Can you separate each flashcard for each disorder. And then within each disorder on the different subheadings e.g. symptoms. So like at the top of each flashcard just right 'SUPRACONDYLAR FRACTURE' then write management or symptoms or whatever it is. UPPER LIMB: WEEK 1: BICEPS TENDON RUPTURE Symptoms: - Bruising tracking down forearm due to gravity - Bulge near shoulder due to biceps brachii contracting upwards causing the bulge as its distal attachment has been disrupted Problems: - Weakened elbow flexion (of supinated arm) and supination (of flexed elbow) Tests: - Tears can be confirmed with soft tissue imaging modalities e.g. ultrasound and MRI Management: Conservative - not ideal for either proximal or distal tears (unless partial - rare) Medical - analgesia and anti-inflammatories Surgery - aim to reattach biceps tendon
Additional information: - Proximal ruptures are more common than distal - Proximal ruptures are most common over the age of 60 years (degenerative) - Distal rupture is usually an injury in younger people associated with heavy lifting or sports SUPRACONDYLAR HUMERUS FRACTURE: Symptoms: - Visible deformity Problems: - Median nerve and brachial particular at risk (lie just anterior) Tests: - Median nerve examination: sensory (tap over distal palmar aspect of digit 2) and physical (e.g. pen touch test - testing abductor pollicis brevis) - Radiograph of elbow (2 views) Management: - Neurovascular compromise requires emergency attention and likely surgery - Undisplaced fractures are stable and can be treated with cast immobilisation for about 3 weeks - Displaced fractures require reduction via possibly pinning plus cast immobolisation Possible risks of treatment: - Malunion: resulting in cubitus varus (could lead to ulnar nerve problems) - Ischaemic contracture due to damage to brachial artery - Damage to the ulnar, median or radial nerve (most commonly injured is anterior interosseous nerve, followed by radial and then ulnar nerve) MALUNION AFTER SUPRACODYLAR HUMERUS FRACTURE: Symptoms: - Left cubitus valgus deformity - POTENTIALLY: ulnar claw Problems: - Ulnar nerve function disruption Tests: - Ulnar nerve examination: sensory (tap over distal palmar aspect of digit 5) and motor (Froment's test + splaying of fingers against pressure) - MRI, plus radiograph/ultrasound Management: - Ulnar nerve transposition surgery Additional information: - Ulnar 'paradox': seemingly more pronounced claw in distal ulnar nerve damage despite reduced functional losses WEEK 2: LATERAL EPICONDYLITIS: Symptoms: - Pain around outer aspect of elbow - Weak and painful grip Tests: - Active wrist extension against resistance - Power grip test Management: Conservative - physiotherapy, splint, ice, rest Medical - NSAIDs Intervention - steroid injections Surgery - very rare (only considered for professional athletes)
MEDIAL EPICONDYLITIS: Symptoms: - Pain around inner aspect of elbow - Weak and painful grip Tests: - Active wrist flexion against resistance - Power grip test Management: Conservative - physiotherapy, splint, ice, rest Medical - NSAIDs Intervention - steroid injections Surgery - very rare (only considered for professional athletes)
HUMERUS FRACTURE: Symptoms: - Bruising and swelling mid arm - POTENTIALLY - wrist drop Problems: - Disrupted radial nerve function - Weakened power grip - Damage to profunda brachii artery Tests: - Radial nerve function: sensory (tap skin over first dorsal interossei) and motor (wrist and finger extension against resistance) - Radiograph Management: Conservative - humeral brace (allows a degree of traction on the fracture to maintain alignment) Medical - analgesia and anti-inflammatories Surgical - open reduction and internal fixation
Risks of treatment: - Infection, bleeding, complication of general anaesthetic, damage to radial nerve and profunda brachii artery in spiral groove Additional information: - Thrower's fracture - transverse fracture of proximal humerus often seen in amateur cricket players due to poor training/technique - Can also have fracture of surgical neck of humerus SHOULDER DISLOCATION: Symptoms: - Severe pain in shoulder and unable to move arm - Abnormal contour compared to other side (acromion appears more prominent, and the deltoid appears to have reduced bulk laterally) - Inability to abduct shoulder past 40 degrees Problems: - Axillary nerve damage (rarely axillary artery) - Musculocutaneous nerve is second most likely affected nerve (but very rarely) - Wasting of the deltoids, leads to squaring of the shoulder Tests: - Axillary nerve function: sensory (regimental badge) - Potentially tests lateral cutaneous nerve of the forearm (terminal branch of musculocutaneous) - Radiograph (2 views) Management: - Reduction - Document sensory loss (or lack thereof) BEFORE and after reduction - Recurrent dislocation may require surgical intervention Problems of treatment: - Damage to axillary nerve (rarely musculocutaneous nerve) - will likely recover Additional information: - 90% are antero-inferior - Posterior dislocations may happen during epileptic seizures /electrocutions or a forceful arrest with arm behind back - Inferior movement of dislocations happen due to lax capsule inferiorly and lack of muscles/tendons - Coracoacromial arch prevents upward dislocation occurring frequently - Recurrent dislocations may stretch and damage the capsule and capsular ligaments + glenoid labrum or humeral head - Other possibilities are fracture of the clavicle, acromioclavicular joint disruption or humeral fracture - Axillary nerve can also be injured by intramuscular injections into deltoid, or fractures of the surgical neck of the humerus WEEK 3: BREAST CANCER: Symptoms: - Nipple contraction (caused by tethering by shortening of the suspensory ligaments which normally fix breast tissue to the skin and underlying fascia - causes elevation, dimple formation or retraction of the nipple) - P'eau d'orange (due to cutaneous lymphatic oedema - local involvement of lymphatic drainage in the breast) Tests: - Careful examination of the axilla - metastatic spread of breast cancer to the axillary lymph nodes is common (cannot assess metastasis to lymph nodes behind sternum) Management: - Mastectomy