-soundsurnulatedoseoeenesisare opLiolu lo prolnole lrealing but are nol subsdrutesfor sound
surpcal principles regardrng fi-aarue czre.

Osteogen:EBI produo
rmplanuble derrce
DC pou'er zupply/sapacinvemetlod

Senemtorplaced in subcuraneousnssue.8- I 0 cm from cathode

-Senemtorremoral nol mandaton'
-teser arailable lo nrake sure il uas Lnplanted correolv/is still rvorliing
bone deposiuon occurs il 5€ mm radius around (cathode)tvire
anodeor cathodeshould nol louch metal
rariable catlrode $'ire conf gurations

-TTA-T- -helix

,-\-f-\_/ _ztg.ag

drill hole (tub -*y-faf s.ale)

tJnscon-figurationallou's e.realeslcontrol in preventing conl2ct rvitl fixatiorr

188
 t
WOUI\TD HEALI]\'G
t
Surgical l-aven
a) skin: epidernris and dermis
b) superficial fascia
l. ouler laver 1pa-ruJorJusadrposis)
I
2- inter layer - lhin membranousiayer
AU vessels.nen'es and llmphatics lie benveen trese laven
c) deep fascia
l. beneath this laver are nrusclesard tendons
t
2. the deepfascramav be conlinuousu'ith thejoint capsuleand;rnoserun
d) bone T
Classif cation of Wounds
a) clean: a non-traumatic. non-infected s'ound s'hjch does nol enter the respiraton'- alimentan. or
gerutourina4' trzrcls
I
or the orophanngeal cavrn'. Accounts {or 75%oof all operaov.eu,ounds.
b) clean<ontaminated: contains normal flora u'itlrou, *',s5 rrl pothogeruc contaminatjon. A clean u'ound
conraminated bv a mrnor break in ascpric technique is consi&red clean-contaminared
c) cotrtarlliluted: includes soff tissue laceratjors. open fraoures peneradng rvounds and otlrer fresh trautrntic
I
injunes. A procedwe u'ith a ma-iorbreak in asepic rechniqueis consideredconutminared
d) dltv and infeacd hear'ilr' conumi-nateds1 gfficall1' urfeoed prior ro surgen'
I
T1'pcs of Wound Healing
a) pnnuf intenuon: initial closure of an incison nit}r accunlell approximated u'ouknd edges, produces t11e
least anrounl of sarring.
b) secondan' intentjon: healing occurs brvformarion of granuladon Dssuecontainrng fibrobtaqs s'hjch close
I
tlre n,ound tn' conrracuon and secondan' grou'th of epirhelium.
c) teniary inrendon: &laved prirnan.closure
I
Phases of Wound Healing
a) subsrate phase Oag phase): dar' I to da-v3{
vascular response -
incrased rasodilanon and permeabilin
I
hemostasis'rra asoradon of clom-ng cascadeand forrruuon of plarelet-fibrin plug
leukoqrre responsetrnargirntion & emigration of WEICs)
capillatl'redirection louand u'ourtd edgesin order lo conu-iburero granulauon tissue
I
inflammator-r' response -
PMNs predomirnre dunng the fi.m fen'days
rracrophages predominate b' d:l' 5 I
b) proliferative phase(repajr phase): da1' 3-a to dal' 2l
controlled bv macrophages
fibroblasts la1'doun colJagen:u.ound e.tges"heap lry' dle ro collagen proliferauon
I
ner 'fiben and vesselsbridge defeo
m1'ofibroblass (''surgeon's cells") migrate fiom erysl6rling
gJ1'cosamrnogJl'cans
these cells have a conracrile characteristic
lissue to lal dorrn coliagen and
I
collagen fiben inidalh'laid doun r-nrandom panern
g) rernodsllingphase(rrnrureuoDphase):da1'21-
collagen fiben re-align a.long long ariis of 0inear) scar $rongest scar has is fibers arranged rn sarne
J
direclion as tle collagen fibers in tlre natve surrounding dennis [idal]1'. ori-einal scar u'ill be parallel ro RSTL]

I
189
t
I
Compiicanors of Wound Heai:rg
a) local factors dela'r'rngu'ound heaitnp
lenslotlluresor nude at an a:rgieoilter t]r"an
l. incisions: irrcislru urrproperlr]piaceduitlun relared s]oll
perpendlcuiar to tle skut srrlace
can lead lo excessive ussue drmage
2. reumanzed nssue:rough irandljng of the s'ound durtrg surgel'
u'hich u'ill dclav u'ound hcaitng
and delal' ltealtng
3 irrrproper irngzuon: fuilure ro i-g"* properll'u'ill allos'foreigm bodies to renrain
A
lna@uate hemosass: crealespooling drSentionof tlssuesand deadspaces
5 . desicarion of nssues:dfvrng of ossuedurrng sur8lcaj eryoslut
the resisance of
b. infecuon: hfecuon occurs i-f the mnoculum and rirulence of the orErulsm overcune
the hos: prrulence separalesu'ound edges
i . prolonged depcncicnq': icads ro eriema $'hich frr,on sepanDonof u'ound edges
and
8 local comcoseroids: large anounLsdelal'granuiauon rissue.depresscapilla4'proliferauon
in3eAed around the surg:calste' and ln Propcr
srippressfbroblaS ptoii{"t uon. CorucoSeroids
dosage-limit excessil'eedenu fomrauon

b) q'senuc fioon llul deiav s'ound heattng

1. turconroued diabetesmelbru-<
also reduces protein
2. alcoholjsm: alcoholics are nurritionallv depleted especiallv m proleul Alcohol
pha:n.
nrerabolism: hl,poprorernenia prolongs rhe iag phaseand slou's tlre onsetof proliferauve
3. glasroionrcsnnalmalabsorpuon
on ascorbic
4. ascorbic acid dcficrencr': sr:rtless of collagen and cpifhelid regenentron are dcpendent
acid
5 seroids: hiph lo'els inhibir coliagens\Tthesisand mucopoll'vcchandeprodrtclton
6 plaeler ittfr;U;utrg drups: drugs Orar impr platelet aggreezuon include asPirin phenYlburazone-
sultrnprazon". -tiluo-1ines. indonrel-btcln ctrJoroprornazhe-tranqrrilizsn and heponn
i 7. alenria: henroglobrn less t}an 10 Sm/dl u'ith a helrutocnt less tlnn 33ozi,is consideredinadeguate
ussue ox)'gen suppl)'for proper healtng
g hepaoc dtse"re' decreasesclonrng faqors and albumrn prodrcuon
g obesin': unsatisfaoon' ox]'gen ussuelevels and hlpercoaguabiitq
connecDvetlssLle
10. age: &creased healing causeCb.r-autoanobodies-altered proteins and diminished
producuon

