SUTURE TECHNIQUES AND COMMON TYPES OF SUTURES

SUTURE SIZES

Size denotes the diameter of the material. Stated numerically, the more zeros (0's) in the number, the smaller the size of the strand. As the number of 0's decreases, the size of the strand increases. The 0's are designated as 5-0, for example, meaning 00000 which is smaller than a size 4-0. (NOTE: Physicians will often say what sounds like "oh vicryl sutures" for instance -- by this they mean 0 Vicryl (zero Vicryl) not the letter "O")

USP	Diameter	Tensile Strength (surgeon's knot)
4-0	0.2mm	7.5N
3-0	0.3mm	12.3N
2-0	0.35mm	19.6N
0	0.4mm	22.3N
1	0.5mm	37.3N

Types of Suture Material:

Vicryl

Braided synthetic absorbable suture
Polyglactin 910
Retains 70% of initial strength at 10 days and 30% at 20 days
Complete absorption in 60 - 90 days

Coated Vicryl

As Above
Coated with a mixture of calcium stearate and polyglactin 370
Maintains 100% strength for ~ 45 days and then decreases to 70% by ~ 50 days
Needle sizes commonly used;
1 36mm taper
2/0 26mm cutting edge
3/0 22mm cutting edge

PDS

Mono-filament synthetic absorbable suture
Polydioxalone
Retains 70% of initial strength for ~ 21 days and is reduced to 50% at ~ 35 days
Absorption usually complete within 180 days
Results in minimal tissue reaction
Needle sizes commonly used;
1 40 or 26mm needle

Catgut

Intestinal submucosa of sheep and intestinal serosa of cattle
Retains tensile strength for ~ 10 days

Chromic Catgut

(Chromatised) retains tensile strength for 20 - 40 days
Both forms of catgut result in a moderate tissue reaction

Proline

Non absorbable synthetic mono-filament suture
Polypropylene (extruded)
Low tissue reaction and easy tissue passage
Needle sizes commonly used;
2/0 & 3/0 26mm cutting edge
6/0 13mm (epitendon)
8/0 6.35mm (digital nerve)

Nylon

Non absorbable synthetic mono-filament suture
Needle sizes commonly used;
5/0 18.7mm cutting edge

Ethibond

Braided non absorbable synthetic suture
Polyester coated with polybutilate (also a polyester) for lubrication to aid tissue passage with good tissue qualities and tensile strength
Needle sizes commonly used;
1 24mm cutting edge

Silk

Natural silk is made up 70% of protein fibre and 30% extraneous material such as gum
Processing involves degumming
Protein make up and extraneous material results in increased tissue reactivity

Steel

316L - SS Stainless steel
Inert with virtually no tissue reaction
Difficult to handle and knot

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PERIBRONCHIAL CUFFING

Incorrect: Peribronchial coughing

Correct: Peribronchial cuffing

Peribronchial cuffing, also referred to as peribronchial thickening or bronchial wall thickening is a radiographic sign which occurs when excess fluid or mucus buildup in the small airway passages of the lung causes localized patches of atelectasis (lung collapse). This causes the area around the bronchus to appear more prominent on an x-ray.

Peribronchial cuffing is seen in a number of conditions including:

• asthma following exercise or during an acute episode
• bronchopulmonary dysplasia
• congestive heart failure
• cystic fibrosis
• diffuse parenchymal lung disease
• Extreme exertion through physical exercise
• Hantavirus pulmonary syndrome
• human metapneumovirus
• Kawasaki disease
• Lung cancer
• Pneumonia
• pulmonary edema
• Smoke inhalation

Treatment -- As peribronchial cuffing is a sign rather than a symptom or condition, there is no specific treatment except to treat the underlying cause.

