Wing tips surgery

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Wing tips surgery par Mind Map: Wing tips surgery

1. D147 - complication fracutre repair

1.1. Disturbed fracture healing

1.1.1. causing

1.1.1.1. delayed union

1.1.1.2. non union

1.1.2. due to

1.1.2.1. local physical factor

1.1.2.1.1. instability

1.1.2.1.2. vascular impairmant

1.1.2.1.3. large gap - smooth tissue imposition

1.1.2.1.4. infection

1.1.2.1.5. metallosis

1.1.2.2. systemic factor

1.1.2.2.1. immune reaction w cortial alloimplant

1.1.2.2.2. nutrtitional

1.1.2.2.3. cancer cachexia

1.1.3. clincal signs

1.1.3.1. persistance

1.1.3.1.1. pain

1.1.3.1.2. warmmth

1.1.3.1.3. motion at #

1.1.3.1.4. relucatance to use limb

1.1.3.1.5. joint stiffness

1.1.3.2. in nonunion - pain can be absent dt psudoarthroiss form

1.1.4. diagnosis

1.1.4.1. sequential rads

1.1.4.2. bone scintigraphy

1.1.4.2.1. 5MT

1.1.4.3. osteomedullography

1.1.5. classification

1.1.5.1. viable still has blood supply

1.1.5.1.1. hypertrophic

1.1.5.1.2. slightly hypertrophic

1.1.5.1.3. oligotrophic

1.1.5.2. nonviable incalable biological response - blood supply poor absent

1.1.5.2.1. dystrophic

1.1.5.2.2. necrotic

1.1.5.2.3. defect

1.1.5.2.4. atrophic

1.1.6. treatment

1.1.6.1. want heal bone AND return function

1.1.6.2. ID primary cause and fix

1.1.6.3. post op physiotherapy

1.1.6.4. Sx repair

1.1.6.4.1. restore stability

1.1.6.4.2. improve anatomic aligments

1.1.6.4.3. eliminate infection

1.1.6.4.4. stimulate vasculisation and bone production

1.2. Malunion

1.2.1. fracture that healed in abnormal position causing functional impairment

1.2.2. cause

1.2.2.1. limb shortengin

1.2.2.2. limb angulation

1.2.2.3. limb rotation

1.2.2.4. uneven weight distrobution over joint surface

1.2.2.5. restriction adjacent joint movement

1.2.3. classification/Sx treat

1.2.3.1. overriding

1.2.3.1.1. tranverse osteotomy and distraction

1.2.3.2. angular

1.2.3.2.1. wedge osteotomy

1.2.3.3. rotational

1.2.3.3.1. tranverse osteotomy

1.2.3.4. intra articular

1.2.3.4.1. excisional arthroplasty

1.2.3.4.2. artifical joint replace

1.2.3.4.3. arthrodesis

1.3. Osteomyelitis

1.3.1. inflamation bone and marrow

1.3.1.1. slow recovery

1.3.1.2. protracted, unrewarding

1.3.2. abs treatment

1.3.2.1. should be present at fracture sitea at time contamination -start preop

1.3.2.2. culutre sensitivity

1.3.2.2.1. aerobic anaerobic

1.3.2.2.2. sewuesterum and loose implant

1.3.2.3. weeks to months

1.3.3. forms

1.3.3.1. haematogenous

1.3.3.1.1. rare dog cat comon shildres

1.3.3.1.2. young animal at metaphyses

1.3.3.1.3. CS - tenderness swelling lamneness

1.3.3.1.4. bone biopsy for culture - blood culture if bacteriamia

1.3.3.2. acute

1.3.3.2.1. complication of open fracture, open reduction closed fracture, bite wouds

1.3.3.2.2. CS pyrexia, lameness, pain over #

1.3.3.2.3. rads proliferative new bone, gas

1.3.3.2.4. FNA culture

1.3.3.3. chronic

1.3.3.3.1. sequale to shit treated acute - allow bacterial colonisation

1.3.3.3.2. bacteria

1.3.3.3.3. CS

1.3.3.3.4. rads - bony proliferation/lysis

1.3.3.4. Rx

1.3.3.4.1. early aggresive

1.3.3.4.2. remove implant when clinical bone union achived - eliminate infection

1.4. Fracture disease

1.4.1. complications of fracture repair

1.4.1.1. atrophy

1.4.1.1.1. mm

1.4.1.1.2. bones

1.4.1.1.3. joints

1.5. Implant failure

1.5.1. stainless suseptable to cyclic stress

1.5.2. take load of limb while bone heal

1.5.2.1. delayed healing

1.5.2.2. innapropriate implant selsction - weak

1.5.3. areas predilection

1.5.3.1. plate - screw hole

1.5.3.2. pins - jn thread

1.5.3.3. cerclage wire - bend twist

1.5.3.4. screws - shank or head

1.5.4. loosening

1.5.4.1. technical error

1.5.4.1.1. innapropriate implant

1.5.4.1.2. shit preparation - hole too big for tap

1.5.4.2. technique

1.5.4.2.1. fail aseptic

2. D148 - Surgical conditions of the skull

2.1. Dispatch

2.1.1. good blood - rapid heal

2.1.2. need to establish normal dental occlusion

2.1.3. pharyngostomy/tracheostomy allow more space to work

2.1.4. tension freee closure gingiva

2.1.5. feeed soft post op/stomach tube

2.2. mandibular fracture

2.2.1. common cat - open fracture dt trauma hbc

2.2.2. muzzle

2.2.2.1. stable mid body unilateral

2.2.2.2. maintain reduction - lock canien together

2.2.2.3. shit in cats brachycephalic dog

2.2.2.4. mouth shut if feedign tube

2.2.2.5. use non elastic tape

2.2.2.6. avoid heat stress

2.2.3. wiring

2.2.3.1. symphaseal

2.2.3.1.1. encircle both rami just cadal to canines

2.2.3.1.2. good for symphasealk #

2.2.3.2. interdental wiring

2.2.3.2.1. for transverse mandibular body fractures

2.2.3.2.2. wire loop around teeth - must be intact solid.

