Orthopaedics + spleen, pancreas and hernias cos you're an idiot Flashcards
1
Q
What may cause adhesive capsulitis?
A
- idiopathic (primary)
- rotator cuff tendinopathy
- impingement
- biceps tendinopathy
- previous surgery or trauma
- diabetes
- inflammatory conditions
2
Q
What are the 3 stages to adhesive capsulitis?
A
- painful stage
- freezing stage
- thawing stage
3
Q
Describe the clinical features of adhesive capsulitis
A
- generalised deep and constant pain of shoulder which may radiate to bicep, disturbing sleep
- then STIFFNESS and reduced function/ ROM
- loss of arm swing, deltoid atrophy, generalised tenderness
- limited active and passive ROM, especially on external rotation and flexion of the shoulder
- affects 40-70 year olds
4
Q
How would adhesive capsulitis be investigated?
A
- clinical diagnosis
- radiograph may be used to rule out OA
- MRI can reveal thickening of glenohumeral joint and rule out impingement but isnt routinely done
5
Q
How is adhesive capsulitis managed?
A
- recovery over months to a year on its own however it often reoccurs and full ROM may not return
- paracetamol and NSAIDS
- physio
- Steroid injections
- if no improvement at all in 3 months of conservative management they can be considered for manipulation under anaesthetic
6
Q
What shoulder problems most commonly affect 10-30 year olds?
A
- instability
Need to define if they have traumatic dislocations or if dislocations are atraumatic which may suggests hypermobility or capsule laxity
7
Q
What shoulder problems most commonly affect 40-year olds?
A
- impingement
- frozen shoulder
- inflammatory arthropathy
8
Q
What shoulder problems most commonly affect 60-80year olds?
A
- degenerative cuff tear
- osteoarthritis
- cuff arthropathy
9
Q
Describe the allman classification of clavicle fractures?
A
- type 1: middle 1/3 of clavicle (75%)
- type 2: lateral 1/3 (20%)
- type 3: medial 1/3 (5%)
10
Q
How are clavicle fractures managed?
A
- almost all are treated conservatively unless open fracture, failed unity or bilateral, as even when theyre very displaced the fragments unite well
- sling to support shoulder until they get pain free movement, should recover within 4-6 weeks
- encourage early mobilisation to prevent frozen shoulder
11
Q
How are cuff tears classified?
A
- acute: <3 months, usually after trauma
- chronic >3 months: usually from degenerative microtears in older ppl
- partial or full thickness
- full thickeness can be small (<1cm), medium (1-3cm), large (3-5cm) or massive (>5cm or multiple tendons)
12
Q
What action do each of the 4 rotator cuff muscles perform?
A
- teres minor and infraspinatus = external rotation
- supraspinatus= first 15 degree abduction
- subscapularis= internal rotation
13
Q
Describe the clinical features of rotator cuff injuries?
A
- pain and weakness in the shoulder
- often hx trauma
- normal passive movement, often reduced active movement
- positive jobes, gerbers lift off or posterior cuff test
14
Q
How are rotator cuff tears managed?
A
- conservative if presents within 2 weeks, small tear, not limited function or significant co- morbidities rule out surgery
- conservative management is physio, analgesia, steroid injections
- some medium, large and massive tears and persisting symptoms will be referred for arthroscopic or open (large complex tears) repairs and physio after- good outcomes
15
Q
Describe 2 intrinsic mechanisms leading to subacromial impingement
A
Pathologies of rotator cuff tendons due to tension, this may be due to:
- muscular weakness leading to humerus shifting proximally towards body
- overuse of shoulder leading to microtrama and soft tissue inflammation
- degenerative tendinopathy
16
Q
Describe 2 extrinsic mechanisms leading to impingement
A
Compression of rotator cuff tendons due to external compression:
- Congenital or aquired anatomical variations in shape and gradient of acromion
- reduction in function of scapular muscles which normally allow humerus to move under the acromion
- glenohumeral instability
17
Q
What is subacromial impingement?
A
Inflammation and irritation of rotator cuff tendons are they pass through the subacromial space. It encompasses a range of pathologies along with it: subacromial bursitis, calcific tendinitis, rotator cuff tendinitis
18
Q
Describe the clinical features of subacromial impingement syndrome
A
- presents age <25 or 40-70
- anterior superior shoulder pain
- pain exacerbated by abduction and relieved by rest
- NEERS TEST +ve: internally rotate then flex arm= pain
- HAWKINS TEST +ve: shoulder and elbow flexed in scapular plain, relax arm and internally rotate = pain
- if left untreated you get degeneration and tears in rotator cuff so may present with cuff tears
19
Q
How is impingement investigated?