\\;6und healins agenls

l. ACCUZ)}4E@ @apa.il-UreaDebriding Oinnnent)

-paparn. tle proleo.htlc enz\ane fiom t}!e fruit caricapapa)'a,is a potent drgesult of nonr"iableploleln
a debriding agent
nraner bur is harnrlessro viable ossue. h is reladvelv ineffecuve u'hen used alone as
and requues the presenceof activatorsto stimulate ifs digesrn'e polenc)

-ln Accuz_rme@.paparnis combrneduith ruea (a derururantof prorerns)ro bnng about tu'o actions: (l )
maner in lesions and tlrerebr'
lo e\pose the acoi'aion of paparnand (2) to derurure nonr"iableprolern
render ll more susceptiblelo cn4maDc digemon

IND]CATIONS AND USAGE

-indrcaed for debridemenrof necrotjc tjssue and liguefication of sloug:hin acule and chtoruc
posl-operaD\re
lesjons such as pressure/decubirusulcers varicose and diabeuc ulcen burns.
q'ounds
u'ourds and rniscellaneous raumatic or infected
-ir digess all non-riable subsrraresfound ir necrostseven ln t}e presenceof infection (and it
does nol harrn healt}r- r"iableussue)
-usualll see resulu in a fen'da1's
- 30g rubes(and slore rn a cool place)
..burning..sensailon
-adr,ersereaclion-<rnciude skin imunon and

r90
 ADN{IMSTRAT]ON

1. clean q'ound ltillt sallne

2 appl.r' Accuzrme@ drrectll' to the u ound and cot'er urth a dry'.sterile dressrng
-3. qd or bid appbcauons prcfcncd
1. rrngate u'ound at each redressrnglo renro\ieanr- accuntulationof liguef ed necrotic nraterial

2. REGRANEX@GEL fuecaPlermin)

-Reg"r:urergel conuurs a recornbjnanlltrunanplateletderived gtou'tlt factor (becaplentrin) for

topical admrrusuatlon
-Becaplermrn is produced b1' recombrnanlDNA technologv bf inseruon of the gene for the
bcu charn of platelet-den'r'ed groslh factor fPDGFJ into t}te ]'east- Sacc, arom.vcescerevistae
-acts lo promote chemoractjcrecruitmenl and proliferanon of cells invol'r'edrn u'ound repair
and enhanctngthe formanon of gralulallon llssue

INDICATIONS AND USAGE

-indtcated for tlte uealnrenl of lou'er e\.rrenun-diabeuc neuropathc u.lcerstltat exerrd irtto tlte
subcutaneoustissue or be1'ondand hal'e an adeguatebiood suppir'
-used as an ad-luncrro good uJcer care includrng rnirjal sharp debndement-pressurerelief and
infecUon conuol
-it has nol be€n Eraluated for the uealmenl of drabetic neu-roprtlucu.lcerst}r;t do nol errend
tJuougJrthe denrus into tlre suLxuta:reouslrssueor isclremic diabeuc ulcers
-congarndlcartonsinclude hrprsensitivrn'(contarns parabers) and }grou'n neoplasnx at lhe
site of application
- 2.7.5 and l5 Eram tube szes
-musl slore rn refrigerator (do nol ftef,ze)

APPLICAT]ON
l. s'ash hands tlrorougNl
?. fin5s u ound u"i0r sahne solulton ot rr?tet
3. do not touch tip of rube to an1' surface
4. applv a carefulll, measuredguandry'of Regranex@gel to the u'ound (enough ro cover lhe
surface)
,i after gel is applied dresst}e u'ound
6. aher 12 hours. remove dressing and gentJvrinse n'ith saline or n'ater
'/
appl'r'neu' dresstng for nexl I2 lrours u'tthoul Regranex@

T1'pesof Scar Formanon

a) h1'pemophic scar
l. resul6 fiom abnornral collapen proliferarion. Burdles of collagen are laid doun psrallel to tle slcrn
surface: ncapsuJatedard su1's u'ithrn margins of original scar
2. beerns to neuualize and sofien affer approximarelv l8months
3 can be treated u'ith topical seroid applicauons

b) keloids
l. fibrous rrssuehvperplasia uith fibroblasts arranged rn randonrll- onented parallel su'ands.Keloids are
deyoid of sebaceousglattds and are non-enctpzulared The lesion eneuds bevond the rrrarguts of the
origlnal scar. fiequentJl' enrapn nen'es and produces exreme pa.tn
2. dtfferenrial dragnosis
. d€rnulofibrosarconu proruberars
. rare maiigrunr rariant of derrratofibrorna
. contirues to en]arge. no hisorl' of prior traurTu
' lllpenroPluc scu

19i
 3. reatrnenl
surpcal excision conra-rndrcarcd - -
ilra-lesonal seroid irliecuon rnavcausekeloid lo flanen
pressuredressrngshelpfiti afier suget1'and/or tniecnon
silrcone gel sheeungrnal'k eflec!\'e

Skin Tersion

Ten-sionis t}e force tlut qausesu,oundslo rvidert artd scarsto h1'peruophr'. l:rcisroru nrusl Lreplaced irt areas of
leas tension lo illsute minimal scarnng
a) Lange/s Lrnes
Describedrn I861. t}ought to bc a refleaion of underlr"ingmuscleprll. In I941. Cox determinedneu' skin
clearageljngs rrtilizinpI ^trger'stechniques
b) Relared Skin Ten-sonLrnes
Deternuned bl Burges and Alexander in 1962. Theu l-rnesare crearedbl' underllrng structuressuch
as muscle. tendon bone or anl struflure tenring dre overlung slon. An rncision made perpendicular
to ilre relared slcn lerxron luresu'ill gap nrdell'. r'r'lrereasirn ircision made parallel to tlreselrrresn'iIJ
rernzun uell approx mated

PRIN'CIPLES AND TECHN]OUES OF FD{.ATION

AO/AStr
a) AO: Arbcirsgemeirschaftfur Oseosnt}esisfagen or The Associaoon of Oseosrnt}esis
b) ASIF: Associauon for the Srudv of Internal Fi-ration
c) Goals of t}e AO - rapid reco'r,eryof the iniured limb
I. anatomtcrevt,tcDon
2. presenzrion of blood suppl)
3. stablernternal f,r.auon
4. earll' acdve mobilization