2.2.3.2.3. dont over tighten - distraction opposite cortex

2.2.3.3. interfragmentary wiring

2.2.3.3.1. simple tranverse and short oblique mandibular fracture

2.2.3.3.2. wire thru holes either side #

2.2.3.3.3. multiple wire - avoid pivot

2.2.3.3.4. short twist minimise mucosal irritation

2.2.3.4. interarcade wiring

2.2.3.4.1. bilateral loop wire passed bt mandible and maxilla

2.2.3.4.2. like muzzle but work brachy dogs and cat

2.2.3.4.3. feed tube/allow lapping

2.2.3.5. intermedullary pins

2.2.3.5.1. shit - narrow medullary cavity w teeth roots

2.2.3.5.2. high rate malocclusion

2.2.3.6. plate

2.2.3.6.1. excellent stabilisation

2.2.3.6.2. avoid teeth roots

2.2.3.6.3. human moulding plates

2.2.3.7. external fixators

2.2.3.7.1. complex comminuted open fracture w bone loss.

2.2.3.7.2. 2 - 3 fixation pins per fragment

2.2.3.7.3. fracture reduction

2.2.3.7.4. join fixation pin w clamps connecting bar/acrylic column - multiple angles

2.3. maxillary fracture

2.3.1. most non displaced - treat conservative w soft feed

2.3.2. thin cortices - shit screw

2.3.3. same principle mandibular

2.3.4. beware

2.3.4.1. airway obstruct

2.3.4.1.1. nasal

2.3.4.2. major vesels nn

2.4. Temperomandibular luxations

2.4.1. isolated or w mandibular #

2.4.2. mandibular condyle displace rostrally or caudall

2.4.3. dx - rads

2.4.4. closed reduction - use fulcrum pivot bakc in

2.4.4.1. dog - dowell

2.4.4.2. cat pencil

2.4.5. acute injury stable after reeuction

2.4.5.1. soft diet weeks

2.4.5.2. unstable - muzzle/intercade wire

2.4.6. chronic luxation

2.4.6.1. open reduction

2.4.6.2. suture imbrication of joint capsule

2.4.6.3. dondylectomy

2.5. mandibulectomy

2.5.1. indicated w non union fracture w infection, neoplasia

2.5.2. differing amounts

2.5.3. tumor - 1 cm margin

2.5.4. complications

2.5.4.1. wound dehicience

2.5.4.2. droolin

2.5.4.3. tongue deviation

2.5.4.4. malocclusion

2.6. maxillectomy

2.6.1. similar to mandibulectomy

2.6.2. multiple approach.

2.6.3. allow sufficient labial/buccal mucosa to close deficit

2.6.4. complication

2.6.4.1. oronasal fistula

2.6.4.2. ulceration upper labial mucosa dt impingment by lower canine

2.7. neoplasm oral cavity

2.7.1. common

2.7.2. fibrosarc

2.7.2.1. histologically low, biologically high

2.7.2.1.1. invasive

2.7.2.1.2. mets to lung

2.7.2.2. 1 year

2.7.2.2.1. radiation resistant

2.7.3. malignant melanoma

2.7.3.1. dont all contain melanina

2.7.3.2. mets to LN, lung

2.7.3.3. bigger worse

2.7.4. SCC

2.7.4.1. feline

2.7.4.1.1. shit

2.7.4.2. rostral better

2.7.4.2.1. radical sx

2.7.5. epulides

2.7.5.1. fibrous ossifiing - slow grow, not invasive

2.7.5.2. acanthomatous locally invesive, dont met

2.7.5.2.1. radical sx - wide margin

2.7.6. osteosarc

2.7.6.1. radical sx

2.8. cranial #

2.8.1. extracranial

2.8.1.1. rare Sx

2.8.2. intercranial

2.8.2.1. decompression

2.8.2.2. remove fragment, cover w temporalis mm

2.8.2.3. avoid tear meningies

2.8.3. Rx concussion and cerebral oedema - increased ICP

3. D149 - Forelimb Fractures

3.1. Scapula

3.1.1. dispatch

3.1.1.1. uncommon - concurrent thoracic

3.1.1.2. difficult to immobilise

3.1.1.2.1. external - sicca splint , non weight bear sling

3.1.1.2.2. internal - intra articular - v unstable

3.1.2. spine and body

3.1.2.1. most comon

3.1.2.2. conservative treat w cage rest

3.1.2.2.1. heal 4 - 6 weeks

3.1.2.3. open reduction coaptation

3.1.2.3.1. gorssly unstabel

3.1.2.3.2. cerclage wire

3.1.2.3.3. smitubular plate where spine join scap

3.1.3. neck

3.1.3.1. watch suprascapular nn

3.1.4. glenoid cavity

3.1.4.1. lag screw and tension band

3.2. humerus

3.2.1. dispatch

3.2.1.1. not common but difficult

3.2.1.2. most shaft and distal

3.2.1.3. coaptation hard - cant immobilise shoulder

3.2.1.4. radial nn/brachial plexus involve

3.2.1.5. bone surface - contour plates over musculospiral groove.

3.2.2. proximal #

3.2.2.1. prox physeal

3.2.2.1.1. infrequent

3.2.2.1.2. type 1 or 2

3.2.2.1.3. young

3.2.2.1.4. old

3.2.2.2. prox metaphyseal

3.2.2.2.1. path dt osteosarc.

3.2.2.2.2. internal fixation

3.2.3. diaphseal #

3.2.3.1. taper - weaker

3.2.3.2. prox - transverse

3.2.3.3. distal - oblique/spiral dt muculospiral groove.

3.2.3.4. plating

3.2.3.5. external fixation

3.2.3.5.1. thru IM pin - stop rotation

3.2.4. distal #

3.2.4.1. supracondylar

3.2.4.1.1. type I or II

3.2.4.1.2. IM pin up each condyle

3.2.4.2. unicondylar

3.2.4.2.1. lateral type IV (perpindicular across physis)

3.2.4.2.2. K wire up epicondyle to penetrate opposite cortex

3.2.4.2.3. w inter condylar lag screw

3.2.4.3. bicondylar

3.2.4.3.1. frequent mature

3.2.4.3.2. T or Y based

3.2.4.3.3. trans olecranon approach

3.2.4.3.4. stabillise intercondyle w lag screw

3.2.4.3.5. supracondyle w crossed pins

3.2.4.4. lateral condyle more likely

3.2.4.5. all require reduction and fixation - proximity to elbow joint

3.3. radius ulna

3.3.1. dispatch

3.3.1.1. distal third radius common

3.3.1.2. commonly both radius ulna

3.3.1.3. prox to skin - open common

3.3.1.4. immoblilise joint above belox - external captation

3.3.1.4.1. non/minimally displaced.