A
- clinical diagnosis
- Xray may should calcific tedonitis which may be cause, or OA (differential)
- MRI sometimes used as may show subacromial osteophytes, sclerosis, bursitis, humeral cystic changes or narrowing or subacromial joint space
20
Q
How is impingement treated?
A
- analgesia, corticosteroid injections and physio is mainstay
- if symptoms persist for 6 months w/ no improvement, surgical intervention recommended
- surgical options inc arthroscopic rotator cuff repairs, bursectomy, acriomoplasty
- mixed results with surgery
21
Q
Describe the clinical features of shoulder OA
A
- progressive pain and loss of active and passive ROM
- age >70 usually
22
Q
How is shoulder OA investigated?
A
- ap and lateral plain radiograph
- CT to see if glenoid is degenerated
- MRI if weakness in any movement suggesting rotator cuff tear
23
Q
What are the surgical options for should OA?
A
- if only humerus is affected-> shoulder hemi
- if glenoid surface is affected also-> total shoulder replacement
- if rotator cuff also affected so unstable-> reverse shoulder replacement (stops shoulder moving medially)
24
Q
Give 5 risk factors for carpal tunnel syndrome?
A
- age 45-60
- female
- pregnancy
- obesity
- diabetes
- wrist injury
- hypothyroidism
- RA
- repetitive hand or wrist movements
25
Describe the clinical features of carpal tunnel syndrome
- pain, numbness, paraesthesia over the volar aspect of the thumb, index finer and middle finger
- palm spared (palmer cutaneous brance arises before flexor retinaculum and goes over the top)
- symptoms worse at night, relieved by hanging wrist out of bed or shaking it
- later you get weakness of thumb abduction and thenar eminence wasting
- percussing over median nerve (tinels) or holding wrist in full flexion for 1 minute (phalens test) may illicit symptoms
26
How will pronator teres syndrome be different from carpal tunnel?
pronator teres syndrome is median nerve compression at level of pronator teres so the symptoms will extend to the proximal forearm and include the palm
27
How is carpal tunnel managed?
```
1st= conservative- wrist splint worn at night, prevents wrist flexion + physio and various training exercises
2nd= corticosteroid injections
3rd= surgery: in severe cases, involved cutting flexor retinaculum to release pressure on the median nerve, 90% successful
```
28
What is dequervains tenosynovitis and how does it present
inflammation of tendons in first extensor compartment (EPB, APL) of wrist, resulting in pain and swelling near the base of the thumb, grasping and pinching are particularly difficult and there may be palpable thickening of the sheath. Finklestein test usually positive.
29
give 3 risk factors for dupuytrens contracture
- smoking
- alcoholic liver disease
- diabetes
- vibration tools and heavy manual work
30
Describe the clinical features of dupurytrens contracture
- reduced ROM of fingers
- reduced skin mobilituy
- nodular deformity
- ring and little finger most commonly involved
- cannot lay palm flat on table top (heustons test)
31
How is dupurytrens contracture managed?
- no functional loss-> hand therapy, keep active with stretched throughout the day
- injectable collagenase clostridium histolyticum used in some in early disease
- if functional impairmenent-> surgery: excision of diseased fascia, needle fascitomy may done under local if unfit for surgery, post op recurrence is 66%
32
Give 2 differentials for a ganglionic cyst and how you'd differentiate
- giant cell tumour of tendon sheath: mass is solid, fixed to sheath and doesnt transilluminate
- lipoma: doesnt transilluminate, less spherical
- OA: can cause hard non cystic immobile masses
- sarcoma: not well circumscribed or mobile
33
How are ganglionic cysts managed?
- most disappear spontaneously
- if causes pain of limits ROM you can aspirate +/- steroid injection although high rate of infection and recurrence
- cyst excision reserved for symptomatic cases recurring after aspiration
34
Describe the clinical features of scaphoid fractures
- high energy trauma (usually FOOSH)
- pain in wrist
- brusing
- tenderness in scuffbox or tubercle on volar or dorsal side of hand
35
How should suspected scaphoid fractures be investigated?