Pnnciples of Rigid Frxauon

Prinran' r'ascularbone fonnauon
a) consistsof simuiuneous remodeling and formanon of nerl bone at fre fracnre srte
b) bpasses fibrocanilage formauon s€enrn secondan' bone healing. neu'bone is rntenuonalJ'r'formedat the
fi-adure margirs akaconrao hcahng: direct reconstrucuon of fragment edgesbv haversan remodel-ing
c) absenceof micronrouon is r,ecessan'for direo haversian renrodeirngand for the cumng coneslo cross lhe
fraqure ste and unite the fracnrre
d) if mouon occurs.;rcnoseal and endoseal callus forms resulting in secondan'bone healing

Principles of LnternalFirauon
a) lnterfoagmenun' Conrpression
l. sauc (compressionremains consant)
>lag screu'
xcc€ntric loadedplate
>enemal fixanon
2. {narnic compress}on
>tensionband
implant absorb,stension and bone absorbscompression
k-nrres proride roudonai sabilin
b) splirtage
f . internal
)neil<: k-qires. inuzmeci:llan' nail
>cerclaeerrire: stainlessseel rure

192
 >neutralplaung
neutralizesforcesappltedro the fraffure slle
*s1rr-s*s
shielding: In the absenccof phvsiolog:csuess.bone resorpuonoccursrn accordancelo
Wol_ffs l-au. This causesdrzuseoseopoross ard possiblerefracrure. Recent research demonsrated
a drrecr correlaDon bern'een the drmrtnnce of blood supplv upon appilcauon of tnternal fi.ranon and
the resuhant oseoporosis lrom rerasculanzauon of the areaa feu'u'eel': laler.

2. exrernal
>exemal fi-raoon

CONCEPTS AND TERMS OF MECHANCS

Smss and Stratn
"suess-Press.srarn-gain"
a)
Suess is i;re pressure trat 1,ouput on a material rn lbstsquareinch. Strain is the lengn-hor a measured
deformadon drat resulu in a matenal after a cenarn srresshasbeen applied to tt
b) Suess-Srain Cun'e
L rrJren $ress ts ploned \iersus suann u'e get a load defornpuon cun'e: drts cun'e repres€ntsa pioure of
the mechanicalbeha'rnorof a panicular intplant under a load
2. I'ield potnt
>Represenrs rhe point be1'onds'hich tle material is no longer Hoolcan (ie-tlre stmrn of a material is no
longer proponional lo t}re stressapplied to it)
>\\rhen vou pass $e laeld point of a material. funher prll or $ress causesan disproporuonallv larger
srerch or srarn
>Be1'ond tlre yeld pornt Ore marcrial qrnnol rclrun lo ru origural shape and lou have enteredthe range
of plasoc deformauon
3. Llldmate Failure Point
. conrinued sress through tlre :.mge of range of plasric deformation eventualh' leads to failure of the
marcrial
. Hook's Lau': tle arnounl of su-ainrn a materiai under a load is proponjonal to t}e amount of srress
applied to it
. Once tlre applied load is removed tlre nraterial uill spring back to is original shape {range of elasoc
defornrauon). The resrltilg slope represens t}le stifl-nessof the nraterial laka-Young's Modulus of
"E"
Elasicrt-r' or tlre moduJus]
. Since rmplanted marcrials Out u,e us€ are much scifer tllan bone. the material absorbstle smsses and
srrajns insread of the bone. This is lgroun as sress 5|dslding ard causesdrsuseoseoperua in the bone.

t- =-* {f'ttt'
-taz-
f.-;t-^
t

I
{1o;e
/-6Ft,
lo1
I'il*
f
t)
ri :
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l4 l 1
c r I
t
/-r' ' I
' t f t 1
t r _ i -

Sr/I-A,N

lr{aterials
316L\4V:
1.tlre"L'' stands
for loq'carbonconlenl

193
 ',\rJtf indtcaresr}at the baseallo]' \as remehedln a \?cuurTl uhich reducestte numLrr of tmpuriues
rjre
tharafleo the material'sphrsicalproperues
2. conrPostuon
iron and carbon. Prol'ide srengtb
cluonuum: ano<orrosive. but n'eakensallo'r
ruckel : resrenplhen allol-. ann+orrosve
rttoll'bdellunt: anD<orrosive
rTulnSanese
siltcon
@prEt
ruuogen
sulfru
phosphorou-<

Odter Temr-.
a) Faugue failure
Failure of a marenal fiont repeutive loadrng and unloading N4anl'materials can undergo a certarn
leyel of suessand if nor exceeded-u'ill nol shon' anv evidenc of fangue failure. Tensile sJesses
causea material to fail at irs surfacc.
b)' Creep
temperarure
A permanenl deformaDonin a metal. Bridgesare tuilt m a semt-arclo pre\renlcreep. Creep is
dependent (ie-rJre ilre
higlrer ilre renrperarure. preater the creep). Creep rates al trcd\. letlrp€t?nue are
)ou.. a1d tlus. an implanr rn the bod\'Ukes severajmontlls to laij fiom creep.
c) \rrscoelasticin'
"Ooq'' (ie-t}e material shoq's elasticbeharior- hrt also a riscous flourng
The abiln'ior a marerial ro
belur.ior). Tlre besr example of a viscoelasocmaterial is cartilage- canilage molecules r€rran8r
drern-seh,es allonrng for tlre arcepance of more $ress
d) Neurral Ar:s of Bone
When a long bone is loaded a rensionsideand a compressionsidedevelops.The axrsthat ex?enences
u'ell. but not
neidrer lerujon nor contpressionis called tre neural ar.rsof bone. PlatescouJds'ithsand tension
bendrng
Therefore. plates are placed on tlre rensionside of t.trebone

BONE SCREWS
Tu,o npes of screu's:u'ood screu'sand machi-ne screu's'
\\,txrri !ic^:}r,shave a tlrreadedup and predrilhng is nol necessalr As ther are driven rnlo bone. tlrY cnrsh and
L<Iimited
compad tlre urarerial. Ttrj-<rs not u'eI tolerared!r' conical bone. and trerefore. tlreu applicadon
have a blunr end and reguire both predrilhng and upprng for iruemon. Self upptng scre\\'s
Irtaihine srrrn,s
all screu's rn cur€nl use ate machine
have a 0ured tip and cut a leadrng rluead as tlrel' are drjven Almos
scre\\'s.