and axillary node clearance Problems with treatment: - Infection, bleeding, DVT, death + lymphedema of the upper limb - Damage to long thoracic nerve, serratus anterior palsy, winging of the scapula, difficulty completing full abduction - Loss/reduction or paresthesia of cutaneous sensation including medial arm Additional information: - Many breast cancers are missed by failure to examine axillary tail of the breast - Breast cancer can also happen in biological males (usually men over 60) ERB'S PALSY: C5/6 Causes: - Forced separation of head from shoulder (e.g. obstetric injury, falling on shoulder - commonly off a motorbike) Symptoms: - Waiter's tip position - adduction at the shoulder , internal rotation at the shoulder, pronation of the forearm, extension at the elbow and flexion at wrist Tests: - Sensory function: press in C5/6 dermatomes - lateral arm, forearm and thumb - Motor function: biceps jerk C5/6 Management: - Physiotherapy (many gain normal function over 3-4 months) KLUMPKE'S PALSY: C8-T1 Causes: - Hyperabduction traction injury - Penetrating trauma to posterior triangle - Pancoast tumour - Thoracic outlet syndrome e.g. cervical rib Symptoms: - Ulnar claw-like hand, but with hyperextension of all MCPJs due to unopposed action of the extensors + flexion at all IPJs Tests: - Sensory function: press in C8/T1 dermatomes: little finger, medial forearm and medial arm - Pen touch test (unable to do with Klumpke's; able to do with ulnar nerve palsy - abductor pollicis brevis) - Froment's test (unable to do due to loss of adductor pollicis - instead patient will try to compensate with flexion) ROTATOR CUFF TEAR: Risk factors: - Largely caused by normal wear and tear that goes along with aging, people over 40 are at greater risk - People who do repetitive lifting are at greater risk - Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers - Painters, carpenters, and others who do overhead work also have a greater change of tears - Although overuse tears caused by sports activity also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall Symptoms: - Pain in right shoulder - Difficulty raising arm above her head Tests: - Full range of movement must be assessed - abduction, flexion, extension, internal and external rotation - Full range of movement restricted suggests adhesive capsulitis - Inability to initiate abduction implies tear of supraspinatus - Painful arc suggests supraspinatus tendinitis and/or subacromial bursitis - All movement a little painful but not very restricted suggests osteoarthritis - Radiograph to test osteological pathology, MRI to test soft tissue problem Management: - For tendinitis/bursitis: conservative (physiotherapy) or medication (analgesia + anti-inflammatories) or steroid injection - For partial/full thickness tear: conservative/medical management first then surgical if required e.g. arthroscopic repair / open repair WEEK 4: DISTAL RADIAL FRACTURES: (Colle's / dinner fork) Causes: - Falling on an outstretched hand (FOOSH) Symptoms: - Pain and deformity around wrist Tests: - Neurovascular examination: radial + ulnar pulses, cutaneous sensation (notably ulnar nerve), motor function e.g. pen touch, Froment's, wrist extension - Radiograph Management: - Immediate analgesia - Manipulate and immobilize with plaster cast applied once fracture reduced Problems with treatment: - Immediate neurovascular complications - Longer term: malunion, osteoarthiritis, rupture of extensor pollicis longus (from Lister's tubercle), chronic pain Additional information: - Comminuted, displaced fracture of the distal radius involving the articular surface + dorsal displacement of the distal portion - Common fracture with osteoporosis - more common in older females SCAPHOID FRACTURE: Causes: - FOOSH Symptoms: - Pain and swelling around the wrist (specifically tenderness over anatomical snuffbox) Problems: - Avascular necrosis of proximal scaphoid due to retrograde blood supply Tests: - Radiograph/CT/MRI Management: - Non-operative: immobilisation with thumb spica cast application - Operative management: for displaced fractures -> screws Problems with treatment: - Non-union - Malunion - Osteonecrosis - Osteoarthritis OTHER POSSIBLE FOOSH: - Clavicular fracture (little consequence except visible deformity) - Supracondylar fracture - Radial head fracture - Posterior elbow dislocation (median and/or ulnar nerve injury OR brachial artery compromise - Triquetrum fracture (FOOSH in ulnar deviation) - Radial collateral ligament of the elbow injury (varus elbow instability) CARPAL TUNNEL SYNDROME: Risk factors: - Pregnancy (likely to resolve after giving birth) - Vocation e.g. constantly typing - Worse at night Symptoms: - Pins and needles and numbness affecting thumb and index fingers - Struggling to have precision grip - Wasting of thenar eminence and weakness Tests: - Tinel's test (tap over median nerve in carpal tunnel) - Phalen's test (hold wrist flexed against eachother) - Median nerve test: sensory (tap over distal palmar aspect of digit 2) and motor (pen touch test + negative for Hand of Benediction as median nerve injury is too distal) - Ultrasound/MRI Management: Conservative - splinting Medical - NSAIDs or corticosteroid injections int carpal tunnel Surgical - open or endoscopic release of flexor retinaculum in cases of pronounced nocturnal pain
Problems with treatment: - Bleeding, infection, median nerve damage, tendon injury, recurrence of CTS DUPUYTREN'S CONTRACTURE: Risk factors: - Smoking - Diabetes - Liver disease - Epilepsy - Certain occupations e.g. drilling Symptoms: - Fixed flexion deformity affecting digit 4 (can be digit 5) - Nodular thickening of palmar aponeurosis and tendon sheaths will be palpable - Unable to passively extend affected fingers Tests: - Ultrasound/MRI Management: Conservative - massage, exercise, therapeutic ultrasound Medical - collagenase injection - inject in dorsal interossei space between digits 3-4 (recurrence is common) Surgical - needle fasciotomy, fasciectomy