3.3.1.4.2. closed reduction - heabvily sedation

3.3.1.5. ulna dont need fixation if radius intact

3.3.1.5.1. except olecroanon

3.3.1.6. IM pins shit - compromise articular surface.

3.3.1.6.1. concientric articular surface

3.3.1.7. plate radius - cranial side - tension

3.3.2. radius

3.3.2.1. proximal

3.3.2.1.1. prox physeal

3.3.2.1.2. radial head

3.3.2.1.3. radial diaphaseal

3.3.2.2. distal

3.3.2.2.1. physeal

3.3.2.2.2. metaphyseal

3.3.2.2.3. fracture styloid process

3.3.3. ulna

3.3.3.1. proximal

3.3.3.1.1. physeal

3.3.3.1.2. olecranon #

3.3.3.1.3. monteggia fracture

3.3.3.2. ulnar diaphaseal #

3.3.3.2.1. dont require fixation if radius ok

3.3.3.2.2. can IM ulna to splint minimally displaced radius

3.3.3.2.3. dont lock ulna to radius distally - some rotation.

3.3.3.3. distal physeal

3.3.3.3.1. cone shaped - suseptable type V (Compressive)

3.3.3.3.2. suspect - cant see on rads will month

3.3.3.3.3. angular deformity dt ansynchronous growth

3.4. carpus

3.4.1. dispatch

3.4.1.1. comon working, uncomon pets.

3.4.1.2. conservative - external coaptation

3.4.1.2.1. ok small

3.4.1.2.2. shit large - reffer

3.4.1.3. complex anatomy

3.4.1.4. good rads - multi view.

3.4.1.5. reduction fragments w k wire or lag screw.

3.4.1.5.1. must counter sink - articular surface

3.4.2. radial carpal bone #

3.4.2.1. jump fall - slabs off articular surface.

3.4.2.2. become joint mice - spontaneus heal rare

3.4.2.3. large bits - stabilise

3.4.2.4. small - remove

3.4.3. accesory carpal bone #

3.4.3.1. racing greyhound

3.4.3.2. avulsion - grade system

3.4.3.3. lag screw chicks in

3.4.3.4. comminuted - cast in 20 degree flexxion

3.5. metacarpus

3.5.1. dispathc

3.5.1.1. young

3.5.1.2. stood on/trapped

3.5.1.3. MC III IV main weight bear - can use to splint others

3.5.1.3.1. external coaptation, heal 6-8 week.

3.5.2. normograde pin from distal to prox w smaller IM pin best.

3.5.2.1. protect metacarpophalangeal

3.6. phalanges

3.6.1. dispatch

3.6.1.1. P1,2 common

3.6.1.2. splint/short cast

3.6.1.3. intra articular - performance animals - open reduction

4. D150 - Pelvic and Hindlimb Fractures

4.1. Pelvic #

4.1.1. dispatch

4.1.1.1. common HBC

4.1.1.1.1. full hx - bladder bowel, spinal cord,

4.1.1.1.2. symetry - pelvic bones triangle

4.1.1.2. biomechanics

4.1.1.2.1. pelvis like box - single # rare.

4.1.1.3. lots muscle

4.1.1.3.1. good support

4.1.1.3.2. hard reduce dt mm contracture

4.1.2. managment

4.1.2.1. conservative

4.1.2.1.1. indicate

4.1.2.1.2. realign w percutaneus/digital manipulation

4.1.2.1.3. cage confine 4 weeks longer

4.1.2.2. surgery

4.1.2.2.1. indicate

4.1.2.2.2. fixation - if intraarticular or weight transfer from hind

4.1.3. sacroiliac seperation/frcature

4.1.3.1. occur w other pelvic # unless bilatera;

4.1.3.2. normally ilium goes craniodorsal

4.1.3.3. fibrocartilage and synovial joint

4.1.3.3.1. heal better w little movement

4.1.3.4. options

4.1.3.4.1. lag screw

4.1.3.4.2. transilial bolt

4.1.4. acetabular #

4.1.4.1. dispatch

4.1.4.1.1. most req internal fixation, esp if cranial part acetab.

4.1.4.1.2. pain and crepitus -

4.1.4.1.3. small dogs conservative - watch DJD.

4.1.4.2. anatomy

4.1.4.2.1. dorsolateral lip - fibrous - in tension - shit screw

4.1.4.2.2. watch sciatic course over ishiatic notch

4.1.4.3. plate fixation

4.1.4.3.1. special plate conform

4.1.4.3.2. applied to tension side - lateral aetabular lip

4.1.5. iliac #

4.1.5.1. dispatch

4.1.5.1.1. oblique ilial shaft.

4.1.5.1.2. caudal part - hip joint. displaced medailly cranially

4.1.5.1.3. hard w muscle builk

4.1.5.1.4. conservative - tape stifel together to pull out.

4.1.5.1.5. wing shit screw

4.1.5.2. plate

4.1.5.2.1. contour to lateral side ilium

4.1.5.2.2. one screw through to sacrum

4.1.5.2.3. stable fixation and restore pelvic canal important

4.1.6. ischial #

4.1.6.1. in accompany w other #, fix it, fix ishium

4.1.6.2. internal fix

4.1.6.2.1. if large, unstable, pinch nn

4.1.6.2.2. pins, wire, plate

4.1.6.3. conservative

4.1.6.3.1. confine

4.1.6.3.2. non weight bear sling in neutral position

4.1.7. pubic #

4.1.7.1. reduction other # fix pubis

4.1.7.2. watch genitourinary, obturater nn, ventral herniation

4.1.7.3. cranial displacement pubic rim - avulsion of prepubic tendon

4.1.7.4. internal fixation w wire suture/small plate

4.2. femur #

4.2.1. dispatch

4.2.1.1. comon hbc

4.2.1.1.1. ext coaptation hard

4.2.1.1.2. ext fixation w new plates

4.2.1.2. IM pin good

4.2.1.2.1. proximal ecentric articular surface.