194
 Jl--

Screu'Anatoml
a) Head: rviLhsome excepuons.it is hexagonal. The hexagonalrecessallou's for nrosl effioenl
translanon of torque from the screu'dnver to the scren' and reducesGun-oul 0rftrng out of t}le
screw'drir,erfrom the screu' head).
Torqurng a scre\\'rcn much on trone increasesthe pressureal lhe bone-screu'rnterface.
causi-ngh'r'perenuaand bone resorptjon around Orescres'u'rtr subse4uenlloosenug
b) I-and' undersrrface of tle head u'hich comes in conuct u'ith the bone
c) Shank untltrcadedponron ofthe screu'{cancellous)
d) Run-oul: -iuncnonbenr,eent}te shank and tlreaded ponron of screu'. It is the u'eakes pornt on tle
screu. The tlucads shouJdcross u'ell into tlre fracture tapurrenl odreruise screu' breakageal dte
nm{ul is ine\"iuble as u,eUas dr-qraoion of the fragmenrs.
tXeep rn nund dral a screu'could break anrnvheredepending upon the forces al the bone-
scrcu'intcrfacc. Houever. a scre\\'is r.r'cakest
at the run-out
e) Thread dia:neter: representsOr dianreterof t-hescreu'
f) lie-a 4.0 nrn scre\r'hasa 4.0 mrn threaddiameter)
g f; Pircb. represenlsthe drsance benveenthe tJueads. A comcal scren' has a tiglrter ptch than a
canccllous screu'. g'hich makesrt rnore suitablefor hard corucal bone.
h) Core diarrreter.represenl( the dianreter of the screu trelu,eenllre l-lrreads.delenrrures tlre srze of
fie thread hole
i) Ttp: eirher rochar. round or fluted ( self-upprng screu)
j) Axx: ccntral line of a screu
k) Tip anPe: tip to $e axs
1) Rake angJe:tluead to axs angJe

Self upping vs- Non-self uprprngscre\l's

a) self tapprng
l. pilot hole larger tlnn u'ith non-seUBpplng scre\r'sand screu' tiueads do not penerrateas deeph' into
bone
2. olrce pilol ]role is drilled into rhe bone. ilre scren' can be iruened (screu'ed in)
3. mav have advanuge over non-self Epplng scre\t'sin fiin cancellousbone and in flat bones (ie-slarll.
pelris.t
b) mus perform insenion carefullr' - rf uni-ntenrjall]'angled t}re screu' nill cut a neu' pat} and desrov tle
abeaqr cut tlreads
b) non-self taPPing
l. requue predrJJed pilot hole and t}en cuning of scren' thread Ftrcrn uith a up
2. lesshea generaed sritlr inseroon due to decreasedresisance

Comcal and CancelJousScreu's

Conical
a) For use ir hard conical bone and function as posjtionai (ie-hold a plate ir, place) or €rsa lag screu' (ie-
fireads of screu' do not engageproximal conex of fraaure)
b) s€guenc€ of comcal screrl iruemon
glide hole. du€ded hole. courrcrsink nreaslre depth up ard irsen screrr deptlt measured befors
upping lo pre\ enl the .eauge from dGrupolg the tlread p€nern

195
 L-anceuous
a) The pitch of l}us screu is lugher t}an that of the conrcai screu. I is eirher filllv or panialli' threaded
Desrprredfor sofi lrteuphvseal aLndepiphvsealbone \\lren used rn lag fas)uon- a-lltire tirreacismus cross
ilre fracture of the oseotomv stle
b) s€quenceof canceUousscreu'irsemon
fireaded holc. countcrsmi; meiLsurcdcplr- up and rnsen scrc$

1 rg Screu'hinciples
Three condiuonsmus elrst for a screu'to funcnon as a lag
l. dte nearcone\ nlusl be &illed s'ith a clearancehole or a elide hole to allorr'ilte screq lo glide freelr
2. the far surface mus be thrcaded
3. trhen upfitened the screu head mus conmct Ore near s:rface or conex so rl cm conlpress the fizoure
seEmenls
Lag screu is bcs ;nsiuoned pc4-rndicular to fracnrre surfacefor nrarrmunl collpressron
lf screu' tluead englges bo0r nsat and far cornccs. compressronacrossfraoure ste u-ill not be achrn'ed and
gapprng n'il occur acrosssrle

Ir{alleolar Screu
Orighalv desiprredfor f,ration of medial malleolu-.
Cluracterisucs -
panialh'threaded
have s.emeOueadprofile and pitch as conical scre\\,s
u'ephine ( self-cunrng) up

Calurulated Screu's
These scres's are desi6nredto mirumrze compbcauonsassocratedrlith screq'irueruon (re-redrrecungscr3\r-s
and repeatedLnne penerauon u'hjch contpronrisebone frration). A k-uire is used ro ac)rjevereducuon and an
rntra-operarivel-rzrJ'ts ulen to confrrm placement. The k-$'rre Lben-.en,esas a gr.lde for t}|e screu'placement
Arail.able in 3.0 mm 4 0 mrn 4.5 mrn 7.0 mm srzes.7.3 mm

Efleqs of Screu'Holesrn Bone

a) decreases the bone'srestsanceto bendingand ro torsionalforces
b) sress concenu?Dont ircrcased lry lo 1.6 umes around a screu' hole
c) fracnrrestluoug} old screu'holes hn'e been docunrentedup 1s I I rnsnrhqafier screu renroral: grsrler
rncloenc€ u draphvsea.lbone snce il r-qunder Eveaterlorque nlotneltt.st}an nreuphvseal bone.
\r'hrch expenencesgTe:|ler compressrvesnEsses
d) follou.ing scre\\ removal. a 3-4 l'eek penod of canrng rs recommended

Plates
a) Description
Plaresfuncuon through interfragmenun'corupression bunressrngand neurallz:tjon
l. lnterfragmenun' Compress)on
>plate ma\. perform more tha:r one fi.rncuonal lhe samedme (re-neuu-alizaoonplate can proreo lag
screu'andalso exen compressionalong long axu of bone)
>eccentric loading of bone crealestension on one side and compressionon lhe otrer
if plate ts appbed lo leruion side-defomrn's'ill be prevented (sith load tlre plare is p.rr under rensjon
and coner opposrreplate urder compression)likeruse. if plate is aplied lo the compresson side.
conex oppositeplate uill gap under load

196
 t
----------
,
I
t
r I
Burress plares
Plate ts aPPliedto fracnrre srteso as lo prevenl shifi of the fragmentsunderload
"l-'. "L". "spoon". "cloverleaf'
t
SpecialdesiElx:

{"-c1
\ ' Ct-
/q
tno
I
I O I t 1 l o
I
Lzr f
{l|r-/)
ilt l o t l
f n f .t o/ o
0
Lf ,Ol

I
3. Neuu-airzauonPlates
I
horeo screq.fixarion. Inrerfragrnenun' scre\r'sare used to sabilze a fracrure and the plarc is applied
lo 'euualize t-hebcrrdurg ronior.raland slrearforces thal u'ould otlrenuse leopardize tlre flrauon
obramed ['lag screu'salone. I
{-tl[|t J
6$ I
b) Plate Sizes
l. rubular plarc: rube uit}t radrus of 6 mm and thiclgress of l mm
T
2. senu-tuhrlar (accomrnodates'1.5lrun screws)
3, one-third ruh:lar (accommodares3-5 mm screu's)
4. oneguaner tubular (accommodarcs2'7 mm scret's)
5. posenor anti-glide Plare
I
>used for Weber B fi-acrues u'ith poserior gike. The fi-acnue has the tendencv to displace superiorlr'
and pnseriorlr'. u'hich is preventedb1' this plate posinon'
>the Plare can redlce tlre fracure
I
>no potenrial for tre screlr' lo go i'nto &e jotnt
>also recommendedfor osleoporouc bone
>the disral fragrnent does not regulre screws I
c) LC-DCP: limjred conncl-d\rlamic compression plare
Funher developmentof the DCP and DCU
Based upon tlrc concep of biolog:cal plaung
I
1. *"n"taf sutgcal disrtrpoon of blood suppll
2. rmprored healrng il l}te zone covered $'tle plarc
3. redJc€d rist of rJ-fi-acrurefoUosi::g plate remorzl because of minimal
plal€
damageto bone beneat}ltlre I
or-riu- as the implanl matenal pror,ides oprimal tissue tolerance
4
T
197
T
 5. prooves on the unders:rface of the LC-DCP
>minimrze damageat -bonerpiare In rerface. u'hi ch -presen'es-blood supph
>allou,s for small bone bridge treneathpiate. rn an oilrenrrse u,eak spor
>allou's for more even dsmbuuon of t}e sriflness of plate (more resi$ant to belrdrng and torque)
6. descnpuon
>egual disance beru'eenscreu'holes along the plate
)screu' holes srrnntetrical and luve obiique undercuts at each end to alou'for uD to 40 rilu:rs of
scre\\'rneachdlreqion in long axs of the bone
>underculs benveenholes
>trapezoid cross-section
7. healng u'rtr the LC-DCP
>lateral undercutareasallou' for bone formauon at piate side of penoseai surface
>fizcrure gap erhibits band of remodeiug ra*rer than rcsorfnon of fracrure surface
>small arnounl of plate-ind:ced rcmodehng

Otlrer Forms of lnrcrnal Fr,ration

a) Kirschner \\/ires (1909) - "k-u'ire"
I suppl)'pnman. supplemenuland prorisionalfiranon
2. supplentennn':lo au€inenlscre\r or otheru'ire fixatron.Readill'prefonrredu.itJrlou, nrorbidin.
\ADenused u'jth a screu'.lbe k-u're aflords routional sabiliqr..
-1. pnnun'ftrauon: used for nreuursal oseotomies. fracturesand fusion-<
4. prousional f,xarjon: used rntratprnrilcll rn tlrc rcconso-ucrionof a comrmnured fracurc. Also
flrauon of choicc in phvseali4iunes
5 the rigidtn' of k-u'ire fixation cantr rncreasedbr rncr€asingthe dianrelerof rhe k-urre and the
number of tlrem used
6. Otreadedk-u'ires provrde E errct f,radon per dramercrvers:s tle smootb k-u'ire. Thev rend ro slip on
nls€ruon and once in-seruonu snned ilter are harder to redirect and have lou,er failure tlrreshold
comparedto a smootr k-rrrre of tie samedrameter
7. Sizes(drameterrn rnches):0 028. 0.035-0.0.15.0.062
b) Steinman Piru
1. consideredlarge k-lires and funcuon tlre sameas k-urres
2. srzesrn rnchesor millimeten
>51& to 12161nch rtiem€t€r(n l/81 lncrements)
>1.9 to.{.7 mm rn diameter

3. tjp dcsip: appliesto bot-bK-u'ires and Sternrnanpuu

>uochar. damond or cul uF
cul rip has an eccenrtc polnl produo-ng a large bole and subopn:rnal fit
trnchal up allons for the leas sbppageon ur.s€nro[ and thus- highes accru:tcv of placement
diamond tip has slightlv less uudal holdrng po\\,er Onn a uochar up

>at acule approachangles.damond and cut ups ualli along corucal surface.
s'hile the rrochar tip penetraes
c) StainlessSrcelMalleable Wire
l. monolilamenl fiom 24-30 guagesainless seel
2. used ufien franure fragmens are loo small. oseoporotic or commrnured to bc
suiuble for screq' firzuon
-i. best usedrn arujsion Facu.res and rn tensionband rccbnque
1. t}reright angJeloop conf guranon is the mos s.able loop conf guration

198
 - Frxanon _
d) Sraple
1. $xrable iilbone irith lugh canc€Uouvcoffcal rauo
(iecalqueus): tJrethicker the coner tire greater ilte properuin' of comnilnutrng it on irueruon
2. propensirl.to drsract the franure f-agmens if not properlv compressedpnor lo appllcaoon
3 --u4 insemon car13es roci,rng of the suple legs and an enlargedellipucal channel for tlre legs a'
u'eU as. sub-ofntmal holrting pou'o
jl. porver driven saple fixanon allows saple to penerate dte bone q'itroul rockrng thu tnrprorr-ng
fixadon: u'ill need to predrill u'hen usedin conical bone
5. saple sze is derermuredbv bridge n'id} and leg lengni
ionger the leg lengr}- the preaterthe pr:llout pos€r
6. reconrmendedapplicauon tn circumferendalfashion lo prevenl fracture gappng qlon u'eig:lttbeanng
7. bartpd saples increasesapie ymrchaseand holding pnwer: t],q' ate hard to remove and produce a
signif cant defea rn bone