- 'scaphoid series of radiographs'- ap lateral and oblique
- MRI is indicated if scaphoid fracture is clinically suspected even when xrays are normal
- while waiting for MRI, manage as fracture
36
How should scaphoid fractures be managed? (3)
- undisplaced fractures managed by strict immobilisation in plaster with a thumb spica splint
- undisplaced fractures of proximal pole have high risk of AVN so surgical treatment considered
- all displaced fractures need operation (usually percutaneous variable pitched screws)
37
give 2 complications of scaphoid fractures
- AVN most common in proximal fractures
- non union is also common in undiagnosed or inappropriately managed fractures due to its poor blood supply, internal fixation and bone grafts are often needd for these pts
38
How are trigger fingers managed?
- splints to hold it in extension overnight
- steroid injections
- surgery: percutaneous trigger finger release via needle under local. severe cases may need surgical decompression of tendon tunnel by splitting it surgically
39
give 4 risk factors for hip OA?
- age >45
- woman
- genetics
- vit d deficiency
- obesity
- Hx hip trauma
- participation in high impact sports
40
Describe the clinical features of hip OA
- dull ache pain around hip and groin extending down the thigh to the knee
- may present with knee pain- if they have trouble putting shoes and socks on the problem is really in the hip
- relieved by rest
- joint feels stiff after periods of immbolity
- quad and glut muscle wasting
- reduced power
- leg length discrepancy
- fixed flexion deformity
- antalgic or trendelenburg gait
- crepitus and reduced active and passive ROM- external rotation tends to go first
41
Give 3 differentials for hip OA and state how theyll be different
- Trochanteric bursitis: pain radiates down lateral leg and point tenderness over greater trochanter
- glut medius tendinopathy: lateral pain and point tenderness over muscle insertion at greater trochanter
- sciatica: lower back and buttock pain, radiates down back of leg and goes below the knee
- femoral neck fracture: hx trauma or known severe osteoporosis, unable to weightbear, acute onset, shortened and externally rotated
42
How is hip OA surgically managed?
- when conservative management not working
- total hip replacement usually
- hemi if less function needed and older
43
Give 3 complications of total hip replacments?
- thomboembolic disease
- bleeding
- dislocations
- infections
- loosening of prosthesis
- prosthesis fractures
- revisions (needed after around 20 yrs)
44
How will the clinical features of meniscal tears differ from ligamentous injury?
- ligamentous injuries tend to swell very quickly due to haemoarthorsis, meniscus is less vascular so swelling is over 6-12 hrs
- both are tearing sensations, ligaments may have popping sounds
- may carry on playing with meniscus tear, cant if ligament
- +ve lachmans, anterior draw or valgus/ varus stress tests with ligament injuries
45
How should suspected ligament/ meniscal injuries be investigated?
- MRI scan
| - radiograph often also to exclude boney injuries
46
When is surgery done in ACL tears?
- active and younger pts, after a period of prehabilitation with physio
- usually use tendon or artificial grafts
47
How are MCL injuries managed?
- if there is a distal avulsion fracture-> surgery
- grade 1-> RICE, return to sport in 6 weeks
- grad 2-> RICE, knee brace, weight bear as tolerated, return in 10 weeks
- grade 3-> RICE, brace, crutches, return in 12 weeks
48
When in arthroscopic surgery indicated for meniscal tears?
when the tear is >1cm
if outer 1/3 of the meniscus is affected then tend to suture it together as good blood supply for regeneration
if inner 1/3 affected they tend to trim it
49
Describe the mechanism for tibial plateau fractures
- usually high energy trauma such as falls from heights or RTA
- often from falls onto feet with extended knee
- varus deforming forces applied in this injury mean the lateral plateau is most commonly injured
50
What other pathology are commonly associated with tibial plateau fractures?
- meniscal tears
- ligament injuries
- popliteal vessel dissection
- common fibular nerve damage
51
how should suspected tibial plateau fractures be investigated?
AP and lateral radiographs of the knee
| CT scan usually needed also
52
How are tibial plateau fractures managed? (3)
- if no ligament damage, tibial sublaxation or articular step is <2mm, it is uncomplicated and can be managed with hinged knee brace and partial non weight bearing for 8-12 weeks + physio and analgesia
- if complicated, evidence of compartment syndrome, medial epicondyle fracture (even if undisplaced), they need surgery
- surgery is ORIF to restore joint surface congruence +/- bone graft to fill metaphyseal gaps
53
What is IT band syndrome?