4.2.1.3. lateral side tension - flat - good plate

4.2.1.4. salvage w excision head neck/hip replace

4.2.2. proximal

4.2.2.1. physeal #

4.2.2.1.1. capital physeal

4.2.2.2. avulsion femoral head

4.2.2.2.1. common w coxofemoral luxation

4.2.2.2.2. samml - excise

4.2.2.2.3. large frag - lag screw

4.2.2.3. femoral neck fracture

4.2.2.3.1. internal fix - lag srew

4.2.2.4. greater trochanter #

4.2.2.4.1. k wire and tension band

4.2.2.4.2. compressive srew

4.2.2.4.3. premature closure not issue

4.2.3. diaphaseal #

4.2.3.1. short oblique and interdigitating (reduce rtation) can do IM

4.2.3.1.1. normograde better for sciatic

4.2.3.2. if rotation

4.2.3.2.1. IM and external skeletal fixation

4.2.3.2.2. IM pin and cerclage wire

4.2.3.2.3. plates

4.2.4. distal #

4.2.4.1. distal physeal

4.2.4.1.1. common young - 1 2 3 4, 2 most tommon

4.2.4.1.2. epiphysis displaced dt pull gastroc

4.2.4.1.3. premature closure common - ok if entire - short leg

4.2.4.2. avulsion of long digital extensor

4.2.4.2.1. bone fragment visible rads

4.3. tibia #

4.3.1. dispatch

4.3.1.1. comon

4.3.1.2. open

4.3.1.3. can immobilise joint above below

4.3.1.3.1. external coaptation

4.3.1.4. IM pin - normograde

4.3.1.5. medtension on medial side - plate

4.3.2. proximal

4.3.2.1. avulsion tibial tuberosity

4.3.2.1.1. internal fixation

4.3.2.2. proximal physeal #

4.3.2.2.1. 1 2 3

4.3.2.2.2. internal fix w small k wire

4.3.3. diaphaseal #

4.3.3.1. easy - good intro to orthapaedics

4.3.3.2. IM pin - not articular surface stifle or hock

4.3.3.2.1. nto too rigid

4.3.3.3. external skeletal fixation

4.3.3.4. plate

4.3.4. distal

4.3.4.1. distal physeal

4.3.4.1.1. 1 or 2

4.3.4.1.2. crossed pins

4.3.4.2. malleolar #

4.3.4.2.1. unstable tarsocrural joint

4.3.4.2.2. fix w K wire and tension band/large screw

4.4. tarsus

4.4.1. dispatch

4.4.1.1. osseus/ligamentous

4.4.1.1.1. palpation

4.4.1.1.2. rads

4.4.1.2. fibial and tibial tarsal bones most common.

4.4.1.3. need internal fixation for return to function

4.4.1.3.1. k wire

4.4.1.3.2. tension band

4.4.1.4. no torniquet during sx, delay cast post op - swelling

4.4.2. # fibial tarsal bone - calcaneus

4.4.2.1. apophyseal # at tuber calcanei

4.4.2.2. stabilise w kwire and tension band

4.4.3. # tibial tarsal bone - talus

4.4.3.1. intrarticular

4.4.3.1.1. small pins srew

4.4.3.1.2. coutersunk

4.4.3.2. neck

4.4.3.2.1. lag screw body talus to calcaneus.

5. D151 - Growth plate injuries

5.1. anatomy

5.1.1. bt epiphysis metaphysis

5.1.2. cartilagenous

5.1.2.1. reserve zone

5.1.2.2. proliferative zone

5.1.2.2.1. column dividing cells

5.1.2.2.2. produce collagen matrix

5.1.2.3. hypertrophic zone

5.1.2.3.1. enlarge size

5.1.2.3.2. degenerate

5.1.2.3.3. WEAKEST

5.1.2.4. ossification zone

5.1.2.4.1. form framework for endochondral ossification

5.2. classification - salter harris

5.2.1. type I

5.2.1.1. along growth plate only

5.2.1.2. young dt shearign forces

5.2.1.3. good prognosis

5.2.2. type II

5.2.2.1. partway along epiphysis an dinto metaphysis.

5.2.2.2. >6months - angulated shearing forces.

5.2.2.2.1. bone frag on side opposite to shearign force

5.2.2.3. most common type

5.2.3. type III

5.2.3.1. partway along physis and into epiphysis

5.2.3.1.1. intra articular

5.2.3.2. uncommmon

5.2.3.3. need anatomic reduction - smooth articular surface

5.2.4. type IV

5.2.4.1. through metaphysis, across physis, into epiphysis - intracrticular

5.2.4.2. >9 months - growth plate totally closed

5.2.4.3. compressive force - damage to germinal cells

5.2.4.3.1. prognosis guarded

5.2.4.4. need perfect apposition to prevent osteoarthrosis and bony union across growth plate preventing growth

5.2.5. type V

5.2.5.1. compressive/impacted fracture to physis

5.2.5.1.1. damage germinal cells

5.2.5.1.2. no displacement

5.2.5.2. poor prognosis

5.2.5.2.1. limb deformity

5.2.5.2.2. mebbe ok if old

5.2.6. rang type VI

5.2.6.1. injury soft tissue adjacent to physis

5.2.6.1.1. result in bony union across plate

5.2.6.2. uncommon - across distal radius and tibia

5.2.7. apopphseal #

5.2.7.1. immature dt trauma

5.2.7.2. traction seperate apophyses from parent bone

5.2.7.2.1. eg supraglenoid tubercle, greater trochanter femur

5.3. principle repair

5.3.1. reduction

5.3.1.1. ASAP

5.3.1.2. gentle manipulation

5.3.1.2.1. watch damage germinal cells.

5.3.2. fixation

5.3.2.1. external coaptation shit

5.3.2.1.1. close joint

5.3.2.1.2. young excited

5.3.2.2. small diamater non threaded pins

5.3.2.2.1. allow continual growth

5.3.2.2.2. remove as soon healed

5.3.2.2.3. screw plates all restrictive

5.4. complications

5.4.1. interupt normal bone growth

5.4.2. premature close entire growth plate - shortened

5.4.2.1. can repair w osteotomy, distraction, bone graft and internal fixation

5.4.2.2. distraction osteogenisi - external distractor increased .5 mm twice daily