I tl
e) AbsorbableFlranon \ V
l. rn,oq'pes
of poll'gJ1'cobc
>Biofui: composed acid
>Ort}osorb:composedof poll'-pdtoxanone
rapered pil anached to stainiess seel pin for drilling
completelv elirninated sithin su montlu
gradualll' losesrcnsile suellglr as the bone heals
PDS hr-srologlcalll'nrore rnen: lessrapidll'degraded
2. undergo hvdroll'ss u'hen placed in iiving tissue
3. possess much less stifliess and shearsrength rs a
k-rvirt. 507o decrea-se in holdrng pou'er 4{ wee}s afier inseruon
4. indicaooru: f,raoon of oseochondral frzpments: dipul fusions. meuursal oseolonues
(re-re.;ecuon
5. cornplicarions: larc inflanrmaton'reacdon and sinus formauon- adverseussue re:tctlors
irriuuon encaPsuJau on)
O Herben Bone Screu'
t . originallv desigrredfor fixauon of carpl scaphoid bone
2. rrun screu' diameter. I6-30 mm lengrh in 2 mm ircrements
"headless".comgrrcd ro conical and carcellous scre\^'s:this fe.erureallou's for rnsenion of the
3. screq,is
screu' through anicular caniia ge
I . can be insened 621rrqll1' or bv the use of a jig
-5. scrert remo\al not normally requtred
6. firg3&d ponions dr-sul and proximal uitlr tighter pirch proximalll". Orediflerence in pitch pro'r'ides
'7
compression beru'eent}le adlacenlbonl'fragmenu
8 composed of Tiunium allol'- uunium allov wit}
9. 6oloalumrnum and 47o'rznadtum
10. indicauons: f,rauon of oseochondral fi-agmenls:meutarsal oseolomlG: Akrn oseotoml

g) ReeseArthrodess Screq
P r h
I
l -
.,
desigrredlo crezrcSrcaler compressionacrossartlrodesls sile
rtuitlo. seel scte\r' uith clockrr"ise (righr-handed) treads proxlmall) and sN-T\\\",
counrercl ockrvi se ( l efi -handed)
(2.0 mm core rliemeter)
rhr€ds diSallr': smooti poruon benteen the rlreaded se€ments
rndicanons: hallux IPi fisjon digiul artlrodess

199
 h) Ten-sionBand ConceP
_1.-
the combiruuon of sanc interfraSrnenuJ'compressron'rrrth lhe.t'ntcnonalloading of the pan to
crcale a duunuc degree of rnterfraprnentalcontpressron
2 nvo basc components.
Load Beam (osseousselment)
Tension Band Deuce
--+lensionband plate
-+drnamt c compressron plate
--rcerclage uue
-1 examples i-nthe ank.leand foor
r aurJsion fraqures of the medjal and lateral melleob rnd 5u' meurarsal bese (although t}lere rs
some disple u'it} the 5o'meuursal bse)
4 u-sedfor trarlsverseand shon obllgue {ractures bul not anrenableto long obligue- spiral fraoures.
or commlnuled fragues

Complications of lnternal Frrauon

a ) inuz rcperative conrpbcauorLs
i . screu'srips: longer screu': iarger dranreterscreu-. redireo the pilot hole and different form of fixadon
2. scres. drill or up brcaks: hollou' reanter/ertraaion bolt trephrneil oul or leave it rn
b) Pos -operauve compbcaDon-<
1. nonunion: resrlts from poor fiaoure reduqion rncorrecl f,rauon or pabenr noncourpliance
2 infecuon: follou infecnon protocol-il rnternal ftration unstable. renrove and replace u'ith exemal
flrauon deuce applled auzl from ste to ursure nabihn'and maintarn blood suppll' of oseotoml' or
fraoure sle
c) necross. secondan'to srtpptng of penoseum and/or excessivecompressronal fraqure ends
d) brcskage. u-suall'r'dueto inappropriarc applicauon of fixation deuce (ie-size: merhod post-op course)

C.onrplicauon-sof Specific Fl-rauon Devrces

a) K-uires and Steinman puo-.
I . skln protrusion as a possible ste of prn trao infection
2- looserung- causesnecrosisof bone al prn srle and mos corrrmonclrse of pin rract infeorors
3. lrugraton - smooth k-uires are mos prone to mrgrarion
mecluurical motion at or nc€u fixauon srteis rmporunt
bendrng promp removal proper applicauon and use of threadedprrs reduceschancesof m:granon
b) Monofilamenl \rtre
l. imunon of tendon or overllrng slcn
2. shifiing of fragmenu on brealcageof t}re urre
3. loss of frranon secon&n' lo poor cntena and appljcanon
c) Staples
l. corucal shanenng
2. drsracuon of tlre fraqure ends
3, fraoure drsplacementon insenion of Oresaple
d) Screu's
l. poor reduaion of fraoure/oseolom-\.
2. screu' thread acrossfracnrreioseot om1' site
3. onepoint offixanon
4. hjrmg the near conex of adjacenl bne
5. incorrectplacement
6. incorrectchoie or sequenceoftnsenjon
7. rncorrectD?e. size or length of screq
8. overaggressivecountersink nith conical disruprion
e) Plaes
1. rncrea-se in operative rjme seconcian'lo exten-siredissecdon of sofi rissue and perioseum
2. imuoon and needfor removal
3. dlsuseoseoperua secondarl'lo stressshieldng or rnascularizarion afier peno$eal stripprng ard the
needfor casing pos remolal

200
 I
Bi oeniiio-nmental Pnop€niesand ReaE oru
T
a) Gahanic Corrosion: causedb1'ru'o dtssimilar metais rn bodt'
b)
c)
Crevce Corrosion. causedb1' one nteuJ ntol"ing aeauls attotiter
Fretung Corrosron.occursu,hen the protecnveoside laver is broken doun due to micromooon !\rhen a
nlsrrlli( implant is placed in rle bodr'. tlre nickel fiom t}e rmplant reasts$'tl}r Ils surroundtng Dssue
I
flujd fornung a prorecuve oxidc laver qmssi'rztion ial'cr) Ont proleos the metal from corroson
d) Suess Craciong. crachng of dre nreul due to clclic suesses. Craclurg resulls fiom corrosion fatigue and
sress corrosion cnclong
I
Classificaoon of Exernal Fixaton
EXTERNAL FIXATION\ t
a) Si-nrplePin Flrators
l. u ilizs half prn or trans-fNauon pirs u'rth one or more longrrudtlal side arms
2. simple lo use and I'ersadle
I
3. rti<2d\3112ge= the bone segrnenu must be properll reduced pnor 10 the appbcauon of the fixator
4. exantples: AO rubular s\,sem: Wag:rersrngje half franrc: tlre on-rinal Roger Anderson deuce
b) Modular Pin Fixators
I. rhe pirs insened rnlo tre bone are subiliz-edb-r'one cl.:lnp to u'luch a unjversal Jornt rs aruched
I
corurecring t}e long:rudinal rods
2. exremell,r'ersadle. alorring lr'rover'nents and adlusrnrenlsiit vanen'of plartes
3. disad\ant"ge = *re appartluqrs compioi. her"r'anci bul\
I
4. examPle: t}re Hoflnlan-Vidal fuame
c) Ring Firaton
l. componens include circular and serni<rrorlat nrlgs *r,atanach to side lonprrudtnal rcds
2.pirs connecl the bonv seSlxenlsto Oreorcular nngs
I
3. disadranuge = bufb'and diflrcult rn galning acccs lo sofl ussues
4. adyanuge. capable of adju-sungrn all planesand usesk-urres rlhich can be irsened in a 360 orienlauon
u'itrout complicaring t}le frame desgn
5. example: t}e classic Tlizqrov fran'ls