Inflammation of the iliotibial band, it is the most common cause of lateral knee pain in athletes.
54
How is IT band syndrome tested for?
press on lateral epicondyle, extend the knee, pain will be felt at 30 degreess when the IT band passes over the lateral epicondyle
55
Who gets achilles tendonitis
classically it is unfit individuals who have sudden increase in excerise frequency
- poor footwear
- male
- obesity
56
How does achilles tendonitis and achilles rupture present
tendonitis: gradual onset pain and stiffness in posterior ankle which is worse with movement, tenderness over achilles tendon usually worse 2-6cm above insertion
rupture: sudden onset severe pain in posterior calf on forced planterflexion, popping sound, palpable step and positive simmonds test
57
How are achilles tendon ruptures diagnosed?
USS
58
How are achilles tendon ruptures managed?
If presents within 2 weeks-> analgesia and splinting in plaster with ankles and toes maximally pointed and non weightbearing for 2 weeks, then plaster at 50% point for 4 weeks, then neutral and plastered for another 4 weeks
If presents >2weeks after injury or re rupture they need surgical fixation and end to end tendon repair
59
What causes a hallux valgus
Increased angle of the 1st intermetatarsal joint, this causes a valgus deformity of the greater toe metatarsalphalangeal joint de to medial tension from the attaching tendons. high heeled and narrow shoes exacerbate the condition but do not cause it
60
how is hallux valgus investigated
- ap and oblique foot xray
| - used to assess degree of deviation and signs of joint subluxation
61
how is hallux valgus managed?
- analgesia
- adjust footwear and consider orthotics if they have flat feet which will make it worse
- physiotherapy for stretching and gait re education
- chevron procedure: shave some metatarsal bone away, realign the bone and put a k wire in for some time to keep the joint aligned
62
What is radiculopathy
conduction block of axons of a spinal nerve or its roots causing paraesthesia, anaesthesia or/ and weakness in one myotome/ dermatome
63
What are the 4 stages to disc disease
- degeneration: nucleus pulposus protrudes inthe annulus fibrosis due to loss of hydration etc
- prolapse: fibrosis and nuculeus prolapse into canal
- extrusion: fibrosis breaks, nucleus extrudes
- sequestration: fiborsis and nucuelus breakdown into canal
64
Give 4 causes for a radiculopathy
- intervertebral disc prolapse (commonest lumbar cause)
- degenerative disease of spine causing spinal canal or neuroformainal canal stenosis (commonest cervical cause)
- fracture
- malignancy
- infection (extradural abscesses, osteomyelitis, herpes zoster)
65
How are radiculopathies managed?
- most prolapses managed conservatively unless unremmitting pain, progressive weakness, new or progressive myelopathy
- analgesia: amytriptyline 1st, pregabaline/ gabapentin 2nd
- physiotherapy
- surgery for some, esp degenerative stenosis
66
Describe the clinical features of cauda equina
- perianal paraesthesia present in all
- loss of anal tone
- urinary retention first, overflow incontinence later (dont realise they needed a wee or that they went, just find it wet)
- constipation
- severe back pain
- bilateral weakess, sensory loss, loss of reflexes, shooting pains going down legs- LMN signs
67
What may cause spinal cord compression (myelopathy)
- neoplasm: breast kindey thyroid lung prostate myeloma primary bone
- trauma
- infections and abscesses
- disc prolapses
68
How are acute spinal cord compressions managed?
- urgent MRI
- routine bloods + group and save
- high dose corticosteroids and PPI immediately
- neurosurgery and spine ortho referral urgently for spinal decompression
- oncology opinion depending on cause
69
What are the 3 principles to fracture management?
- reduce
- hold
- rehabilitate
70
Why are fractures reduced?
- tamponade bleeding at fracture site
- reduce traction on soft tissues, reducing swelling
- reduce traction on nerves, reducing neuropraxia
- reduce pressure on blood vessels (restores blood supply)
- reduces risk of non union
71
What are the 4 types of neck of femur fractures?
- intracapsular: subcaptial (through junction of head and neck, or basocervical (through neck)
- extracapsular: intertrochanteric or subtrochanteric
- can also classify through the garden classification which is based off displacement and how complete the fracture is
72
How does the leg of a NOF appear?
shortened and externally rotated
73
How should NOFs be investigated?