Problems with treatment: - Bleeding, wound failure or infection, scarring - Damage to digital nerves, damage to recurrent branch of median nerve to thenar eminence - RARELY finger loss Additional information: - Most often reported in Caucasians of North-Western European descent - Some family history link - Related conditions: tenosynovitis - inflammation of the flexor tendons and synvoial sheaths may occur with chronic repetitive use THORAX: WEEK 1: DAMAGE TO SPINAL ACCESSORY NERVE: Risk factors: - Damage during cervical lymph node biopsy Symptoms: - Weakness of trapezius - Loss of muscle bulk at the neck - Drooping shoulder (depressed and laterally displaced) - (there is no cutaneous sensory loss) Tests: - Raise shoulders against resistance (test trapezius) - Turn head against resistance (test SCM) - Ultrasound Management: - Conservative management (orthosis) - Physical repair - Surgical repair SPINAL STENOSIS: Causes: - Bony structures e.g. facet oseophytes or posterior vertebral body osteophytes - Soft tissue structures e.g. herniated or bulging discs / hypertrophy or bulking of the ligaments - Trauma, tumours, Paget disease of bone Symptoms:
- Long history of neck pain and lower back pain - Some pins and needles in both hands - Increasing clumsiness recently with progressive weakness - Suddenly unable to walk Tests: - Radiograph (signs of degenerative change in cervical spine - narrowing of the IV-disc spaces and degenerative changes at the facet joints - CT (some of the vertebra are wedge-shaped and have lost height) - MRI (posterior extrusion of intervertebral discs + overall narrowing of the spinal canal) Management: Conservative - patient education, analgesia, exercise/physiotherapy, epidural steroid and/or anaesthetic injections Surgical - laminectomy, spinal fusion, minimally invasive surgery
Problems with surgery: - No treatment: may get worse or spontaneously improve -> some symptoms might become permanent Additional information: - Spinal stenosis is a condition where a portion of the spinal canal narrows at which it can exert pressure on the spinal cord - Men more affected than women - Prevalence increases with age - Acquired cases more common than congenital ones - Most common cause is osteoarthritis PNEUMOTHORAX: Causes: - Subclavian +IJV catheterisation can be cause pneumothorax and haemothorax with poor technique - (IJV catheterisation is more commonly implicated with arterial puncture + chylothorax) Symptoms: - Sharp pain on breathing in Tests: - Radiograph - loss of lung markings in upper zones Management: - Provide analgesia, have oxygen easily available - Observe - Inspiration/expiration CXR performed multiple times - If it progresses and he becomes symptomatic: needle aspiration and chest chain if aspiration unsuccessful Additional information: - IJV catheterisation on right is preferable as lymphatic damage drains just upper right quadrant of body WEEK 6: PANCOAST TUMOUR: Risk factors: - Smoking Symptoms: - Persistent cough with occasional streaks of blood - Breathless on exertion - Drooping of his right eyelid + constricted right pupil + anhidrosis on right side (Horner's syndrome) - Pain down the inner side of his right arm - Weight loss Problems: - Disruption of cervical sympathetic chain to the head (stellate ganglion) - Lower brachial plexus involvement - Phrenic nerve palsy Tests: - Biopsy and/or bronchoscopy - CT, PET Management: - Management of symptoms and support for diagnosis - Chemoradiotherapy - Surgery - Palliative care Additional information: - Lung cancer does not usually cause notable symptoms until it's spread through the lungs or into other parts of the body - Most common cause of cancer death in the UK (21%) ASPIRATION: Symptoms: - Cough and difficulty breathing - Increased respiratory rate - Nasal flaring - Normal oxygen saturations - Reduced breath sound on auscultation on the right Problems: - Airway obstruction, leading to lobar collapse - If incomplete obstruction, may result in lobar pneumonia Tests: - Radiograph Management: - Bronchoscopic retrieval Additional information: - Likely object has passed into right inferior lower lobe: the right main bronchus is wider, shorter and more vertical than the left, so when a patient is standing up the object would pass here - If patient was in supine position, object may have passed into apical segment of lower lobes high up on the posterior chest wall (often site of aspiration of gastric contents when vomiting whilst lying down) PNEUMONIA: Causes: - Community acquired/hospital acquired - Bacteria such as streptococcus pneumoniae, haemophilus influenzae Symptoms: - Productive cough, shortness of breath and a fever - Reduced breath sounds in some lobes of the lungs - Percussion - dull in these same lobes Problems: - Worsening of infection - Empyema (pus in pleural cavity) - Sepsis + septic shock + death Tests: - Full auscultation examination must be completed (including listening at the back). - Radiograph: heart borders may be obscured due to consolidation of some lobes of the lungs + obscured diaphragmatic recess + prominent mediastinal lymph nodes can be seen consistent with reactive lymphadenopathy - Blood tests Management: - Oxygen, broad spectrum antibiotics and IV fluids WEEK 7: CARDIAC ISCHAEMIA: Risk factors: - Family history, male, smoking, obesity, raised cholesterol, hypertension, diabetes Symptoms: - Sudden onset of crushing central chest pain radiating to his left arm Problems: - Significant myocardial infarction and arrythmia - could cause sudden cardiac death Tests: - Respiratory and cardiovascular examination - Vital signs: heart rate, blood pressure, respiratory rate, oxygen saturations - ECG: 12-lead ECG obtained using 10 electrodes - Radiograph - Cardiac monitor - Coronary angiography Management: - Aspirin (ASAP) - Pain relief - Oxygen therapy (if oxygen saturation <90%) - Antiplatelet therapy - Intravenous nitrate - Coronary artery stenting - Coronary artery bypass grafting (e.g. radial artery, long saphenous vein, internal thoracic artery CARDIAC TAMPONADE: Symptoms: - Severe shortness of breath - Distended external jugular vein - Pericardial effusion: Beck triad of cardiac tamponade - low blood pressure, muffled heart sounds and distended neck veins Problems: - Fast accumulation of fluid does not allow pericardium to stretch as much to accommodate large volumes of fluid (opposite for slow gradual accumulations) - Can