5.4.3. asymmetric

5.4.3.1. angular deformity

5.4.3.1.1. distribute load unevenly across joint

5.4.3.2. fix

5.4.3.2.1. immature

5.4.3.2.2. mature

5.4.4. closure of one bone in pair - angulra deformity and joint incongruity

5.4.4.1. esp antebrachium

5.4.4.2. closure distal ulnar

5.4.4.2.1. lateral deviation

5.4.4.2.2. cranial bowing

5.4.4.2.3. external rotation

5.4.4.2.4. immature

5.4.4.2.5. mature

5.4.4.3. closure distal radius

5.4.4.3.1. normally in conjunction with distal ulnar plate close

5.4.4.3.2. lengthen radius

6. D152 - Joint injuries Fractures

6.1. principle

6.1.1. aseptic

6.1.2. adequote visualisation

6.1.2.1. osteotomy

6.1.3. incisions parrale to axis limb

6.1.3.1. not over tendon - adhesions

6.1.4. into joint capsule- watch l igaments

6.1.5. monofilament sutur

6.2. tendon

6.2.1. dense ittegular collagen tissue

6.2.2. bundle colalgen surrounded by enotendon - carry vessels nerves

6.2.2.1. vessels from musculotendinous jn

6.2.3. entire tendon covered in epitendon

6.2.4. paratenon - areas local pressure form sheath

6.2.4.1. more vescular than synovium coverent tendon

6.2.5. mech helaing

6.2.5.1. paratenon heal faster - extrinsic blood supply

6.2.5.2. time - fibroblast amke collagen then rearange longitudinally

6.2.5.3. increase in tensile strength dt 2ndry remodel - max strength 20 weeks

6.2.6. type injuries

6.2.6.1. lacerations

6.2.6.2. avulsions

6.2.6.3. strain - injury at myotendinous junction

6.2.7. Sx

6.2.7.1. dont trasect tendon - retract

6.2.7.2. partial tentotomy better than trnasvers myotomy

6.2.7.2.1. better suture holding of tendon

6.2.7.3. osteotomy tendon

6.2.7.3.1. fasten w kwire and tension band

6.2.7.4. end end tarsorhaphy

6.2.7.4.1. monofilament

6.2.7.4.2. locking lop pattern

6.2.7.4.3. close paratendon

6.3. ligament

6.3.1. pure collagen w long parrale fibres, some elastic

6.3.2. relatively hypovascular

6.3.3. mech healing

6.3.3.1. diff lig better

6.3.3.2. inflamation

6.3.3.3. repair and regen

6.3.3.4. remodel/regeneration

6.3.3.4.1. 12 months

6.3.3.5. weaker

6.3.4. type injuries

6.3.4.1. sprains

6.3.4.1.1. result in abnormal joint mobility

6.3.4.1.2. type 1

6.3.4.1.3. type 2

6.3.4.1.4. type 3

6.3.5. Sx

6.3.5.1. slow heal, breakdown

6.3.5.1.1. dont transect

6.3.5.1.2. osteotomy

6.3.5.2. unload sutured tendon w screw anchor and figure 8 wire

6.4. articular cartilage bone

6.4.1. chondrocytes embed in colalgen matrix

6.4.2. 4 zones

6.4.3. lack BV - low metabolic activity

6.4.4. subchondral bone - vascular

6.4.5. healing

6.4.5.1. confined to cartilage

6.4.5.1.1. heal poorly

6.4.5.1.2. chondrocytes cont migrate in

6.4.5.2. to subchondral bone

6.4.5.2.1. access to marrox cells

6.4.5.2.2. reparitive fibrocartilage not same

6.4.6. type injuries

6.4.6.1. trauma

6.4.6.2. slter harris type 3 and 4

6.4.6.3. chip fractures - avulsion bone

6.4.7. Sx

6.4.7.1. need perfect anatomic reduction - articular congruity

6.4.7.2. lag screw - compression - bone heal without callus

6.4.7.3. screw

6.4.7.3.1. cancellous

6.4.7.3.2. cortical

6.4.7.3.3. Kwires

6.4.7.4. continous passive motion

6.4.7.4.1. better cartilage heal

6.4.7.4.2. gentle flexionextension for 20 mins 2id

6.4.7.5. cage rest/external coaptation

6.4.7.6. NSAIDS

6.4.7.7. chondroprotective drugs - glucosamine

6.5. meniscus

6.5.1. extensions of tibia to accomodate femoral condyles

6.5.2. circumfrential and radial collagen fibre

6.5.3. blood vessels from medial and lateral genicular vessels - supply peripheral 30%

6.5.4. held in position by 6 meniscial ligaments

6.5.5. fn

6.5.5.1. load transmission

6.5.5.2. lubrication

6.5.5.3. improve joint stability

6.5.6. pertial meniscectomy increased load

6.5.7. healing

6.5.7.1. peripheral supply

6.5.7.2. fibrous scar

6.5.7.2.1. becomes fibrocartilage

6.5.7.2.2. unknown properties

6.5.8. type injuries

6.5.8.1. common secondary to joint instability

6.5.8.1.1. cruciate and colalteral lig

6.5.8.2. medial more common

6.5.8.3. longitudinal, radial tears, folding injury

6.5.9. Sx

6.5.9.1. meninsectomy

6.5.9.1.1. degenerative changes to joint

6.5.9.1.2. partial

6.5.9.2. depend zone

6.5.9.2.1. pink zone - vascular better

6.5.9.2.2. cna extend into white zone - vascular channel

6.6. joint

6.6.1. open fractures

6.6.1.1. shearign injuries to tarsus carpus

6.6.1.2. contamination

6.6.1.3. tret early

6.6.1.3.1. aggresive debride

6.6.1.3.2. stabilisation

7. D153 - Osteochondrosis and Arthritis

7.1. Osteochondrosis

7.1.1. disturbance of endochondral ossification leading to retention of cartilage

7.1.1.1. cartilage become thick

7.1.1.1.1. Articular

7.1.1.1.2. growth plate

7.1.1.2. OCD - manifectation of OC - flap of cartilage lift from articular surface

7.1.2. aritilogy

7.1.2.1. rapid growth in large breeds

7.1.2.2. hereditory

7.1.2.3. overnutrition - high intake calcium

7.1.3. common sites

7.1.3.1. shoulder

7.1.3.1.1. caudal part humeral head

7.1.3.1.2. male large

7.1.3.1.3. lameness worse after exercise

7.1.3.1.4. mm atrophy deltoids

7.1.3.1.5. spontaneus healing if flap dislorge

7.1.3.1.6. sx

7.1.3.1.7. normally bilaters

7.1.3.2. elbow

7.1.3.2.1. OC leading to

7.1.3.2.2. young big breed male

7.1.3.2.3. medcal

7.1.3.2.4. surgical

7.1.3.3. stifle

7.1.3.3.1. lateral femoral condyle

7.1.3.3.2. osteoarthosis develop no matter what treatment

7.1.3.4. hock

7.1.3.4.1. medila ridge talus (lateral ridge)