NEUROLOGICAL EXAMINATION

Five-part short neurological examination

Part I neurological examination

• General demeanor
• Speech
• Gait
• Arm swinging

Part II neurological examination

• Fundi
• Pupils
• Eye movements
• Facial movements
  Tongue

Part III neurological examination

• Posture of outstretched arms
• Wasting, fasciculation
• Power, tone
• Coordination
• Reflexes

Part IV neurological examination

• Power (hip flexion, ankle dorsiflexion)
• Tone
• Reflexes
• Plantar responses

Part V neurological examination

• Ask the patient

1. Look at the patient

2. Examine the head

3. Examine the upper limbs

4. Examine the lower limbs

5. Assess sensation

The relevant findings are drawn together in a brief written diagnostic summary. This will form the basis for investigations, transfer of information, and management.

Ten-part neurological examination

Orientation in time and place, recall of recent and distant events (memory, level of intellect, language and speech/cerebral dominance, other disorders of skilled function, e.g. apraxia)

Upper limbs:

· Wasting and fasciculation

· Posture of arms: drift, rebound, tremor

· Tone: spasticity or extrapyramidal rigidity

· Power: 0-5 scale

· Tendon reflexes: + or ++ normal; +++ increased:

· 0 absent with reinforcement

Thorax and abdomen:

· Respiration

· Thoracic and abdominal muscles

· Abdominal reflexes

· Cremasteric reflexes

Lower limbs:

· Wasting and fasciculation

· Tone, power and tendon reflexes

· Plantar responses

First, ask whether feeling in the limbs, face and trunk is entirely normal

Posterior columns:

• Vibration (using a 128 Hz tuning fork)
• Joint position
• Light touch
• 2-point discrimination (normal: 0.5 cm fingertips, 2 cm soles)

Spinothalamic tracts:

• Pain: use a split orange-stick or a sterile pin
• Temperature: hot or cold tubes