lead to severe impaired cardiac output and death Tests: - Radiograph - Ultrasound (can see pericardial fluid) Management: - Oxygen and constant monitoring - If small, asymptomatic, then conservative management is usually favoured (not here) - In cases where effusions are recurrent and symptomatic the pericardial fenestration can be performed (from under xiphisternum angled upwards) Additional information: - Symptoms relate to impaired cardiac function due to intrapericardial pressure approximating intracardiac pressure leading to an impaired filling of low-pressure chambers, particularly the right atrium AORTIC DISSECTION: Risk factors: - Hypertension - Atherosclerosis - Connective tissue disease - Male Symptoms: - Sudden onset chest pain that is 'tearing' and goes to the neck and down the back - Some difficulty speaking (damage to recurrent laryngeal nerve) - Tachycardia - Right sided radial and carotid pulses are weaker than the left (occurs when dissection flap involves origin of brachiocephalic artery) Problems: - Aortic rupture (mortality of 80%) - May be indicated by hypotension, syncope, haemothorax, or retroperitoneal haemorrhage - Impacts on branches e.g. coronary arteries - Tamponade if rupture occurs in aortic root - Risk of ischaemic stroke + pulse deficit Tests: - CT angiograms using iodine based contrast medium injected intravenously - Transthoracic echocardiography Management: - Immediate: high-flow oxygen, IV access, continuous observations, immediate control of blood pressure, analgesia - Surgical: Type A dissections require open surgery to prevent aortic rupture and carry worse prognosis than Type B dissections + involves removal of ascending aorta with or without aortic arch and replacement with synthetic graft (branches of aortic arch involved in the dissection may require reimplantation into the graft Additional information: - Type A: ascending aorta - Type B: distal to left subclavian artery WEEK 8: CONGENITAL DIAPHRAGMATIC HERNIA: Causes: - Failed fusion of septum transversum, pleuroperitoneal folds, dorsal mesentery of the oesophagus and lateral body / thoracic wall Symptoms: - Signs of respiratory distress on left side of chest (70 breaths pm) - Not feeding very well - Concave abdomen - Cyanotic extremities - High heart rate - Decreased breath sounds of left side of the chest Problems: - Pulmonary hypoplasia - Development of pulmonary hypertension - Cardiac dysfunction - High mortality (perinatal mortality as high as 80%) Tests: - Radiograph - bowel loops within the left hemithorax Management: - Immediate: oxygen and support - Surgery: repaired using prosthetic material Additional information: - Two common types: Bochdalek hernia (more common on the left, posterolateral, large and associated with poorer outcome + Morgagni hernia (less common, anterior, presents later) - Most commonly caused by failure of one or both pleuroperitoneal membranes to separate the thorax (Bochdalek) - Can have some associated anomolies TRACHEOOESOPHAGEAL FISTULA: Causes: - Unsuccessful fusion of lung bud and foregut Symptoms: - Increased oral secretions - Early signs of respiratory distress (tachypnoea) - Unsuccessful attempts at feeding in first few hours - Slight tachycardia Problems: - Aspiration pneumonia - GORD with acid leaking into oesophagus - Asthma-like symptoms - Recurrent chest infections Tests: - Radiograph - Contrast study using fluoroscopy (shows type of tracheo-oesophageal fistula) Management: - Immediate: respiratory support - Surgical: closing off abnormal connection and joining upper and lower parts of the oesophagus Additional information: - Often associated with other conditions e.g. ASD, VSD ATRIAL SEPTAL DEFECT: Symptoms: - Persistent cough - Auscultation of the heart reveals systolic murmur (aortic or pulmonary valve stenosis, mitral or tricuspid regurgitation or congenital septal defect Problems: - Overload of pulmonary system eventually leads to damage of the pulmonary vasculature and pulmonary hypertension develops - Eventually right sided pressure will exceed left, causing some deoxygenated blood to pass through defect to left atrium, causing cyanosis (acyanotic -> cyanotic conditions) - Heart failure will ensue Tests: - Auscultation test - Radiograph, ECG, echocardiogram, cardiac MRI (can see ASD) Management: - Most small defects will close in the first year of life - Options include: percutaneous catheter closure or surgical intervention PATENT DUCTUS ARTERIOSUS: Causes: - Failure of ductus arteriosus to obliterate after birth (should close due to decrease in maternal prostaglandins and release of bradykinin from lungs) Symptoms: - Acyanotic - Slight heart murmur - Mainly asymptomatic Problems: - Heart failure, pulmonary hypertension or endarteritis by 40, 2/3 die by age 60 TETRALOGY OF FALLOT: Causes: - Pulmonary stenosis - Right ventricular hypertrophy - Ventricular septal defect - Overiding aorta with right sided aortic arch - Caused by failure to form spiral septum (neural crest cells) Symptoms: - Cyanosis (due to right-to-left shunting) ABDOMEN: WEEK 9: INGUINAL HERNIA: Symptoms: - Colicky abdominal pain - Vomiting - Constipation - Abdominal distension - Tender mass in the groin Problems: - Risk of strangulation followed by ischemia and tissue death Tests: - Radiograph + CT - Ask patient to cough/Valsalva → feel for impulse. - Reduce the hernia, then occlude deep inguinal ring with finger: - Indirect: Hernia reappears only after releasing pressure (blocked at deep ring). - Direct: Hernia reappears immediately (bypasses deep ring). Management: - Immediate decompression and IV fluids + pain relief - In irreducible hernia, surgery is most likely required - If bowel becomes strangulated it must be resected and an anastomosis formed Additional information: - Could be small bowel obstruction secondary to adhesions (history of previous surgery), colorectal tumour, diverticular mass with obstruction, volvulus or femoral hernia - Indirect inguinal hernia: pass through inguinal canal and both inguinal rings: lateral to IEA (weakness in processus vaginalis during testicular descent) - Direct inguinal hernias: pass through 'Hasselbach's triangle' so not through canal, do not enter deep ring, may pass through superficial ring arising medial to IEA (more common in older people due to weakened conjoint tendon) - Femoral hernia: through the femoral canal below the inguinal ligament APPENDICITIS: Symptoms: - Lower right abdominal pain - Pain began in the umbilical region before moving - Fever - Tachycardia Problems:
- Peritonitis Tests: - Routine blood test, especially full blood count (white cells) and inflammatory markers - Ultrasound, CT Management: Immediate: resuscitation, antibiotic and pain relief Non-surgical: in 30% of cases where appendix has been perforated, the patient can be treated with just antiobitics and drainage of peri-appendiceal abcesses Surgical: appendectomy - open or laparoscopically; done using Gridiron incision if open
MECKEL'S DIVERTICULITIS: Symptoms: - Umbilical pain moving to right iliac fossa region Tests: - Laparoscopy (pus in abdominal cavity) - Endoscopy - Imaging Management: - Immediate: resuscitation, IV fluids - Laparoscopic or open diverticulectomy if needed Additional information: - 2% affected, 2 inches long, 2 feet from ileocaecal valve - May contain gastric, pancreatic, liver carcinoid or lymph tissue - May also be vitelline cyst or fistula COLORECTAL CARCINOMA: Symptoms: - Pale - Weight loss - Palpable mass in the left iliac fossa Problems: - Large bowel obstruction (surgical emergency) Tests: - Examination of the liver (hepatomegaly secondary to metastases) - Digital rectal exam (any evidence of rectal mass?) - Blood test - Rectal exam - Sigmoidoscopy + colonoscopy - Radiograph Additional information: - Could be diverticular mass, gynecological mass - Colorectal carcinoma is third most commonly diagnosed carcinoma after lung and breast cancer DIVERTICULAR DISEASE + DIVERTICULITIS: Symptoms: (of diverticular disease) - Intermittent lower abdominal pain - Bloating (flatulence) - Altered bowel habits - Rectal bleeding (if erode into blood vessels) Problems: (leads to diverticulitis) -Severe left iliac fossa pain - Fever - Nausea/vomiting - Constipation - Peritonitis Additional information: - Common in Western countries with about half of those over 60 affected in Canada and US - Greater prevalence with a low-fibre diet typical of Western populations - Typically occur in sigmoid colon SIGMOID VOLVULUS: Symptoms: - Distended abdomen - Large bowel obstruction (may be intermittent if it twists and untwists Problems: - May become necrotic if blood supply is hindered Tests: - Radiograph (coffee bean sign) Additional information: - Prone to volvulus as it is on relatively broad and log mesentery + can also happen in caecum WEEK 10: OMPHALOCELE: Causes: - Return of bowels during their rotation can fail causing them to herniate through umbilical cord Symptoms: - Mass protruding from anterior abdominal wall - Covered in membrane Tests: - Fetal ultrasound can detect this before birth Management: Immediate: cover intestines with membrane (e.g. plastic cling wrap) + IV fluids to counter evaporative losses Surgery:
- Small: immediate surgical closure - Reduction and closure should be accomplished gradually Additional information: - Often associated with poorer diagnosis because it is often associated with abnormalities e.g. cardiac, chromosomal, genitourinary GASTROSCHISIS: Causes: - The bowel herniates out after they have successfully returned to the abdomen - Herniation occurs lateral to the umbilicus most commonly on the right where the umbilical vein weakens the anterior abdominal wall Symptoms: - Mass protruding from anterior abdominal wall - No peritoneal sac / amnion membrane coverings over the herniated viscera Additional information: - Associated anomalies are uncommon, and survival rates are 90% - But as an isolated anamoly, the prognosis is worse because the herniated viscera have no peritoneal or amniotic covering and can be damaged by the exposure to amniotic fluid UMBILICAL HERNIA: Symptoms: - Mass protruding from the umbilicus - Covered by skin Additional information: - Can be congenital or acquired - Often contains omental fat or possibly small bowel - Hernia occurs through umbilical ring - Congenital hernias often resolve over some years without need of surgery - Acquired umbilical hernias have increased risk of strangulation and incarceration MALROTATION: Symptoms: - Colicky abdominal pain - Abdominal distension - Bilious vomiting - Constipation Problems: - Ischaemia to small bowel Tests: - CT, radiograph, endoscopy Management: Immediate: IV fluids Surgical: laparoscopy or open surgery
GALLSTONES (with cholecystitis): Symptoms: - Severe pain in right hypochondrium - Pain began as dull ache in the epigastrium, then moved to right hypochondrium - Right shoulder pain (referred from phrenic nerve) - Passing of pale stools and dark urine - Jaundice (yellow sclera) and yellowy skin Tests: - Murphy's sign: patient exhales fully whilst you have your fingers placed under their right costal margin. Patient then inhales -> if pain is felt this is a positive Murphy's sign - Ultrasound, CT, endoscopy Management: - Immediate: fluid resuscitation, antibiotics and analgesia - Surgical: consider cholecystectomy (laparoscopic or open) Additional information: - If gallstones without cholecystitis: no inflammation, stones may occasionally block ducts temporarily causing biliary colic (but no infection of inflammation), normal Murphy's sign, no shoulder pain - Cholecystitis can occur without gallstones with bile stasis, infection or ischaemia PORTAL HYPERTENSION: Causes: - Prehepatic e.g. portal vein thrombosis - Intrahepatic e.g. cirrhoris - Posthepatic e.g. at level of hepatic veins into IVC Risk factors: - Alcoholism causing liver cirrhoris Symptoms: - Vomiting bright red blood, faint and dizzy - High heart rate - Low blood pressure - Distended abdomen - Caput medusae (umbilical anastomosis) - Rectal bleeding (rectal anastomosis) - Splenomegaly - Ascites (due to increased hydrostatic pressure) Problems: - Oesophageal varices + torrential haemorrhage - Rectal varices - Hepatic encephalopathy Tests: - Ultrasound (Doppler setting can be used: blood flowing in opposite direction in portal vein indicatews portal hypertension) - Endoscopy Management: Immediate: resuscitation with IV fluids + blood Urgent: endoscopic banding of oesophageal varices When stable: treatment of portal hypertension + lifestyle advice + beta-blocker