- ap and lateral xray of affected hip
- full length of femur fractures if suspicion of pathological fracture (eg pmh cancer, low trauma fracture)
- fbc, u&e, inr/ clotting, group and save, creatinine kinase if long lie time
- urine dip, CXR, ECG for pre op assessment
- investigate cause of fall
74
What surgery is most commonly used for subtrochanteric fractures?
intramedullary femoral nail
75
What surgery is most commonly used for non displaced intracapsular fractures?
cannulated hip screws
76
What surgery is most appropriate for an intertrochanteric or basocervical fractures in young and active pts?
dynamic hip screw
77
What surgery is most appropriate for displaced intracapsular fractures?
if younger and more active- total hip replacement
| if more elderly and less mobile as baseline- hip hemiarthroplasty
78
Give 4 complications of hip fracture repair surgery
- pain
- bleeding
- infection
- neurovasc damage
- UTI
- HAP
- pressure sores
- joint dislocations
- aseptic loosening
- peri prosthetic fractures
- ANV of head if DHS or CN
79
Describe the clinical features of colles factures
- FOOSH with volar side up
- dinner folk deformity of wrist
- pain and swelling in wrist
- sometimes neurovasc compromise fo hand
80
Describe the 3 features of a normal wrist x ray that you must look for, what are the importance of these features?
- radial inclination of 22 degrees
- radial height 2mm above ulnar
- volar tilt of radius of 11 degrees
- some/ all of them are disrupted in colles fractures, successful reduction will re- establish these features
81
Describe the management of colles fractures?
- most can be pulled in A&E, under a heirs block then held in plaster cast backslab
- some may need K wires to keep them in place
- few will need plates and screws
- they need follow up 1 week after closed reduction to ensure theres no displacement
- further follow up needed around 6 weeks later to check for good bone healing
- physio input often needed to regain full function
82
What is an bartons fracture?
- intraarticular fractures of the distal radius
| - usualy need plates and screws to be stabilised
83
What are salter harris fractures?
- fractures through growth plates
| - 5 types
84
Describe the weber classification of ankle fractures?
```
A= below syndesmosis
B= at level of syndesmosis
C= above syndesmosis
```
85
How do you assess an ankle fractures for stability?
Stable ankle fractures should have:
- gap between the medial talus and medial malleolus <5mm
- even space around talus and tibia (no talar shift)
- no medial ligament injury signs (bruising or tenderness)
- weber A or B classification
86
How should stable ankle fractures be managed?
- put in cast or boot, allow weightbearing and bring them back in a week for repeat xray to check it hasnt displaced
- can do weight bearing xray to check it doesnt displace on weightbearing if unsure
87
How should unstable ankle fracture be managed?
- closed reduction
- cast
- xray a week after they start weight bearing
- can do surgery as 15% slip after closed reduction but surgery has 10% complication rate so tend todo only if closed reduction fails
- if very displaced they tend todo an ORIF
88
What must be thought about when considering doing an ankle fracture ORIF
- skin viability as soft tissue layer here is thin
| - if fracture blisters present, dont operate till these have healed
89
How are weber C ankle fractures managed?
ORIF always required to stabilise the fibula
90
What 6 things must you think about when initially assessing an open fracture?
- SKIN: small wounder or needing skin graft (plastics should be called to all open #)
- SOFT TISSUES: any tendon/ muscle/ ligament injuries that need repairing also
- NEUROVASCULAR status
- INFECTION: abx should be given within the 1st hr, esp think about contamination from marine, agriculture or sewerage
- Take a picture on admission
- Think about compartment syndrome
- should also think about haemodynamic stability and tetanus status
91
Describe the classification of open fractures? (5)
Type 1: <1cm wound, no contamination
Type2: 1-10 cm wound, no contamination
Type3: wound>10cm, or periosteal stripping or comminution or high energy trauma or farm, sewerage or river contamination
Type3A: wound covered by overlying tissue (suturable)
Type3B: required skin flap
Type3C: any vascular injury (50% amputation rate)
92
Describe the immediate management of open fractures?