7.1.3.4.2. widened joint space on dorsoplantar RAD, flattened medial ridge

7.1.3.4.3. arthrotomy via caudomedial approach

7.2. osteoarthritis

7.2.1. or DJD or osteoarthritis

7.2.1.1. progressive destruction irreversible adamage to articular cartilage

7.2.1.2. inflamation - osteoarthritis

7.2.2. dt

7.2.2.1. instability

7.2.2.2. incongruity

7.2.2.3. OC

7.2.2.4. trauma

7.2.3. dx

7.2.3.1. RAD

7.2.3.1.1. joint capsule distencion

7.2.3.1.2. periarticula soft tissue swell

7.2.3.1.3. periarticular osteophyte

7.2.3.2. arthrocentesis

7.2.3.2.1. inflamatory

7.2.3.2.2. osteoarthrosis

7.2.4. Rx

7.2.4.1. relive pain

7.2.4.1.1. NSAID

7.2.4.2. improve joint fun

7.2.4.3. minimise progression

7.2.4.3.1. weight loss

7.2.4.3.2. exercise modification

7.2.4.3.3. medical

7.2.4.4. id treat inciting cause

7.2.4.4.1. surgical

7.2.4.5. salvage

7.2.4.5.1. excision arthroplasty

7.2.4.5.2. arthrodesis

7.2.4.5.3. prosthetic joint replace

7.3. Inflamatory arthritides

7.3.1. septic

7.3.1.1. bacterial

7.3.1.1.1. haematogenous

7.3.1.1.2. penetrating injury

7.3.1.1.3. local extension

7.3.1.2. dx

7.3.1.2.1. acute onset w pyrexia

7.3.1.2.2. joint painful swollen warm

7.3.1.2.3. left shift on haemogram

7.3.1.2.4. arthrocentisis

7.3.1.3. Rx

7.3.1.3.1. Sx

7.3.2. Immune mediated

7.3.2.1. Rheuatoid arthritis

7.3.2.1.1. intermitient shifting lameness multiple joint

7.3.2.1.2. RAD

7.3.2.2. SLE

7.3.2.2.1. multisystmeic

7.3.2.2.2. polyarthritis

7.3.2.3. idiopathyic polyarthritis

7.3.2.3.1. cyclic lameness, pyrexia, anorexia

7.3.2.4. Rx

7.3.2.4.1. glucocorticoid

7.3.2.4.2. azothiaprin

8. D154 - Surgery of Hip joint

8.1. Luxation of hip

8.1.1. comon

8.1.1.1. no colaterals

8.1.1.2. only ball socket, round lig

8.1.2. craniodorsal

8.1.2.1. dt external trauma

8.1.2.1.1. blow to rump

8.1.2.1.2. tear round and dorsal joint capsule

8.1.2.1.3. held out w gluteal

8.1.2.2. CS

8.1.2.2.1. thigh adducted

8.1.2.2.2. stifle rotate out

8.1.2.2.3. hock in

8.1.2.2.4. pain crepitus on palpation

8.1.2.2.5. altered landmark

8.1.2.2.6. check predisposing factor

8.1.2.3. closed reduction

8.1.2.3.1. fresh injury without ships

8.1.2.3.2. like cow

8.1.2.3.3. support w ehmer sling

8.1.2.4. open reduction

8.1.2.4.1. very unstable, avulsion fracture, cant sling

8.1.2.4.2. craniolateral approach w trochanteric osteotomy

8.1.2.4.3. remove hameatoma, ship, round lig

8.1.2.4.4. if joint capsul ok

8.1.2.4.5. no capsule

8.1.3. caudoventral

8.1.3.1. trauma from landing

8.1.3.2. carrly leg abducted an dinward rotate

8.1.3.3. closed reduction and hobbles

8.1.3.4. or open reductio n- came technique caraniodorsal

8.2. Canine hip dysplasia

8.2.1. disparity bt primary muscle ass and rapid skeletal growth

8.2.2. development

8.2.2.1. large breeds

8.2.2.1.1. genetic

8.2.2.2. environment

8.2.2.3. normal at birth

8.2.2.4. joint instability and subluxation

8.2.2.4.1. retard normal joint development

8.2.2.4.2. predispose DJD

8.2.3. CS

8.2.3.1. pain lameness

8.2.3.2. joint laxity on palpation

8.2.3.2.1. ortolani sign

8.2.3.3. pain dt microfracture on dorsal acetabular rim

8.2.4. Rx

8.2.4.1. may not be clinical

8.2.4.1.1. RAD changs severe

8.2.4.2. conservative

8.2.4.2.1. non concussive exercise

8.2.4.2.2. weight control

8.2.4.2.3. NSAID

8.2.4.2.4. cartophen - pentosan

8.2.4.3. sx

8.2.4.3.1. triple pelvic osteotomy

8.2.4.3.2. total hip replacement

8.2.4.3.3. femoral head and neck excision

8.2.4.3.4. denervation of craniodorsal joint capsule

8.2.4.3.5. pectineus myectomy

8.3. Legg calve perthes disease (Avascular necrosis of femoral head)

8.3.1. 1 yo minature toy breeds - similar condition in children

8.3.1.1. inherited

8.3.2. ichaemic necrosis

8.3.2.1. acellular subchondral bone

8.3.2.2. articular cartilage collapse

8.3.2.3. replace w fibrovascular repair tissue

8.3.2.4. asymetric new bone formation

8.3.2.4.1. mishshapen femoral head

8.3.2.5. DJD hip joint

8.3.3. CS

8.3.3.1. weight bearing lameness

8.3.3.2. restricted joint move

8.3.3.2.1. disuse mm atrophy

8.3.3.3. early RAD

8.3.3.3.1. woden joint space

8.3.3.3.2. decreased density epipysis

8.3.3.3.3. sclerossis femoral neck

8.3.3.4. late

8.3.3.4.1. moth eaten femorla head

8.3.3.4.2. flattening

8.3.3.4.3. DJD

8.3.4. Rx

8.3.4.1. excision arthroplasty - femoral head and neck excision

8.3.4.2. early

8.3.4.3. conservative - protracted

9. D155 - Orthapaedic conditions of stifle and tarsus

9.1. steifel

9.1.1. patellar luxation

9.1.1.1. acquired traumatic

9.1.1.2. developmental

9.1.1.2.1. small breeds, medial lux

9.1.1.3. casue secondary changes in hip

9.1.1.4. grade

9.1.1.4.1. grade 1

9.1.1.4.2. grade 2

9.1.1.4.3. grade 3

9.1.1.4.4. grade 4

9.1.1.5. sequale

9.1.1.5.1. cranial crusiacte rupture

9.1.1.6. sx

9.1.1.6.1. lateral retinacular imbrication

9.1.1.6.2. trochlear groove deepening

9.1.1.6.3. tibial derotational suture

9.1.1.6.4. tibial tuberosity/crest transposition

9.1.1.6.5. medial desmotomy

9.1.1.6.6. corrective osteotomy

9.1.1.6.7. salvage

9.1.1.7. after care

9.1.1.7.1. rapid heal dt young

9.1.1.7.2. restrict activity

9.1.1.7.3. joint - passive physiotherapy in first 2 weeks

9.1.1.7.4. active physiotherapy

9.1.2. Cranial cruciate rupture

9.1.2.1. dispatch

9.1.2.1.1. acute - trauma

9.1.2.1.2. chronic

9.1.2.1.3. anatomy

9.1.2.1.4. fn

9.1.2.1.5. concurrent meniscial injury

9.1.2.1.6. contralateral cruciate injury

9.1.2.2. dx

9.1.2.2.1. trauma

9.1.2.2.2. hx

9.1.2.2.3. cranial drawer

9.1.2.2.4. rads

9.1.2.2.5. ecploratory arthoscopy

9.1.2.3. Rx

9.1.2.3.1. conservative

9.1.2.3.2. primary repair

9.1.2.3.3. Intra-capsular reconstruction

9.1.2.3.4. extra-capsular reconstruction

9.1.2.3.5. must assess menisci integrity

9.1.3. Caudal cruciate rupture

9.1.3.1. dispatch

9.1.3.1.1. isolated rare - multiple lig dt trauma

9.1.3.1.2. from lateral surface medial femoral condyle

9.1.3.1.3. to lateral edge popliteal notch tibia

9.1.3.1.4. prevent caudal draw, stop hyperextension

9.1.3.2. dx

9.1.3.2.1. caudal draw

9.1.3.2.2. tibial sag

9.1.3.3. Rx

9.1.3.3.1. avulsion - similar CrCL

9.1.3.3.2. interstital tears - extracapsular technique

9.1.4. Femorotibial collateral lig injuries

9.1.4.1. stabilise stifle from valgus/varus movement

9.1.4.2. dx

9.1.4.2.1. adduction/abduction limb.