Functions
a) lenghening
I
b) neur-alizarion
c) cornpresson I
Uses of Exernal Flrauon
a) open fraoures
I
b) cornnunuted fraoures
c) anhrodess
d) oseotoml'flrauon
I
e) sofi tissue$2lilizqrisilflrauon

Confguntion
a) unilareral (one or tw'o Planes)
I
l. excellentu'ound access
2. not as suble as biPlane
b) bilareral (one or rn'o Planes)
I
1. rncrea-s€dstabilit\
2. i-ocrea-sed chance of danrage lo analonuc $ructures
I
I
201
t
 Unilateral Bilateral

Biodeeradable Firat ion

ldeal oseosrrrtlresisder"icesbould renrarn firm enough for rhe durauon of bone healing
and tlren lose its srrenpnhand transfer tlre normal suesslo rhe heahngbone. lt should
then drsappearfrorn the bodl afier heahng is complete

Firation t1'pcs(CurrentJlavailablein U.S.)

* Screg's
*Rods / Prns

Historical:
1973-84: Basic rescarchon animais
I985: Cluiical trials on lrumans-absorbablerods
I987: Firs totaUv absorbableself-reinforced screq'used

Basic Polyners:
PGA - polvgJvcolide
PLLA - polr'-L-lactide
PDS - polldrosaruone
* Fixanon deuces are produced b1' a self-reinforcrng procedurethat combrnespolrmers
lo inrprove suengh (SR-PGA SR-PLLA)

242
 I
" Degr::ded bn' hvdrolvsis - evenrualll' entenng rnto the Kreb's clcle and excreled rn
uri-ne.fec€s or expued COt
t
Loss of mechanica.lresistance:
SR-PGA - 3060 davs
SR-PLLA - 3-12 months
I
Complcte absorPtion:
SR-PGA - 5-10 months
I
SR-PLLA - l5{0 ntontlts
. Acluaj time dependson De shape.srze.molecuJaru'eight and variable ussue
envi ronmenrsof imPlanution I
.Advanl ages:
t. Avoids sress shieldrngor suessprolecltonosteoPerua
:. Eliminares burden (phvsiologlc and finarcial) of secondan'proccduresfor firauon
I
retrroval.
3. Does not lead to intage anifacls s'iten using MRI or CT post implantatlon
4. N4a1,be lefi In sites of infecuon as rmplants are baclenosuuc. t
I
2
Disadvantages:
Screu's are radiolucent - unable to confirm fixation position \\-lth x-ra\'.
l-ess interfrapttenl2n' contpressiont-lral lridr con'r'entiotralscreu's.
I
. Possible foreiprr bodl' reaction

Corricaj Bonc Pins

I Allofui @ made bv MTF tu O4usculoskeleralTransplant Foundanon)
I
Srudtes ulden'av usrng prn lo auErlcnl fi,rauon of Cherron (Austrn) oseololrues
2
tand rts mcdificarions) and to flrate PIPJ toe fusions
I
I
3 madc fiom conjcal bone drat has trecn turned on a lathe lo va4-lng slzes
a- 2.0 mrn 2.4 mm- 2.7 mn 3.0 mrn 3.5 mm
, rnsenion }rts available correspondlng to stze of prn
I
SUTURE MATERIALS
I
Purrnses-
a) approrimate ltssue until heahng ralies place
b) ligare vessels
I
c) rag fi-agile or imponant stntclures

Selection ba-sedon.
I
a) biologic and mecharilcalperfornrance
b) slruclure to be sutured (tendon. fascia. skin. r'essels.bone)
c) bactenal presence
l) conuminated ) monofllanlent (nrJon. pollpropvlene)
I
I
2) clean

I
2A3
t
I
Surure charactensucs:
sl. strength andtread dimenston
I ) t'arres u'itlr bastcnuterial coutpositiottattd duttenslons

b) nrosl used sundard measurenlenl

l) USP (UruredSutes PharmacoPeia)
2) denotes dlntettsionand icrot prll suength

c) suture volume
I ) use of smaller suluresdecreasesforeign bodv volume but sacrif ces knot pull srenpnh

d) elonganon
I ) elasttcrq'
i rerurn to ongrnal leng:thuith cessalion of slraln
i stainlesssreel.braided polvester.catgru.silk
2l Plasuctn
)- elongauon pcrststss'jtb cessationof slra:n
i polrprop'r'lenc
3 ) inlenttedrate
z possesboth eiastic and plasnc properues
i n'r'lon-poh'glaatn 910

e) flexjbilin
I ) based on material and drameterof suture
i smal.ldtarnelerts ntore flexjble tlnn large d:ameler

i nrlon. catgut = stifl

f) monofilament ys. braided

I ) ntonofilament has a lo'n'coeffrcientof fnction and is bener su:tedfor contalniruled u'ound.
2) braided has a high cocfficient of friction gtearelstrengtlr-and capillarit_t

g) capillann'
l) fluid and bacrenama]' frnerl:lle lnlo rnlersticesof braided sulures
2) Plr{N's. macrophagesroo large to reach intersrices(tncreases nsk of infeaion)

h) coalrng
1) helps decreasecaPillann
2) imProl'es lslrlling
3) reducesrissuedrag

Surureneedles.
a ) desirablecharaaenmcs
1) made of high qualin suinless seel
2) slim as possibleuitltout cornpromising suength
3) sharp enoughlo Frnerale trssueu'itt minimum resisance
4) rigid enougfito not bend but duaile enough lo nol breaj'

