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exposed, the fractured area remains covered by the surrounding soft tissues. Reduction is accomplished by using instruments or implants that are introduced away from the fractured zone. The technique is indicated for mutifragmentary diaphyseal and metaphyseal fractures. The aim of indirect reduction is to restore the overall length of the bone, as well as the axial and rotational alignments.
The technique is more demanding than direct reduction and require an accurate preoperative assessment and meticulous planning. Reduction is controlled by help
of image intensifier, clinical checks for the alignment
or intraoperative x-ray. The techniques for fixation
are: Interlocking nail, external fixation, splinting with conventional plates, plate and rod, bridging the fracture with a locked internal fixator as the LCP (Locking Compression Plates).
In conclusion either direct and indirect reduction are useful techniques and have their place in the repertoire of the orthopaedic surgeon. A clear understanding of the role of this techniques, together with an informed assessment of the relationship between fracture pattern and soft tissue trauma, lead to correct decisions on strategies and choice of implants compatible with the biological demanding of the fracture.
New principles and methods will continue o develop however some principle will never change:
“There is danger inherent in the mechanical efficiency of our modern methods. Less the craftsman forget that union cannot be imposed but may have to be encouraged for the bone is a plant with its roots in the soft tissues.
When the vascular connections are damaged, it often requires not the technique of a cabinetmaker but rather the patient care and understanding of a gardener.”
Dr. Girdlestone (Orthopaedic influence on the treatment of fractures, a clinical study. Oxford 1943)
L. Smart1
1Murdoch University, College of Veterinary Medicine, Murdoch, Australia
There has been much interest in the use of intravenous lipid emulsion (IVLE) therapy for many different types of small animal toxicoses in the last 10 years. Although there is some evidence for its efficacy in specific toxicoses, its unbridled use in clinical toxicology is still controversial.
What is IVLE?
Intravenous lipid emulsion therapy involves injection of a fairly large dose of lipid emulsion over a short period of time in order to counteract the effects of particular toxins. It is usually provided as a sterile 20% solution of soybean oil, egg phospholipids and glycerine suspended in water. It is traditionally used for providing a fat source
in parenteral nutrition formulations but in recent times, certainly in our hospital, it is more frequently used as poison antidote therapy. Once the bottle is punctured,
it should be discarded within 24 hours due to risk of bacterial growth in the solution. It is ideal to consider each bottle to be single-use only. The IV catheter should be checked for patency before started the infusion and the catheter should be flushed well after use. You do not need a dedicated IV line as it is delivered over a short period of time. However, if using as a continuous rate infusion (CRIs) for more than 1 hour, then attention should be paid to the level of the sterility of the catheter that is used. When considering CRIs, bear in mind that there is no evidence for efficacy of this approach. In general, it is recommended to stop administering IVLE if the serum/ plasma is grossly lipaemic.
Mechanism of action
The use of IVLE for toxicoses had its beginnings as an antidote for local anaesthetic overdose. Initial experimental studies showed improved survival after IVLE in dogs and rats that received a bupivacaine overdose.(1, 2) Since then, infusion of IVLE during resuscitation for bupivacaine has been reported
to be successful in multiple human case reports.(3) Bupivicaine decreases cardiac adenosine triphosphate (ATP) synthesis. Lipid emulsion is thought to reverse the cardio-toxicity by providing fatty acids to the myocardium and increasing ATP production, thus improving myocardial contractility. It may also increase intracellular myocyte calcium, also assisting positive inotropy. Since this discovery, the use of IVLE for resuscitation of local anaesthetic overdose has been become routine in human medicine.
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