EXERCISE HELPS
PROBLEM
Supination-pronation exercise is recommended for forearm and elbow fractures. Patient does not get in rhythm to do this, and moves wrist and fingers instead of the forearm.
Suggestion: By applying short wrist splint and semi-immobilizing the wrist, patient would be able to do supination and pronation exercises (Figs. 1.1A to D).
Figs. 1.1A to D: (A and B) Patient moves hand instead of moving of the forearm; (C and D) Proper supination and pronation exercise with short wrist splint.
2When we ask patient to do ankle-mobilizing exercises after surgery, he tries to move only toe extensors and hence ankle is not exercised (Figs. 1.2A to C).
Suggestion: Strap the toes and he will do proper ankle exercises.
Figs. 1.2A to C: (A) Ankle exercises using shoe; (B) Trying to do ankle exercises but moving only toes; (C) By doing toe strapping.
SHOULDER MOBILIZING EXERCISES
Immobilize elbow with splint, so patient can do shoulder exercises better (Figs. 1.3A to C).
After a long rehabilitation for injury or surgery of lower extremity, most of the patients walk with broad-based gait and find it difficult to correct this gait with conventional exercises. They can walk without pain. Fractures have already united and are pain free. They walk perfectly with stick on opposite side, but not on same side. They can walk without stick without pain but it is a hurried gait and broad base-like walking in a moving vehicle, in plane or on ship. This is typical of inability to walk perfectly due to loss of balancing.
When you ask him to stand on normal one leg stance, he can balance and stand straight. When he stands on affected one leg, he bends on opposite side to regain his balance but can stand without pain (Figs. 1.4A and B).
In this position if we give a stick to opposite hand, he can immediately stand straight without tilting on the opposite side (Fig. 1.4C).
Figs. 1.4A to C: (A) Standing on normal leg; (B) Standing on the affected leg. Body turns on side to balance; (C) Body is straight if stick is on the opposite side.
He should train himself when standing straight with stick in front of a mirror, and try to get balance and slowly reduce 5the pressure on the stick, keeping the body straight, ultimately standing straight without stick.
Also, he should be trained to walk in a straight line and should walk on one tile on the floor, with equal steps, without steps going on the other tile, avoiding unequal hurried steps.
This will allow him to relearn the balance and he will be able to walk straight. This has been very well written by George Perkins in his book of reminisces many years back.
Suggestion: Do pay attention toward gait training of the patient after long convalescence (Figs. 1.5A to E).
Blunt injury with hematoma formation in soft tissue (Fig. 1.6) results in serum exudates after 1 week, and is difficult to treat. After aspiration, it fills up again and this is due to dead space remaining in the area after aspiration, which refills in short time.
Suggestion: I suggest to put vacuum drainage and allow the cavity to collapse for 3/4 days. Enough adhesions form between the layers of the seroma cavity, and dead space will be obliterated, avoiding seroma formation again.
My suggestion is, put the tube in before aspiration so that placing of the tube is perfect when fluid is inside. It may end up in an empty cavity if introduced after seroma is evacuated and then tried to introduce in collapsed space.
PROCEDURE (FIGS. 1.7A TO D)
On palpation, dependent part is localized and a triple trocar (used for external fixation) is pierced into the swelling. Do not drain the serum after confirming the correct cavity. Now remove trocar and keep outer hollow tube and confirm the patency. Introduce an 8 mm drainage tube in this sleeve and connect it to the vacuum bottle with negative suction after removing the hollow outer tube. Keep this negative suction bottle tied up on patient's extremity for 3 days and allow him to walk about.
CEREBROSPINAL FLUID LEAK
Cerebrospinal fluid (CSF) leaks, after major missed dural tears or unsuccessful repairs, can be treated by “Proximal CSF diversion” by passing an intradural catheter at a level higher than the dural tear level. Pass lumbar puncture needle and on confirmation of CSF, pass a catheter used for epidural, through this needle and then remove the needle, confirm CSF flow, and attach it to a sterile dependent (not negative suction) drain bottle. In 3/4 days, dural tear would have healed as CSF is now bypassed proximally leaving the leak area to dry and to close. Catheter can then be pulled out. Supportive treatment of head low position, plenty of fluids, and tablet acetazolamide (Diamox) and complete bed rest, for whatever it is worth, are given.