WEEK 11: ABDOMINAL AORTIC ANEURYSM: Risk factors: - Smoking - Hypertension Symptoms: - Hypovolemic shock - Severe low back pain (involvement of posterior parietal peritoneum) Problems: - 80% of AAA patients die before reaching hospital or do not survive surgery Tests: - Radiograph - Ultrasound - CT Management: - Resuscitation - Prompt endovascular aneurysm repair or open surgery (distal colon still vascularised if graft blocks IMA because of marginal artery of Drummond) Additional information: - Different types of AAA: suprarenal, pararenal, juxtarenal, infrarenal - Aneurysms involving the renal arteries are associated with increased morbidity - Pancreatitis and a perforated gastric ulcer can both present with back pain + both are life-threatening PEPTIC ULCER: Risk factors: - Regular use of aspirin, NSAIDs or steroids - Age - Drinking alcohol - Smoking - H. pylori infection Symptoms: - Severe epigastric pain - Pain immediately after eating + often relieved several hours after eating - Gastrointestinal bleeding leading to haematemesis + melena (black tarry stools) Problems: - Perforation at anterior surface of stomach leads to acute peritonitis - Posterior stomach wall perforation into lesser may present with pain radiating to the back - Can erode into gastroduodenal artery branches - Scarring can narrow pyloric canal - non-bilious vomiting PANCREATITIS: Causes: - Acute/chronic: self-digestion by pancreatic enzymes Symptoms: - Severe epigastric pain radiating to the back - Jaundice + dark urine and pale stools Tests: - Grey Turner's sign: flank bruising (due to retroperitoneal haemorrhage) - Imaging e.g. CT KIDNEY STONES: Symptoms: - Severe right sided colicky loin pain radiating to his groin - Some blood in the urine Tests: - Radiograph - CT is the gold standard Additional information: - Kidney stones can be stuck in PUJ, pelvic brim or vesico-ureteric junction Management: Immediate: analgesia Surgery: with hydronephrosis urgent decompression of the collecting system ureteroscopy with ureteral stenting may be indicated
Additional information: - Blood supply of ureters: renal artery (superior), gonadal artery (middle) and superior vesical artery (inferior) HORSESHOE KIDNEY:
Causes: - Fusion of two kidneys occurs during their ascent in embryological development when they are in close contact Symptoms: - Dull, aching loin pain (on and off) - due to kidney irritation Problems: - PUJ obstruction leading to hydronephrosis - Recurrent urinary tract infections - Renal calculi - More susceptible to blunt abdominal trauma - Associated with congenital defects and chromosomal abnormalities Tests: - Ultrasound - CT Management: - Do not require any treatment if without complications Additional information: - Kidneys are lowered (barely reach 12th rib and renal hila is at L2) - ascent is restricted by the inferior mesenteric artery WEEK 8: PROSTATE CANCER: Risk factors: - Family history of breast cancer - African American men experience highest rates of prostate cancer Symptoms: - Urinary frequency - Nocturia (waking up to urinate) - Hesitancy - Poor stream - Back pain (suggests advanced disease) - Haematuria (suggests advanced disease) Tests: - Microscopic haematuria can be detected - Rectal examination: enlarged prostate can be palpated anteriorly - MRI - Biopsy aided by ultrasound (rectum must be clear of faeces + antibiotics required to prevent rectal bacteria causing prostatitis Management: - Prostatectomy potentially - Chemotherapy, immunotherapy or chemotherapy Problems after treatment: - Risk of loss of erectile function through damage to cavernous nerves lying posterolateral to the prostate: carry parasympathetic innervation from S2-4 to facilitate penile erection Additional information: - May be benign prostatic hypertrophy that has caused urinary symptoms - Prostate tumours often arise in the posterior/peripheral prostate gland more commonly than in anterior gland and central zone, thus no symptoms in the early stages - Prostate cancer frequently metastasises to the vertebrae via Batson's plexus (valveless) - Rectoprostatic (Denonvilliers') fascia separates the prostate and urinary bladder from the rectum and initially prevents posterior spread of prostate cancer OVARIAN CANCER: Risk factors: - Mutations in either breast cancer gene: BRCA1 or BRCA2 Symptoms: - Abdominal heaviness, shortness of breath, weight loss and early satiety (non-specific symptoms) - Pelvic pain - Fullness in the left iliac fossa - Swollen left thigh and leg (may be due to DVT - increased risk with malignancy and also with any pelvic mass; including a pregnant uterus) - Distended abdomen (suspected ascites) Tests: - Ultrasound trans-vaginally - CT, MRI Additional information: - Lymphatic drainage is to para-aortic nodes TESTICULAR TORSION: Causes: - Twisting of the spermatic cord within the scrotum Symptoms: - Severe pain in right testicle - Nausea - Slight swelling of left side of scrotum - Acutely painful to touch - Right testicle feels a little higher than left side Problems: - Occlusion of testicular venous return - Compromise of the arterial supply, resulting in ischaemia of the testis Tests: - Ultrasound with doppler VARICOCELE (left vs right): Causes: - Dilatation of the pampiniform plexus of veins Symptoms: - Dragging sensation in left scrotum and noticed a 'bag of worms' Tests: - CT Additional information: - 15% of the general male population affected - Left testis is affected much more commonly than the right - maybe due to shorter course of the right testicular vein and its oblique insertion into the IVC which is also at a lower pressure vs. left testicular vein has longer course and inserts into left renal vein at a right angle and the renal veins are at a higher pressure - Bilateral varicoceles are not uncommon - Secondary varicocele comes from increased pressure in the testicular veindue to compression e.g. extrinsic mass LOWER LIMB: WEEK 13: DEEP VEIN THROMBOSIS: Risk factors: - Recent pregnancy - Recent surgery - Immobility - Overweight - History of DVT - Cancer - Male + over 60 - Smoking Symptoms: - Shortness of breath - Sharp pain on breathing in with pain and swelling of her 'leg' Tests: - CT + ultrasound with doppler Management: Immediate: oxygen, pain relief, IV access for cardiovascular support if needed Medical: anticoagulation - suitable if patient is stable Surgical: catheter-directed thrombolysis OR mechanical embolectomy