9.1.4.2.2. compare intact contralateral

9.1.4.2.3. laxity w abrupt endpoint - grade 1 2

9.1.4.2.4. laxity w gradual endpoing - grade 3

9.1.4.2.5. RADS - avulsion, stress views

9.1.4.3. Rx

9.1.4.3.1. grade 1

9.1.4.3.2. grade 2

9.1.4.3.3. grade 3

9.1.4.3.4. protect joint w lateral splint

9.1.5. stifle luxatin

9.1.5.1. multiple ligaments, capsular, meniscal damage

9.1.5.1.1. global instability - rotate through 180 degrees

9.1.5.2. cats small dog

9.1.5.2.1. transarticular pin

9.1.5.3. large dogs

9.1.5.3.1. each injury as above

9.1.5.4. treat menisci

9.1.5.4.1. suture if pink

9.1.5.4.2. trim damaged

9.1.5.5. protect w lateral splint and rest 6 weeks

9.2. tsar

9.2.1. tarsocrural collateral

9.2.1.1. clsoe skin - shearing

9.2.1.1.1. shit heal conservative

9.2.1.2. medial - from medial malleolus

9.2.1.2.1. short - to talus

9.2.1.2.2. long - to first tarsal and metatarsal

9.2.1.3. lateral - from lateral malleolus

9.2.1.3.1. short - to talus calcaneus

9.2.1.3.2. long - to 5th metatasal

9.2.1.4. dx

9.2.1.4.1. test short in flexion, long in extension

9.2.1.4.2. rads - avulsion

9.2.1.5. Rx

9.2.1.5.1. avulsion - lag screw, tension band

9.2.1.5.2. interstital - locking loop

9.2.1.5.3. replace - prosthetic ligment

9.2.1.5.4. stabilise w transarticular external skeletal fixation

9.2.1.5.5. shearing - debride, leave open then repair lig

9.2.2. Plantar ligament fracture

9.2.2.1. present w plantigrade stance

9.2.2.2. conservative shit dt contant tension

9.2.2.3. 3 lig

9.2.2.3.1. middle important

10. D156 - Orthapaedic conditions of the Shoulder elbow carpus

10.1. shoudler luxation

10.1.1. medial lateral more comon cranial caudal

10.1.2. stabilised w medial lateral glenohumeral lig

10.1.3. congenital

10.1.4. traumatic

10.1.4.1. medial

10.1.4.1.1. non weight bear lame

10.1.4.1.2. limb flexed

10.1.4.1.3. foot rotate out

10.1.4.2. lateral

10.1.4.2.1. limb flexed

10.1.4.2.2. foot rotate in

10.1.5. rx

10.1.5.1. recent traumatic

10.1.5.1.1. closed reduction w external coaptation

10.1.5.2. ctabilise w square suture thru scapular neck and humeral head

10.1.5.3. tranposition biceps brachi tendon

10.1.5.4. salvage - excision arthroplasty/arthrodesis

10.2. Bicipital tenosynovitis

10.2.1. dt repeated stress, OCD fragments

10.2.2. dx

10.2.2.1. pain over craniomedial palpation

10.2.2.2. rads - exostosis of intertubercular groove and minerlaisation tendon

10.2.2.3. us - thickenign and increased fluid

10.2.2.4. arthroscope

10.2.3. rx

10.2.3.1. acute

10.2.3.1.1. rest

10.2.3.1.2. sling

10.2.3.1.3. NSAID

10.2.3.1.4. intrarticular steroid injection

10.2.3.2. Sx

10.2.3.2.1. transect tendon

10.2.3.2.2. resect bursa

10.2.3.2.3. reattatch through bone tunnel in greater tubercle

10.2.3.2.4. suture back on self

10.3. Mineralisation of supraspinatous tendon

10.3.1. large breed, chronic intermittnet unilateral lameness

10.3.2. dx

10.3.2.1. pain palpation

10.3.2.2. rads

10.3.2.2.1. mineralisation

10.3.2.2.2. cranioproximal craniodistal skylie view

10.3.3. rx

10.3.3.1. surgical removal mineralised tendon

10.4. infraspinatus contracture

10.4.1. hunting working dogs

10.4.2. abnormal gait

10.4.2.1. elbow adduct

10.4.2.2. foot abduct

10.4.2.3. lateral swing limb

10.4.2.4. mm atrpphy infraspinatous

10.5. scapular dislocation

10.5.1. tear serratus ventralis dt trauma

10.5.1.1. dorsal border scapula higher

10.5.2. small - velpau sling

10.5.3. large - wire suture around rib

10.6. elbow luxation

10.6.1. normally good stability

10.6.1.1. lateral luxa tion most common

10.6.2. 3 joints

10.6.2.1. humeroradial

10.6.2.1.1. most stability

10.6.2.2. humeroulnar

10.6.2.2.1. restrict saggital plane

10.6.2.3. proximal radioulnar

10.6.2.3.1. limited rotation

10.6.3. congenital

10.6.3.1. humeroulnar

10.6.3.1.1. lateral rotation proximal ulna

10.6.3.1.2. cant support weight - cant extend

10.6.3.1.3. craniocaudal rads

10.6.3.2. lateral luxation radial head

10.6.3.2.1. reduced flexion

10.6.3.2.2. palpated lateral to joint

10.6.3.2.3. rad show abnormal position

10.6.4. traumatic

10.6.4.1. radius and ulna go lateral

10.6.4.2. antebrachium abducted and externally rotated

10.6.4.3. rads

10.6.4.3.1. lateral displacement

10.6.4.3.2. avulsion of collaterals

10.6.5. Rx

10.6.5.1. closed better

10.6.5.1.1. cant if chronic/severe bony deformation

10.6.5.1.2. hook anconeal process into olecranon fossa and fulcrum in