- NO2 if sats are ok
- 2x wide bore cannula
- bloods: fbc, u&e, INR, Xmatch, glucose
- IV morphine 10mg + antiemetic
- 1L Normal saline over 15 mins + further fluid and blood resus if necessary
- Co- amox 1.2g IV or clinadmycin if pen allergic
- check tetanus status
- remove large debris from wound and take picture
- dress wound with non sticky absorbant dressing
- immobilise with back slab and reduce
- recheck neurovasc status
- xray
- call surgeon, plastics and anaesthetist for operation within 12-24 hrs (sooner if contamination)
- VTE prophylaxis prescription for after surgery
93
What mechanism cause anterior- inferior shoulder dislocations?
force applied to an extended, abducted and externally rotated humerus
94
How should you asses the radiographic appearance of shoulder xrays when dislocation suspected?
- look for light bulb sign on AP xray which suggests posterior dislocation
- look for inferior movement of the humeral head
- look at if the humerus head is in the middle of the glenoid on the lateral view
95
What 6 things must you think about when initially assessing an open fracture?
- SKIN: small wounder or needing skin graft (plastics should be called to all open #)
- SOFT TISSUES: any tendon/ muscle/ ligament injuries that need repairing also
- NEUROVASCULAR status
- INFECTION: abx should be given within the 1st hr, esp think about contamination from marine, agriculture or sewerage
- Take a picture on admission
- Think about compartment syndrome
- should also think about haemodynamic stability and tetanus status
96
Describe the classification of open fractures? (5)
Type 1: <1cm wound, no contamination
Type2: 1-10 cm wound, no contamination
Type3: wound>10cm, or periosteal stripping or comminution or high energy trauma or farm, sewerage or river contamination
Type3A: wound covered by overlying tissue (suturable)
Type3B: required skin flap
Type3C: any vascular injury (50% amputation rate)
97
How are patella dislocations managed?
- diagnosis is clinical but can do an xray
- reduction by extension of the knee while pushing on the medial side of the knee cap
- re xray and recheck neurovasc status
- immobilise for 2-4 weeks to allow structures to heal inside a cylinder cast or cricket splints
- physio needed after for rehabilitation
98
What mechanism cause anterior- inferior shoulder dislocations?
force applied to an extended, abducted and externally rotated humerus
99
How should you asses the radiographic appearance of shoulder xrays when dislocation suspected?
- look for light bulb sign on AP xray which suggests posterior dislocation
- look for inferior movement of the humeral head
- look at if the humerus head is in the middle of the glenoid on the lateral view
100
How should shoulder dislocations be investigated
- AP, Y scapular and axial radiographs
- check axillary nerve (sensation, deltoid muscle)
- check suprascapular nerve: lateral rotation and first 15 degrees of abduction
101
How should shoulder dislocations be managed?
- A-E
- check neurovasc status + xray
- closed reduction by hippocratic method
- recheck neurovasc status
- immobilise with broad arm sling for 2 weeks, longer for posterior dislocations
- all require physio and assessment of rotator cuff 4- 6 weeks later
102
how are finger dislocations managed
- DIPJ and PIPJ are most common to dislocate
- treated with closed reduction and splinting
- may get skin puckering which needs pulling out to stop skin necrosis
- traction neuropraxia is common in the digital nerves, but should resolve on its own
- AP, lateral and oblique views recommended
103
Describe the clinical features of splenic rupture
- blunt force trauma hx
- abdo pain
- hypovolaemic shock
- LUQ tenderness and/or peritonism
- left shoulder pain if blood irritates the diaphragm
- grey turners sign sometimes present
104
How should ruptured spleens be managed?
- A-E resus + fluid resus, transfusions etc
- if haemodynamically unstable-> straight to theatre for laparotomy
- if stable-> urgent CT CAP with IV contrast which will show splenic injuries
- If grad 1-3 tears permissive hypotension, resus, HDU and serial abdo exams to check for deterioration, repear CT at one week, encapsualted organisms vaccine
- if tenderness or peritonitis -> low threshold for laparotomy and/ or re imaging
- splenic vessel embolisation can also be tried for high grade tears
105
Give 3 complications of splenic ruputre
- ongoing bleeding
- splenic necrosis
- splenic abscess
- splenic cyst
- thrombosis
- strep pneumonia, haemophilus influenza and meningococcus// other encapsulated organism infection
106
What can cause a splenic infarct?