VARICOSE VEINS: Risk factors: - Immobility - Pregnancy - Obesity - Genetics Causes: - Incompetent valves leading to blood pooling in the superficial veins Symptoms: - Visible, bulging, twisted veins under skin - Swollen ankles - Heavy feeling in legs SAPHENA VARIX: Symptoms: - Bulge inferolateral to pubic tubercle - Bluish tinge Tests: - Tap test: place one finger over the saphena varix at the saphenofemoral junction -> use your other hand to tap over the great saphenous vein lower down -> if a transmitted impulse is felt at the SFJ it suggests valve incompetence is present - Cough impulse test: place fingers gently over groin swelling -> ask patient to cough -> sudden outward impulse against fingers suggests saphena varix / inguinal hernia / femoral hernia Management: - Conservative management with compression therapy may improve symptoms of chronic venous insufficiency - Surgery using ligation DEVELOPMENTAL DYSPLASIA OF THE HIP: Risk factors: - Premature birth - Female - First born Symptoms: - Mother is struggling to put the nappies on because the babies 'hips did not seem to spread fully' - Asymmetric gluteal and thigh creases and an audible clunk on moving the right hip Problems: - Hypertrophy and tearing of the fibrocartilaginous labrum with degeneration of the hyaline articular cartilage - Delay in learning to walk - Pain - Decreased function - Shortening of affected limb and a limp (or 'waddle') - Eventually develop hip osteoarthritis Tests: - Ultrasound, radiograph (femoral head is smaller and a shallow acetabulum and superolateral displacement of the proximal femur), CT, MRI (ultrasound recommended as it uses no ionising radiation - MRI not recommended as difficult to keep babies still) Management: Conservative/medical: Pavlik harness - usually for younger patients + physiotherapy may be needed Surgical: closed reduction, open reduction, may require total hp replacement later life if not successfully treated in childhood
ACUTE LIMB ISCHAEMIA: Risk factors: - Smoking - Diabetes mellitus - Advanced age - Known atherosclerotic disease elsewhere - Hypertension - Hypercholesterolaemia - Chronic kidney disease Symptoms: - Sudden onset of severe pain in right lower limb - Cannot move it or walk - Pulseless distally in leg - Leg is cold - Pallor (paler skin) - Paraesthesia Problems: - Irreversible ischaemic damage to the muscles - Amputation may be the only option Tests: - Pulse tests e.g. femoral pulse, popliteal pulse, posterior tibial pulse, dorsalis pedis pulse - Blood tests + ECG (if he has atrial fibrillation it could be an embolus rather than a thrombus) - Ultrasound with doppler - Angiography (using X-rays for fluoroscopy and an iodine based intravascular contrast agent) Management: Conservative: lifestyle adjustment and management of risk factors - after immediate management Medical: thrombolysis Surgical: embolectomy/thrombectomy and/or stent placement
WEEK 14: TIBIAL/FEMORAL FRACTURE: Symptoms: - Unable to weight bear - Considerable pain - Bruising and swelling on lateral aspect of knee - Tender to touch - Some deformity in the leg Problems: - Superficial fibular nerve damage - Compartment syndrome: pain, pressure, paresthesia, paralysis, pallor, pulselessness Tests: - Sensory and motor examination - Radiograph Management: If patient has compartment syndrome, urgent fasciotomy is required as it is a surgical emergency Otherwise: conservative / medical
TRENDELENBERG GAIT: Causes: - Loss of function of gluteus medius, tensor fascia lata and minimus e.g. due to superior gluteal nerve damage Risk factors: - Hip replacement recently: lateral approach can damage the inferior division of the superior gluteal nerve which innervates gluteus medius and gluteus minimus Symptoms: - 'Waddling' when he walks -> he leans over to the right side to be able to keep his balance and to swing his left leg forward FOOT DROP: Causes: - Common fibular nerve injury Risk factors: - Hip replacement recently: posterior approach can damage sciatic nerve Symptoms: - Numbness below his knee on the outside of leg - Foot 'catches' on the floor and 'slaps down' when he walks HIP FRACTURE: Risk factors: - Old age - Increased risk with osteoporosis Symptoms: - Severe pain in her right hip - Unable to weight bear on that side - Lower limb is short and laterally/externally rotated (due to pull via iliopsoas, adductors and lateral rotators) Problems: - Intracapsular hip fracture risks ischaemia of femoral head due to retrograde blood supply - Bleeding, infection and nerve injury - Hospital acquired infection and DVT/PE - Poor mobility, chronic pain and dislocation Management: - Hemi-arthroplasty (partial hip replacement) - Intertrochanteric fracture treated with plate and screw - Total hip replacement (e.g. osteoarthritis) Problems after treatment: - Risk of dislocation following hip replacement is greater as capsule and supporting ligament must be disrupted to remove the femoral head - Total hip replacement causes increased risk of posterior hip dislocations, leading to damage of the sciatic nerve Additional information: - Risk of dislocation following hip replacement is greater as capsule and supporting ligament must be disrupted to remove the femoral head PAGET'S DISEASE: Causes: - Excessive action of osteoclasts degrading bones Symptoms: - 80% of patients have no symptoms - Can have loss of appetite, headache, abdominal pain, constipation, compression of nerves, pain from fracture or deformation of bones, weakness, fatigue Tests: - Radiograph KNEE INJURY: Causes: - ACL is damaged from hyperextension - PCL is damaged from hyperflexion - Lateral blow may rupture the MCL - Medial blow may rupture the LCL - Twisting is associated with ACL, PCL and meniscus tears - MCL often torn with medial meniscus - Lateral meniscus and LCL are separated by tendon of popliteus, so they don't get injured together Symptoms: - Pain and swelling of the knee - Difficulty weight bearing Tests: - Anterior drawer test: pull tibia forwards relative to femur with patient with flexed knee - excessive anterior movement suggests ACL damage - Posterior sag sign: if tibia sags beckwards relative to the femur in flexed knee - suggests PCL damage - Valgus stress for MCL, varus stress for LCL - MRI, CT, ultrasound Management: Immediate: ice, analgesia, ani-inflammatories, rest, elevation Medical: physio and rehabilitative therapy Surgery: (for athletes)