10.6.5.1.3. support w spica splint

10.6.5.2. Sx

10.6.5.2.1. unstable or irreducible

10.6.5.2.2. ligament repair/replace

10.6.5.2.3. congenital humeroulnar

10.6.5.2.4. congenital lateral luxation radial head

10.6.5.2.5. salvage

10.7. carpal ligament injury

10.7.1. trauma, shearing

10.7.2. conservative w external coaptation only good for inactive

10.7.3. 3 joints, multiple short collaterals

10.7.4. collateral lig injury

10.7.4.1. radial collateral most common

10.7.4.1.1. distal radius

10.7.4.1.2. across antebrachiocaropal joint

10.7.4.1.3. insert radial carpal bone

10.7.4.2. assess w valus/varus stress test

10.7.4.3. rads - widen joint space

10.7.4.4. rprimary repair lig and take load w synthetic thru bone tunnel

10.7.5. shearing injury

10.7.5.1. similar tarsus

10.7.6. Hyperextension injury

10.7.6.1. fall jump from height

10.7.6.1.1. pupture palmar lig

10.7.6.1.2. palmigrade stance

10.7.6.2. external coaptation shit

10.7.6.3. rad asses which joint worst

10.7.6.4. arthodesis mifddle carpal and carpometacarpal

10.7.6.4.1. pins

10.7.6.4.2. plate

10.7.6.5. antebrachiocarpal - most movement

10.7.6.5.1. arthrodesis

10.7.6.6. protect w cast or palmar splint

10.7.7. sesamoid disease

10.7.7.1. racing greyhound fracture, rotty sesamoid disease

10.7.7.2. dx w rads show bony proliferation

10.7.7.3. rx - sx resection affested ses

10.7.7.3.1. hard visualise - rad escised tissue

10.7.7.3.2. early physiotherapy

11. D157 - Salvage procedures

11.1. arthrodesis

11.1.1. dispatch

11.1.1.1. removal motion in joint

11.1.1.1.1. cf ankyloiss - abnormal mobilit dt peri/intra articular pathology

11.1.1.2. indications

11.1.1.2.1. continued motion of joint counterproductive

11.1.1.2.2. relive pain - dt instabillity

11.1.1.2.3. anatomical repair not poddible

11.1.1.2.4. improve mechanical fn

11.1.1.2.5. neurological problems - e.g radila nn paralasis

11.1.1.2.6. limb spare - neoplesai w allogenic bone graft

11.1.2. sx

11.1.2.1. asepsis

11.1.2.2. remove articular cartilage down to bone

11.1.2.2.1. promote early bony union

11.1.2.2.2. watch heat from burr

11.1.2.3. contact area subchondral bone

11.1.2.3.1. follwo normal contour bone

11.1.2.3.2. create flat surface

11.1.2.4. normal angle

11.1.2.4.1. measure contralateral pre op

11.1.2.5. absaloute stability w compresion

11.1.2.6. autogenous bone graft

11.1.2.7. external coaptation

11.1.2.8. appropriate time

11.1.2.8.1. check w rad

11.1.2.9. remove fixers post op

11.1.2.9.1. fatigue fractures

11.1.2.9.2. loosening

11.1.3. complications

11.1.3.1. increase stress to adjacent joint

11.1.3.1.1. DJD

11.1.3.1.2. esp multi joint - carpus hock

11.1.3.2. infection

11.1.3.3. failure stabilise

11.1.3.4. shorten/lengthen limb dt incorrect angle

11.1.4. specifics

11.1.4.1. carpus/hock

11.1.4.1.1. most common

11.1.4.1.2. rad stress vie wto determine what joint

11.1.4.1.3. plating better if big enough

11.1.4.1.4. panarthrodesis good

11.1.4.2. stifle

11.1.4.2.1. watch deragned limb fn

11.1.4.2.2. remove menisci and cruciates, remove articular cartilage

11.1.4.3. shoulder

11.1.4.3.1. need severe problem

11.1.4.3.2. rigid fixation w plate along cranial aspect spine scapula and humerus

11.1.4.3.3. scapular provides adequate mobility

11.1.4.4. elbow

11.1.4.4.1. plate on caudal surface

11.1.4.4.2. watch derange limb fn

11.2. amputation

11.2.1. quadrapeds adapt very well

11.2.1.1. test w sling

11.2.1.1.1. more for owner sake

11.2.2. 'exercise in regional anatomy, not butcher'

11.2.3. level

11.2.3.1. scapular good

11.2.3.2. mid thigh protect package

11.2.3.3. middle/distal IP joint preserve digital pad

11.2.3.4. digit 3 4 major weight bearing

11.2.4. joint mm

11.2.4.1. amputate at bone end

11.2.4.1.1. form callous, atrophy.

11.2.4.2. muscle origon - minimise haemmhorage

11.2.5. vessels nn

11.2.5.1. aa double ligate

11.2.5.2. not aa vv together - anastomosos

11.2.5.3. watch air emboli vein

11.2.5.4. if neoplasia

11.2.5.4.1. vein first then artery quick

11.2.5.4.2. top spread

11.2.5.5. neuroma not problem

11.2.6. close stump

11.2.6.1. haemostasis and cosmetics

11.2.6.2. planning

11.2.6.2.1. 'like closing the petals of flower'

11.2.6.2.2. deep short

11.2.6.2.3. superficial long - fold over

11.2.7. post op

11.2.7.1. blood loss in limb

11.2.7.2. pain

11.2.7.2.1. phantom limb?

11.2.7.3. pressure bandage