204
b) -needle analom)
-l)-surure
atuc-hment
2) bodl
3) Polnl C h o r dL e n q { f
h.leeclleI- I
c) meastuemenls PoirI1
I ) chord iengt-b
2) needle radru-'
3) needle djameter
I T
\
4) needle length . \
d) sulure anachment u s\ 1
I) closedleved) \
2) French (sPlit or sPnng)
3) su'agedleveless)
i most colrunon
), suture aruchment Needle iengtf,
drrectJf into needle
,.
. decreasestlssue damage
e) bodt'
l) srraight- % cun'ed % circle. lz cicle (nrost colrrmon). 3/8 circle. 5/8 cucle
2) geometnc shaPe
i round flaL oval. mangular
3) lenPnlr({nrm4()nutt)
f) poinl
I) blunt
) used for friable tissue
2) uPered
i usefirl for nssueoffertng sbghl reslsance
i paratenon tendon sheath"subcutaneousllssue
3) curung
; convenuffi
edeeon conqr'ecun'arure
l- .ur.,-tiroulh dense.drflrcult lo peneu?le areas(tendon ltgament)
"rip"
cate musl be taken nol lo througlr tissue
z r€\i€rs€-
-r-^ ^r^^
r cu[rn8 edSe on convex cun'alure
I pre\/entsneedle from "npprng'Ouough tissue (slon)
I greJrer suength

,ss
H", o Qsk
Regutar(:rtttrnlr

K S6ralula
ask
ReverseCuttrng;

Sururenpes:
a) absorbable
I) generallt lose tensile srength s'ithin 60 &r's
2) narural
7 degnded bJ'lvsosonral elzvlttes
; catgut
- nane ma'r ongilate fuom "kitgut" meamng riolin snrng

205
 *made from submucosaof sheepintestrneor serosaof bovine tntemne
- *can be rreatedlrth chromic saltsand formaldehvde for greater srengt-h
-srored rn aicohol for presen'atlon
*highest rissuereactir"in'of all sulures
i collagen
' nradefrom long flexor tendon of steer
- pnnrarilv used rn ophtlralnuc sutge4
+lesstissuereaclrvethan catgut

3) srntheuc

+ braided
't good Lrror-pull and tensile sreng:th
+ ven'inen
* compietelJ'hvdrollzedin 100-200da'r's
- rmv b€ coaredrrrtlr polvcaprolatefor rnrprovedussue passage.|r.andhnglmonrng
* slan and subcuraneoustissue
i poil'pactin 910 (Vicn'l)
+ braided
- 659" tensiie suength remains at l4 davs
+ \'en' rnen
+ complctelv hldrolrzed in 80 days
+ nu]' be coateduitlr polYglactrn370 and calciunr siearalefor bener handltng

* monofilament
+ high flexibilrn-and tensile strengrh
+ completel]'hvdrollzed in 90 davs
+'r'ery inen
+ 70Torensilesuengrlrat l4 da1's
i poll'glvconate(lr4aron)
+ monofilamenl
+ resisl< kinlong and curirng
+ becornessofier as it's exposedto trssuefluid
+ complerel]' hr drollzed at 180 da1's(longes of an1'"absorbable'' suture)
i poliglecapronefMonocryl)
+ monofilanrenl
+ ver-\'pliableand rnen
* completel]'hvdrolrzedin 90-120 davs
' 20-30o]otensile suenptlt remarnsal l4 dal's
b)

d) nonabsorbable
l) generaljl marnlaln tensile strengrhlonger tlran 60 dar
2) rnrural
i silk
- rnade fiom silk of tbe silk rvorm
+ Igrour for supenor handhng ptop€nres especialh's'hen braided
? unpregnaledand coatedl\'tth ru\Ture of lla-riesand sibcone
+ lou' rensile suengh u'hich is completelr' los at 360 davs (r,en' slonil' absorbable)
+ h:ghji' tissue reacul'e
i conon- hnen
+ similar to silir
- rncreasedDssuereaglroD
+ \'en' lo'n tensile srength. u'eakesl surure

206
 _ 3) srnthetic
nrlon (Ethilon Surgilon.l
r posS€sses "nlernonr' ( the telrdertcl for a filantent to \\'anl to $raia'luen)
* elaStiCrn rultrre thereforervell srutedfor relention and rvound closure
+ high tensile strenplhand lou'tlssue reacn\1n'
+ monofilamenl and braided
- nlzt]'be used in conrartri:ratedn'ou:td'
polvester (Ethibond Dacron )
+ braided
+ higl ussue suength
'+ lou' tissuereactt\'ln
1 m3]'be coated u'ith silicone for smoothness.reducestissuerauma
+ used u'hen suong apposition of ttssuesls neededindefinitelr'
pollpropl'lene (Prolene. Surgilene)
+ \rer-\'tnen
+ monofilament
' bcner pliabilin' and luendlrngtlran nvlon thereforeholds limotstrner
+ excellent tensile suengtlr
+ passestjuoupfr ttssueu"jtlt nrtmntal drag
-t ofien used in contaminaledu'ounds and plamc sutger-\'
stahless seel (Fleron = braided)
+ monofilament and bra.ldcd
- nreasuredin dre Bros'n and Sharpe(B&S) gaugesald nol rn the USP nretlrod
+ m3]'conode especialll al sllesspolnls
* mild to moderatehssuelcacD\tn'
+ nut)'fraoure. faugue. or }odi
+ u-sedfor bone fixatron- lendon tepau. and relenbon sulures

Sraples:
a) corunon uses
t ) gasrrorntestinalanaslomoses
2) u'ound closure
3) bgature substrtule
b) bener resisunce ro infecrjon than rlounds contanrinaledbv the leasl reacDl'esurure
c) often used to aft>i slon grafrs
d) ilDplementauon
I ) even skin edges uit} trl'o araumanc forceps
I ) deliver tlre suple al 60 degree angJe to t-}reskin
-
2) g'hen suple assurnesan uprighr posiuon tle top spanu'ill nol be rn conucl ruth tle skin thjs
helPs
lo pre\,eDl''cross-hatchrng='

ST,APLE)R
STAPLE
+

207
J aDes
at mate ln a vanen 6f forms thatTin-in baclong and adheslve'formuiarton-
b) porous sruclure of adltestveand backnrgallou's for evaporauott
ci supenor resisunce to rnfecuon over an] olher \\'ound closuretechniqtte
d) nral' onl1' be used as pnman' closure deuce on u'oundsu'ith mrnimal stauc and drnanlc tenslon
e) ma1'bc supplcmentedu'ith derma.lsururcson thc lugh tension skir of the exrremiues

Fibrin sealants.
il biolopc ttssueadhestve
b) Derma Bond€

208