- occlusion of splenic artery
- usually due to haematological diseases such as leukaemia, lymphoma, myelofibrosis, sickle cell, CML, hypercoagulable states
- may be due to emboli from endocarditis, AF or post MI mural thrombus
- small number are due to vasculitis, trauma or surgery
107
Describe the clinical features of splenic infarcts
- LUQ pain radiating to the left shoulder
- less common symptoms inc fever, N+V, pleuritic chest pain
- LUQ tenderness
- many are asymptomatic and picked up in imaging or explorative surgery
108
Give 3 differentials for splenic infarcts
LUQ pain may be caused by peptic ulcer disease, pyelonephritis, ureteric colic or left sided basal pneumonia
109
How is a splenic infarct diagnosed
Gold standard is a CT abdo with contrast
110
How should a splenic infarct be managed?
- no specific management
- make sure haemodynamically stable
- analgesia
- manage underlying condition
- splenectomy should be avoided due to risk of OPSI syndrome but may be unavoidable
- may need long term anticoagulation
111
Give 3 complications of splenic infarct
- splenic rupture
- splenic abscess
- pseudocyst formation
- auto- splenectomy (repeated infarcts lead to progressive fibrosis and atrophy of the spleen)
- most complications warrent splenectomy
112
Give 5 causes of chronic pancreatitis
- 50% due to chronic alcohol abuse
- 30% idiopathic
- metabolic: hyperlipidaemia or hypercalcaemia
- infection: HIV, mumps
- hereditary: cystic fibrosis
- autoimmune (SLE)
- obstruction: stricture or neoplasm
113
Describe the clinical features of chronic pancreatitis
- chronic epigastric pain radiating to the back
- may get recurring attacks of acute pancreatitis
- endocrine dysfunction (diabetes) or exocrine dysfunction (steatorrhea or malabsorbtion)
114
give 3 differentials for chronic pancreatitis
- cholecystitis
- peptic ulcer
- hepatitis
- sphincter of odi dysfunction
115
How should chronic pancreatitis be investigated?
- BMs: secondary endocrine dysfunction
- serum calcium: hypercalcaemia as cause
- LFTs: abdnormal often, may indicate hepatic aetiology
- amylase and lipase are rarely significantly raised in chronic pancreatitis
- faecal elastase: usually low
- abdo USS first line
- CT abdo pelvis may demonstrate pancreatic calcification or pseudocyst formation
- MRCP if biliary duct obstruction suspected
116
How is chronic pancreatitis managed?
- initial: analgesia, manage complicatons, pancreatic enzyme supplements
- definitive: avoid alcohol, ERCP to extract stones
- endoscopic USS facilitate drainage of pseudocysts, bile duct stents can be used to relieve strictures
- partial or total pancreatectomy can be performed but doesnt relieve pain and often reduced QoL
- whipples procedure if paraduodenal pancreatitis or neoplasia cant be excluded
- steroids can reduce symptoms if auto immune cause
117
What is a whipples procedure
resection of pancreas head, gall bladder, bile duct, the pyloric antrum and first part of the duodenum.
the tail of the pancreas is anastomosed to the duodenum and body of the stomach
118
Give 3 complications of chronic pancreatitis
- pseudocysts
- steatorrhoea and malabsorbtion (needs enzyme replacement)
- diabetes
- effusions
- pancreatic malignancy
119
How may pancreatic cysts present?
- 70% asymptomatic
- abdo, back pain, post obstructive jaundice or vomiting from mass effect
- if it becomes infected-> sepsis
- if it becomes malignant-> systemic features of maligancy (weight loss, loss of appetite, change in bowel habit)
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What is a pancreatic pseudocyst?
A collection of fluid in the pancreatic tissue due to necrotic space formation from pancreatitis
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How should pancreatic cysts be investigated?
pancreatic protocol CT or MRCP
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What is the difference between high and low risk cysts
low risk- <3cm, cystic morphology, asymptomatic, central calcification
high risk: >3cm, main duct dilation, solid component, mural nodule
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How should high and low risk cysts be managed?
High risk- resection then follow up MRI every 2 yrs
| Low risk cysts- left and MRI every 5 years
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What is the most common type of pancreatic cancer
ductal carcinoma
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give 3 risk factors for pancreatic cancer
- fhx
- smoking
- chronic pancreatitis
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Describe the clinical features of pancreatic cancer
- may present with obstructive jaundice
- some present with abdo pain radiating to the back due to invasion of coeliac plexus
- weight loss and other systemic features are common presentations
- jaundice with palpable gall bladder is malignancy of bilairy tree until proven otherwise
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How should suspected pancreatic cancer be investigated?