If sensation is abnormal, chart areas involved

1. State of consciousness, arousal, appearance (e.g. coma)

2. Mental state, attitude, insight

3. Cognitive function

4. Gait and Romberg's test

5. Skull shape- circumference, bruits

6. Neck- stiffness, palpation and auscultation of carotid arteries

7. Cranial nerves

8. Motor system

9. Coordination and fine movements

10. Sensory system

LIST OF SOME COMMON ORTHOPEDIC TESTS

Shoulder

1. Empty Can (Supraspinatus) Test

2. Yergason Test

3. Speed's Test

4. Ludington's Sign

5. Drop Arm Test

6. Apley's Scratch Test

7. Cross-Over Impingement Test

8. Neer Impingement Test

9. Hawkins-Kennedy Impingement Test

10. Sternoclavicular (SC) Joint Stress Test

11. Acromioclavicular (AC) Joint Distraction Test

12. Acromioclavicular (AC) Joint Compression Test (Shear)

13. Piano Key Sign

14. Apprehension Test (Anterior)

15. Apprehension Test (Posterior)

16. Sulcus Sign

17. Anterior Drawer Test

18. Posterior Drawer Test

19. Jobe Relocation Test

20. Feagin Test

21. Load and Shift Test

22. Grind Test

23. Clunk Test

24. O'Brien Test

25. Brachial Plexus Stretch Test

26. Shoulder Abduction Test

27. Adson's Maneuver

28. Allen's Test

29. Roos Test

30. Military Brace Position

31. Pectoralis Major Contracture Test

Temporomandibular

1. Chvostek's Sign

2. Loading Test

3. Palpation Test

Cervical Spine

1. Vertebral Artery Test

2. Foraminal Compression Test (Spurling)

3. Foraminal Distraction Test

4. Valsalva's Maneuver

5. Swallowing Test

6. Tinel's Sign

Elbow

1. Resistive Tennis Elbow Test (Cozen's Test)

2. Resistive Tennis Elbow Test

3. Passive Tennis Elbow Test

4. Golfer's Elbow Test

5. Hyperextension Test

6. Elbow Flexion Test

7. Varus Stress Test

8. Valgus Stress Test

9. Tinel's Sign

10. Pinch Grip Test

Wrist and Hand

1. Tap or Percussion Test

2. Compression Test

3. Long Finger Flexion Test

4. Finkelstein Test

5. Phalen Test

6. Tinel's Sign

7. Froment's Sign

8. Wrinkle Test (Shrivel Test)

9. Digital Allen's Test

10. Bunnel Littler Test

11. Murphy's Sign

12. Watson Test

13. Valgus Stress Test

14. Varus Stress Test

15. Section VI: Thoracic Spine

16. Kernig/Brudzinski Signs

17. Lateral Rib Compression Test

18. Anterior/Posterior Rib Compression Test

19. Inspiration/Expiration Breathing Test

Thoracic Spine

1. Kernig/Brudzinski Signs

2. Lateral Rib Compression Test

3. Anterior/Posterior Rib Compression Test

4. Inspiration/Expiration Breathing Test

Lumbar Spine

1. Valsalva's Maneuver

2. Stoop Test

3. Hoover Test

4. Kernig/Brudzinski Signs

5. 90-90 Straight Leg Raise Test

6. Bowstring Test (Cram Test)

7. Sitting Root Test

8. Unilateral Straight Leg Raise Test (Lasegue Test)

9. Bilateral Straight Leg Raise Test

10. Well Straight Leg Raise Test

11. Slump Test

12. Thomas Test

13. Spring Test

14. Trendelenburg's Test

15. Stork Standing Test

Sacral Spine

1. Sacroiliac (SI) Joint Fixation Test

2. Gillet Test

3. Sacroiliac (SI) Joint Stress Test

4. Squish Test

5. Yeoman's Test

6. Gaenslen's Test

7. Patrick or FABER Test

8. Long-Sitting Test

Hip

1. Hip Scouring or Quadrant Test

2. Nélaton's Line

3. Craig's Test

4. 90-90 Straight Leg Raise Test

5. Patrick or FABER Test

6. Trendelenburg's Test

7. Ober's Test

8. Piriformis Test

9. Thomas Test

10. True Leg-Length Discrepancy Test

11. Apparent Leg-Length Discrepancy Test

12. Ely's Test

13. Tripod Test

14. Femoral Nerve Traction Test

Knee

1. Patella Tendon/Patella Ligament Length Test

2. Patellar Apprehension Test

3. Ballotable Patella or Patella Tap Test

4. Sweep Test

5. Quadriceps or Q-Angle Test

6. Medial-Lateral Grind Test

7. Bounce Home Test

8. Patellar Grind Test (Clarke's Sign)

9. Renne Test

10. Noble Test

11. Hughston's Plica Test

12. Godfrey 90/90 Test

13. Posterior Sag Test (Gravity Drawer Test)

14. Reverse Pivot Shift (Jakob Test)

15. Anterior Lachman's Test

16. Anterior Drawer Test

17. Slocum Test With Internal Tibial Rotation

18. Slocum Test With External Tibial Rotation

19. Pivot Shift Test

20. Jerk Test

21. Posterior Drawer Test

22. Hughston Posteromedial Drawer Test

23. Hughston Posterolateral Drawer Test

24. Posterior Lachman's Test 27

25. External Rotation Recurvatum Test

26. Valgus Stress Test

27. Varus Stress Test

28. McMurray Test

29. Apley Compression Test

30. Steinmann’s Tenderness Displacement Test

31. Rectus Femoris Contracture Test

Ankle and Foot

1. Homans' Sign

2. Anterior Drawer Test

3. Talar Tilt Test (Inversion)

4. Talar Tilt Test (Eversion)

5. Thompson Test

6. Tap or Percussion Test

7. Feiss Line 30

8. Interdigital Neuroma Test

9. Compression Test

10. Long Bone Compression Test

11. Swing Test

12. Kleiger's Test

13. Tinel's Sign