Problems with treatment: - Bleeding infection - Re-rupture is the biggest risk - Long term osteoarthritis if there is associated meniscal/cartilage damages Additional information: - Tear in ACL can tear a fragment of bone from the tibia causing bleeding from the tibial plateau ACHILLES TENDON RUPTURE: Risk factors: - Sports-related injury (especially basketball) - Male (as a result of more sport) - Age (30-50 years) - Unfit people Symptoms: - Swollen ankle with palpable gap in the calcaneal tendon - Plantar flexion will be impaired - Inability to initiate the gait (having to depend on the toe flexors on the affected side Tests: - Thompson's test: gently squeezing the calf will not cause plantar flexion - Ultrasound, MRI Management: Immediate: pain-relief, anti-inflammatories and ice pack Conservative/physical: ankle immobilisation in cast Operative: open surgery or percutaneous repair
Additional information: - Muscles that cross two joints are especially susceptible to injury e.g. gastrocnemius - Other common injuries of lower limb: hamstrings, quadriceps, adductors, tibialis posterior RUPTURE OF TIBIALIS POSTERIOR: Risk factors: - Old age - Overuse - Chronic recurrent tenosynovitis - Overweight women Symptoms: - Pain and swelling along the medial aspect of the foot and ankle - Flat foot deformity - There may be an everted foot, valgus heel positio, weakness of inversion and forefoot may appear abducted Additional information: - Acute 'flat foot' can occur too in children via lacerations PES ANSERINUS BURSITIS: Risk factors: - Overuse e.g. runners - Inflammatory arthropathies - Diabetes - Obesity Symptoms: - Pain and swelling along proximal medial tibia - May be exacerbated by activities like ascending or descending stairs Management: - Responds well to conservative treatment e.g. rest, analgesia BAKER'S CYST: Symptoms: - Tender lump at the back of the knee - Numb foot (compression of tibial nerve) - Weakened function of flexor hallucis longus Problems: - Rupture can lead to leaking of cyst fluid into popliteal fossa, between fascial planes and surrounding the hamstrings and medial gastrocnemius muscles, as well as edema of soft tissue and irregularity of cyst wall - Compression of popliteal vessels and tibial nerve - Compartment syndrome Tests: - Ultrasound, MRI Management: Conservative Medical: steroid injections shown to be beneficial Surgery: if symptoms persist or cyst is large, surgical excision is an option
WEEK 16: RICKETS - VITAMIN D DEFICIENCY: Causes: - Lack of exposure to the sun and poor nutrition - Insufficient milk absorption - children who are lactose intolerant have a higher risk of Ricket's Symptoms: - Legs bending outwards - Swelling of his knees and ankles - Expanded and irregular growth plates with a cupped and frayed appearances on radiographs - Diffuse bone pain, tenderness and muscle weakness Tests: - Radiograph (decreased bone density) OSTEOGENESIS IMPERFECTA: Causes: - Mutations leading to defective collagen Symptoms: - Bone fracturs and limb deformities, scoliosis, macrocephaly, hearing loss etc. CLEIDOCRANIAL DYSPLASIA: Causes: - Defective Runx2 gene Symptoms: - Clavicle is missing CHILDHOOD FRACTURE THROUGH THE GROWTH PLATES: Consequences: - Early closure of the growth plate - Complete: bone stops growing and is short - Partial: bone grows at an abnormal angle - Other: delayed healing of bone, non-healing, infection and loss of blood flow to the area causing death of part of the done ACHONDROPLASIA: Causes: - Mutations in the FGF3 receptor (dominant mutations) Symptoms: - Shortened stature PATELLA DISLOCATION: Risk factors: - a shallow intercondylar groove and less prominent lateral condyle - a high riding patella that is not located in the intercondylar groove (patella alta) - wasting of the quads – especially vastus medialis. These fibres waste (atrophy) quickly after bed rest or prolonged effusion->unsteady feeling with lateral pull - being female (wider pelvis and larger Q angle which increases the lateral component of the quadricep vector. - previous dislocation and tear of the medial patella retinaculum Symptoms: - Patella is laterally displaced Tests: - Radiograph Management: - Pain relief - Reduction of the dislocation - Physiotherapy to build up vastus medialis - Surgery considered for recurrent dislocations Additional information: - Mechanics predisposes lateral dislocation of the patella due to the Q angle MEDIAL MALLEOLUS FRACTURE: Symptoms: - Pain and swelling in ankle, with bruising up to the mid-calf - Restricted ankle movements - Tenderness on palpation Tests: - Radiograph Management: - Stable fracture can be treated with simple plaster cast - Unstable fracture requires open reduction and internal fixation MEDIAL MALLEOLUS + FIBULA FRACTURE and DISLOCATION: Symptoms: - Pain and swelling in ankle - Displaced ankle Problems: - Damage to superficial or deep common fibular nerve branches - Damage to saphenous and sural nerves in severe lateral displacement - Damage to anterior talofibular and lateral calcaneofibular ligaments Tests: - Assess pulses: posterior tibial pulse, anterior tibial pulse, dorsalis pedis pulse - Assess sensory function: first dorsal web space is supplied by the deep branch of the common fibular nerve + rest of dorsum is supplied by the superficial branch of the common fibular nerve Additional information: - Eversion injuries can damage deltoid ligament - Different types of inversion injuries of the ankle (e.g. tear of calcaneofibular ligament OR lateral malleolus fracture with intact ligament OR lateral+medial malleolus tear with intact ligament - Calcaneus (or talus) likely to be fractured when falling from a height |