- FBC, LFT, CA19-9
- abdo uss initially which may show pancreatic mass or dilated biliary tree
- pancreatic protocol CT will diagnose and stage
- PET CT often warranted
- endoscopic USS and fine needle aspiration done for grading
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How should pancreatic cancer be managed
- radical resection via whipples procedure
- peritoneal, liver and distant mets are contraindicated for surgery as morbidity post op is high
- adjuvant chemo
- majority is just palliative as usually presents late-> chemo, stents, manage complications, pain relief
- 5 yr survival is 5% so poor prognosis
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Other than ductal carcinomas, name 3 other cancers of the pancreas and how they tend to present
- G cell-> secrete gastrin-> lead to severe refractory peptic ulcers
- a cell-> glucagon-> hyperglycaemia, diabetes
- B cells-> insulin-> frequent hypoglycaemia
- delta cell-> somatostatin-> diabetes mellitus, steatorrhoea, gall stones
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Describe the course of direct inguinal and indirect inguinal hernia?
Direct: through weakness in posterior wall of canal, through hesselbachs triangle (medial to inferior epigastric)
Indirect: much more common- enters canal at deep inguinal ring (lateral to inferior epigastric vessels), exits superficial ring. Arises due to incomplete closure of the processus vaginalis
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Give 3 risk factors for inguinal hernias
- male
- increasing age
- raised intra abdo pressure (cough, heavy lifting, constipation)
- obesity
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Describe the clinical features of a normal, incarcerated and a strangulated inguinal henia
normal: soft, reducible lump in groin which protrudes more on coughing or lying down
Incarcerated: painful, tender, erythematous, non reducible +/- features of bowel obstruction
Strangulated: irreducible, very tender, severe pain out of proportion with clinical signs, n+v, obstruction features
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How do you differentiate between a direct and indirect inguinal hernia?
Press on deep inguinal ring (midpoint of inguinal ligament) and ask them to cough- direct hernia will still come out, indirect wont
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give 3 differentials for inguinal hernia
- femoral hernia
- saphena varix
- inguinal lymphadenopathy
- lipoma
- groin abscess
- internal iliac aneurysm
- femoral pseudoaneurysm
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How should inguinal hernias be investigated
USS only done if diagnostic uncertainty to exclude other pathology
Ct with contrast if ? Femoral pseudoanyeursm
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How should inguinal hernias be managed
- surgical repair only if symptomatic (significant mass or discomfort)
- repair can be open mesh (primary, unilateral) or laparoscopic (female, bilateral, recurrent)
- emergency management of strangulated or incarcerated hernia= urgent open surgery, diagnosis is clinical so doesnt need imaging
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give 3 complications of inguinal hernia
- incarcerated
- obstruction
- strangulation
- pain
- brusing
- haematoma
- infection
- urinary retention
- recurrence
- chronic pain
- damage to vas or testicular vessels are complications of hernia repair
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Where do lumps from femoral hernia appear?
inferolateral to pubic tubercle but can roll up superiory to be infront of the tubercle
tightness of the femoral ring means theyre unlikely to be reducible
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How should femoral hernia be managed
- all need surgery within 2 weeks due to high risk of strangulation
- so need routine pre op blood and USS to confirm diagnosis
- high approach used in emergency surgery as easier to access small bowel
- surgery normally just reduced the hernia and narrows the femoral ring with sutures or a mesh plug
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how should lower GI bleeds be managed
- resus with A-e, 2x wide bore cannulae, fluids, oxygen, x match
- 95% settle spontaneously with conservative management
- on going lower GI bleeds with instability or requiring constant transfusions may require endoscopic or radiological interventions
- CT angio and arterial embolisation can be trialed if vessel identified and its wide enough
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give 5 causes of PR bleeding
- malignancy
- IBD
- diverticulitis (most common)
- ischaemic, infective or radiation colitis
- haemorrhoids
- angiodysplasia
- anal fissure
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What tool can be uses to asses risk of poor outcomes in a pt with mechanical back pain? What forms part of this assesment?
Keele Start back tool
Has it spread down the legs
Have you had any shoulder or neck pain
Have you only walked short distances due to the pain
Have you dressed more slowely because of the pain
Do you think it’s not safe to be physically active with your condition
Has your pain worried you
Do you think the pain is terrible and will never get better
Do you enjoy things less because of the pain
